Late last week, I had an article published on STAT First Opinion called “By shunning medication-assisted therapy, 12-step meetings are making the opioid crisis worse.” I encourage you to read it if you have not already, because in this post I’m going to cover some topics not discussed in that article, and some of the controversies that have arisen because of that article.
So many people left comments telling me that I should “read the literature” before making this commentary. Well, of course I read the literature. It is insulting that anybody thinks I was just spouting off my opinion without doing actual research. And the fact is, this wasn’t a blog post. It was published by a respected third-party. I could be wrong, but I don’t think that STAT is in the business of publishing random stuff that isn’t researched. I had a conversation with my editor about some of the more controversial points made here, and we verified everything and were careful to word statements intentionally. This was not written on-the-fly. I did a good amount of research for this piece, and anyone who believes NA does not have an official stance on medication-assisted treatment (MAT) should read Bulletin 29.
Why I Don’t Follow The 12-Steps And Never Will
Opinion pieces tend to be short and punchy. They focus on one central point that often revolves around a much more complex topic, as was the case here. Most of my interviews and research didn’t make the final cut. I bypassed other issues I personally have with 12-step programs to touch on this big issue that goes beyond the personal. So here’s my Stat First Opinion postscript, where I include other research and reasons besides those in the original, MAT-focused article.
If the 12-step fellowships became more inclusive about medication-assisted treatment, I would change my opinion that they are making the opioid crisis worse. But I still wouldn’t go myself. I’ve attended a couple meetings, but I’ve never “worked the steps.” Here’s why I never will.
In my First Opinion piece, I told “Jay’s” story. I chose his because it was short, to-the-point, and illustrative of the basic message in all the other stories I heard. But his was not the only one. Not by a long shot. I can’t tell them all here (there’s so damn many), but here’s one more:
When Kelly, a former hair-stylist, landed a bed in a Columbus, OH treatment center to detox from heroin, she expected it to be rough. It was one of the few rehabs in the area that accepted Medicaid or patients without insurance, and the accommodations reflected the poor funding. It boasted a small common room with a TV, surrounded by several bunkers with steel-frame beds bolted to the floor. But she was firm in her purpose, and ready to endure a few discomforts if it meant freedom from heroin addiction. She never expected, however, to be scolded only a few days into her sobriety, simply for taking the medication she was being prescribed by a doctor.
Kelly’s treatment center provided patients with buprenorphine. The center also relied on volunteers from local 12-step groups to help run the facility, a common practice among low-income rehab centers. When Kelly was just a few days into the program, and still adjusting to her buprenorphine, two representatives from AA came by to give the patients a presentation about their fellowship. Kelly recalls agreeing with them when they began talking about the way that addicts replace one addiction with another. She had struggled with alcoholism before turning to heroin and pills after her mother’s death, so the idea of trading addictions made sense to her. Then one of the presenters mentioned buprenorphine.
“Even if you aren’t trying to abuse it, it’s still an addiction,” she said. “You’re physically and mentally dependent on it, therefore it’s an addiction. Which means, if you’re on it, you’re in active addiction, and if you’re in active addiction you are not sober.”
(This line of thinking does not reflect the official definitions of addiction versus dependency, but that doesn’t seem to matter to the 12-step members who espouse it.)
Kelly was furious. She was still struggling to gain purchase on her sobriety, and she was proud of the sober-time she’d already racked up. Every patient in that room was new to recovery, and all of them were using buprenorphine as a catalyst to changing their lives. Kelly felt it was inappropriate for unqualified strangers to enter a place of recovery and give a lecture about everything they felt the patients were doing wrong.
Two years later, Kelly reports that she is still using buprenorphine, and has not touched heroin in that time. She is proud to be a stay-at-home-mom, able to care for her kids because of the stability provided by her medicine.
She says, “Sobriety for me means nothing you can be impaired on.” But that is not an attitude she feels safe sharing at the 12-Step meetings she attends. When will NA update their stance so that Kelly can be honest with her peers about her recovery?
It’s not just medication assisted patients who are affected by these archaic opinions. It’s also their families, and psychiatric patients taking psychotropic meds for their disorders.
Sheila was in the hospital for psychiatric reasons, but decided to attend an in-house Alcoholics Anonymous meeting to address some problematic drinking behaviors. While there, her medication alarm went off. Not realizing it would be a problem, she took her meds, just like she was supposed to. These were medications prescribed to her in order to treat several psychiatric conditions which she’d recently been diagnosed with, and which she was still suffering from acutely enough to be hospitalized.
Sheila reports that while nobody said anything, the mood in the room changed palpably when she took her meds. Later, a friend at the meeting told her she would be wise not to take medications in the rooms, as there were some members who looked down on the use of any mood-altering substance. That chagrin doesn’t seem to include caffeine, nicotine, sugar, or oxygen, but let’s move on.
Although this AA pamphlet addresses the issue of medications (besides addiction meds), many member still espouse the prior no-medicine attitude. As one commenter wrote in response to my First Opinion piece, “if it has a street value, an addict has no place taking it.”
Sheila decided to attend a meeting that did not intersect with the time when she needed to take her medications so that she would not have any problems. She thought it was strange, but also understood that there were people attending who were in recovery from various addictions, including to pills. Maybe taking her meds was triggering?
While at one of these meetings, she overheard a couple of fellows discussing buprenorphine, the agonist medication her father had used to get sober from heroin. Like Jay’s lecturer, like the presenters at Kelly’s rehab, and like countless other stories I’ve heard, they were saying that taking buprenorphine is the same as using heroin, that it’s just trading one drug for another, and that the people who use it are self-deluding and not truly sober.
Sheila grew up not knowing her father. Because he was bouncing between periods of use and sobriety, and freedom and incarceration, her mother kept them apart. They did not begin to get to know each other until she was 19, when he began taking buprenorphine and engaging with his recovery in earnest. Through meeting her father, Sheila also gained a brother–she owes a major portion of her family to buprenorphine. So she did not take kindly to hearing it discussed in such negative and medically inaccurate terms. She says that she stayed quiet during the meeting, but decided not to return to the 12-steps after that.
The medication bias embedded into 12-step culture does not only affect people in opioid recovery, it also affects their loved ones. It’s driving people away who could potentially benefit from the fellowship, and there’s no damn reason for it.
My Addiction Wasn’t Caused By A God-Shaped Hole
This is a big one for me. I am not going to step on other people’s rights to view recovery in a religious light, or to incorporate religion into every aspect of their life, including addiction recovery. I’m not saying 12-steps should not be a leader in the recovery community because of the religious component (though I do think we need more prominent and available secular alternatives); but I am saying that I don’t use the 12-steps (in part) because of the religious component.
I’m not an atheist. I do believe there is more to reality than meets the eye, though I think physics is more likely to hold the key to understanding divine truths than the Bible or the Qua’ran. A fat man with a beard in the sky sounds ridiculous. God as a infinite moment of constant creation, which includes me, creates me, and is created by me sounds more likely. God=constant motion. I also think that science is modern expression of divinity, while religions are archaic. But I’m going on a tangent…
I’ve heard 12-step people say that you don’t have to be a Christian to use the 12-steps; that you don’t have to believe in religion at all. My problem isn’t so much with which religion they use, but rather with the whole surrendering concept as a whole.
I had a friend who paid good money to go to rehab. Like too many rehabs in this country, it was 12-step based. While she was there, she mentioned that she was an atheist, and was forced to go to spiritual counseling. Why can’t an atheist recover? She relapsed after leaving that place, but once she hooked up with a center that used Cognitive Behavioral Therapy instead, she got sober, and has stayed sober something like a decade. Or more. And she’s an awesome person with an awesome life who volunteers and is kind and lovely, and does not go to 12-step meetings.
“Fuck the 12-steps,” says my friend.
I do not have such hubris as to believe that anything truly difficult can usually be accomplished by one individual. I do believe there is an element of personal accomplishment in addiction recovery though. We need our community supports. We need ourselves too. Recovery doesn’t have to be surrendering. It can be empowering. I don’t think that I am powerless over my addiction. I think that it is within my power to fight against the disease, work through the trauma, and choose to use the tools available to me to engage with recovery instead of active addiction.
Or maybe my Higher Power is buprenorphine. Oh, but we can’t have that, can we? (watch: that joke’s going to get more responses than anything else)
I Want My Recovery To Be About More Than Being In Recovery
I don’t go to meetings, but I have been to meetings. I have known my fair share of 12-step followers. I’ve heard the chanting. I’ve read the steps and traditions and been privy to the mantras. They are all about working the steps all the time. It may not be true for everyone who follows the 12-steps, but everyone I have met who follows the 12-steps seems to be working the steps all the time. I don’t get that. If my recovery is about obsessing over not using heroin, then I may as well be using heroin. It’s the same fixation, just inverted.
I enjoy being in recovery because I don’t think about it all the time. I am doing my best to address the trauma that led to my addiction, to develop sober supports, and to find alternative ways to handle stress. But I am also enjoying other aspects of my life. I have been writing about addiction recovery a lot, but I’m not constantly working through my recovery. What 12-step people have demonstrated to me is that they think about recovery a lot. When it comes down it, honestly, their fixation on the righteousness of the 12-steps tells me two things: 1. they are not secure in their recovery. 2. the 12-steps fellowships function very much like a cult. I have no need for a cult.
Then there is this thing. “13th stepping,” where (usually) guys who’ve been working the steps for a while prey on newly sober (usually) women. For people who try to defend the 12-steps, saying this doesn’t happen in all the rooms…well it happens in enough of them to have a name. And a reputation. It’s sexual harassment. It’s creepy, and it’s really really wrong. But just about anything with the kind of built-in power dynamic and requirement of blind, dogmatic surrender is going to come with an element of sexual harassment, so it’s no surprise.
Part of the allure of hooking-up within the 12-steps is that booze-filled bars are a major part of the conventional dating scene. Of course, while those established in their recovery may be able to safely enter a bar, those new to recovery really should stay away. But people in recovery really, really crave human connection. I’ve seen it in my own (not 12-step based) peer support groups; so many members talk about wanting a romantic connection. I get it. Recovery is lonely. But it’s ill-advised. Nobody’s picking anyone up at my peer support group, in part because it’s facilitated by a professional. But at the average 12-step group, there’s no licensed treatment provider, making it a free-for-all.
12-step Meetings Are Not For Me, And Never Will Be
Several people left comments on my article stating that I needed to find a new meeting rather than just being turned away from one. I was never turned away from one. I was just told horror stories from many, many other people who were treated like shit for using medication assisted treatment.
Several people left comments stating that I wasn’t working the steps well enough…I’m not. I’m not working them at all. And I never will. Because I don’t need the 12-steps to recover. Neither do you, if you’ll just choose to believe it.
When I asked the NA regional chairperson I interviewed (who was actually a pretty nice, if misinformed, guy) whether it was possible to attain sobriety without using the 12-steps, he said, “Yeah, evidence shows yes…but why would you do that to yourself?”
Because I want to live a meaningful, empowered, and intelligent life, that’s why.