Three years ago, I checked myself out of a Colorado detox center against medical advice. I had nowhere to go but the broken-down van in which I’d been sleeping with my husband, but I was in the worst part of heroin withdrawal and all I could think about was ending the pain.

On my way out, the resident peer support specialist made one last attempt to stop me.

“The only way you can get sober is by working the steps,” he said, referring to the 12 steps of Narcotics Anonymous.

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I told him I was going to try medication-assisted treatment instead. In response, he predicted that I was destined to be a “lifer” — someone who bounces between street drugs, prescribed medications, and brief periods of sobriety, but who never truly turns her life around.

He was right about one thing: I relapsed within hours of leaving the center. But the following month I enrolled in a buprenorphine program. It has worked for me. Today, I live drug-free in stable housing with my husband and our two daughters — and I’m still taking buprenorphine combined with naloxone, prescribed by my doctor.

Buprenorphine latches onto natural receptors in the brain, the same ones that heroin, oxycodone, and other opioids bind to. These receptors are involved in many of the body’s basic functions, like eating, breathing, sleeping, pleasure, and the perception of pain. Buprenorphine partially binds to these receptors, which is why it’s called a partial opioid agonist. It is prescribed as an alternative to methadone, which is a full agonist. Naloxone blocks the effects of opioids, and is added to prevent the abuse of buprenorphine.

Both medications stave off withdrawal symptoms and decrease physical cravings for drugs. They also deter people from abusing other opioids by preventing them from feeling their effects. Buprenorphine and methadone are recognized by World Health Organization as the most effective methods for lowering health problems, overdoses, and deaths related to opioid abuse.

Sadly, there’s a lot of misinformation out there about medication-assisted therapy for drug addiction. Take, for example, a comment made about medication assisted treatment by Tom Price, who recently resigned as secretary of Health and Human Services. “If we’re just substituting one drug with another,” he infamously said, “we’re not moving the dial much,” indicating his clear preference for faith-based and non-psychoactive interventions.

The most recognized providers of those kinds of interventions are the 12-step fellowships, which include Alcoholics Anonymous and Narcotics Anonymous. If that’s what the secretary of health said works best, we should count ourselves lucky that thousands of free 12-step meetings occur every day across the country. Right?

Wrong. These programs are making the opioid crisis worse by making recovery from opioid addiction harder than it already is. By turning their backs on people like me on medication-assisted therapy to kick opioid addictions, these programs are prolonging addiction and contributing to overdose deaths.

Here’s what a regional chairperson for Narcotics Anonymous told me. “People on methadone and buprenorphine are getting high every day, they’re just not buying it on the streets. It’s like you’re replacing one addiction with another.” (As part of their creed, service members of 12-step fellowships are required to maintain anonymity when speaking in the media. This individual agreed to be quoted anonymously.)

But that thinking about total abstinence is outdated. Dr. Mary Jeanne Kreek, who helped develop methadone as a treatment for addiction and who now heads Rockefeller University’s addictive diseases laboratory, believes it is necessary for habitual opioid users to take replacement therapy medications to correct endorphin deficiencies that developed during their use of opioids.

“You’re not going to treat genetics and brain changes with counseling and psychological support,” she told me by phone.

Writing in STAT, two Seattle-area addiction experts said that medication-assisted therapy helps stabilize brain receptors thrown out of whack by an opioid addiction, allowing the body and brain to establish a “new normal.”

Narcotics Anonymous and other 12-step programs describe themselves as wholly abstinence based, but claim to welcome anyone interested in pursuing addiction recovery. The reality, however, is that if someone in medication-assisted therapy seeks the support of a 12-step fellowship, he or she will most likely be met with a lecture or worse — denied the ability to speak during meetings.

I met with a Narcotics Anonymous secretary, who asked me to share his story under a pseudonym (I call him Jay) in keeping with the organization’s media guidelines and to protect his privacy.

Jay, who is in recovery from a 30-year opioid addiction, regularly attends 12-step meetings in Seattle — both AA and NA — and also takes buprenorphine. He recounted that when he first began attending meetings and mentioned his prescription, one member spent 15 minutes ranting that buprenorphine was “just a maintenance drug,” that Jay needed to “get off that crap,” and that he was “still a drug addict” as long as he continued to follow his doctor’s instructions.

“It really affected me,” Jay told me over coffee. “I was reaching out for help. It was really disheartening.” He admitted to relapsing shortly after leaving that meeting. “I thought: There’s no hope for me. I’m a drug addict.” Now sober from heroin for almost a year, he is very selective about where he shares information about his use of medication-assisted therapy.

Honesty and community support are essential to addiction recovery. Forced secrecy about medication-assisted therapy compromises an addicted person’s recovery by causing him or her to repeat patterns of deception implemented during active addiction. It is antithetical to every modern addiction treatment model. So why are we still relying on programs that vilify people who use evidence-based treatment for their recovery?

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Narcotics Anonymous and Alcoholics Anonymous are not just widely available — they are often mandated by Drug Courts, the system that oversees many nonviolent drug-related offenders. Even costly rehab centers across the country employ 12-step programs and the accompanying abstinence-based approach.

This doesn’t make sense to me, since the science of addiction has evolved in recent years to include medication-assisted therapy as a cornerstone of treatment, while the 12-steps have not been touched by science since the 1940s.

As someone who has struggled with heroin addiction, I know how difficult recovery is. Beyond the physical and psychological discomforts, addicted individuals face being ostracized, sometimes even by our own families. Now, the stigma against using medication-assisted therapy is so rampant it’s even in the White House.

As we approach the second year of the Trump administration, the need for camaraderie between those of us in recovery is greater than ever. Many of us rely upon the 12 steps for our sobriety, but many also rely upon medication-assisted treatment.

The time has come for Narcotics Anonymous, Alcoholics Anonymous, and other 12-step programs to update their approach, or step aside. Abstinence-based models are too dangerous to rule the recovery community any longer.

Elizabeth Brico is a writer based in the Pacific Northwest who blogs at Betty’s Battleground. She is also a contributing writer for the HealthyPlace trauma blog.

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  • To Adam’s comment…Hello,

    Maybe using that Harvard analogy wasn’t the best.

    How about I run a free vegetarian soup kitchen because I believe in not eating meat and the folks are complaining because they want meat?! Should I change my beliefs and values and serve meat because some people don’t like it? Especially because no one from my facility is forcing them to eat there??

    BTW I’m not a vegetarian 🙂

    We have similar backgrounds personal recovery and education. I do not think the 12 step should change their program but of course it should be welcoming to all. We welcome people if they had their last drink in the parking lot so why not those on MAT? My gripe was the article suggested the fellowships change their abstinence culture or modality. Anyway it’s a ancient argument where no one really wins. The key is to “Know thyself” as all the spiritual practices state 🙂

    Thanks for writing, it’s a fun topic to hash about!

  • I would like to start by indicating that my opinions are based on my experience with opioid abuse on the west coast. I know heroin on the east coast in far more pure than what we get out here so if you are an east coast heroin user, please conduct your research from that perspective. I will give further information on east coast opiate maintenance at the end.

    So here is the deal, trying to eliminate judgment in the 12-step programs is a fool’s errand. For one, those who attend have shattered self-esteem. This is worn on the sleeve or concealed but make no mistakes, those of us who “need” drugs daily to “function” have deep-rooted psychological problems. I have been an opiate addict for a combined 7 years and a general drug addict for over 20. I’m not casting judgement, just calling it as I see it. When I have gone to meeting while on methadone, everyone has an opinion without having any expertise. This is mostly from new comers. I never hold it against as I’m sure they are doing what they can to stay clean and if saying things that make them feel smart or superior, fine by me. The truth is that all 12-step meets have a success rate of less that 10% give or take. No exact number can be cited as the groups refused to track members in any way, even progress. In comparison, methadone is one of the most well researched medications and the wealth of research is quite clear. I will speak on a few journal articles below.

    Before talking about the research, I want to let those who are not familiar with scientific journals that not all journals are created equal. There are highly reputable journals such as Nature and other smaller publications that may not have the best submissions. A way to sort journals is by the impact factor (IF). The higher the factor, the better the journal. For example, Nature has an IF of ~41. Any journal that has an IF from 3 – 6 can be thought of as reliable and those 10+ as experts in their fields.

    In the Cochrane Database of Systematic Reviews ( IF = 6.124 as of 2016) reports in report titled, “Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence” it’s reported that when methadone is compared to buprenorphine (subutex/suboxone minus the narcan), methadone and Buprenorphine worked better than placebo alone, and under certain circumstances, methadone had the highest success rate. You can find this research paper by entering the title in google scholar. It’s available for free.

    As the paper cited above states, many studies have found the use of methadone maintenance ( or suboxone) works to keep clients from relapsing back to street opiates, most commonly heroin.

    Talk to folks in the program and you will hear that suboxone is safer than methadone (untrue), that clinics will force you to stay on for life (also untrue), and that only a life free of all narcotics leads to long term sobriety (untrue). And the one that I think causes the most bad sentiments is that methadone maintenance is an excuse to still get high every day (untrue). Once a client levels off, tolerance kicks in and within one day, the “high” effects are no longer present. I like 12 step programs so I am trying to be fair to them. Those who come in on a maintenance program will catch some jealousy for those who think maintenance still gets their clients high. Members with anxiety or sleeping problems are free to take narcotic medication and attend without judgement but opiates are treated differently.

    To those reading this thinking that an opiate maintenance program is a life sentence, I will say this: for most it is not but for some, just as with clients with high blood pressure or diabetes or a severe mental illness, life-long medication is the only solution. I think that if a client has been on methadone or suboxone for a long time and is leading a productive life, don’t touch a thing. Who cares what others think, you are in charge of your life and it looks like your decisions are working out. For everyone else, maintenance programs are implemented at the client’s request. If someone is not going down in dose, that is their decision. Doctors can not force anyone to take medication, even if stopping it means certain death. We all have medical choice.

    What keeps clients on long term I feel like shares things that reduce the effect of 12-step programs. In both programs, clients are made to feel like they are not in control. See the fourth step and for maintenance, the fact that it’s supervised by a physician will make most look to them for answers. In both programs, there is not enough client center focus. A higher power didn’t put in the work to stay clean, the client did. I hate when I hear NA members minimize their efforts and say it was all their higher power. I understand the purpose of the 4th step: stop trying to be proactive in your actions regarding your recovery. Just chill for a bit and spend time with clean folks. But the clean time that exists in all programs is not the result of higher powers, it’s all member effort. All of it. With methadone clinics, counselors are not given enough time with clients to build a therapeutic relationship so they have the power to encourage and have clients listen. In fact, only a couple counselors I have seen while in and out of programs had a solid understanding of the medication being dispensed and the clients role in their own recovery. Most were complacent just working for a check. I understand — addicts will wear a counselor down if the counselor is a pushover. The amount of lies, and terrible lies at that, must be numbing. I can see how that would be deflating.

    To wrap this up, if you are going to a 12-step program, keep going. If you are also on maintenance, it’s nobody’s business but yours. And if the first person you ask to sponsor you is not on your side, find another one or leave your recovery outside of the meetings to yourself. Stay on methadone and only go up to what’s known as a blocker dose. It’s the dose in which the effects of your normal amount of recreational opiates cease. Like if taking 10 mgs of oxy get you high, stop increasing the methadone at that point. You will experience mild withdrawal symptoms for a few days and I do mean mild. The cravings will be the most intense thing. Maybe some sweating and sleep problems but don’t keep upping your recreational dose or maintenance dose because of it. I have seen petite people on an insane amount of methadone: like close to 200 mgs. I’m 6’6″ and ~300 lbs and 70 mgs was my blocker. Myhabit was almost 2 grams of good quality west coast heroin. At 60 mgs, where I am at right now and have found the most success is not a blocker but I have lost the taste for chasing dope all together. For how long, I cannot say but I’m getting better and I’ll take that over active using.

    At the end of Feb ’19, I will start decreasing. I worked out that plan. I have been able to be clean long enough to get weekend take homes and still waited a month to see if I remain stable before starting my dismount. I will need to talk to the doctor but I will not be asking to go down, I’ll tell them I am going down. Take that attitude if you think you will get some resistance at your clinic. Be firm, you cannot be forced to take a dose that you do not want to, unless you are court mandated. If you are there on your own free will, listen to your docs objections with an open mind to see if you are blind to your own behavior. Not saying you will be but I always try to keep an open mind even if I’m almost certain everything they say will be forgotten instantly. If you have given positive UAs, maybe reconsider. If you haven’t but know you still use in between UAs, maybe stay on for a bit. If you miss days frequently, maybe get more stable. But the choice is yours. If you want off, then you will be brought off at your request.

    I will be chopping of 5 mgs at a time and waiting to stabilize + 2 weeks before going further down. I tried the 2 mgs a week and after 6 weeks, I knew I was going down too fast but didn’t correct. I substituted H for the withdrawal symptoms. I was back on HE just a month later. If you want to stay on and have found stability and are living a productive life, then talk to the doc about life-time medication. I know any opiate addict would much rather be tied to a clinic or doctor than their dope dealer. The hell of that life needs no explanation.

    Keep working at getting off even if you relapse, take many steps back, or whatever. If the desire is there, keep at it. This is not easy so please be kind to yourself, regardless of what others want to label you as.

    As for east coast users, The cited paper above speaks about subutex or suboxone being more successful for those with a high recreational dose. Many talk with your family doctor about both options if you are using east coast heroin. I would stay away from calling clinics for their thoughts as they will be biased to get you to be a client there where your family doctor will show no preference. Keep in mind that I have only seen methadone covered by public health insurance. Not 100% sure about suboxone so please do your own research.

    take care

  • It’s a tough call. I am recently retired from the addictions field after 31 years. I treated many people who were getting high on methadone and suboxone. THIS DOES NOT MEAN I AM AGAINST THE PRESCRIBED USE. I have seen people turn their lives around.

    • Hey Al. It is true that any form of opiate will be abused. One policy that I found helpful while on methadone maintenance is how long the wait time is until a client can earn take-home privileges. In addition, multiple clean UAs must be submitted. This prevents methadone from being abused from the start. Sure, clients can increase their dose but that will reach a ceiling at some point and within 48 hours, methadone loses its narcotic effects. Once a client has take-home privileges, any dirty UA will result in them being removed completely. In CA, testing positive for opiates is considered a fail, here in NV, any illegal substance that tests positive is considered a fail.

      I really appreciate your hesitation. It shows the high quality of your work in the field, I’m sure.

  • Saddens and angers me at ignorant judge mental 12 step groups . AA says if you take meds as prescribed and according to your conscience you are sober . Keep looking for a better group mtg. I personally don’t see pot as sober but am not going to turn an addict away from a group

    • Phil,

      I’m sure you are sincere in your trust and faith in 12 Step. However, your reaction points (in a roundabout way) to one of the key problems in 12 Step: it is imagined to be organized and follow healthy guidelines for its members, but because of the idea of each group being “independent” AA is both responsible and not responsible when individual groups are abusive.

      However, now I’m going to say that you are sadly mistaken in your interpretation that most groups support MAT because from my time in 12 Step they don’t. As I think this article points out, Narcotics Anonymous even has official literature that says that it doesn’t believe in MAT. If NA has official literature that discourages MAT, you can’t reasonably say that 12 Step supports MAT.

      Yes, if one has an overuse/abuse issue with opioids and goes to AA the rules are a little bit different in terms of how you are treated if you use MAT, but still if someone announces that they use MAT in a meeting, that person is going to get strong negative reactions from many, many people.

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