Jessica Gregg is medical director for substance use disorders at Central City Concern in Portland, Ore., and an associate professor of medicine at Oregon Health and Science University.
Addiction has long been medicine’s unwanted stepchild. Doctors didn’t understand it, didn’t know how to treat it and felt helpless in the face of the wreckage it brought to their patients’ lives. As a result, while providers addressed the consequences of addiction — endocarditis, liver failure, seizures, overdose — they rarely treated the disease itself. That mysterious task has been left to others: counselors, peers in recovery and 12-step programs.
But this is changing. There is now a general consensus in medicine that addiction is best understood as a chronic disease that can be treated with pharmacological interventions. Providers now have access to an array of medications that reduce cravings and addictive behaviors. As a result, doctors in increasing numbers are seeking training in addiction management and are willing to assume responsibility for treatment of this complicated disease.
This is all to the good. And yet.
That attention may come at a price. The medical profession has a long, undistinguished history of turning its gaze to particular conditions , assuming its own competence and then dismissing the hard-won expertise of other disciplines. Think, for instance, of the marginalization of midwives as doctors assumed management of pregnancy. With addiction, as doctors grow interested in the disease, there has been increased criticism of traditional approaches, particularly medicine’s old ally, the 12 steps.
The criticism is not entirely unfounded. As an intervention based on anonymity and welcome to all comers, 12-step groups are virtually impossible to study in a controlled way. Consequently, no rigorous experimental data exists demonstrating that 12-step interventions, in and of themselves, can be credited for any participant’s successes. Further, 12-step programs don’t work for everyone. They are a specific intervention with a particular philosophy. Many credit them with saving their lives. Others find them less useful — or even harmful. Finally, many 12-step programs rely on a definition of abstinence that precludes the use of medication to treat addiction. Thus, individuals who would benefit from a medication may be dissuaded from its use, with potentially lethal results.
But it is critical that doctors pause before righteously pushing the 12 steps aside to make way for a brave new era of medically driven solutions — an era of addicts as patients and doctors as cure. The 12 steps exist because during decades of medical neglect, people struggling with addiction learned to look to themselves and to their peers for solutions. In 12-step programs, addicts learn that they can name their disease, admit the problems it causes and find community in overcoming it — every day. According to adherents, sincerely working the steps is both intensely difficult and transformative. No magic pills or elixirs can take the place of that work, they say.
And they are correct. Pills won’t cure addiction. They help, yes, and at the right time with the right person, they can be lifesaving. But the most effective treatment for any chronic disease involves much more than medication. These diseases are not resolved with a clinic visit or cured with a prescription. Rather, chronic disease outcomes improve most when the individuals suffering have the motivation, skills and confidence to monitor and manage their symptoms, and when the clinician plays a relatively minor role in disease management. Outcomes are even more robust when this self-management occurs within social networks that support individuals as they learn those skills.
Those using the 12 steps are highly engaged in the management of their disease. Furthermore, they learn to manage their illness in an intensely supportive context, a variable that may be even more important for addiction than for other chronic illnesses. Evidence suggests that rats and humans alike are more likely to become and stay addicted when their social networks are limited. Individuals in 12-step programs can attend groups daily, or even multiple times a day, and in each group they can find support in their search for sobriety.
My point isn’t that everyone struggling with addiction will recover with the 12 steps. Nor is it that 12-step groups succeed because they offer training in chronic disease management. Rather, it is that the 12 steps work for many people, and it would be arrogant and shortsighted to dismiss that success. It is imperative that, in the drive to provide our neglected stepchild with the newest medical bells and whistles, clinicians do not undermine the extraordinarily engaged community and powerful tools built by recovering individuals during the decades our backs were turned.