Buddy
System," issue 17.10.) And in April, a paper published in Annals of Internal
Medicine concluded that a person is 50 percent more likely to be a heavy
drinker if a friend or relative is a boozehound. Even if an alcoholic's
nonsober friends are outwardly supportive, simply being around people for
whom drinking remains the norm can nudge someone into relapse. It is much
safer to become immersed in AA's culture, where activities such as studying
the Big Book supplant hanging out with old acquaintances who tipple.
As for the steps themselves, there is evidence that the act of public
confession-enshrined in the fifth step-plays an especially crucial role in
the recovery process. When AA members stand up and share their emotionally
searing tales of lost weekends, ruined relationships, and other
liquor-fueled low points, they develop new levels of self-awareness. And
that process may help reinvigorate the prefrontal cortex, a part of the
brain that is gravely weakened by alcohol abuse.
To understand the prefrontal cortex's role in both addiction and recovery,
you first need to understand how alcohol affects the brain. Booze works its
magic in an area called the mesolimbic
pathway-the reward system. When we experience something pleasurable, like a
fine meal or good sex, this pathway squirts out dopamine, a neurotransmitter
that creates a feeling of bliss. This is how we learn to pursue behaviors
that benefit us, our families, and our species.
When alcohol hits the mesolimbic pathway, it triggers the rapid release of
dopamine, thereby creating a pleasurable high. For most people, that buzz
simply isn't momentous enough to become the focal point of their lives. Or
if it is, they are able to control their desire to chase it with reckless
abandon. But others aren't so fortunate: Whether by virtue of genes that
make them unusually sensitive to dopamine's effects, or circumstances that
lead them to seek chemical solace, they cannot resist the siren call of
booze.
Once an alcoholic starts drinking heavily, the mesolimbic pathway responds
by cutting down its production of dopamine. Alcohol also messes with the
balance between two other neurotransmitters: GABA and glutamate. Alcohol
spurs the release of more GABA, which inhibits neural activity, and clamps
down on glutamate, which stimulates the brain. Combined with a shortage of
dopamine, this makes the reward system increasingly lethargic, so it becomes
harder and harder to rouse into action. That's why long-term boozers must
knock back seven or eight whiskeys just to feel "normal." And why little
else in life brings hardcore alcoholics pleasure of any kind.
As dependence grows, alcoholics also lose the ability to properly regulate
their behavior. This regulation is the responsibility of the prefrontal
cortex, which is charged with keeping the rest of the brain apprised of the
consequences of harmful actions. But mind-altering substances slowly rob the
cortex of so-called synaptic
plasticity, which makes it harder for neurons to communicate with one
another. When this happens, alcoholics become less likely to stop drinking,
since their prefrontal cortex cannot effectively warn of the dangers of bad
habits.
This is why even though some people may be fully cognizant of the problems
that result from drinking, they don't do anything to avoid them. "They'll
say, 'Oh, my family is falling apart, I've been arrested twice,'" says Peter
Kalivas, a neuroscientist at the Medical University of South Carolina in
Charleston. "They can list all of these negative consequences, but they
can't take that information and manhandle their habits."
The loss of synaptic plasticity is thought to be a major reason why more
than 90 percent of recovering alcoholics relapse at some point. The newly
sober are constantly bombarded with sensory cues that their brain associates
with their pleasurable habit. Because the synapses in their prefrontal
cortex are still damaged, they have a tough time resisting the urges created
by these triggers. Any small reminder of their former life-the scent of
stale beer, the clink of toasting glasses-is enough to knock them off the
wagon.
AA, it seems, helps neutralize the power of these sensory cues by whipping
the prefrontal cortex back into shape. Publicly revealing one's deepest
flaws and hearing others do likewise forces a person to confront the
terrible consequences of their alcoholism-something that is very difficult
to do all alone. This, in turn, prods the impaired prefrontal cortex into
resuming its regulatory mission. "The brain is designed to respond to
experiences," says Steven Grant, chief of the clinical neuroscience branch
of the National Institute on Drug Abuse. "I have no doubt that these
therapeutic processes change the brain." And the more that critical part of
the brain is compelled to operate as designed, the more it springs back to
its pre-addiction state. While it's on the mend, AA functions as a temporary
replacement-a prefrontal cortex made up of a cast of fellow drunks in a
church basement, rather than neurons and synapses.
Finally, the 12 steps address another major risk factor for relapse: stress.
Recovering alcoholics are often burdened by memories of the nasty things
they did while wasted. When they bump into old acquaintances they
mistreated, the guilt can become overwhelming. The resulting stress causes
their brains to secrete a hormone that releases corticotropin, which has
been shown to cause relapse in alcohol-dependent lab rats.
AA addresses this risk with the eighth and ninth steps, which require
alcoholics to make amends to people they've wronged. This can alleviate
feelings of guilt and in turn limit the stress that may undermine a person's
fragile sobriety.
Bill W., as Wilson is known today, didn't know the first thing about
corticotropin-releasing hormone or the prefrontal cortex, of course. His
only aim was to harness spirituality in the hopes of giving fellow
alcoholics the strength to overcome their disease. But in developing a
system to lead drunks to God, he accidentally created something that deeply
affects the brain-a system that has now lasted for three-quarters of a
century and shows no signs of disappearing.
But how effective is AA? That seemingly simple question has proven
maddeningly hard to answer. Ask an addiction researcher a straightforward
question about AA's success rate and you'll invariably get a distressingly
vague answer. Despite thousands of studies conducted over the decades, no
one has yet satisfactorily explained why some succeed in AA while others
don't, or even what percentage of alcoholics who try the steps will
eventually become sober as a result.
A big part of the problem, of course, is AA's strict anonymity policy, which
makes it difficult for researchers to track members over months and years.
It is also challenging to collect data from chronic substance abusers, a
population that's prone to lying. But researchers are most stymied by the
fact that AA's efficacy cannot be tested in a randomized experiment, the
scientific gold standard.
"If you try to randomly assign people to AA, you have a problem, because AA
is free and is available all over the place," says Alcohol Research Group's
Kaskutas. "Plus, some people will just hate it, and you can't force them to
keep going." In other words, given the organization's open-door membership
policy, it would be nearly impossible for researchers to prevent people in a
control group from sneaking off to an AA meeting and thereby tainting the
data. On the other hand, many subjects would inevitably loathe AA and drop
out of the study altogether.
Another research quandary is how to account for the selection effect. AA is
known for doing a better job of retaining drinkers who've hit rock bottom
than those who still have a ways to fall. But having totally destroyed their
lives, the most desperate alcoholics may already be committed to sobriety
before ever setting foot inside a church basement. If so, it might be their
personal commitment, rather than AA, that is ultimately responsible for
their ability to quit.
As a result of these complications, AA research tends to come to wildly
divergent conclusions, often depending on an investigator's biases. The
group's "cure rate" has been estimated at anywhere from 75 percent to 5
percent, extremes that seem far-fetched. Even the most widely cited (and
carefully conducted) studies are often marred by obvious flaws. A 1999
meta-analysis of 21 existing studies, for example, concluded that AA members
actually fared worse than drinkers who received no treatment at all. The
authors acknowledged, however, that many of the subjects were coerced into
attending AA by court order. Such forced attendees have little shot at
benefiting from any sort of therapy-it's widely agreed that a sincere desire
to stop drinking is a mandatory prerequisite for getting sober.
Yet a growing body of evidence suggests that while AA is certainly no
miracle cure, people who become deeply involved in the program usually do
well over the long haul. In a 2006 study, for example, two Stanford
psychiatrists chronicled the fates of 628 alcoholics they managed to track
over a 16-year period. They concluded that subjects who attended AA meetings
frequently were more likely to be sober than those who merely dabbled in the
organization. The University of New Mexico's Tonigan says the relationship
between first-year attendance and long-term sobriety is small but valid: In
the language of statistics, the correlation is around 0.3, which is right on
the borderline between weak and modest (0 meaning no relationship, and 1.0
being a perfect one-to-one relationship).
"I've been involved in a couple of meta-analyses of AA, which collapse the
findings across many studies," Tonigan says. "They generally all come to the
same conclusion, which is that AA is beneficial for many but not all
individuals, and that the benefit is modest but significant . I think that
is, scientifically speaking, a very valid statement."
That statement is also supported by the results of a landmark study that
examined how the steps perform when taught in clinical settings as opposed
to church basements. Between 1989 and 1997, a multisite study called Project
Match
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