Throughout my career, I have heard various experts suggest that Alcoholics Anonymous (AA) did not work or that 12-Step programs were not evidence-based treatments. My mentor, while a leader in the use of medications in opioid use disorders, taught me to take patients from the Yale Emergency Room to AA meetings for alcohol problems.
He helped me understand the importance of AA, encourage people with alcohol use disorders (AUD) to find and go to AA meetings and get a sponsor, and also where to find meetings. Nowadays, medical students are often encouraged to go to an open AA meeting and learn about AUD and AA. Some experts had problems with AA because of its spirituality and also that 12-step programs dominated residential treatment in the United States for decades.
Mrs. Ford, the Betty Ford Center, and numerous celebrity real-life stories provided additional support for AA. But while AA became a household name, it became a target at the same time. Some literature reviews concluded that AA was without proven effectiveness [1] and general audience hyperbole increased to the point that one asserted,”… researchers have debunked central tenets of AA doctrine and found dozens of other treatments more effective” [2].
They could make such claims because regardless of how well-known AA is as a successful program helping people with alcohol use disorder, Alcoholics Anonymous is not a research organization. AA, while free of charge, does not have research in its mission.
So, it follows that traditional treatment outcomes research is necessary if it was to be claimed that AA was the treatment of choice. While we waited for this research, AA has been criticized for not having the addiction outcomes research to back up its efficacy.
That all changed with the recent Stanford and Harvard-let analysis of AA [3] Scientific data [4]. These new AA data were robust by themselves, but, also are supported by an extensive Yale neuroimaging study of patients with alcohol use disorders [5], showing that one day at a time (an AA mantra) helps the brain heal from alcohol-related changes researchers reported August 28 in the American Journal of Psychiatry.
What Is Alcoholics Anonymous (AA)?
AA is a self- help or mutual aid fellowship which aims to help alcoholic members achieve and maintain sobriety. The goals are simple “stay sober and help other alcoholics achieve sobriety,” but have been achieved by these recovering nonprofessional volunteers.
While politicized, AA is apolitical. Anyone can become an AA membership as long as they express a desire to stop drinking and try to achieve this by following a recovery program detailed in the AA Twelve Steps. In 1935, AA was founded in Akron, Ohio, by alcoholics Bill Wilson and Bob Smith.
Alcoholics Anonymous (AA) has helped millions of alcoholics and their loved ones, but it has also influenced our societal view of the alcoholic. The guiding principles of AA are the 12 steps, reinforced and explained in the “Big Book” as well as other AA literature.
These guidelines call for a spiritual transformation. Members themselves take responsibility for changing and helping others. AA members are encouraged to seek a spiritual awakening by appealing to a higher power, praying and meditating, admitting sins and errors, making amends to people they have hurt, and finally, carrying the message to others.
They publicly admit out loud that they are powerless and have lost power over alcohol. They need help, a higher power’s intervention as alcohol has made their lives unmanageable.
AA gained prominence during the time period when physicians and other health providers avoided patients with AUDs. There was an absolute lack of alternatives for treating or helping the alcoholic. AA began and soon flourished, helped by favorable publicity, committed members, and AA publications.
We argue that its founder, Bill W., played a crucial role as a charismatic leader and that AA found a unique organizational solution to the problem of charismatic succession. This solution helped AA maintain growth and stability beyond the life of its founder [6].
AA Traditions encourage members to remain anonymous and avoid mass or public media. Members are told to act altruistically and always help other alcoholics. AA groups avoid official affiliations with other organizations.
AA is open to all, free of charge, worldwide. AA now has over 2 million active members in 180 nations, with more than 118,000 functional AA groups [7]. Meetings are in every city, many times a day in some cities too. Attending an AA meeting can change medical students’ attitudes about addiction Attending an AA meeting and reflecting on the experience may be one way to decrease addiction stigma among medical students [i].
AA’s point of view is not to claim that it is a specific treatment for AUD. AA makes a distinction between mutual aid and alcoholism treatment. AA is called a fellowship for a good reason. It provides a social activity.
AA can be a substitute for the socializing that comes with going to bars or drinking. Members make new friends at AA, have a sponsor, and these experiences help them to learn new ways to cope with cravings. As in any self-help or group therapy program, listening to others and their life stories helps people to realize that AUD patients have a great deal in common, they are not alone, and recovery is possible.
In Project MATCH, patients who followed the 90-day treatment with AA participation were asked a year later whether they had been a sponsor or had completed the twelfth step: “We try to carry the message to other alcoholics and to practice these principles in all our affairs.” Only 8% thought they met it. But those who did had a much lower relapse rate even after correction for the number of AA meetings they attended.
Studies have shown that single people continue to attend AA meetings longer than married people. This AA is not a specific treatment is a nuanced argument as AA is a recommendation given to AUD patients by health providers. Still, when AA works, it works because of peer social interactions.
AA members give emotional support and rather practical tips from their experiences on alcohol, drinking, and abstinence. If you want to change your drinking, behavior, and relationship to alcohol, AA makes it easy to find many recovering people who are trying to make the same changes [ii].
New Analysis and Cochrane Report on Alcoholics Anonymous [iii]
Cochrane Database of Systematic Reviews found that AA, the premier mutual aid peer-recovery program, definitely helps people get sober. But, in addition, AA also has significantly higher rates of continuous sobriety compared with evidence-based professional mental health therapy, such as cognitive-behavioral therapy.
In a recent interview [iv], lead author Dr. John Kelly, a professor of psychiatry and addiction medicine at Harvard Medical School, said: “In the popular press, there have been reports of AA not working or being even harmful to people. So, we wanted to clarify the scientific picture of the highest scientific standard.”
This recent study had the opposite findings of the 2006 study [8] that concluded there were “no experimental studies unequivocally demonstrated the effectiveness of AA or TSF (twelve-step facilitation) approaches for reducing alcohol dependence or problems.” How could this happen?
One difference between the old and the new studies was that the 2006 review included only eight research studies, while the recent review included 27 studies of more than 10,500 people. The new review concluded that AA’s improved the duration of abstinence and the amount they reduced their drinking– if they continued drinking.
AA also had harm reduction features as well. AA reduced the medical consequences of drinking and health care costs. While not a random assignment treatment comparison study, in this analysis, AA was never found less effective than other treatments.
The new study results were very compelling. Humphreys noted that the findings were consistent whether the study participants were young, elderly, male, female, veterans, or civilians; the studies in the review were also conducted in five different countries. “It absolutely does work,” he said of AA’s method.
AA was often was found to be markedly better than other interventions or quitting cold turkey. One study found the program 60% more effective than alternatives.
Clearly, AA helps and could be added to any treatment for AUDs and expected to make that treatment better. For example, adding AA to Vivitrol would be expected to be better than just giving a MAT for AUDs.
The data does not assume that AA is ideal for all people with AUDs, dual disorders, PTSD, or other current psychiatric diseases. But I am encouraged by these findings and also find them even more compelling because Keith Humphreys, co-author of the study and a Stanford University psychiatry professor, often had been skeptical of AA’s effectiveness in the past.
Like other academics, psychologists and psychiatrists are often believe that evidence-based therapies like cognitive behavioral therapy and motivational enhancement therapy are the gold standard. AA’s beneficial effects seem to be carried predominantly by social, cognitive, and affective mechanisms [9]. But, while it is not exactly clear how it works when it comes to the treatment of AUD patients, it is clear that AA is safe, effective, and better than other therapies everyone considers evidence-based medicine.
Yale Professor Rajita Sinha and “One day at a time.”
Patients with alcohol use disorder (AUD) struggle with poor treatment adherence, early dropout, and high risk of relapse. Over 35% of AUD patients entering outpatient treatment relapse within 30 days, and over 65% relapse within 90 days.
Abstinence may be an answer, but even with AA and treatment, it is hard to attain. Clinicians and patients with AUDs may not know it, but these relapse findings have also been shown in basic science that alcohol-related brain structural changes persist. With each day of abstinence, there is an improvement in the functioning of prefrontal-striatal circuits known to be critical for executive control, resilient coping, and regulation of craving and reward responses.
One day at a time is a slogan but more like a mantra for recovering alcoholics. Take it one day at a time, and each and every sober day matters. A new brain imaging study by Rajita Sinha and her group of Yale researchers shows why the approach works.
Imaging scans of those diagnosed with showed disruptions of activity between the ventromedial prefrontal cortex and striatum- a brain network linked to decision making. Time is necessary for re-learning how to be sober but also for brain recovery.
The more recent the last drink, the more severe the disruption, and the more likely the alcoholic will relapse to drinking. Their August 28 report in the American Journal of Psychiatry only reinforces the importance of sobriety in functional brain circuit recovery.
The Yale researchers also found that the severity of disruption between these brain regions recovers very slowly, day after day gradually over time. They conclude the longer AUD subjects abstain from alcohol, the better.
Their imaging studies support the importance of extensive and intense early treatment for those in their early days of sobriety. Drinking less may be a harm reduction strategy, but it may not help the brain recover.
Conclusions
Although AA is not a research organization or even lists research as part of its mission, addiction researchers conducted thousands of studies of AA. Some of these are better than others. Recent studies and the preponderance of recent evidence supports the effectiveness of 12-step program involvement in sustaining abstinence [10].
Psychiatrists may wonder why both addiction treatment and the 12-step programs recommend abstinence [v]. In his 50-year follow-up of two groups of alcoholics, Vaillant compared those who established secure abstinence with those who continued to drink.
Stable and long-term abstinence was associated with: Living longer, Better mental health, Better marriages, Being more responsible parents, Being successful employees. Vaillant recommended that clinicians: Offer the patient a nonchemical substitute for alcohol. Remind the patient ritually that even one drink can lead to pain and relapse.
AA is a popular approach to AUD and alcohol problems in the USA. As many as 1 in 10 Americans have attended at least one AA meeting. Alcoholics Anonymous is often referred to as the worldwide fellowship of sobriety seekers.
The recent study by Harvard and Stanford addiction researchers of 10,565 subjects [vi] was published on March 11 in the Cochrane Database of Systematic Reviews. This is a top evidence-driven review. “Cochrane Reviews are the gold standard in medicine for the integration of all the research about a particular intervention,” Humphreys said. “The investigators determined that AA was nearly always found to be more effective than psychotherapy in achieving abstinence.”
AA participation lowered health care costs. Humphreys noted that AA works just as well if the person with AUD was young, elderly, male, female, veterans, or civilians. When asked if AA works, Professor Humphreys said: “It absolutely does work. AA works best if the patient with AUD sticks to the treatment program.
The longer a person remains in AA, generally, the better he or she does. In an 8-year follow-up, study investigators found that patients who continue to participate for more than two years drank less and had fewer adverse consequences, and were more likely to be abstinent. Patients who continued AA four months or less did no better than those who did not participate at all.
Today we know that AUD and other addictions are chronic relapsing and life-long diseases without a specific cure. In this way, they are like type 2 diabetes or cardiovascular disease, which requires long-term self-management.
Medications, like those for AUDs, can help and make other treatments more effective. It is very difficult to reverse the kind of pervasive behavioral and brain changes produced by decades of alcohol misuse. Alcohol changes in the way a person lives, but AA can help to reverse these changes.
The new Sinha data support this approach, one day at a time, with abstinence as a primary outcome measure to ensure the necessary alcohol-free time for the brain and behavioral healing. The number of days of alcohol abstinence at treatment initiation significantly affected functional disruption of the prefrontal-striatal responses to alcohol cues in patients with AUD and brain imaging abnormalities.
AA plus medication-assisted therapies for AUD, like naltrexone, Vivitrol, and acamprosate, is an ideal way to start AUD therapy and follow-up after 90 AA meetings and 90 days of Vivitrol treatment. It is not a case of either-or. But, instead of adding 90 AA meetings in 90 days, getting a sponsor and helping others with AUDs to the existing treatments for AUDs.
We also have medications that can allow us to detoxify patients with AUDs from alcohol safely. Detoxification is safe and effective with DTs, and convulsions are prevented in most cases. The discipline and fellowship of AA are valuable for many alcoholics because they fulfill that function in a way no other treatment can [11].
Resources:
1. Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database Syst Rev. 2006;(3):CD005032. Published 2006 Jul 19. doi:10.1002/14651858.CD005032.pub2
2. https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/
3. Kelly JF, Abry A, Ferri M, Humphreys K. Alcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers [published online ahead of print, 2020 Jul 6]. Alcohol Alcohol. 2020;agaa050. doi:10.1093/alcalc/agaa050
4. https://med.stanford.edu/news/all-news/2020/03/alcoholics-anonymous-most-effective-path-to-alcohol-abstinence.html
5. https://news.yale.edu/2020/08/27/why-one-day-time-works-recovering-alcoholics
6. Trice HM, Staudenmeier WJ Jr. A sociocultural history of Alcoholics Anonymous. Recent Dev Alcohol. 1989;7:11-35. doi:10.1007/978-1-4899-1678-5_1
7. https://en.wikipedia.org/w/index.php?title=Alcoholics_Anonymous&oldid=976054603
8. Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database Syst Rev. 2006;(3):CD005032. Published 2006 Jul 19. doi:10.1002/14651858.CD005032.pub2
9. Kelly JF. Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behavior change research. Addiction. 2017;112(6):929-936. doi:10.1111/add.13590
10. Gross M. (2010). Alcoholics Anonymous: still sober after 75 years. 1935. American journal of public health, 100(12), 2361–2363. https://doi.org/10.2105/AJPH.2010.199349
11. https://www.health.harvard.edu/newsletter_article/How_Alcoholics_Anonymous_works
i. Balasanova AA, MacArthur KR, DeLizza AA. “From All Walks of Life”: Attending an Alcoholics Anonymous Meeting to Reduce Addiction Stigma Among Medical Students [published online ahead of print, 2020 Aug 31]. Acad Psychiatry. 2020;10.1007/s40596-020-01302-0. doi:10.1007/s40596-020-01302-0From
ii. https://med.stanford.edu/news/all-news/2020/03/alcoholics-anonymous-most-effective-path-to-alcohol-abstinence.html
iii. Kelly JF, Abry A, Ferri M, Humphreys K. Alcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers [published online ahead of print, 2020 Jul 6]. Alcohol Alcohol. 2020;agaa050. doi:10.1093/alcalc/agaa050
iv. https://www.usatoday.com/story/news/health/2020/03/11/alcoholics-anonymous-aa-helps-people-stay-sober-longer-study-finds/5008835002/
v. Chappel JN, DuPont RL. Twelve-step and mutual-help programs for addictive disorders. Psychiatr Clin North Am. 1999;22(2):425-446. doi:10.1016/s0193-953x(05)70085-x
vi. Kelly JF, Abry A, Ferri M, Humphreys K. Alcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers [published online ahead of print, 2020 Jul 6]. Alcohol Alcohol. 2020;agaa050. doi:10.1093/alcalc/agaa050
About the Author:
Mark S. Gold, M.D., Professor, Washington University School of Medicine – Department of Psychiatry, served as Professor, the Donald Dizney Eminent Scholar, Distinguished Professor and Chair of Psychiatry from 1990-2014. He was the first Faculty from the College of Medicine to be selected as a University-wide Distinguished Alumni Professor and served as the 17th University of Florida’s Distinguished Alumni Professor.
Dr. Gold is also a Distinguished Fellow, American Society of Addiction Medicine; Distinguished Life Fellow, the American Psychiatric Association; Distinguished Fellow, American College of Clinical Pharmacology; Clinical Professor of Psychiatry, Tulane University School of Medicine; Professor( Adjunct), Washington University in St Louis, School of Medicine, Department of Psychiatry; National Council, Washington University in St Louis, Institute for Public Health
Learn more about Mark S. Gold, MD
The opinions and views of our guest contributors are shared to provide a broad perspective of addictions. These are not necessarily the views of Addiction Hope, but an effort to offer a discussion of various issues by different concerned individuals.
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Published on September 14, 2020
Reviewed by Jacquelyn Ekern, MS, LPC on September 14, 2020
Published on AddictionHope.com