Are Alcoholics Anonymous and Other 12-step Programs Effective for Alcohol Use Disorder?

A recent Cochrane Library systematic review included randomized trials, quasi-experimental studies, and non-randomized trials to assess the effectiveness of Alcoholics Anonymous (AA) and twelve-step facilitation (TSF) for alcohol use disorder. TSF is therapist-provided, formal, manual-guided behavioral counseling that is designed to encourage and supplement AA attendance. Twenty-seven studies (1 purely economic, 16 randomized) with 10,565 participants were included and the risk of selection bias was substantial, high, or unclear in most.

• A comparison of TSF with other clinical interventions combined 2 studies. One study (n=1726) compared TSF with motivational enhancement therapy and cognitive behavioral therapy; the other (n=210) compared network support (supporting AA involvement) with case management. The relative risk for abstinence at 12 months was 1.2 favoring TSF/network support compared with case management or the other psychotherapies (42% versus 35% of participants achieved abstinence, respectively).
  • One other trial described as very low quality (n=121 patients with severe mental illness) compared TSF with another psychosocial treatment and found 1.8 fewer drinks per drinking day favoring TSF.
• Three studies were identified that compared therapist-provided manualized behavioral counseling covering AA-relevant topics with lower intensity coverage and found 16% more days abstinent in one (n=95) and a relative risk of 1.2 for abstinence favoring higher intensity therapy in 2 others (n=659).
• The review identified one more study (n=307) that compared standard AA referral with more intensive encouragement to attend AA; the relative risk for abstinence was 1.3 favoring encouragement to attend AA.

Comments: Despite appearing to be a report of AA effectiveness in over 10,000 people in comparative studies, the report’s main findings of effectiveness come from modest effects on secondary outcomes in studies with substantial risk of bias in just over 3000 people. More importantly, the studies tested manualized psychotherapy provided in conjunction with or supporting AA attendance or intensive referral to AA, not AA itself. The findings are not inconsistent with the idea that AA can help some people with alcohol use disorder, but they are not solid evidence for substantial effectiveness.

Richard Saitz, MD, MPH

Reference: Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database Syst Rev. 2020;3:CD012880.