AA, evidence and Glaser

Science writer John Horgan takes a look at the Gabrielle Glaser Atlantic article that’s gotten so much attention.

Here’s his overview:

The addiction-treatment industry is a racket, which cries out for critical investigation. But Glaser’s article is embarrassingly shallow and one-sided. She cherry-picks data and anecdotes to make A.A. look bad and alternatives look good.

Here’s some detail on her cherry-picking:

Here’s an example of how Glaser misrepresents sources: She quotes a 2006 report by the Cochrane Collaboration on A.A. and other twelve-step programs (so-called because they are based on A.A.’s recommendations for maintaining sobriety).Cochrane Collaboration is a terrific source of independent analyses of health-related issues, but for the most part its work does not support Glaser’s thesis.

She quotes Cochrane’s conclusion that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.” She neglects to mention that the 2006 report also examined studies comparing twelve-step programs to other treatment methods. The result? “Severity of addiction and drinking consequence did not seem to be differentially influenced by [twelve-step programs] versus comparison treatment interventions,” Cochrane states, “and no conclusive differences in treatment drop out rates were reported.”

Glaser faults the zero-tolerance tenet of A.A. and touts programs that seek reduction rather than elimination of drinking. But a 2012 Cochrane evaluation found no rigorous studies of so-called “managed alcohol programs.” The report states: “The lack of evidence does not allow for a conclusion regarding the efficacy of [managed alcohol programs] on their own, or as compared to brief intervention, moderate drinking, no intervention or 12-step variants.”

Glaser is also keen on pharmaceutical treatments, particularly those involving naltrexone, which blocks opioid receptors and is more commonly used to counter opioid addiction. Glaser reports that after taking naltrexone herself for ten days, she “no longer looked forward to a glass of wine with dinner,” and she lost two pounds to boot.

Glaser cites other personal testimonials and studies that supposedly demonstrate naltrexone’s effectiveness. Actually, the evidence is, at best, mixed. A 2010 Cochrane analysis of 50 studies involving 7,793 subjects concluded that “more patients who took naltrexone were able to reduce the amount and frequency of drinking than those who took an identical appearing, but inert substance.” The effect was hardly overwhelming. “On average,” the Cochrane report noted, “one out of nine patients was helped by naltrexone.” Even that modest effect was not supported by a double-blind study reported in the New England Journal of Medicine in 2001. Those authors found no difference between naltrexone and placebos for treating “chronic, severe alcohol dependence.”

A piece in New York magazine offers similar criticisms and actually interviews experts who have done actual research on 12 step groups and 12 step facilitation:

. . . throughout the piece, Glaser is simply ignoring a decade’s worth of science.

“No, that’s not true,” said Dr. John Kelly, a clinical psychologist and addiction specialist at Massachusetts General Hospital and Harvard Medical School, when I ran Glaser’s argument by him. “There’s quite a bit of evidence now, actually, that’s shown that AA works.” Kelly has a front-row view of the current generation of research: Alongside Dr. Marica Ferri, the original report’s lead author, and Dr. Keith Humphreys of Stanford, he’s currently at work updating the Cochrane Collaboration guidelines (he said they expect to publish their results in August).

Kelly said that in recent years, researchers have begun ramping up rigorous research on what are known as “12-step facilitation” (TSF) programs, which are “clinical interventions designed to link people with AA.” Dr. Lee Ann Kaskutas, a senior scientist at the Alcohol Research Group who has conducted TSF studies, explained that while these programs take on different forms, they’re generally oriented toward preparing participants for the (potentially weird-seeming, especially at first) culture and philosophy of 12-step programs like AA. By randomly assigning a group of study participants to either TSF programs or standard treatment, researchers can overcome some of the self-selection issues inherent to studying AA “in the wild” (that is, it could be that people who choose to go to AA are simply more motivated to kick their addiction).

The data from these sorts of studies, argued Kelly, Kaskutas, and other researchers with whom I spoke, suggest that it outperforms many alternatives. “They show about a 10 to 20 percent advantage over more standard treatment like cognitive behavioral therapy in terms of days abstinent, and typically also what we find is that when people are engaged in a 12-step-oriented treatment and go to AA, they have about 30 percent to 50 percent higher rates of continuous abstinence,” said Kelly.

In an interview about her article, Glaser tries to deflect criticism by misrepresenting her own written criticism of 12 step groups and 12 step facilitation by stating she was really only criticizing 12 step facilitation and not 12 step groups. Even it it were true, this is a problem:

In an email and phone call, Glaser said that TSF programs are not the same thing as AA and the two can’t be compared. But this argument doesn’t quite hold up: For one thing, the Cochrane report she herself cites in her piece relied in part on a review of TSF studies, so it doesn’t make sense for TSF studies to be acceptable to her when they support her argument and unacceptable when they don’t. For another, Kelly, Katsukas, and Humphreys, while acknowledging that TSF programs and AA are not exactly the same thing, all said that the available evidence suggests that it’s the 12-step programs themselves that are likely the primary cause of the effects being observed (the National Institutes of Health, given the many studies into TSF programs it has sponsored, would appear to agree).

In the midst of all this, the New York Times highlights a recent study. The study founds that alcoholics attending AA did better than those who did not and then tried to determine whether this was because those who attended AA were more motivated–whether they did better and attended AA because they were more motivated rather than doing better because of AA. The NY Times article summarizes the findings this way:

Not everyone will comply with treatment. But, among those who do, are they made better off? That’s a question worth answering.

The Humphreys study does so and tells us that A.A. helps alcoholics, apart from the fact that it may attract a more motivated group of individuals. With that established, the next step is to encourage even more to take advantage of its benefits.

Horgan concluded his piece with this thought:

But as psychologists Hal Arkowitz and Scott Lilienfeld noted in Scientific American in 2011, given “the wide availability of meetings and the lack of expense, A.A. is worth considering for many problem drinkers.” [Italics added.] If all treatments are as effective as each other, cost should be the determining factor. Judged by that criterion, no treatment beats A.A., because A.A. is free.