Alcoholics Anonymous and other 12-step programmes for alcohol dependence (Review) Ferri M, Amato L, Davoli M This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2009, Issue 3 http://www.thecochranelibrary.com Alcoholics Anonymous and other 12-step programmes for alcohol dependence (Review) Copyright �� 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

T A B L E O F C O N T E N T S 1 HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 AUTHORS��� CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 WHAT���S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i Alcoholics Anonymous and other 12-step programmes for alcohol dependence (Review) Copyright �� 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

[Intervention Review] Alcoholics Anonymous and other 12-step programmes for alcohol dependence Marica Ferri1, Laura Amato2, Marina Davoli2 1Project Unit: EBM and Models of Health Assistance, Agency of Public Health, Rome, Italy. 2Department of Epidemiology, ASL RM/E, Rome, Italy Contact address: Marica Ferri, Project Unit: EBM and Models of Health Assistance, Agency of Public Health, Via di Santa Costanza 53, Rome, 00198, Italy. ferri@asplazio.it. maricaferri@hotmail.it. Editorial group: Cochrane Drugs and Alcohol Group. Publication status and date: Edited (no change to conclusions), published in Issue 3, 2009. Review content assessed as up-to-date: 19 March 2006. Citation: Ferri M, Amato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD005032. DOI: 10.1002/14651858.CD005032.pub2. Copyright �� 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. A B S T R A C T Background Alcoholics Anonymous (AA) is an international organization of recovering alcoholics that offers emotional support through self-help groups and a model of abstinence for people recovering from alcohol dependence, using a 12-step approach. Although it is the most common, AA is not the only 12-step intervention available there are other 12-step approaches (labelled Twelve Step Facilitation (TSF)). Objectives To assess the effectiveness of AA or TSF programmes compared to other psychosocial interventions in reducing alcohol intake, achieving abstinence, maintaining abstinence, improving the quality of life of affected people and their families, and reducing alcohol associated accidents and health problems. Search strategy We searched the Specialized Register of Trials of the Cochrane Group on Drugs and Alcohol, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE from 1966, EMBASE from 1980, CINAHL from 1982, PsychINFO from 1967. Searches were updated in February 2005. We also inspected lists of references for relevant studies. Selection criteria Studies involving adults (18) of both genders with alcohol dependence attending on a voluntary or coerced basis AA or TSF programmes comparing no treatment, other psychological interventions, 12-step variants. Data collection and analysis One reviewer (MF) assessed studies for inclusion and extracted data using a pre-defined data extraction form. Studies were evaluated for methodological quality and discussed by all reviewers. Main results Eight trials involving 3417 people were included. AA may help patients to accept treatment and keep patients in treatment more than alternative treatments, though the evidence for this is from one small study that combined AA with other interventions and should not be regarded as conclusive. Other studies reported similar retention rates regardless of treatment group. Three studies compared 1 Alcoholics Anonymous and other 12-step programmes for alcohol dependence (Review) Copyright �� 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

AA combined with other interventions against other treatments and found few differences in the amount of drinks and percentage of drinking days. Severity of addiction and drinking consequence did not seem to be differentially influenced by TSF versus comparison treatment interventions, and no conclusive differences in treatment drop out rates were reported. Included studies did not allow a conclusive assessment of the effect of TSF in promoting complete abstinence. Authors��� conclusions No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed. P L A I N L A N G U A G E S U M M A R Y Alcoholics Anonymous (AA) is self-help group, organised through an international organization of recovering alcoholics, that offers emotional support and a model of abstinence for people recovering from alcohol dependence using a 12-step approach. As well as AA, there are also alternative interventions based on 12-step type programmes, some self-help and some professionally-led. AA and other 12-step approaches are typically based on the assumption that substance dependence is a spiritual and a medical disease. The available experimental studies did not demonstrate the effectiveness of AA or other 12-step approaches in reducing alcohol use and achieving abstinence compared with other treatments, but there were some limitations with these studies. Furthermore, many different interventions were often compared in the same study and too many hypotheses were tested at the same time to identify factors which determine treatment success. B A C K G R O U N D Alcohol consumption is rising in many developing countries and in Central and Eastern Europe (WHO 2005). Alcohol���s abuse sig- nificantly contributes to the global burden of disease and in parts of Central and Eastern Europe alcohol abuse has been linked to an unprecedented decline in male life expectancy (WHO 2001). On average, alcohol dependence one-year prevalence is around 7% and its life-time prevalence rates are 14% in the general pop- ulation (Regier 1993 Kessler 1994). Alcohol dependence (also called alcoholism) is a condition that involves four main symp- toms: craving (a strong need to drink) uncontrolled behaviour (after the first drink it is impossible to stop) physical dependence (if one does not drink enough then withdrawal symptoms such as nausea, sweating, shakiness and anxiety occur) and tolerance (the need to increase the amount of alcohol intake to feel satisfied) ( NIAA 2003). Substance dependence is defined (DSMIV 1994) as a ���cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues using a substance despite significant substance-related problems���. Dependence on alcohol is characterised by tolerance and withdrawal symptoms. Tolerance is a progressive reduction in the susceptibility to the effects of a sub- stance, resulting from its continued administration. It is present when a person must use an increasing quantity of a given sub- stance, to achieve the same perceived effect as time passes (Gitlow 2001). Tolerance is also experienced when the person notices a decreased sensation with similar doses of a substance over time. Tolerance can be measured objectively, for example when a person with high blood alcohol level can still perform given perceptual and motor tasks such as walking in a straight line. Withdrawal symptoms are physiological and psychological symptoms associ- ated with withdrawal from a substance after prolonged adminis- tration or habituation. Withdrawal is present when a characteristic physiological pattern associated with a certain substance is expe- rienced, or when the person uses the substance to avoid or reduce specific symptoms (Gitlow 2001). People compulsively using alco- hol may devote substantial time to obtain and consume alcoholic beverages and continue to use alcohol even if they experience se- vere psychological and physical consequences such as depression, blackouts, liver disease or other sequelae (DSMIV 1994). There is no unique and known cause of alcohol dependence and several factors may play a role in its development: familiar and 2 Alcoholics Anonymous and other 12-step programmes for alcohol dependence (Review) Copyright �� 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

genetic factors, psychological attributes such as high anxiety, on- going depression, unresolved conflicts within a relationship or low self-esteem, and social factors such as availability of alcohol, so- cial acceptance and promotion of the use of alcohol, peer pressure and a demanding lifestyle (A.D.A.M. 2002). Risk factor studies conducted on animals suggest that genetic vulnerability to alcohol dependence is multigenic. In humans, evidence about the genetic vulnerability is typically provided by studies involving monozy- gotic and dizygotic adult twins, suggesting that alcohol depen- dencecanbeattributedintheratio2/3to geneticfactorsand 1/3 to environmental factors, without gender differences (Heath 1997). Alcoholic dependence syndrome is three to four times higher in the relatives of alcohol dependent people compared with the gen- eral population (DSMIV 1994). Stress and emotional problems can also play a role in the development of alcohol abuse (NIAA 2000). Remission is spontaneous in about 20% of people with alcohol dependence, who achieve long term sobriety without active treat- ment (DSMIV 1994). Gender and age do not substantially affect prognosis. Positive prognostic factors are good social functioning (employment, family relationship, absence of legal problems) and good health status. Retention in treatment for at least one month increases the likelihood of remaining abstinent for one year (Hales 1999). Psychiatric comorbidity is a negative prognostic factor. The health,social and economic consequences of alcohol abuse are usually devastating. Although many individuals do achieve long- term sobriety with treatment, others continue to relapse and dete- riorate despite multiple courses of treatment. Alcohol dependence contributes to accidents, violent behaviours, suicide, loss of work- ing days, work related accidents and low productivity. Mortality and morbidity are increased in people with alcohol dependence ( Hales 1999). Attendance of self-help groups is often suggested to people with a diagnosis of alcohol dependence. Participation in self-help or- ganization meetings can be an adjunct to professional treatment, or a treatment in itself in particular for long periods. Alcoholics Anonymous (AA) is an international organization composed of recovering alcoholics that offers self-help group emotional sup- port and a model of abstinence for people recovering from alco- hol dependence. The practice of AA is the 12-step approach, an intervention based on the assumption that substance dependence is a spiritual and a medical disease (Nowinksi 1992). The 12-step approach consists of a brief, structured, manual-driven approach to facilitating recovery from alcohol abuse, and it is intended to be implemented over 12 to 15 sessions. In addition to AA, there are also other, alternative, interventions based on the 12-step ap- proach: some include a spiritual approach and others do not and some are led by a professional and others are led by former alcohol dependents. AA self-help groups are widely available and are well known in many countries. Although it is the most common, AA is not the only 12-step intervention available: in this review we have considered all 12-step approaches. However, as AA is the most widely available we have distinguished, wherever possible, those that are conventional AA self-help programmes from other 12-step approaches. The latter have been labelled Twelve Step Facilitation (TSF) in one of the most powerful studies recently conducted on this treatment (MATCH 1998). A meta-analysis by Tonigan (Tonigan 1995) reported that many of the available studies were not focused on AA per se but rather on AA-inspired or AA-focused treatment and on AA involvement and outcomes within formal therapeutic interventions. The meta- analysis included 74 studies, 10 of which were randomised. The re- sults were grouped by global study quality, a multidimensional tool considering random allocation as one of several weighting factors. Therefore it was not possible to distinguish results by study design. Another meta-analysis by Kownacki (Kownacki 1999) identified severe selection bias in the available studies, with the randomised studies yielding worse results than non-randomised studies. This meta-analysis is weakened by the heterogeneity of patients and interventions that are pooled together. Emrick 1989 performed a narrative review of studies about characteristics of alcohol-depen- dent individuals who affiliate with AA and concluded that the ef- fectiveness of AA as compared to other treatments for alcoholism was not clear and therefore needed to be demonstrated. This systematic review updates previous reviews and meta-analyses and also incorporates the results from Project MATCHMATCH 1997 MATCH 1997b MATCH 1998b), a large randomised con- trolled trial conducted in the United States in the late 90���s with the aim of identifying the predictors of success in different non- pharmacological interventions for alcohol dependence. O B J E C T I V E S To assess the effectiveness of Alcoholics Anonymous and other Twelve Step Facilitation (TSF) programmes in reducing alcohol intake, achieving abstinence, maintaining abstinence, improving the quality of life of affected people and their families, reducing alcohol associated accidents and health problems. The following interventions will be compared: twelve-step programmes versus no intervention twelve-step programmes versus other interventions (e.g. Motiva- tional Enhancement Therapy (MET), Cognitive-behavioural cop- ing skills training (CBT), Relapse Prevention Therapy (RPT)) twelve-step programmes versus Twelve-Step programme variants (e.g. spiritual, non-spiritual, professionally led, lay led). M E T H O D S 3 Alcoholics Anonymous and other 12-step programmes for alcohol dependence (Review) Copyright �� 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.