Alcoholics Anonymous/12-Step Facilitation (AA/TSF) NICE Recommendation and Cochrane Evidence Review

National Institute for Health and Care Excellence (NICE) Recommendation

We have had fantastic news for AA!

The NICE Quality Standard (QS11) ‘Alcohol-use disorders: diagnosis and management’, commissioned by NHS England, published July 2023, provides ‘best practice’ recommendations in England and Wales. The Quality standard is the new Gold Standard for Alcohol-use disorders (AUDs).

QS11 covers identifying and supporting adults and young people (aged 10 and over) who may have an alcohol problem, and caring for people with alcohol-related health problems, as well as support for their families and carers.

Out of the 5 Quality Statements set out in QS11, Quality Statement 2 sets out:

‘Adults seeking help for an alcohol-use disorder are given information on, and support to access, community support networks and self-help groups.’

This is relevant to the 12-step programme offered by AA.

Further information on the NICE QS11 can be found at: https://www.nice.org.uk/guidance/qs11

Cochrane Evidence Review

The Cochrane Review of 27 relevant scientific studies showed that AA/TSF produced similar benefits to cognitive behaviour therapy and motivational enhancement therapy on all drinking-related outcomes, except for continuous abstinence and remission, where AA/TSF was superior. This is achieved largely through the long-term use of TSF and enduring AA participation.

(Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12-step programs for alcohol use disorder. Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No.: CD012880. DOI: 10.1002/14651858.CD012880.pub2.)

The Cochrane Review can be found at: https://www.cochrane.org/CD012880/ADDICTN_alcoholics-anonymous-aa-and-other-12-step-programs-alcohol-use-disorder

In light of this evidence, Kelly has been quoted:

‘The quality of the research evidence supporting the clinical and public health utility of Alcoholics Anonymous has grown substantially in recent years. Evidence now indicates that when patients suffering from serious alcohol problems are clinically referred to AA, they have higher rates of continuous remission and have longer stable recoveries than patients linked to other treatments that also address alcohol problems.

Evidence also now demonstrates that the way AA is able to confer this long-term benefit is by its ability to mobilize a number of helpful therapeutic factors simultaneously over time, including by boosting relapse prevention coping skills, enhancing and maintaining recovery motivation, reducing craving and impulsivity, and by increasing spirituality, which can help people to reframe and better cope with stress.

All in all, given the massive burden of disease, disability, and premature mortality attributable to alcohol problems each year, and the fact that AA is widely available and accessible for free in most communities, this new evidence indicates AA may be the closest thing public health has to a ‘free lunch’.’

John F. Kelly, PhD, Professor of Psychiatry, Harvard Medical School.

Alcoholics Anonymous 2020 Membership Survey and ‘Spirituality’

NICE highlighted the 2020 AA Membership survey of Great Britain and the English-Speaking Continental European Region in their evidence base. When members were asked about spirituality and their notion of a ‘Higher Power’, 65% of respondents reported that these were based on a secular foundation, compared with only 35% whose views had an overtly religious basis. This myth buster explodes the widely-held misconception that AA is a religious organisation, which has historically led to reticence in accessing AA services. AA has members of all religions, no religion and different cultures.

The AA membership survey can be found at https://www.alcoholics-anonymous.org.uk/Members/2020-Survey

On ‘spiritual’ matters, Kelly suggests:

‘In tapping into the “God idea” and borrowing some religious concepts, language, and practices (e.g., faith, prayer, meditation, confession), arguably AA might be considered “relig-ious”, but not a relig-ion. Without any formally agreed upon definition of what “spirituality” actually is, AA’s focus on gratitude, hope, forgiveness, and compassion, might be considered spiritual in essence. It has facilitated a self-defined notion of spirituality, including even a non-spiritual, secular spirituality if one chooses, to ensure everyone has a chance at making use of its “protective wall of human community” and all that it has to offer. So, circling back to the original question posed at the outset, “Is AA religious, spiritual, neither?” The answer, would appear to be, “Yes”.’

Kelly JF. Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behaviour change research. Addiction. 2017 Jun;112(6):929-936. doi: 10.1111/add.13590. Epub 2016 Oct 8. PMID: 27718303; PMCID: PMC5385165.

Free AA support

AA support for and from members is both accessible and free, an important consideration, especially when leaving treatment / hospitals and the difficulties and variation in accessing community alcohol services. To members of AA/TSF, it is potentially a lifelong commitment, rather than a typically time-limited NHS treatment.

The ‘alcoholic’ stigma

NICE recognises the stigma associated with people who misuse alcohol. AA members self-define as ‘alcoholic’, which is fundamental. Unfortunately, AUDs are still often perceived elsewhere as a ‘self-inflicted lifestyle choice’ rather than as a disease.

‘Better than Well’

Dr David Best of the University of the West of Scotland and Louise Hibbert found that Quality of Life (QoL) continues to improve over periods exceeding 5 years in recovery, and in those who make it to this point, their wellbeing can exceed that typically reported by those never addicted. This concept of ‘Better than Well’ offers a model of hope and change. It suggests that the goal of recovery is a QoL process of ongoing growth.

Dr Kieran Moriarty CBE, MA (Cantab), MD, FRCP, FRCPI
Non-Alcoholic Trustee Alcoholics Anonymous (2022 – Current)
Consultant Physician in General Medicine, Gastroenterology and Liver Disease, Bolton NHS Foundation Trust (1990 – 2018)
Alcohol Adviser to Chief Medical Officers and Westminster and Stormont Governments (2000 – 2020)
Alcohol Lead, British Society of Gastroenterology (2009 – 2020)