• What is known about the effectiveness of AA?

    I know people who have benefited from Alcoholics Anonymous (AA). But I can’t cite that as evidence of its effectiveness in a paper, not if I want that paper published anyway. So, I’m compelled to do the scholarly thing–which is what I want to do anyway–and examine the results of actual studies. You know, go to the evidence.

    That’s what I did, by reading the Cochrane Database of Systematic Reviews paper on the topic (Ferri, Amato, Davoli 2009). The authors considered eight randomized controlled trials meeting their inclusion criteria and that compared AA and other twelve-step facilitation (TSF) programs to other psychological treatments. Seven trials were based in the U.S., one in Canada. The trials lasted from 15 weeks to three years. The table below summarizes the treatments examined by the studies.

    Here are the findings:

    AA may help patients to accept treatment and keep patients in treatment more than alternative treatments, though the evidence for this is from one small study that combined AA with other interventions and should not be regarded as conclusive. Other studies reported similar retention rates regardless of treatment group. Three studies compared AA combined with other interventions against other treatments and found few differences in the amount of drinks and percentage of drinking days. Severity of addiction and drinking consequence did not seem to be differentially influenced by TSF versus comparison treatment interventions, and no conclusive differences in treatment drop out rates were reported. Included studies did not allow a conclusive assessment of the effect of TSF in promoting complete abstinence.

    No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems.

    If you were hoping for AA and TSF programs to be shown to be tremendously effective, these result might seem disappointing. But what they’re really saying is that, based on studies examined, AA and TSF are no more effective than other treatments to which they were compared. So, a full interpretation depends on the nature of the comparison treatments. These included cognitive-behavioral therapy and motivational enhancement therapy, relapse prevention, educational interventions, “minimal treatment” (I don’t know if that has a technical definition).

    At this point, I do not know enough about the other treatment types to judge whether it is promising or disappointing that AA and TSF are about as effective. Maybe that’s good. Maybe not. Maybe some therapies are easier or cheaper to implement. Maybe AA/TSF are the easiest/cheapest. I’ll keep reading and let you know. (Or you tell me, if you know.)

    References

    Brown 2002

    Brown TG, Seraganian P, Tremblay J, Annis H. Matching substance abuse aftercare treatments to client characteristics. Addictive Behaviors 2002;27:585–604.

    Brown TG, Seraganian P, Tremblay J, Annis H. Process and outcome changes with relapse prevention versus 12-Step aftercare programs for substance abusers. Addiction 2002;97:677–89.

    Cloud 2004

    Cloud RN, Ziegler CH, Blondell RD. What is Alcoholics Anonymous affiliation?. Substance Use & Misuse 2004;39(7): 1117–36.

    Davis 2002

    Davis WT, Campbell L, Tax J, Lieber CS. A trial of “standard” outpatient alcoholism treatment vs. a minimal treatment control. Journal of Substance Abuse Treatment 2002;23(1):9–19.

    Kahler 2004

    Kahler CW, Read JP, Ramsey SE, Stuart GL, McCrady BS, Brown RA. Motivational enhancement for 12-step involvement among patients undergoing alcohol detoxification. Journal of Consulting and Clinical Psychology 2004;72(4):736–41.

    MATCH 1998

    Cutler RB, Fishbain DA. Are alcoholism treatments effective? The Project MATCH data. BMC Public Health 2005; Vol. 5, issue 1: 75.

    Project MATCH research group. Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol 1997;58:7–29.

    Project MATCH research group. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism: Clinical & Experimental Research 1998;22: 1300–11.

    Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: treatment main effects and matching effects on drinking during treatment. Journal of Studies on Alcohol 1998;59:631–9.

    McCrady 1996

    McCrady BS, Epstein EE, Hirsch LS. Issues in the implementation of a randomised clinical trial that includes Alcoholics Anonymous: studying AA-related behavior during treatment. Journal of Studies on Alcohol 1996;57(6):604–12.

    McCrady BS, Epstein EE, Kahler CW. Alcoholics anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes. Journal of Consulting and Clinical Psychology 2004;72(5):870–8.

    Walsh 1991

    Walsh DC, Hingson RW, Merrigan DM, Levenson SM, Cupples LA, Heeren T, et al.A randomised trial of treatment options for alcohol-abusing workers. The New England Journal of Medicine 1991;325(11):775–82.

    Zemore 2004

    Zemore SE, Kaskutas LA. Helping, spirituality and alcoholics anonymous in recovery. Journal of Studies on Alcohol 2004;65(3): 383–91. ∗ Zemore SE, Kaskutas LA, Ammon LN. In 12-step groups,

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    • Have you contacted AA’s General Service Office? They survey the membership every few years, which may offer some useful information.

      Apologies if this comment comes through twice … I had some trouble with the procedure.

    • The Cochrane review was conducted in 2006, not in 2009 as this post says. The implications of this are large, as multiple strong randomized clinical trials have been published since which establish the effectiveness of Alcoholics Anonymous, Narcotics Anonymous and 12-step facilitation.
      This post and the comments (especially by Dr. John Kelly of Harvard University) present the evidence in more detail
      http://www.samefacts.com/2010/08/drug-policy/science-supports-the-12-steps-for-addiction/

      • @Keith – Yes, I wasn’t sure how to cite it. My copy is copyrighted 2009, says it was edited with no change to conclusions in that year, but also says the content was assessed as up-to-date in 2006.

        Is there a more up-to-date review? Feel free to send links to specific articles. As best I can tell, one that you reference in the post you linked to is from 2002. I couldn’t find the other one. Or, to be precise, what I found didn’t seem exactly on point, but I was stumbling in the dark.

    • Hello Austin,

      The review is confusing date wise because the PubMed abstract for the Cochrane review in the journal Addiction says 2008, but what this publication was but not a review but a comment by a researcher noting serious scholarly errors in Cochrane review, including the counting of papers that should not have been counted (The Cochrane team published a rebuttal in the same issue).

      Here is a link to one good trial of which there are several now published in the years since 2006 (if Cochrane was revised and missed all of them, that is truly sloppy on their part). This one is of AA and Narcotics Anonymous combined
      http://www.chce.research.va.gov/docs/pdfs/pi_publications/Timko/2007_Timko_intensive_referral_to_12-step_self-help_groups_One-year_outcomes.pdf

      • @Keith – Thanks for the link to that paper. I’ll read it. It seems the best way to get up to speed on a topic these days is to read a credible (though not necessarily complete) review of the literature, post something about it on one’s blog, and then see what the real experts think. 🙂

        Seriously, you and others are making me far more informed far more quickly than I’d be otherwise. I’m grateful!

    • “At this point, I do not know enough about the other treatment types to judge whether it is promising or disappointing that AA and TSF are about as effective. Maybe that’s good. Maybe not. Maybe some therapies are easier or cheaper to implement. Maybe AA/TSF are the easiest/cheapest. I’ll keep reading and let you know. (Or you tell me, if you know.)”

      Based on my admittedly non-methodical reading on the subject (I am an AA member myself), the impression I have is that AA has a somewhat, but not dramatically, higher recovery rate than other treatments, and that those treatments have somewhat, but not dramatically, higher recovery rates than no treatment at all. Overall, recovery rates for alcohol dependence are not very encouraging, but AA and other treatments do give a slight improvement.

      As AA has no fees and is supported entirely by voluntary contributions (typically $1-$2 a meeting, with members attending anywhere from 1-2 meetings a week to a meeting every day), it’s pretty cost effective.