Center for Addiction Medicine

Medicine, Australia

Center for Addiction Medicine

Medicine, Australia
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NEW YORK--(BUSINESS WIRE)--Pfizer announced today that the U.S. Food and Drug Administration (FDA) approved updates to the CHANTIX® (varenicline) labeling, including removal of the boxed warning regarding serious neuropsychiatric events. The removal of the boxed warning is based on the outcomes of EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study), the largest smoking cessation clinical trial in patients without and with a history of psychiatric disorder, and is consistent with the recent recommendation of the FDA Psychopharmacologic Drugs and Drug Safety and Risk Management Advisory Committees. Additional labeling revisions based on EAGLES include updates to the corresponding warning regarding neuropsychiatric safety and the addition of information on the superior efficacy of CHANTIX compared to bupropion or nicotine patch.1,2 “For millions who smoke, stopping smoking is one of the most important steps they can take to improve their health, and Pfizer is committed to helping smokers in their quit journey,” said Freda Lewis-Hall, M.D., DFAPA, chief medical officer and EVP, Pfizer Inc. “We are pleased with the FDA’s decision to update the CHANTIX labeling based on EAGLES – the largest clinical trial of smoking cessation medications - and we expect this new information may further facilitate an informed discussion about quitting with CHANTIX between smokers and healthcare providers.” “While the benefits of quitting are immediate and substantial, few smokers are able to quit on their own and need the help of counseling and smoking cessation therapy,” said Dr. A. Eden Evins, director, Massachusetts General Hospital Center for Addiction Medicine and William Cox Family Associate Professor of Psychiatry in the Field of Addiction Medicine, Harvard Medical School. “As healthcare providers work on the front lines to help people who are struggling to quit smoking, this new labeling provides clinically relevant information on the safety and efficacy of CHANTIX to help them and their patients make informed decisions about smoking cessation treatment.” In the U.S., smoking is the leading preventable cause of death, responsible for roughly 540,000 deaths each year.3,4 Stopping smoking has significant health benefits, including reducing the risk of tobacco-related diseases such as lung cancer, heart disease, stroke, chronic respiratory disease and other conditions.5 While smoking rates have declined overall, some segments of society have not made the same progress,6,7 including people living with mental illness, Veterans, LGBTQ and other minority communities.8-10 The updated warning in the CHANTIX labeling notes that postmarketing reports of serious or clinically significant neuropsychiatric adverse events in patients treated with CHANTIX included changes in mood (including depression and mania), psychosis, hallucinations, paranoia, delusions, homicidal ideation, aggression, hostility, agitation, anxiety, and panic, as well as suicidal ideation, suicide attempt, and completed suicide. Patients attempting to quit smoking with CHANTIX should be observed for the occurrence of such symptoms and instructed to discontinue CHANTIX and contact a healthcare provider if they experience such symptoms.1 In EAGLES, in the cohort of patients without a history of psychiatric disorder, CHANTIX was not associated with an increased incidence of clinically significant neuropsychiatric adverse events in a composite endpoint comprising anxiety, depression, feeling abnormal, hostility, agitation, aggression, delusions, hallucinations, homicidal ideation, mania, panic, and irritability. In the cohort of patients with a history of psychiatric disorder, there were more events reported in each treatment group compared to the non-psychiatric cohort, and the incidence of events in the composite endpoint was higher for each of the active treatments compared to placebo: Risk Differences (RDs) (95%CI) vs. placebo were 2.7% (-0.05, 5.4) for CHANTIX, 2.2% (-0.5, 4.9) for bupropion, and 0.4% (-2.2, 3.0) for transdermal nicotine. The neuropsychiatric events of a serious nature were reported in 0.6% of CHANTIX-treated patients, with 0.5% involving psychiatric hospitalization. In placebo-treated patients, serious neuropsychiatric events occurred in 0.6%, with 0.2% requiring psychiatric hospitalization. EAGLES is a randomized, blinded, active- and placebo-controlled clinical trial, which was conducted by Pfizer in collaboration with GlaxoSmithKline at the request of and designed in consultation with the FDA and the European Medicines Agency (EMA). The trial is the first and largest to compare the safety and efficacy of CHANTIX, bupropion and nicotine replacement patch in approximately 8,000 smokers without and with a history of psychiatric disorder. The trial was designed to compare the risk of clinically significant neuropsychiatric adverse events in patients using CHANTIX, bupropion, nicotine replacement therapy or placebo as smoking cessation aids over 12 weeks of treatment, and to determine whether smokers with a history of psychiatric disorder are at a greater risk for developing clinically significant adverse events compared to smokers without a history of psychiatric disorder.2 CHANTIX® (also known as CHAMPIX® in the EU and other countries) was approved by the FDA in May 2006 as a prescription medication that, along with support, helps adults 18 and over stop smoking. CHANTIX is approved in more than 100 countries and has been prescribed to over 20 million patients worldwide, including more than 11 million in the U.S.11 Adults who smoke may benefit from quit-smoking support programs and/or counseling during their quit attempt.12 It’s possible that patients might slip up and smoke while taking CHANTIX. If patients slip up, they can stay on CHANTIX and keep trying to quit.1 CHANTIX is contraindicated in patients with a history of serious hypersensitivity or skin reactions to CHANTIX. Postmarketing reports of serious or clinically significant neuropsychiatric adverse events have been reported in patients treated with CHANTIX. These included changes in mood (including depression and mania), psychosis, hallucinations, paranoia, delusions, homicidal ideation, aggression, hostility, agitation, anxiety, and panic, as well as suicidal ideation, suicide attempt, and completed suicide. Observe patients attempting to quit smoking with CHANTIX for the occurrence of such symptoms and instruct them to discontinue CHANTIX and contact a healthcare provider if they experience such adverse events. During clinical trials and the postmarketing experience, there have been reports of seizures in patients treated with CHANTIX, with or without a history of seizures. CHANTIX should be used cautiously in patients with a history of seizures or other factors that can lower the seizure threshold. Instruct patients to discontinue CHANTIX, and contact a healthcare provider immediately if they experience a seizure while on treatment. There have been postmarketing reports of patients experiencing increased intoxicating effects of alcohol while taking CHANTIX, including unusual and sometimes aggressive behavior directed to oneself or to others and often accompanied by amnesia. Advise patients to reduce the amount of alcohol they consume while taking CHANTIX until they know whether CHANTIX affects their tolerance for alcohol. Cases of somnambulism have been reported in patients taking CHANTIX. Some cases described harmful behavior to self, others, or property. Instruct patients to discontinue CHANTIX and notify their healthcare provider if they experience somnambulism. Patients should be informed that there have been reports of serious skin reactions, such as Stevens Johnson Syndrome and Erythema Multiforme and of angioedema, with swelling of the face, mouth, and neck that can lead to life-threatening respiratory compromise. Patients should be instructed to discontinue CHANTIX and immediately seek medical care if they experience these symptoms or at the first sign of rash with mucosal lesions or any other signs of hypersensitivity. In a meta-analysis of clinical trials including a trial in patients with stable cardiovascular disease, while serious cardiovascular events were infrequent overall, certain serious cardiovascular events were reported more frequently in patients treated with CHANTIX than placebo. These events occurred primarily in patients with known cardiovascular disease. Instruct patients to notify their health care providers of new or worsening cardiovascular symptoms and to seek immediate medical attention if they experience signs and symptoms of myocardial infarction or stroke. The most common adverse reactions include nausea (30%), abnormal dreams, constipation, flatulence, and vomiting. Patients should be informed that they may experience vivid, unusual, or strange dreams during treatment with CHANTIX. Patients should be advised to use caution driving or operating machinery or engaging in other potentially hazardous activities until they know how CHANTIX may affect them. Safety and efficacy of CHANTIX in combination with other smoking cessation drug therapies have not been studied. Dosage adjustment with CHANTIX is recommended in patients with severe renal impairment or in patients undergoing hemodialysis. Smoking cessation, with or without treatment with CHANTIX, may alter the pharmacokinetics or pharmacodynamics of some drugs, such as theophylline, warfarin, and insulin. Dosage adjustment for these drugs may be necessary. Click here for full Prescribing Information and Medication Guide. About Pfizer Inc.: Working together for a healthier world® At Pfizer, we apply science and our global resources to bring therapies to people that extend and significantly improve their lives. We strive to set the standard for quality, safety and value in the discovery, development and manufacture of healthcare products. Our global portfolio includes medicines and vaccines as well as many of the world's best-known consumer health care products. Every day, Pfizer colleagues work across developed and emerging markets to advance wellness, prevention, treatments and cures that challenge the most feared diseases of our time. Consistent with our responsibility as one of the world's premier innovative biopharmaceutical companies, we collaborate with health care providers, governments and local communities to support and expand access to reliable, affordable health care around the world. For more than 150 years, Pfizer has worked to make a difference for all who rely on us. For more information, please visit us at In addition, to learn more, follow us on Twitter at @Pfizer and @Pfizer_News, LinkedIn, YouTube, and like us on Facebook at DISCLOSURE NOTICE: The information contained in this release is as of December 16, 2016. Pfizer assumes no obligation to update forward-looking statements contained in this release as the result of new information or future events or developments. This release contains forward-looking information about CHANTIX/CHAMPIX (varenicline), including its potential benefits, that involves substantial risks and uncertainties that could cause actual results to differ materially from those expressed or implied by such statements. Risks and uncertainties include, among other things, uncertainties regarding the commercial impact of the results of the EAGLES trial and the updates to the U.S. label for CHANTIX, including removal of the boxed warning regarding serious neuropsychiatric events; decisions by regulatory authorities regarding labeling and other matters that could affect the availability or commercial potential of CHAMPIX (including uncertainties regarding the impact of the EAGLES trial on the product labeling for CHAMPIX in other jurisdictions); the risk that clinical trial data are subject to differing interpretations, including by regulatory authorities; the uncertainties inherent in research and development; and competitive developments. A further description of risks and uncertainties can be found in Pfizer’s Annual Report on Form 10-K for the fiscal year ended December 31, 2015 and in its subsequent reports on Form 10-Q, including in the sections thereof captioned “Risk Factors” and “Forward-Looking Information and Factors That May Affect Future Results”, as well as in its subsequent reports on Form 8-K, all of which are filed with the U.S. Securities and Exchange Commission and available at and

News Article | March 1, 2017

TEL AVIV, Israel, March 01, 2017 (GLOBE NEWSWIRE) -- Alcobra Ltd. (NasdaqGM:ADHD), an emerging pharmaceutical company focused on the development of new medications to treat central nervous system and cognitive disorders, today announced that it will host an investor forum on Tuesday, March 28, 2017 from 8:00-9:30 a.m. EST in New York City. The forum will feature several experts in the field of prescription medication abuse and the treatment and management of attention deficit and hyperactivity disorder (ADHD). In addition, Alcobra’s executive management team will provide an evidence-based overview of the commercial potential for its proprietary Abuse-Deterrent, Amphetamine Immediate Release product candidate called ADAIR. At the forum, Dr. Timothy Wilens and Dr. Stephen Faraone will provide a general overview and answer questions regarding prescription medication abuse and the treatment and management of ADHD. Timothy Wilens, M.D. is chief, Division of Child and Adolescent Psychiatry and co-director Center for Addiction Medicine at Massachusetts General Hospital (MGH). He is also associate professor of psychiatry at Harvard Medical School in Boston.  His residency in child, adolescent, adult, and addiction psychiatry was completed at MGH under the auspices of Harvard Medical School. Dr. Wilens' research interests include the relationship among attention deficit and hyperactivity disorder (ADHD), bipolar disorder and substance use disorders, and the pharmacotherapy of ADHD across the lifespan. Stephen Faraone, Ph.D., vice president of the World Federation of ADHD, studies the nature and causes of mental disorders in childhood. In 2014, 2015 and 2016 Thompson Reuters named Dr. Faraone one of the world’s most highly cited scholars in the fields of psychiatry and psychology. He is an author on over 800 journal articles, editorials, chapters and books, his research interests include genetics, biomarker development, psychopharmacology and research methodology. Dr. Faraone is editor for the journal Neuropsychiatric Genetics and also deputy editor for the Journal of the American Academy of Child and Adolescent Psychiatry. The event will be webcast live beginning at 8:00 a.m. EST. The webcast and accompanying presentation materials will be accessible live and archived on the Investor Relations section of Alcobra’s website at, the content of which is not incorporated herein by reference. To attend the event in person, please contact the company at About ADAIR Alcobra's Abuse-Deterrent Amphetamine Immediate-Release (ADAIR) product candidate is a proprietary, abuse-deterrent oral formulation of immediate-release (short-acting) dextroamphetamine that is currently under development for the treatment of ADHD. ADAIR is being specifically designed to limit abuse by snorting or injecting. The U.S. Department of Health and Human Services reported recently that approximately five million people misuse or abuse prescription stimulants annually in the US, with studies reporting that 40 percent or more do so by snorting or injecting these products. The ADAIR formulation was developed in close collaboration with Capsugel, a global leader in delivering high-quality, innovative dosage forms and solutions. About Alcobra Alcobra Ltd. is an emerging pharmaceutical company primarily focused on the development and commercialization of medications to treat CNS and cognitive disorders. For more information, please visit the company's website,, the content of which is not incorporated herein by reference.

Maity N.,M S Ramaiah Medical College | Chand P.,Center for Addiction Medicine | Murthy P.,Center for Addiction Medicine
Indian Journal of Psychiatry | Year: 2014

One in three adults in India uses tobacco, a highly addictive substance in one or other form. In addition to prevention of tobacco use, offering evidence-based cessation services to dependent tobacco users constitutes an important approach in addressing this serious public health problem. A combination of behavioral methods and pharmacotherapy has shown the most optimal results in tobacco dependence treatment. Among currently available pharmacological agents, drugs that preferentially act on the α4 β2-nicotinic acetyl choline receptor like varenicline and cytisine appear to have relatively better cessation outcomes. These drugs are in general well tolerated and have minimal drug interactions. The odds of quitting tobacco use are at the very least doubled with the use of partial agonists compared with placebo and the outcomes are also superior when compared to nicotine replacement therapy and bupropion. The poor availability of partial agonists and specifically the cost of varenicline, as well as the lack of safety data for cytisine has limited their use world over, particularly in developing countries. Evidence for the benefit of partial agonists is more robust for smoking rather than smokeless forms of tobacco. Although more studies are needed to demonstrate their effectiveness in different populations of tobacco users, present literature supports the use of partial agonists in addition to behavioral methods for optimal outcome in tobacco dependence.

News Article | February 17, 2017

At a press conference held for local and state media, Dr. Thompson was joined by the Lieutenant Governor Ralph Northam, Attorney General Mark Herring and Secretary of Public Safety Brian Moran in announcing this new collaboration. Dr. Thompson was introduced as the physician who made the project possible and spoke just before the keynote from the Lieutenant Governor. The following is an excerpt from his remarks. “Rescue naloxone has already saved the lives of a number of my patients – some who were given their first opportunity for treatment and recovery after being rescued. This effort to make a life saving medication more widely available will save many more. The lives saved are those of good people struggling with a terrible disease, a disease that takes away their dignity, their morality, their health, their freedom, all their worldly possessions, and their freedom, before it finally takes their life. The lives saved will be people we know and love, even admire – our children, spouses and friends. Through this simple device, a medication that can be carried in a purse or briefcase or backpack or kept in a medicine cabinet at home, people with a lifetime of promise and potential can be given a chance to get treatment and find recovery.” The Virginia Center for Addiction Medicine (VCAM) was founded by Dr. Thompson and partners in the Fall of 2016, as Richmond’s first comprehensive Addiction Medicine outpatient practice working fully along the guidelines of the American Society for Addiction Medicine. The goal of VCAM is to provide help without delay and to address all the different facets and the most common co-morbidities of the disease of addiction. The Virginia Center for Addiction Medicine is a long-term treatment home for a lifelong illness and provides the long-missing center needed to create a true continuum of care. Services include drug and alcohol detox, addiction psychiatry, recovery coaching, medication assisted treatment, vivitrol, family counseling, educational programs and more. For more information about The Virginia Center for Addiction Medicine visit: For more information, please visit

Kelly J.F.,Center for Addiction Medicine | Kahler C.W.,Brown University | Humphreys K.,Stanford University
Addiction Research and Theory | Year: 2010

Substance use disorder (SUD) patients who become involved in 12-step mutual-help groups (MHGs), such as Alcoholics Anonymous, experience better outcomes and have reduced healthcare costs. In spite of this, many do not attend at all and other initial attendees drop out. Reasons for non-attendance and dropout have not been systematically studied, yet such knowledge could enhance the efficiency of twelve-step facilitation (TSF) efforts or help clinicians decide which patients might prefer non-12-step MHGs (e.g., SMART Recovery). This study developed and tested a measure of reasons for non-participation and dropout from 12-step MHGs. Items were generated and clustered into eight domains using a rational keying approach. Male veterans (N 60; M age 49; 41 African American) undergoing SUD treatment were asked to complete a brief assessment about prior MHG experiences. Psychometric analyses produced a 24-item measure containing seven internally consistent, face-valid, subscales. Co-morbid psychiatric issues and, to a lesser degree, spiritual concerns, were found to be particularly important dimensions relating to this phenomenon. The measure could serve as a useful screening tool for barriers to 12-step participation and subsequently focus TSF efforts or inform referral to non-12 step MHGs. © 2010 Informa UK Ltd.

Greenfield B.L.,University of New Mexico | Venner K.L.,University of New Mexico | Kelly J.F.,Center for Addiction Medicine | Slaymaker V.,Hazelden Foundation | Bryan A.D.,University of New Mexico
Psychology of Addictive Behaviors | Year: 2012

A large proportion of emerging adults treated for substance use disorder (SUD) present with symptoms of negative affect and major depressive disorder (MDD). However, little is known regarding how these comorbidities influence important mechanisms of treatment response, such as increases in abstinence self-efficacy (ASE). This study tested the degree to which MDD and/or depressive symptoms interacted with during-treatment changes in ASE and examined these variables' relation to outcome at 3 months' posttreatment. Participants (N = 302; 74% male) completed measures at intake, midtreatment, end-of-treatment, and at 3-month follow-up. ASE was measured with the Alcohol and Drug Use Self-Efficacy (ADUSE) scale; depressive symptoms were assessed with the Brief Symptom Inventory 18 (BSI 18) Depression scale; and current MDD diagnoses were deduced from the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Random coefficient regression analyses focused on during-treatment changes in ASE, with BSI 18 scores and MDD diagnosis included as moderators. At intake, individuals with MDD or high levels of depressive symptoms had significantly lower ASE, particularly in negative affect situations. No evidence for moderation was found: ASE significantly increased during treatment regardless of MDD status. There was a main effect of BSI 18 Depression scores: those with lower BSI 18 scores had lower ASE scores at each time point. MDD and BSI 18 Depression did not predict 3-month outcome, but similar to previous findings ASE did predict abstinence status at 3 months. Treatment-seeking emerging adults with MDD merit particular clinical attention because of their lower reported self-efficacy throughout treatment. © 2011 American Psychological Association.

Schuman-Olivier Z.,Harvard University | Schuman-Olivier Z.,Center for Addiction Medicine | Connery H.,Harvard University | Griffin M.L.,Harvard University | And 5 more authors.
American Journal on Addictions | Year: 2013

Background and Objectives Concern about diversion of buprenorphine/naloxone (B/N) in the United States may affect prescribing patterns and policy decisions. This study examines addiction treatment clinician beliefs and attitudes regarding B/N diversion. Methods Participants (n = 369) completed a 34-item survey in 2010 during two national symposia on opioid dependence. We conducted multivariable regression, examining the relationship of perceived danger from B/N diversion with clinician characteristics and their beliefs about B/N treatment and diversion. We compared causal beliefs about diversion among clinicians with and without B/N treatment experience. Results Forty percent of clinicians believed that B/N diversion is a dangerous problem. The belief that B/N diversion increases accidental overdoses in the community was strongly associated with perceived danger from B/N diversion. Conclusions and Scientific Significance Attitudes and beliefs, not education level, were associated with clinician's perceived danger from B/N diversion. Clinicians with greater B/N patient experience were more likely to believe treatment access barriers are the major cause of B/N diversion. (Am J Addict 2013;22:574-580) Copyright © American Academy of Addiction Psychiatry.

Evins A.E.,Harvard University | Cather C.,Harvard University | Cather C.,Center for Addiction Medicine | Laffer A.,Center for Addiction Medicine
Harvard Review of Psychiatry | Year: 2015

Addiction to tobacco-derived nicotine remains highly prevalent in the United States, with 18% using daily, and 53% of those with serious mental illness using daily. While smokers with serious mental illness have been excluded from most large nicotine-dependence treatment studies, a growing evidence base is available to guide clinicians in assisting their patients with psychiatric illness to quit smoking. The aim of this review is to present the evidence on safety and efficacy of smoking cessation interventions for those with serious mental illness. Smokers with schizophrenia spectrum disorders should receive varenicline or bupropion with or without nicotine replacement therapy in combination with behavioral treatment. Although more research is needed, preliminary evidence suggests that varenicline in combination with behavioral support is efficacious and well tolerated for smoking cessation for those with bipolar disorder and major depressive disorder. Controlled trials have found no evidence that in patients with serious mental illness, the use of pharmacotherapeutic cessation aids worsens psychiatric symptoms or increases the rate of psychiatric adverse events. Converging evidence indicates that a majority of smokers with seriousmental illness want to quit smoking and that available pharmacotherapeutic cessation aids combined with behavioral support are both effective for, and well tolerated by, these smokers. © 2015 President and Fellows of Harvard College.

Yeterian J.D.,Center for Addiction Medicine | Greene M.C.,Center for Addiction Medicine | Bergman B.G.,Center for Addiction Medicine | Kelly J.F.,Center for Addiction Medicine
Alcoholism Treatment Quarterly | Year: 2013

The majority of adolescents treated for substance use disorder in the United States are now referred by the criminal justice system. Little is known, however, regarding how justice-system involvement relates to adolescent community treatment outcomes. Controversy exists, also, over the extent to which justice system involvement reflects a lack of intrinsic motivation for treatment. This study examined the relation between justice system referral and reported reason for treatment entry and tested the extent to which each predicted treatment response and outcome. Adolescent outpatients (N = 127; M age = 16.7, 24% female) with varying levels of justice-system involvement (i.e., no justice system involvement [No-JSI, n = 63], justice-system involved [JSI, n = 40], justice system involved-mandated [JSI-M, n = 24]) and motivation levels (i.e., self-motivated, n = 40, externally-motivated, n = 87) were compared at treatment intake. Multilevel mixed models tested these groups' effects on percent days abstinent (PDA) and odds of heavy drinking (HD) over 12 months. JSI-M were less likely to be self-motivated compared to No-JSI or JSI (p =.009). JSI-M had higher PDA overall, but with significant declines over time, relative to no-JSI. Self-motivated patients did not differ from externally motivated patients on PDA or HD mandated adolescent outpatients were substantially less likely to report self-motivated treatment entry. Despite the notion that self-motivated treatment entry would be likely to produce better outcomes, a judicial mandate appears to predict an initially stronger treatment response, although this diminishes over time. Ongoing monitoring and/or treatment may be necessary to help maintain treatment gains for justice system-involved adolescents. © Copyright Taylor and Francis Group, LLC.

Labbe A.K.,Center for Addiction Medicine | Greene C.,Center for Addiction Medicine | Bergman B.G.,Center for Addiction Medicine | Hoeppner B.,Center for Addiction Medicine | Kelly J.F.,Center for Addiction Medicine
Drug and Alcohol Dependence | Year: 2013

Background: Participation in 12-step mutual help organizations (MHO) is a common continuing care recommendation for adults; however, little is known about the effects of MHO participation among young adults (i.e., ages 18-25 years) for whom the typically older age composition at meetings may serve as a barrier to engagement and benefits. This study examined whether the age composition of 12-step meetings moderated the recovery benefits derived from attending MHOs. Method: Young adults (n= 302; 18-24 years; 26% female; 94% White) enrolled in a naturalistic study of residential treatment effectiveness were assessed at intake, and 3, 6, and 12 months later on 12-step attendance, age composition of attended 12-step groups, and treatment outcome (Percent Days Abstinent [PDA]). Hierarchical linear models (HLM) tested the moderating effect of age composition on PDA concurrently and in lagged models controlling for confounds. Results: A significant three-way interaction between attendance, age composition, and time was detected in the concurrent (p= 0.002), but not lagged, model (b= 0.38, p= 0.46). Specifically, a similar age composition was helpful early post-treatment among low 12-step attendees, but became detrimental over time. Conclusions: Treatment and other referral agencies might enhance the likelihood of successful remission and recovery among young adults by locating and initially linking such individuals to age appropriate groups. Once engaged, however, it may be prudent to encourage gradual integration into the broader mixed-age range of 12-step meetings, wherein it is possible that older members may provide the depth and length of sober experience needed to carry young adults forward into long-term recovery. © 2013 Elsevier Ireland Ltd.

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