The 2020 Cochrane review of AA has been released

The 2020 Cochrane review of AA efficacy has finally been released. Unlike the old 2006 review, which stated that “available experimental studies did not demonstrate the effectiveness of AA or other twelve-step approaches in reducing alcohol use and achieving abstinence compared with other treatments”, the new 2020 Cochrane review has this to say:

clinically-delivered TSF [twelve-step facilitation] interventions designed to increase AA participation usually lead to better outcomes over the subsequent months to years in terms of producing higher rates of continuous abstinence

Looking at the study, the strongest data shows that Alcoholics Anonymous significantly increases abstinent rates: When comparing Alcoholics Anonymous and/or Twelve Step Facilitation to other alcohol use disorder interventions, at the 12-month follow up, studies show a 41.8% abstinent rate for AA/TSF treatments, compared to 34.5% abstinent using non-AA interventions.

The New York Times, in an article about this review, has this to say:

A.A. leads to increased rates and lengths of abstinence compared with other common treatments

While the full review is behind a paywall, its summary is freely available for anyone to read.

This is the final nail in the coffin for the “AA has a 5% success rate” nonsense the media was spreading around in the mid-2010s.

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.

June 2015 round-up

OK, I'm back, but just to summarize a couple of articles and comments I have found.

First of all,  a recent study concluded that "increasing AA attendance leads to short- and long-term decreases in alcohol consumption that cannot be attributed to self-selection." (PMC4285560). Austin Frakt wrote a New York Times piece about it: http://www.nytimes.com/2015/04/07/upshot/alcoholics-anonymous-and-the-challenge-of-evidence-based-medicine.html 

This study is pretty key: It's been well-established by the science that, as we say in AA, "meeting makers make it"; the question now being asked is "do meeting makers make it because those that go to meetings are more motivated to get sober, or because AA helps keep alcoholics sober?" This study concludes it's the actual program which keeps people sober.

* * *

Here's another good refutation of Lance Dodes's book: http://www.amazon.com/gp/cdp/member-reviews/A3HLE5G8L7A4OQ For example, here's an excerpt from one study (PMC2746426; I have taken the liberty to remove references to other parts of the study placed in parenthesis in the original):

Rates of abstinence are about twice as high among those who attend AA; higher levels of attendance are related to higher rates of abstinence; these relationships are found for different samples and follow-up periods; prior AA attendance is predictive of subsequent abstinence; and mechanisms of action predicted by theories of behavior change are present in AA. However, rigorous experimental evidence establishing the specificity of an effect for AA or Twelve Step Facilitation/TSF is mixed, with 2 trials finding a positive effect for AA, 1 trial finding a negative effect for AA, and 1 trial finding a null effect. Studies addressing specificity using statistical approaches have had two contradictory findings, and to that reported significant effects for AA after adjusting for potential confounders such as motivation to change.

This is how Dodes quotes that in his book:

Rigorous experimental evidence establishing the specificity of an effect for AA or 12 Step Facilitation is mixed, with two trials finding a positive effect for AA, one trial finding a negative effect for AA, and one trial finding a null effect. Studies addressing specificity using statistical approaches have had two contradictory findings, and to that reported significant effects for AA after adjusting for potential confounders such as motivation to change.

Only someone with a strong anti-12-step bias would take a study that states that "rates of abstinence are about twice as high among those who attend AA" and conclude that the study is saying that "the strong evidence that one would expect if AA were clearly effective is simply not present."

What Dodes is doing here is a dishonest: He is not arguing that meeting makers make it, although he tries to imply that using unrelated data. The evidence that "meeting makers make it" is so well-established in the addiction science academic community that Dodes does not even try to directly argue that adage. What he is instead arguing is that perhaps meeting makers make it because they were more motivated to get sober at the start, or because of AA's social network. 

It's a strictly academic question, and does not affect the fact that AA is the only alcohol support group in the world with thousands upon thousands of free meetings. Even here, the studies are at worst inconclusive, only because AA is so successful and universal that anyone seeking treatment for alcoholism has been exposed to AA. To go from "it's really hard to decide whether someone going to AA is successful because of the program itself or because of other factors" to "AA doesn't help alcoholics" is a really large, and downright intellectually dishonest, leap.

Anyway, studies like PMC4285560 have tried really hard to eliminate other factors, and conclude that there's something about the AA program itself that is helping keep people sober. While not directly looked at in this study, I say it is the 12 steps as written in the first 164 pages of the Big Book that are keeping people sober.

As we were talking about at a meeting yesterday, the problem with the press is that the only news that attracts the press is bad news. The numerous studies giving us more and more evidence that AA works are ignored by the press; it was Lance Dodes's very biased, inaccurate, and negative book which got so much mainstream press attention last year.