Familiarizing yourself with Alcoholics Anonymous dictums

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From “90 minutes in 90 days,” to “people, places, and things,” to “cucumbers and pickles,” Alcoholics Anonymous (AA) slogans have been influencing the public’s understanding of the addictive process for almost a century. Regrettably, these terms have, inadvertently, alienated the scientific community. The translation and subsequent use of AA slogans has been a valuable tool in engaging science experts with mutual-help fellowships such as AA.

Recent advances in the neurobiology and neurochemistry of addiction have validated several of the memorable sayings of AA.1 As a result, physicians and scientists are now more willing to explore AA’s mottos.

Here are five well-known AA slogans that we have translated into medical terms and then briefly assessed in terms of their validity and relevance in today’s treatment of alcohol addiction:

1. “90 meetings in 90 days”

This refers to the participant’s first three months of sobriety. This period is characterized by enhanced (but gradually decreasing) glutaminergic activity.

TRUE! Clinically, the first three months of sobriety constitute the most severe part of prolonged withdrawal syndrome and pose the most dangerous opportunities for a relapse.

2. “Keep it simple”

This refers to the notion that monotherapy is superior to combination therapy.

NOT TRUE! Clinical research and everyday practice of addiction treatment show that combination approaches—with medications, group psychotherapy, individual psychotherapy, involvement in mutual-help groups, family therapy, primary care, and treatment of psychiatric comorbidities—typically result in better outcomes than singular approaches.2

3. “Denial is not just a river in Egypt”

This implies that psychotherapy during the pre-contemplation stage of change is futile.

NOT TRUE! Since motivational inter-viewing was introduced in the treatment of addiction, we have learned how to effectively work with patients who are in complete denial and have absolutely no interest in changing anything about their life.3

4. “Beware of people, places, and things”

This means to identify, avoid, and cope with triggers of relapse. 

TRUE! Otherwise known as “cues” in psychology literature, triggers of relapse have been implicated in both the basic understanding of the addictive process and its treatment. “Classical conditioning” and “operant conditioning” models of behavior incorporate triggers. Additionally, cognitive behavior therapy helps extensively with maintaining sobriety. Even the DSM-5 gives a nod to “people, places, and things” by introducing “cravings” as a bona fide criterion of a substance use disorder.

5. “A cucumber that has become a pickle cannot become a cucumber again”

This saying means that once the neuroadaptations that signal the engraving of the addictive process at the mesolimbic system (and related structures) have been set, the “brain switch” is turned on and stays on for the remainder of the person’s life.

EQUIVOCAL. It is not clear, and highly debatable, whether an alcoholic who has been sober for more than 20 years still has a heightened vulnerability to reverting to alcoholism after consumption of alcohol. What is evident is that, even if the neuroadaptations responsible for hijacking the pleasure-reward pathways of the brain one day return to a normal, pre-addiction state, this healing process takes a long time—probably measured in decades, not years.

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The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

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