Some history behind Pendery 1982

Let me finish off 2018 by taking about how the seminal work refuting the notion that alcoholics can moderate their drinking again, Pendery 1982, came to be published.

Pendery 1982 (i.e. M.L. Pendery, I.M. Maltzman, and L.J. West. "Controlled Drinking by Alcoholics? New Findings and a Reevaluation of a Major Affirmative Study" Science 217) is a very key paper in the history of alcoholism studies; the release of the paper was the last nail in the coffin that alcoholics can engage in sustained controlled drinking again. It humiliated the controlled drinking for alcoholics proponents; the study undeniably shows that alcoholics who try moderate drinking end up either dead, drinking like an alcoholic, or abstaining from alcohol.

The paper has a very interesting history which can be seen in two articles from 1982, when this very important paper was published:

• Alcoholism study under new attack. This article shows how the 1970s Sobell studies resulted in alcoholism experts from that era believing that alcoholics could learn to drink in a responsible manner, and how Pendery 1982 refuted that notion.
• Showdown nears in feud over alcohol studies. This article shows how hard Pendery and Maltzman had to work to make their paper a reality: “At every step of the way the Sobells have tried to block the investigation by Dr. Pendery and Dr. Maltzman. [...] The Sobells refused to hand over their list of the participants [...] Undaunted by the Sobells' resistance, the Pendery group tracked down a list of the patients' names at a county alcoholism center [...] The Sobells retaliated with a suit to block the use of the names, but a Federal District court dismissed their action in April 1977 [...] It took Dr. Pendery, using thousands of dollars of her own money and whatever time she could squeeze in among her other obligations, several more years to track down patients”

However, despite all this resistance, the paper was published and the notion that alcoholics could control their drinking again was no longer mainstream addiction research. 60 Minutes broadcast a segment describing the Pendery paper; Al Gore, long before he became vice president, wanted to investigate the Sobells for fraud.

Ultimately, the addiction experts who supported Sobell’s point of view would appear to have never let go of Pendery 1982. As recently as 2015, in a poorly researched anti-AA polemic, Glaser inaccurately describes the Sobell study. The Sobell study was not accurate; while an initial 1982 panel felt the Sobells were reasonably accurate in their research, a later 1984 Federal investigation (you know, with subpoena powers) pointed out that the Sobells were “careless in preparing their manuscripts for publication”. Indeed, some of the “controlled drinking” subjects in the study sued the Sobells.

Since people who think alcoholics can drink moderately again bring this up: How the alcoholics given abstinence treatment fared is a red herring. The Sobell study was done in the early 70s, some four decades before we starting finding twelve step facilitation treatments which effectively got more people going to 12-step meetings and abstaining from alcohol.

The fact of the matter is this: With one exception, Pendery 1982 shows us that the supposedly moderately drinking alcoholics in the Sobell study were either dead, engaging in out of control drinking, or were abstaining from alcohol 10 years later.

More people are realizing that AA is effective

Just yesterday, someone wrote an article for a small regional magazine (which comes off as like those magazines which were free on every street corner back in the days before the Internet took over publishing) regurgitation the same old “AA only has a 5% success rate” nonsense which has long been refuted.

However, instead of the comments agreeing with the bogus 5% success figures, the comments pointed out how inaccurate those figures are. At the beginning of this year, with the exact same online magazine, I was the only commentator with accurate figures for AA’s success.

This indicates that the tide is really starting to turn; the days of being able to post an article claiming AA has only a 5% success rate without getting devoured in the comments section are behind us.

Charlie Sheen, clean and sober in AA

Charlie Sheen, back in 2011, claimed that Alcoholics Anonymous has only a 5% success rate. Thankfully, over the years, he realized that those numbers are questionable.

He now has one year clean and sober in Alcoholics Anonymous. I'm very happy that he was able to let go of outdated ideas like the idea that science shows AA is ineffective (it doesn't), and instead use the program to become clean and sober.

What is AA's real success rate?

The question is this: What is AA's real success rate? We can never know the true number for two key reasons:

• AA does not keep track of members.
• "AA success" is a poorly defined term, which can have several actual meanings

While AA itself did not keep track of members, Moos and Moos 2006 did. It found the following: Of the people who were serious about AA, 67% of them were sober 16 years later.

But what about the dropouts? Not everyone who did the study did the 16-year followup, so we can't know the true success rate number, but looking at only the people who did follow up gives us a reasonable number (Dodes 2014 claims that Moos/Moos 2006 has completely invalid numbers because of these dropouts, but Dodes appears to have had no interest in an honest assessment of AA's success). Overall, 46% of the people in the Moos and Moos 2006 survey (again, only those who did the 16-year followup) were sober, regardless of their level of AA attendance.

Now we are getting in to the realm of philosophical questions: Do we count someone who was not serious about AA but still stayed sober as a success or failure for AA? Should we count people who weren't serious about meetings when calculating AA's success rate? Polemics like Dodes's The Sober Truth consider every single person who was not serious about AA a failure when making artificially low numbers for AA's success, even if the person got sober after all.

There are a lot of ways we can come up with a "success rate" number based on Moos and Moos 2006:

• There were 461 people in the survey who did a 16-year followup
• Of those, 25% (115) took the AA program seriously. Of those 115, 77 (67% of serious AA members, 17% overall) were sober, and 38 (33% of serious AA members, 8.2% overall) were not sober. We could use these numbers to argue that AA has "only" a 17% success rate, but that argument is dishonest because it discounts the 16% of people (72) who had some level of exposure to AA and still stayed sober.
• Overall, 214 (46%) got sober.  Since pretty much any alcoholic out there at least knows of AA's existence, we could make a case this is a 46% success rate.
• If we look at just people who had a least a little bit of AA treatment, this is 58% (269 of 461 total) of the people in the survey; of those 55% (149) were sober 16 years later. Contrast this with the 42% (192) who didn't try AA at all, 34% or 14% overall (65) were sober 16 years later.

Point being, there are a lot of ways to measure AA success, but to consider people who didn't take AA seriously but still got sober as "failures" (as Dodes and others have done) is downright dishonest.

Alcoholics Anonymous's own success claims
 
Alcoholics Anonymous has, since 1939, made the following claim about AA's success "Rarely have we seen a person fail who has thoroughly followed our path." This claim was expanded in the mid-1950s: "Of alcoholics who came to A.A. and really tried, 50% got sober at once and remained that way; 25% sobered up after some relapses, and among the remainder, those who stayed on with A.A. showed improvement."

Alcoholics Anonymous has never claimed it would help people who did not take the program seriously. Any claim about AA's success should only look at the people who take AA seriously; once we discount the people who did not take AA seriously, the numbers we get are in line with the numbers AA gave us in the mid-1950s (75% success rate among those whose who "really tried" AA).

It is true that AA has a high drop out rate, so I contend this: Have we found a treatment which is effective for alcoholics who, for whatever reason, refuse to work the AA program? Zemore 2019 makes a strong case that people in other programs can also stay clean and sober, as long as the goal is abstinence from alcohol. So, yes, I think people who will not work the AA program can still be clean and sober, but I also think it's dishonest to label all such people "failures" when measuring AA success.

Brandsma 1980 redux

Here’s a paragraph I wrote criticizing Bradsma 1980 when I restored that study to the Effectiveness of Alcoholics Anonymous article (using footnotes):

This study had poor methodology. There was no effort to stop the people in the control group from attending Alcoholics Anonymous meetings, and the "Alcoholics Anonymous" treatment patients underwent in the Brandsma study did not use actual Alcoholics Anonymous meetings. "The control condition allowed for participation in actual AA meetings, while those in the AA condition attended a weekly AA-like meeting administered by the study (that was not an actual AA meeting)"

That might not have been neutral, so another editor tried to make that paragraph more balanced:

Notably, there was no effort to stop the people in the control group from attending Alcoholics Anonymous meetings, and the "Alcoholics Anonymous" treatment patients underwent in the Brandsma study did not use community Alcoholics Anonymous meetings. A later critical analysis noted: "the control condition allowed for participation in actual AA meetings, while those in the AA condition attended a weekly AA-like meeting administered by the study (that was not an actual AA meeting)"

I feel this wording undermines the significant criticism Kaskutas 2009 has about Brandsma 1980, so I reworded it again, hopefully more neutral:

There was no effort to stop the people in the control group from attending Alcoholics Anonymous meetings. The "Alcoholics Anonymous" treatment patients underwent in the Brandsma study did not use community Alcoholics Anonymous meetings; a later analysis says that there are "concerns with the Brandsma trial which call its experimental results into question" because "the control condition allowed for participation in actual AA meetings, while those in the AA condition attended a weekly AA-like meeting administered by the study (that was not an actual AA meeting)"

This study has been heavily abused

I think this is pretty neutral, especially in light of just how problematic Brandsma 1980 is, especially when quoted out of context in anti-AA polemics. As just one example of this, here is how Dodes’s The Sober Truth describes Brandsma 1980:

The investigators found “significantly more binge drinking at the 3-month follow-up” among the people assigned to the AA-oriented meetings. As the year mark approached, the researchers noted, “All of the lay-RBT clients reported drinking less during the last 3 months. This was significantly better than the AA or the control groups at the 0.005 level [meaning the finding was highly statistically significant].” The final data led the researchers to conclude: “In this analysis the AA group was five times more likely to binge than the control group and nine times more likely than the lay-RBT group. The AA group average was 2.4 binges in the last 3 months.”

Brandsma, who passed away in 2008, is probably rolling in his grave that his legacy is this particular study that he did in 1979-1980 being misrepresented. Scott Alexander, in his blog, does not view how this study has been abused very kindly:

Brandsma (1980) is the study beloved of the AA hate groups, since it purports to show that people in Alcoholics Anonymous not only don’t get better, but are nine times more likely to binge drink than people who don’t go into AA at all.

There are a number of problems with this conclusion. First of all, if you actually look at the study, this is one of about fifty different findings. [...]

Second of all, the increased binge drinking was significant at the 6 [this is an error; it was at three months we saw the increased binge drinking] month followup period. It was not significant at the end of treatment, the 3 month [Scott probably means 6-month] followup period, the 9 month followup period, or the 12 month followup period. Remember, taking a single followup result out of the context of the other followup results is a classic piece of Dark Side Statistics and will send you to Science Hell.

Scott also has the same issues with this study Kaskutas 2009 had:

Brandsma didn’t use a real AA group, because the real AA groups make people be anonymous which makes it inconvenient to research stuff. He just sort of started his own non-anonymous group, let’s call it A, with no help from the rest of the fellowship, and had it do Alcoholics Anonymous-like stuff. On the other hand, many members of his control group went out into the community and…attended a real Alcoholics Anonymous, because Brandsma can’t exactly ethically tell them not to. So technically, there were more people in AA in the no-AA group than in the AA group.

Point being, this study has been criticized for its methodological problems, abused by people more interested in attacking AA than in objective facts, and has possibly done more harm than good in finding out the truth of Alcoholics Anonymous’s efficacy.

The 1990 triennial survey: 26%, not 5% one year retention rate

There is an old myth that a 1990 AA Triennial survey shows a 5% one-year retention rate for Alcoholics Anonymous. This is a false belief: That graph, frequently brought up by anti-steppers with little interest in objective truth, actually shows a 26% retention rate, as pointed out in the article "Alcoholics Anonymous (AA) Recovery Outcome Rates".

The graph is not a membership retention graph; it is a simple count of, among the members in their first year, how many were around a given number of months.  If AA had a 100% retention rate, the graph would have shown 8.3% (i.e. 100% divided by 12) of members (instead of the 5% it shows) in their 12th month of sobriety.

The wording in the survey itself says it is a graph of "the number of members that have been around a given number of months"; it was not a graph of per-month membership retention.

This graph does not show an 80% first month drop out rate and it does not show a 5% one-year retention rate.  It shows a 70% first-month retention rate and a 26% one-year retention rate.

Here are a number of books and papers which claimed the 1990 Triennial survey showed a 5% retention rate before "Alcoholic Anonymous Recovery Outcome Rates" was published:

• McIntire, Don (2000). "How Well Does A.A. Work?". Alcoholism Treatment Quarterly. 18 (4): 1. doi:10.1300/J020v18n04_01. "at 12 months the figures are 5% remaining and 95% departed."
• Carl G. Lukefield, "Behavioral Therapy for Rural Substance Abusers", 2000 has this quote: "By 12 months, 90 percent have dropped out (McCrady & Miller, 1993)"
• Charles Bufe, AA: Cult or Cure 1997 has this quote Quote: "AA produced a large monograph, “Comments on A.A.’s Triennial Surveys,” that analyzed the results of all five surveys done to that point. [...] AA has a 95% new-member dropout rate during the first year of attendance."

However, after "Alcoholic Anonymous Recovery Outcome Rates" was published, a number of sources all of a sudden decided that the 1990 Membership retention survey showed a 26% one-year retention rate, which just happens to be the number in that paper. Even anti-AA polemics like Dodes' (poorly-argued) The Sober Truth now use the 26% figure. For example:

• Lance Dodes, M.D.; Zachary Dodes (2014). The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. ISBN 978-0807033159. "AA itself has published a comparable figure in a set of comments on its own thirteen-year internal survey, stating that only 26 percent of people who attend AA stay for longer than one year"
• Adrian, Manuella (2012). "Can Failure Carefully Observed Become a Springboard to Success?". Substance Use & Misuse. 47 (13–14): 1384. doi:10.3109/10826084.2012.706178. "the Alcoholics Anonymous triennial surveys from 1977 through 1989 found that one quarter (26%) of those who first attend an AA meeting are still attending after 1 year"

Point being, the conclusion in "Alcoholic Anonymous Recovery Outcome Rates" that those old surveys showed a 26% one-year retention rate are considered reliable among treatment experts.

As Slate Star Codex puts it: "Almost everyone’s belief about AA’s retention rate is off by a factor of five because one person long ago misread a really confusing graph and everyone else copied them without double-checking."

Moderation for alcoholics: Maybe not

Let’s take a look at this article (original link); this article is an opinion from 2016 on what the science says about Alcoholics Anonymous. First of all, it accurately shows that the 2006 Cochrare review on AA effectiveness is out of date:

Ferri, Amato, and Davoli’s conclusion in a 2006 meta-analysis published in the Cochrane Review [13] has been widely quoted (see e.g., [14]): “No experimental studies unequivocally demonstrated the effectiveness of AA or [Twelve-Step Facilitation] TSF approaches for reducing alcohol dependence or problems” [13].
[...]
Several studies do support some efficacy of TS programs of recovery [15-19]. AA participation is associated with fewer drinks and more abstinent days [15-17], and recent studies show that AA attendance improves sobriety even while controlling for self-selection bias [18]. While these studies do not show unequivocal evidence of success—and are not evidence of sufficient effectiveness to recommend AA/TS programs for everyone—they do support inclusion of TS in the set of appropriate interventions.
[...]
13. Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database Syst Rev. 2006;(3):CD005032.
14. Frakt A. What is known about the effectiveness of AA? Incidental Economist. December 20
15. Walitzer KS, Dermen KH, Barrick C. Facilitating involvement in Alcoholics Anonymous during out-patient treatment: a randomized clinical trial. Addiction. 2009;104(3):391-401.
16. Witbrodt J, Ye Y, Bond J, Chi F, Weisner C, Mertens J. Alcohol and drug treatment involvement, 12-step attendance and abstinence: 9-year cross-lagged analysis of adults in an integrated health plan. J Subst Abuse Treat. 2014;46(4):412-419.
17. Moos RH, Moos BS. Participation in treatment and Alcoholics Anonymous: a 16-year follow-up of initially untreated individuals. J Clin Psychol. 2006;62(6):735-750.
18. Humphreys K, Blodgett JC, Wagner TH. Estimating the efficacy of Alcoholics Anonymous without self-selection bias: an instrumental variables re-analysis of randomized clinical trials. Alcohol Clin Exp Res. 2014;38(11):2688-2694.
19. Kaskutas LA. Alcoholics Anonymous effectiveness: faith meets science. J Addict Dis. 2009;28(2):145-157.

So far so good; this shows that AA effectiveness for a subset of alcoholics is pretty much undeniable at this point, and it even links to an experimentatal study (Walitzer 2009) showing this. At this point, the article jumps the shark by giving us this inaccurate whopper without footnotes:

Additionally, TS [Twelve Step] programs promote the goal of abstinence, but moderation is a better goal for some people.

This is a really bold claim, so we would expect about seven footnotes showing research supporting this claim, like we had with the claim that AA helps some alcoholics. But, no, this claim is made without a single footnote.

I will link to two articles which make a strong case this claim is downright false:

• Return to Moderate Drinking is Still a Lie (original article)
• Here’s What Happened When I Tried Moderation Management (original article)

After the disaster that was Sobell 1973, where the moderate drinkers who supposedly did well were either drunk, dead, or abstinent 10 years later, I will not believe any study showing alcoholics moderately drinking again without a 10-year followup. The reason why we need a 10-year followup is because alcoholics are really good at being dishonest about their alcoholic drinking being “moderate”, and it takes up to a decade for the drinking to get so bad the alcoholic can no longer deny their drinking is out of control.

Kelly 2017: The kids assigned to AA did better, but we can't prove it

Let's look at the paper "Incorporating 12-step program elements improves youth substance-use disorder treatment." Here, the conclusion in the abstract is this " in terms of abstinence, a novel integrated 12‐Step facilitation treatment for adolescent substance use disorder (iTSF) showed no greater benefits." However, the conclusion is inaccurate.

The kids in the study who were assigned to TSF (Twelve Step Facilitation; the consoler tells the kid to go to more 12-step meetings) treatment did better than the kids who just had Cognitive Behavior Therapy (CBT), the control condition for this experiment.

In particular, nine months after the study ended (in the final follow-up), the group who randomly underwent TSF had a higher percentage of days abstinent (58% vs. 49% at the nine-month follow-up, overall p=0.33) and a larger number of subjects either completely or "mostly" abstinent (33% vs. 21% at the nine-month followup, overall p=0.30).  

The reason why these improvements were not considered significant is because there is a pretty high p value; in plain English, a p value of 0.33 means that there is a one-in-three chance the kids who were assigned to undergo TSF treatment (i.e. they went to more AA meetings) only did better because of random chance (the kids assigned to TSF might have been, by chance, more likely to do better).

The main problem with this experiment is that there were only 59 subjects; this is not enough people for them to conclude that, while the kids who used AA treatment did better, and it is more likely than not this was because of the TSF (i.e. "get your butt to an AA meeting") treatment they received, we can not be sure this was because the randomly picked kids who got TSF treatment were ones who would do better anyway.

12-step class vs. 12-step fellowship

There are a few randomized controlled trials out there, such as Brandsma 1980 [1] and Stahlbrandt 2007 [2] where the "Alcoholics Anonymous" experimental condition was questionable. With both of these experiments, there was no difference between subjects who had the 12-step-like condition and the control group.

What happened?

The 12-step condition was not an actual AA meeting.

With Brandsma 1980, as Kaskutas 2009 [3] describes it, the subjects undergoing "AA" treatment weren't actually going to AA meetings:

The description of the AA condition states that the steps were used for discussion content, the group focused on newcomers, and they told patients about sponsors, but it is not clear whether the meetings were led by AA members, whether crosstalk was allowed, whether the meeting leader shared their story as part of the meeting, or whether the meeting format was what one would encounter at an actual AA meeting. The meetings may not have been open to other AA members in the community, and not been listed in the AA meeting directory, which would mean that a potentially important therapeutic ingredient of AA--the experience of longer-term members--would not have been present in the AA condition.

With Stahlbrandt 2007, here is how the supposed "AA" meetings were run:

The TSI intervention was a 3-hour formal lecture, given by
therapists trained in the 12-step method.

Like Brandsma 1980, they did not see a difference between the supposed AA condition and the control group.

Point being, if an experimental condition is supposed to be an AA meeting, the numbers will not be reliable unless the AA condition is, in fact, an actual meeting. Which it wasn't with these two studies.

More recent studies, such as Litt et al. 2009, where we give the experimental group treatment which gets them going to more real AA meetings, show that the more people go to meetings, the more days they will be sober. It is unfortunate that these poorly done surveys have incorrectly given the wrong impression about 12 step efficacy.

[1] Brandsma, Jeffery M; Maultsby, Maxie C; Welsh, Richard J (1980). Outpatient Treatment of Alcoholism: a review and comparative study. Baltimore, MD: University Park Press. ISBN 0-8391-1393-5

[2] Stahlbrandt, Henriettæ; Johnsson, Kent O.; Berglund, Mats (2007). "Cluster Randomized Trial". Alcoholism: Clinical and Experimental Research. 31 (3): 458–66. doi:10.1111/j.1530-0277.2006.00327.x. PMID 17295731

[3] Kaskutas, Lee Ann (2009). "Alcoholics Anonymous Effectiveness: Faith Meets Science". Journal of Addictive Diseases. 28 (2): 145–157. doi:10.1080/10550880902772464. PMC 2746426. PMID 19340677.

It helps to actually understand the studies

The Fix has no, for all intents and purposes, editorial control over what gets posted to their magazine. It's a pleasant surprise to see someone post there use peer reviewed research; it's an unpleasant surprise to see how poorly they actually quote the research.

Case in point: This 2017 article from the members of the group "Handshake Media." Two points for actually quoting peer reviewed research.  -10000 points for ignoring key points made by recent addiction research. 

Let’s see here: Discounting studies showing showing TSF/12-step effectiveness without a control group (even though the surgeon general didn't), but accepting the results of Zenmore 2017/2018 which also didn't have a control group. Ignoring experimental studies which do show TSF effectiveness (e.g. Walitzer 2009, which she should have been aware of because it was mentioned in Humphreys 2014).

Discounting Humphreys without presenting a compelling argument: This silly article claims that "Their methods were inadequate for determining whether increased participation is causally linked to increased abstinence, or whether increases in abstinence occurred without self-selection bias", but can not show any actual problem with this paper. Humphreys 2014 shows that, when looking at the increase in AA caused by a randomized experimental condition, that, among other things "The 3 month model showed that an increase in attendance of 1% (i.e., one absolute percentage point, not 1% of prior attendance) predicted an increase in PDA [Percent days abstinent from alcohol] of about a third of a percentage point (B = 0.38, p = .001)." It would seem that they did not fully read or did not understand Humphreys 2014.

Also: There's no need to link to the paywall version of Humphreys 2014; It's a PMC open access article.

The author’s bias is obvious.

That said, happy 4th of July everyone. As per request, this page is now open to moderated comments and please be patient; it may take days or weeks to moderate your comment.

Edit: To be fair, this author later conceded that Humphreys 2014 shows evidence that 12-step approaches can be helpful.

People in AA or NA should not play doctor

People in AA and NA should not play doctor. Full stop. End of discussion. The Big Book is clear on this. From page 133:

we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.

Point being, it's not the place of people in the rooms of AA (or NA, or any other 12-step program) to play doctor. There's a reason why it takes years of study to become a doctor: Medical science is hard. An average alcoholic or addict seeking recovery is not qualified to give medical advice.

This brings us to this article. The problem: People in NA think they are in a position to tell recovering addicts to not engage in Opioid replacement therapy. No, they are not. Full stop. Never let someone in the 12 step rooms play doctor! If a recovering addict is recommended by a doctor to take, say, Suboxone, it's not the duty of someone in NA to question that doctor. 

Dodes 2014: Bad science

Lance Dodes' book The Sober Truth is, bottom line, bad science. I have read it and compared what it says to the papers Dodes cites; in multiple cases, Dodes makes fundamental errors in his research. For example, Dodes claims that Fiorentine 1999 showed a 40% sobriety rate among active AA members; however, reading this study shows that it actually demonstrates a 75% sobriety rate. As another example, Dodes claims that Moos and Moos 2006 didn't look at how many active AA members stayed sober; actually Moos and Moos 2006 reports that 67% (or 77 people) were sober 16 years later.

I am not the only one who finds Dodes' reasoning flawed. The New York Times calls it a "polemical and deeply flawed book." The esteemed doctors Chad Emrick and Thomas Beresford, who find Dodes entire reasoning process questionable, looking at the second way Dodes tries to claim AA has a 5% success rate and say that "Albeit harsh to say, it appears that Dodes and Dodes did not let facts get in the way of drawing their second conclusion about AA’s effectiveness." The psychiatrists Jeffrey D. Roth and Edward J. Khantzian, in their review of The Sober Truth called Dodes' reasoning "pseudostatistical polemic." Addiction experts John Kelly and Gene Beresin also found Dodes' reasoning flawed.

For the record, the scientists criticizing Dodes' work come from the best schools: John Kelly, Eugene Beresin, and Edward J. Khantzian are all from Harvard. In addition, Jeffrey Roth graduated from Yale, and Thomas Beresford graduated from Stanford. I see a lot of very prestigious doctors strongly criticizing Dodes' work.

The outrage press (NPR, The Atlantic, Salon) placed far too much weight on the opinion of one doctor and his son even though so many other experts have looked at his reasoning and found it deeply flawed.

Dodes and Moos and Moos 2006

Since Moos and Moos 2006 invalidates a central thesis of Dodes' false claim that Alcoholics Anonymous has a 5% success rate, Dodes goes to some effort to try to discredit this key study.

After discussing how the people who were successful in Moos and Moos 2006 were compliant (which is just another way to word the "self selection bias" problem), Dodes writes this:

The Moos study also employs some objectionable statistical methods. In one critical omission, its conclusions ignore all the people who died and the large number of people who dropped out of the study altogether, despite conceding that these were the people who statistically consumed the most alcohol. As early as year eight, the number of subjects who were left in AA had already shrunk by nearly 40 percent (from 269 to 166), yet these people are erased from the conclusions as if they had never existed at all. Add up all the people who died and the dropouts, and the results for AA become far grimmer than the authors suggest.

Dodes is flat out inaccurate here. The multiple Moos studies which use the same subjects, including Moos and Moos 2006, had a total of 628 people who said they would participate in the studies. Moos and Moos 2006 looks at 461 of them. We have a drop out rate (in other words, people who elected to be in the study but didn't follow up) of under 27%, yet Dodes is stating Moos/Moos 2006 had a drop out rate of 40%. It would appear Dodes is confusing the number of people who stopped going to meetings with the number of people who didn't do two or more follow-ups; while these are both "drop outs", they are very different figures.

What Moos and Moos measured was this: Of the 115 people who were heavily involved with AA in the first year, and who did two or more follow ups, 77 of them (67%) were sober 16 years later.

What about those 167 subjects in Moos and Moos 2006 who didn't do two or more follow ups? We can go back to Timko and Moos 1993, the one-year follow-up study which used the same subjects. Here, they look at 515 of those 628 people. Even when looking at a larger subset of subjects, we get the same level of people who tried AA: Moos and Moos 2006 has 269 of the 461 subjects studied who tried AA in their first year (that's 58%).  Timko and Moos 2003 has 294 of the 515 subjects trying AA in their first year (57%). It would appear that the drop outs who did not finish two or more surveys did not significantly affect the results.

Dodes continues:

The stated size of this survey is also misleading. Although the researchers began with 628 people, the total number of people who remained through the sixteen-year follow-up and also stayed in AA for longer than six months -- that is, the group on which the authors’ major findings are based -- was just 107, or 17 percent of the original sample. And of the remaining 107, the researchers never revealed the actual number of people who improved, or even stayed sober. They told us only which group "had better outcomes."

Dodes, again, is not correctly reading Moos and Moos 2006. First of all, there were 115 (not 107) people heavily involved with AA in the first year. Moos and Moos 2006, in addition, looked very closely at the number of people who were sober 16 years later: "Individuals who received 27 weeks or more of [Alcoholics Anonymous] treatment in the first year were more likely to be abstinent and less likely to have drinking problems at 16 years than were individuals who remained untreated in the first year." In addition, Moos and Moos 2006 tells us exactly how many people in that group were sober 16 years later in Table 3: 67% of 115. I will save Dr. Dodes the bother of bringing out a calculator: That's 77 people. I can not see how Dodes can look at Moos and Moos 2006 and claim it did not state how many people who took AA seriously were sober 16 years later.

In terms of other factors, table 2 of Moos and Moos 2006 shows a strong correlation between AA treatment and improvement in both self-efficacy and social functioning. To quote Moos/Moos 2006: "a longer duration of AA was independently related to a higher likelihood of 16-year abstinence, enhanced self-efficacy, and good social functioning, and less likelihood of 16-year drinking problems."

As far as I can tell, Dodes did not even fully read Moos and Moos 2006 before writing up a polemic trying to discredit its numbers. I expected better.

Let's get some real figures for AA success:  Moos and Moos 2006 showed that 67% of the people who took AA seriously were sober 16 years later. If the self section issue is problematic and you want experimental studies, both Litt et al. 2009 and Walitzer 2009 show that correctly getting subjects in the rooms of 12-step meetings work better than other addiction treatments.  Bottom line, AA works.

Cochrane 2006: Out of date

The Cochrane 2006 review of Alcoholics Anonymous (Ferri 2006), which concluded that no experimental studies show the effectiveness of Alcoholics Anonymous compared to other treatments, is out of date. There have been multiple experimental studies showing twelve step facilitation (which is when a doctor on counselor helps an alcoholic go to AA meetings and become a part of AA's culture) effectiveness which are more recent than this old review.  I just added two of those studies to the Wikipedia:

Litt et al. 2009
Litt et al. 2009 randomly assigned to patients to one of three treatments: Network support, network support and contingency management, or a control condition (case management). The network support condition, which was "designed to use AA as an efficient means to engage patients in a supportive abstinence-oriented social network", had significantly better abstinence rates compared to the control and the combined treatments. This study is PMC2661035.

Walitzer 2009
Walitzer 2009 is an experimental study which randomly assigned patients to one of three treatments. Two of the treatments were Twelve Step Facilitation (TSF) treatments: Treatments which helped patients become involved with Alcoholics Anonymous and other twelve step programs.

One of the two TSF treatments, the 12-Step-based directive approach, resulted in increased number of days abstinent and other positive outcomes compared to the other two treatments. This study is PMC2802221.

Both of these studies are free to read; I encourage anyone who believes that the old Cochrane study still shows that Alcoholics Anonymous does not work to read these post-Cochrane studies.

Fiorentine 1999: 75% success rate

I just added this to Effectiveness of Alcoholics Anonymous:

Fiorentine 1999 was a 24-month longitudinal study measuring the effectiveness of AA and Narcotics Anonymous. Like other longitudinal studies, it shows a strong correlation between 12-step attendance and being both clean from drugs and sober from alcohol: People who went to 12-step meetings in the study had about a 75% success rate.

In more detail, at the 24 month follow up, 77.7% of people who went to one or more meetings a week self-reported being clean; urinalysis was very close to that figure, showing some 76.4% of the regular attenders begin clean. For participants who did not regularly go to meetings, the self reported figure for being clean was 56% and the drug test showed 57.9% being clean. The self-reported figures for alcohol abuse were similar: 74.8% of regular 12-step attenders self-reported being completely sober, but only 40% of people who did not go to 12-step meetings claimed to be sober. Urinalysis showed 96.6% of people regularly going to meetings as sober, in contrast to the 88.9% of people who didn't go to meetings once a week or more whose urine sample was alcohol-free.

The report then sees if 12-steps meetings have a specific effect (in other words, if there is causation or merely correlation) by using statistical analysis to compare participants self-reported level of motivation, 12-step attendance, and successfully getting clean and sober. The result of this observation was that "Weekly or more frequent 12-step participants are 1.59 times more likely than less-than-weekly participants to maintain abstinence after controlling for the differences in recovery motivation measured by the scale."

---

Not added to that article: Lance Dodes falsely claims that Fiorentine 1999 states that "approximately 40 percent of individuals categorized as having continued active participation in AA maintained high rates of abstinence." and then multiplies an unrelated figure to falsely claim that AA has an 8% success rate. Fiorentine 1999 makes no such claim. No where in this paper does the above quote appear. I was unable to find this quote. Thomas Beresford was unable to find this quote. As far as either of us can tell, this quote is a figment of Dodes' imagination.

AA has no opinion on whether God exists

From another of my recent Disqus postings:

The existence of God is a theological question, not a question that can be answered by science. However, we can measure how much AA helps alcoholics stay sober.

We know that the more often people go to meetings (especially in the first year), the more likely they are to stay sober. Moos and Moos 2006 shows an undeniable correlation. Humpreys 2014 makes a strong case that the AA program is the cause for meeting makers making it. Galanter 2016 goes even further: It shows objective scientific evidence that praying helps successful AA members stay sober.

Now, we don't have peer reviewed science asking people “did you work the steps as written in the first 164 pages to the best of your ability?”, but we do have Gabriel Segal's essay "How an addict's power of choice is lost and can be regained" which makes a very strong case that 99% of alcoholics who get serious about the program stay sober.

Moderate drinking redux; also more on the Sinclair Method

Let me just post some of my recent disqus postings:

The fact is that the Sobell 1973 study [a study which claimed alcoholics could moderately drink again] was so bad, a fraud investigation was opened. As a 1984 New York Times article put it (look for “Panel finds no fraud by alcohol researchers”):

>>The panel also said it had found ''several errors'' and ''use of ambiguous terminology'' in scientific publications by the Sobells, which indicated that they were ''careless in preparing their manuscripts for publication.'' But the panel said it had seen no evidence that these errors and ambiguities ''represent scientific misconduct - defined as 'fraudulent or highly irregular research practices.' ''<<

Anyway, facts are facts. Those “moderate” drinkers from the Sobell 1973 study were either drinking alcoholically again, or were dead from drinking, or were abstaining from alcohol when a 10-year-followup was performed.

--

Sobell 1973 and the moderate drinkers: Four of those “moderate drinkers” died. Also: Six were abstinent, nine of the “moderate” drinkers were engaging in out of control drinking. There was only one person who, ten years later, could be considered a “moderate” drinker. Please read Pendery 1982 or any of the numerous books which correctly cite it.

Sobell 1973 in comparison to the non-moderate drinkers: This is cherry picking data. The Sobells only compared the fatalities of the “moderate” drinkers with the non-moderate drinkers. I have not seen the abstinent or out-of-control drinking figures for this other group; and it is telling that the Sobells never shared (or, it would seem, even bother to get) those figures.

Since there were only 20 subjects in each study, whether six or four died is an error of approximation, nothing more.

Davies 1962: These “moderate” drinkers also reverted to serious drinking again. Reference: G. Edwards. "D.L. Davies and 'Normal drinking in recovered alcohol addicts': the genesis of a paper" Drug and Alcohol Dependence 35.3 (1994)

Rand report: The 1980 four-year followup shows many of the 1976 Rand report moderate drinkers relapsing.

Moderation management: No peer-reviewed science was ever done with this group, but it’s very telling that its founder drank heavily, to the point police took her to detox in handcuffs while she was still the leader of Moderation Management. She soon afterwards killed two people while driving drunk and eventually killed herself [1].

Point being, pretty much any study showing successful “moderate” drinking, when followed up, shows those same “moderate” drinkers drinking heavily again.

[1] There are claims that the Moderation Management founder was a member of AA at the time of her crash, but as per her autobiography, she did not work the 12-step program in any meaningful way. Instead, she was coming up with excuses for not going to meetings.

--

In response to a claim that the “moderate” drinkers in Sobell 1973 had better success rates than people trying abstinence:

In terms of more recent studies, people who choose to work the AA program have between a 75% (Vaillant 1995) and 67% (Moos and Moos 2006) success rate. The Sobell moderation group had, by comparison, a 30% abstinence success rate and a 5% moderation success rate.

--

In response to a claim that the Sinclair method works better when trying complete abstinence, and works better the longer it is applied:

OK, let me go back to PMC3970823. They use a ”magic number” called “g” which is summarized near the end: “the aggregated Hedges’ g for naltrexone and acamprosate compared to placebo was 0.209 (CI: 0.157 – 0.262) – indicating a small but significant effect. In comparison to other medications prescribed for mental health (e.g., for depression), the effects of naltrexone and acamprosate are somewhat smaller”

So, this information in mind, let’s look at table 2 in PMC3970823. Naltrexone has an abstinence aggregate of .116—which is not very different than a placebo. However, the numbers for “heavy drinking” (.189), craving (.144), and both heavy drinking and craving (.180) are not much better—they are “small but significant.”

It also looks like, when looking at multiple studies, the effect diminishes when doing follow-ups: “naltrexone studies tended to have effect sizes for heavy drinking outcomes at the last follow-up point (g = .135, k = 6) that were slightly smaller compared to end-of-treatment (g = .189, k = 39). Although only two studies provided data, the naltrexone-placebo effect sizes for craving at the last follow-up point were close to zero (g = .053).” In other words, this meta-study didn’t see naltrexone helping people not drink heavily over longer periods.

In light of Pendery 1982, and in light of what happened with the founder of Moderation Management (while she claimed to drink moderately without problem for years, she killed two people while driving drunk, and eventually killed herself), when people suggest moderation as an outcome for alcoholics, I will remain very very skeptical until when and if we have 10-year-followups with very high “g” values and very low “p” values.

The Sinclair method revisited

An advocate for the Sinclair method pointed out, in an online debate, the study “Targeted Naltrexone for Problem Drinkers.”  Here is my response:

That 2011 study (“Targeted Naltrexone for Problem Drinkers”) is a 12-week trial, and the study considers “moderate drinking” a successful outcome. This is a very short trial period, and short-term studies since the 1960s showing alcoholics “successfully” drinking moderately have, if followed up, shown the same drinkers having serious drinking problems five or 10 years later (the most famous example of this is Sobell 1973, showing “moderate” drinking among alcoholics, but Pendery 1982 showed that the same “moderate” drinkers were either dead, abstinent, or drinking heavily a decade later).

The meta-study (a study looking at other studies) “Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful?” (PMC3970823) points out that “Several reviews and meta-analyses have reported small or mixed effects for each medication (both naltrexone and another medication called acamprosate), and treatment providers cite concerns over efficacy as one barrier to greater medication use.”

This isn’t the first study which showed good results for Naltrexone, but considering the number of other studies which show only a modest effect, and considering the need for a long term follow up to see if an alcoholic is in fact successfully moderately drinking, I will need to see studies with five-year or 10-year follow ups showing continued “moderate” drinking before I will believe this drug is a functional way to let alcoholics control their drinking.

12 Steps is not too many (Miller 2008)

Back in 2009, Time magazine published an article claiming 12 steps are too many. This article, in addition to having a section praising Naltrexone (a pill with limited value), uses a single study to conclude the 12 steps are not helpful.

The dubious study was led by pro-moderate-drinking-for-alcoholics advocate William Miller, and is entitled “Spiritual direction in addiction treatment: Two clinical trials.”

This paper is an outlier. A 2012 meta-study of hundreds of papers about religion, spirituality, and health (Religion, Spirituality, and Health: The Research and Clinical Implications by Harold G. Koenig) looks at hundreds of similar studies.  Of the 178 studies about depression and spirituality with the highest methodological rigor, the 2008 Miller paper is one of only 13 which showed spirituality resulting in more depression symptoms. In addition, this meta-study looked at whether spirituality helps people get clean and sober. Of the 145 studies with the best methodologies directly investigating the question of whether spirituality helps overcome substance abuse, 131 showed that it did, and only one could make the case that spirituality hurts someone’s chances of getting off of alcohol and/or drugs.

Koenig 2012 is not the only paper that contradicts Miller 2008. J. P. B. Goncalves et al. 2015 (Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials) looks at 23 studies; Miller 2008 is the only study they look at which concludes there is a negative correlation between spirituality and better results. 

Another paper may explain the issues with the methodology in Miller 2008. Greene 2012 (Gary Greene and Tuyen D. Nguyen The Role of Connectedness in Relation to Spirituality and Religion in a Twelve-Step Model) speculates that Miller 2008 “may point to the  immeasurable therapeutic value of the spiritual connectedness between members of  twelve-step and other groups and a measurable disconnect often present in research trial” (emphasis in original). In other words, Greene 2012 speculates that the subjects of Miller 2008 who got “spiritual” guidance did not get it in the form a newcomer gets it in the rooms of 12-step meetings, since the subjects did not experience the same connectedness.

Cherry picking a single study whose results are different than the results of the majority of similar papers does not make for a very compelling case against using the 12 steps to stay clean and sober.

The 12 steps work. A single study saying otherwise does not change this fact.

A tale of two papers

I look at two papers in this blog entry, one of which will be questionable, the other of which is well written.

The Alcohol industry is funding a “Moderate Drinking” study

The New York Times has published an exposé last month showing how the NIH solicited contributions from the alcohol insustry for a “Moderate drinking” study.  It would seem that, in order to fund an expensive study on drinking called the “Moderate Alcohol and Cardiovascular Health Trial (M.A.C.H.)” trial, the alcohol industry has spent millions of dollars to make this study a reality.

Whatever finding this study has about moderate drinking are at best suspect, especially for anyone who is a potential alcoholic; the NY Times piece reports that “many people whose health might be compromised by light drinking — anyone with a history of addiction, psychiatric, liver or kidney problems, certain cancers or a family history of breast cancer — will not be allowed to participate. People who have never drunk alcohol also are excluded.”

Knowing how studies are quoted out of context by the kinds of people with an agenda against Alcoholics Anonymous, and knowing how often those kinds of people try to justify moderate drinking for alcoholics, even though that is, as I pointed out before and will point out again, is a fool’s errand, I would not be surprised if those kinds of people, years down the road, use this study to “prove” that Alcoholics Anonymous’ model of abstinence is “harmful.”

A realistic look at Alcoholics Anonymous

Marc Galanter, who helped write a paper showing how prayer helps AA members stay sober, has another excellent paper out there.

Entitled “Combining medically assisted treatment and Twelve-Step programming: a perspective and review”, this paper goes over, among many other things, why Cochrane 2006 had methodological issues in concluding that AA does not work any better than other methods.

A very good paper well worth reading. Nicely enough, this paper is not paywalled.

Naltrexone, acamprosate, and the Sinclair Method

Since I have been in an online debate with someone who claims AA doesn't work and advocates the Sinclair Method, I should go over the newer medication assisted therapies.

The Sinclair Method is simply suggesting to use the medication Naltrexone along with engaging in moderate drinking. There have been studies showing that people can more easily moderately drink when taking Naltrexone, but the effect has also been described as being modest. 

The Sinclair Method has the same problem all other moderation methods have: Yes, it shows some, albeit modest, level of short term success, but we do not have long term studies. Short-term studies advocating moderate drinking are unreliable; long term follow ups show the "moderate" drinkers drinking heavily again. Until we have a 10-year follow up study showing people still using Naltrexone to moderate their drinking, or being able to abstain from drinking altogether after using Naltrexone for a while, I am very skeptical. We have had too many people die deceiving themselves with "moderate drinking" approaches; I have not seen evidence that Naltrexone is a silver bullet that will change things.

Naltrexone is not an effective therapy for people who want to abstain; there are two studies showing this drug has little to no effect when the patient pursues abstinence. 

Acamprosate, on the other hand, seems to work better when the goal is abstinence. The effect is "small but significant", but it may help alcoholics achieve abstinence when used with other therapies.

I think, when used with the 12 steps and regular Alcoholics Anonymous, Acamprosate may be a helpful drug for achieving long-term sobriety. Bill Wilson had no objection to the use of medications to successfully work the AA program. That said, while the effect for both drugs is there, it's small.

I also oppose dogmatism in AA

There is remarkable little I disagree on with the author of https://www.recoveringfromrecovery.com/

The fact of the matter is this: A quarter of a century ago, when a home computer was an investment which cost as much as a good used car, and the internet was only something only occasionally mentioned in magazines, people were a lot more dogmatic in AA meetings. The steps, outlined in the first 164 pages of the Big Book were the only way to save sober, and if you didn't get serious about working the steps right now you would surely relapse again. People enjoyed beating the program over people's head and using the program as an excuse to bully newcomers. 

I found the dogmatism of those people repulsive, and managed to stay sober, even though I had to fire my sponsor just before working my fifth step. According to the AA fundamentalists, I was on the path to relapse since I didn't finish the steps. It took me a decade to finally finish up the steps (where step nine has been by and large living amends), a decade where I never relapsed.

The point being: I was not, for large parts of my recovery, a Big Book thumper. There was a brief period when I started thumping the Big Book pretty heavily at meetings, to the point someone with more time than me told me to stop beating the drum. The program, as written in the first 164 pages of the Big Book, is a very effective program, but I no longer pretend that it is the only, or even necessarily best, way to stay sober.  

And, the AA program has changed. It used to be standard fare to hear people proclaim "The program as written in the first 164 pages is the way to stay sober." Recently, I got in a heated discussion when I pointed out that a person can stay sober with just the 164; telling people they must work the program a certain way is just not how things are done at AA meetings any more.

Atheists, who used to hide in the corners, now openly proclaim their atheism in the rooms. Indeed, the Gravevine is looking for atheists and agnostics who are still sober to publish their stories in official AA literature. They may still be Big Book meetings, but there are also people with years clean and sober who openly admit that they do not like the Big Book in meetings.

That said, the fanaticism of people with an agenda is even worse. https://www.recoveringfromrecovery.com/anti-aa-forums-and-blogs/ describes them well. When they were a loud spoken minority, that was one thing. Once Lance Dodes's book made their viewpoints get printed in mainstream journals, that was when a line was crossed. I knew, from my decades of experience with AA, that claims of AA not being helpful were simply not true. I started reading scientific papers, started to understand what was being discussed; the page http://slatestarcodex.com/2014/10/26/alcoholics-anonymous-much-more-than-you-wanted-to-know/ is a good, reasonably balanced introduction to what the science has to say about AA effectiveness. 

AA works if you work it. The science shows that. The AA Big Book, in the preface to the second edition, claims a 75% success rate among "alcoholics who came to A.A. and really tried." Multiple observational studies support this figure, to name just three: Valliant 1995, Fiorentine 1999, and Moos and Moos 2006. 

No, AA is not for everyone. There are people who may be better off staying sober using SMART Recovery, Life Ring Fellowship, The Sinclair Method, whatever. Or the first 164 pages of the Big Book: I have well over 10,000 days clean and sober working the Big Book program. But making false claims that AA fails the majority of people who really try the program is downright dishonest. Making claims that AA has a 5% success rate is downright dishonest. Using 38-year-old or 50-year-old studies to claim AA doesn't work while ignoring studies from this century showing AA effectiveness is downright dishonest.

Hence, this blog. I correct the record when people with an agenda against AA use outdated or inaccurate information to downplay AA's huge success keeping people sober.

Surprise! An article in a stoner magazine doesn't like Alcoholics Anonymous

Surprise! An article in a stoner magazine doesn't like Alcoholics Anonymous.

This article uses the following two anti-AA tropes to claim that AA does not work:

• Lance Dodes' claim that AA has a 5-8% success rate, which I have have dealt with four years ago in this blog, and which has been fully refuted in the article "Alcoholics Anonymous and The Atlantic: A Call For Better Science"
• That table in Handbook of Alcoholism Treatment Approaches which anti-steppers (such as stoners lying to themselves) love to bring out, which is also quite inaccurate (yes, I have already blogged about this table). Did I mention that its author, William R. Miller, has recently written a book telling alcoholics how to moderate their drinking which is, quite bluntly, a fool's errand.

The article also claims the AA Big Book is inaccurate when it claims a 75% success rate. Actually, I have seen multiple studies with this figure or similar figures; e.g. Moos and Moos 2006 shows, among alcoholics who took AA seriously, 67% of them were still sober 16 years later.

2018 is starting off as a great year

2018 is starting off as a great year.

The Vox published today a well-researched story about Alcoholics Anonymous with information which actually reflects what treatment experts know about AA today, called Why some people swear by Alcoholics Anonymous — and others despise it.

Unlike the anti-AA polemics posted by NPR, The Atlantic, and Salon over the past few years, they did not waste their time interviewing known anti-AA critics Lance Dodes or Stanton Peele. Instead, they talked to people with a more balanced view, such as Keith Humphreys.

There’s no nonsense about AA having a 5% success rate; they say about a third of alcoholics are successful using AA. This is actually higher than the numbers I have seen; for example, Moos and Moos 2006 shows that AA  has a 67% success rate among the 25% or so of alcoholics who choose to be highly involved in the program their first year sober.

I am glad to see the mainstream press is starting to publish articles showing the real success rate for AA, instead of publishing articles with deceptive success rate figures (there is no peer-reviewed study which concludes AA has a 5% success rate!) which discourage people from going to a program which can save their life.