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 First of all, it accurately shows that the 2006 Cochrare review on AA effectiveness is out of date: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.

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.

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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.

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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.

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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.

There is no evidence Audrey Kishline was an active member of AA in 2000

Audrey Kishline was the founder of the group "Moderation Management", which pretended that chronic alcoholics could drink moderately again. Audrey Kishline was never able to drink moderately; in 2000, she got behind the wheel of her truck, and killed two innocent people while driving drunk. 

Soon afterwards, Kishline admitted that "moderation management is nothing but alcoholics covering up their problem."

Audrey Kishline ended up killing herself in late 2014. This was the end result and ultimate consequence of denying she had a drinking problem and deceiving herself and others that she could drink moderately again: Death. Not only her own death, but the death of two innocent bystanders.

One refrain anti-steppers attempt to make when people point out the consequences of Audrey Kishline lying to herself about her moderate drinking, is that she was in AA when she had her fatal drunken driving episode.

There is no evidence that Audrey ever actively worked an AA program before this tragic incident.

The evidence anti steppers bring up is this: http://archive.is/yDrVt where Audrey finally admits she can not drink moderately to the Moderation Management mailing list; she wrote that "I am now following a different path, and to strengthen my sobriety I am attending Alcoholics Anonymous, but will also attend Women for Sobriety and SMART Recovery. I am sure I can learn much from all of these fine programs."

Did Audrey get a sponsor? How often did Audrey go to meetings? Did she work the program as described in the first 164 pages of the Big Book? Was she serious about the program, or was she just trying to look good to others?

The fact that she was considering other programs when she wrote this sentence indicates that she was not serious about AA. I suspect she was just trying to look good to others.

In fact, let's look at an obituary posted after she killed herself to get more details of her life when she drove drunk like that: http://archive.is/SyhFU

When she wrote the email saying that moderation was not working any more, her drinking was so bad, she was forced by law enforcement to go to a detox program. Not a peep in her email about the fact her drinking was so bad, it was giving her legal problems, The email she sent to the listserv was dishonest, so its claim that Audrey was actively going to AA meetings is, at best, suspect.

The only evidence that Audrey went to even a single AA meeting between the time she wrote the email claiming she was going to AA and the time she killed two people driving drunk is an email which we now know was dishonest. 

(Update: The Dateline piece on Audrey's drunk driving has a tiny bit more detail about Audrey's supposed membership in AA between the time she left Moderation Management and that her fateful accident: "The creator of MM was admitting defeat. She checked herself into a detox facility followed up by AA meetings, but she couldn’t play by those rules either.  It did not go unnoticed by her 10-year-old daughter. [Kishline said that] 'I would keep falling off the abstinence wagon.' " Again, no details about the number of AA meetings Audrey went to or whether she actually got serious about working the program)

Update #2: Here is how Audrey Kishline described her year-2000 Alcoholics Anonymous supposed attendance in her autobiography Face to Face:

In the two months that followed [after she wrote the email to the Moderation Management list saying she could not moderate her drinking and before her tragic drunk driving accident] I was supposed to be attending AA meetings, abstaining from drinking, and "working the program." I had huge remorse about having become so drunk and calling the police [This refers to the event where she was forcibly put in detox]. Remorse was my motivation this time to get my act together and quit drinking. But the same old cycle I lived for years began to repeat. I'd abstain for a few days and immediately fall off. Each fall was getting worse and worse. It became increasingly harder for me to remain anonymous too. I was easily recognizable when I attended AA, which only added to my discomfort. I never identified myself as anyone other than "Audrey," but lots of people knew exactly who I was. 

(emphasis in bold like this mine; notes in italics and brackets [like this] added by me to give context)

This is a description of someone who almost never went to AA because they found excuses and justifications not to go, not the story of someone who took AA seriously and worked the 12 steps to the best of their ability. Supposed-to-be-going-to-AA but finding excuses not to go (such as thinking people will recognize and judge them) is not good enough for someone to get sober using the AA program.

The press has been very hostile to AA this month

The press has been very hostile to AA and other 12-step programs this month.

First of all, numerous articles about that Moderation Management group have been hitting the mainstream press this week. Never mind that MM's founder died drinking, and killed two innocent people because of her drinking. There are undoubtedly heavy drinkers out there who can moderate their drinking, but I don't care. There are also active alcoholics who think they are merely heavy drinkers who can somehow moderate their drinking, and who will go to great lengths to believe that lie. Countless alcoholics have died thinking they could moderate their drinking; I pointed out a few examples in my posting yesterday.

Here is a post from over a year ago refuting the claims that serious alcoholics can moderate their drinking: https://elplatt.com/return-moderate-drinking-still-lie

Not only has Moderation Management been getting a lot of press this month, but also anti-stepper Gabrielle Glaser just got a long article with the same tired old anti-stepper talking points published in The Atlantic. The best refutation to her talking points published so far is the article "Why Alcoholics Anonymous Works" by Jesse Singal: http://nymag.com/scienceofus/2015/03/why-alcoholics-anonymous-works.html 

Back in the time before I started drinking and during my active drinking, the mainstream press was not this hostile towards Alcoholics Anonymous. Indeed, in my day, 60 Minutes aired a segment about how one controlled drinking program was a failure that killed no less than four alcoholics. The fact the press was so friendly to the 12-step program is one of the reasons I got clean and sober as quickly as I did.

I am worried about the bullshit active alcoholics are reading these days. Moderation Management's bullshit that a heavy alcoholic can drink normally again already killed its founder and two innocent people; I wonder how many other people MM and the positive press it is getting this month will kill. I wonder how many active alcoholics will read Glaser's article in The Atlantic and take the drink that kills them instead of getting to a meeting and getting better.

Alcoholics need help, not people cosigning their bullshit.