There are some who suggest that alcoholism and drug abuse are not diseases at all and that they are not consequences of a brain disorder, as espoused recently by the American Society of Addiction Medicine (ASAM). Some would argue that addicts could quit on their own and moderate their alcohol or drug intake, as in controlled drinking. However, when given a choice of a treatment program such as the 12 Step Program & Fellowship, many addicts finally achieve complete abstinence.
However, when controlled drinking fails, there may be successful alternatives that fit certain groups of individuals. In this piece, we attempt to help define personal differences in recovery, despite risk gene polymorphisms for addiction, by clarifying the molecular neurobiological basis of each step of the 12-Step Program.
This has already been accomplished in part by Blum and others in a 2013 Springer Neuroscience Brief. The purpose of this current examination is to provide a short scientific background for molecular neurobiological and genetic links, and especially relating the role of epigenetics, not only in addiction but possibly in individuals attending AA meetings regularly. It begs the question as to whether “12-steps programs and fellowship” actually induces neuroplasticity (enhanced recruitment of neuronal activity of the brain) and continued dopamine D2 receptor proliferation in spite of carrying hypodopaminergic type polymorphisms such as DRD2 A1 allele.
“Like minded” doctors of ASAM are cognizant that in treatment without the psycho-social-spiritual trio, patients may not being obtaining the important benefits afforded by adopting 12-step doctrines. Are we better off with a program that couples medical-assisted treatment (MAT) that favors combining dopamine agonist modalities (DAM) as possible histone deacetylase activators with the 12 steps than a program that embraces one or the other?
While there are many unanswered questions, at least we have reached a time when “science meets recovery,” and in doing so, can further redeem joy in recovery.
Even with the many unanswered questions concerning the actual effect of 12-step programs and fellowship, whether for alcoholics, narcotic addicts, or even those with behavioral addictions such as gambling and sex, we are making significant progress with the advent of neuroimaging techniques.
In the past there has been great controversy about the real benefits of this well-known and universally adopted modality. Harvard professor George Vaillant surprisingly did not find evidence for effectiveness of the AA 12-step program relative to a control having no AA treatment. In his article “Psychiatry, religion, positive emotions and spirituality,” Vaillant concluded that:
“AA may be a good and comfortable fit for a few people who have a problem with alcohol, the majority of people with alcohol problems appear to do better with a different approach. We would love to see a study of why so many people dropped out of AA. We hypothesize that this may be due to the fact that AA’s theological notions of the powerlessness of humanity and of the need for a rescuing God are unpalatable not only to many atheists and agnostics but to almost all theists who are not Calvinists as well.”
Furthermore Vaillant suggests based on his research that:
“It may also be the case that the AA philosophy of “powerlessness” over alcohol and slogans such as “one drink, one drunk”, “one is too many and a thousand is never enough”, and “alcohol is cunning, baffling, and powerful” actually set people up to binge drink rather than to practice damage control when they slip up and fail to abstain as intended. More data on this topic is definitely needed.”
Vaillant summarized that:
- AA is a good fit for a small number of people with alcohol problems and helps them to abstain.
- AA is a poor fit for the majority of people with alcohol problems and can make some people worse.
- AA is better at creating “true believers” than it is at eliminating problem drinking.
- Whether or not AA is a good fit for a person has little if anything to do with how much a person drinks or the number of alcohol-related problems that a person has—the essential factor is personality type.
- AA is a good fit for black-and-white thinkers who accept proof by authority.
- AA is a poor fit for people who think in shades of gray and demand empirical evidence and scientific proof.
There are examples of why AA does not work for everybody, and neuroscientists assert it may be possible in the future to test for specific genes that would better match individuals to accepting the doctrines of AA. Interestingly, a PUBMED search in September 2014, using terminology “why alcoholics anonymous does NOT work” did not retrieve any results. However, Kelly (2003) pointed out that:
“Regarding subpopulations, current evidence suggests non- or less-religious individuals benefit as much from self-help groups as more religious individuals and women become as involved and benefit as much as men. However, participation in, and effects from, traditional self-help groups for dually diagnosed patients may be moderated by type of psychiatric comorbidity. Some youth appear to benefit, but remain largely unstudied. Dropout and nonattendance rates are high, despite clinical recommendations to attend.”
In Part 2 of this discussion, I will outline the molecular biology of each step of the 12-step process.
Blum, K., Femino, J., Teitlebaum, S., Giordano, J., Oscar-Berman, M., & Gold, M. (2013). Molecular Neurobiology of Addiction Recovery: The 12 Steps Program & Fellowship. Springer Briefs in Neuroscience, New York, London, Heidelberg.
Kelly, J. F. (2003). Self-help for substance-use disorders: History, effectiveness, knowledge gaps, and research opportunities. Clinical Psychology Review, 23(5), 639-63.
Vaillant, G. E. (2013). Psychiatry, religion, positive emotions and spirituality. Asian Journal of Psychiatry, 6(6), 590-594. doi: 10.1016/j.ajp.2013.08.073