Alcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers
A recently completed Cochrane review assessed the effectiveness and cost-benefits of Alcoholics Anonymous (AA) and clinically delivered 12-Step Facilitation (TSF) interventions for alcohol use disorder (AUD). This paper summarizes key findings and discusses implications for practice and policy.
Cochrane review methods were followed. Searches were conducted across all major databases (e.g. Cochrane Drugs and Alcohol Group Specialized Register, PubMed, Embase, PsycINFO and ClinicalTrials.gov) from inception to August 2, 2019 and included non-English language studies.
Randomized controlled trials (RCTs) and quasi-experiments that compared AA/TSF with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants or no treatment, were included. Healthcare cost offset studies were also included.
Studies were categorized by
- design (RCT/quasi-experimental; nonrandomized; economic),
- degree of 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).
Random-effects meta-analyses were used to pool effects where possible using standard mean differences (SMD) for continuous outcomes (e.g. percent days abstinent (PDA)) and the relative risk ratios (RRs) for dichotomous.
A total of 27 studies (21 RCTs/quasi-experiments, 5 nonrandomized and 1 purely economic study) containing 10,565 participants were included.
AA/TSF interventions performed at least as well as established active comparison treatments (e.g. CBT) on all outcomes except for abstinence where it often outperformed other treatments. AA/TSF also demonstrated higher health care cost savings than other AUD treatments.
AA/TSF interventions produce similar benefits to other treatments on all alcohol consumption-related outcomes except for continuous abstinence and remission, where AA/TSF is superior.
AA/TSF also reduces healthcare costs.
Clinically implementing one of these proven manualized AA/TSF interventions is likely to enhance outcomes for individuals with AUD while producing health economic benefits.
Implication for practice
The evidence suggests that compared to other well-established treatments, clinical linkage using well-articulated TSF manualized interventions intended to increase AA participation during and following AUD treatment can lead to enhanced abstinence outcomes over the next months and years. Findings also indicate that AA/TSF may perform as well as other clinical interventions for alcohol use intensity outcomes.
Economic analyses suggest that substantial healthcare cost savings can be obtained when treatment programs proactively and systematically link people with AUD to AA using TSF strategies, such as those used in the studies included in this review. Analyses indicate that the reason for this benefit is due to the ability of the AA/TSF to increase AA participation and thereby increase abstinence rates.
Thus, a relatively brief clinical intervention (AA/TSF) can help people with AUD to become engaged in a long-term, freely available, community-based, recovery support resource that can help sustain ongoing remission.
If people with AUD are opposed to attending AA, despite the strong evidence for its potential to aid recovery, clinicians might consider linkage to alternative mutual-help organizations as they may confer benefits at similar levels of engagement.
It is plausible, for example that other AUD recovery-supportive, mutual-help organizations, such as Self-Management and Recovery Training (SMART), LifeRing, and Women for Sobriety, may confer similar benefits. Although these organizations may espouse different theoretical orientations and variations in their approaches to help people attain and maintain recovery from AUD, there may be more similarity than differences in the therapeutic dynamics operating within these groups.
More research is needed to support this conjecture, but such preliminary results are promising from a public health and long-term recovery management perspective because AUD tends to be highly heterogeneous in its clinical course and impact, and those suffering can often have different preferences as to the kinds of recovery pathways they wish to follow.
Another critical clinical implication of the review is the large range of populations in which AA’s benefit has been demonstrated – young and old, racial and ethnic minorities, women and men, religious and nonreligious, people in different settings and indeed different nations. There is no case for concluding on the basis of a patients’ demographic characteristics that they should not give AA a try.
The results also indicate that clinicians who have prejudged AA should give it another look. A study of NHS workers found that clinicians were highly confident they understand what happens at AA meetings but had never actually visited one. To the extent that such attitudes emerge from a perception that AA is ineffective, the researchers hope the Cochrane Review will prompt a re-evaluation and in turn a greater willingness to help AUD patients test out this remarkable fellowship for themselves.