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Am Fam Physician. 2021;104(2):117-118

Original Article: Alcoholics Anonymous and Other 12-Step Facilitation Programs for Alcohol Use Disorder [Cochrane for Clinicians]

Issue Date: March 1, 2021

To the Editor: Global engagement in Alcoholics Anonymous (AA) is high, with several million members in 180 countries.1 However, the effectiveness of AA has been difficult to study because of a lack of randomized controlled trials (RCTs). The RCTs have not reported a positive effect of AA; however, many cross-sectional and cohort studies have shown improved abstinence with engagement in AA compared with no engagement in 12-step facilitation programs.2,3 The Cochrane review emphasized the positive findings of AA and 12-step program affiliation.4 However, two details of the review should cause primary care physicians to hesitate before referring patients to AA as an alternative to traditional treatment for alcohol use disorder.

AA and other 12-step facilitation programs that produced higher rates of continuous abstinence over other established treatments in the Cochrane review were described as manualized, which was defined as following a session-to-session outline offering treatment based on “standardized content delivered in a linear or modular fashion to ensure that the same treatment is delivered across time and different sites”.5 Community AA programs would not be considered manualized because each group is autonomous.

Significantly positive results were related to the time abstinent from alcohol, continuous period of abstinence, and percentage of days abstinent. The most meaningful patient-oriented outcome examined is the negative impact of consequences of drinking, including physical, social, and psychological consequences. These consequences make up most of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. criteria for diagnosis of an alcohol use disorder, whereas percentage of time abstinent or length of continuous abstinence plays no role in diagnosing or determining the severity of alcohol use disorder. Unfortunately, none of the reviewed studies showed an advantage for AA or 12-step facilitation programs in reducing the negative consequences of drinking.5

Effective treatments for alcohol use disorder are medications and behavioral therapy. Although this review provides evidence that participation in AA or other 12-step programs may be helpful for people with alcohol use disorder who seek abstinence, the evidence is not compelling enough to consider community AA programs a replacement for formal treatment. Primary care physicians should include counseling on mutual aid groups (including AA) while developing a treatment plan with their patients. Physicians should feel comfortable discussing what to expect at meetings and the benefits of affiliation, and be aware of local mutual aid groups, including being able to provide contact information and meeting availability for patients who express interest.

In Reply: Thank you for highlighting these important points. We generally agree with your interpretation of the findings of the Cochrane review. We were not suggesting that AA and 12-step facilitation programs should be recommended instead of licensed addiction treatment services. However, many licensed addiction treatment programs in the United States use 12-step facilitation as a central component of their programming; therefore, the Cochrane review findings provide further support for this practice.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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