March 16, 2020

Does Alcoholics Anonymous really work? Here's what the latest evidence says.

Daily Briefing

    Alcoholics Anonymous (AA), the no-cost, 12-step treatment program for alcohol use disorder (AUD), is as effective—and in some cases, more effective—than other evidence-based treatment programs, according to a systematic review published Wednesday by the Cochrane Collaboration.

    Cheat sheets: Evidence-based medicine 101

    Study details

    In the United States, alcohol is tied to more deaths than any other drug and represents the majority of treatment cases for substance use disorders. On top of that, alcohol leads to at least $250 billion in lost productivity and costs related to health care, crime, and incarceration annually, according to the New York Times' "The Upshot."

    For the review, the researchers updated Cochrane Collaboration's 2006 systematic review of AA's effectiveness, which had been based on eight studies. The 2006 review found that there wasn't sufficient evidence available to determine whether AA was more effective than other methods.

    Since 2006, higher-quality research—including randomized clinical trials and quasi-experiments—on AA's effectiveness has become available for the Cochrane Collaboration to update the 2006 review.

    The latest review involves 27 studies—including 21 randomized clinical trials—with a total of 10,656 participants, comparing whether AA is more effective than other interventions, such as motivational enhancement therapy (MET), cognitive behavioral therapy (CBT),or no treatment.

     The researchers focused their analysis on whether AA results in:

    • Longer periods of abstinence;
    • Lower health care costs;
    • Reductions in drinking intensity;
    • Reductions in alcohol‐related consequences; and
    • Reductions in alcohol addiction severity.

    Findings

    Overall, the researchers found AA appears to result in higher rates of sustained abstinence and when compared to other treatment programs. According to the researchers, AA may result in between 22% to 37% of participants remaining abstinent, whereas other treatment programs may result in about 15% to 25% of participants remaining abstinent.

    In addition, the researchers noted the no-cost program is likely to generate "substantial healthcare cost savings," when compared to cognitive behavioral treatments, which they found lead to twice as many outpatient care visits as AA, costing $7,000 more per year.

    However, the researchers found AA appeared as effective as other treatment programs in other categories, including rates of alcohol‐related consequences, alcohol addiction severity, and drinking intensity. As such, the researchers point out AA may not be the best option for all patients with AUD.

    Discussion

    John Kelly—a professor of psychiatry at Harvard Medical School, director of the Recovery Research Institute at Massachusetts General Hospital, and the review's lead author—said, "These results demonstrate AA's effectiveness in helping people not only initiate but sustain abstinence and remission over the long term."

    Kelly noted the positive results likely stem from the mutual support AA provides as well as the program's ubiquity—and not necessarily one of the program's unique traits. "Pure and simple, it links people to an indigenous, ubiquitous community resource. If you're treating a chronic illness, you want to link people to something that can help sustain that gain made initially in treatment, but over time."

    Kelly added that, "The fact that AA is free and so widely available is also good news. It's the closest thing in public health we have to a free lunch."

    Other experts noted the challenges of fully assessing the effectiveness of AA. For example, Austin Frakt and Aaron Carroll in the "The Upshot" wrote, "Rigorous study of programs like [AA] is challenging because people self-select into them. Those who do so may be more motivated to abstain from drinking than those who don't."

    And others caution that it's important to remember AA will not work for all patients with AUD.

    J. Scott Tonigan, a researcher at the University of New Mexico Center on Alcoholism, Substance Abuse, and Addictions, said a "rule of thirds" applies to programs like AA, which means a third of patients will recover from their AUD, a third may experience benefits but not recover, and another third will not experience any benefits. That means at least two-thirds of patients with AUD will not recover from exclusively using AA (Frakt/Carroll, "The Upshot," New York Times, 3/11; Lopez, Vox, 3/11).

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