The Problem with 12-Step Programs

In 1993 Nirvana front man Kurt Cobain appeared on the cover of The Advocate, alongside the caption, "I am gay in Spirit." That was the first time I made the connection between the war on drugs and the war on other disenfranchised communities, in this case the LGBTQIA+ community. The following year Cobain would die from suicide, but those who followed his story know it was a bit more complicated than that. He died from the war on drugs. He died because he couldn't get a clean, safe supply of consistent heroin, and because he didn't have the social support that might have saved him. He died because he became convinced that there was no hope.

He died from Tough Love.

27 years after Kurt's death, things have not improved much. The CDC reported yesterday (1/15/21) an all-time high in annual deaths from overdose: 81,000 between June of 2019 and June of 2020.

12-step programs are ineffective by any standard of science or medicine. But they have become the norm in our culture of prohibition; 80-90% of all US treatment programs rely on 12-step tenets.

Around 70% of those referred to AA drop out within 6 months, presumably without finding some other method of abstaining from their problematic use or behavior. These folks are generally ignored in research looking at success rates. As for those who keep coming back, less than 50% of active participants make it a year or more without relapse. In any other area of medicine we would be working to fix that number. With addiction it passes as good enough.

Since 12-step programs are built on the idea of needing to hit "rock bottom," they support the idea of punishment as treatment. The United States is awful at a lot of things, but it is great at locking people up. We account for less than 5% of the planet's population but more than 20% of its prisoners. And all that incarceration funds a massive complex of corporations, organizations, facilities and institutions—a prison-industrial complex.

Addiction is not a disease, it is a learning disorder. Our understanding of it as a disease is dangerous. Addicted people who claim to believe Step 1 (of the 12-Steps), that addiction is a disease over which they are powerless, relapse more often than those who don't view it that way. Our ignorance is hurting people.

12-step programs are often the only show in town when it comes to treatment, and they work, in part, by initiating social connections. Bruce Perry & Maia Szalavitz , have found that the most valuable aspect of successful 12-step programs is community engagements, and Johann Hari has described addiction as a disease of loneliness. 12-step meetings act as wonderful treatment for some people simply because they nurture connections. But we don't need all the other garbage that comes along with those social connections.

Instead of embracing compassion and harm reduction as a strategy of combatting drug related harm, the US has repeatedly doubled down on punishment and torture, in large part because 12-Step programs have normalized rock bottom narratives that defend the application of tough love. Between 1925 and 1986 the prison population expanded by more than 500%, from less than 92,000 inmates in 1925 to more than 503,000 in 1986. Then, between 1985 and 2018, it happened again: State correctional expenditures went from $6.7 billion to almost $61 billion, and the prison population expanded by more than 400%. Much of that expansion came from the war on drugs. In 1980 there were around 40,000 people in jail or prison for drugs, but by 2018 that number had grown ten fold to 443,000.

The explosion in inmates wasn't in response to crime. As Maia Szalavitz has summarized:

"...between 1980 and 2011, the annual number of drug arrests of black men rose 164%, while arrests for property crime and violent crime fell: homicide arrests fell by 46%, robbery arrests by 27%, and burglary by 42%...a 2003 Analysis found that black people are ten times more likely to get arrested for drug crimes, compared to whites. African Americans are also ten times more likely to be sent to prison for these offenses...Conviction rates, too, are higher. In federal prison, on average blacks serve nearly as long for drug offenses as whites do on average for violent ones." (Unbroken Brain, pg. 226-7).

The war on drugs is and always has been a system of power designed to employ enough people who come to rely upon it for their bread that it can persist indefinitely, becoming more of a necessity each year at the cost of countless lives locked up or killed by preventable overdose.

We could end the opioid overdose crisis tomorrow with 9 simple goals, outlined in S2 E2:

Decriminalization so nobody goes to jail...ever.

Police Protection for users and dealers, so nobody ever feels like they need to avenge a drug-related crime.

Safe Markets for those who want to purchase clean, safe drugs without the threat of crime.

Clean paraphernalia to prevent the spread of communicable diseases.

Safe injection sites so users who do overdose or buy unsafe drugs can avoid death.

Safe Drugs because getting high shouldn't come with the risk of infection or overdose.

Affordable Drugs: heroin and cocaine cost a few bucks per gram to produce, but hundreds of dollars per gram on the streets of the US.

Affordable & Accessible Treatment because once addicted people are stabilized, we often decide to stop using without anyone threatening or coercing us.

Oh, and love, but none of that tough shit, that is, if it isn’t too much to ask.