A STRAINED RELATIONSHIP
Alcoholics Anonymous and Medication-Assisted Treatment
UNLIKE JACKSON, PHIL GREW UP with a mother devoted to his happiness. A hardworking ER nurse, she would describe the dangers of drugs to Phil at the dinner table. She was tired of seeing the same teenagers and young adults frequenting the ER, overdose after overdose, as if on a hamster wheel of opioids. She thanked God that her son was not one of those kids. Like many parents, she would soon have a rude awakening.
Ever since his dad died of a heart attack when Phil was only fifteen, Phil had felt an intractable void. Awkward and shy as a teenager, he turned into a cloistered introvert as a college freshman. Living at home with his mother to save money, he rarely left the confines of his room except to attend class. His life felt purposeless and empty. He used alcohol and weed to alleviate boredom but found that he didn’t much like either. Phil then tried the oxycodone in his mother’s medicine cabinet, fully aware of the dangers. A doctor had prescribed the medication for her following nasal surgery, but she had used only a few pills and failed to discard the others. Phil wasn’t exactly looking to get high; he just wanted to see what the medication did for people. Why were they so obsessed with it? Swallowing it, Phil didn’t see the big deal. But snorting it, he quickly discovered the answer. Oxycodone made him feel numb and relaxed, two feelings he had strived for since he was fifteen: “It was just like a light bulb went off and I thought, this is great. I could function, and I could still go to school while doing it because I didn’t smell like alcohol or weed. It was the answer to all my problems. I could talk to women. I felt better about myself. It was just like a cure-all.”
But rather than closing a hole in his life, oxycodone ripped open new ones. Classes started to feel more pointless than ever, so he stopped going. He dropped out of school and spent his days playing video games. Other than his local drug dealers, he had no friends. To support his drug use, Phil regularly stole money from his mother, something she was too busy and too trusting to notice. When she finally did notice, she kicked him out, believing the tough road would be therapeutic. A year passed before Phil was tired of being sick and couch surfing. He contacted his mother, telling her he was ready to stop using. He admitted he needed help. There began a winding journey through abstinence-only rehab centers, support groups, counseling, and buprenorphine treatment. Fortunately for Phil, various factors outside of his control have helped him along the way: his mother’s great health insurance through her hospital job, the recently enacted Affordable Care Act policy allowing him to stay on her insurance until age twenty-six, and his urban location with a variety of treatment options. In retrospect, Phil was luckier than most. Even so, the journey has been hard and sometimes he has felt like giving up. Looking back, Phil feels that two tools have helped him the most on his path toward recovery: Alcoholics Anonymous and buprenorphine. But the relationship between these two recovery methods has been less than cordial.
PHIL HAS PARTICIPATED in AA meetings ever since his first stint in rehab. In fact, daily AA meetings were a required component of that program, which took place in a facility affiliated with his mother’s hospital. Every evening after dinner, Phil’s cohort would gather on chairs positioned in a circle in a meeting room with motivational messages plastered on an otherwise empty white wall. The meeting always began with the Serenity Prayer: “God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.” Next, whoever chose the chair with a laminated green paper would read out loud the rules of the program, called the “traditions,” after which the person seated on the chair with the laminated red paper would read out loud the twelve steps.
The chairperson of the meeting, an alternating volunteer position, then introduced himself or herself and shared any announcements. Then the chairperson would ask if this was the first day of anyone’s sobriety, after which he or she distributed plastic chips resembling coins indicating other people’s progress: one month of sobriety, two months of sobriety, and so forth. Finally, the chairperson would introduce the meeting’s topic, typically one of the steps, and anyone who had something to say could jump in, starting with an introduction of himself or herself as “an alcoholic” or “an addict,” since the rehab center catered to people recovering from any type of drug.
At first Phil didn’t care much for the meetings, but he soon began to enjoy hearing the perspectives of a wide range of people, many of who looked nothing like him but had had similar experiences. Unlike formal counseling sessions, the AA meetings did not have a professional in charge; the group was for peers by peers. But AA meetings were also the foundation of the group counseling offered by the center that was led by professionals, with topics of discussion almost always focused on the twelve steps of AA. Even the reading material available in the bedrooms and common areas was overwhelmingly twelve-step literature.
At the end of the twenty-eight-day residential program, Phil’s case manager sat Phil and his mother down for a final talk. The case manager looked Phil squarely in the face and announced, “We have given you the tools for recovery. You have all you need. What you do now is up to you.” She then strongly recommended that Phil attend Alcoholics Anonymous or Narcotics Anonymous (NA) daily in the community to stay in recovery. She gave Phil a pamphlet with meeting times and locations. As they drove away from the facility, Phil and his mother felt optimistic. After all, Phil now had the tools for recovery. What could possibly go wrong?
Phil moved back in with his mother. He was neither in school nor working. Recovery was intentionally his full-time focus. He attended AA meetings daily in a nearby Baptist church. He read AA literature at home. He searched the internet for college programs. His mother even joined Phil for “open” AA meetings, meaning meetings open to people not in recovery. She was pleased with Phil’s progress. He had a sponsor with whom he met regularly for coffee and to watch comedy films.
But within a few months, Phil’s mother started getting pangs of anxiety. They were caused by little things, such as seeing Phil falling asleep randomly or scratching himself. Unbeknownst to her, Phil had started using again only a few weeks after being released from rehab—small amounts at first, allowing him to hide the behavior—but like before, the habit quickly escalated. Looking back, he doesn’t really know why he relapsed, other than he still had physical and psychological cravings and thought about getting high daily.
Phil’s mother confronted her son and threatened to kick him out of the spare bedroom if he didn’t stop using opioids. Unlike a year ago, Phil was eager to get help. He had plans for college. He did not want to resume couch surfing. So, he asked his mother to send him to rehab again, and once more she agreed. Like a Twilight Zone episode, history repeated itself. Phil returned to the same hospital-affiliated rehab center. Combined, insurance and his mother paid close to $30,000.
Trapped inside the facility, he did great. He brushed up on the tools for recovery. He rekindled his motivation to stay drug-free. As before, he returned home and resumed daily AA meetings. He once more met regularly with his sponsor. Then one evening Phil’s mom called home from work to check in and heard a stream of incongruous sentences and gibberish on the other end of the line. There was no doubt—he was using yet again. Worried that he was at risk of overdose, she rushed home. She would have preferred to call an ambulance, but she didn’t want the police showing up with the paramedics. She did not want her son going to jail and ruining any chances for his future. Despite its seeming failures, the rehab center had at least taught them that addiction was a disease that could be treated.
In the ER that night, a physician named Dr. Aman was making rounds, temporarily replacing another physician who could not attend work that day. Dr. Aman’s son was in recovery from heroin addiction through a medication called Suboxone. The fortuitousness of this chance meeting continues to strike Phil as one of those weird coincidences that changes your life. Dr. Aman recommended that Phil start taking Suboxone, although Dr. Aman could not prescribe it himself, at least not more than a few days’ worth. Phil would need to find a different, regular prescriber. Phil had heard of Suboxone, but AA participants and the rehab center had taught him that Suboxone was just another drug, and that if he took it, he would not be truly sober. He knew his drug dealer sold it, though at a higher price than other substances, seemingly confirming the rehab center’s and AA members’ beliefs. As a result, Phil had never before seriously considered it a recovery option.
His mother Googled “Suboxone prescriber” and found a few names. No office was accepting new patients; some said they were simply no longer prescribing Suboxone. Finally, she discreetly asked some colleagues at work and got the name of a local prescriber accepting new patients. In one week Phil would have his first appointment. In the meantime, Phil restarted AA yet again. He is pretty sure that without AA and his sponsor, he would have started using oxycodone during the weeklong gap before starting buprenorphine.
EVEN THOUGH AA DOESN’T SEEM to help him with cravings or withdrawal, it does give Phil a powerful sense of community. Seeing others in long-term recovery has repeatedly inspired him to continue his own journey. Maybe there is light at the end of the tunnel. Phil explained that prior to attending support groups, “I felt so alone and so isolated . . . but when I started going to these meetings, I started hearing other people sharing their stories and it was like seventy to eighty percent of their experience was my experience. It didn’t matter if they were a rich black woman, poor black woman, orphan, male, female. It didn’t matter where they were coming from; they had so much in common with me, and I started to feel this sense of kinship. And I was able to talk about things that I never talked about to anybody else because there was this understanding and this safe space.”
Nevertheless, the combination of AA and buprenorphine has not been easy. When Phil started buprenorphine treatment, his relapses decreased significantly in frequency and intensity, and then they finally stopped. He last misused an opioid two years ago. Today he continues daily buprenorphine treatment and considers himself both sober and in recovery. Unfortunately, others in his AA group do not. Or at least Phil thinks they would not; he has never actually told them about his buprenorphine treatment because of the sprinkling of derogatory comments he hears from time to time. Only Phil’s current and previous sponsors know.
Phil’s previous sponsor had suggested stopping buprenorphine, but the medication was keeping cravings and withdrawal symptoms at bay, so Phil ignored the advice and eventually found a different sponsor. His latest sponsor is more open to buprenorphine but conversations about the medication remain awkward, as if it is a taboo topic. So Phil usually doesn’t mention it. Even if people in AA were to view the medication as helpful, Phil explained, they would still consider it just a Band-Aid or a crutch—not exactly something to be proud of. But Phil is proud of himself; two years is a long time to not misuse drugs, especially when drugs were once the only thing that brought him happiness. Without withdrawal symptoms and cravings, he can focus on his college degree and his relationship with his girlfriend.
Not discussing buprenorphine treatment during group meetings feels uncomfortable. Phil wishes he could discuss it openly. After all, AA teaches you to be honest with yourself and others. I ask Phil how deep the feelings against medication-assisted treatment run in the local AA community. Pretty deep, he thinks, because even his current buprenorphine-prescribing doctor warned him about the stigma he might experience in AA. Nevertheless, she advised Phil to continue twelve-step group participation. She suggested that hiding his buprenorphine treatment status was no big deal: “You don’t tell your group about antibiotics you are on, do you? So why should you tell them about your buprenorphine treatment?” But Phil thinks it is relevant. AA is supposed to support you in your recovery through narrative sharing and identity building. And he cannot fully participate in the group without sharing his own recovery story, which involves buprenorphine.
I ask Phil why he continues attending twelve-step meetings. He responds that both buprenorphine and AA are central to his recovery in their own way. AA offers something that buprenorphine cannot offer: practical approaches to living a life that for him, as for many other people in recovery, has been traumatic and chaotic. He gives the following example, “So [AA is] always [emphasizing] taking care of my side of the street. If I’m getting mad about something, it’s because of me, not because of what the other person did. There’s something inside of me that’s making me upset and I need to address [that], not the other person. I can’t control anything other than my reaction. Those sorts of things, which are very simple and sound very simple, were just [foreign] to me. You know? . . . That’s when I talk about sobriety versus being dry. That’s what I’m talking about and that’s when I say there needs to be some kind of treatment other than just the chemical side of it.”
MILLIONS OF AMERICANS believe that twelve-step support groups have improved their physical, psychological, and spiritual health, and significant research evidence supports this conclusion.100 But twelve-step support groups, such as Alcoholics Anonymous and Narcotics Anonymous, have a complex relationship with MAT. And MAT has a significantly stronger evidence base for managing opioid use disorder than do behavioral methods such as counseling and support groups.101
Twelve-step support groups are America’s best known and most widely used addiction management tool.102 They are the foundation of over half of America’s publicly funded addiction treatment centers.103 Twelve-step participation is routinely mandated as treatment within the criminal justice system104 and even as discipline by professional medical and legal organizations.105,106 In much of the United States, twelve-step support groups and treatment centers based on the twelve steps are the only available options for people with substance use disorders, making it almost certain that a person in treatment will be exposed to them.107 Broadly speaking, this prominence has resulted in an expectation that anyone with a substance use disorder follow the same formula, even though many people disagree with the twelve steps or find them unhelpful. Most concerning, though, is that many twelve-step groups promote an abstinence-only treatment philosophy: the idea that addiction treatment should be medication-free. Nevertheless, people subscribing to MAT may still want to attend AA or NA meetings or may be required to do so by their treatment center or the criminal justice system. Furthermore, people’s perceptions of MAT, including whether or not they seek MAT, are likely influenced by twelve-step philosophy. Therefore, to understand the current addiction treatment landscape, including MAT stigma and other barriers to MAT adoption, one must understand twelve-step groups. Let’s start with the most common one: AA.
ALCOHOLICS ANONYMOUS is the prototypical twelve-step group on which other twelve-step groups are based. Bill Wilson cofounded AA in the 1930s after a series of life-changing events. While institutionalized for the fourth time for alcoholism, Bill W., as he came to be known, had a spiritual awakening. Also while institutionalized, he encountered a neurologist who claimed that alcohol addiction was an allergy to alcohol. If you could not stop at one drink, then you had the allergy. People without the allergy, on the other hand, could stop drinking whenever they wanted. This conceptualization of addiction convinced Bill W. that alcoholism was a disease rather than a mark of immorality or insufficient willpower. At the time, the disease concept was hardly mainstream. Some wealthy urbanites pursued psychoanalysis in private psychiatrist offices,35 but even psychoanalysts claimed that addiction was a character flaw resulting from immaturity and requiring personality transformation.35
Following detoxification, Bill W. went on a business trip to Akron, Ohio, where he once more felt the uncontrollable urge to drink. At the same time, he felt a strong impulse to speak to another person with alcohol addiction. He contacted a clergyman at random and asked to be connected to a local alcoholic. The clergyman connected Bill W. with Dr. Bob Smith, a proctologist. The two men met and spent hours discussing their urge to drink and ways to overcome the urge. The experience of storytelling and mutual support gave them both psychological relief and stopped them from hitting the bottle. Soon the two men began searching for others with whom to share their stories, forming new personal identities in the story-sharing process.35
The first regular story-sharing group met as part of the Oxford Group, an evangelical Protestant organization. But the direct association with the Oxford Group was short-lived, as Bill W. and Dr. Bob wanted a spiritual rather than a religious group identity, fearing that the latter would deter participation. They formed their own group, which eventually became known as Alcoholics Anonymous, or AA. Nevertheless, AA remained strongly influenced by the beliefs of the Oxford Group and its founder, Frank Buchman.
Buchman, a Lutheran minister, had preached against worldliness and the idea that man could achieve happiness through personal achievement, riches, or fame. He especially abhorred the concept of the self-made, middle-class man aspiring to wealth and success, which he called an American “spiritual sickness.” Instead, Buchman argued for “spiritual surgery” consisting of complete surrender to God as understood through the teachings of Jesus Christ and reorientation of one’s life around honesty, purity, unselfishness, and love.108 Only through such surrender could man truly be happy and at peace.
Bill W. combined these basic spiritual concepts from the Oxford Group, though stripped of their explicit religious connotations, with the belief that alcohol addiction was a disease. The result was the twelve steps to recovery: a progression of spiritual, moral, and practical steps for daily living and a recipe to prevent one from drinking. The steps were fodder for discussion during AA group meetings, but each individual member was ultimately responsible for working through the steps on his or her own with the help of a sponsor. The sponsor was another AA member who provided emotional and practical support.109
AA’s twelve steps, which have been adopted in similar form by other twelve-step groups, are as follows:
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.110
Within thirty years of Bill W. and Dr. Bob’s first meeting, AA became the primary alcohol treatment mechanism in 88 percent of state hospitals. In 1979, sociologist Robert Tournier wrote that AA’s assumptions about addiction and addiction treatment had “virtually been accepted as fact by most of the field.”111 A spiritually based, nonprofessional support group had become the dominant treatment method for addiction in an increasingly medicalized world. Some called it the most successful social movement in the history of America. Soon AA’s program would be applied to other addictions, ranging from drug addiction to eating disorders to gambling addiction. Narcotics Anonymous took the twelve steps and applied them to people recovering from drugs, though many people whom I have interviewed go to AA despite having nonalcohol drug problems. AA and NA still remain the most popular twelve-step groups, with an estimated 1.2 million members112 and 250,000 members113 in the United States, respectively, though accurate numbers are difficult to come by given members’ anonymity. An estimated 6–9 percent of the US adult population has at one time or another attended a twelve-step meeting.113,114
AA and NA are not treatment per se. In fact, they do not even refer to themselves as treatment. But they can be misunderstood as such given the frequency with which they are used in treatment centers. Instead, they are peer-led mutual support groups available in the community at no cost. They are not professional or clinical services. However, many treatment centers provide “twelve-step facilitation therapy” in which counselors prepare people for twelve-step groups in the community, further confusing the public as to the “treatment” status of AA and NA.
That said, the twelve steps are about far more than stopping drug or alcohol use. Only the first of the twelve steps directly relates to substances. The remaining steps are about living life in general. Phil says, “I think the twelve steps are not about the drug side; they’re more about the spiritual or the mental [psychological] well-being of the person. I think anybody would benefit from that particular program. It just happened to be a bunch of alcoholics who hit on this. And I think if they weren’t alcoholics, it probably would be some kind of cult.” The twelve steps’ broad focus on spirituality, morality, and daily habits can complement MAT’s focus on physical health, just as exercise and healthy diet can complement insulin treatment in diabetes care.
The broad twelve-step perspective may explain the method’s influence on so many lives, especially when one considers social cohesion and spirituality as recovery end points, rather than the mere absence of drugs on urine screens.115 For example, the American Society of Addiction Medicine believes the combination of medications and therapy is the best treatment for opioid use disorder, but it also describes twelve-step support groups as improving social interconnectedness with others, boosting spirituality, and encouraging help-seeking behaviors.116
Unfortunately, despite these benefits, AA and NA are associated with an abstinence-only philosophy in treatment centers and among counselors. For example, one-third of centers in a nationally representative 2011 study cited abstinence-only ideology as a barrier to MAT, including the perception that MAT was “just another drug,” and twelve-step philosophy was associated with this abstinence-only ideology.117 Studies show that counselors who oppose MAT are particularly likely to have adopted a twelve-step philosophy.118,119
Abstinence-only treatment centers may exhibit their antimedication ideology in various ways. Many explicitly prohibit clients from starting MAT or continuing MAT previously begun outside of the treatment center. Other treatment centers only allow MAT for detoxification rather than for long-term maintenance, or they only allow MAT at a low dose. Yet longer-term, higher-dose MAT is associated with better opioid relapse prevention, decreased overdose rates, and greater adherence to HIV/AIDS medications.17,120,121 These anti-MAT attitudes are influenced by treatment centers’ reliance on twelve-step philosophy, which they interpret as prohibiting MAT, especially buprenorphine and methadone.
In addition to contributing to MAT stigma in treatment centers, twelve-step groups have also directly stigmatized their own members in the community who use MAT. This very stigma led to the creation of Methadone Anonymous as an alternative to AA and NA, though this alternative group is only available in a few areas. Methadone Anonymous follows essentially the same twelve steps but explicitly accepts people undergoing methadone treatment. In step one, the group states, “We admitted we were powerless over illicit drugs, including alcohol.” By adding the word “illicit,” the group hopes to clarify that utilizing a medication properly as prescribed by a physician is not a problem, because it is licit.122
In its most recent pamphlet on the topic, Narcotics Anonymous and Persons Receiving Medication-Assisted Treatment (2016),123 NA has dialed back the anti-MAT tone found in some of its previous publications (such as Bulletin #29 from 1996)124 and are encouraging a judgment-free atmosphere to attract newcomers. But even still, NA headquarters reiterates individual NA groups’ freedom to bar people utilizing MAT from full participation: “Some NA meetings make no distinction as to whether those receiving medication to treat addiction may share in a meeting, while other NA meetings limit the participation of those who are taking this type of medication. Each group is free to make its own decision on recovery meeting participation and involvement in group services for those receiving medication assistance for drug addiction.”123
Problematically, NA also continues to identify people recovering through MAT as not being “clean.” For example, they state, “Clean in NA typically refers to being free of all drugs, or abstinent. However, an addict who is not clean is free to attend meetings. . . . Sometimes people come to NA meetings while still using drugs, detoxing from drugs, or on drug replacement therapy. Regardless of what you may be taking when you first come to NA, you are welcome.”123 Clearly, people on “replacement therapy,” a term referring to buprenorphine or methadone, are still not clean but rather in the same category as those misusing drugs or detoxing from illicit drugs. Explaining that it takes some people longer to get clean than others, the 2016 publication also describes a former methadone patient: “He wanted what he saw in the rooms of Narcotics Anonymous but was afraid of returning to his old life if he quit methadone. For ten months, he went to meetings every day—and finally he got clean.”123 Again, this quote implies the man was not clean until he stopped his methadone treatment.
One can easily imagine the disappointment and cognitive dissonance experienced by a person who has not misused opioids for a year being told that they are not really clean, sober, or in recovery—that there is no meaningful difference between receiving MAT as prescribed with no euphoria and using heroin daily to get high. Such stigma can be especially harmful for a population that has already experienced significant social isolation and psychological trauma.125 Stan, another of my interviewees who is undergoing methadone treatment, thinks the nonjudgmental language of AA and NA literature is meaningless without full participation for people utilizing MAT. He says, “And of course, the twelve-step program is going to say it is okay for you to go to meetings. You could go to the meetings where you can’t talk. You can’t open your mouth, which is completely ridiculous and upsets me just thinking about that right now.”
How common is MAT stigma within twelve-step groups? There has never been a national survey of twelve-step group members’ opinions on MAT, but smaller studies and my own qualitative research suggest that stigma is deeply entrenched in AA and NA groups. In a recent study of over 250 twelve-step members undergoing methadone treatment, one quarter reported serious problems related to their methadone status.126 Problems included hearing negative comments about methadone, pressure to reduce or stop methadone, being unable to speak at a meeting or hold a position in the meeting, and being unable to act as a sponsor. In the study, approximately 40 percent of people undergoing methadone treatment kept their status hidden from the support group. Interestingly, despite the stigma, a majority found twelve-step groups helpful to their own recovery, but two-thirds did not recommend twelve-step referrals for others treated with methadone.126
A similar study of buprenorphine patients in twelve-step groups found that a third of them did not reveal their treatment status to their groups or sponsors for fear of being stigmatized.125 Another study found that people coparticipating in buprenorphine treatment and twelve-step groups frequently failed to consider their time on buprenorphine as “clean time.” Some participants started viewing buprenorphine as a “crutch,” causing them to want to discontinue treatment early.127 Early discontinuation is dangerous; rates of relapse after buprenorphine discontinuation are consistently 50 percent across studies.128 Julie, a young woman in Florida, has had a similar experience: “I was very pro-MAT, and I always stayed pro-MAT. But to be completely honest with you, I went to [AA] meetings that saved me and everything, and at some point I became anti-MAT. I still accepted everyone that came into the meeting, but I definitely started forming a negative connotation toward it my first year in recovery until I started educating myself more again. I don’t want to say I was almost brainwashed, but I just really wanted people to like me.” Eventually Julie started standing up for participants at her meetings undergoing MAT and then started an alternative local support group for those who felt rejected by AA.
So why do so many twelve-step groups and abstinence-only treatment centers stigmatize MAT? Is it possible that twelve-step groups and MAT can be effectively combined for some people, ending the battle between these recovery methods once and for all? Why can’t everyone just get along?
PHIL DOES NOT BELIEVE he would be here today without both MAT and AA in his life. He says they are two important recovery tools that are largely misunderstood, both inside and outside of the recovery community. He is tired of having to explain to friends, family, and treatment providers that MAT is not just another drug and that AA is not just some religious cult. But for my sake, I ask him to walk me through his thought process. What exactly is recovery and can both MAT and AA fit in? Why does it seem like there is a battle between them?
According to Phil and others whom I have interviewed, recovery is an ambiguous concept, sometimes defined as the process of creating a meaningful life or improving one’s quality of life. With such a loose definition, recovery is difficult to measure empirically, especially as one person’s definition of a meaningful life may differ from another’s. Measuring recovery is further complicated by it being both a process and a destination. You can be in recovery even if you relapse, so long as you are still generally on the path toward improving your own life according to your own goals. If this makes recovery sound mushy and kind of boundaryless, that’s because it is.
The concept of recovery is broad enough to include personal self-improvement goals ranging from physical health to employment, housing, spiritual health, mental health, family life, and social life. MAT clearly fits into the recovery model, as it improves physical health. Furthermore, by stabilizing one’s life, MAT can improve employment, family life, social life, and the progress of other personal goals. Likewise, twelve-step groups also fit within the recovery model by improving mental health, spiritual health, and social life.
But even though the concept of recovery is wide enough to encompass both twelve-step groups and MAT, treatment centers and support group meetings often present them as opposing forces—as if MAT prevents recovery while twelve-step groups further it. This misconception is largely due to a basic misunderstanding of the meanings of recovery, sobriety, treatment, physical dependence, and addiction.
Recovery, when viewed as a destination, incorporates a broad spectrum of end points that can include abstinence from all drugs but also everything from harm reduction (using drugs in a less dangerous manner than before) to an enhanced mental state, improved social networks, or development of healthy habits. Only the person in recovery can answer the question “Are you in recovery?” because the definition is so individualized. Nevertheless, compared to chaotic or constant drug use without harm reduction measures, recovery is almost certainly a place of better health outcomes.
Sobriety, in contrast, is the mere abstinence from drugs to which you are addicted. Sobriety presents a dichotomy rather than a spectrum: either you are using drugs to which you are addicted or you are completely sober. You are never “kind of sober” or “almost sober.” In contrast, recovery is a much more flexible concept allowing for different stages of change. It is thus more pragmatic and realistic. For example, you cannot be sober if you used heroin this morning, but you could still be in recovery if you experienced a momentary relapse that you are already taking steps to address. As a process, recovery can include professional treatment such as MAT. But recovery can also include other life-enhancing tools, ranging from religion to support groups. Phil explained it to me this way: “Treatment, I’ve been in treatment, but I want to be in recovery . . . and again, treatment’s something you can force somebody into and recovery isn’t.”
Recovery, sobriety, and treatment are all related to the concept of drug addiction. Simply put, drug addiction is the compulsive use of a substance resulting in an overwhelmingly negative impact on one’s life. The negative impact on one’s life is critical to the definition or else breathing oxygen would be considered an addiction simply because it is compulsive. Likewise, just because someone is taking opioids regularly and exhibits withdrawal symptoms or tolerance does not mean they have an addiction, even if their body is physically dependent. Someone prescribed opioids for pain could experience a generally positive impact from finally being able to get out of bed and attend work or play with their children. On the other hand, someone with an opioid addiction experiences a generally negative impact from opioids. For example, the compulsive opioid use causes their marriage to crumble and their bank account to be drained.
Methadone and buprenorphine are opioids that activate the opioid receptors in the brain, so people taking methadone or buprenorphine as addiction treatment will almost certainly become physically dependent on the medications. But they are not addicted to the medications if the overall impact on their life is positive. And we know from decades of studies that buprenorphine and methadone promote a more stable life for people with opioid addiction, letting them refocus on work, their families, and other responsibilities. Their lives often feel more meaningful too because they are not living merely for the next high. Since their cravings and withdrawal symptoms are controlled, they might even go hours, days, or weeks without thinking about misusing drugs. And they are also significantly less likely to die of an overdose24,101,129–133—surely a net positive. So, when abstinence-only treatment centers and twelve-step groups call MAT “just another drug” or “just another addiction,” they are really confusing physical dependence with addiction.
If the net-effect of MAT on someone’s life is positive, then MAT is promoting recovery, especially when one considers such wide-reaching recovery goals as life stability. But how can you be sober if you have an opioid—any opioid—in your system? Isn’t sobriety, after all, the absence of drugs? Not entirely. Sobriety is the absence of drugs to which you are addicted. That is why a person with cancer pain taking hydrocodone as prescribed for pain management is sober: he is not compulsively taking it despite negative consequences. Will he experience physical withdrawal symptoms if the hydrocodone is terminated abruptly? Probably. He has also likely reached a tolerance threshold. But again, this is physical dependence, not addiction. Likewise, someone taking methadone or buprenorphine as prescribed for addiction treatment without negative consequences is sober. If anything, they are taking a medication with overwhelmingly positive consequences, such as physiological stability due to elimination of cravings and withdrawal symptoms.
The way in which twelve-step groups limit the definition of recovery can cause confusion, stigma, and shame. Stan, who was concurrently undergoing buprenorphine treatment and participating in AA in North Carolina explained, “There were some years [in AA] where I was told that I had never experienced real recovery because my only amount of sobriety was on [Suboxone]. And I bought into [it], I believed it as well. I’ve kind of gone through all the different stages of AA and views on [Suboxone]. Like I’ve looked down on it myself, I’ve done it and been frowned upon. I guess the most supportive period I got in AA while on [Suboxone] was that first sponsor who said, ‘I wish you’d get off of it, but you can still work the steps.’ ”
I asked Stan how such statements made him feel. I heard the frustration in his voice as he responded, “I knew that my life on Suboxone looks a hell of a lot different than my life in chaotic heroin drug use. Like I’m not being homeless, getting arrested, all the really horrible things that can happen in drug use. So, when they say, ‘oh, that’s not recovery,’ well Suboxone was nothing like heroin for me. The whole time in the program, people tell you, ‘Take what you want, leave the rest’ but at the same time they’re saying, ‘Your thinking got you here, so you need to listen to us.’ And you can have a lot of cognitive dissonance where you just make it up for yourself.”
AA WAS INSTRUMENTAL in catalyzing the recovery movement, so if any group should have an accurate understanding of recovery, it should be AA. It has always viewed drug use as nested within the broader context of one’s daily habits, spirituality, and social support. Unfortunately, some AA and NA groups have squeezed MAT out of their recovery definition, despite the fact that AA literature refers medical issues to physicians rather than support groups. But according to many people in AA and NA whom I have interviewed, there is no technical reason why AA and NA could not incorporate MAT into their definitions of recovery. It would require changing culture at the group level and some pro-MAT statements from AA and NA headquarters. And according to an interview with Vincent P. Dole, the famous methadone researcher, Bill W. did not oppose methadone. In fact, Bill W. encouraged Dole to research a medication that would do for alcohol addiction what methadone does for opioid addiction.134
Even when twelve-step participants, counselors, or treatment centers understand the potential benefits of MAT, they are sometimes concerned that MAT will push people away from other recovery methods, such as support groups or counseling. For example, during my presentations, counselors frequently ask, “But won’t people who take medication just stop coming to counseling, harming their overall recovery?” A cynical person might view these attitudes as mere self-preservation, but many treatment providers sincerely believe that MAT leaves little room for anything else. I’ve also heard the concern phrased, “Since taking medication is so easy, why would anyone do the hard work of the twelve steps or counseling?”
When asked whether he would sponsor someone in AA taking Suboxone, Jake, a long-term AA adherent with an abstinence-only philosophy, responded, “I’m not going to cosign that because in that case you’re basically using [Suboxone] as your Higher Power—that’s what’s keeping you from shooting dope. . . . It makes people just comfortable enough to where they don’t really need to do the steps. Anybody can go to a meeting, anybody can go to the gym, but are you actually lifting weights?” As Jake’s comment reveals, some AA members fear that Suboxone will prevent one from working through the steps or having a relationship with a Higher Power, as if full AA participation rather than recovery is the end goal. It’s like worrying that a diabetic will not watch their diet or exercise if you offer them insulin, so maybe we should just keep the insulin away.
In fact, later in his interview, Jake suggested that people on MAT should be welcome at AA meetings because the exposure to AA principles might lead them to quit MAT and follow AA exclusively. This is not acceptance of MAT. It’s like an evangelical church telling homosexuals that they are welcome, not because the church approves of homosexuality, but because by packing the pews with homosexuals, the church has the opportunity to show them how to lead “godly” lives instead. As Jake explains, “Whether they’re under the influence of MAT or not, I think the seeds still get planted regardless. I’ve got a friend that used to go to meetings in Boston drunk every week. He’s been sober twelve years now.”
Ironically, MAT likely promotes counseling and support group attendance, perhaps because people whose cravings and withdrawal symptoms are controlled can better focus on their social and psychological problems.130 It’s really common sense, a version of Maslow’s hierarchy in which people’s basic physiological needs must be addressed before they can focus on their psychological needs. As Alyssa, a former sex worker in the Midwest, explained to me, “To this day, I credit being alive to Suboxone, because what the Suboxone did for me was I was able to focus on what was being said in [AA] meetings and to listen to the message of recovery because I wasn’t constantly thinking about my physical symptoms because they were not present. I wasn’t craving. I felt like how I imagined normal people feel when they wake up.” It gave her the space to do the emotional work of recovery, to examine the underlying reasons for her drug use. She calls buprenorphine the “legs of a chair,” providing the stability on which to build recovery.
But despite having attended meetings daily and sponsoring people, and even being a circuit speaker for AA, Alyssa was very careful to whom she revealed her Suboxone treatment. At one meeting, one of the “hard-core” AA participants told her, “You’re not really in recovery,” even though she was back in school and no longer selling sex for drugs or sleeping in her car. She was no longer getting high. In fact, everything in her life had changed for the better. But even her fiancé, whom she met in AA, pressured her to quit Suboxone, telling her it was a condition of them getting married. The marriage lasted only one year.
Eventually the anti-MAT stigma became too much, and there were other issues with her local AA groups as well. Some of the older men were predatory toward younger women. Plus, she’d never had problems with alcohol and she liked to have a glass of wine with dinner, something the group, of course, opposed. So even though Alyssa had not misused opioids for years, between Suboxone treatment and drinks with dinner she was never allowed to claim “clean time.”
Today, Alyssa no longer attends AA or actively works the steps. But still she says, “I use the principles in my life constantly, about letting go and about recognizing that I’m powerless. And, in fact, what I learned from AA has helped me in every single relationship: work relationships, romantic relationships, relationships with my children . . . it’s helped me have more positive interactions with people.” She firmly believes that AA is important for many people, especially those seeking a new social network and the tools to lead a fulfilling life after quitting drugs or alcohol. Yet she admits it’s not for everyone.
Also, quitting AA was hard at first. Alyssa missed the camaraderie. It was like axing her whole social network, including a very robust dating scene, sometimes jokingly referred to as the “thirteenth step.” But over the last few years, she has found camaraderie elsewhere—in the local harm reduction coalition.
I have spent much time speaking with two pillars of the national harm reduction community, Chris Abert in the Midwest and Justin Kunzelman in the Southeast, learning how harm reduction saves lives, a fact supported by a wide variety of studies.50,135,136 Harm reduction is an approach to treatment in which you meet people where they are at, offer them a variety of evidence-based recovery tools, and help them make and meet their own goals. It is the opposite of the one-size-fits-all abstinence-only treatment on which US addiction care has been based for decades. Harm reduction philosophy says you can quit heroin but still have a beer; you can be in buprenorphine treatment and still consider yourself sober. And if you aren’t ready to quit heroin, harm reductionists will at least give you the tools to stay safe until you are ready. These tools might include clean needles through a syringe exchange program, so you don’t get HIV/AIDS; supervised heroin injection sites with drug quality tests, so you don’t accidently overdose when heroin is laced with elephant tranquilizer; and take-home naloxone, so your loved one or friend can give you an antidote if you overdose. A key harm reduction phrase is “You can’t recover if you’re dead.” And once you are ready to recover, harm reductionists will connect you to resources, including MAT.
In her current volunteer work, Alyssa helps local sex workers: a vulnerable group that faces tremendous stigma and violence and is often plagued with opioid addiction. Before recovering, Alyssa would spend fifteen minutes in the backseat of local politicians’ cars for $300, thus funding her heroin purchases. Now she teaches sex workers harm reduction practices she wishes she had known all those years ago—such as not using water from the toilet to distill your drugs.
Eventually, after her physiological opioid cravings and withdrawal symptoms stopped, Alyssa transitioned off buprenorphine. Nevertheless, she wants to understand why she used drugs for so many years. She thinks it has something to do with her childhood trauma and history of low self-esteem, for which she has been receiving mental health therapy. She explained, “When my sister takes an opiate, she vomits and can’t stay awake. I take an opiate and it’s like cocaine for me—I’m awake and I want to chat, I want to talk and I want to do things and I want to play the piano and then I want to go run a marathon, and I feel like I’ve been held underwater my whole life and somebody finally let me up to breathe, and I’m just taking my first breath. That’s what it always felt like to me. And when people asked me what it’s like to do heroin, I’m like, ‘God, don’t ever do it because it’s the best thing I’ve ever felt in my whole life.’ But I couldn’t sustain it because I had such a dark hole inside of me that I wasn’t able to fill. There was no bottom to it. So, for me it was kind of like figuring out how to plug the hole. The hole was trauma and insecurity. And I’m kind of finding my way back from that.”
FEW TREATMENT CENTERS offer MAT. When they do, many outpatient and residential addiction treatment centers force patients into twelve-step programs or counseling as a prerequisite or corequirement for MAT. Medication is used as a carrot: if you learn the twelve steps, then we will give you your medication. Of course, I have never seen the reverse: if you take your medicine, we will let you attend counseling or support groups. Numerous practical and ethical problems exist with this coercive treatment approach. In fact, the federal government now recommends against it.23,28 But let’s start with the problem of forcing spirituality onto someone who may not be spiritual in an increasingly secular society.
Like a religion, AA and NA put their trust in a Higher Power and have components of a subculture: their own way of speaking (“My name is John, and I’m an alcoholic”), their own philosophy, and their own traditions (e.g., sitting in a circle, reading the twelve steps with coffee in hand). But Phil, like the vast majority of AA adherents whom I have interviewed, calls AA spiritual rather than religious: “In the beginning, it was heavily, heavily Christian. And there were a couple people involved who really raised a stink about using phrases like ‘the Higher Power’ or ‘God of understanding,’ rather than the Judeo-Christian God. And those little differences for me made all the difference. I never would have showed up if it was just a Christian thing.”
Phil does not believe in God, so he admits that the Higher Power concept was hard to wrap his head around at first: “That’s tough. For a long time, I didn’t [buy into it] . . . just ‘fake it till you make it.’ Then I started saying the collective consciousness of the group is my Higher Power, my sponsors. And it’s not a specific person, it’s just an institutional, generational knowledge that’s sponsor to sponsor, from the very beginning of guys and men and women who have been sober and have found ways to be happy after they were suicidal from their abuse and whatever tragedy happened to them. They found this way by talking to other alcoholics and sharing their experience, and by following these twelve simple steps. And that is still my Higher Power.”
Fascinatingly, even though Phil does not believe in God, he prays daily. Why, I asked. “I pray because people that I know that are happy pray. And my sponsors told me to pray. And so I prayed, but I don’t believe in a God. If some kind of God wants to reveal itself to me, I’m open to that, but barring any of that, I don’t think about it that much, honestly.” Basically, Phil goes through the motions without dwelling on exactly how AA works. All he knows is that AA helps him. Yet even he admits that some AA groups adopt an overtly religious tone. He describes meetings that begin with the Lord’s Prayer, which makes him feel uncomfortable since he identifies as an agnostic Jew. And Phil is not the first person to tell me about AA meetings in which a Christian prayer is said. Another interviewee described an AA meeting in a state university’s clinic where everyone said the Lord’s Prayer in a circle while holding hands.
Even if AA is spiritual rather than religious, some people are uncomfortable with any spirituality being used to manage what they perceive as a predominantly medical condition. Megan, whose twenty-six-year-old son, Daniel, is recovering from heroin addiction through the help of methadone and counseling, said Daniel was regularly forced to attend twelve-step programs in rehab centers. She explains, “My son has faith but not traditional faith. . . . He has had to do twelve-step meetings. I just don’t know that it’s the answer for everyone all the time, and if people are deep in that stuff, if they believe, then I respect that, but I don’t think it’s the only way. And I guess for me personally, I have a hard time with saying it’s a disease and then saying that a religious-based program is what’s going to treat it. So, I think there’s a place for both, but he needs to be able to have [other] options.”
Of course, no problem exists if someone chooses to attend an AA or NA group because of, or in spite of, the group’s spiritual components. But it is problematic when treatment centers force spirituality on unwilling participants. And spirituality in addiction treatment centers is difficult to avoid, even though spirituality rarely, if ever, appears as a routine component of treatment for other medical conditions. For example, a 2004 study of nationally representative publicly funded addiction treatment centers, meaning those that received at least 50 percent of their funding from the federal, state, or local government, found that spirituality was more often emphasized than medication. Over 60 percent of those treatment centers had a twelve-step group attendance requirement. And over 50 percent said their center was based on a twelve-step model, with the majority of the remaining centers incorporating the twelve steps in some way.103
Even aside from spirituality, some people simply do not relate to the twelve steps or mutual support groups. Even spiritual people don’t always find AA or NA helpful. Approximately 40 percent of people who start AA drop out within one year, suggesting that more alternatives are needed.137 Personality may partly predict who likes and doesn’t like twelve-step groups. People with higher “affiliative need,” meaning people who are feelings-oriented, are more likely than those with lower affiliative need to participate in AA.111 People with an external locus of control, meaning those who feel that things happen to them rather than because of them, may also be more responsive to the twelve steps. In fact, one large survey found that having an external locus of control was the single most powerful predictor of AA affiliation.107 AA teaches that putting your life in your own hands spells disaster. You have already tried to control your drinking or drug use by “playing God” and it has repeatedly failed.138 Now it is time to be “not God” and look beyond yourself to a Higher Power, whether that is your support group or Jesus. In this context, taking medication to control your cravings, withdrawal symptoms, and to prevent highs may seem too self-reliant, as if you are once more playing God rather than relying on your Higher Power.
Instead of forcing AA onto clients, treatment centers should try to match recovery methods to clients’ individual belief systems. In health care, person-centered care is better care, resulting in greater treatment retention and adherence, which then leads to better health outcomes.139 Person-centered care has different dimensions, including respecting a person’s treatment preferences and values, providing adequate information about his or her health care, providing emotional support, integrating family and significant others in the health care process, providing physical comfort, and aiding transition back into the community.139 A treatment center that adopts a one-size-fits-all approach or prevents MAT unless you participate in a twelve-step group is not person-centered. Instead, treatment centers should explicitly acknowledge that AA does not work for everyone and offer alternatives. But traditionally, when someone drops out of AA or relapses, the interpretation is that the person did not work the steps, did not have sufficient motivation, or is still in denial about their addiction.107 The interpretation is rarely: AA did not work for this person.
FORTUNATELY OR UNFORTUNATELY, a top-down change is not possible in AA or NA. They are decentralized organizations with decision-making power held almost entirely at the individual group level. Over time, changes may filter up the food chain, but that can take decades. Therefore, individual support groups must initiate change rather than wait for mandates from the top. They have an obligation to do so. After all, AA and NA are the most widely available help for persons with addiction, both geographically and financially. One study suggests that the acceptance of MAT in twelve-step groups is more likely to begin with buprenorphine than with methadone,127 so maybe that’s where the discussion should begin, given that stigma against methadone is often more pronounced than stigma against buprenorphine. Even if a group is not ready to make a bold statement of support for those undergoing MAT, the group can at least refrain from disparaging the treatment method. After all, a key AA principle is to not directly give advice but rather to teach through storytelling.
Sarah, a regular AA attendee, has taken the bold step of speaking out in favor of MAT at her AA meetings. She proudly explains, “I sponsor people on medication-assisted treatment, which is not really the consensus in AA at this time. A lot of people are kind of closed off to that concept in this area. But I do, and whenever somebody asks me to speak at a meeting, I speak about me sponsoring. I don’t really care if it offends someone. Some people may think that’s wrong, or me imposing my views, but I have my reasons and I’m really passionate about it.” This is not easy to do, as support groups often replace old social networks that once revolved around drug use. Alienating one’s key recovery-oriented social network can be a risk to successful recovery.
Stan likewise described how NA affected his beliefs about MAT. He says, “I used to be one of those people that would say that [methadone treatment is not recovery] . . . I turned into the person I hated. I really did. I got that chip on my shoulder, you know, that I’m better . . . I think for a period I thought I was better than everybody else. And look where it ended. I relapsed just as quick as everybody else did.” He eventually dealt with the stigma by leaving NA.
In dozens of interviews with people in recovery across many states, almost every interviewee has described serious anti-MAT stigma in twelve-step groups. At the minimum, MAT prescribers should prepare patients for the stigma they may face.125 They should provide methods for navigating this stigma without necessarily discouraging twelve-step support group participation. They can encourage patients to “shop around,” trying different groups. Interviewees frequently tell me that they feel more comfortable in AA than in NA when undergoing MAT, so shopping around should include both types of twelve-step groups. Many AA groups welcome people with drug addiction, not only people with alcohol addiction.
Equally importantly, treatment centers and providers can encourage alternatives to twelve-step groups. Research suggests that twelve-step group effectiveness is closely related to simply changing the drug user’s social network by replacing time spent with former drug-using friends.140 If this is true, then being part of any support group is likely to be helpful, regardless of whether it follows a twelve-step program. Recent studies support this conclusion, demonstrating that non-twelve-step support groups have equivalent outcomes as twelve-step support groups for alcohol addiction, though no study to date has compared outcomes for opioid addiction.141,142 Alternative groups include LifeRing, SMART Recovery, SOS (Secular Organizations for Sobriety), and Women for Sobriety, to name a few. For example, in contrast to AA’s spiritual approach, SMART Recovery uses principles from cognitive behavioral therapy and motivational interviewing, teaching people how to problem-solve and recognize triggers. For those who like the twelve steps but want a support group explicitly open to MAT, they can try Methadone Anonymous or Medication-Assisted Recovery Anonymous.
Unfortunately, twelve-step alternatives are rarely available outside of major metropolitan areas. They are also rarely recommended; addiction treatment centers are four times as likely to recommend twelve-step groups over other support groups, and only a small minority of programs recommend multiple support group options.143 Counselors who have themselves recovered through twelve-step programs are more likely to refer clients to twelve-step programs, resulting in few recommendations for twelve-step alternatives.144 Part of the problem lies in the assumption that treatment requires spiritual components. Research does not support this assumption, as belief in a Higher Power does not predict abstinence, even though it does predict twelve-step participation.141
At a recent annual American Society of Addiction Medicine conference, one of the preeminent conferences in the world about addiction, I attended a tightly packed presentation called “Combining Medications with 12 Step, Abstinence-Based Treatment for Opioid Use Disorders.” Finally, I thought, an attempt to bridge the gap between these two treatments. While the presentation was indeed groundbreaking, I was taken aback by the question-and-answer session. Handed a microphone, I asked, “Shouldn’t we be talking about expanding non-twelve-step support groups as well as twelve-step support groups?” The answer, precipitated by audience laughter, was, “If non-twelve-step groups actually worked, they would be more popular, wouldn’t they?” And that was the end of that question. Clearly, we still have a long way to go.
IN A NONDESCRIPT STOREFRONT OFFICE, Julie leads a weekly support group called MARA, short for Medication-Assisted Recovery Anonymous. It’s a twelve-step peer support group that is a safe space for people undergoing MAT. She explained the local MARA group’s humble beginning: “Basically, the common consensus in the area was that these people on medication-assisted treatment really, truly did want to go to twelve-step meetings, for the most part. But they just felt completely out of place or judged. So, my boss and I started doing research, and we found a group that was formed in Virginia. And we basically just printed out the literature and revised it, and we just started having it every Tuesday. We built it, and they came. It started off with just me, my buddy John, who’s also in AA with me, and then a kid named Ryan, who is on medication-assisted treatment. And slowly but surely, more people started coming, and now it’s been about two months, and it’s up to like twenty people, give or take. And it’s growing.”
How do Julie’s MARA meetings compare to local AA meetings? Like in AA, group members sit in a circle, usually with coffee in hand. They share stories of recovery and the pitfalls along the way. In contrast to local AA groups, they openly discuss MAT, including stigma, access problems, and any side effects they experience. They discuss what it’s like to start and come off the medications. Even though there is no technical leader of the group, Julie serves as the informal chairperson. If the discussion gets too deep in the medical weeds, such as when participants have questions about medication-to-medication interactions, Julie reminds the participants that they should speak to a physician. But sometimes the discussion isn’t about MAT at all. Sometimes it’s just about classic twelve-step concepts, such as gratitude or avoiding triggers, except in a space where people utilizing MAT are recognized as truly in recovery.
Unlike local AA meetings, Julie’s MARA group spends little time discussing a Higher Power, but no one would shut the topic down if it were brought up. Julie also describes the MARA meetings as more flexible than local AA meetings: “It’s a little bit more compassionate than AA meetings. I won’t shut anyone down if someone goes off on a tangent. Sometimes in AA, the chairperson will shut it down. I won’t. I’ll just let someone go, because obviously they needed to say it. And there’s no formal correct way. Like in AA, it’s almost frowned upon if you don’t say, ‘Hi. My name is so and so. I’m an alcoholic.’ . . . I usually say at MARA meetings, ‘Hi. My name’s Julie. I’m in recovery.’ ” In other words, Julie feels this new group offers greater flexibility, allowing people to forgo some of the traditional components of twelve-step groups.
Julie thinks more people are joining her MARA group because anti-MAT stigma is spreading among young adults on social media. She describes anti-MAT memes shared on Facebook recovery groups, making fun of people on buprenorphine or methadone. At the same time, she doesn’t put up with “twelve-step bashing” that sometimes creeps into MARA meetings, because ultimately Julie thinks the problem lies not with the twelve steps but rather with the way some AA groups are implementing them. She emphasizes that AA groups should be open to all regardless of their preferred recovery methods. Being open to the newcomer and meeting them where they are at is a fundamental component of the original twelve-step program, as is not judging others. She believes it is completely possible for AA groups to accept MAT and those who use MAT. But in describing local group approaches to MAT, Julie grimaces saying, “They’re literally taking the main principle of how the program was built in 1938, and just fucking stepping on it.”
But some AA adherents disagree with Julie’s beliefs about twelve-step and MAT compatibility, though only a small minority of people whom I have interviewed. For example, discussing buprenorphine and methadone, interviewee Lee explains, “I don’t understand why somebody would want to introduce addictive substances to a community that’s trying to get off of addictive stuff.” While admitting that MAT saves lives and that newcomers on MAT should be welcomed into meetings, he later explains that AA should never accept MAT as a recovery method. He then reads from a post he found on a recovery Facebook page with 1.5 million viewers: “But at some point some people are going to have to stand up for AA. Those people that judge us for protecting a program that has saved millions and millions of lives from those that would have their way of having people on narcotics sponsor others, be active members of AA, teaching people to be dependent upon God while they are actively dependent at best on a narcotic, well these people are not only dangerous to the very core of AA but they are also judgmental of AA and are sharing an opinion that is in direct conflict [with] our program.” With almost biblical reverence for the AA literature, called “the Big Book,” the Facebook post continues: “Your opinion almost killed you, try not to kill others with it. Call me a Big Book Thumper, an AA Nazi, whatever. I call you someone who is not in AA if you are against the Big Book and a detriment to others’ sobriety. Once again, the Big Book is AA, your opinion is not.”