Why Critics Are Afraid to Admit That NIDA’s Addiction Model and AA Are Two Sides of the Same Coin
As our predestined fates would have it, several prominent books (including by authors as distinguished as Marc Lewis, Sally Satel and Johann Hari) have recently confronted the supposedly scientific neurobiological chronic brain disease theory of addiction. The theory, which is associated worldwide with Nora Volkow, director of the National Institute on Drug Abuse (NIDA), was reaffirmed as national policy by US Surgeon General Vivek Murthy just last month.
Yet these same bold authors, and many others, are often reluctant to similarly criticize Alcoholics Anonymous in its mission of directing people born with the inescapable disease of alcoholism to become “recovering alcoholics” forevermore.
Doesn’t it seem strange that critics can attack the modern disease theory while they treat the 80-year-old religious-cum-spiritual AA disease theory as sacrosanct?
To take one further example, at the most recent Drug Policy Alliance conference in Washington, DC a year ago, I was one of a crowded room of spectators at a spirited panel discussion of the brain disease theory. Aside from the quite defensive (even apologetic) representative from NIDA, the other four panel members were vociferously opposed to the NIDA model.
But no one on the panel, nor in the overwhelmingly anti-disease audience, once mentioned AA’s disease model of addiction, based on folk wisdom and America’s temperance tradition, which precedes the neurobiological model by a half century.
We’ll return to the question of why in a moment.
But first, am I right to claim that these two movements—the disciples of Nora Volkow and those of Bill Wilson—represent the same American meme?
Critics might attack me (as they have) for unjustifiably conflating the two models. But the two are inextricably linked. In fact, as I point out in my book Recover!, AA paved the way for the established dominance of Volkow et al. by creating the widespread addiction-disease consciousness in the US into which the brain disease model could neatly be slotted.
Here are the essential similarities between these two disease models:
1. Both models, the AA and neurobiological, make addiction out to be an incurable disease, whether inbred or ineradicably imprinted on the brain, which can never be reversed, only managed. I made this clear for the neurobiological model in a 2016 article in Addictive Behavior Reports, as I have been doing for AA and its offshoots for decades, such as in American Health Magazine in 1983.
2. Both addictive disease models ignore environmental and psychological factors in addiction in favor of supposedly biological and inbred factors. My 1991 book (with Archie Brodsky and Mary Arnold), The Truth About Addiction and Recovery, listed as one of eight essential flaws of AA’s disease model that “It ignores the rest of the person’s problems in favor of blaming them all on the addiction.” At the DPA conference, critics rounded on the brain disease model’s role in ignoring issues of poverty and social disempowerment.
3. Both models remove choice and free will from the addiction equation. AA’s mythology indicates that only a fool tries to control their problem drinking, an effort that must always fail. Meanwhile a video on NIDA’s home page announces “Dr. Nora Volkow on Addiction: A Disease of Free Will.”
4. More than anything, both models discourage individual and cultural beliefs in people’s agency—in both their resistance to addiction, and their ability to overcome an addiction should they form one. Instead of encouraging empowerment, brain disease proponents strive to find some futuristic neurological intervention to cure addiction once and for all, while AA prescribes surrendering to its guiding Higher Power.
5. And disease models of both kinds share little ability to reverse addiction. Neurobiology has produced no diagnostic or treatment tools for addiction. Meanwhile, William Miller and his University of New Mexico colleagues ranked 12-step facilitation and AA 37th and 38th most successful out of 48 treatments for alcoholism, according to their systematic assessment of clinical trials. A generalized belief in a disease model has been shown to retard recovery, while the most successful models of addiction therapy, per Miller et al., are built on supporting self-efficacy as the key ingredient in recovery.
You’ll admit, won’t you, that there are some significant similarities?
Given the identical emphases of these two disease models, why should most outspoken public criticism be directed towards only one—the brain disease model?
The thing about attacking the brain disease model of addiction is that such attacks don’t seem personal. The culprits are well-positioned addiction theorists like Nora Volkow and high-priced medical providers like members of the American Board of Addiction Medicine. Relatively few of us have any of those types in our family. So when someone points out the brain model’s soul-crushing inadequacy for facing our society’s addiction problems, we don’t stand a chance of another family member walking out of a holiday dinner.
With AA, which has 2 million active members, the vast majority in North America, the situation is much more personally threatening. Almost all of us have some kind of personal connection to people involved with the elevation of AA to its position as a national monument.
Perhaps it’s our sister Shelly’s daughter, Rachel, who was partying a lot, getting Cs and Ds. Shelly sent Rachel to AA at age 18 and the young woman turned over a new leaf. She’s an honor student in college now.
Perhaps it’s our Uncle Moshe, who was drinking six shots of scotch daily (he called the drinks “schnapps”). Moshe didn’t seem to think that was a problem at all, but not everyone in the family agreed. Finally, at age 87, he found himself in AA. That was three months ago. So far, so good, family members announce!
Perhaps it’s our cousin, Benjamin, who really was drinking and using meds dangerously. He’s 39 and hasn’t had a job in the six years since he developed back problems and his wife left him. Now he’s grateful for his two years “sober,” some friends in the Rooms, and a belief that he has an incurable disease.
I would propose that Rachel would have benefited instead from some clear expectations and early examples and experiences of responsible drinking—and that, in any case, she would have straightened out on her own.
And that, since Uncle Moshe achieved his ripe old age while apparently doing little harm to others or himself by drinking that much, he should have carried on making his own decisions about alcohol.
And that Benjamin desperately needed opportunities to improve his health, his work prospects and his personal relationships, rather than to adopt a stop-gap life identity as an alcoholic/addict.
And the thing is, deep down, most of those anti-brain disease, pro-AA folks in the addiction field agree with me (indeed, some privately tell me so). But they don’t want to say so publicly—at least, not in so many words.
Because when AA membership becomes a person’s identity—and many view it, because of their subjective experience, as a lifesaving identity—it can be impossible to point out AA’s demonstrated failures, both for individuals and for society, without its being received as a personal attack.
And so, in the interest of mercifully avoiding giving offense, these experts, who should and often do know better, prop up the continued dominance in American culture of a disease-based program with outcomes for people with addiction ranging from nonexistent to mediocre to disastrous.
If that’s kindness, I want no part of it. Instead, as I wrote for the British RSA Journal in 2012:
Neurobiological models of addiction are consistent with the privatized American healthcare system. Meanwhile, the American vision of addiction is spreading rapidly, due to proselytizing by AA advocates, the scientific claims of the NIDA and the pharmaceutical industry’s marketing. Yet our best data—including the NESARC results—show that addiction should be de-medicalized in favor of a model that encourages the advancement of psychological and environmental conditions that naturally prevent and dispel addiction.
Although AA will remain a beneficial community resource for some alcoholics, it further entrenches the disease model in our culture and works against the natural recovery that research shows is more common and enduring. Community supports and therapies will be more effective if they focus on enhancing natural recovery processes by working with people on reducing or managing their substance use, developing more productive coping skills, and improving their housing, employment and relationships.
I rest my case.