Abstract

Key Points:

These data from a nationally representative sample of US adults with alcohol use disorders revealed a robust significant association of high symptom severity with access, continuation and discontinuation from Alcoholics Anonymous.

The association of high symptom severity and negative life events supports the behavioral economic model of AA access and continuation as proposed in this paper.

Variables associated with access to AA were also associated with continuation in AA, except for the variables for gender and education level. Women were less likely to attend AA, but more likely to continue attending. College educated respondents were less likely to attend AA, but more likely to continue attending.

A sub-group of US adults with severe externalizing disorders, identified in this study, are associated with access to and continuation in AA

In the US there is a a significant geographic regional variation in access to and continuation in AA

1. INTRODUCTION

This working paper provides an analysis of variables associated with access to AA prior to the past year and continuance in AA during the past year in a representative sample of DSM-IV alcohol abuse and alcohol dependent respondents in the United States .

Understanding the characteristics of persons with alcohol use disorders who did not attend AA, those who attended AA and those who dropped out may lead to improved AA referral and attendance.

This understanding may assist in providing appropriate encouragement for persons with alcohol use disorders who are in need of abstinence support but at a high risk for failing to seek support through AA membership.

The purpose of this study is to present and test a theoretical model of access to and continuance in AA.

The theoretical model of access to and continuance in AA used in this analysis is adapted from the Beckman and Kocel [1] model of the use of alcohol treatment services, the Aday and Anderson [2] model of societal and individual determinants of medical care utilization, the Rosenstock [[3] Health Belief Model, and the behavioral economic models of Carrillo and Mariotti [4].

The proposed concepts associated with access to and continuance in AA are:

Help-seeking associated with high severity and low efficacy/powerlessness. Carrillo’s[5]behavioral economic concept of abstinence as a second-best decision based on time-inconsistency (perceived severity) and Fiorentine and Hilhouse’s[6] Addicted-Self model, low self-efficacy associated with increase in abstinence acceptance.
Help-seeking associated with negative life events (social control hypothesis, change in consciousness due to increased sensitivity to other’s drinking behavior, Cahalan/Room[7] concept of intrapunitiveness) Value Expectancy theory emphasizing cognitive factors that are associated with motivation for behavior change.
Alcoholics Anonymous as a self-control commitment device [8] used by respondents, with high perceived severity of alcohol-related problems, to achieve and supporting abstinence

2. ANALYSIS

The descriptive statististics in this study are categorical data therefore the chi-square test is used to determine whether there is association between the categorical variables and access to and continuance in AA.

In this study the multiple categorical variables will collapsed to form 2 x 2 contingency tables to test the null hypothesis of no association.

For the purposes of this study the acceptance of the null hypothesis that there is no association is a P-value greater than 0.05.

3. METHODS

3.1 Sample

This study was based on the 1992 National Longitudinal Alcohol Epidemiologic Survey, sponsored by the National Institute on Alcohol Abuse and Alcoholism data were collected via personal interviews onducted in respondents’ homes by US Bureau of the Census interviewers. The survey sample consisted of adults 18 years or older who were selected at random from a nationally representative sample of households.

3.2 Measures

3.2.1 Alcohol Use Disorders

Diagnoses of alcohol use disorders (AUD), as classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), were derived from the Alcohol Use Disorders and Associated Disabilities Interview Schedule, a fully structured psychiatric interview designed to be administered by trained lay interviewers[9]

The interview schedule included an extensive list of symptom items that operationalized the DSM-IV criteria for alcohol abuse and dependence. Respondents were classified with past year dependence if they met at least 3 of the 7 DSM-IV criteria for dependence within the 1-year period preceding the interview: tolerance; withdrawal or avoidance of withdrawal; desire or attempts to cut down or stop drinking; much time spent on drinking, obtaining alcohol, or recovering from its effects; reduction/ cessation of important activities in favor of drinking; impaired control; and continue drinking despite physical or psychological problems caused or exacerbated by drinking. Respondents were classified with past-year alcohol abuse if they met at least 1 of the 4 DSM-IV criteria for abuse in the 1-year period preceding the interview: alcohol related legal problems, continued drinking despite interpersonal problems, neglect of role responsibilities as a result of drinking, and drinking in hazardous situations.

3.2.2 Alcoholics Anonymous Attendance

Attended AA = Item 7003 and item 7015-2 or 7015-3

Attended AA meeting during period prior-to-past year

Continued AA Attendance = item 7003 and item 7015-3

Attended AA prior-to-past year and past year

Discontinued AA Attendance = item 7003 and item 7015-2

Attended AA prior-to-past year and did not attend AA during past year

3.2.3 Severity Measure

High Severity

For the purpose of this study High Severity was defined as having met 15 or more of the Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS) items used to diagnose DSM-IV Alcohol Abuse and Dependence. A Rasch model analysis[10] of the alcohol abuse and dependence items in the the AUDADIS demonstrated the unidemensional nature of the AUDADIS items and supports the creation of an additive index of items as a measure of severity.

3.2.4 Negative Life Events

Mental Health Problems

Item 6168 “Have you ever had a mental or emotional problem”,

item 7170 “Have you ever seen anyone for a mental or emotional problem – a doctor, counselor, or any othe health professional?”.

Item 7171 “Have you ever been a patient in any type of hospital or clinic overnight because of mental or emotional problems?”

Health Problems

Item 2244 “Did you ever have any health problem as a result of your drinking – like stomach or liver disease, memory problems, or pancreatits?”

Item 2142 “Continue to drink even though you knew it was causing you a health problem or making a health problem worse?”

Item 2217 ” Continue to drink even though you had a sertious health problem that might be made worse by drinking?”

School/job problems

Item 2224 Have job or school trouble because of your drinking – like missing too much work, not doing your work well, being demoted at work, or dropping out of school?”

Family problems

Item 2225 “Drift apart from a spouse, boyfriend/girlfriend, relative, or friend you cared about because of your drinking?”

Personal Accidents

Item 2243 ” Accidentally injure yourself while under the influence of alcohol, for example , have a bad fall or cut yourself badly, get hurt in a traffic accident, or anything else.”

Vehicle Accidents

Item 2226 “Have a car, notorcycle, truck, boat, or other accident becuse of your drinking?”

Arrests

Item 2227 “Get arrested or held at a police station because of your drinkig?”

Fights

Fights

Item 2228 “Get into a physical fight while drinking or right after drinking?”

Driving problems

Item 2111 “Drive a car, motorcycle, truck, boat, or other vehicle after having too much to drink?”

Drug Use

Sedatives

Item 5104 Did you ever use sedatives, for example sleeping pills, barbituates, Seconal, Quaaludes, or Chloral Hydrate at least 12 times, on your own, before past year

Tranquilizers

Item 5123 Did you ever use tranquilizers or ant-anxiety drugs, for example Valium, Librium, muscle relaxants,or Xanax at least 12 times, on your own, before past year

Painkillers

Item 5142 Did you ever use painkillers, for example Codine, Darvon, Percodan, Dilaudid, or Demerol at least 12 times, on your own, before past year

Stimulants

Item 5161 Did you ever use stimulants, for example Preludin, benzadrine, methedrine, uppers, or speed at least 12 times, on your own, before past year

Marijuana

Item 5180 Did you ever use marijuana, hash, THC, or grass at least 12 times, on your own, before past year

Cocaine

Item 5199 Did you ever use cocaine or crack at least 12 times, on your own, before past year

Heroin

Item 5219 Did you ever use heroin at least 12 times, on your own, before past year

Methadone

Item 5234 Did you ever use methadone at least 12 times, on your own, before past year

Any Other Drug

Item 5251 or item 5268 Did you ever use other medicines, drugs or substances, for example, amyl nitrate, nitrous oxide, elavil, thorazine, or hallucinogens, such as LSD, mescaline, psilocybin, PCP, angel dust or peyote least 12 times, on your own, before past year

3.2.5 Socio-demographic Variables

Gender

1) Male

2) Female

Age

1) 18-29

2) 30-39

3) 40-49

4) 50-59

5) 60+

Race

1) White

2) Black

3) American Indian/Alaskan Native

4) Asian/Pacific Islanders

Marital Status

1) Married

2) Cohabited

3) Widowed

4) Divorecd

5) Separated

6) Never married

Education

1) grade 7 or less

2) grade 8

3) grade 9-11

4) grade 12

5) some college

6) completed college

Employment Status

1) Employed

2) Unemployed

3 Retired

4) In-school

5) Full-time homemaker

6) Other

Geographic Region

US census regions

1) North-East

2) Mid-West

3) South

4) West

Urban/Rural

US Census Bureau 1990 urban and rural definition

1) Urban

2) Rural

Age First Drinking

1) 14 years or younger

2) 15 Years or older

4. RESULTS

The analysis found that only a minority, 15%, of the respondents, meeting the DSM-IV alcohol abuse/dependence diagnostic criteria, ever attended Alcoholics Anonymous meetings during the period prior-to-past year, (table 1).

The chi-sqare analysis of the 1992 NLAES indicated that the following variables were associated with access to AA:

high severity of diagnostic symptoms
prior-to-past year drug use
negative life events
male gender
age 30 years and older
divorced
lower education level, 12th grade or less
unemployed
mid-west and west geographic regions
early age, 14 years or younger, of first drinking,

Only 34% of the respondents who attended AA prior to the past year continued to attend Alcoholics Anonymouis meeting during the past year. The analysis indicated that the following variables where associated with continuation in AA:

high severity of diagnostic symptoms,
mental health, health, school/job, and family problems
personal and vehicle accidents

female gender
divorced
higher education level, some college or higher
north-east and west geographic regions
urban population
early age, 14 years and younger, of first drinking
prior-to-past year stimulant, heroin, and methadone use

Following are descriptive tables of the study variables and their relationship to AA access and continuation. The descriptive figures may be enlarged by double-clicking on the figure.

Access to Alcoholics Anonymous

Alcoholics Anonymous Attendance

Figure 1. AA attendance

Table 1.   Prior-to-past year DSM-IV alcohol abuse/dependence by access to Alcoholics Anonymous during the period prior to the past year: 1992 National Longitudinal Epidemiologic Survey

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                                N               5728

______________________________________________________________________

Never attend AA                       85%

Attend AA                                   15%

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Severity

Figure 2. AA attendance by level of symptom severity

Table 2.   Access to Alcoholics Anonymous by level of severity: 1992 National Longitudinal Alcohol Epidemiologic Survey

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                                                              Never Attended                Ever Attended         Significance

                                                              AA                                      AA                             Level

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                                  N                            4,861                                    867

High Severity                                            13%                                     54%                   < .0001

Low Severity                                             87%              `                     46%

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Negative Life Events

Figure 3. AA attendance by negative life events

Table 3   Access to Alcoholics Anonymous by negative life events: 1992 National Longitudinal Alcohol Epidemiologic Survey

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                                                              Never Attended                Ever Attended         Significance

                                                              AA                                      AA                             Level

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                                  N                            4,831                                    860

Mental Health Problems                            9%                                    45%                   < .0001

Health Problems                                        5%             `                      28%                   < .0001

School/Job Problems                                9%                                    42%                   < .0001

Family Problems                                      34%                                    81%                   < .0001

Personal Accidenrts                                 20%                                   48%                  < .0001

Vehicle Accidents                                    14%                                    42%                   < .0001

Arrests                                                       19%                                    57%                   < .0001

Fights                                                         29%                                    54%                   < .0001

Driving Problems                                      77%                                    86%                   < .0001

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Prior-to past year drug use

Figure 4. AA attendance by prior-to-past year drug use

Table 4. Access to Alcoholics Anonymous by prior-to-past year drug use: 1992 National Longitudinal Alcohol Epidemiologic Survey

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Never Attended Ever Attended Significance

AA AA Level

_______________________________________________________________________

N 4,831 860

Sedatives 7% 21% < .0001

Tranquilizers 7% ` 23% < .0001

Painkillers 7% 20% < .0001

Stimulants 14% 31% < .0001

Marijuana 39% 53% < .0001

Cocaine 12% 30% < .0001

Heroin 1% 6 % < .0001

Methadone 1% 3% < .0001

Other 8% 21% < .0001

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