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12-Step Approaches to Alcohol Treatment Receive Major Support in Review

March 11, 2020

Structured 12-Step Facilitation approaches to alcohol use disorder treatment result in outcomes at least as favorable as interventions such as cognitive-behavioral therapy (CBT), concludes the largest research review to date of 12-Step based approaches.

Published today in the Cochrane Library, the review of 27 studies concludes that 12-Step Facilitation works because it increases patient participation in Alcoholics Anonymous (AA). These results offer a significant boost to the research claims around 12-Step approaches and engagement in AA; a previous Cochrane review that was published in 2006 was based on results of only eight studies.

“We have something that is free and ubiquitous and helps people achieve remission—that is good news from a public health standpoint,” John F. Kelly, PhD, lead author and director of the Recovery Research Institute at Massachusetts General Hospital, tells Addiction Professional regarding AA.

A critically important finding of the review, Kelly points out, is that more structured and better articulated 12-Step approaches are associated with the strongest effects on abstinence and other recovery outcomes. It appears that it is not enough for a 12-Step oriented treatment program simply to encourage patients to attend meetings. Treatment programs that go beyond that to teach patients about AA and its importance, and then to track patients' meeting attendance and help connect patients to peers, generate optimal results, says Kelly, professor of psychiatry at Harvard Medical School.

Summary of review

The review, encompassing trials conducted through Aug. 2, 2019, included both randomized and non-randomized studies comparing 12-Step Facilitation and/or AA with interventions such as CBT and motivational enhancement therapy in the treatment of alcohol use disorder. The review did not include comparisons of 12-Step approaches with medication treatment for alcohol use disorder, a limitation of the analysis.

The 27 studies selected for the review had a combined total of 10,565 patients, with average patient ages in the studies ranging from 34.2 to 51 years.

The most striking finding for manualized 12-Step approaches was related to abstinence from alcohol use, with these approaches improving rates of continuous abstinence at 12 months compared with other clinical interventions. The researchers reported that 42% of AA participants were abstinent at 12 months, compared with 35% of patients in other programs. The result remained consistent at 24 and 36 months, the researchers reported.

For the other outcomes studied, such as percentage of days abstinent, drinking intensity and alcohol-related consequences, the 12-Step approaches were found to be as effective as CBT and the other interventions.

The review also examined four studies that compared the cost-effectiveness of the various treatment approaches. The researchers found that in three of the studies, 12-Step Facilitation/AA resulted in greater savings in healthcare costs than CBT and other outpatient treatment. Kelly believes this finding carries great importance in light of the significant but often overlooked burden of alcohol use disorder relative to other substance use problems.

Boost for other recovery support

Kelly believes the review's positive assessment of AA's benefits also has meaning for other recovery support that is not 12-Step based.

“AA is one example of a need for recovery support services, in different flavors,” he says. “Not everyone wants to go to AA. We need other ones, like SMART Recovery.”

He suggests that a stronger research base for all recovery support groups would go a long way toward seeing addiction treated legitimately as the chronic illness it is. Since SMART Recovery is grounded in cognitive-behavioral approaches, it would be extremely useful to establish the same linkage between CBT and SMART Recovery that is evident in the connection between 12-Step Facilitation and AA, Kelly says.

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