Abstinence-Based Addiction Recovery: Proven Effective & Low-Cost

Editorial Team

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Alcoholics Anonymous, other 12-Step programs, and similar mutual-help programs have long existed on the periphery of professional addiction treatment and recovery, providing popular local and low-cost community-based meetings for its members, and a vital sense of fellowship as individuals seek to live a life abstinent from the addictive substances that have proven so detrimental and damaging personally, socially and economically.

The world’s most widely available and most widely used mutual-help program is Alcoholics Anonymous (AA), which has helped countless millions of alcoholic individuals find sustained respite from their chronic disease throughout its 85-year history.

However, the late 20th century saw clinical scientists and addiction experts begin to question and debate its actual effectiveness, citing a lack of cohesive and reliable data to accurately ascertain AA’s position in the field of recognized addiction therapy – if it had an actual position at all.

Now, the long wait for a referenced research study about the overall effectiveness of AA and similar mutual-help programs is over – with one that has professionally collated all existing collected data (subject to strict criteria), determined initially if that data is cohesive and reliable, analyzed all of the diverse findings, and, finally, produced clear, scientifically-proven results.

alcoholics anonymous meeting

New Effectiveness & Cost Study of Alcoholics Anonymous (2020)

Entitled “Alcoholics Anonymous & Other 12-Step Programs for Alcohol Use Disorder,” and published by the Recovery Research Institute, a leading nonprofit research institute of Massachusetts General Hospital (an affiliate of Harvard Medical School), the research study not only looked at AA itself, but it also included “Twelve-Step Facilitation” (TSF) therapy, an active engagement strategy that systematically and directly links individuals in recovery to 12-step mutual-help organizations, like AA, and encourages the active participation of those individuals.

Before we look in detail at the overall results of this study, and how these can benefit all those involved in addiction treatment and recovery – the patients and their families, the addiction treatment providers (eg. rehab centers and addiction services), the scientific community, and the policymakers – let’s, however, provide a quick summary of its findings, in terms of both effectiveness and cost:

  • Alcoholic Anonymous & Twelve-Step Facilitation (AA/TSF) produces rates of alcohol abstinence (and subsequent alcohol use) comparable to first-line clinical interventions and outperforms them over follow-up
  • In terms of solely alcohol abstinence, among the 27 studies reviewed and involving over 10,000 research participants, AA/TSF generally performed as well as first-line clinical interventions at the end of treatment, and, in the majority of studies, performed better over timed follow-ups (e.g., at 6, 12, 24, and 36 months after treatment); for example:
    • a 21% lower risk of return to alcohol use among those going to AA compared to those receiving other clinical interventions at 12-month follow-up
    • a 66% lower risk of return to alcohol use among those going to AA versus those receiving clinical interventions at 6-month follow-up

Specifically, in a 3-year follow up study of individuals with severe AUD, it was found that AA participants had alcohol-related outcomes similar to outpatients receiving clinical addiction treatment, yet the alcohol-related health care costs associated with AA participation were 45% lower (with $2,856 saved per person)

What Does This New Mutual-Help Study Mean For Addiction Recovery?

In simple terms, there is a fundamentally strong and now proven case for mutual-help groups (through organizations like AA or the more scientifically-based SMART Recovery – Self-Management And Recovery Training) to play an even greater role than they currently do in the field of professional addiction treatment.

Additionally, to make matters even clearer, “mutual-help” is not a new concept – the methodology of a peer-based group support system, in essence, has long been established as an essential behavioral therapy in the field of substance addiction, and a significant part of its evidence-based treatment.

The National Institute on Drug Abuse (NIDA) publication: “Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition),” states, “Participation in group therapy and other peer support programs during and following treatment can help maintain abstinence.”

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Twelve-Step Facilitation (TSF)

Furthermore, again according to NIDA, Twelve-Step Facilitation (TSF), as mentioned above as behavioral therapy, is classified as an “evidence-based approach” – along with other more science-based therapies such as Cognitive-Behavioral Therapy (CBT) and Motivational Enhancement Therapy (MET).

In fact, before we go on to look in detail to see how the study compared TSF with both CBT and MET, let’s first look at the actual principles and assumptions of TSF.

TSF is a therapeutic strategy designed to increase the likelihood of an individual becoming affiliated with and actively involved in 12-step groups (in no way is it viewed as a condition of treatment) – thus promoting abstinence as a treatment goal and a vital way forward during long-term recovery.

Abstinence through Mutual-Help Groups

TSF originated from the Minnesota Model of addiction treatment (also known as the “abstinence model”), created in the 1950s. The primary objective of the Minnesota Model is engaging patients with AA and other 12-step mutual-help organizations in their local community.

Kathleen Carroll, Joseph Nowinski, and Stuart Baker developed the first manualized TSF as part of the randomized trial called “Project MATCH” in the early 1990s (“MATCH” stands for “Matching Alcoholism Treatment to Client Heterogeneity”). Several studies during the trial demonstrated that TSF was as or more effective at enhancing abstinence over time than Motivational Enhancement Therapy (MET), and a cognitive-behavioral approach. The strategy revolves around 3 core ideas, which are:

  1. Acceptance: the understanding that substance addiction is a chronic, progressive disease over which you have no control, that your life has become unmanageable, that your willpower alone is insufficient to overcome it, and that abstinence is the only viable alternative
  2. Surrender: giving yourself over to a “higher power,” accepting the fellowship and support of other recovering individuals, and following the recovery activities (the 12 Steps) laid out by the program, and
  3. Active Involvement: Your involvement in both 12-step meetings and related activities (TSF) has been established for AUD, while, although the research on its usefulness for other forms of substance abuse is more preliminary, the treatment appears promising for helping drug-addicted individuals

Twelve-Step Facilitation: Central Ethos

  • Addiction is a multi-faceted illness influenced by various factors: medical, social, emotional, and spiritual
  • Consistent with 12-step mutual-help organization philosophy, abstinence is the most vital (though not the only) facet of recovery from substance use disorder; emotional and, in some cases, spiritual growth is also a critical recovery process
  • AA participation will help patients achieve and sustain recovery over the long-term
  • Facilitation is effective only insomuch as the provider helps to engage the patient with AA and other 12-step mutual-help organizations
  • A professional clinical provider can help the patient address practical and attitudinal obstacles to AA attendance
Alcoholics Anonymous Group

Review: Effectiveness & Cost Study of Alcoholics Anonymous

Many early studies on the AA highlighted its benefits – however, the methodology and criteria of many of these studies have been endlessly questioned, and, even up to the late 1980s, there had been very few randomized controlled trials or studies. Then, in the early 1990s, the U.S. National Institute of Alcohol Abuse and Alcoholism (NIAAA) called for a far more rigorous investigation of AA.

Researchers responded by (i). developing increasingly sophisticated methods for evaluating AA, and (ii). testing its clinical interventions, and (iii). developing a rigid methodology to compare such interventions to other treatments, such as CBT and MET. This new systematic review and meta-analysis is the result of this ongoing work.

1. Organization & Criteria

The review study was conducted through the Cochrane Library of systematic reviews, considered the gold standard in scientific rigor for medical research. This particular report on AA represents the most comprehensive and up-to-date review and analysis of the scientific literature on AA. An official summary of its findings was subsequently published in “Alcohol & Alcoholism.”

The report centered on:

  • The systematic review and meta-analysis of 27 clinical trials of AA, and
  • The clinical intervention known as Twelve-Step Facilitation (a clinical protocol for linking patients to 12-step programs like AA).
  • Furthermore, the actual trial data for review was initially collected from a total of 10,565 participants.

Additionally, the selected studies were evaluated using the Cochrane Risk of Bias criteria, and studies that looked at costs were evaluated separately for quality using the Evers checklist for economic evaluations. Across the 27 included studies, all participants were clinically diagnosed with alcohol use disorder (AUD), and the average sample age ranged from 34.2 to 51.0 years.

2. Detailed Report Findings

EFFECTIVENESS: In essence, this comprehensive report found that AA produces rates of alcohol abstinence and alcohol use comparable to first-line clinical interventions (eg. CBT), and outperforms them over follow-up. Therefore, the results showed that:

  • AA/TSF was found to be better than other standard treatments (eg. CBT and MET) in achieving:
    • Continuous abstinence, and
    • Remission
  • AA/TSF was at least as effective as other standard treatments in reducing:
    • Intensity of drinking
    • Alcohol-related consequences, and
    • The severity of alcohol addiction

A more detailed look at the report’s findings finds that even the most rigorous studies employing a randomized, controlled trial* with AA/TSF, and then comparing with a different “theoretical orientation” (treatment therapy), such as CBT (cognitive-behavioral therapy), resulted in no clear difference between the clinical treatments at the end of their respective treatment lengths.

*Randomized, Controlled Trial (RCT): A study where participants are assigned into either an experimental group or a control group. As the study is conducted, the only expected difference between the control and experimental groups in a randomized controlled trial (RCT) is the outcome variable

However, there were clear benefits found for AA/TSF at all of the follow-up time points, such as at the following stages: 6, 12, 24 and 36 months). The clear benefits ranged from:

  • a 21% lower risk of return to alcohol use among those going to AA compared to those receiving other clinical interventions at 12-month follow-up, to
  • a 66% lower risk of return to alcohol use among those going to AA versus those receiving clinical interventions at 6-month follow-up

Additional findings included:

  • AA/TSF showed a distinct advantage in terms of the percentage of days abstinent from alcohol use – most noticeably:
    • at the 24-month stage, there was an average improvement of 12.1% days, and 
    • at the 36-month stage, there was an average improvement of 6.6% days
  • Among studies that employed a non-randomized design** and, again, where AA/TSF was compared to a different therapy such as CBT, all studies showed the AA/TSF intervention had significantly less risk of a return to alcohol use at all three follow-up times:
    • at the 6-month stage, there was a 50% lower risk of return to alcohol use,
    • at the 12-month stage, there was a 25% lower risk of return to alcohol use, and
    • at the 24-month stage, there was a 34% lower risk of return to alcohol use

**A Non-Randomized, Controlled Trial (NRCT): A study where participants are specifically assigned into either an experimental group or a control group

  • One specific study found that a more intensive AA/Twelve-Step Facilitation intervention had a 15% higher proportion of participants abstinent at the 12-month follow-up compared to the less intensive AA/Twelve-Step Facilitation intervention.

All of the above individual findings confirm the overall finding that participation in AA, either via the TSF strategy or not, results in a comparable or better rate of abstinence.

COST: The use of AA as a mutual-help group is associated with significant cost savings.

In fact, one particular study – “Reduced Substance Abuse-Related Health Care Costs among Voluntary Participants in Alcoholics Anonymous” – found AA participants with severe AUD had alcohol-related outcomes similar to outpatients receiving clinical addiction treatment over a 3-year study period.

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However, the study found that the alcohol-related health care costs associated with AA participation were 45% lower, with per-person savings of $,2856. Furthermore, it was found in the same study that inpatient program individuals using AA/TSF had higher abstinence rates, ie. 45.7% with AA/TSF, compared to 36.2% with CBT.

With regard to the addiction treatment of adolescents, one long-term study of adolescents aged 13-18 years that analyzed 2-year outcomes and associated healthcare costs found that AA/TSF program participants had 30% lower costs (totaling savings of around $3,678) when compared with CBT.

3. The Potential for Bias

The rigor of included studies was generally high; however, some evidence of research bias was noted. In the field of research, bias is a systematic distortion of the relationship between treatment, risk factor or exposure, and clinical outcomes. Although researchers obviously try to minimize bias potential in their studies, even well-designed studies can be vulnerable. 

In this report, 11 of the 27 studies were rated as potentially high risk for selection bias. However, generally, the authors of the report considered the included studies to be of high quality, and their findings can be considered valid.

4. Report Implications

The various implications of this report affect all those involved in substance addiction treatment and outcomes, from the addicted individual and their families, right up to those individuals who decide actual state health policy. Here’s a breakdown of these implications:

  • For Patients & Families: The report shows AA produces comparable results to first-line, clinical AUD treatments in the short-term, and subsequently outperforms these treatments in the long-term, all the while with significant cost savings. Therefore, if an individual is opposed to AA for whatever reason, they should consider similar mutual-help organizations, eg. Self-Management and Recovery Training (SMART), LifeRing, Refuge Recovery, and Women for Sobriety.
  • For Addiction Treatment Providers (eg. rehab centers and addiction services): Importantly, simply referring patients to 12-step meetings is likely to be less successful than the strategy of Twelve-Step Facilitation, in terms of patients more permanently engaging in 12-step programs on a long-term basis.
  • Scientific Community: Because AUD is highly diverse in its clinical course and impact, and those with AUD may often have different preferences as to their treatment, significantly more research is needed to study AA and other mutual-help programs, including the study of mental health and functional/social outcomes (e.g., employment), as well as perceived well-being.
  • Policy Makers: AA is clear proof that community recovery support services can help people recover from addiction and save healthcare systems economically. For example, supporting addiction recovery community centers is a great way to indirectly support 12-step programs, as these neighborhood venues offer meeting space and resources for AA members.

The Role of TSF in AA Participation & Abstinence Outcomes

The authors of the report recognized that by including Twelve-Step Facilitation (TSF), in addition to AA, it was possible that TSF could be the element conferring all these benefits as a clinical intervention. In other words, TSF could somehow be helping patients independently of any benefits derived from actual AA participation.

Additionally, a clinician can powerfully influence the likelihood of an AUD individual’s participation in AA – hence, the demonstrated benefits of TSF clinical interventions. Lastly, it is important to note that TSF is an active intervention, and that is very different to more passive referrals to AA.

SpringBoard Recovery

SpringBoard Recovery: AA & Twelve-Step Facilitation

“Mutual-help” is a simple ethos that is intrinsic to our care, and is present throughout our treatment programs here at SpringBoard Recovery in Scottsdale, Arizona. All individuals that receive care and treatment in these programs are encouraged to participate actively in 12-Step meetings and explore the fellowship and teachings of AA. In fact, studying the “Big Book” – AA’s essential, go-to tome of recovery from substance addiction – is an integral part of each of our treatment programs.

Contact us today to find out how we can help you break free from the chains of substance addiction, and begin to look forward to your deserved, substance-free future.

Sources:

  1. Alcoholics Anonymous: https://www.aa.org/
  2. National Library of Medicine: https://pubmed.ncbi.nlm.nih.gov/8807683/
  3. National institute on Drug Abuse: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
  4. Google Books: https://books.google.com.co/books?id=7TkZz3l4Dr0C&pg=PA1&source=gbs_toc_r&cad=4#v=onepage&q&f=false
  5. National Library of Medicine: https://pubmed.ncbi.nlm.nih.gov/8116822/#:~:text=Project%20MATCH%20is%20a%20multisite,treatment%20interactions%20relate%20to%20outcome.
  6. National Library of Medicine: https://pubmed.ncbi.nlm.nih.gov/8747503/
  7. National Institute on Alcohol Abuse and Alcoholism: https://www.niaaa.nih.gov/
  8. Oxford Academic: https://academic.oup.com/alcalc/article/55/6/641/5867689
  9. Recovery Research Institute: https://www.recoveryanswers.org/resource/twelve-step-facilitation-tsf/
  10. US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3196245/
  11. National Library of Medicine: https://pubmed.ncbi.nlm.nih.gov/15921065/
  12. US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746426/
  13. National Library of Medicine: https://pubmed.ncbi.nlm.nih.gov/8807683/
  14. US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3430743/
  15. US National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900086/
  16. SMART Recovery:  https://www.smartrecovery.org
  17. LifeRing: https://lifering.org/
  18. Refuge Recovery: https://refugerecovery.org/
  19. Women for Sobriety: https://womenforsobriety.org/

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WRITTEN BY ROBERT CASTAN
JANUARY 20, 2021

Robert Castan is a member of the Executive Leadership Team at SpringBoard Recovery. Robert started his professional career as a house manager and has become an industry leader and trusted voice in the treatment world. He brings extensive knowledge of organizational growth, industry-leading outcomes, and comprehensive marketing to SpringBoard Recovery. Robert has been walking his own path of recovery for over 10 years. This path has truly driven his ambition to help make treatment available to others who are struggling with addiction. Robert finds great joy in traveling and keeping physically active, with an emphasis on biking. Robert resides in Arizona with his husband and two four-legged children.   The U.S. Alcohol Crisis, Still Deadlier Than the Opioid Epidemic   Zombies and Other Future Threats to the Health of American Youth Dire Mental Health: A Catalyst for Post-Pandemic Drug Addiction The Benefits of Rehab Center Staff Working Their Own Recovery Opinion: The Opioid Crisis + COVID-19 = The Perfect Storm Robert Castan on Successful Addiction Treatment and Entrepreneurship Castan: The road less traveled of addiction & recovery in Scottsdale Opioids & COVID Driving Phoenix’s Rising Fatal Drug Overdoses Opinion: The Opioid Crisis + COVID-19 = The Perfect Storm Successful Addiction Treatment Programs & Entrepreneurship

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