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Meta-Analysis
. 2020 Mar 11;3(3):CD012880.
doi: 10.1002/14651858.CD012880.pub2.

Alcoholics Anonymous and other 12-step programs for alcohol use disorder

John F Kelly  1 , Keith Humphreys  2 , Marica Ferri  3
Affiliations
Meta-Analysis

Alcoholics Anonymous and other 12-step programs for alcohol use disorder

John F Kelly et al. Cochrane Database Syst Rev. .

Abstract

Background: Alcohol use disorder (AUD) confers a prodigious burden of disease, disability, premature mortality, and high economic costs from lost productivity, accidents, violence, incarceration, and increased healthcare utilization. For over 80 years, Alcoholics Anonymous (AA) has been a widespread AUD recovery organization, with millions of members and treatment free at the point of access, but it is only recently that rigorous research on its effectiveness has been conducted.

Objectives: To evaluate whether peer-led AA and professionally-delivered treatments that facilitate AA involvement (Twelve-Step Facilitation (TSF) interventions) achieve important outcomes, specifically: abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offsets.

Search methods: We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, CINAHL and PsycINFO from inception to 2 August 2019. We searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 15 November 2018. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and bibliographies of included studies.

Selection criteria: We included randomized controlled trials (RCTs), quasi-RCTs and non-randomized studies that compared AA or TSF (AA/TSF) with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants, or no treatment. We also included healthcare cost offset studies. Participants were non-coerced adults with AUD.

Data collection and analysis: We categorized studies by: study design (RCT/quasi-RCT; non-randomized; economic); degree of standardized 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). For analyses, we followed Cochrane methodology calculating the standard mean difference (SMD) for continuous variables (e.g. percent days abstinent (PDA)) or the relative risk (risk ratios (RRs)) for dichotomous variables. We conducted random-effects meta-analyses to pool effects wherever possible.

Main results: We included 27 studies containing 10,565 participants (21 RCTs/quasi-RCTs, 5 non-randomized, and 1 purely economic study). The average age of participants within studies ranged from 34.2 to 51.0 years. AA/TSF was compared with psychological clinical interventions, such as MET and CBT, and other 12-step program variants. We rated selection bias as being at high risk in 11 of the 27 included studies, unclear in three, and as low risk in 13. We rated risk of attrition bias as high risk in nine studies, unclear in 14, and low in four, due to moderate (> 20%) attrition rates in the study overall (8 studies), or in study treatment group (1 study). Risk of bias due to inadequate researcher blinding was high in one study, unclear in 22, and low in four. Risks of bias arising from the remaining domains were predominantly low or unclear. AA/TSF (manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) RCTs comparing manualized AA/TSF to other clinical interventions (e.g. CBT), showed AA/TSF improves rates of continuous abstinence at 12 months (risk ratio (RR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 2 studies, 1936 participants; high-certainty evidence). This effect remained consistent at both 24 and 36 months. For percentage days abstinent (PDA), AA/TSF appears to perform as well as other clinical interventions at 12 months (mean difference (MD) 3.03, 95% CI -4.36 to 10.43; 4 studies, 1999 participants; very low-certainty evidence), and better at 24 months (MD 12.91, 95% CI 7.55 to 18.29; 2 studies, 302 participants; low-certainty evidence) and 36 months (MD 6.64, 95% CI 1.54 to 11.75; 1 study, 806 participants; low-certainty evidence). For longest period of abstinence (LPA), AA/TSF may perform as well as comparison interventions at six months (MD 0.60, 95% CI -0.30 to 1.50; 2 studies, 136 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at 12 months, as measured by drinks per drinking day (DDD) (MD -0.17, 95% CI -1.11 to 0.77; 1 study, 1516 participants; moderate-certainty evidence) and percentage days heavy drinking (PDHD) (MD -5.51, 95% CI -14.15 to 3.13; 1 study, 91 participants; low-certainty evidence). For alcohol-related consequences, AA/TSF probably performs as well as other clinical interventions at 12 months (MD -2.88, 95% CI -6.81 to 1.04; 3 studies, 1762 participants; moderate-certainty evidence). For alcohol addiction severity, one study found evidence of a difference in favor of AA/TSF at 12 months (P < 0.05; low-certainty evidence). AA/TSF (non-manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) For the proportion of participants completely abstinent, non-manualized AA/TSF may perform as well as other clinical interventions at three to nine months follow-up (RR 1.71, 95% CI 0.70 to 4.18; 1 study, 93 participants; low-certainty evidence). Non-manualized AA/TSF may also perform slightly better than other clinical interventions for PDA (MD 3.00, 95% CI 0.31 to 5.69; 1 study, 93 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at nine months, as measured by DDD (MD -1.76, 95% CI -2.23 to -1.29; 1 study, 93 participants; very low-certainty evidence) and PDHD (MD 2.09, 95% CI -1.24 to 5.42; 1 study, 286 participants; low-certainty evidence). None of the RCTs comparing non-manualized AA/TSF to other clinical interventions assessed LPA, alcohol-related consequences, or alcohol addiction severity. Cost-effectiveness studies In three studies, AA/TSF had higher healthcare cost savings than outpatient treatment, CBT, and no AA/TSF treatment. The fourth study found that total medical care costs decreased for participants attending CBT, MET, and AA/TSF treatment, but that among participants with worse prognostic characteristics AA/TSF had higher potential cost savings than MET (moderate-certainty evidence).

Authors' conclusions: There is high quality evidence that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non-manualized AA/TSF may perform as well as these other established treatments. AA/TSF interventions, both manualized and non-manualized, may be at least as effective as other treatments for other alcohol-related outcomes. AA/TSF probably produces substantial healthcare cost savings among people with alcohol use disorder.

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Conflict of interest statement

JK: has received funding from the US National Institues of Health and the US Veterans Health Administration to conduct research into alcohol use disorders, comorbidities, treatment response, and mechanisms of behavior change in Alcoholics Anonymous (AA) and Self‐Management and Recovery Training (SMART).

KH: has received funding from the US National Institutes of Health and US Veterans Health Administration to evaluate a range of treatments and mutual‐help organizations focused on alcohol and other drugs.

MF: none known

Figures

1
1
PRISMA study flow diagram.
2
2
Manualized = the treatment covers standardized content in a linear or modular fashion to ensure that the same treatment is delivered across time and different sites where the intervention may be implemented. This ensures that the treatment can be replicated – a key factor in confirming the findings across different studies using the same treatment.
3
3
S = number of studies from Cochrane Review R = number of reports from Cochrane Review N = number of participants in the cell subcategory Manualized = the treatment covers standardized content in a linear or modular fashion to ensure that the same treatment is delivered across time and different sites where the intervention may be implemented. This ensures that the treatment can be replicated – a key factor in confirming the findings across different studies using the same treatment. aThe total Ns added across study types will not add to 10,565 because some of the participants that are in the other groupings (e.g. non‐randomized designs) are also in the economic category.
bWalitzer 2009 and its participants are included in both the 1A and 2A grouping in the review, but for the purposes of this table, the study and its participants (n = 169) are only counted once in the 1A group.
cOuimette 1997 and its participants are included in both the 3B and 4B grouping, but for the purposes of this table, the study and its participants (n = 3018) are only counted in the 3B group.
4
4
Risk of bias graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.
5
5
Risk of bias summary: review authors' judgments about each risk of bias item for each included study. Note: 27 primary studies
1.1
1.1. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 1: Proportion completely abstinent
1.2
1.2. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 2: Percentage days abstinent (PDA)
1.3
1.3. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 3: Longest period of abstinence (LPA, months)
1.4
1.4. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 4: Drinks per drinking day (DDD)
1.5
1.5. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 5: Percentage days heavy drinking (PDHD)
1.6
1.6. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 6: Alcohol‐related consequences (DrInC)
1.7
1.7. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 7: Alcohol‐related consequences (SIP)
1.8
1.8. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 8: Alcohol‐related consequences (SIP‐2R)
1.9
1.9. Analysis
Comparison 1: 1A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to different theoretical orientation, Outcome 9: Addiction Severity Index (ASI)
2.1
2.1. Analysis
Comparison 2: 1B Grouping: RCT/quasi‐RCT, 1 + treatments non‐manualized, compared to different theoretical orientation, Outcome 1: Proportion completely abstinent
2.2
2.2. Analysis
Comparison 2: 1B Grouping: RCT/quasi‐RCT, 1 + treatments non‐manualized, compared to different theoretical orientation, Outcome 2: Percentage days abstinent (PDA)
2.4
2.4. Analysis
Comparison 2: 1B Grouping: RCT/quasi‐RCT, 1 + treatments non‐manualized, compared to different theoretical orientation, Outcome 4: Drinks per drinking day (DDD)
2.5
2.5. Analysis
Comparison 2: 1B Grouping: RCT/quasi‐RCT, 1 + treatments non‐manualized, compared to different theoretical orientation, Outcome 5: Percentage days heavy drinking (PDHD)
3.1
3.1. Analysis
Comparison 3: 2A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to TSF variant, Outcome 1: Proportion of participants completely abstinent
3.2
3.2. Analysis
Comparison 3: 2A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to TSF variant, Outcome 2: Percentage days abstinent (PDA)
3.3
3.3. Analysis
Comparison 3: 2A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to TSF variant, Outcome 3: Days of use (PDA)
3.4
3.4. Analysis
Comparison 3: 2A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to TSF variant, Outcome 4: Drinks per drinking day (DDD)
3.5
3.5. Analysis
Comparison 3: 2A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to TSF variant, Outcome 5: Addiction Severity Index (ASI)
3.6
3.6. Analysis
Comparison 3: 2A Grouping: RCT/quasi‐RCT, all treatments manualized, compared to TSF variant, Outcome 6: European Addiction Severity Index (EuropASI)
4.1
4.1. Analysis
Comparison 4: 2B Grouping: RCT/quasi‐RCT, 1 + treatments non‐manualized, compared to TSF variant, Outcome 1: Proportion of participants completely abstinent
5.1
5.1. Analysis
Comparison 5: 3B: Non‐randomized, 1+ treatments non‐manualized, compared to different theoretical orientation, Outcome 1: Proportion of participants completely abstinent
5.2
5.2. Analysis
Comparison 5: 3B: Non‐randomized, 1+ treatments non‐manualized, compared to different theoretical orientation, Outcome 2: Drinks per drinking day (DDD)
5.3
5.3. Analysis
Comparison 5: 3B: Non‐randomized, 1+ treatments non‐manualized, compared to different theoretical orientation, Outcome 3: Alcohol‐related consequences (SIP)
5.4
5.4. Analysis
Comparison 5: 3B: Non‐randomized, 1+ treatments non‐manualized, compared to different theoretical orientation, Outcome 4: Alcohol‐related consequences
5.5
5.5. Analysis
Comparison 5: 3B: Non‐randomized, 1+ treatments non‐manualized, compared to different theoretical orientation, Outcome 5: Alcohol addiction severity (Alcohol Dependence Scale)
6.1
6.1. Analysis
Comparison 6: 4B: Non‐randomized, 1+ treatments non‐manualized, compared to TSF variant, Outcome 1: Proportion completely abstinent
6.2
6.2. Analysis
Comparison 6: 4B: Non‐randomized, 1+ treatments non‐manualized, compared to TSF variant, Outcome 2: Percentage days abstinent (PDA)
6.4
6.4. Analysis
Comparison 6: 4B: Non‐randomized, 1+ treatments non‐manualized, compared to TSF variant, Outcome 4: Addition Severity Index‐Lite (ASI‐L)
See this image and copyright information in PMC

Comment in

References

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Mundt 2012 {published data only}
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Ouimette 1997 {published data only}
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Timko 2006 {published data only}
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Walitzer 2015 {published data only}
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References to studies excluded from this review

Banerjee 2007 {published data only}
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Mueller 2007 {published data only}
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Ståhlbrandt 2007 {published data only}
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References to other published versions of this review

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