How Alcoholics Anonymous stacks up against other approaches

Worldwide, alcohol misuse and dependence are responsible for 3.3 million deaths per year, 10 times the number of fatalities from all illicit drugs combined. Photo / Tony Cenicola, The New York Times

For a long time, medical researchers were unsure whether Alcoholics Anonymous worked better than other approaches to treating people with alcohol use disorder. In 2006, a review of the evidence concluded we didn't have enough evidence to judge.

That has changed.

An updated systematic review published by the Cochrane Collaboration found that AA leads to increased rates and lengths of abstinence compared with other common treatments. On other measures, like drinks per day, it performs as well as approaches provided by individual therapists or doctors who don't rely on AA's peer connections.

What changed? In short, the latest review incorporates more and better evidence. The research is based on an analysis of 27 studies involving 10,565 participants.

The 2006 Cochrane Collaboration review was based on just eight studies and ended with a call for more research to assess the program's efficacy. In the intervening years, researchers answered the call. The newer review also applied standards that weeded out some weaker studies that drove earlier findings.

In the last decade or so, researchers have published a number of very high-quality randomised trials and quasi-experiments. Of the 27 studies in the new review, 21 have randomised designs. Together, these flip the conclusion.

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

Studies generally show that other treatments might result in about 15 per cent to 25 per cent of people who remain abstinent. With AA, it's somewhere between 22 per cent and 37 per cent (specific findings vary by study). Although AA may be better for many people, other approaches can work, too. And, as with any treatment, it doesn't work perfectly all the time.

Rigorous study of programs like Alcoholics Anonymous 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.

Unless a study is carefully designed, its results can be driven by who participates, not by what the program does. Even randomised trials can succumb to bias from self-selection if people assigned to AA don't attend and if people assigned to the control group do. (It may go without saying, but we'll say it: It would be unethical to prevent people in a control group from attending Alcoholics Anonymous if they wanted to.)

Despite these challenges, some high-quality randomised trials of Alcoholics Anonymous have been conducted in recent years. One, published in the journal Addiction, found that those who were randomly assigned to a 12-step-based directive AA approach, and were supported in their participation, attended more meetings and exhibited a greater degree of abstinence, compared with those in the other treatment groups. Likewise, other randomised studies found that greater Alcoholics Anonymous participation is associated with greater alcohol abstinence.

Alcoholics Anonymous is often paired with other kinds of treatment that encourage engagement with it. "For people already in treatment, if they add AA to it, their outcomes are superior than those who just get treatment without AA," said Keith Humphreys, a Stanford University professor and co-author of the new Cochrane review.

Alcoholics Anonymous not only produced higher rates of abstinence and remission, but it also did so at a lower cost, the Cochrane review found. AA meetings are free to attend. Other treatments, especially those that use the health care system, are more expensive.

One study found that compared with Alcoholics Anonymous participants, those who received cognitive behavioural treatments had about twice as many outpatient visits — as well as more inpatient care — that cost just over $7,000 per year more in 2018 dollars. (Cognitive behavioural treatments help people analyse, understand and modify their drinking behaviour and its context.)

Another study found that for each additional AA meeting attended, health care costs fell by almost 5 per cent, mostly a result of fewer days spent in the hospital and fewer psychiatric visits.

AA meetings are ubiquitous and frequent, with no appointment needed; you just show up. The bonds formed from the shared challenge of addiction — building trust and confidence in a group setting — may be a key ingredient to help people stay on the road to recovery.

Worldwide, alcohol misuse and dependence are responsible for 3.3 million deaths per year, 10 times the number of fatalities from all illicit drugs combined.

In the United States, alcohol is a larger killer than other drugs; accounts for the majority of all addiction treatment cases; and is responsible for at least $250 billion per year in lost productivity and costs related to crime, incarceration and health care. Moreover, American deaths related to alcohol more than doubled between 1999 and 2017.

Reducing the human and financial burdens of alcohol is an often overlooked public health priority, and the new evidence suggests that on balance one of the oldest solutions — Alcoholics Anonymous has been around almost 85 years — is still the better one.

Written by: Austin Frakt and Aaron E. Carroll
Photographs by: Tony Cenicola
© 2020 THE NEW YORK TIMES