alison beck presents on smart recovery australia | apsad conference 2015

Exploring the Evidence: A Systematic Review of SMART Recovery Evaluations

Alison Beck, Amanda Baker, Peter Kelly, Anthony Shakeshaft, Frank Deane & David Hunt

The University of Newcastle www.newcastle.edu.au

Funding

Partnership

3 | The University of Newcastle www.newcastle.edu.au

IntroductionMutual Aid is an important element of addiction recovery

Evidence primarily derived from 12-step models.

Recommended by Australian & International Clinical Guidelines

Tailoring is an important element of addiction recovery

SMART Recovery represents an alternative


ObjectivesTo provide an overview of the current state of evidence for SMART Recovery for adults with experience of substance and/or behavioural addiction(s)

Does SMART Recovery promote change in the severity of addiction & its consequences?Is outcome influenced by treatment engagement or other process measures?What is the evidence for feasibility?


Methods

Studies Randomised Non-Randomised Cross sectional Qualitative Only

Participants ‘Problematic’ addictive

behavior Current/ past Patient/carer report, self-

report assessment and/ or clinical interview

Interventions Group SMART Recovery Trained facilitator Stand alone/ in

combination

Comparison Active Inactive No comparison

Outcomes Severity of addiction & its

consequences Treatment engagement Other process measures Feasibility Clinician and/ or patient

rated with or without collateral

Objective and/ or subjective

Any follow-up period


MethodsSCIENTIFIC DATABASES

(139)

NON-SCIENTIFIC DATABASES

(875)

MANUAL SEARCH TITLES/ ABSTRACTS(875)

FULL TEXT ASSESSED FOR ELIGIBILITY(118)

EVALUATION(12)

DISCUSSION(18)

REVIEW(10)

OTHER(8)

CLASSIFIED(48)


Methodology: Included Published Studies#

Study Design N Focus Special Population

Description of ‘SMART Recovery’ Comparison (s)

Intensity Setting Additional Components

Hester et al (2013).

RCT 86 Alcohol Attending < 4 weeks

Drug dependence

Not specified

Community Groups

Not specified Online Web Application (alone vs in combination with SMART groups)

Brooks & Penn (2003)

Pre- post(Alternate allocation)

58 Alcohol (45.7%)

Dual diagnosis

5 hrs/day, 5 days/wk (6months)2 days/wk ‘Aftercare’ as needed

Intensive outpatient/ partial hospitalisation

Yes 12-step program adapted for dual diagnosis

Penn & Brooks (2000)

Pre- post(Alternate allocation)

112# As above Dual diagnosis

As above

As above

Yes As above

Li et al (2000)Cross Sectional

33 ‘Alcoholics’ ‘In recovery’ (8 weeks attendance)

Once per week for 1-2 hours

Community Groups

Not specified Community AA Groups

Atkins & Hawdon (2007) ##

Cross Sectional

924 (321 SMART)

Alcohol (>3/4 sample)

‘In recovery’ (no definition)

Not specified Community Groups

Not specified Community Mutual Aid Groups: 12-step (AA/ NA), WFS, SOS

O’Sullivan, et al (2015)

Cross Sectional

81 Alcohol (50.6%)

3 months attendance

Not specified Community Groups

Not specified None

Kelly et al (2015)

Cross Sectional

124 Alcohol (72.6%)

NA Not specified Community Groups

Not specified None

#Awaiting one publication; #Data only available for the full sample (not broken down according to treatment group)


Study Design N Focus Special Population

Description of ‘SMART Recovery’ Comparison(s)

Intensity Setting Additional Components

Guarnotta (2015)

Cross Sectional Thesis

58 Alcohol Abstinent > 30 days

Not specified

Community Groups


Milin (2007)


60 Alcohol (96.6%)

NA Not specified

Community Groups


Trumble (2015)


70 Alcohol NA Not specified

Community Groups


Methodology: Included Unpublished Studies#

# Awaiting one thesis


Summary of Outcome Variables Severity of Addiction and Its Consequences Feasibility Process Variables

Alcohol Substance Behavioural

Func

tioni

ng

Qua

lity

of L

ife

Econom

ic

Satisfaction

Treatment Engagement

Ther

apeu

tic

Proc

ess

Locu

s of

Cont

rol

Spiri

tual

ity/

Relig

iosi

ty

Self-

Effica

cy

Quantity

Severity

Quantity

Severity

Frequency

Severity

No. Sessions

Session

Frequency

Treatment

completion

Duration of

involvem

ent

Participation

7 7 6 5 0 0 2 2 0 2 3 3 3 4 2 5 3 4 1

Hester et al (2013) RCT


Pre-post

Penn & Brooks (2000)

Pre-post

Li et al (2000) Cross Sectional

Atkins & Hawdon (2007)

Cross Sectional

Kelly et al (2015) Cross Sectional

O’Sullivan et al (2015)

Cross Sectional

Guarnotta (2015)# Cross Sectional

Milin (2007)# Cross Sectional

Trumble (2015)# Cross Sectional


SMART Recovery vs. SMART Informed Web App (alone or in combination) n Severity of Addiction and Its

consequences Process Variables

SMART

OA/

OA+

SMART Alcohol Treatment

Engagement

Study

Quantity Severity No. Sessions

Hester et al (2013). 3 month outcomes

681 831 % Days Abstinent SMART: 43.61 vs 71.18 (effect size .91) Between Groups: N.S.D Drinks per drinking day SMART: 8.25 vs. 4.66 (effect size .77) Between Groups: N.S.D

InDUC SMART: 41.47 vs 18.88 (effect size .78) Between Groups: N.S.D

SMART only # sessions predictive of improvement/ 3 month tx outcome (% Days abstinent, mean drinks per drinking day & InDUC Recent Total)

N.S.D = No Significant Difference; InDUC=Inventory of Drug and Alcohol Use Consequences 1.Number of participants with 3 month follow-up data (original allocation = 19 OA only; 83 to OA + SMART; 87 SMART only; 2. Significance not assessed/ reported

Summary of Findings


SMART Recovery Informed versus AA Informed Patient or population: Adults with Serious Axis I mental illness and concurrent substance dependence Settings: Intensive outpatient/ partial hospitalisation Severity of Addiction and Its consequences Process Variables Study n Alcohol Functioning Quality of Life Treatment

Engagement

SMA

RT

AA Quantity Severity No.

Sessions Treatment completion


58 54 Urine Reduction in ‘any substance’ (2 months) Between Groups N.S.D.

ASI Improvement ‘over time’ Alcohol 12-step Employment, Legal, Psychiatric Between Groups N.S.D

HOSP SMART 5.52(13.7) vs 0

Lehman Social Interaction 12-step Perceived Health Status SMART Overall Functioning/ Leisure/ financial Between Groups N.S.D

Between Groups N.S.D

Between Groups N.S.D

Addiction Severity Index; N.S.D = No Significant Difference; HOSP= Hospitalisation


SMART Recovery vs. AA Participants: Adults with self reported addiction Setting: Community delivered SMART or AA groups Severity of Addiction

and Its consequences Feasibility Process Variables

Study n Alcohol

Satisfaction

Treatment Engagement Therapeutic

Process Locus of Control

Spirituality/ Religiosity Self-Efficacy

SMAR

T

AA Quantity Severity Session

Frequency Duration

Li et al (2000)

33 48 AA > SMART

AA more external

AA > SMART

Guarnotta (2015)

58 64 Abstinence AA > SMART1

Not reported + correlation: Intention/ attitude & self efficacy

+ correlation: Self efficacy & days sober Between GroupsN.S.D

Milin (2007)

60 56 AUDIT, ASI DrInC

All AA > SMART

Years of abuse: N.S.D

‘Like/ dislike’ AA > SMART

AA > SMART

Pre Contemplation AA > SMART Contemplation AA < SMART

Trumble et al 2015

70 36 Days of Sobriety AA > SMART1

DRIE SMART more internal

Belief in a higher power AA> SMART1

ASI: Addiction Severity Index; AUDIT: Alcohol Use Disorders Identification Test; DrInC: Drinker Inventory of Consequences; N.S.D = No Significant Difference; 1. Significance not assessed/ reported;


Patient or population: Adults ‘in recovery’ Settings: Community delivered SMART or 12 step (AA/ NA) meetings

n Severity of Addiction

and Its consequences Process Variables

SMART

12-step Alcohol Treatment

Engagement Religiosity/ Belief in Higher power

Quantity Severity Participation Atkins & Hawdon (2007)

321 161 Sobriety No significant difference

Linked to improved recovery SMART less likely to ‘participate’1

Unrelated to sobriety Less effective in stimulating SMART Participation than 12-step

1. As defined by a 9 item scale developed for the study, items included how often respondents participated in group discussion at meetings, led meetings, helped set up or clean up, read group literature outside of meetings, helped newcomers, talked with members outside of meeting settings, did things with other members that were not directly recovery related


SMART Recovery vs no comparison condition Participants: Australian Adults attending SMART Recovery Setting: Community delivered SMART groups Severity of Addiction

and Its consequences Fidelity Process Variables

Alcohol Satisfaction Treatment Engagement Therapeutic Process

Study N Duration Session Frequency

Duration of involvement

Participation

Kelly et al (2015)

124 Problematic Addiction 18.11 years (SD = 10.97))

Majority = Weekly (72.8%)

8.78 months (SD = 14.11; Range, one week to 96 months)

“sometimes” to “frequently” use CR or BA

CR> BA

Homework a predictor of BA

Group Cohesion predicts both CR and BA Quality of facilitation + correlation with group cohesion r = .38

O’Sullivan, D., et al. (2015)

81 Problematic addiction for 3 months to 40 years (M = 15.62, SD = 11.5)

Confident in capacity for SMART to meet recovery goals 8.16 (SD = 1.24) Qualitative Data

M=4.69 meetings per month (SD = 2.64)

3 months to 10 years (M = 1.58, SD = 1.81)


Satisfaction Internal locus of control

(self-directed, self-empowered) 36%

Supportive environment (giving & getting help, positive reinforcement) 33%

Many tools/ resources for relapse prevention 28%

Scientific nature, theoretical 23%

Non-judgemental (absence of guilt, slip is not catastrophic) 11%

“Alignment with SMART Recovery program’s philosophy, principles and format” (51.6%)

“Difficulties with surrendering to religious affiliations, such as a higher power, and the adoption of a powerlessness identity” (26.6%)


Summary & Conclusions

Does SMART Recovery promote change in the severity of addiction & its consequences?

Preliminary findings Alcohol (days abstinent, drinks per

day, consequences) Functioning (hospitalisation) Quality of life (perceived health status) Other substance and behavioural

addictions Other indices of functioning



Is outcome influenced by treatment engagement or other process measures?

Preliminary findings Attendance Self-efficacy Participation Quality of facilitation Group cohesion



What is the evidence for feasibility?

Preliminary findings Satisfaction Economic outcomes

alison beck presents on smart recovery australia | apsad conference 2015

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