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Am Fam Physician. 2021;103(5):272-273

Related letter:Community Alcoholics Anonymous Programs Are Not a Replacement for Formal Treatment

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Author disclosure: No relevant financial affiliations.

Clinical Question

Are Alcoholics Anonymous (AA) and similar 12-step facilitation programs as effective as other established treatments for helping people with alcohol problems achieve abstinence and/or reduce drinking intensity, alcohol-related consequences, and alcohol addiction severity?

Evidence-Based Answer

Manualized (standardized and replicable) AA and similar 12-step facilitation programs produce higher rates of continuous abstinence than other established treatments. (Strength of Recommendation [SOR]: A, based on consistent, good-quality patient-oriented evidence.) Nonmanualized (nonstandardized) 12-step programs perform as well as other established treatments investigated across a variety of alcohol-related outcomes. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) Overall, 12-step programs may be superior to other treatments for increasing percentage of days of abstinence (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) and probably perform as well as other treatments at reducing drinking intensity.1 (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Excessive alcohol use continues to be a major cause of preventable morbidity and mortality.2 In the United States, it is the third leading preventable cause of death. Each year, 88,000 U.S. deaths are attributable to alcohol.3 Excessive alcohol use poses a substantial economic burden, costing the United States $249 billion in 2010.4 AA is a free, nonprofessional, peer-to-peer, community-based program focused on helping individuals with alcohol use disorder to achieve abstinence.5 Founded in the United States in 1935, AA has millions of members and is available in nearly every community worldwide.6 Twelve-step facilitated programs use the methodology and concepts of AA within the context of larger clinical/addiction treatment environments. Often, the goal of offering a 12-step program in an addiction treatment program is to engage people with alcohol use disorder, orient them to the principles and concepts of AA, and encourage their engagement in community-based AA programming posttreatment.7

The authors of this Cochrane review included 27 studies with 10,565 participants.1 The study designs included randomized controlled trials (RCTs), quasi-RCTs, and nonrandomized studies that compared 12-step programs with usual treatment or other behavioral interventions, including motivational enhancement therapy, cognitive behavior therapy, or 12-step program variants. Twelve-step interventions were also stratified by manualized vs. nonmanualized programs; manualization in this context refers to the degree of standardization and replicability. None of the included studies examined the role of pharmacotherapy for alcohol use disorder as part of the treatment regimen. Fifteen studies used a manualized 12-step approach, and 11 used a partial/nonmanualized approach. Outcomes included abstinence, drinking intensity, alcohol-related consequences, and alcohol addiction severity. The average age of participants ranged from 34 to 51 years and the proportion of female participants ranged from 0% to 49%. Eleven of the 27 studies had a high risk of selection bias.

Compared with the other interventions studied, manualized 12-step programs improved rates of continuous abstinence at 12 months from the start of therapy (number needed to treat = 13.6; 95% CI, 6.8 to 90.9), and this effect remained at 24 and 36 months. Manualized 12-step programs did not have a statistically significant difference from other interventions for the following outcomes: percentage of days abstinent at 12 months, drinking intensity at 12 months (measured by drinks per drinking day and percentage of days of heavy drinking), and alcohol-related consequences at 12 months. Manualized 12-step programs were associated with an increase in the percentage of days abstinent at 24 months and 36 months based on very low-certainty evidence.

For nonmanualized 12-step programs, the quality of the evidence was lower compared with manualized programs and studies were of shorter duration (nine months or less). The analysis suggested that nonmanualized 12-step programs may perform as well as other interventions with regard to the proportion of participants maintaining complete abstinence at three to nine months, drinking intensity (drinks per drinking day), and percentage of days of heavy drinking. They may perform slightly better than other interventions in percentage of days abstinent.

The U.S. Preventive Services Task Force recommends screening adults 18 years and older for unhealthy alcohol use in primary care settings and providing brief behavioral counseling interventions to reduce unhealthy alcohol use (Grade B recommendation).8 When family physicians identify patients with unhealthy alcohol use, they should assess for alcohol use disorder and, when clinically indicated, offer pharmacotherapy and referral to behavioral support services.9,10 Many licensed addiction treatment providers offer 12-step facilitation as part of their programming, although licensed addiction treatment access is limited in many parts of the country. AA programs can be found in most communities and are increasingly available online.6

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