Comments on the Cochrane Review on Alcoholics Anonymous effectiveness.

In 2006, the Cochrane Collaboration conducted a review of randomized studies involving Alcoholics Anonymous (AA) or Twelve-Step Facilitation (TSF) [1]. While the authors are to be commended for undertaking this challenging task, regrettably, the review is confusing, it contains serious errors and its conclusions are misleading. For instance, the review aims to study the effectiveness of AA and of TSF programs but conflates the two, writing that ‘the practice of AA is the 12-step approach’ which is an intervention that ‘consists of a brief, manual-driven approach to facilitating recovery’ (p. 3). The practice of AA is not a manualized intervention; TSF is. Because the Cochrane reviews are highly influential in the health field, and because of the potential help that AA might represent for alcoholics, I am concerned that providers be made aware that this particular review should be interpreted with caution. As a co-author of two studies considered for their review [2,3], and as a knowledgeable reader of Project MATCH results, I would like to share my concerns with the readership of Addiction. I believe that the review’s handling of Project MATCH is incomplete. The review concluded that ‘TSF participants had a better percentage days abstinent than the other groups’ at 1-year follow-up, but that at 3 years no significant differences were found for the TSF condition compared to motivational enhancement and cognitive behavior therapy, even in the outpatient arm (p. 8). In fact, several superior results have been reported for TSF in the Project MATCH trial, especially in the out-patient arm: more abstinence 1 year post-treatment, for patients low in psychiatric severity who had been randomized to TSF (P < 0.01) ([4], p. 18); and slightly higher rates of abstinence at 3 years overall in TSF (36%) compared to cognitive therapy (24%) and motivational enhancement (27%) (P < 0.007) ([5], p. 1307). The aftercare arm of Project MATCH involved 28-day residential treatment that had encouraged clients to attend AA, so that rates of AA attendance were high in all three conditions of the aftercare arm [6], creating a ceiling effect. A related phenomenon obtains for another included paper which compared in-patient treatment to AA [7] and found high levels of AA in the in-patient condition. This highlights the inherent limits of experimental design to study AA: patients cannot be stopped from attending AA, even in the non-AA condition. The authors’ conclusions regarding implications for practice state that ‘People considering attending AA or TSF programmes should be made aware that there is a lack of experimental evidence on the effectiveness of such programmes’ (p. 9). I do not agree with this conclusion, primarily because of the consistent superior abstinence outcomes, both 1 and 3 years post-treatment, for Project MATCH TSF out-patients compared to the other treatment conditions. These are robust findings from a rigorous trial. I also urge providers to consider the mounting body of non-experimental research on AA’s effectiveness, in judging what to tell patients. Experimental evidence is but one of the six criteria for establishing causation; for the other five criteria, the evidence for AA is compelling [8].