Alcoholics Anonymous vs. Other Approaches: The Evidence Is Now In

An updated review shows it performs better than some other common treatments and is less expensive.

By Austin Frakt and Aaron E. Carroll
Published on March 11, 2020 in The New York Times

For a long time, medical researchers were unsure whether Alcoholics Anonymous worked better than other approaches to treating people with alcohol use disorder. In 2006, a review of the evidence concluded we didn’t have enough evidence to judge.

That has changed.

An updated systematic review published by the Cochrane Collaboration found that AA leads to increased rates and lengths of abstinence compared with other common treatments. On other measures, like drinks per day, it performs as well as approaches provided by individual therapists or doctors who don’t rely on AA’s peer connections.

What changed? In short, the latest review incorporates more and better evidence. The research is based on an analysis of 27 studies involving 10,565 participants.

The 2006 Cochrane Collaboration review was based on just eight studies, and ended with a call for more research to assess the program’s efficacy. In the intervening years, researchers answered the call. The newer review also applied standards that weeded out some weaker studies that drove earlier findings.

In the last decade or so, researchers have published a number of very high-quality randomized trials and quasi-experiments. Of the 27 studies in the new review, 21 have randomized designs. Together, these flip the conclusion.

“These results demonstrate AA’s effectiveness in helping people not only initiate but sustain abstinence and remission over the long term,” said the review’s lead author, John F. Kelly, a professor of psychiatry at Harvard Medical School and director of the Recovery Research Institute at Massachusetts General Hospital. “The fact that AA is free and so widely available is also good news.”

“It’s the closest thing in public health we have to a free lunch.”

Studies generally show that other treatments might result in about 15 percent to 25 percent of people who remain abstinent. With AA, it’s somewhere between 22 percent and 37 percent (specific findings vary by study). Although AA may be better for many people, other approaches can work, too. And, as with any treatment, it doesn’t work perfectly all the time.

Rigorous study of programs like Alcoholics Anonymous is challenging because people self-select into them. Those who do so may be more motivated to abstain from drinking than those who don’t.

Unless a study is carefully designed, its results can be driven by who participates, not by what the program does. Even randomized trials can succumb to bias from self-selection if people assigned to AA don’t attend, and if people assigned to the control group do. (It may go without saying, but we’ll say it: It would be unethical to prevent people in a control group from attending Alcoholics Anonymous if they wanted to.)

Despite these challenges, some high-quality randomized trials of Alcoholics Anonymous have been conducted in recent years. One, published in the journal Addiction, found that those who were randomly assigned to a 12-step-based directive AA approach, and were supported in their participation, attended more meetings and exhibited a greater degree of abstinence, compared with those in the other treatment groups. Likewise, other randomized studies found that greater Alcoholics Anonymous participation is associated with greater alcohol abstinence.

Alcoholics Anonymous is often paired with other kinds of treatment that encourage engagement with it. “For people already in treatment, if they add AA to it, their outcomes are superior than those who just get treatment without AA,” said Keith Humphreys, a Stanford University professor and co-author of the new Cochrane review.

Alcoholics Anonymous not only produced higher rates of abstinence and remission, but it also did so at a lower cost, the Cochrane review found. AA meetings are free to attend. Other treatments, especially those that use the health care system, are more expensive.

One study found that compared with Alcoholics Anonymous participants, those who received cognitive behavioral treatments had about twice as many outpatient visits — as well as more inpatient care — that cost just over $7,000 per year more in 2018 dollars. (Cognitive behavioral treatments help people analyze, understand and modify their drinking behavior and its context.)

Another study found that for each additional AA meeting attended, health care costs fell by almost 5 percent, mostly a result of fewer days spent in the hospital and fewer psychiatric visits.

AA meetings are ubiquitous and frequent, with no appointment needed – you just show up. The bonds formed from the shared challenge of addiction – building trust and confidence in a group setting – may be a key ingredient to help people stay on the road to recovery.

Worldwide, alcohol misuse and dependence are responsible for 3.3 million deaths per year, 10 times the number of fatalities from all illicit drugs combined.

In the United States, alcohol is a larger killer than other drugs; accounts for the majority of all addiction treatment cases; and is responsible for at least $250 billion per year in lost productivity and costs related to crime, incarceration and health care. Moreover, American deaths related to alcohol more than doubled between 1999 and 2017.

Reducing the human and financial burdens of alcohol is an often overlooked public health priority, and the new evidence suggests that on balance one of the oldest solutions — Alcoholics Anonymous has been around almost 85 years — is still the better one.

Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and a senior research scientist with the Harvard T.H. Chan School of Public Health.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine and the Regenstrief Institute who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. He is the author of “The Bad Food Bible: How and Why to Eat Sinfully.”


9 Responses

    • Roger says:

      Thanks Lee. I have tried to include that link in the article but, for whatever reason, it has gone bad several times so I have to give up and remove it. Hopefully this one will work.

  1. Gordy in Hornell says:

    I think I’d like to read the new Cochran study, rather than a summary of a newspaper summary before I began thinking of doing a happy dance, AND also read the peer review responses.

    The problems with studying alcohol use disorders are numerous. Among them – What stage or point on the broad spectrum is the person at? Are all subjects at the same stage? Is it a disease or symptom of behavior at the stage that individual is at? What defines success – abstinence of use or absence of adverse consequences? It’s complex.

    Then there’s AA itself. Individual meetings are NOT the same, varying from Back to Basics Sandy Beach style to fully secular Fellowship Preamble based. And the variety is not just between meetings, but among multiple geographic regions. Would the results be the same if the analysis was done in Scandinavia? Probably not – treatment facilities for AUD there are not based on 12 Step Facilitation, while nearly all in the U.S. are.

    An excellent book by a qualified Harvard clinical psychologist presenting this complexity is The Sober Truth: Debunking the Bad Science Behind 12 Step Programs and the Rehab Industry by Lance Dodes, MD. It’s well worth reading.

    Sober Truth
    For myself, after 30+ years of complete abstinence from alcohol and any other drug, it’s academic. Since leaving religion 16 or so years ago, I increasingly practice and attend at secular Fellowship style meetings with Reality as my uncaring, unloving, conciousless HP and find life lived with a brain free of drugs and uncluttered by culturally conditioned myths to be awesome – truly happy, joyous, and free.

    AA in the mainstream is religious. It has unchanging scripture, dependency on supernatural intervention, dead prophets, guaranteed redemption in recovery, steps as sacraments, preachers, pilgrimages to holy sites in Akron, and the True Coffee Pot.

    But it doesn’t have to be; it just chooses that path.

  2. Bullwinkle says:

    Thank you for this article, Roger!

    I’m going to contribute what wasn’t covered in this article from my experience (perception) of why some meetings in the AA fellowship worked for me, and worked for others similar to me. Even though I’m an atheist, I continued to attend the meetings of my choice from the 100’s of AA meetings in greater Los Angeles. I chose meetings closest to the ideal information, that I received from those that came before me.

    Each fellowship / meeting is autonomous, there is no hierarchy, i.e. meetings can be facilitated any way the members choose, even by not following what I consider the ideal. The ideal meetings I attended welcomes everyone, regardless of race, gender, sexual preference (LGBTQ), agnostic, atheist, etc. Contrary to what some AA fellowship / meetings believe, the General Service Office (GSO) NYC has no authority over an AA fellowship / meeting, that doesn’t endorse the GSO, including what’s called conference approved literature. Autonomous Alcoholics Anonymous fellowships can read any thing they want or read nothing. Alcoholics Anonymous (Big Book) which is the 12 Steps, is a suggested program of recovery, therefore, there is no dogma for recovery.

  3. Thomas says:

    Wonderful article Roger — thanks for re-publishing it here for us . . .

    It’s been my opinion for most of my long-term recovery in AA, most especially in Secular AA meetings during the past decade, that the secret sauce in AA is the Identification that one drunk/druggie in AA has with other drunk/druggies, as shared in our stories; through our stories we experience H O P E: hearing other people’s experience . . .

  4. Larry g says:

    Fantastic article. Really there are no surprises for me and me only. Structured mutual aid groups always provide superior outcomes to either going it alone or medical model alone interventions. Someday a meta/meta research model will be developed and implemented. I hypothesize a similar set of conclusions for all mutual aid groups.

    Now my humble opinion on why it works. Some will say it’s the god or higher power thing. I’ve actually heard scores of AA folk make such claims at meetings. For me and me only I conclude the following. I divide AA’s dogma/program into two large categories. The first is belief oriented or the hp and god thing. The second is the action part of the program. I am able to read all “”AA conference approved material” into these two large categories. I maintain/hypothesize that the program works just as well for those who embrace only the later category as those that embrace both. If AA would ever fully allow a writing and publishing of “conference approved literature” for agnostics and atheist and free thinkers, as well as continued growth of agnostic, atheist, and free thinking meetings, we could see a set of studies of outcomes for both. I hypothesize that outcomes would be identical for both. I think that as a possibility frightens many of my more traditional AA colleagu s. I so love science and well reasoned discussion. Lar. Thanks for AA Agnostica!!!

  5. Doc says:

    I’m going to take off my sober alcoholic hat for a moment and put on my professional hat. For many years I was the research director for a public opinion research firm whose clients included hospitals and treatment centers. For these clients we did follow-up surveys of their patients, which included tracking alcoholics and addicts for two years following treatment. In general, our findings correlated closely with those reported above.

  6. Jerry S. says:

    Having been in the medical field for 40yrs and now sober nearly 11yrs it is not surprising to read this article. I’ve known for years that AA was not a magic bullet, it had a better chance of saving patients and finally myself than all the other treatments.

    Since this article was posted on AA Agnostica I feel compelled to reiterate that AA IS NOT a religious organization (regardless of court rulings). AA is accepting of all persons and their individual beliefs. The only common fact of belief is alcohol was a power greater than ourselves was killing us. Any form of belief that can obtain long term sobriety whether it be atheism, agnostic, religious or psychiatric education. AA only provides an outline to use for a living life in a Good Orderly Direction, something we lost during our life while when we were using.

    • Bullwinkle says:

      Yes, Myself and some of the Alcoholics Anonymous founders, including Bill Wilson didn’t believe that Alcoholics Anonymous, which is the 12 Steps was the magic bullet, it’s a suggested program of recovery. Alcoholics Anonymous suggests seeking professional help. The last page of Alcoholics Anonymous states, “Our book is meant to be suggestive only. We realize we know only a little.”

      The common fact you mentioned doesn’t apply to me. The First Step was worded incorrectly, i.e., alcohol is an inert substance, therefore it has no power. I drank as a bartender, but never got drunk, due to being responsible for my business and my customers. This is Good Orderly Conduct involved with work ethic, that I learned from my parents. The wording in this context of alcohol “power greater than ourselves”, I’ve observed with those in the AA fellowship that believe this and are faith based, viewing alcoholic drinking as insanity. Therefore, they Came to believe a power greater than themselves could restore them to sanity, (Second Step). I wasn’t insane, I had emotional / mental problems.

      Along with Alcoholics Anonymous (self-examination) and psychotherapy (self-examination), I realized that my drinking addiction was a symptom (indicator), that helped my depression. That my drinking amounts increased due to tolerance and my medicinal alcohol use began to stop working as it once had. This is where questioning my addiction began and through my recovery process, I finally reached my bottom and was abstinent, until I fully recovered and achieved sobriety.

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