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Alcoholics Anonymous: Much More Than You Wanted To Know

[EDIT 10/27: Slight changes in response to feedback; correcting some definitions. I am not an expert in this field and will continue to make changes as I learn about them. There is a critique of this post here and other worse critiques elsewhere. My only excuse for doing this is that I am failing less spectacularly than other online sources writing about the same topic.]

I’ve worked with doctors who think Alcoholics Anonymous is so important for the treatment of alcoholism that anyone who refuses to go at least three times a week is in denial about their problem and can’t benefit from further treatment.

I’ve also worked with doctors who are so against the organization that they describe it as a “cult” and say that a physician who recommends it is no better than one who recommends crystal healing or dianetics.

I finally got so exasperated that I put on my Research Cap and started looking through the evidence base.

My conclusion, after several hours of study, is that now I understand why most people don’t do this.

The studies surrounding Alcoholics Anonymous are some of the most convoluted, hilariously screwed-up research I have ever seen. They go wrong in ways I didn’t even realize research could go wrong before. Just to give some examples:

– In several studies, subjects in the “not attending Alcoholics Anonymous” condition attended Alcoholics Anonymous more than subjects in the “attending Alcoholics Anonymous” condition.

– Almost everyone’s belief about AA’s retention rate is off by a factor of five because one person long ago misread a really confusing graph and everyone else copied them without double-checking.

– The largest study ever in the field, a $30 million effort over 8 years following thousands of patients, had no untreated control group.

Not only are the studies poor, but the people interpreting them are heavily politicized. The entire field of addiction medicine has gotten stuck in the middle of some of the most divisive issues in our culture, like whether addiction is a biological disease or a failure of willpower, whether problems should be solved by community and peer groups or by highly trained professionals, and whether there’s a role for appealing to a higher power in any public organization. AA’s supporters see it as a scruffy grassroots organization of real people willing to get their hands dirty, who can cure addicts failed time and time again by a system of glitzy rehabs run by arrogant doctors who think their medical degrees make them better than people who have personally fought their own battles. Opponents see it as this awful cult that doesn’t provide any real treatment and just tells addicts that they’re terrible people who will never get better unless they sacrifice their identity to the collective.

As a result, the few sparks of light the research kindles are ignored, taken out of context, or misinterpreted.

The entire situation is complicated by a bigger question. We will soon find that AA usually does not work better or worse than various other substance abuse interventions. That leaves the sort of question that all those fancy-shmancy people with control groups in their studies don’t have to worry about – does anything work at all?

I.

We can start by just taking a big survey of people in Alcoholics Anonymous and seeing how they’re doing. On the one hand, we don’t have a control group. On the other hand…well, there really is no other hand, but people keep doing it.

According to AA’s own surveys, one-third of new members drop out by the end of their first month, half by the end of their third month, and three-quarters by the end of their first year. “Drop out” means they don’t go to AA meetings anymore, which could be for any reason including (if we’re feeling optimistic) them being so completely cured they no longer feel they need it.

There is an alternate reference going around that only 5% (rather than 25%) of AA members remain after their first year. This is a mistake caused by misinterpreting a graph showing that only five percent of members in their first year were in their twelfth month of membership, which is obviously completely different. Nevertheless, a large number of AA hate sites (and large rehabs!) cite the incorrect interpretation, for example the Orange Papers and RationalWiki’s page on Alcoholics Anonymous. In fact, just to keep things short, assume RationalWiki’s AA page makes every single mistake I warn against in the rest of this article, then use that to judge them in general. On the other hand, Wikipedia gets it right and I continue to encourage everyone to use it as one of the most reliable sources of medical information available to the public (I wish I was joking).

This retention information isn’t very helpful, since people can remain in AA without successfully quitting drinking, and people may successfully quit drinking without being in AA. However, various different sources suggest that, of people who stay in AA a reasonable amount of time, about half stop being alcoholic. These numbers can change wildly depending on how you define “reasonable amount of time” and “stop being alcoholic”. Here is a table, which I have cited on this blog before and will probably cite again:

Behold. Treatments that look very impressive (80% improved after six months!) turn out to be the same or worse as the control group. And comparing control group to control group, you can find that “no treatment” can appear to give wildly different outcomes (from 20% to 80% “recovery”) depending on what population you’re looking at and how you define “recovery”.

Twenty years ago, it was extremely edgy and taboo for a reputable scientist to claim that alcoholics could recover on their own. This has given way to the current status quo, in which pretty much everyone in the field writes journal articles all the time about how alcoholics can recover on their own, but make sure to harp upon how edgy and taboo they are for doing so. From these sorts of articles, we learn that about 80% of recovered alcoholics have gotten better without treatment, and many of them are currently able to drink moderately without immediately relapsing (something else it used to be extremely taboo to mention). Kate recently shared an good article about this: Most People With Addiction Simply Grow Out Of It: Why Is This Widely Denied?

Anyway, all this stuff about not being able to compare different populations, and the possibility of spontaneous recovery, just mean that we need controlled experiments. The largest number of these take a group of alcoholics, follow them closely, and then evaluate all of them – the AA-attending and the non-AA-attending – according to the same criteria. For example Morgenstern et al (1997), Humphreys et al (1997) and Moos (2006). Emrick et al (1993) is a meta-analyses of a hundred seventy three of these. All of these find that the alcoholics who end up going to AA meetings are much more likely to get better than those who don’t. So that’s good evidence the group is effective, right?

Bzzzt! No! Wrong! Selection bias!

People who want to quit drinking are more likely to go to AA than people who don’t want to quit drinking. People who want to quit drinking are more likely to actually quit drinking than those who don’t want to. This is a serious problem. Imagine if it is common wisdom that AA is the best, maybe the only, way to quit drinking. Then 100% of people who really want to quit would attend compared to 0% of people who didn’t want to quit. And suppose everyone who wants to quit succeeds, because secretly, quitting alcohol is really easy. Then 100% of AA members would quit, compared to 0% of non-members – the most striking result it is mathematically possible to have. And yet AA would not have made a smidgeon of difference.

But it’s worse than this, because attending AA isn’t just about wanting to quit. It’s also about having the resources to make it to AA. That is, wealthier people are more likely to hear about AA (better information networks, more likely to go to doctor or counselor who can recommend) and more likely to be able to attend AA (better access to transportation, more flexible job schedules). But wealthier people are also known to be better at quitting alcohol than poor people – either because the same positive personal qualities that helped them achieve success elsewhere help them in this battle as well, or just because they have fewer other stressors going on in their lives driving them to drink.

Finally, perseverance is a confounder. To go to AA, and to keep going for months and months, means you’ve got the willpower to drag yourself off the couch to do a potentially unpleasant thing. That’s probably the same willpower that helps you stay away from the bar.

And then there’s a confounder going the opposite direction. The worse your alcoholism is, the more likely you are to, as the organization itself puts it, “admit you have a problem”.

These sorts of longitudinal studies are almost useless and the field has mostly moved away from them. Nevertheless, if you look on the pro-AA sites, you will find them in droves, and all of them “prove” the organization’s effectiveness.

III.

It looks like we need randomized controlled trials. And we have them. Sort of.

Brandsma (1980) is the study beloved of the AA hate groups, since it purports to show that people in Alcoholics Anonymous not only don’t get better, but are nine times more likely to binge drink than people who don’t go into AA at all.

There are a number of problems with this conclusion. First of all, if you actually look at the study, this is one of about fifty different findings. The other findings are things like “88% of treated subjects reported a reduction in drinking, compared to 50% of the untreated control group”.

Second of all, the increased binge drinking was significant at the 6 month followup period. It was not significant at the end of treatment, the 3 month followup period, the 9 month followup period, or the 12 month followup period. Remember, taking a single followup result out of the context of the other followup results is a classic piece of Dark Side Statistics and will send you to Science Hell.

Of multiple different endpoints, Alcoholics Anonymous did better than no treatment on almost all of them. It did worse than other treatments on some of them (dropout rates, binge drinking, MMPI scale) and the same as other treatments on others (abstinent days, total abstinence).

If you are pro-AA, you can say “Brandsma study proves AA works!”. If you are anti-AA, you can say “Brandsma study proves AA works worse than other treatments!”, although in practice most of these people prefer to quote extremely selective endpoints out of context.

However, most of the patients in the Brandsma study were people convicted of alcohol-related crimes ordered to attend treatment as part of their sentence. Advocates of AA make a good point that this population might be a bad fit for AA. They may not feel any personal motivation to treatment, which might be okay if you’re going to listen to a psychologist do therapy with you, but fatal for a self-help group. Since the whole point of AA is being in a community of like-minded individuals, if you don’t actually feel any personal connection to the project of quitting alcohol, it will just make you feel uncomfortable and out of place.

Also, uh, this just in, Brandsma didn’t use a real AA group, because the real AA groups make people be anonymous which makes it inconvenient to research stuff. He just sort of started his own non-anonymous group, let’s call it A, with no help from the rest of the fellowship, and had it do Alcoholics Anonymous-like stuff. On the other hand, many members of his control group went out into the community and…attended a real Alcoholics Anonymous, because Brandsma can’t exactly ethically tell them not to. So technically, there were more people in AA in the no-AA group than in the AA group. Without knowing more about Alcoholics Anonymous, I can’t know whether this objection is valid and whether Brandsma’s group did or didn’t capture the essence of the organization. Still, not the sort of thing you want to hear about a study.

Walsh et al (1991) is a similar study with similar confounders and similar results. Workers in an industrial plant who were in trouble for coming in drunk were randomly assigned either to an inpatient treatment program or to Alcoholics Anonymous. After a year of followup, 60% of the inpatient-treated workers had stayed sober, but only 30% of the AA-treated workers had.

The pro-AA side made three objections to this study, of which one is bad and two are good.

The bad objection was that AA is cheaper than hospitalization, so even if hospitalization is good, AA might be more efficient – after all, we can’t afford to hospitalize everyone. It’s a bad objection because the authors of the study did the math and found out that hospitalization was so much better than AA that it decreased the level of further medical treatment needed and saved the health system more money than it cost.

The first good objection: like the Brandsma study, this study uses people under coercion – in this case, workers who would lose their job if they refused. Fine.

The second good objection, and this one is really interesting: a lot of inpatient hospital rehab is AA. That is, when you go to an hospital for inpatient drug treatment, you attend AA groups every day, and when you leave, they make you keep going to the AA groups. In fact, the study says that “at the 12 month and 24 month assessments, the rates of AA affiliation and attendance in the past 6 months did not differ significantly among the groups.” Given that the hospital patients got hospital AA + regular AA, they were actually getting more AA than the AA group!

So all that this study proves is that AA + more AA + other things is better than AA. There was no “no AA” group, which makes it impossible to discuss how well AA does or doesn’t work. Frick.

Timko (2006) is the only study I can hesitantly half-endorse. This one has a sort of clever methodological trick to get around the limitation that doctors can’t ethically refuse to refer alcoholics to treatment. In this study, researchers at a Veterans’ Affairs hospital randomly assigned alcoholic patients to “referral” or “intensive referral”. In “referral”, the staff asked the patients to go to AA. In “intensive referral”, the researchers asked REALLY NICELY for the patients to go to AA, and gave them nice glossy brochures on how great AA was, and wouldn’t shut up about it, and arranged for them to meet people at their first AA meeting so they could have friends in AA, et cetera, et cetera. The hope was that more people in the “intensive referral” group would end out in AA, and that indeed happened scratch that, I just re-read the study and the same number of people in both groups went to AA and the intensive group actually completed a lower number of the 12 Steps on average, have I mentioned I hate all research and this entire field is terrible? But the intensive referral people were more likely to have “had a spiritual awakening” and “have a sponsor”, so it was decided the study wasn’t a complete loss and when it was found the intensive referral condition had slightly less alcohol use the authors decided to declare victory.

So, whereas before we found that AA + More AA was better than AA, and that proved AA didn’t work, in this study we find that AA + More AA was better than AA, and that proves AA does work. You know, did I say I hesitantly half-endorsed this study? Scratch that. I hate this study too.

IV.

All right, @#%^ this $@!&*. We need a real study, everything all lined up in a row, none of this garbage. Let’s just hire half the substance abuse scientists in the country, throw a gigantic wad of money at them, give them as many patients as they need, let them take as long as they want, but barricade the doors of their office and not let them out until they’ve proven something important beyond a shadow of a doubt.

This was about how the scientific community felt in 1989, when they launched Project MATCH. This eight-year, $30 million dollar, multi-thousand patient trial was supposed to solve everything.

The people going into Project MATCH might have been a little overconfident. Maybe “not even Zeus could prevent this study from determining the optimal treatment for alcohol addiction” overconfident. This might have been a mistake.

The study was designed with three arms, one for each of the popular alcoholism treatments of the day. The first arm would be “twelve step facilitation”, a form of therapy based off of Alcoholics Anonymous. The second arm would be cognitive behavioral therapy, the most bog-standard psychotherapy in the world and one which by ancient tradition must be included in any kind of study like this. The third arm would be motivational enhancement therapy, which is a very short intervention where your doctor tells you all the reasons you should quit alcohol and tries to get you to convince yourself.

There wasn’t a “no treatment” arm. This is where the overconfidence might have come in. Everyone knew alcohol treatment worked. Surely you couldn’t dispute that. They just wanted to see which treatment worked best for which people. So you would enroll a bunch of different people – rich, poor, black, white, married, single, chronic alcoholic, new alcoholic, highly motivated, unmotivated – and see which of these people did best in which therapy. The result would be an algorithm for deciding where to send each of your patients. Rich black single chronic unmotivated alcoholic? We’ve found with p < 0.00001 that the best place for someone like that is in motivational enhancement therapy. Such was the dream. So, eight years and thirty million dollars and the careers of several prestigious researchers later, the results come in, and - yeah, everyone does exactly the same on every kind of therapy (with one minor, possibly coincidental exception). Awkward. “Everybody has won and all must have prizes!”. If you’re an optimist, you can say all treatments work and everyone can keep doing whatever they like best. If you’re a pessimist, you might start wondering whether anything works at all.

By my understanding this is also the confusing conclusion of Ferri, Amato & Davoli (2006), the Cochrane Collaboration’s attempt to get in on the AA action. Like all Cochrane Collaboration studies since the beginning of time, they find there is insufficient evidence to demonstrate the effectiveness of the intervention being investigated. This has been oft-quoted in the anti-AA literature. But by my reading, they had no control groups and were comparing AA to different types of treatment:

Three studies compared 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.

So the two best sources we have – Project MATCH and Cochrane – don’t find any significant differences between AA and other types of therapy. Now, to be fair, the inpatient treatment mentioned in Walsh et al wasn’t included, and inpatient treatment might be the gold standard here. But sticking to various forms of outpatient intervention, they all seem to be about the same.

So, the $64,000 question: do all of them work well, or do all of them work poorly?

V.

Alcoholism studies avoid control groups like they are on fire, presumably because it’s unethical not to give alcoholics treatment or something. However, there is one class of studies that doesn’t have that problem. These are the ones on “brief opportunistic intervention”, which is much like a turbocharged even shorter version of “motivational enhancement therapy”. Your doctor tells you ‘HELLO HAVE YOU CONSIDERED QUITTING ALCOHOL??!!’ and sees what happens.

Brief opportunistic intervention is the most trollish medical intervention ever, because here are all these brilliant psychologists and counselors trying to unravel the deepest mysteries of the human psyche in order to convince people to stop drinking, and then someone comes along and asks “Hey, have you tried just asking them politely?”. And it works.

Not consistently. But it works for about one in eight people. And the theory is that since it only takes a minute or two of a doctor’s time, it scales a lot faster than some sort of hideously complex hospital-based program that takes thousands of dollars and dozens of hours from everyone involved. If doctors would just spend five minutes with each alcoholic patient reminding them that no, really, alcoholism is really bad, we could cut the alcoholism rate by 1/8.

(this also works for smoking, by the way. I do this with every single one of my outpatients who smoke, and most of the time they roll their eyes, because their doctor is giving them that speech, but every so often one of them tells me that yeah, I’m right, they know they really should quit smoking and they’ll give it another try. I have never saved anyone’s life by dramatically removing their appendix at the last possible moment, but I have gotten enough patients to promise me they’ll try quitting smoking that I think I’ve saved at least one life just by obsessively doing brief interventions every chance I get. This is probably the most effective life-saving thing you can do as a doctor, enough so that if you understand it you may be licensed to ignore 80,000 Hours’ arguments on doctor replaceability)

Anyway, for some reason, it’s okay to do these studies with control groups. And they are so fast and easy to study that everyone studies them all the time. A meta-analysis of 19 studies is unequivocal that they definitely work.

Why do these work? My guess is that they do two things. First, they hit people who honestly didn’t realize they had a problem, and inform them that they do. Second, the doctor usually says they’ll “follow up on how they’re doing” the next appointment. This means that a respected authority figure is suddenly monitoring their drinking and will glare at them if they stay they’re still alcoholic. As someone who has gone into a panic because he has a dentist’s appointment in a week and he hasn’t been flossing enough – and then flossed until his teeth were bloody so the dentist wouldn’t be disappointed – I can sympathize with this.

But for our purposes, the brief opportunistic intervention sets a lower bound. It says “Here’s a really minimal thing that seems to work. Do other things work better than this?”

The “brief treatment” is the next step up from brief intervention. It’s an hour-or-so-long session (or sometimes a couple such sessions) with a doctor or counselor where they tell you some tips for staying off alcohol. I bring it up here because the brief treatment research community spends its time doing studies that show that brief treatments are just as good as much more intense treatments. This might be most comparable to the “motivational enhancement therapy” in the MATCH study.

Chapman and Huygens (1988) find that a single interview with a health professional is just as good as six weeks of inpatient treatment (I don’t know about their hospital in New Zealand, but for reference six weeks of inpatient treatment in my hospital costs about $40,000.)

Edwards (1977) finds that in a trial comparing “conventional inpatient or outpatient treatment complete with the full panoply of services available at a leading psychiatric institution and lasting several months” versus an hour with a doc, both groups do the same at one and two year followup.

And so on.

All of this is starting to make my head hurt, but it’s a familiar sort of hurt. It’s the way my head hurts when Scott Aaronson talks about complexity classes. We have all of these different categories of things, and some of them are the same as others and others are bigger than others but we’re not sure exactly where all of them stand.

We have classes “no treatment”, “brief opportunistic intervention”, “brief treatment”, “Alcoholics Anonymous”, “psychotherapy”, and “inpatient”.

We can prove that BOI > NT, and that AA = PT. Also that BT = IP = PT. We also have that IP > AA, which unfortunately we can use to prove a contradiction, so let’s throw it out for now.

So the hierarchy of classes seems to be (NT) < (BOI) ? (BT, IP, AA, PT) - in other words, no treatment is the worst, brief opportunistic intervention is better, and then somewhere in there we have this class of everything else that is the same.

Can we prove that BOI = BT?

We have some good evidence for this, once again from our Handbook. A study in Edinburgh finds that five minutes of psychiatrist advice (brief opportunistic intervention) does the same as sixty minutes of advice plus motivational interviewing (brief treatment).

So if we take all this seriously, then it looks like every psychosocial treatment (including brief opportunistic intervention) is the same, and all are better than no treatment. This is a common finding in psychiatry and psychology – for example, all common antidepressants are better than no treatment but work about equally well; all psychotherapies are better than no treatment but work about equally well, et cetera. It’s still an open question what this says about our science and our medicine.

The strongest counterexample to this is Walsh et al which finds the inpatient hospital stay works better than the AA referral, but this study looks kind of lonely compared to the evidence on the other side. And even the authors admit they were surprised by the effectiveness of the hospital there.

And let’s go back to Project MATCH. There wasn’t a control group. But there were the people who dropped out of the study, who said they’d go to AA or psychotherapy but never got around to it. Cutter and Fishbain (2005) take a look at what happened to these folks. They find that the dropouts did 75% as well as the people in any of the therapy groups, and that most of the effect of the therapy groups occurred in the first week (ie people dropped out after one week did about 95% as well as people who stayed in).

To me this suggests two things. First, therapy is only a little helpful over most people quitting on their own. Second, insofar as therapy is helpful, the tiniest brush with therapy is enough to make someone think “Okay, I’ve had some therapy, I’ll be better now”. Just like with the brief opportunistic interventions, five minutes of almost anything is enough.

This is a weird conclusion, but I think it’s the one supported by the data.

VI.

I should include a brief word about this giant table.

I see it everywhere. It looks very authoritative and impressive and, of course, giant. I believe the source is Miller’s Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 3rd Edition, the author of which is known as a very careful scholar whom I cannot help but respect.

And the table does a good thing in discussing medications like acamprosate and naltrexone, which are very important and effective interventions but which will not otherwise be showing up in this post.

However, the therapy part of the table looks really wrong to me.

First of all, I notice acupuncture is ranked 17 out of 48, putting in a much, much better showing than treatments like psychotherapy, counseling, or education. Seems fishy.

Second of all, I notice that motivational enhancement (#2), cognitive therapy (#13), and twelve-step (#37) are all about as far apart as could be, but the largest and most powerful trial ever, Project MATCH, found all three to be about equal in effectiveness.

Third of all, I notice that cognitive therapy is at #13, but psychotherapy is at #46. But cognitive therapy is a kind of psychotherapy.

Fourth of all, I notice that brief interventions, motivational enhancement, confrontational counseling, psychotherapy, general alcoholism counseling, and education are all over. But a lot of these are hard to differentiate from one another.

The table seems messed up to me. Part of it is because it is about evidence base rather than effectiveness (consider that handguns have a stronger evidence base than the atomic bomb, since they have been used many more times in much better controlled conditions, but the atomic bomb is more effective) and therefore acupuncture, which is poorly studied, can rank quite high compared to things which have even one negative study.

But part of it just seems wrong. I haven’t read the full book, but I blame the tendency to conflate studies showing “X does not work better than anything else” with “X does not work”.

Remember, whenever there are meta-analyses that contradict single very large well-run studies, go with the single very large well-run study, especially when the meta-analysis is as weird as this one. Project MATCH is the single very large well-run study, and it says this is balderdash. I’m guessing it’s trying to use some weird algorithmic methodology to automatically rate and judge each study, but that’s no substitute for careful human review.

VII.

In conclusion, as best I can tell – and it is not very well, because the studies that could really prove anything robustly haven’t been done – most alcoholics get better on their own. All treatments for alcoholism, including Alcoholics Anonymous, psychotherapy, and just a few minutes with a doctor explaining why she thinks you need to quit, increase this already-high chance of recovery a small but nonzero amount. Furthermore, they are equally effective after only a tiny dose: your first couple of meetings, your first therapy session. Some studies suggest that inpatient treatment with outpatient followup may be better than outpatient treatment alone, but other studies contradict this and I am not confident in the assumption.

So does Alcoholics Anonymous work? Though I cannot say anything authoritatively, my impression is: Yes, but only a tiny bit, and for many people five minutes with a doctor may work just as well as years completing the twelve steps. As such, individual alcoholics may want to consider attending if they don’t have easier options; doctors might be better off just talking to their patients themselves.

If this is true – and right now I don’t have much confidence that it is, it’s just a direction that weak and contradictory data are pointing – it would be really awkward for the multibazillion-dollar treatment industry.

More worrying, I am afraid of what it would do to the War On Drugs. Right now one of the rallying cries for the anti-Drug-War movement is “treatment, not prison”. And although I haven’t looked seriously at the data for any drug besides alcohol. I think some data there are similar. There’s very good medication for drugs – for example methadone and suboxone for opiate abuse – but in terms of psychotherapy it’s mostly the same stuff you get for alcohol. Rehabs, whether they work or not, seem to serve an important sort of ritual function, where if you can send a drug abuser to a rehab you at least feel like something has been done. Deny people that ritual, and it might make prison the only politically acceptable option.

In terms of things to actually treat alcoholism, I remain enamoured of the Sinclair Method, which has done crazy outrageous stuff like conduct an experiment with an actual control group. But I haven’t investigated enough to know whether my early excitement about them looks likely to pan out or not.

I would not recommend quitting any form of alcohol treatment that works for you, or refusing to try a form of treatment your doctor recommends, based on any of this information.

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175 Responses to Alcoholics Anonymous: Much More Than You Wanted To Know

  1. IllidanStR says:

    All I can say is that this is beautiful writing, and, Scott, you crack me up.

    And this is sometimes how I feel about nutrition.

    Maybe the best thing to do is to try to act like a rich person. They always seem to have the best outcomes!

    • Keller says:

      Relevant question: is it wealth, or high socioeconomic status attitudes that matter? I would guess college students, Harvard Law grads working as public defenders by choice, and the like would have outcomes that reflect their background and not their current income or wealth.

      • Anonymous says:

        Simply being genetically superior shouldn’t automatically be disregarded as a hypothesis.

      • IllidanStR says:

        My guess:

        1. Habits and beliefs high SES families tend to have

        2. Not having to worry about paying hospital bills or getting evicted or the heat shut off or whether you can afford to buy the organic arugula

        3. Maybe genetics to some extent? Highly interesting, I have no idea

        4. Being surrounded by a very different atmosphere than in poor SES households (often cleaner, all the effects that come from not having to worry about money)

        5. Being surrounded by people who, if they decide to help you, have all sorts of ability and pull and money to do so without starving or getting evicted

      • Doug S. says:

        There was a study that showed that people who won Academy Awards lived, on average, four years longer than people who were nominated and lost. A follow-up study said that the original study didn’t take into account that people get nominated at different ages (and winning an Oscar can’t retroactively affect your health in the time before you won it), so the effect of winning an Oscar is closer to 1 year and wasn’t statistically significant.

    • Quite Likely says:

      Haha, that should really be the conclusion of every study: “For best results, be rich”

    • 27chaos says:

      You jest, but I bet it will work. Gonna try talking myself into a rich person’s mindset now.

      • Jaskologist says:

        The real lesson here is that we could solve a lot of problems if doctors would just take five minutes with each of their patients and ask “Hey, have you tried being rich?”

  2. Kaminiwa says:

    Beautifully written, and a fascinating conclusion.

    I wonder how much this scales to other concepts? Is a 5 minute sales pitch as effective as an hour long one? Should we be aiming for 5 minute mini-meetings? 5 minute TED Talks?

    • somnicule says:

      5 minutes to actually think of something seems to be a rationalist culture standard now. It’s my primary personal anti-akrasia technique, too. “Spend 5 minutes doing thing, and then decide if you want to carry on.”

      I think it’s a pretty good balance for high-akrasia/poor impulse control people, such as myself and those at risk of becoming addicts, for “can plausibly get something done” and “not a big scary task”

  3. BenSix says:

    …I do this with every single one of my outpatients who smoke, and most of the time they roll their eyes, because their doctor is giving them that speech…

    Interesting. My orthodontist waited until I was open-mouthed and defenceless, mid-way through a cleaning, before she launched into the story of the man whose oral cancer she had recognised that week. It did make an impression (though perhaps that was because I could associate tobacco with searing pain).

    • houseboatonstyx says:

      It did make an impression (though perhaps that was because I could associate tobacco with searing pain).

      Apprehension of pain, in a physically helpless situation, is a factor I hadn’t thought of here, but it might be one factor in the high rating of acupuncture in that study. (Not that competent acupuncture is actually painful.) Several of the factors mentioned above as helpful in conventional treatments are contained in the acupuncture situation also. The client has decided to try to stop, has made an appointment, is paying money for the service, has gotten close attention of a professional, has been seriously questioned about his personal experience of smoking and why he wants to quit, and then is put for perhaps an hour in a helpless and possibly uncomfortable position with little to think about except just WHY he is here and to renew his commitment to stopping, promptly so as not to need a repeat treatment.

  4. zz says:

    Very nice. Any chance I could get you to do Weight Watchers next?

  5. ciil says:

    Question: All of those studies seem to be US only. Did it occur to anybody to take some socio-economically similar people from other countries that don’t use AA nearly as much (though everybody knows it due to Hollywood pop-culture references) and use them as control?

    On second thought, every country, even without US-style AA probably has some kind of self-help-group-concept for alcoholics … but you could at least try to compare different kinds of self-help groups and try to get to the underlying concept in those that works better than no treatment?

    • Using a different country would throw up a whole new host of confounders (is wine easier to quit than beer? How about depressed vodka addicts? Does having a better social safety net help?)

      • ciil says:

        That’s certainly correct, but as the US is so big and different in different parts, I guess most of those confounders could already be found within the country. Maybe you could mitigate the effects by using groups in different US states that have known differences in AA attendance? (Yeah, you’re opening a new can of worms with that, because then you have to think about the differences in the AA programs that cause the disparity … damn.)

        But then again, there’s probably more overlap between a carefully chosen US group and a carefully chosen abroad group in a country without AA than there is between some US groups. So you can test for differences in treatments in that special group and have one data point and repeat for other groups so that in the end you may be able to extrapolate to the population.

        If you want a real control group you’ll have to work around the ethics requirements that say a doctor can’t just prohibit people from attending AA. And using other countries where doctors don’t even think AA a viable alternative to Some Other Treatment Method would be a fast and easy solution with the least amount of meddling with the Ethics Board required.

        • Deiseach says:

          So what would the control group be – people who go to A.A. versus people who drink until their liver gives out? People who go to A.A. versus people who go to hospital, or quit on their own, or are locked up in jail and can’t get alcohol (though it seems you could get other substances instead there)?

          I don’t know how you would pick a control group: homeless shelters? hospitals where people have been admitted because they passed out drunk in the streets? put an ad in the paper asking for volunteers to be observed in a study?

    • Scott Alexander says:

      Some of these studies were in the UK, but I admit that still leaves a lot of foreign. A lot of it is the language barrier – if there are non-English speakers investigating this, I can’t read them, Google can’t find them, and the research community doing the reviews I read doesn’t seem interested.

      • Richard says:

        What I like most about this blog is that it makes me think about stuff I never would have without it. I’ve just moseyed around reading articles from the norwegian centre for addiction research

        (quite a few of the articles are in English, but the place seems most focused on opioid research rather than alcohol)

        It turns out that in Norway, less than 5% of treatments include 12-step groups because: “The majority of health professionals find the religious aspects of 12-step programs to be troubling”.
        I get the feeling that whether or not the program works is perceived to be less important than not exposing patients to religious nut-jobs, which I can sort of understand.

        Anyways, if you read around a bit on the site, you may or may not find relevant information. Enjoy 🙂

        edit: after a closer look on the AA related articles, it seems they are probably useless for this purpose. They all seem to conclude that 12-step programs should be investigated more to see if they can be of any use despite the religious aspects, which is less than helpful information.

        • Harald K says:

          You’re quite wrong that Norway makes it a priority not to expose addicts to “religious nutjobs”. Associations like Evangeliesenteret (a pentecostal drug treatment center established by the romani lay preacher Ludvig Karlsen) get support over the state budget. A lot of “secular” addiction treatment too is administered by religious organizations such as Blue Cross (no relation to the US insurance provider).

          Norway has collected public health statistics longer than most other states, and is pioneering on the systematic study of social interventions. The Campbell collaboration, a sister project to Cochrane, is based in Oslo. There is cross-political agreement that treatment and policy interventions should be evidence based.

          • Richard says:

            [nitpick]

            There is a difference between getting support over the state budget and individual health professionals referring people to treatment.

            As long as 95%+ of health practitioners won’t refer a patient to 12-step groups, you won’t get a lot of people attending.

            Since I personally don’t think religion is a strong sign of sanity, it seems Norway has saner doctors than politicians, which comes as no great surprise 🙂

            [/nitpick]

      • Douglas Knight says:

        But isn’t all European medical research in English? (as Richard says!) At least, anyone who thinks their study is a big deal wants attention possible only by publishing in English. The big hole in the scientific literature is Japan, because they don’t care about impressing foreigners.

        • Richard says:

          There are probably also a lot of studies published only in either Russian, German or Spanish because those languages are large enough to support a significant research community. This was why I looked at Norwegian studies, since Norwegian is small enough that they need to publish in English if they want more than about three people to read it.

  6. This was fascinating. I have relatives who are very active in AA and who swear by it, including one who attends regularly some 40(?) years after being alcoholic. The main thing that I note is that for her, AA is mostly a community of people with a similar life experience, bound together by common rituals, ie. a church. (She also goes to church, but I think she likes AA better.) We shouldn’t gloss over the non-alcohol-related benefits of this, especially AA is one of the only church-like organizations that a lot of people who don’t go to actual churches will consider.

    • Quite Likely says:

      But if you want to go to church, why not just do so? I assume that people who don’t because they’re anti-religion aren’t exactly going to be happy with AA either.

      • Vulture says:

        I know a number of secular-but-spiritual people who are somewhat repulsed by dogma/Christianity and end up attending a mushy believe-what-you-want Unitarian Universalist church that’s just organized like a Protestant church. Might be a similar deal.

      • In addition to what Vulture says, there are other sorts of cultural reasons why people might go to AA but not to a church. In the lower-income milieu where this part of my family lives, people may view churches as places for decent, respectable people, which they are not. The local AA meeting, OTOH, mostly contains other trailer trash, and so is less culturally foreign and more welcoming to them as a place for recovery.

  7. Emily H. says:

    I suspect “Harm reduction, not prison” doesn’t have much oomph as a political slogan, but for nonviolent drug offenders “treatment if you want it, needle exchange if you don’t” might be a reasonable way to go. (Supposing that spending a lot of rehab dollars on somebody who doesn’t want to stop using is not very efficient.)

    The MATCH study tries to get at this and doesn’t find anything, but I wonder whether “everything works a little bit” obscures, at all, whether certain treatments are more effective for certain people than others. Even if intensive inpatient treatment doesn’t work better on average, there may be some small number of people who really need it.

  8. Vaniver says:

    this also works for smoking, by the way. I do this with every single one of my outpatients who smoke, and most of the time they roll their eyes, because their doctor is giving them that speech, but every so often one of them tells me that yeah, I’m right, they know they really should quit smoking and they’ll give it another try.

    Someone in the LW-sphere carries around single-use e-cigs to hand out to smokers; Blu‘s run $10 each. This turns out to have a surprisingly good return even with very pessimistic estimates of how many people will stop smoking after trying one. I’m not sure this is appropriate for you to do as A Doctor Talking To Patients, but has the additional benefit of being something doable by anyone in the audience (even you!).

  9. Vaniver says:

    I recently read Triumphs of Experience about the Grant Study, which has a chapter on alcoholism (which I’m sure you can find the actual studies for). A quote from it:

    It isn’t easy to identify who is and is not an alcoholic. Until now, most major longitudinal studies of health (for example, the Framingham Study in Massachusetts and the Alameda County Study in California) have taken into account only alcohol consumption, not alcohol abuse. Unfortunately, as I’ve said before, reported alcohol consumption identifies alcohol abuse almost as poorly as reported food consumption reflects obesity. In contrast, the Grant Study has always focused on alcohol-related problems. Where alcohol is concerned, it is what people do, not what they say, that is important.

    Because they have 75 years of data on the people involved, and they started with a broad sample, it’s easy to believe their claim that alcohol abuse precedes problems (and thus causes them) rather than being a reaction to problems. But when it comes to treatment, they don’t solve any of the methodological problems you mention (they find that people who go to AA do better than people who don’t, but only slightly).

    They also claim that returning to drinking is only possible for borderline alcoholics, and even then half of the people who successfully return to controlled drinking decide to switch to abstinence.

  10. Partisan says:

    Re: “Okay, I’ve had some therapy, I’ll be better now” – I’d like to know how common this outcome is. I think it’s something that worked for me in a different context.

    Since a childhood trauma (sudden, violent death of a close relative) I’d had these short (several minutes) panic or anxiety attacks. Never very often – anywhere from once every 4 months to once every 9 months.

    After one episode I decided to make an appointment with a counselor to talk about it. I wasn’t particularly enamored with this counselor’s approach to dealing with it – it all seemed like platitudes about grief and the sort of things you can imagine a counselor saying in a movie.

    However… I’ve not had a recurrence since. This is the longest I’ve gone without having such an episode, and I’ve been through some events that would have probably triggered one in the past.

    If I’d known I could trick my mind into fixing this problem so easier I would have seen the counselor years ago. This post makes me wonder if I could have had a 5 minute discussion instead of two hour long appointments.

    • somnicule says:

      Doing literally anything regarding anxiety can be beneficial, IME. Anxiety is largely self-reinforcing, so if you become less anxious about the anxiety itself you can break the loop. This can be by having medication on hand if you need it, a simple technique you want to try next time you get anxious, or knowing that you have professional support if you want it.

    • Anonymous says:

      I had horrible paranoia about my heart and always noticed when it was pounding. After a few months of this I went to a cardiologist and got an EKG. He said everything was fine. I have not had a single instance of anxiety about my heart since then.

  11. Ilya Shpitser says:

    “Bzzzt! No! Wrong! Selection bias!”

    It’s actually even worse than that, it’s time-dependent confounding. If you go to an AA meeting every month, and we even went so far as to record your life, including things we think lead to you going to AA every month, call them C, (those are the plausible confounders for the effect of AA), then it is very tricky to adjust for them. That is because at time k, C acts as a confounder for the effect of AA at time k, but _at the same time_ it acts as a mediator for the effect of AA at time k-1. So if you just adjust for C at all time points you will get garbage.

    I write about this issue a lot (and I could probably spend the rest of my days just harping on this one point, people almost always get this wrong in longitudinal data analysis). Of course most people either just look at associations over time, or use things like “propensity scores,” which is worse than wrong, because it gives you a false sense of confidence that you are getting the right causal answers out.

    Good post :).

    • Noumenon72 says:

      Would you explain what “acts as a mediator for the effect of AA” means?

      • Ilya Shpitser says:

        Sure!

        Imagine we had an antibiotic that was also anti-inflammatory. Imagine we had a bacterial disease that can kill you either directly (bacteria trashing your system) or via a severe inflammatory reaction of the immune system to the disease. Imagine further that different people have different immune response — some get much worse inflammation. And finally, imagine that we had some observed measure of how jumpy their immune system is. The question is, do we adjust for this measure when thinking about the causal effect of the drug on the outcome. My claim is “no” — if we are interested in the overall effect, we want to know if the drug kills bacteria well, and in addition if the drug brings the dangerous inflammation down. If we adjusted for immune response, we would remove some of the effect (because conditioning on the immune response screens off part of the effect, immune response lies on a causal pathway from drug to outcome, e.g. mediates the effect). This kind of variable is called a mediator.

        In the AA case, your AA session at time k-1 influences your C (resolve/willpower/etc) at time k, which influences the eventual outcome. So C at time k is a mediator for AA at time k-1 and the outcome. So if we adjust for it naively, we screen off part of the effect of AA, specifically the part at time k-1 that moves through C at time k. But if we don’t adjust for it, then it serves as a confounder for AA at time k. So we must be sneaky to do this right.

        Not sure if helpful or clear.

  12. Protagoras says:

    Very interesting discussion! I used to drink a lot (I won’t call myself an alcoholic because I’m one of the non-fans of AA), and the thing that really helped me cut it down was getting drug therapy for my depression, either because being less depressed made it easier for me to not drink or because the fact that my depression medication mixed badly with alcohol gave me extra incentive to avoid alcohol. That’s one of the reasons I don’t like AA, because at least old school AA is pretty committed to the idea that drugs are the problem, they’re never the solution. I’m also really interested in drug therapies like the Sinclair method that you very briefly allude to. I’m also interested in cases where addiction is present alongside other psychological issues; when and to what extent does treatment of the other issues help with the addiction as well?

  13. Zubon says:

    To what extent are the problems of self-reported data addressed as confounding factors? Someone can be genuinely well, think they’re well and have exactly the same problem, know they’re unwell but lie to get out of AA, or know they’re unwell but lie because of social desirability bias. “How much are you drinking?” is a great one for collecting data because of not knowing/remembering how much you drank.

    Q: “Have you ever drank to the point of blacking out?”
    A: “Yes.”
    Q: “The latest time this happened, how many drinks did you have that night?”
    A: “I don’t know. I blacked out.”

    • Alan says:

      One doctor told me that when she dealt with medical problems that were side effects of alcohol (accidents, fights, passing out, whatever) the person had always drank two drinks: the one that started the evening, and the one immediately before the problem. Any other drinks were not remembered.

  14. Ken Arromdee says:

    However, various different sources suggest that, of people who stay in AA a reasonable amount of time, about half stop being alcoholic.

    It is my understanding that AA doesn’t define an alcoholic in such a way that someone is required to drink alcohol in order to be considered one. (And such redefinition of terms is also a cultish sign.)

    • estelendur says:

      Yeah, there’s this idea of the “alcoholic personality” which indicates a genetic predisposition manifesting as a set of personality and neuroconfiguration traits that mean someone Is An Addict. I am unclear on what exactly these traits are, but at least one of them can be phrased as “if something is worth doing, it’s worth overdoing.”

    • Anonymized says:

      “Alcoholic” in AA is like “sinner” in a Christian church, I think: if you believe that it’s a legit category, you don’t think you can ever escape it.

    • n. says:

      AA doesn’t define alcoholic in a way that would be clinically useful. An alcoholic is someone that has problems and wants to stop drinking. All that AA asks from its members is a desire to stop drinking, which is a very practical definition if all you care about is helping people stop. Its less useful if you’re trying to do research on addiction. If you choose to see this as a sign of cultish behavior, I think you’re probably reaching. There’s plenty of other places to criticize AA, but a willingness to take all comers can’t possibly be one of them.

      • Ken Arromdee says:

        An alcoholic is someone that has problems and wants to stop drinking. All that AA asks from its members is a desire to stop drinking, which is a very practical definition if all you care about is helping people stop.

        If this is really what they meant, then someone who had stopped drinking would, by definition, no longer be an alcoholic. This is true for normal definitions of the term, but not AA’s definition.

    • Harald K says:

      There is no official definition of alcoholism as far as I know. There is “alcohol use disorder”, “alcohol abuse” and “alcohol dependence” etc.

      You can’t blame AA for redefining alcoholism, since they were the ones who (at least to the public) originally defined it, and certainly the ones most responsible for making us think of alcoholism as a disease. Wrongly, many say.

      Pre-AA, alcohol abuse was seen as a collective and social problem (“drunkenness”), after, as an individual and medical one (“alcoholism”).

  15. Lila says:

    I’ve also heard that hospitalization+medication can be quite effective. I wanted to get this added to my advance directive, but unfortunately, an addict is still considered competent in the legal sense, so this is not possible. My solution to the war on drugs: create a legal option for an addiction advance directive and have doctors offer it to their patients at their checkups. The directive would say something like “I agree that if three psychiatrists independently find me to meet the symptoms of addiction [detailed here], my agents are authorized to hospitalize and medicate me.”

    This would mean that people who remain addicts have “chosen” it in a way, by declining to sign the addiction-treatment form when they had the chance.

    • Scott Alexander says:

      Hospitalization + medication is better than nothing, but if someone’s addicted enough it still has a way less than 50% success rate.

      In my experience, most people who are bad enough that their addiction comes to the attention of the medical system, and their insurance is willing to pay for treatment, are willing to go for inpatient treatment and very happy to take medications.

    • J says:

      I like the way you think. I’ve proposed similar solutions for people who are bad with money. We need more ways to take advantage of willpower when we can manage it.

  16. estelendur says:

    In AA’s defense, or at least in Al-Anon’s defense (which is 12 steps for friends and family of addicts), a lot of the things they do are very good for helping some people figure out how to deal with life and people in general more serenely…? less dysfunctionally…? My father became way less angry after he started going to Al-Anon.

    But there’s a lot of weird cultish stuff and a very specific model of what addiction is (which I described a bit of upthread), that sketches it as something inherent and eternal.

    • Anonymized says:

      I think any effectiveness AA shows is probably bound up in the cultish/small-community/granfalloonical aspects, not the busted addiction model. I went to meetings for about six months, and it’s as you say: a life-changer for many people, giving them a sense of purpose, a way to atone by helping others, and someone to talk to.

      As a cult, it’s pretty benign.* There are really low barriers to entry and exit. AA won’t try to get you to sign over your estate, or lock you in a closet if you try to leave. The taboo against breaking anonymity – while it’s de facto breached all the time – means that the social sanctions apostates face are minimal.

      But all of the cultish stuff, however mild, and the absolute prohibitionism, drives people away, for sure. It would be nice to see a proliferation of addiction-support communities with other kinds of beliefs and practices. (There’s some diversity in tone and intensity between different AA meetings, but I kind of doubt anyone is running an AA meeting anywhere [keeping the name] that doesn’t proscribe alcohol use altogether, for instance.)

      * As far as I know. Now I am imagining all kinds of AA horror stories involving god-knows-what. They probably have happened, humans being humans. 🙁

      • estelendur says:

        I got exposed to the AA dogmas on the how and why of addiction as an emotionally fragile and somewhat unstable middle schooler, so I’ve pretty much always viewed them with suspicion (and a little fear; I am the child of an alcoholic therefore I too might be an alcoholic! but this seems to not have been the case).

        A thing that does happen is becoming attached to emotionally needy completely dysfunctional people, which is a thing my mother has done and is unable to, er, undo.

        I do wonder how Al-Anon is different from AA, because Al-Anon is all about, afaict, how to not let other people make you deal with their crap for them, how to live your own life without it being controlled by your partner’s alcoholism (or alcoholic-ness). I’ve never gone, because I’m allergic to 12 step programs. But it seems to have helped my father a lot.

        • A says:

          Being in Al-Anon, with my boyfriend in AA for two years, the difference I’ve heard from AA/Al-Anon members, is that often AA is dogmatic and harsh at times because people within the program see the “allergy” of alcohol as life threatening, and in Al-Anon the program is less by-the-book and gentle, because the behavior is not life-threatening (typically). Al-Anon focuses on what you said above; how to live your life as your own without conforming it around the alcoholic via being the clean up crew, caretaker, etc.

          I didn’t get into Al-Anon because of my partner’s behavior. Rather, I met him, and given my past he recommended I try Al-Anon as a way to meet healthier friends and receive support. And yes, it has very much helped me personally, specifically the group meetings and having a sponsor. Sponsors are non-judgmental acting people, not quite a friend (clarify: should not be a friend as this can get complicated), that you call when you feel you are feeling concerned about yourself and/or a situation. As well as usually once a day for accountability, even if you have nothing to talk about.

  17. Tarrou says:

    That “opportunistic intervention” stuff gets fucking annoying after a while. I recall a point in my life where I was drinking hard and continuously. The doctors would always ask me how much I drank and pull the old “Oh MY! You should really cut back, and here’s a list of programs!”.

    I told them to stuff it, they’d rather me drink than the alternative. Frankly, in the state I was at the time, any health concerns were far less dangerous than my psychological state sober.

    Ten years on, I drink very little (<1/day on average). And do you know what the doctors say when I tell them that? "Oh MY! You should really cut back, and here's a list of programs!".

    That's when I realized that the difference between health care and moralizing wasn't actually there. As a patient, there's no way to tell (without doing more research than Scott here) whether the doctor is giving you actual medical advice or his own puritanical bullshit. We might as well give prescription privileges to preachers.

    • caryatis says:

      I’m surprised you were honest about your drinking. I wouldn’t be. Why give a doctor an opportunity to pigeonhole you as an addict when you’re seeking care for something else?

      • Tarrou says:

        Meh, I knew I was drinking far more than normal. And I also know there wasn’t anything the doctors could do directly, and I am as honest as possible about medical stuff.

        It also kept them from prescribing me more drugs, because everything seems to react poorly with alcohol.

      • Desertopa says:

        Well, even if he wasn’t planning to stop, if he started suffering from ailments related to excessive alcohol consumption, it would be useful for his doctors to know that the ailments were probably caused by alcohol and not something else.

    • LHN says:

      Opportunistic intervention might have the invisible downside of dissuading people who are tired of hearing it from going to the doctor.

      Anecdotally, I tend to put off checkups when I’ve gained weight– partly to avoid the lecture, and partly in hopes that I can lose some first and not be “caught”. This is ridiculous– whatever the health/social/whatever consequences of gaining weight, being shamed by the doctor should be de minimis. But I doubt I’m unique.

      • Cadie says:

        Also, discouraging honesty, if it’s done too many times to the same person.

        After self-medicating with nicotine for years, I started telling doctors I lived with a smoker but had quit myself, just to make the lecturing stop. Luckily, I wasn’t on any medication for which it mattered, and my lab work was fine. But if those weren’t the case and I didn’t know to check my meds for interactions myself, I could have ended up with dangerous treatments, or costly investigations as to why my lab results were off. I eventually did switch to electronic cigarettes to save money and smell better, and disclose that info, but I was fibbing for a few years in between.

        Which is not to say opportunistic intervention is bad. It sounds like a good method from the info here. Just that giving the same patient many exposures to it with few/no visits without it provides a disincentive for them to tell the truth.

    • Deiseach says:

      What I’m interested in is what happens after the five-minute approach; suppose Dr Bob tells Patient Joe “Hey, have you ever considering stopping drinking?” and Patient Joe says “Now you mention it…”

      What does Patient Joe do then? Does he go home and pour all his cheap sherry/Dutch Gold lager down the sink and quit cold turkey? Does he decide to look up the local AA chapter because if the doctor is telling him his drinking is bad, it must be getting serious?

      If your patients are going to AA after the five minute chat, then maybe that influences the outcome?

      And re: the “opportunistic intervention” stuff, I’m with Tarrou on that. Not for drinking, but for losing weight. The one and only time I ever blew up and threw the head in a doctor’s appointment was precisely the one time too many I got the “did you ever consider going on a diet?” line.

      Instead of being all contrite and “yes doctor, sorry doctor, I know I’m bad and awful doctor” as I should have been, instead I reacted with sarcasm: “Why, nobody in my entire life has ever suggested such a thing to me and certainly not a doctor ever before!”

      Things went as badly as you’d imagine after that. Doctors like telling you “diet’n’exercise”, they don’t like hearing “yeah, I actually did try that; I’ve been trying that all my life, and it’s not working because X, Y and Z.” They like giving you the party line, no support or suggestions as to how to do this (apart from “Try WeightWatchers” or “join a gym”), and no backchat from you about how previous diets haven’t worked, and if you fail to lose weight then it’s all down to moral failing on your part, being too fat, lazy and stupid to make the simple easy effort to lose weight.

      (Rant over).

      • Deiseach says:

        Re: the moralising – that’s true, also. I went to a young pup of a doctor for a checkup who ordered a blood test and was visibly furious when the results came back, because they were in the normal range for cholesterol, blood glucose etc. and he wanted so badly to tell me I was diabetic because of being overweight as a punishment for my sins – not that he’d have dreamt of using a term like “sin”, but as the deserved and all my own fault result of my moral failings for not being thin? Oh, yeah.

      • Nicholas says:

        The body of research in human nutrition I am familiar with, and the body of research in the psychology of food I am familiar with, suggests that the last sentence of your post is the world most of us actually live in. If you are an exception to “almost all fat people are liars” and you say as much, well that’s exactly what a liar would say, isn’t it?

    • Tracy W says:

      I ran across a quote once, to the effect of that a doctor’s job was not to try to persuade their patient to change their lifestyle to live longer, but to keep their patient alive as long as possible while enjoying whatever lifestyle they wanted.

      Unfortunately that memory is not specific enough to find it by google. I think it was from about 100 years ago so the terminology has changed too much.

    • Cat says:

      As a medication-refusing bipolar patient, I get this all the time and am sick of it. It’s part of the reason why akrasia strikes every time I need to go to the doctor.

  18. Captainbooshi says:

    This was a great post! I’ve been curious about the actual effectiveness of AA for years, but any time I tried to research, there was just too many conflicting studies and opinions that I wasn’t able to get anywhere. Even beyond the useful information, it’s comforting to know someone with a bunch of medical training agrees that the whole subject is a hot mess. It also answers several of the questions I had that I had no luck finding myself, tells me stuff I didn’t know, and corrects several things I thought that was wrong. Thanks for that!

  19. StataTheLeft says:

    There’s at least some evidence from probation enforcement experiments that swift and certain sanctions for people who relapse may reduce the likelihood of relapse (at least in the short term). http://www.nij.gov/topics/corrections/community/drug-offenders/Pages/hawaii-hope.aspx

  20. mp says:

    Thoughts on ibogaine as a treatment for addiction?

  21. J says:

    My grandma worked in public health for 50 years and told me stories about an aversion therapy (emetic + liquor of choice) center where she worked, and how successful they had been.

    Ever since then I’ve wanted to know if it would work to have a substance that could be applied to one random cigarette in each pack (by an assistant to the addict) that would cause nausea, and if that’d work for counteracting the relief caused by smoking. Each light up would be playing roulette with losing your lunch.

    • Legendary humorist Dave Barry once proposed a more entertaining version of this:

      No, we need something stronger than warnings. We need cigarette loads. For those of you who were never obnoxious 12-year-old boys, I should explain that a “load” is an old reliable practical-joke device, a small, chemically treated sliver of wood that you secretly insert into a cigarette, and when the cigarette burns down far enough, the load explodes, and everybody laughs like a fiend except, of course, the smoker, who is busy wondering if his or her heart is going to start beating again.

      I think Congress ought to require the cigarette manufacturers to put loads in, say, one out of every 250 cigarettes. The result, I can assure you, would be a real deterrent to smokers thinking about lighting up, especially after intimate moments:
      MAN: Was it good for you? (inhales)
      WOMAN: It was wonderful. (inhales) Was it good for you?
      MAN: Yes. (inhales) I have an idea: Why don’t we … B‑L‑A‑M!!!!!

  22. Thomas says:

    Anything at all on Al-Anon Family Groups?

  23. Chris says:

    In all these studies, the only ones that sound plausible to me (based on your descriptions, anyway) are where the researchers actually have control over the experimental condition: that is, where the independent variable is the doctor’s behavior, not the patient’s. A doctor can choose to do a “brief intervention” or not, and so they can perform a believable study. But whether a patient chooses a voluntary treatment or not simply can’t be an independent variable in a controlled study, and when they try to do the study anyway, it leads to the absurdities you’ve pointed out. Maybe patient choices and outcomes are a knot of cause and effect that can’t be untangled so easily.

    Is there some literature of qualitative studies, where, for example, they interview a whole lot of people who have and haven’t stopped drinking, and describe the common themes that emerge: what events they describe, what choices they made, what they think worked and didn’t work? I’d think one could contextualize some of these flawed studies better with that kind of information.

    • Anonymous says:

      I just want to let you know that I really liked the turn of phrase
      | a knot of cause and effect that can’t be untangled so easily

    • RCF says:

      Well, patients choosing AA isn’t really what’s at issue, anyway. For doctors, the question is whether they should recommend AA. So studies where one group has AA recommended to them, and another doesn’t, do address that question.

    • Sober for Good is a book on that very subject– it’s based on interviews with people who solved their drinking problem.

      More than half of them didn’t use AA, and every generalization from AA isn’t absolutely true. There are people who’ve stopped on their own, who didn’t use a higher power, who made a single decision (rather than one day at a time), who were eventually able to drink moderately….

      From memory, the only commonalities the author found were at least a year of abstinence and mental focus on the good things made possible by not abusing alcohol.

  24. suntzuanime says:

    So if I’m reading this correctly, the Sinclair Method means you take a pill that prevents you from being happy, and then you drink a bunch of alcohol, but the pill keeps it from making you happy, so you learn (on an instinctive level) that not even drinking works, and you give up on it. I can see why they call it the Sinclair Method instead of anything descriptive, that’s the most horrifying idea for curing addiction I’ve ever heard. Makes me long for the days when you would just wear a collar that gave you an electric shock every time you took a drink.

    • Shmi Nux says:

      naltrexone does not prevent you from being happy, only from being alcohol-induced happy, thus counteracting one’s genetic predisposition to alcoholism. I am not sure why Scott did not spend time researching it more.

      • suntzuanime says:

        The wikipedia article linked made it sound like it was just blocking endorphins and wouldn’t distinguish between endorphins produced by alcohol and those produced by any other activity.

      • Deiseach says:

        How effective is this kind of treatment, though, for people who are not drinking for the “yay, I feel great!” effect on those without other underlying problems?

        I’m drinking because I’m depressed, I’m still depressed even after drinking, the depression remains after the reliance on alcohol to anaesthetise me is gone – is there any follow-up on how many people go on for treatment of depression, and how many people kill themselves when even the drink doesn’t help anymore?

        (Yes, I’m a cheerful sort).

        • Vilhelm S says:

          Well, but does drinking really help depressed people? E.g. webmd suggests it hurts: depression causes someone to drink, and alcoholism makes them more depressed. If that’s the case, then quitting drinking should be helpful in itself.

          • Creutzer says:

            Drinking helps in the moment by numbing emotional pain. So at a given point, a depressed person is likely to be happier drunk than sober. All the while, it may well be that habitual drunkenness lowers your baseline even further. Then there is a sense in which quitting drinking is not helpful in itself.

    • Scott Alexander says:

      No. First of all, the pill doesn’t prevent you from being happy – I’m not sure exactly what’s going on in the brain, but the people I know who have been on it say it leaves general happiness intact but somehow only touches alcohol-related reinforcement.

      Second, it has a short-ish half-life, and you only take it right before you’re planning to drink. So if you only drink once a month, you only take the pill once a month.

      • RCF says:

        Does taking a pill right before drinking take significantly less willpower than just not drinking?

        • Harald K says:

          I question that too. Such approaches aren’t anything new. Disulfiram has been available since the twenties.

          Addicted, you do not want to tie yourself to the mast, whether by pharmacological means or other means. There are serious paradoxes about preferences in addiction, that aren’t so easily swept under the carpet.

        • Tracy W says:

          I remember when I was pregnant I really struggled to find non-alcoholic drinks that were interesting and didn’t leave me feeling bloated or overloaded with sugar over an evening out.

          • Cadie says:

            My go-to non-alcoholic drink when I don’t feel like drinking or am the DD is soda water and juice, especially pineapple. There’s some sugar in the juice, but it’s diluted with unsweetened soda water, so it tastes drier and and doesn’t pack nearly as much of a sugar hit. But it still has enough sweetness and flavor to taste good. If carbonation is an issue, the bar should have plain water too.

        • Scott Alexander says:

          In my experience, people don’t stick to Antabuse for exactly this reason. I have never had a patient on Sinclair Method, but from what I’ve heard they do stick to naltrexone, because there’s no obvious ill effects, so it’s just like “You mean I can drink as much as I want if I just take this pill first! Great!”

      • Eric says:

        Naltrexone doesn’t have to be taken as a pill, it can be taken as a once-a-month injection (Vivitrol). Conflict of interest alert — my dad worked for the company that makes it. I haven’t reviewed the research myself, but there have been a number of RCT’s published on it demonstrating efficacy vs placebo, which was required for its FDA approval, e.g.: http://jama.jamanetwork.com/article.aspx?articleid=200637

        Would be great to see this article updated (or a separate post) with info on medical treatments. The medical treatments don’t get popularized because people think it’s a willpower problem rather than a medical disease.

      • caryatis says:

        Why would someone still want to drink if the naltrexone kills the pleasure of drinking? I guess to the extent drinking is a habit, not having to break the habit would be good. But you would still have to make a new habit of taking a pill an hour before you wanted to drink, every time for the rest of your life (!). If I were doing that, I would quickly decide drinking wasn’t worth it. Maybe that’s the point?

  25. Anonymous says:

    I wonder to what extent “everything works equally well” obscures “certain things work better for certain individual dispositions.” Even if you can’t measure those dispositions and do controlled studies based on them, you could try giving multiple treatments and put an upper or lower bound on the overlap in the populations treatable by different methods. Same thing for diet and productivity and treating depression and so on. That could at least tell us whether it’s worthwhile for an individual to keep trying different things until they hit one that works for them.

    (Also, more posts like this, please.)

    • Douglas Knight says:

      You could do an experiment of the value of a protocol like “Try A and if that doesn’t work, try B, …” I don’t think anyone is going to do such an experiment for addiction, for many reasons mentioned in this post, but also because there is such diversity in the treatments.

      But a lot of people believe that a good protocol for depression is to try lots of drugs, a protocol which would be easy to test.

    • caryatis says:

      My takeaway was, if you have a drinking problem, try dealing with it yourself first. That method is as likely to work as any other and comes free of the side effects of stigma, expense, cultishness.

  26. Rks says:

    Maybe I didnt read this well enough but I see some misconceptions here about Alcoholics Anonymous that should be addressed.

    Alcoholics Anonymous membership. What defines a member in an anonymous organization? There are no dues or fees. There are no forms to complete. Most of their membership use only their first names and occasionally a last initial. The answer can be found in Alcoholics Anonymous’ literature where it states “The only requirement for membership is a desire to stop drinking.” This is important. Many of the people found in Alcoholics Anonymous meetings are there to fulfill a requirement imposed on them from the courts on alcohol related offenses They are given an attendence card and instructions to attend a number of Alcoholics Anonymous meetings in lieu of jail time, community service and fines. In essence the offender has been sentenced to Alcoholics Anonymous meetings. They are there because they have to be.

    Another major misconception is that Alcoholics Anonymous meetings are the program. This is anything but true. Alcoholics Anonymous has meetings for members to support one another but the program itself requires dedication and work. Sober members have followed the suggestions written in the book “Alcoholics Anonymous”. There are Twelve Steps each member tries to take in an effort to recreate their lives. Alcoholics Anonymous is not a just a program, it is a way of life that requires a genuine desire to be free from alcohol. At the end of the day it’s up to each member to use the tools the program suggests.

    Alcoholics Anonymous is the oldest and largest organization for the treatment of alcoholism. It is free of charge or obligation. There are no contracts to sign. The only real expense to a member is the cost of a book and many Alcoholics Anonymous groups give them away for free to those who cannot afford them in hopes that the member will get sober and use his experience to help another do the same. Everything including attending meetings is voluntary.

    Frankly all this cult talk gets tiring. It reeks of ignorance and demeans the alcoholic in need of a solution. Many alcoholics have tried the finest contemporary scientific solutions, sometimes at the cost of ten to thirty thousand dollars, and have failed. Sometimes more than once. Does that make the health care professionals who accepted the money charlatans? Of course not. What it means is that there is no single solution to a very large problem.

    • Drew Hardies says:

      The only real expense to a member is the cost of a book

      The opportunity cost is much more important than the monetary expense; people who adopt AA’s paradigm aren’t take up other ones.

      So, it’s very important to ask if AA is supported by evidence. Oherwise it could be doing quite a great deal of harm by providing the illusion of treatment.

    • Nita says:

      In essence the offender has been sentenced to Alcoholics Anonymous meetings. They are there because they have to be.

      Everything including attending meetings is voluntary.

      These two parts of your comment seem to contradict each other. If people are being sentenced to “turn [their] will and [their] lives over to the care of God” or go to jail, that is a problem. Especially if AA’s advertising/evangelism works so well that research and funding for other treatments dry up.

      • caryatis says:

        I think Rks was saying that not everyone who attends meetings is a true “member,” since some are forced to be there and don’t really want to stop drinking.

        But you’re right to point out the contradiction. Why does a voluntary program accept those who are forced to be there?

    • no one special says:

      For cult concerns, I will again post this link: The Advanced Bonewits’ Cult Danger Evaluation Frame (Because figuring out if you’re in a cult should be elementary.)

      (I posted this on the “more links for October” thread.)

      I’m not a big fan of the religious aspects of AA, but AA scores low on all factors except 17 (Surrender of Will.) A cult that doesn’t isolate it’s members is no cult at all, IMO.

      • caryatis says:

        Matter of opinion. I would rate it high on 10 factors. When AA recommends avoiding old drinking buddies or locations, which for many heavy drinkers means avoiding most or all friends, isn’t that isolation? Probably good advice for those who want to stop drinking, but still.

        • no one special says:

          That’s a fair call on isolation, which puts it higher than most groups. Many cults try to keep people from interacting with non-cult-members though, while AA doesn’t tell you you can’t be friends with non-AAs, just that you can’t be friends with heavy drinkers. That is, AA doesn’t tell you you stop seeing your Mom and Dad. Unless you regularly go drinking with your parents, that is.

          I’d like to know which factors you think AA is high on. I think the first 10 factors are all low, and the next 8 are only moderate (except surrender of will, which is high.) Maybe some AA groups are sexy kink-a-thons with charismatic leaders who are considered infallible, but that doesn’t match my (quite a while ago) experience.

          (Context: I am not an AA, but have family members who are/were. I went to some Al-anon/Alateen meetings, which were… less than helpful. All my information is at a distance.)

          • DW says:

            Pacific Group and.spin offs have infallible leaders. Midtown Group, one such spinoff, had high levels of sexual exploitation of vulnerable members.

    • Anonymous says:

      There are some members of AA who will sign off an entire court card if the person doesn’t want to be there. Unfortunately, with any diverse group, there will be people who blindly follow instructions because authority. I’ve also known bartenders who will pass a court card among the patrons, too.

    • DW says:

      Anecdotes compared to larger studies. Dogmatic insistance that it’s the BIg Book, and hand waving about how offensive calling AA a cult is. You’re the type of cult induced personality that turns people off to AA.

  27. Anders says:

    As someone with a mother who has been in and out if various rehabs and treatment regimes, I am very greatful for your attempt of elucidating the very murky issue of scientific evidence in this field. Like you, I am also optimistic about the Sinclair Method, and will maybe try to push for that the (seemingly) inevitable “next time”. If you found the time to investigate that issue as well, I would very much appreciate it.

    🙂

  28. Mary says:

    You might find Romancing Opiates by Theodore Dalrymple interesting, discussing quitting opiates at length.

    On the third hand, he explicitly contrasts it with quitting alcohol. Of course, on the third hand, he had to deal with their detox ward, and the physical side of giving up alcohol should not be neglected, since it can be fatal.

  29. JRM says:

    Wow. Great stuff. Quick thoughts:

    First, some people in AA are effectively forced to do it. Many people with alcohol-related crimes are forced into AA as a condition of bail or release. I suspect this is a relatively small percentage of AA’ers, but these people are very likely to quit as soon as they can. This is a confounder of the washout data.

    I see a lot of alcoholics in my work as a prosecutor, and I’ve read a bunch of the studies. While I’m sure lots of alcoholics moderate their drinking eventually, they don’t seem to go from alcoholic-to-moderate-drinker the following week. Aging out is different than a workable solution.

    As a prosecutor with a great deal of experience in the field, I have no answers at all. Accounts of horror omitted; I’ve handled way, way too many vehicular manslaughters and then the not-infrequent followup DUI’s after the manslaughterer gets released. Many of them get more time for the followup DUI than the manslaughter.

    I would like to see things that work.

    On the addiction issue, California is making almost all drug possession crimes and theft crimes (inclusive of stealing guns) misdemeanors as of Election Day – currently, simple drug possession normally results in treatment, and then if you fail treatment, you go to jail for a little bit. Because of other policy changes and an emptying of the prisons, almost no one does actual jail time for misdemeanors. So we’re doing an experiment of our own.

    • RCF says:

      Making AA a condition of release is unconstitutional. It is constitutional to release conditional on the defendant going to a program of their choice, and AA being one of the choices, but specifically requiring AA is unconstitutional, due to the religious content.

      You seem quite confident that 47 will pass. Most of it sounds good to me, but I really don’t see why whether writing bad checks should be a felony or misdemeanor should depend on whether the defendant is a registered sex offender.

    • Tracy W says:

      Do you know why the sentences for the follow-up DUI tend to be higher than the manslaughter?

      • JRM says:

        Tracy W:

        Here’s more than you wanted to know:

        Vehicular manslaughter while intoxicated with simple negligence is 16 months, 2 years or 4 years in state prison at half time, or a year or less in jail. Prison is more common than jail, but people do get jail sometimes.

        With gross negligence and intoxication, it’s 4, 6, or 10 years at half time, or less than a year in jail. The less-than-a-year is rare.

        So off you’ve gone to prison for (say) a four year sentence and done two. Get out, get thirsty, get quenched, get in the car, get hooked. Now your new DUI is a felony (because you’re not supposed to do that any more), and you have a strike and prison prior, so your exposure is 44 months, five years, or seven years in state prison at 80%. (You can earn extra credits by stalling the case as long as possible, but once you go to prison, the rest is at 80%.)

        It’s structural. Hope that’s helpful without being too technical.

        Aside: Yes, 47’s going to pass. I’m prepared to bet Toyotas to Tonkas on that.

        • Tracy W says:

          Thanks for explaining. I get roughly why, though please don’t give me an exam on the details. 🙂

    • David says:

      I had a look at that initiative 47. It really drives home the weird disconnect whereby most things that are crimes are actually behaviours that deliberately or recklessly victimise other people, and yet personal possession of drugs, in the absence of any actual harm or significant risk of harm to others, is still up there as the obvious low-hanging fruit of ‘what criminal laws are our descendants going to be bamboozled about, in the same way that we are bamboozled that many of our ascendants thought it was just to criminalise people for gay sex, voting while Black, practising Catholicism in a Protestant-majority country (and vice-versa), etc.
      And yet it’s still not being taken off the books, it’s merely being downgraded from a serious crime to a less serious crime.

  30. Sigil says:

    This was amazing, thank you.

  31. KJbGcX says:

    Scott, I know of a simple, easy way you could save even more lives of your smoker patients. Want to know what it is? Instead of nagging them, pitch them: https://www.youtube.com/watch?v=TC8RJCczChU

    I = B + C. Interest = Benefits + Curiosity. Hey Mr. Jones, how would you feel if by the time your daughter graduated from college, you were still fit and healthy enough to sprint around the block? Etc.

  32. KJbGcX says:

    Also have you actually tried acupuncture? It’s very relaxing and for me, at least, has weird psychological effects: I normally have a hard time napping, but when being acupuncted, I very quickly fall in to a dream-filled sleep state. It’s not implausible to me that it would be effective for addiction.

    • houseboatonstyx says:

      That, too. Above I made a case for unpleasant experiences of acupuncture being effective against smoking. But all the actual exposure I’ve had to it was pleasant and could bring on a pleasant effective state. (Of course the setting could make a lot of difference: meditational music, scent, etc.)

    • theLaplaceDemon says:

      As far as I can, the research says acupuncture is mostly placebo, with a small contribution from endogenous opioid release (in response to the mild skin trauma) thrown in.

      Things with elaborate ritual, like sticking a bunch of needles into someone (as well as the stuff houseboatonstyx mentions below – the music, scent, etc) are very susceptible to placebo.

      • Douglas Knight says:

        Several kinds of sham acupuncture have been shown to be just as effective as credentialed acupuncture. In particular, retracting needles that do not break the skin are just as effective. Maybe there’s still skin trauma and opioid release, but it’s a lot more mild than regular.

        So, yes, acupuncture is placebo, but it is the best known placebo. For chronic back pain, it is dramatically better than any other treatment, placebo or “legitimate.”

  33. Anonymous says:

    A reply from /u/keleesi on reddit’s /r/ psychology:

    As an addiction researcher, this was a pretty annoying read—a lot of misinformation and lack of understanding about therapy for addiction. Not surprising considering the author wrote it after “several HOURS of study”. Much of the author’s criticism of 12-step research is valid (although there are a number of good arguments in favor of 12-step programs- http://commonhealth.wbur.org/2014/04/defense-12-step-addiction), but he misrepresents the research on other, empirically-supported treatments for substance abuse. Some examples of errors are summarized below:
    “The largest study ever in the field, a $30 million effort over 8 years following thousands of patients, had no control group”
    The author conflates control group with no-treatment control group. A control group is just the group you’re comparing your experimental condition to–it can be nothing (or more ethically, a wait-list condition) or some sort of standard or comparison treatment. Demonstrating that your treatment is better than nothing is a pretty low bar and plenty of studies have demonstrated that therapies for alcoholism are better than nothing–the author seems to have missed them completely (For example, here is a meta-analysis showing the effectiveness of CBT aka Relapse Prevention- http://psycnet.apa.org/journals/ccp/67/4/563/). In the case of project MATCH (the study in question), the point wasn’t really to establish that therapies were better than nothing because that had already been established by previous research (at least for motivational enhancement and CBT). Researchers were more interested in identifying characteristics of individuals that would make certain therapy techniques more or less effective for certain people. He is correct that the results of MATCH were super underwhelming. There were a couple interesting findings though like motivational enhancement therapy working better than the other treatments for people who have anger problems.
    “The first arm would be “twelve step facilitation”, the fancy name for Alcoholics Anonymous.”
    12-step facilitation wasn’t just a fancy name for AA. The 12-step facilitation in project MATCH was actually 12 therapy sessions with a counselor working with participants on the first few steps and encouraging them to attend AA. The condition was researchers’ attempt to have a condition consistent with 12-step principles but as much of a “dose” of intervention for it to be reasonably compared to the CBT condition. In other words, people in the CBT condition were getting 12 sessions of CBT, so it wouldn’t really be “fair” if participants in the 12-step condition just got an instruction to go to AA.
    “The third arm would be motivational enhancement therapy, which is where your doctor tells you “Hey, have you ever considered quitting alcohol??!!” and then meets with you every so often to see how that’s going. More shall be said on this later.”
    He does say more about it later—and it’s mostly wrong. Motivational enhancement therapy is actually a blend of providing people with non-judgmental feedback about their use (e.g., you’re drinking more than x% of your peers; the frequency with which you drink is associated with a high risk of dependence; you’re spending x amount on alcohol each week–here are some other things you could have spent that money on) and motivational interviewing (MI; http://en.wikipedia.org/wiki/Motivational_interviewing) to try to push people, in a directive but not forceful way, toward change. MI is a lot more than asking people if they’ve ever considered change and it tends to be deceptively simple if you’ve seen a skilled clinician use it. It mostly involves using reflective listening (i.e., repeating in your own words) and expressing empathy to subtly steer people toward talking about, and making a commitment, to change.
    “The “brief treatment” is the next step up from brief intervention. It’s an hour-or-so-long session (or sometimes a couple such sessions) with a doctor or counselor where they tell you some tips for staying off alcohol.”
    This part was just confusing as “treatment” and “intervention” are synonymous in the research literature. Most of the brief intervention studies are one or two sessions with a counselor, but brief interventions have been adapted to be implemented in a primary-care or other medical settings (maybe that’s the distinction?). The vast majority of these brief interventions are motivational-enhancement based and are not as short as 5 minutes.
    The bashing of evidence-based therapies in the blog obscures a lot of valid (and lesser-known) points that are mixed in. I’ll give a few examples of these to be fair:
    “So if we take all this seriously, then it looks like every psychosocial treatment (including brief opportunistic intervention) is the same, and all are better than no treatment. This is a common finding in psychiatry and psychology – for example, all common antidepressants are better than no treatment but work about equally well; all psychotherapies are better than no treatment but work about equally well, et cetera. It’s still an open question what this says about our science and our medicine.”
    “most alcoholics get better on their own”
    “Furthermore, they are equally effective after only a tiny dose: your first couple of meetings, your first therapy session”

    • RCF says:

      That’s a rather long quote.

    • Brian Potter says:

      Hmm, do those criticisms seem fairly weak to anyone else?

      • 27chaos says:

        A lot of it is quibbling over definitions. He was right to point out that Scott’s criticism of project MATCH was mistaken and that Scott didn’t pay much attention to individuals rather than aggregates.

        • Douglas Knight says:

          Really? The part about MATCH was also just quibbling over definitions. The difference was that Scott went into great detail about what definitions he was using and why. Keleesi complains that MATCH didn’t need a no-treatment arm because everyone knows that treatment is better than no treatment, whereas Scott spends half his post arguing that the evidence is crap. And Keleesi does acknowledge this disagreement, attributes it to Scott failing to find relevant papers, and links to a meta-analysis that finds that treatment is not better than no treatment.

      • Nornagest says:

        I’m a little surprised that anyone could read statements like this:

        you’re drinking more than x% of your peers; the frequency with which you drink is associated with a high risk of dependence; you’re spending x amount on alcohol each week–here are some other things you could have spent that money on…

        …as non-judgmental. Sure, it doesn’t come out and say “you’re an addict, which is bad and you should feel bad”, but the implication is clear.

      • Zubon says:

        The “to be fair” at the end approvingly cites the main points of the post other than “the research is lousy.” (At least, my takeaway from the post, which is “what conclusions do we come to after reviewing all this research?”) The opening and tone sound like angry disagreement, but one could equally start with, “I mostly agree with the conclusions, but as a practitioner in this field, I would like to correct some misunderstandings of therapeutic interventions.”

        I’m not sure I’d go with “weak,” but rather there are distinctions that really matter to you if you are in that field but might not to outside parties. Think of how annoyed you get when other people talk about your field, or the common observation that news reports about anything get important details wrong.

  34. KJbGcX says:

    Also…

    On the other hand, Wikipedia gets it right and I continue to encourage everyone to use it as one of the most reliable sources of medical information available to the public (I wish I was joking).

    Better than WebMD, Mayo Clinic, etc.?

  35. Sister Y says:

    I wonder if it’s a net good to get psychiatric patients to stop smoking. Smoking is pleasurable, one of the few positive social rituals that people in awful social situations still have available. Studies on the positive effects of smoking on e.g. the inhibition of psychiatric symptoms are almost as messed-up as the AA studies, but at any rate, e-cigs and nicotine don’t seem to do the same magic as the smoking ritual (http://www.nature.com/npp/journal/v27/n3/full/1395914a.html). And this approach completely ignores the positive psychological effects of smoking aside from inhibition of psychiatric symptoms. I recently started smoking and I think it’s pretty great, and that the benefits vastly outweigh the harms. I suspect this may be extra-true for people with severe psychiatric disorders. Nicotine fluid vaporizers are great and many people love them, but they produce none of the beneficial effects in my experience.

    • Deiseach says:

      Having watched my mother die of lung cancer directly caused by her life-long addiction to smoking (she made various attempts over the years to quit and relapsed, switched to low-tar brands, etc.), I can assure you, Sister Y – the benefits do NOT outweigh the harms.

      Dying of lung cancer is a horrible, horrible, miserable, painful way to die. If you want to smoke and enjoy the pleasures but avoid the pains, I sincerely and genuinely urge you to have a fool-proof painless way of killing yourself should you develop lung cancer from your pastime (I was going to say “committing suicide” but if you start smoking, you are committing very drawn-out suicide). You’ll probably have just about enough time to put your plan into action if this happens: time from certain diagnosis to death in my mother’s case was about six months. So it was a fast path to death, but it was not painless or ‘quick’ in that sense. A very speeded-up decline.

      Or you could simply not start at all, but that does not seem to recommend itself to you.

    • Steve Sailer says:

      There’s a Unitarian church near my house that hosts a lot of 12 step programs for alcohol and drugs. The participants are out on the sidewalk during coffee breaks smoking like chimneys. It seems like a reasonable trade off for them of short term survival v. long term survival.

      • Cadie says:

        Smoking is harmful, but the harm is partially reversible at first and usually builds up over a long time. So quitting smoking provides health benefits, but in the special case of someone in early-stage treatment for a far more immediately dangerous substance abuse problem or psychiatric illness, there’s a cost/benefit ratio to consider. The benefit is better health; the cost is adding a short-term stressor and making treatment more unpleasant. It seems reasonable that for at least some of them, making them give up smoking would threaten their recovery enough that allowing them to delay smoking cessation until they’re more stable and have stronger supports is less dangerous than forcing them to quit immediately.

    • Scott Alexander says:

      This is part of why I only do this for outpatients – they usually have fewer psychiatric problems. The inpatients I feel like they’re at a bad enough point in their life that if they solve their other problems, then they can start worrying about smoking.

  36. US says:

    Like others have said, this is a good and interesting post.

    A few others have already pointed to ‘nagging patients’ likely having negative effects as well as positive effects; effects which may also be very hard to observe. A patient might decide not to go see the doctor in a specific situation where a visit might have been warranted because they thought they’d just get ‘the speech’ again. A patient may perhaps in particular in this context become less likely to bring a medical complaint to the attention of the doctor if they think the problem is related to the ‘problematic behaviour’. You don’t get to observe mr. Johnson finally quitting smoking as a result of your efforts, but you also don’t get to realize that one of the reasons why miss Adams presented much too late when the lung cancer finally hit her was that she knew that her doctor would just, again, tell her that she wouldn’t be having those lung issues in the first place if she’d just stopped smoking. Health problems caused by e.g. smoking, overeating or alcohol all cause a lot of suffering, and if ‘society’ is already stigmatizing the behaviour it’s not to me immediately obvious that health care professionals should do that as well (I can think of arguments why one might consider a model where everybody stigmatizes to be optimal, but it’s not ‘obvious’). It’s important to note that although I can’t imagine Scott behaving like a moralizing jackass, the doctor and the patient may not feel the same way about the things the doctor does in such contexts (‘I wasn’t being pushy and moralizing’ – ‘yes, you were’), so simply avoiding overt moralizing may not stop negative consequences from accumulating as well.

    A different and related point which I don’t think has been mentioned – a point I believe is often brought up in screening contexts – is that there’s also an efficiency loss related to devoting time to such things, because the time spent talking to mr. Jones about his alcohol habits is time not spent dealing with Miss Adams’ hernia. My impression is that people often find that such opportunistic screening methods usually don’t work nearly as well as the people who’re considering implementing them think they might. Cost-effectiveness may be an issue. (Then again it’s probably not Scott’s job to worry about that sort of thing).

    • Deiseach says:

      Also, another side-effect of the nagging may be the assumption on the doctor’s part that Ms. Adams’ chest pains, breathlessness and cough are due to her smoking, I’ve told her to quit, well what does she expect to happen?

      And the idea that maybe something else is causing it doesn’t get checked out – Ms Adams gets the usual lecture about ‘stop smoking’, may be recommended to buy an over-the-counter nostrum like cough medicine, and it’s only when she turns blue in the face, collapses and has to be rushed to the emergency department of the local hospital that it turns out she has pneumonia.

      • suntzuanime says:

        I don’t know that that’s a side-effect of the nagging per se; it’s a side effect of the doctor knowing that the patient has a condition that can cause the symptoms. Which is going to throw the doctor off if the symptoms are caused by some totally different unknown condition, and that’s why House MD is so exciting a show to watch, but it’s not an argument against trying to get people to quit smoking.

    • Scott Alexander says:

      I understand this is a problem and so far my best solution is to lampshade it, something like “Okay, mind if I give you the same five minute speech about smoking that you’ve already heard from every other doctor you’ve ever had?”

      If someone gets really upset and refuses, I usually let it be, both for therapeutic relationship reasons and because I feel like to some degree I have already reminded them about smoking and done at least a little bit. If someone says okay, I try to at least say a couple things they haven’t heard before, usually by bringing up e-cigarettes (which are a real winner here; people are pretty happy to hear something more actionable than “you are a bad person for smoking and need to stop”). I also like to bring up varenicline and bupropion, not because I think they work super well (although they kind of do) but because people feel less patronized if I’m saying exciting high-tech medical things to them, like “Oh, he must just be giving me this speech to inform me of exciting high-tech options” rather than “He thinks I’m too dumb to realize smoking is bad”.

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  38. richard kopperdahl says:

    Been in and around AA for about 45 years, sober the last 35. I live in New York City and have been to many meetings. I prefer going to local meetings where I see people I’ve known for years and keep up with the gossip: who died, who slipped, who’s hooked-up with whom, that sort of stuff. In short, AA’s a community and people who get sober without it are in for a hard time. All my close friends are AA members; many of us no longer go to meetings; a lot of us don’t believe in God or religion but do believe that the power to stay sober is in the group of drunks who are no longer drinking… ’nuff said.

  39. LeeJohnson says:

    Fascinating article.

    I’ve been sober 26 years. I was forced into a 16-week class after a DUI; as part of that, I had to attend five AA meetings. I went to 18 months of AA after that.

    So the question is this — is it possible that what AA says is NOT conducive to social science research? What AA promises is a roadmap to sobriety. If you do this, then you will get sober. Note the personal choice involved. Good luck measuring that. Did you do what AA says — don’t drink, get a sponsor, go to meetings, get involved, do service, pray, share at meetings and don’t stuff your feelings, etc. No way to measure all that. Can you measure the degree of rigorous honesty required — because a lot of AA is about stopping bullshitting yourself and others.

    AA is a roadmap that promises sobriety for those who follow it. It’s not about being a data point that might be in the lucky half, but by taking the steps that will get you sober.

    The question, then, is: Can I do this on my own? If not, here’s what we AAers did to get sober. We promise you that if you do it, it will work. My experience is that the promises work exactly as advertised. But you gotta do it.

    Do most people quit on their own? I’ve heard that — God bless ’em. Do some grow out of it and can drink responsibly again? Great, God bless ’em, too.

    We’ve recently had two celebrities with more than 20 years of sobriety — Robin Williams and Philip Seymour Hoffman — die in circumstances related to relapse. I’m not taking chances. Part of the reason is I think: Who the hell wants to drink responsibly?

    That said, I loved this article. But I believe there’s something about the human soul that can never be captured by social science, and that the individual knower can know.

  40. Mike Carpick says:

    I was an AA dropout in 1967, one conversation, one meeting.

    I also ‘dropped out’ in 1969, and 1970.

    By your measures I was an AA failure, or a failure of AA.

    In 1971 I ‘quit’ – dropping out. Sober ever since, which I attribute to AA.

    This is one of the problems of many AA studies – they don’t follow up long enough.
    AA itself does not make that easy – but results can be inferred.

    In my treatment program, which included a heavy does of AA and recommended AA involvement as a primary aftercare method we were able to demonstrate over 12 years a five year ‘success’ rate (sober, improved life stability and quality) of 66% of 4,400 patients, almost all of whom were continuously involved with AA.

    Due to grant requirements we had to have (after the first five years) annual third-party followup studies.

    • caryatis says:

      Sounds like you had no control group, though. So no way of knowing how many would have been successful with no/another treatment.

  41. Brian Donohue says:

    Good post, Scott.

    On an unscientific note, what do you think of David Foster Wallace and, in particular, Infinite Jest?

  42. Anonymous says:

    Tangential. At least it’s about alcohol, but — did you know that utilitarianism correlates positively with drunkenness?

    http://www.theatlantic.com/health/archive/2014/10/the-cold-logic-of-drunk-people/381908/

  43. RCF says:

    Why is it unethical to have a no-treatment control group? Don’t drug studies have them?

    • Anonymous says:

      If (we know that) the treatment really works, it is unethical to deny it to the patient. There is often a diversity of opinions on whether it has really been established. Much of the point of a study is to establish it, so the people designing the study don’t believe it. But the IRB may.

      The usual control group is the standard treatment, which may be nothing, but usually is something. In fact, while the FDA can approve drugs just because they are safe and effective, they usually require proof that they are better than existing treatments for some population. Also, if you want to convince insurance to pay for it, you’d better prove it’s better than the alternative.

  44. Steve Sailer says:

    Thanks, most informative.

    Have there been adequate studies of the causes of and treatments for alcoholism among indigenous peoples, such as American Indians, Inuits/Eskimos, and Australian aborigines? They tend to suffer severely from alcohol, presumably due to having less time to evolve defenses against it. This would seem like a low-hanging fruit — there’s something about the biochemistry of aboriginal peoples that makes it harder for them than for Mediterranean peoples like Italians and Jews to deal with alcohol. If we knew what it was, we might be able to devise a work-around for them.

    • Scott Alexander says:

      In terms of causes, I’ve only seen various “stress of poverty” explanations and the same Greg Cochran posts that you no doubt have. I’ve never heard anything particular about treatment, but this isn’t my area and we don’t have many of those people where I work.

  45. Cassie says:

    You happily linked to the study so people can read it themselves. Surprisingly, the paper actually says: “Such results can be interpreted to show the probability that a member will remain in the Fellowship a given number of months.” Now to me, that says that there is only a 5% chance that people will remain in AA after 12 months.

    He also explicitly says that about 50% of people stop attending AA in just 3 months.

    So, I’m curious as to //how// people misinterpreting the graph and data presented in the study? Because they say themselves that their graph says there is only a 5% chance that people will remain members after 12 months.

    • Alex Godofsky says:

      Imagine they found that 8.33% (i.e. 1/12) of members in their first year were in their twelfth month of membership. That would not imply that only 8.33% remain by the end of the first year; in fact, it is exactly what we would see if no one ever quit.

      • suntzuanime says:

        If no one ever quit and the rate at which they joined remained constant over time.

        • Alex Godofsky says:

          Sure, you also have to assume that people join equally in every month of the year. The point is that the “5% are in their twelfth month of membership” plainly does not mean that only 5% remain by the end of the first year.

          • RCF says:

            Except that the graph doesn’t say “5% are in their twelfth month of membership”. It says that 5% those coming to AA within the first year have remained 12 months.

    • Douglas Knight says:

      For anyone else who is interested, here is the graph. It is page 12 of the article Scott linked, but here’s a retyped version here (bonus: not scribd).

      Note that the number at 3 months is not 50%, so if he interpreted the graph to get the number 50%, there is more work than reading the number.

  46. RCF says:

    It would it would good to make it clearer where you’re getting that quote.

    “So, I’m curious as to //how// people misinterpreting the graph and data presented in the study?”

    Do you mean, what other interpretation is there, or do you mean “Why is that the correct interpretation?”

    I agree that what Scott is calling the “incorrect” interpretation is strongly suggested by the graph, and if it is indeed the wrong interpretation, most of the responsibility for the confusion lies with whoever made the graph.

  47. Here’s one more thing to take a look at: Heal Thyself: A Doctor at the Peak of His Medical Career, Destroyed by Alcohol–and the Personal Miracle That Brought Him Back— the miracle was finding out that baclofen (a muscle relaxant) made the craving go away. It also ended a shopping compulsion the author didn’t realize he had, until he suddenly found it was possible to go into a store without buying anything.

    The comments at Amazon include some accounts of people getting good results from baclofen.

    http://en.wikipedia.org/wiki/Olivier_Ameisen

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61814-5/fulltext

  48. Anthony says:

    Finally, perseverance is a confounder. To go to AA, and to keep going for months and months, means you’ve got the willpower to drag yourself off the couch to do a potentially unpleasant thing. That’s probably the same willpower that helps you stay away from the bar.

    Perseverance is probably the common casual element.

    However, as noted by a few comments with direct experience, AA tries hard to make going to its meetings pleasant – it’s a social occasion with people whom you have something big in common with. So once you’ve gotten over the initial barrier of admitting to yourself, and a bunch of strangers, that you need help, it’s probably almost as rewarding to go socialize with your AA buddies as to go to the bar with your drinking buddies.

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  50. Welcome to the ‘addiction’ clusterflux. As you’ll discover it’s a whole lotta nuthin. It’s not only the research on AA but the ‘science’ about addiction itself that is completely bogus. It’s a small cabal of 12-stepper public policy experts and scientists that seems to be running the show. Here are some names I’ve come across:

    Aaron White – NIAAA/NIH – rat models for ‘blackouts’
    George Koob – NIAAA/NIH – rat models for human ‘addiction’
    Keith Humphreys – Psychiatrist – “Scientific evidence alone is not sufficient basis for health policy”
    Thomas McClellan – Psychiatrist – ‘addiction is a mangeable disease like diabetes’

    Also there is one huge blindspot in AA research: suicides. I suspect AA greatly increases risk of suicide, but of course expect that inconvenient truth to be suppressed.

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  52. Surprised that disulfiram (Antabuse) came up only briefly in the comments. It’s been around a while and its effectiveness is limited because people won’t take it. This is similar to antipsychotics, which fortunately have depot formulations. And now, so does disulfiram – Esperal, used at this point mostly in Poland for reasons unclear to me.

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  55. JGivskud says:

    I just startet reading your blog and I like it a lot.

    I have done research on addiction and I agree with you that its terrible. To me, that is what happens when the wrong science studies a phenomenon or seeks to study something that is not even scientific like the concept of addiction – which ended up my conclusion. What I understand is that (alcohol)addiction was a concept introduced by the temperance movement and only reluctantly acceptet by APA some years after antabus was discovered, though this version is probably somewhat conspirational and I cannot confirm it. But addiction “science” shows very clearly what happens when political and moral ideas seeps into medical science and doctors try to “fix” peoples lives without becoming socially engaged.

    The critique of missing control groups is, however, naive in my opinion, unless you have very large sample sizes and control for socioeconomic factors as well as for life events. What AA does, in my view, is offer you support and possibly a new identity. Maybe you need more than that, maybe you need support, but not a new identity and you group enforces that, or maybe you need a new identity but is only offered support. Or maybe your group is just good or bad – just like every other group. Any other group could probably do the same job, but you might not be invitet into other groups and they might be less tolerant of relapses. From an epistemic point of view, AA is not very good, but as a social tool for changing your life I think it is quite effective, especially if other social support is scarce.

    I think one of the most interesting studies on addiction is Bruce K Alexanders “Rat park” and he also have very interesting things to say about addiction in his Globalization of Addiction”. Unfortunatey his concepts become too broad.

    It is an interesting subject though, but getting an interesting hold on it is hard.

  56. Ken Hooper says:

    Where is Section II? I might have liked reading it.