Alcoholics Anonymous is most effective path to alcohol abstinence

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After evaluating 35 studies – involving the work of 145 scientists and the outcomes of 10,080 participants – Dr Keith Humphreys, Cochrane professor of psychiatry and behavioural sciences, and his fellow investigators determined that Alcoholics Anonymous (AA) was nearly always found to be more effective than psychotherapy in achieving abstinence. In addition, most studies showed that AA participation lowered health care costs.

AA works because it's based on social interaction, Humphreys said, noting that members give one another emotional support as well as practical tips to refrain from drinking. "If you want to change your behaviour, find some other people who are trying to make the same change," he said.

Cochrane requires its authors to undertake a rigorous process that ensures the studies represented in its summaries are high-quality and the review of evidence is unbiased. "Cochrane Reviews are the gold standard in medicine for integration of all the research about a particular intervention," Humphreys said. "We wanted to do this work through Cochrane because of its rigor and reputation."

The other co-authors are a researcher from Harvard Medical School and a researcher from the European Monitoring Centre for Drugs and Drug Addiction.

Although AA is well-known and used by millions around the world, mental health professionals are sometimes sceptical of its effectiveness, Humphreys said. Psychologists and psychiatrists, trained to provide cognitive behavioural therapy and motivational enhancement therapy to treat patients with alcohol-use disorder, can have a hard time admitting that the lay people who run AA groups do a better job of keeping people on the wagon.

Early in his career, Humphreys said, he dismissed AA, thinking, "How dare these people do things that I have all these degrees to do?" Humphreys noted that counselling can be designed to facilitate engagement with AA – what he described as "an extended, warm handoff into the fellowship." For the review article, Humphreys and his colleagues evaluated both AA and 12-step facilitation counselling.

AA began in 1935 when two men in Akron, Ohio, were searching for a way to stay sober; they found it by forming a support group. They later developed the 12 steps, the first being accepting one's inability to control drinking; the last, helping others sustain sobriety by becoming a sponsor of a new member. The AA model – open to all and free – has spread around the globe, and now boasts over 2m members in 180 nations and more than 118,000 groups.

Though the fellowship has been around for more than eight decades, researchers have only recently developed good methods to randomise trial participants and measure its effectiveness, Humphreys said.

For the Cochrane review, the researchers found 57 studies on AA; of those, 35 passed their rigorous criteria for quality. The studies used various methods to measure AA's effectiveness on alcohol use disorder: the length of time participants abstained from alcohol; the amount they reduced their drinking, if they continued drinking; the consequences of their drinking; and health care costs.

Most of the studies that measured abstinence found AA was significantly better than other interventions or no intervention. In one study, it was found to be 60% more effective. None of the studies found AA to be less effective.

In the studies that measured outcomes other than complete abstinence, AA was found to be at least as effective. For the studies that considered costs, most showed significant savings associated with AA participation: One found that AA and 12-step facilitation counselling reduced mental health costs by $10,000 per person.

The researchers looked only at studies of AA; they excluded Narcotics Anonymous and organisations focused on addiction to other substances. While it was beyond the scope of their study, Humphreys said the AA review is "certainly suggestive that these methods work for people who use heroin or cocaine."

Humphreys noted that the findings were consistent whether the study participants were young, elderly, male, female, veterans or civilians; the studies in the review were also conducted in five different countries. "It absolutely does work," he said of AA's method. He added that he feels validated in giving advice to so many patients to try AA: "That was really good advice, and that continues to be good advice," he said.

Background: Alcohol use disorder (AUD) confers a prodigious burden of disease, disability, premature mortality, and high economic costs from lost productivity, accidents, violence, incarceration, and increased healthcare utilization. For over 80 years, Alcoholics Anonymous (AA) has been a widespread AUD recovery organization, with millions of members and treatment free at the point of access, but it is only recently that rigorous research on its effectiveness has been conducted.
Objectives: To evaluate whether peer‐led AA and professionally‐delivered treatments that facilitate AA involvement (Twelve‐Step Facilitation (TSF) interventions) achieve important outcomes, specifically: abstinence, reduced drinking intensity, reduced alcohol‐related consequences, alcohol addiction severity, and healthcare cost offsets.

Search methods: We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, CINAHL and PsycINFO from inception to 2 August 2019. We searched for ongoing and unpublished studies via and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 15 November 2018. All searches included non‐English language literature. We hand-searched references of topic‐related systematic reviews and bibliographies of included studies.
Selection criteria: We included randomized controlled trials (RCTs), quasi‐RCTs and non‐randomized studies that compared AA or TSF (AA/TSF) with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants, or no treatment. We also included healthcare cost offset studies. Participants were non‐coerced adults with AUD.

Data collection and analysis: We categorized studies by: study design (RCT/quasi‐RCT; non‐randomized; economic); degree of standardized manualization (all interventions manualized versus some/none); and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). For analyses, we followed Cochrane methodology calculating the standard mean difference (SMD) for continuous variables (e.g. percent days abstinent (PDA)) or the relative risk (risk ratios (RRs)) for dichotomous variables. We conducted random‐effects meta‐analyses to pool effects wherever possible.
Main results: We included 27 studies containing 10,565 participants (21 RCTs/quasi‐RCTs, 5 non‐randomized, and 1 purely economic study). The average age of participants within studies ranged from 34.2 to 51.0 years. AA/TSF was compared with psychological clinical interventions, such as MET and CBT, and other 12‐step program variants.

We rated selection bias as being at high risk in 11 of the 27 included studies, unclear in three, and as low risk in 13. We rated risk of attrition bias as high risk in nine studies, unclear in 14, and low in four, due to moderate (> 20%) attrition rates in the study overall (8 studies), or in study treatment group (1 study). Risk of bias due to inadequate researcher blinding was high in one study, unclear in 22, and low in four. Risks of bias arising from the remaining domains were predominantly low or unclear.
AA/TSF (manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi‐randomized evidence)
RCTs comparing manualized AA/TSF to other clinical interventions (e.g. CBT), showed AA/TSF improves rates of continuous abstinence at 12 months (risk ratio (RR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 2 studies, 1936 participants; high‐certainty evidence). This effect remained consistent at both 24 and 36 months.

For percentage days abstinent (PDA), AA/TSF appears to perform as well as other clinical interventions at 12 months (mean difference (MD) 3.03, 95% CI ‐4.36 to 10.43; 4 studies, 1999 participants; very low‐certainty evidence), and better at 24 months (MD 12.91, 95% CI 7.55 to 18.29; 2 studies, 302 participants; very low‐certainty evidence) and 36 months (MD 6.64, 95% CI 1.54 to 11.75; 1 study, 806 participants; very low‐certainty evidence).
For longest period of abstinence (LPA), AA/TSF may perform as well as comparison interventions at six months (MD 0.60, 95% CI ‐0.30 to 1.50; 2 studies, 136 participants; low‐certainty evidence).
For drinking intensity, AA/TSF may perform as well as other clinical interventions at 12 months, as measured by drinks per drinking day (DDD) (MD ‐0.17, 95% CI ‐1.11 to 0.77; 1 study, 1516 participants; moderate‐certainty evidence) and percentage days heavy drinking (PDHD) (MD ‐5.51, 95% CI ‐14.15 to 3.13; 1 study, 91 participants; low‐certainty evidence).
For alcohol‐related consequences, AA/TSF probably performs as well as other clinical interventions at 12 months (MD ‐2.88, 95% CI ‐6.81 to 1.04; 3 studies, 1762 participants; moderate‐certainty evidence).

For alcohol addiction severity, one study found evidence of a difference in favor of AA/TSF at 12 months (P < 0.05; low‐certainty evidence).
AA/TSF (non‐manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi‐randomized evidence)
For the proportion of participants completely abstinent, non‐manualized AA/TSF may perform as well as other clinical interventions at three to nine months follow‐up (RR 1.71, 95% CI 0.70 to 4.18; 1 study, 93 participants; low‐certainty evidence).
Non‐manualized AA/TSF may also perform slightly better than other clinical interventions for PDA (MD 3.00, 95% CI 0.31 to 5.69; 1 study, 93 participants; low‐certainty evidence).

For drinking intensity, AA/TSF may perform as well as other clinical interventions at nine months, as measured by DDD (MD ‐1.76, 95% CI ‐2.23 to ‐1.29; 1 study, 93 participants; very low‐certainty evidence) and PDHD (MD 2.09, 95% CI ‐1.24 to 5.42; 1 study, 286 participants; low‐certainty evidence).
None of the RCTs comparing non‐manualized AA/TSF to other clinical interventions assessed LPA, alcohol‐related consequences, or alcohol addiction severity.
Cost‐effectiveness studies

In three studies, AA/TSF had higher healthcare cost savings than outpatient treatment, CBT, and no AA/TSF treatment. The fourth study found that total medical care costs decreased for participants attending CBT, MET, and AA/TSF treatment, but that among participants with worse prognostic characteristics AA/TSF had higher potential cost savings than MET (moderate‐certainty evidence).
Authors' conclusions: There is high quality evidence that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non‐manualized AA/TSF may perform as well as these other established treatments. AA/TSF interventions, both manualized and non‐manualized, may be at least as effective as other treatments for other alcohol‐related outcomes. AA/TSF probably produces substantial healthcare cost savings among people with alcohol use disorder.

John F Kelly, Keith Humphreys, Marica Ferri

Stanford Medicine material

Cochrane Database of Systemic Reviews abstract

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