Narcotics Anonymous members in recovery from methamphetamine use disorder

Abstract Background and Objectives Methamphetamine use disorder (MUD) is a major public health problem, but there are no evidence‐based, best‐practice, pharmacologic, or behavioral treatments for it. Narcotics Anonymous (NA) may provide an option for referral for such patients. Methods Two waves of surveys were sent to a sample of NA members to evaluate demographic, drug use, and NA‐related issues. Of 4445 responses received from US residents, 647 listed themselves as abstinent from their worst drug problem, methamphetamine. Twelve possible sources of support were scored by these latter respondents for how important each was for their own recovery. Results Methamphetamine respondents were longstanding NA members, with their first NA meeting 30.2 years ago, 84.3% having served as sponsors for other members, and with little current craving (0.65 out of 10). Although now abstinent for an average of 13.4 years, at some point over the course of the membership, 47.4% had experienced a relapse, for an average of 16.7 months. In a factor analysis of resources scored, 29.6% of the variance fell under NA social and 29.2% spiritual; and 11.8% under outside professional support. Discussion and Conclusions NA served as a resource for supporting abstinence for some members with MUD. They scored social resources of NA support higher than both spiritual and outside institutional ones. Scientific Significance NA can serve as a community‐based resource for MUD. Determining the nature of recovery that members with MUD have in NA can be useful for further research of socially grounded support for recovery in substance use disorders.


INTRODUCTION
There are limited pharmacologic treatment options for methamphetamine (N-methamphetamine) use disorder (MUD) 1 and approaches for promoting recovery rely on nonpharmacologic, psychosocial care 2-5 because there are no Food and Drug Administration (FDA)-approved medications for MUD, and most efforts for promoting recovery rely on nonpharmacologic, psychosocially based approaches. The Twelve Step-based fellowship Narcotics Anonymous (NA) may serve as an option to aid some persons with MUD in achieving recovery from this disorder.
Because of this, we studied a sample of NA members who reported methamphetamine as their principal drug problem.
Although methamphetamine can be used singly, it can also be injected intravenously in combination with heroin. 6 Its clinical manifestations can be contrasted with those of the other major stimulant subject to misuse, cocaine, which has a slower onset of action and a longer duration of effect. Depending on these factors, the effects of the two may be comparable in onset and duration.
Neurotoxic effects of methamphetamine occur from repeated use, resulting in neurocognitive defects, and persisting even after a period of abstinence. 7 In 2012, federal legislation was passed to limit over-the-counter sales of ephedrine and pseudoephedrine because of their use in synthesizing methamphetamine in local US laboratories. 8 Subsequent illicit importation of the drug from Mexico, however, has made large quantities available. Consequently, subsequent increased availability of higher purity methamphetamine has made medical consequences more prominent 9 ; use of the drug has increased considerably in the United States in recent years. As seen in a report from the US Center for Disease Control and Prevention, among adults reporting methamphetamine use in 2018, 27.3% reported using it on more than 200 days, and 22.3% had injected it. 10 Data from poison control centers show admission to healthcare facilities rose from 30.2% in 2000 to 47.8% in 2019. 11 Methamphetamine-related hospital admissions as a portion of all drug-related admissions 10 increased from 15.1% in 2008 to 23.6% in 2017. Increased attention to opioids in recent years, such as heroin and fentanyl, has predominated regarding the problem of drug overdoses, but by 2018, methamphetamine accounted for 11% of all reported overdose deaths. 8 Despite the high prevalence of methamphetamine use in the United States and its notable contribution to overdose deaths, the availability of treatment for this major public health problem is limited. Numerous pharmacologic agents have been applied to address MUD in clinical trials in an attempt to reduce this drug's misuse, such as modafinil, 12 topiramate, 13 sertraline, 14 and naltrexone. 15 A reduction in craving has not been reported in a comprehensive literature review on clinical pharmacologic trials. 16 The National Institute on Drug Abuse (NIDA) has pointed out that there are currently no medications "that prolong abstinence or reduce misuse" of the drug. 17 With regard to psychosocial treatment, two uncontrolled studies have shown positive results, one on contingency management 18 and another employing the Matrix model, a multimodal, manualized approach. 19 NIDA points out that the "most effective" treatments for MUD are behavioral, such as cognitive behavioral and contingency management interventions. 17

METHOD
We established an agreement with the NA World Service office, located in Chatsworth, CA, for their membership office to email anonymous surveys to subscribers of the NA newsletter. Its purpose was to assess experience in the fellowship relative to recovery from substance use disorder (SUD). The initiative to study NA members who designated methamphetamine as their principal SUD was approved by the Institutional Review Board of the Chestnut Health System, with no consent required. Emails were sent to NA members stating that they could volunteer to respond to the anonymous survey if they chose to do so. Anonymous responses were analyzed by the authors for US respondents, with the files to be subsequently deleted to protect respondents' personal information. This allowed for assessing the impact of relative isolation during the stay-at-home period of COVID-19 on the respondents' participation in NA meetings and when restrictions were being lifted. The use of two waves also allowed for limiting the amount of time the data solicited would be required for completion in a given sitting.

Measures
In the first wave survey (June 2020), respondents were asked to score demographic, substance use, and recovery-related items. Two types of meetings were distinguished: face-to-face (f/f), those held in the traditional fashion, with participants located in the same place, and virtual, those held on the internet, typically in the Zoom format.
Craving for drugs or alcohol was assessed by response to a 0-to 10-point visual analog scale, similar to one applied in previous surveys. 20 Duration of abstinence was queried in the survey: "How many months has it been since you last used alcohol or drugs?" In the second wave survey (June 2021), 12 potential sources of support for recovery were listed, both before and during the COVID-19 period. These were based on the experience of two of the authors' past interviews with NA members and their published research. 20 The sources of support were: Other members you got to know, face-to-face meetings, NA Basic Text and NA literature, my sponsor, your own service work, God, NA Prayers, spiritual awakening, and meditation. Three institutionally sanctioned items, outside the umbrella of NA, were also queried: a professional therapist, medication for psychological distress, and attendance at a house of worship (like a church). These labels are abbreviated in the text and tables as italicized above. In the second survey, respondents were asked to score each of these 12 items for how important they were for support for their own recovery. To ascertain respondents' relative reliance on a given source of support independent of the impact of COVID-19, they were also asked to score items of support for abstinence before the COVID-19 period: 0 for not important, indicating a score of zero (not important) using a nonparametric chi-square test.
The diversity of respondents' reliance on the resources of support was illustrated as such: Some respondents did not rely on certain sources of support (score zero). This was illustrated by their scoring of the highest-rated items in each of the three factors that emerged from the factor analysis, namely for members, God, and therapist. For those who scored zero for each of these three items, scoring was calculated for how respondents rated each of the other resources.
Paired samples t-tests were conducted to compare the number of f/f meetings before COVID-19 to the number of virtual meetings and f/f meetings in the past week. Independent samples t-tests were conducted to compare participants who experienced an increase in drug craving to those who did not relative to other items surveyed.
All analyses were conducted using the Statistical Package for the Social Sciences, version 26 (SPSS; IBM Corporation).

RESULTS
There were 347 respondents in the first wave survey who listed methamphetamine as their principal drug of abuse. They are characterized in Table 1 For the 304 responses to the second wave, Table 2   there was no clinically significant portion on any of the resource items (score 1-4, vs. 0) as to whether or not respondents indicated having relapsed since joining.
Responses on relative reliance on different sources of support are provided in Table 3 for those who scored no support at all (scores zero) versus those who scored any support (1-4) for three respective resources, members, God, and therapist. This is illustrated by considering the patterns of reliance for respondents who indicate no support (score zero) on the three resources, other members, God, and therapist, as listed in Table 3. Thus, respondents who indicated that other members were not  Based on our experience with Twelve Step members, we, therefore, selected resources within NA that members could use in bolstering their recovery and solicited respondents to score the degree to which they found these respective resources support their recovery. Resources were scored for two periods, "Currently," (i.e., during the pandemic during which they were responding) and "before the pandemic," (i.e., the patterns of reliance, before, and therefore independent of the pandemic).
Scoring before the pandemic is reported here to clarify the respondents' patterns of support independent of the COVID-19 era. We found that the difference in resources did not meet the criteria for a small effect in scores distinguishing the two periods. Effective transition from f/f to virtual meetings during the COVID-19 period illustrates the adaptability of the Twelve Step format even when the typical mode of meetings was usually not available.
Notably, however, craving ratings were higher for the COVID-19 period than in the period before the pandemic. Craving was also associated with a shorter period of membership and lesser involvement in the NA format of sponsorship and service to other members. To provide comparable findings for the potential resources of support outside the fellowship, we included three possible options, namely a house of worship, an outside therapist, and medications for psychological (nondrug) problems.
Reliance on at least one of these three items was scored by the large majority of respondents. This underlines the need to examine the many non-NA sources relevant to recovery, indicating that an examination of other community-based options for support merits examination. Family, friends, and occupational roles are illustrative of this larger pattern of support, and also underline the importance of examining the interaction between the many sources of support outside NA that are available to members and those sources that are in NA. While interactions among these resources are complex, they indicate the importance of considering such resources needed by clinicians for treatment planning in treating a given patient. The finding that 27% of respondents were referred to NA by a health professional also indicates the possible utility of the fellowship for professionals treating MUD patients.
Respective members may draw differently on the resources available to them. This was illustrated by certain members whose scores reflected that they did not rely on three of the resources that were scored highly by other respondents. For example (as in Table 3), the large majority of those who indicated not relying on a therapist did indicate reliance on their sponsor and other members. Additionally, the finding that females are more likely than males to rely on professional help reflects further the differences in the use of resources among members.

LIMITATIONS
The findings presented here are limited to the small number of persons accessed from the larger NA membership. Certain limitations in this approach are clear. Respondents were fully committed members, having many years since their first encounter with NA, had experienced a spiritual awakening, and had involvement with sponsorship. None of the data we accessed came from NA members who had recently joined or had left the fellowship because of relapse.
Only a limited number of resources within or outside the fellowship were presented for scoring. While these are illustrative of respondents' options, other resources are important as well. Additionally, respondents' reports of abstinence as reported here could not be corroborated by independent confirmatory evidence, such as urinalyses.

CONCLUSION
MUD is a major public health problem, in terms of the high degree of morbidity and mortality associated with it, and the need for sufficient resources for its treatment. This study of NA members who have this disorder and the ratings for sources of support they turn to indicates that at least, for some persons with this disorder, the fellowship can offer a non-pharmacologic approach to achieving recovery. The findings are also useful in gaining an understanding of how members themselves with MUD see their recovery as stabilized in the fellowship. Such findings can be helpful for investigating mechanisms of action for this peer-based program, and as a resource for clinicians to consider for their patients with MUD.