PATHWAYS TO ABSTINENCE: IMPACT OF ALCOHOLICS ANONYMOUS

Abstract

-The results of the present study support the effficacy of the fellowship of Alcoholics Anonymous to promote abstinence

-In 1992 Americans with alcohol use disorders who continued to attend AA were more likely to achieve abstinence (64%) than those who dropped out of AA (37%) or those who never attended AA (16%)

-Abstinence recovery status varies as a function of increasing age and level of severity of alcohol
symptoms.

-The findings suggest that a substantial portion of the “AA drop outs” attain sobriety or abstinence after a period of AA membership and maintain their abstinence without AA

– The unmet need for AA referral is concentrated in the younger age groups, 35% in the 18-29 years group and 30% in the 30-39 years age group.

INTRODUCTION

Alcoholics Anonynous (AA) attendance is an important predictor of improved outcomes, such as abstinence, among persons with alcohol use disorders[1].  Severity of alcohol use disorders and age are characteristics associated with AA attendance and dropout rates[2].  Dropout rates, in turn, are associated with relapse and return to high risk drinking.

 

Russell et al[3] in a study of 211 alcoholics identified in four community studies found that the majority of alcoholics who recover do so without the benefit of treatment without the benefit of treatment or participation in AA.  This process of recovery without the benefit of treatment or participation in AA is referred to as “natural” recovery.  A review of natural recovery studies[4] found them to be limited in number and seriously deficient in their description of respondent samples.  None of the natural recovery studies have examined a national representative sample of alcoholics and alcohol abusers to compare the outcomes of natural recovery and AA participation.

 

Understanding the characteristics of persons with alcohol use disorders who did not attend AA, those who attended AA and those who dropped out may lead to improved AA referral and attendance.   This understanding may assist in providing appropriate encouragement for persons with alcohol use disorders who are in need of abstinence support but do not seek support through AA membership.

  

This report examines the association of severity and age characteristics with abstinence outcomes of those persons with alcohol use disorders who do not attend AA , those who dropped out of AA,  and those who continued to attend AA.   In addition, this report identifies the level of unmet needs for AA referral and attendance, by age group, within the hgh severity alcohol use disorders sub-group.

 

Using data from the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES), a national representative sample of data on demographic characteristics, alcohol use problems, drinking behavior and treatment use, this report examines the relationship between AA attendance and proportion of abstinence among persons with alcohol use disorders (AUD), i.e. DSM IV alcohol abuse and alcohol dependence.

 

 

 

MEASURES

 

Past Year Drinking

Abstinence  =  No consumption of alcoholic beverages during the past year

 

Severity

For the purpose of this study  High Severity was defined as having met 15 or more of the 30 Alcohol Use Disorders and Associated Disabilities Interview Schedule (AUDADIS) items used to diagnose DSM-IV Alcohol Abuse and Dependence.  Low Severity was defined as 14 or less items.

 

Age

1)   18-29 years

2)  30-39 years

3)  40-49 years

4)  50 years or older

 

Alcoholics Anonymous Attendance

Never Attended AA  =  during the period prior to the past year never attended an AA for any reason related to the respondent’s drinking

Dropped Out of AA   =  during the period prior to the past year attended AA meetings and did not attend AA meetings during the past year

Continuous AA Attendance  =  during the period prior to the past year attended AA meetings and attended AA meetings during the past year

 

RESULTS

 

Of the Americans with symptoms of alcohol use disorders, i.e. alcohol abuse and dependence, during the period prior to the past year, a total of 85% never attended AA, a total of 10% attended AA and dropped out, and a total of 5% attended AA during the period prior to the past year and continued to attend AA during the past year  (Figure  1.)

Figure 1.   Percentage of Americans with alcohol use disorders by Alcoholics Anonymous attendance:  1992 NLAES (To enlarge the figure double-click the figure image)

 

In 1992 Americans with alcohol use disorders who continued to attend AA were more likely to achieve abstinence (64%) than those who dropped out of AA (37%) or those who never attended AA (16%) (Tables 1-3).

 

 

Figure  2.  Percentage of Americans with alcohol use disorders who were abstinent during past year by AA attendance; 1992 NLAES     As shown in Figures 3-6 and Tables 1-3,  abstinence recovery status varies as a function of increasing age and level of severity of alcohol symptoms.  The percentage of  ”natural” recovery, i.e. never attended AA,  varied from a low of 7%  (age 18-29 and low severity) to a high of 56% ( age 50+ years and high severity).   The percentage of abstinence outcome of those who dropped out of AA ranges from a low of 12%  (age 18-29 and low severity) to 68%  (age 50+years and high severity) .   Abstinence in those who continued to attend AA varies from a low of 32%  (age 18-29 years and low severity) to 84% ( age 50+ years and high severity).  The data in this study show that when the age and severity variables are controlled abstinence is associated with AA attendance.

 

 

Figure  3.  Percentage of Americans, age 18-29 years, with alcohol use disorders who were abstinent during past year by AA attendance: 1992 NLAES

 

 

 

Figure  4.  Percentage of Americans, age 30-39 years, with alcohol use disorders who were abstinent during past year by AA attendance: 1992 NLAES

 

 

 

Figure  5.  Percentage of Americans, age 40-49 years, with alcohol use disorders who were abstinent during past year by AA attendance: 1992 NLAES

 

 

Figure  6.  Percentage of Americans, age 50+ years, with alcohol use disorders who were abstinent during past year by AA attendance: 1992 NLAES

 

 

 

 

 

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Table  1.  Abstinence in Americans with alcohol use disorders who never attended AA by age group and level of severity of alcohol symptoms: 1992 NLAES

_______________________________________________________________________________________

 

AGE GROUP	SEVERITY LEVEL	NO.	%	TOTAL
18-29 YEARS	LOW SEVERITY	93	7%	1387
	HIGH SEVERITY	21	11%	183
30-39 YEARS	LOW SEVERITY	161	`12%	1316
	HIGH SEVERITY	39	22%	180
40-49 YEARS	LOW SEVERITY	124	16%	774
	HIGH SEVERITY	46	31%	148
50+ YEARS	LOW SEVERITY	233	32%	736
	HIGH SEVERITY	77	56%	137
TOTAL SEVERITY	LOW SEVERITY	611	15%	4213
	HIGH SEVERITY	183	28%	648
TOTAL  ABSTINENT NEVER ATTENDED AA		794	16%	4861

 

 

 

		______________________________________________________________________________________   Table  2.  Abstinence in Americans with alcohol use disorders who dropped out of AA by age group and level of severity of alcohol symptoms: 1992 NLAES ______________________________________________________________________________________
		AGE GROUP  SEVERITY LEVEL  NO.  %  TOTAL  18-29 YEARS  LOW SEVERITY  10  12% 84   HIGH SEVERITY  11  23%  48  30-39 YEARS  LOW SEVERITY  20 21%  96   HIGH SEVERITY  33  42%  78  40-49 YEARS LOW SEVERITY  20 34%   59   HIGH SEVERITY   46 60%  62 50+ YEARS  LOW SEVERITY  27  43%   63    HIGH SEVERITY 53 68%  78 TOTAL SEVERITY   LOW SEVERITY 77  25%  302    HIGH SEVERITY  134  50%   266 TOTAL  ABSTINENT DROPPED OUT OF AA    211  37%  568         ______________________________________________________________________________________   Table  3.  Abstinence in Americans with alcohol use disorders who continued in AA by age group and level of severity of alcohol symptoms: 1992 NLAES ______________________________________________________________________________________           AGE GROUP  SEVERITY LEVEL  NO.  %  TOTAL  18-29 YEARS  LOW SEVERITY  7  32% 22   HIGH SEVERITY  19  45%  42 30-39 YEARS  LOW SEVERITY  19 53%  36   HIGH SEVERITY  38  63%  60  40-49 YEARS LOW SEVERITY  9 45%   20   HIGH SEVERITY   42 82%  51 50+ YEARS  LOW SEVERITY  14  78%   18    HIGH SEVERITY 42 84%  50 TOTAL SEVERITY   LOW SEVERITY 49  51%  06   HIGH SEVERITY  141 69%   201 TOTAL  ABSTINENT CONTINUED IN  AA    190 64%  299       To determine the unmet need for AA referral in the sub-group of high severe externalizing disorders the number of “natural” abstinence recoveries, the base rate,  was subtracted from the total alcohol use disorders respondents who never attended AA.  The remainder provided an estimate of the number of high severity respondents who potentially are AA refererals.    As shown in Table  4,  the unmet need for AA referral is concentrated in the younger age groups, 35% in the 18-29 years group and 30% in the 30-39 years age group.   ______________________________________________________________________________________ Table  4.  Unmet need for AA referral, by age group, in Americans with high severity alcohol use disorders :  1992 NLAES ______________________________________________________________________________________    AGE GROUP  NO. HIGH SEVERITY  NO. NATURAL RECOVERY  NO. UNMET NEED  %   18-29 years  183  21  162   35%   30-39 years  180 39   141  30%   40-49 years  148 46   102  22%    50+  years    137  77  60   13% TOTAL      465  100%        CONCLUSION   The results of the present study support the efficacy of the fellowship  of Alcoholics Anonymous to promote abstinence.  AA members achieved abstinence at a significantly higher rate than the “natural” recovery base rate of non-members.  The AA effects are partly mediated by age and severity.  The abstinence recovery rate for Americans with high severity alcohol disorders who continue to attend AA ranges from a low of 45%, age 18-29, to a high of 84%, age 50+ years. The findings of this study support the findings of Kaskutas et al[5] that  ”disengagement from AA does not necessarly translate to a return to drinking”.    The rates of abstinence, over 60%, in the  40+ years high severity AA drop outs are similar to the rate of abstinence, 63%, in the 30-39 year age high severity group who continued in AA..  The findings suggest that a substantial portion of the “AA drop outs” attain sobriety or abstinence after a period of AA membership and maintain their abstinence without AA attendance.  The findings from the Kaskutus et al study and from this study population[6] suggest that the disengagement from active AA membership is by five years. The maintinence of abstinence by the AA drop out group supports Carrillo’s behavioral economic concept of abstinence[7] as a second-best decision based on the strategic ignorance model of self-control. The Carrillo and Mariotti strategic ignorance model[8] builds on the idea that abstinence substantially decreases how much the individual learns about his own preferences.  Since, under time-inconsistent preferences learning can induce a future level of consumption excessively high from the current perspective, abstinence then provides a commitment device against such inefficient behavior. AA appears to serve an a self-control commitment device supporting abstinence[9].  Following an initial period, one to five years, of a sober productive life style in AA, and the development of supportive social networks as described by Kaskutus[10] and Bond[11], many respondents are able to maintain abstinence without AA attendance. The results of this study indicate that only a minority of Americans with high severity alcohol use disorders abstain without attending AA.  The unmet need for AA referral identified in this study is 465 survey respondents, representing a projected population estimate of 900,000 individuals in need of AA referral.      Additional research is needed on the estimated 900,000 individuals in need of AA referral to determine the nature of their resistance to AA and to develop effective methods of referral.  Research is needed on specific target groups, young people, women and college educated.  An example of needed research is the simple, but effective, approach to encourage AA participation demonstrated by Sisson and Mallams[12] as a component of the Community Reinforcement Approach.    The Betty Ford Institute Consensus Panel[13] defined recovery as “a voluntarily maintained lifestyle composed of sobriety, personal health, and citizenship”.  The concept of Quality of Life (QOL) is a multidimensional construct generally measured in terms of physical, mental and social health, the last two components of the Consensus Panel recovery definition.   Research is needed on the comparible level of QOL in the abstinent individuals within the three groups measured in this study, i.e. those who never attend AA, those who attend AA and drop out and those who continue to attend AA. Generic QOL instruments such as WHO-QOL-100, SF-36 and SF-12 are available to measure positive health and social functioning as well as life satisfaction .   This study has significant limitations.  The data is cross-sectional and is over 15 years old.  The analysis is limited to the high severity sub-group and the abstinence drinking outcome.  Additional research is also needed on the low severity sub-group using a measure of low risk drinking outcome.