AA Superior to CBT for Alcohol Addiction

A new Cochrane review shows Alcoholics Anonymous (AA) and related Twelve-Step Facilitation (TSF) programs are superior to other treatment approaches, including cognitive behavioral therapy (CBT), in achieving long-term abstinence in alcohol use disorder (AUD).

Investigators analyzed 27 studies comprising more than 10,000 individuals. These studies compared AA and TSF interventions to other evidence-based modalities including CBT and motivation enhancement therapy (MET) and found "high-certainty evidence" that participation in AA/TSF leads to higher rates of continuous abstinence up to 3 years post-treatment compared with the other approaches.

Moreover, AA/TSF substantially reduced healthcare costs and performed as well, or slightly better, in other outcomes, such as intensity of alcohol use, alcohol-related consequences, and addiction severity.

"High-certainty clinical research evidence now clarifies that AA is a viable recovery option," John Kelly, PhD, Elizabeth R. Spallin professor of psychiatry in addiction medicine, Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

"Implementing well-articulated TSF clinical strategies can help clinicians and treatment programs boost remission rates and lower healthcare costs," said Kelly, who is also director of the Recovery Research Institute, Massachusetts General Hospital, Boston.

The review was published online March 11 in the Cochrane Database of Systematic Reviews.

A Leading Cause of Preventable Death

"AUD is one of the leading causes of disease, disability, and preventable death worldwide, and AA is a widespread international recovery support organization designed to address it," Kelly said.

"While AA has remained popular and influential for many decades, until recently, the quantity and quality of the research on AA and clinical treatments designed to stimulate AA involvement — TSF treatments — have not been evaluated rigorously," he added.

This systematic review and meta-analysis used the rigor of the Cochrane review system to subject AA/TSF to the same scientific standards as other clinical interventions, said Kelly.

The investigators identified 27 studies (10,565 participants) that met the inclusion criteria. Of these, 21 were randomized controlled trials (RCTs) or quasi-RCTs, five were nonrandomized trials, and one was a purely economic study.

Both manualized and nonmanualized AA/TSF were included in the analysis and compared with other psychological clinical interventions (eg, MET and CBT) and other 12-step variants (eg, studies that compared different styles and intensities of 12-step interventions).

The primary outcomes included:

Abstinence (17 studies)
Longest period of abstinence (LPA) (two studies)
Percentage of days abstinent (PDA) (16 studies)
Drinking intensity (ie, drinks consumed per drinking day) (16 studies)
Percentage days of heavy drinking (PDHD) (four studies); alcohol-related consequences (eight studies)
Alcohol addiction severity (seven studies)

Secondary outcomes focused on economic analyses investigating whether AA/TSF reduced healthcare costs relative to other treatments.

Worse Prognosis, Higher Savings

In RCTs/quasi-RCTs across the board, AA/TSF interventions showed superior improvement — or at least similar performance — in primary outcomes compared with the other studied treatments.

In particular, manualized AA/TSF showed superior rates of continuous abstinence at 12 months (risk ratio [RR], 1.21; 95% CI, 1.03 - 1.42]; two studies, high-certainty evidence), with benefits remaining consistent at 24 and 36 months.

For PDA, AA/TSF performed as well as other interventions at 12 months (four studies), although with "very low-certainty evidence." On the other hand, it was superior to other interventions at 24 and 36 months (two studies and one study respectively, both "low-certainty evidence").

For LPA, drinking intensity, and PDHD, AA/TSF "may perform as well" as the comparison interventions at 6 months; it may also perform as well at 12 months for drinking intensity and alcohol-related consequences (moderate-certainty evidence).

Nonmanualized AA/TSF "may perform as well as other clinical interventions" in achieving complete abstinence at 3 to 9 months of follow-up (RR, 1.71; 95% CI, 0.70 - 4.18; one study, low-certainty evidence); and at 9 months it may perform "as well as other clinical interventions" in improving drinking intensity (one study, very low-certainty evidence) and PDHD (one study, low-certainty evidence).

Three studies found AA/TSF to yield higher healthcare cost savings compared with outpatient treatment, CBT, and no AA/TSF treatment.

A fourth study showed that total medical care costs decreased for participants attending CBT, MET, and AA/TSF treatment — although participants with worse prognostic characteristics had higher potential cost savings when using AA/TSF versus MET (moderate-certainty evidence).

Camaraderie, Accountability, Reduced Stigma

"There has been a great deal of research also on how exactly AA/TSF confers these benefits over time," Kelly commented.

"We have found that TSF clinical treatment produces these positive benefits by its ability to increase AA engagement during and, importantly, following professional treatment," he continued.

He enumerated several reasons for AA's success rates in achieving and/or maintaining sobriety.

"The camaraderie inherent in AA and the lived experience of active addiction and recovery" can reduce "stigma effects — feelings of shame and guilt," he said.

Moreover, Kelly added, "the supervision and accountability that an AA sponsor (mentor) can provide has been shown to be very helpful in maintaining sobriety."

"Rigorous studies" have demonstrated AA reduces relapse risk by "helping individuals change their social networks" and "engage in a lifestyle more suited to continuous sobriety."

The spiritual aspects of AA may help some people to "reframe and reinterpret stress so that it has some purpose to it — such as being a spur to personal growth...and thereby reduce relapse risk," he added.

Powerful Adjunct

Commenting on the review for Medscape Medical News, Laurence M. Westreich, MD, associate professor of clinical psychiatry, Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine, said the take-home message is that "AA can be a powerful adjunct for those trying to stop addictive behaviors."

Westreich, who was not involved with the research, said he uses components of CBT in clinical work because "CBT ideas, like identifying distortions in thinking and understanding emotional responses, are excellent ways for the person with a substance use disorder to move toward sobriety."

However, the "social support and 12-step ideas ingrained in AA are also very helpful to many sufferers."

Westreich, who is also past president of the American Academy of Addiction Psychiatry (AAAP) and was not involved with the review, noted that individuals "who are most successful in addressing an addiction choose the most productive idea from professional therapies and peer-led support groups like AA in bolstering their recovery."

Sense of Optimism

Also commenting on the review for Medscape Medical News, Carol J. Weiss, MD, clinical associate professor of psychiatry, Weill Cornell Medical College/NewYork-Presbyterian Hospital, said that AA has "many valuable components."

"It's universally available any time of day, any day of the week, and it's free. Additionally, group [therapy] is usually a more effective modality than individual therapy in addictive disorders," added Weiss, who is also chair of the Scientific Program Committee at AAAP and was not involved with the study.

Moreover, "AA provides a sense of optimism that is a wonderful antidote to the demoralization of having an addictive disorder."

In her clinical practice, Weiss uses AA and other 12-step programs as well as CBT and other treatment modalities.

"Addiction is a complex, multifaceted illness, so the treatment approach also has to be multifaceted, and use of modalities must be selective — you determine what is most compatible and what would work best with that individual, which is why you need the full array of tools in your toolkit," Weiss said.

Kelly added that more research is needed on "similar types of entities that can support remission over the long term."

Support for this study was provided by the Recovery Research Institute, Center for Addiction Medicine, Massachusetts General Hospital, and Harvard Medical School. Support was also provided to Kelly by the Elizabeth R. Spallin Professorship in the Field of Addiction Medicine at Harvard Medical School and the National Institute on Alcohol Abuse and Alcoholism. Kelly has received funding from the US National Institutes of Health and US Veterans Health Administration to conduct research into alcohol use disorders, comorbidities, treatment response, and mechanisms of behavior change in AA and Self-Management and Recovery Training (SMART). Disclosures for the other authors are listed in the article. Westreich and Weiss have reported no relevant financial relationships.

Cochrane Database Syst Rev. Published online March 11, 2020. Abstract

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