Vice Squad
Tuesday, August 22, 2006
Twelve-Step Success?

Treatment programs for addiction often have vocal adherents, but rarely is there much solid scientific evidence for dramatic (or even not so dramatic), replicable success. ´╗┐The sense of futility that infuses the war on drugs* has a parallel with respect to drug treatment. Here is Jon Elster, in the Introduction (page xvii) to his 1999 edited volume, Addiction: Entries and Exits: "There is a wide range of drug treatments. The main thing they have in common is that they rarely work."

Alcoholics Anonymous and similar 12-step-style treatment programs have been popular for decades, but again, the evidence for their success is more anecdotal than systematic. AA itself generally has not been subjected to randomized trials, which offer the best hope for gauging treatment effects. Claimed success rates often seem to cherry-pick, ignoring, for instance, those patients who drop out of treatment or who cannot be located post-treatment. But researchers have been chipping away at this longstanding dearth of evidence.

The May 2006 issue of Addiction opens with a two-page editorial by Keith Humphreys ("The Trials of Alcoholics Anonymous") that summarizes what has been learned so far from methodologically sophisticated analyses of 12-step programs. One study, for instance, documented a harm reduction-versus-abstinence-style result, in which intensive referral to couples therapy (AA and Al-Anon) led to more abstinence but also to more severe problems for those drinkers who did not achieve abstinence.

The systematic evidence remains far from conclusive. Here is how Humphreys, however, concludes his editorial:
Strong views about AA one way or the other will always survive, no matter what evidence accumulates, but the studies of the past 15 years have established beyond any reasonable doubt that high-quality AA trials are possible, and that such studies usually reinforce rather than undermine the excellent reputation the fellowship enjoys around the world.
Update: A less sanguine view, however, is found in a review undertaken under the auspices of The Cochrane Collaboration, an organization that evaluates the evidence concerning the effects of healthcare interventions. The Cochrane review of AA, written by M. Ferri, L. Amato, and M. Davoli, offers these "Authors' conclusions":
No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [Twelve Step Facilitation] 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.

*Incidentally, I don't accept that the war on drugs is futile -- if only it were! With respect to an alcohol-style regulatory structure, our current prohibition probably does lower the consumption of some drugs, while worsening a host of other social ills.

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