Evidence-Based Reviews

Does AA work? That’s (in part) up to you

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Clinician support improves Alcoholics Anonymous’ success rate.


 

References

Many clinicians refer alcohol-dependent patients to Alcoholics Anonymous, but how effective is AA in reducing drinking? Evidence is elusive—partly because of AA’s tradition of anonymity—but clinician encouragement is among three variables that appear essential to successful AA use.

The pioneer of twelve-step programs (Box 1),1,2 AA is a widely accessible, free adjunct to professional alcohol abuse treatment. This article describes the evidence supporting AA’s efficacy for reducing drinking among persons with alcohol use disorders. We also recommend referral strategies that increase AA participation and discuss special needs of alcohol-dependent patients with comorbid psychiatric disorders.

Box 1

AA: Mutual help for alcohol abstinence

Alcoholics Anonymous (AA) was founded in 1935 in Akron, OH, by Bill Wilson and Robert Smith, MD, two professionals struggling with alcohol dependence. They joined together to help each other stop drinking.

Their success inspired them to help others, and this mutual-aid society grew under the name Alcoholics Anonymous. AA redefined the then-prevalent view of alcohol dependence as a moral failing, instead conceptualizing it as a disease that can be arrested—but not cured—by alcohol abstinence. The only requirements for AA membership are “a desire to stop drinking,” a respect for maintaining anonymity, and a desire to join a fellowship of mutual support for the goal of abstaining from alcohol.

In 1939, Wilson described AA’s theory and fellowship methods and defined its twelve steps of personal recovery,1 referred to in AA as “The Big Book.” Today, the worldwide fellowship has more than 2 million members, with a male:female ratio of 2:1.2

KEYS TO AA SUCCESS

Besides clinician encouragement, two patient variables—severity of alcohol dependence and self-efficacy—have been associated with successful AA use.

Clinician encouragement. When psychiatrists and other clinicians encourage alcohol-dependent patients to attend AA, the rate of AA use increases and drinking decreases.3-7 When clinicians remain interested in alcohol-dependent patients’ AA use—rather than simply recommending AA—patients are more likely to follow through with a referral and to participate long enough to obtain benefit.

Clinicians play an important role in helping patients benefit from AA referral (Box 2).6 Patients who are personally helped to an AA group will rapidly attend, whereas those only given referral information are unlikely to follow up.7 Moreover, clinicians who encourage patients to attend AA and follow up on that attendance have more patients who attend and participate in AA than do less proactive clinicians.8

Box 2

How to help patients benefit from AA

Disseminate information about alcohol dependence self-help groups such as AA

Become knowledgeable about local AA options to facilitate referral and cooperation

Invite AA groups to use your institutional or clinic space to hold groups and meetings

Offer appropriate self-help referrals to family members, such as Al-Anon and Al-Ateen family groups

Try to match patient preferences with local AA groups, such as women’s AA, and young people’s AA meetings

Use AA as an adjunct to professional care, rather than stand-alone treatment

Learn about alternatives to 12-step treatments—such as SMART Recovery (a CBT-based treatment), Secular Organization for Sobriety, or Women for Sobriety—for patients who prefer other self-help options

Source: Adapted from Workgroup on Substance Abuse Self-Help Organizations’ expert consensus statement, reference 6.

Dependence severity. The more severe a patient’s alcohol dependence, the more likely he or she will attend and participate in AA.4,5,9,10 This finding suggests that persons most severely impaired by alcohol dependence are most likely to accept that they need help.

Self-efficacy. Believing that one can abstain from drinking is associated with being able to reduce one’s drinking. Alcohol-dependent patients with self-efficacy are more likely to use AA, and this trait is believed to be a component of the change process associated with reduced drinking.11,12

HOW EFFECTIVE IS AA?

Randomized, controlled trials (RCTs) may be the “gold standard” for determining any treatment’s efficacy, but constructing an RCT of AA use is complicated. AA does not engage in or support research, which makes AA use difficult to administer as a controlled variable in clinical trials. Also, the variability of AA groups and environments confounds the interpretation of study results and limits their application to populations at large.13

Even so, AA can be effective as an adjunct to professional treatments—such as detoxification—and as aftercare to maintain reduced drinking:

  • Kelly’s14 comprehensive review and critical analysis of the main studies through 2003 showed a correlation between professional treatment plus AA attendance and improved outcomes.
  • Project MATCH-—a large RCT—also supports AA’s benefits, as reported in smaller, less rigorously controlled studies.4,5
Three meta-analyses—using statistical analyses to pool and integrate data from smaller individual studies of AA use—arrived at somewhat different conclusions:
  • Kownacki and Shadish15 found poorer 12-month drinking outcomes with AA alone, compared with other treatments or no treatment. Their review assessed attendance as a predictor of alcohol use outcomes, and most subjects were attending AA under court orders. Because AA’s philosophy stresses that members must desire to stop drinking (Table 1), these study results may not apply to the voluntary, motivated individuals who usually use AA.
  • Two other meta-analyses9,10 that included nonrandomized studies and RCTs showed that attending AA has modest, favorable effects in reducing drinking and improving psychosocial functioning.

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