The Science Behind Addiction: Beyond the 12 Steps

To the outsider, it looks mind-boggling: why would an otherwise sane, happy, and healthy mother of three sip wine from a juice bottle while her kids are napping? Why does a lawyer show up drunk in court, get disbarred, work hard to reestablish his career — only to do it all over again?

And yet, it happens to many of us. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) reports that in 2022, close to 29.5 million people ages 12 and over struggled with alcohol use disorder (AUD). That’s more than one in every 10 people in this age group! What’s more, according to the National Center for Drug Abuse Statistics, as many as half of the U.S. population over the age of 12 has used illegal drugs at least once, and drug overdose deaths in the last two decades are close to a million.

So why do so many of us get addicted to substances that damage our health and even take our lives? Here’s Beat Generation author William S. Burroughs’ take on the question.

“You don’t wake up one morning and decide to be a drug addict … I tried it as a matter of curiosity. I drifted along taking shots when I could score. I ended up hooked. Most addicts I have talked to report a similar experience. They did not start using drugs for any reason they can remember. They just drifted along until they got hooked. If you have never been addicted, you can have no clear idea what it means to need junk with the addict’s special need. You don’t decide to be an addict. One morning you wake up sick and you’re an addict.”

Still, although it might feel like we just “drift” into it, there’s science behind addiction. Let’s take a closer look at what the latest addiction science tells us, and how that differs from the view of addiction that many 12-Step programs take.

Addiction Through the Ages

“When you can stop you don't want to, and when you want to stop, you can't ...” ― Luke Davies, author, Candy: A Novel of Love and Addiction

One thing that’s certainly true about addiction is that it’s nothing new. Ever since our ancient ancestors started making booze, it’s been a worldwide phenomenon.

Back in the days of ancient Greece, Aristotle argued that addiction is a problem with willpower — akrasia. (Spoiler alert: modern science says it’s not true.) Plato, in turn, was one of the first advocates for moderation: in his Dialogues, the philosopher warned against the dangers of excessive wine consumption, arguing that it could lead to poor decision making and moral degradation. As for the ancient Egyptians, there are texts dating back to 4000 BC that talk about herbs that could be used to treat opium addiction.

By the time the 20th century came around, addiction was increasingly seen as a disease. However, just what that disease was caused by, why some people seemed to be more prone to it than others, and whether or not it could be cured took another century to sort out.

When 12-Step Programs Enter the Scene

The view of addiction as a disease, in turn, is partially reflected in Alcoholics Anonymous (AA) and other 12-Step programs that followed in its footsteps throughout the 20th century. Dating back to the 1930s, AA was started by stockbroker Bill Wilson, who spontaneously recovered from alcoholism and whose personal turnaround led him to establish a fellowship of like-minded people. Centered around meetings attended by members who share their “experience, strength, and hope,” AA is all about sharing stories of recovery and giving others hope that they can do the same. (For a deep dive, check out “How Does Alcoholics Anonymous Work?” and “What To Expect at an AA Meeting.”)

Do 12-Step Programs Work?

It might be a step up from seeing AUD as a character flaw rather than an illness, but does AA actually work? And what is the 12-Step program success rate? It depends on who’s answering the question. While some swear by AA, others find it less than effective (or even harmful to their recovery). In the end, though, there are some clear positives of AA and some pretty serious downsides.

Here are the pros — the aspects of AA that tend to serve people well:

• It provides community support. The alcohol journey can be a lonely one, especially at the beginning. There’s nothing like being able to walk into a room full of people who’ve seen it all, done it all, and are willing to support us no matter what. Plus, seeing that others have been in our shoes and made it can be incredibly uplifting, inspiring, and motivating. It reminds us that recovery is possible (with or without AA)!
• It provides structure and accountability. Another aspect of the 12 Steps that can be helpful is that they’re, well, steps. As such, they provide structure for sober living and help get us into the habit of being productive as well as setting and meeting goals (because let’s face it, booze does the opposite). As for accountability to others, science says that it can work wonders for staying on track.

And those cons we were talking about? Well, there are some serious ones to consider.

• The “God” thing is a problem for many. AA claims to be “spiritual but not religious.” However, the 12 Steps mention God many times, and most members refer to their Higher Power as “God.”
• The lack of science is also a problem. An equally (if not more) concerning fallout of the spiritual slant that AA takes on addiction is that it fails to incorporate much of modern science into its model of addiction and recovery. Neuroscience has grown by leaps and bounds in the last few decades, but AA is still a bit stuck in the 20th century, seeing alcoholism as a spiritual disease.
• Seeing AUD as an “allergy” fosters an all-or-nothing mindset. Granted, for some of us — as we may have found through harsh experience — drinking just doesn’t end well. Those with AUD may have a genetic predisposition for alcohol dependence, and once dependence sets in, it’s difficult to go back to the relationship with alcohol we had before (more on that later). However, this is not true for everyone — some folks might be truly looking to cut back rather than quit or explore the benefits of a sober lifestyle. Dependence might not be an issue, and AA might not be the right fit.

Want to explore this question in more detail? Take a look at “Can AA Be Harmful?”

12-Step Program Success Rate

It depends on whom we ask, as well as what we mean by success. Sobriety is a lifelong process, and what works for some in the short term might not provide a satisfying solution later on. Still, for those who aim to stay away from booze for good, 12-Step programs can be helpful — mostly thanks to the social support they provide.

The Science Behind Addiction

“Remember: synapses used are synapses strengthened; they are the ruts in the garden where rainwater flows, forming deeper and deeper troughs.” — Mark Lewis, Memoirs of an Addicted Brain

These days, the medical and scientific definition of addiction has outgrown much of the terminology in use when AA got started. For one thing, the term “alcoholism” has long gone the way of the dinosaurs, making way for the more scientific “alcohol use disorder” (AUD) and substance use disorder (SUD) to refer to other substance addictions. And while AA still sees addiction as a partially moral issue (that “spiritual malady” we talked about), the modern science community generally prefers to see it as a brain-based condition that doesn’t reflect our authentic character (or, for that matter, our spiritual qualities).

Instead, SUD and AUD are seen as complex brain disorders characterized by compulsive substance use despite harmful consequences. Let’s take a closer look at the brain in addiction — as well as the brain in recovery.

The Brain in Addiction

What makes something addictive? While the science is complex, substances that change our brain chemistry and cause us to seek more of them can become addictive. The star of the show is the brain’s reward system, which evolved to keep habits going in order to ensure our survival. For better or worse, we’re naturally driven to seek things that make us feel good. If those things are nutritious food or fulfilling relationships, all is well, and our chances of making it through the trials and tribulations of life to pass on our genes increase. However, the system behind habits is pretty primitive and easy to hijack. The neurotransmitter dopamine that runs the reward system acts as a neurological “gold star,” giving us a boost of pleasure when we engage in a particular habit. Unfortunately, substances such as alcohol also lead to dopamine release. Here’s how biologist Mark Lewis describes it:

“Brains just do what hundreds of millions of years of evolution have determined to be useful, and that includes identifying things that taste good or feel good to us. The brain distinguishes those things from everything else — the background music of the humdrum world — and propels us to go after them.”

See the problem? That’s right, our brain will latch onto any source of dopamine no matter what the fallout is. And alcohol is the mother-of-all sources. Here’s an overview of the changes that happen to the brain when we drink and the shifts that take place as misuse leads to dependence:

• Alcohol messes with our neurotransmitters. That brief burst of pleasure we sometimes feel after a few sips? That’s dopamine at work. In addition to boosting dopamine, it increases the levels of GABA, an inhibitory neurotransmitter, while lowering glutamate, its excitatory counterpart.
• Tolerance builds and dependence sets in. Over time, the brain adapts to the high dopamine levels, reducing its natural production. The result? We need more booze to experience the same effects, eventually relying on alcohol just to feel “normal” and experiencing withdrawal if we stop.
• More fundamental brain changes make it hard to stop. Chronic substance use alters brain structure and function, particularly in areas responsible for decision making, impulse control, and stress regulation. These changes make quitting difficult and relapse more likely.

As a result, a three-step cycle sets in, with each stage affecting a particular area of the brain.

• The “binge/intoxication” stage is when the (destructive) action happens. This stage is all about the basal ganglia — brain circuits associated with reward activated by booze. Alcohol floods our brain with pleasure-inducing neurotransmitters, and we drink — sometimes to the point of binging and even alcohol poisoning. The breaks are off as far as the reward system is concerned, and the prefrontal circuit takes a back seat.
• The “negative affect” stage is the crash that follows the binge. What goes up must come down, and the high of the intoxication stage is followed by an inevitable crash. In an effort to balance out the flood of dopamine, the brain overcompensates, suppressing its release and triggering a “hypodopaminergic” state (characterized by low dopamine levels). Moreover, the activation of the stress response and the release of cortisol, dynorphin, and norepinephrine contribute to the post-binge anxiety and low mood. The blues that come with the negative affect stage center in the amygdala, which is associated with stress circuits and negative emotional states.
• The “contemplation/preoccupation” period sets the stage for the next binge. The last stage is governed by the prefrontal cortex, which is involved in thinking and planning. Repeated episodes of intoxication set in motion powerful cravings that lead to impairments in rational thinking, which would otherwise keep the impulses in check. As a result, our prefrontal cortex gets hijacked by these lower-order impulses, and we feel as if we have no choice but to give in and plan our next binge.

But this doesn’t necessarily happen to everyone who picks up a drink. There are some people who are more likely to get addicted to alcohol than others.

Why Do Some People Get Addicted?

There’s also science behind the reasons why some people seem to “take it or leave it” while others get hooked. According to the National Institute on Drug Abuse, there are three factors at play:

• Biology plays a role. Science shows that our genetics play a large role in our addiction potential. According to the NIDA, a person’s genes account for about half of a person’s risk for addiction. Other factors such as gender, ethnicity, and coexisting mental disorders also influence the risk, but genetics is the biggest factor.
• Environment can act as a trigger. In addition to genetic predisposition, the behavior of those around us and the pressure we might feel to conform also makes a difference. If our friends and family members normalize heavy drinking, we might be more prone to do it. It might also be harder for us to recognize that we’re sliding into the alcohol trap until we’re well on our way to dependence.
• Age makes a difference. Although we can develop AUD or other substance use disorders at any age, early exposure to drugs or alcohol makes it more likely. As teenagers, we’re not only more prone to peer pressure, but we’re also still developing. In fact, our prefrontal cortex only matures by our mid-20s! (No wonder you have to be 25 to rent a car.)

As we can see, there are many factors at play when it comes to AUD, and there’s solid science behind them. But, guess what: there’s science behind recovery, too!

The Brain in Recovery

Luckily, the ability of the brain to change in response to our activities — known as neuroplasticity — can also help us recover! Here’s what happens when we stop drinking:

• Our neurotransmitter balance gets restored. Without alcohol interfering in the delicate balance of neurotransmitters, our brain has a chance to rebalance itself. We can help this process along by engaging in activities that naturally boost dopamine, such as socializing, playing games, being outdoors, and exercising. A dopamine-friendly diet helps, too! This neurotransmitter is produced from tyrosine, so eating poultry, beans, legumes, and other tyrosine-rich foods can give us an extra boost.
• Our memory recovers. While the hippocampus — the part of the brain in charge of storing new memories — shrinks with alcohol misuse, its functions get restored when we give it a chance to recover.
• Our prefrontal cortex increases in volume. Over time, our brain even regains its volume! Science shows that seven months of abstinence was enough to increase cortical thickness in participants, proving the brain’s remarkable ability to heal itself.

Even better news? Science-based therapies such as cognitive behavioral therapy (CBT) help us recover at an even deeper level. Even after we put down the drink, we might still feel some emotional attachment to booze. This is where CBT comes in! By teaching us to uncover and reframe our subconscious beliefs about alcohol, we can change the neural circuitry around it. The result? We stop seeing booze as the be-all and end-all of social gatherings, relaxation, and fun. In short, it becomes irrelevant and insignificant, making sobriety easy!

Science-Based 12-Step Alternatives

There are plenty of science-based 12-Step alternatives out there. For a deep dive, check out “The Best AA Alternatives.” For now, here’s the gist:

• Medication-assisted treatment (MAT). These days there are several routes to consider when it comes to medication for AUD, including meds that reduce alcohol’s pleasurable effects, those that cause unpleasant (to put it mildly) reactions when mixed with booze, and ones that target cravings directly. (For more information, take a look at “Which Medications Work Best To Help Me Stop Drinking?”)
• Therapy. Just as with pharmaceutical treatments, there’s a range of therapy options available for AUD and other substance misuse disorders. Science has moved beyond the psychoanalyst’s couch and dream analysis (although if you feel the need to tell someone about that dream when you lost all your teeth while performing on stage, be our guest!). Check out “How Can Cognitive Behavioral Therapy (CBT) Help With Alcohol Misuse?” and “How Can Dialectical Behavior Therapy (DBT) Help With Alcohol Misuse?” for some great options.
• Contingency management (CM). Studies show CM can significantly improve treatment outcomes. It’s all about engaging the brain’s reward system by providing an incentive for a desired behavior (in this case, staying sober).
• Mindfulness-based approaches. Mindfulness practices, like meditation and yoga, help manage cravings and reduce relapse risk. (Want to learn more? Check out “How Can Meditation Help Me Overcome Alcohol Misuse?”)
• Neurofeedback. Neurofeedback, also known as EEG biofeedback, involves training the brain to self-regulate. During sessions, individuals learn to modify their brainwave patterns through real-time feedback. This can improve brain function and reduce addiction symptoms.
• Exercise and nutrition. Last but not least, exercise is one of the best science-backed ways to stay on track in recovery by rebuilding your body and busting through cravings. It’s a natural way to release all those happy neurochemicals without booze! And, of course, proper nutrition is key to supporting brain function and repair. Think whole grains, healthy fats, lean proteins, and lots of fruits and veggies.

And remember, Reframe is here to provide you with science-backed tools, motivation, and access to a thriving community of like-minded folks who’ve been in your shoes and know what it’s like. We believe in you — and we’ve got science on our side to help you every step of the way!

Key Takeaways

There are plenty of science-based 12-Step alternatives out there. For a deep dive, check out “The Best AA Alternatives.” For now, here’s the gist: