Effectiveness of Alcoholics Anonymous

The effectiveness of Alcoholics Anonymous in treating alcoholism has been extensively studied. Many papers have been published studying the degree to which Alcoholics Anonymous (AA) helps alcoholics keep sober. The subject is controversial with some studies showing AA helping alcoholics, while other studies do not show AA efficacy. The U.S. Surgeon General states in a 2016 report on addiction that "Well-supported scientific evidence demonstrates the effectiveness of twelve-step mutual aid groups focused on alcohol and twelve-step facilitation interventions." The program appears to be helpful for a subset of alcoholics; Alcoholics Anonymous appears to be about as effective as other support groups recommending abstinence from alcohol and other drugs of abuse.

Overview

There are a number of ways one can determine whether AA works and numerous ways of measuring if AA is successful. The 2020 Cochrane review of Alcoholics Anonymous determines success as "abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offsets."[1]

Because of the anonymous and voluntary nature of Alcoholics Anonymous ("AA") meetings, it is difficult to perform random trials with them; the research suggests that AA can help alcoholics make positive changes.[2] The Surgeon General of the United States 2016 Report on Alcohol, Drugs, and Health states "Well-supported scientific evidence demonstrates the effectiveness of twelve-step mutual aid groups focused on alcohol and twelve-step facilitation interventions." [3][4]

The research is quite complex and is still developing;[2] some studies have suggested an association between AA and increased abstinence or other positive outcomes,[5][6][7][8][9] but other studies have not.[10][11] Likewise, some articles in the popular press state that Alcoholics Anonymous helps some alcoholics get sober,[12][13][14][15] but others claim AA is not effective.[16][17]

While older studies did not show a correlation between being assigned to AA and better treatment outcomes,[18] newer studies show that Alcoholics Anonymous significantly increases abstinence after treatment.[19][20][21][1] The 2020 Cochrane review saw, at the 12-month follow up, a 42% abstinent rate for AA and twelve-step facilitation treatments which encourage patients to regularly attend AA meetings, compared to 35% abstinent using non-AA interventions.[19][22]

Alcoholics Anonymous appears to be about as effective as other abstinence-based support groups.[23]

Systematic reviews, meta-analyses and large clinical studies

Cochrane Reviews

The 2020 Cochrane review of Alcoholics Anonymous shows that AA results in more alcoholics being abstinent and for longer periods of time than some other treatments, but only as well in drinks-per-day and other measures.[19][24] When comparing Alcoholics Anonymous and/or Twelve Step Facilitation to other alcohol use disorder interventions, at the 12-month follow up, studies show a 42% abstinent rate for AA/TSF treatments, compared to 35% abstinent using non-AA interventions.[22][25]

The study concludes that "Manualized AA/TSF interventions usually produced higher rates of continuous abstinence than the other established treatments investigated. Non-manualized AA/TSF performed as well as other established treatments [...] clinically-delivered TSF interventions designed to increase AA participation usually lead to better outcomes over the subsequent months to years in terms of producing higher rates of continuous abstinence."[1] Here, a "manualized" treatment is one where a standard procedure was used.[26] A TSF treatment is a "twelve-step facilitation" treatment: A treatment which encourages a patient to attend Alcoholics Anonymous.[27]

An older 2006 Cochrane review stated that the "available experimental studies did not demonstrate the effectiveness of AA or other twelve-step approaches in reducing alcohol use and achieving abstinence compared with other treatments".[18]

Humphreys, Blodgett, and Wagner 2014

A 2014 meta-analysis of the data from five studies by Keith Humphreys, Janet Blodgett and Todd Wagner concluded that "increasing AA attendance leads to short and long term decreases in alcohol consumption that cannot be attributed to self-selection."[6][13]

Kaskutas 2009

In 2009, Lee Ann Kaskutas performed a meta-analysis of other studies looking at how effective Alcoholics Anonymous is. The article notes that "rates of abstinence are about twice as high among those who attend AA" but concluded that whether Alcoholics Anonymous has a specific effect is unclear (a specific effect, in this context, is whether it's the actual Alcoholics Anonymous program which helps keep people sober, instead of other factors, including the fact that people more motivated to stay sober will go to more meetings, or that the group support helps alcoholics regardless of the actual program, etc.), stating that there were "2 trials finding a positive effect for AA, 1 trial finding a negative effect for AA, and 1 trial finding a null effect."[28]

Moos and Moos 2006

A 2006 study by Rudolf H. Moos and Bernice S. Moos saw a 67% success rate for the 24.9% of alcoholics who ended up, on their own, undergoing a lot of AA treatment: Of subjects highly involved with AA in their first year of alcohol treatment, 67% were sober 16 years later. The study looked at the outcome of a group of alcoholics seeking treatment over a 16-year period. The subjects decided on their own whether to use AA, and how much AA treatment they got. The study stated that "individuals who participated in AA for 27 weeks or more had better 16-year outcomes", showing that "only 34% of individuals who did not participate in AA in the first year were abstinent at 16 years, compared to 67% of individuals who participated in AA for 27 weeks or more."[5]

The study's results may be skewed by self-selection bias.[28][29]

Project MATCH (1998)
Main article: Project MATCH

Project MATCH was an 8-year, multi site, $27-million investigation that studied which types of alcoholics respond best to which forms of treatment. MATCH studied whether treatment should be uniform or assigned to patients based on specific needs and characteristics. The study concluded that twelve-step facilitation was as effective as the other psychotherapies studied.[30]

Brandsma 1980
Main article: Outpatient Treatment of Alcoholism

The 1980 book Outpatient Treatment of Alcoholism describes a mid-1970s study. Participants were assigned randomly within five treatments, including an Alcoholics Anonymous-like meeting.[31] Later analysis says that there are "concerns with the Brandsma trial which call its experimental results into question".[28]

Membership retention

In 2001–2002, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducted the National Epidemiological Survey on Alcoholism and Related Conditions (NESARC). Similarly structured to the NLAES, the survey conducted in-person interviews with 43,093 individuals. Respondents were asked if they had ever attended a twelve-step meeting for an alcohol problem in their lifetime (the question was not AA-specific). 1441 (3.4%) of respondents answered the question affirmatively. Answers were further broken down into three categories: disengaged, those who started attending at some point in the past but had ceased attending at some point in the past year (988); continued engagement, those who started attending at some point in the past and continued to attend during the past year (348); and newcomers, those who started attending during the past year (105).[32] In their discussion of the findings, Kaskautas et al. (2008) state that to study disengagement, only the disengaged and continued engagement should be utilized (pg. 270).[32]

The Sober Truth

Lance Dodes, in The Sober Truth, says that most people who have experienced AA have not achieved long-term sobriety, stating that research indicates that only five to eight percent of the people who go to one or more AA meetings achieve sobriety for longer than one year.[16] Gabrielle Glaser used Dodes' figures to state that AA has a low success rate in a 2015 article for The Atlantic, which says that better alternatives than Alcoholics Anonymous for alcohol treatment are available.[17]

The 5–8% figure put forward by Dodes is controversial;[15] Thomas Beresford, M.D., says that the book uses "three separate, questionable, calculations that arrive at the 5–8% figure."[33][34] The New York Times calls The Sober Truth a "polemical and deeply flawed book".[35] John Kelly and Gene Beresin state that the book's conclusion that "[12-step] approaches are almost completely ineffective and even harmful in treating substance use disorders" is wrong (Dodes responded by pointing out that "I have never said that AA is harmful in general"), noting that "studies published in prestigious peer-reviewed scientific journals have found that 12-step treatments that facilitate engagement with AA post-discharge [...] produce about one third higher continuous abstinence rates."[14][36] Jeffrey D. Roth and Edward J. Khantzian, in their review of The Sober Truth, called Dodes' reasoning against AA success a "pseudostatistical polemic."[37]

Lance Dodes has not, as of March 2020, read the 2020 Cochrane Review which shows AA efficacy, but in response to it says that he does not feel creating a social support network helps with addiction.[38]

See also

References
  1. Kelly, John F.; Humphreys, Keith; Ferri, Marica (2020). "Alcoholics Anonymous and other 12-step programs for alcohol use disorder (Open access summary)". Cochrane Database of Systematic Reviews. 3: CD012880. doi:10.1002/14651858.CD012880.pub2. PMID 32159228.
  2. "Frequently Asked Questions: Searching for Alcohol Treatment". NIAAA. 2018-11-29. the free and flexible support provided by mutual help groups can help people make and sustain beneficial changes and thus promote recovery
  3. https://addiction.surgeongeneral.gov/sites/default/files/chapter-5-recovery.pdf Page 5-2
  4. Recovery: The Many Paths to Wellness. US Department of Health and Human Services.
  5. Moos, Rudolf H.; Moos, BS (June 2006). "Participation in Treatment and Alcoholics Anonymous: A 16-Year Follow-Up of Initially Untreated Individuals". Journal of Clinical Psychology. 62 (6): 735–750. doi:10.1002/jclp.20259. PMC 2220012. PMID 16538654.
  6. Humphreys; Blodgett; Wagner (2014). "Estimating the efficacy of Alcoholics Anonymous without self-selection bias: an instrumental variables re-analysis of randomized clinical trials". Alcoholism: Clinical and Experimental Research. 38 (11): 2688–94. doi:10.1111/acer.12557. PMC 4285560. PMID 25421504.
  7. Walitzer; Dermen; Barrick (2009). "Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial". Addiction. 104 (3): 391–401. doi:10.1111/j.1360-0443.2008.02467.x. PMC 2802221. PMID 19207347.
  8. Litt, Kadden; Kabela-Cormier, Petry (2009). "Changing network support for drinking: network support project 2-year follow-up". J Consult Clin Psychol. 77 (2): 229–42. doi:10.1037/a0015252. PMC 2661035. PMID 19309183.
  9. Moos, Rudolf H.; Moos, BS (February 2006). "Rates and predictors of relapse after natural and treated remission from alcohol use disorders". Addiction. 101 (2): 212–222. doi:10.1111/j.1360-0443.2006.01310.x. PMC 1976118. PMID 16445550.
  10. Ståhlbrandt, Henriettæ; Johnsson, Kent O.; Berglund, Mats (2007). "Two-Year Outcome of Alcohol Interventions in Swedish University Halls of Residence: A Cluster Randomized Trial of a Brief Skills Training Program, Twelve-Step Influenced Intervention, and Controls". Alcoholism: Clinical and Experimental Research. 31 (3): 458–66. doi:10.1111/j.1530-0277.2006.00327.x. PMID 17295731.
  11. Terra, Mauro Barbosa; Barros, Helena Maria Tannhauser; Stein, Airton Tetelbom; Figueira, Ivan; Palermo, Luiz Henrique; Athayde, Luciana Dias; Gonçalves, Marcelo de Souza; Da Silveira, Dartiu Xavier (2008). "Do Alcoholics Anonymous Groups Really Work? Factors of Adherence in a Brazilian Sample of Hospitalized Alcohol Dependents". American Journal on Addictions. 17 (1): 48–53. doi:10.1080/10550490701756393. PMID 18214722.
  12. Lopez, German (2 January 2018). "Why some people swear by Alcoholics Anonymous — and others despise it". Vox. About a third of people maintain recovery from alcohol addiction due to 12-step treatment, another third get something out of the treatment but not enough for full recovery, and another third get nothing at all.
  13. Frakt, Austin (2015-04-06). "Alcoholics Anonymous and the Challenge of Evidence-Based Medicine". The New York Times. Retrieved 2015-06-21.
  14. Kelly, John F.; Beresin, Gene (7 April 2014). "In Defense of 12 Steps: What Science Really Tells Us about Addiction". WBUR's Common Health: Reform and Reality. Archived from the original on 2014-04-11. Retrieved 2018-01-05.
  15. Singal, Jesse. "Why Alcoholics Anonymous Works". The Cut. Retrieved 2017-12-25. [Lance Dodes] has estimated, as Glaser puts it, that "AA's actual success rate [is] somewhere between 5 and 8 percent," but this is a very controversial figure among addiction researchers.
  16. Lance Dodes, M.D.; Zachary Dodes (2014). The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. ISBN 978-0-8070-3315-9. University of California professor Herbert Fingarette cited two [...] statistics: at eighteen months, 25 percent of people still attended AA, and of those who did attend, 22 percent consistently maintained sobriety. [Reference: H. Fingarette, Heavy Drinking: The Myth of Alcoholism as a Disease (Berkeley: University of California Press, 1988)] Taken together, these numbers show that about 5.5 percent of all those who started with AA became sober members.
  17. Glaser, Gabrielle. "The Irrationality of Alcoholics Anonymous". The Atlantic. Retrieved 2016-04-15.
  18. Ferri, Marcia; Amato, Laura; Davoli, Marina (19 July 2006). "Alcoholics Anonymous and other twelve-step programmes for alcohol dependence". Cochrane Database of Systematic Reviews (3): CD005032. doi:10.1002/14651858.CD005032.pub2. PMID 16856072.
  19. Kelly, John F.; Humphreys, Keith; Ferri, Marica (2020). "Alcoholics Anonymous and other 12-step programs for alcohol use disorder". Cochrane Database of Systematic Reviews. 3: CD012880. doi:10.1002/14651858.CD012880.pub2. PMC 7065341. PMID 32159228.
  20. Litt, Mark; Kadden, Ronald; Kabela-Cormier, Elise; Petry, Nancy (2009). "Changing Network Support for Drinking: Network Support Project Two-Year Follow-up". J Consult Clin Psychol. 77 (2): 229–242. doi:10.1037/a0015252. PMC 2661035. PMID 19309183.
  21. Walitzer; Dermen; Barrick (2009). "Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial". Addiction. 104 (3): 391–401. doi:10.1111/j.1360-0443.2008.02467.x. PMC 2802221. PMID 19207347.
  22. Becker, Deborah. "New Review Finds Alcoholics Anonymous Is Effective, But Not For Everyone". NPR.
  23. Zemore, Sarah E; Lui, Camillia; Mericle, Amy; Hemberg, Jordana; Kaskutas, Lee Ann (2018). "A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD". Journal of Substance Abuse Treatment. 88: 18–26. doi:10.1016/j.jsat.2018.02.004. PMC 5884451. PMID 29606223. Lay summary.
  24. Frakt, Austin; Carroll, Aaron. "Alcoholics Anonymous vs. Other Approaches: The Evidence Is Now In". The New York Times.
  25. Lopez, German (11 March 2020). "A new, big review of the evidence found that Alcoholics Anonymous works — for some". Vox.
  26. "manualized therapy". American Psychological Association.
  27. "12-Step Facilitation Therapy (Alcohol, Stimulants, Opiates)". National Institute on Drug Abuse.
  28. Kaskutas, Lee Ann (2009). "Alcoholics Anonymous Effectiveness: Faith Meets Science". Journal of Addictive Diseases. 28 (2): 145–157. doi:10.1080/10550880902772464. PMC 2746426. PMID 19340677.
  29. Szalavitz, Maia (2016). Unbroken Brain: A Revolutionary New Way of Understanding Addiction. the research that does show AA to be effective is overwhelmingly flawed by what is known as selection bias.
  30. Keith Humphreys. "Here's proof that Alcoholics Anonymous is just as effective as professional psychotherapies". The Washington Post. Archived from the original on 2016-05-31. Retrieved 2018-05-29. AA skeptics were confident that by putting AA up against the best professional psychotherapies in a highly rigorous study, Project MATCH would prove beyond doubt that the 12-steps were mumbo jumbo. The skeptics were humbled: Twelve-step facilitation was as effective as the best psychotherapies professionals had developed.
  31. Brandsma, Jeffery M; Maultsby, Maxie C; Welsh, Richard J (1980). Outpatient Treatment of Alcoholism: a review and comparative study. Baltimore, MD: University Park Press. ISBN 978-0-8391-1393-5. OCLC 5219646.
  32. Kaskutas, Lee Ann; Ye, Yu; Greenfield, Thomas K.; Witbrodt, Jane; Bond, Jason (30 June 2008). Epidemiology or Alcoholics Anonymous Participation. Recent Developments in Alcoholism. 18. pp. 261–282. doi:10.1007/978-0-387-77725-2_15. ISBN 978-0-387-77724-5. PMID 19115774.
  33. Beresford, Thomas (2016), Alcoholics Anonymous and The Atlantic: A Call For Better Science, National Council on Alcoholism and Drug Dependence, archived from the original on 2019-07-15, retrieved 2019-07-16, [Herbert Fingarette used] two publications from the Rand Corporation [...] At 4-year follow-up the Rand group identified patients with at least one year abstinence who had been regular members of AA 18 months after the start of treatment: 42% of the regular AA members were abstinent, not the "calculated" 5.5% figure.
  34. Emrick, Chad; Beresford, Thomas (2016). "Contemporary Negative Assessments of Alcoholics Anonymous: A Response". Alcoholism Treatment Quarterly. 34 (4): 463–471. doi:10.1080/07347324.2016.1217713. S2CID 151393200.
  35. Friedman, Richard A. (2014-05-05). "Taking Aim at 12-Step Programs". The New York Times.
  36. Humphreys, Keith; Moos, Rudolf (May 2001). "Can encouraging substance abuse patients to participate in self-help groups reduce demand for health care? A quasi-experimental study". Alcoholism: Clinical and Experimental Research. 25 (5): 711–716. doi:10.1111/j.1530-0277.2001.tb02271.x. PMID 11371720. 12-step patients had higher rates of abstinence at follow-up (45.7% versus 36.2% for patients from CB [cognitive-behavioral] programs, p < 0.001)
  37. Roth, Jeffrey D; Khantzian, Edward J (2015). "Book Review: The Sober Truth: Debunking the Bad Science behind 12-step Programs and the Rehab Industry". Journal of the American Psychoanalytic Association. 63: 197–202. doi:10.1177/0003065114565235. S2CID 145764030.
  38. Becker, Deborah. "AA Keeps People From Drinking Alcohol Longer Than Other Tools, Cochrane Review Finds". WBUR-FM.

Further reading
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