Archive for the ‘12-Step Recovery’ Category

Combining Medication-Assisted Treatment and 12- Step recovery: One Patient’s Success Story

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A few weeks ago, I posted a few articles about 12-step recovery. Several readers became very upset, even saying that if I was pro-12-step, I couldn’t really be an advocate for medicated-assisted treatment of opioid addiction. That’s their opinion, and I honor their views, though I heartily disagree with them.

Now I’d like to present an interview I did with a very successful Suboxone patient who did find help from 12-step meetings.

JB: Please tell me about your experience with pain pill addiction and your experiences with buprenorphine (Suboxone).

XYZ: For me, my opiate addiction got so bad, I was taking two hundred and forty to three hundred and twenty milligrams of OxyContin per day, just to stay normal. It had gotten really, really bad. And it started out with a reason. I had kidney stones, and I was in all this pain, but then it got to the point where it solved some other problems in my life and it got out of hand. I tried a lot of different things. I went to detox, and they helped me, but it was…it was almost like I never came out of withdrawal.

JB: How long were you off pain pills?

XYZ: Even after being clean for thirty or sixty days, I would still feel bad. Bowels, stomach…really all the time.

JB: Did it feel like acute withdrawal or just low grade withdrawal?

XYZ: No…I’d try to fix it myself, sometimes, and I would just put myself back where I was. It got to the point where I was making myself sicker and sicker and sicker. And then I got off of it, and stayed off of it for a hundred and twenty days, I guess…but still just sick. Just miserable, and not feeling right. I was miserable. I wouldn’t eat, I was losing weight…

It [buprenorphine] gave me something that replaced whatever was going on in my head physically, with the receptors. It took that [prolonged withdrawal] away, to the point that I felt well. All that energy I would spend getting pills…and I was going to the doctors almost daily. Because taking that much medicine, nobody would write me for that much, so I had to doctor shop.

My only life was going to the doctors, figuring out what pharmacy I could use. I had a whole system of how many days it could be between prescriptions, what pharmacy to go to. It was sick. I was just trying to not get sick.

JB: And you were working during that time?

XYZ: Yeah! I was working, if you want to call it that. I wasn’t a very good employee, but I held a job. I was a regional vice president for “X” company. I traveled a lot, so I had new states where I could see new doctors. That was bad. When I came off the road, I owed $50,000 in credit card bills.

JB: And your wife didn’t know about it?

XYZ: No. It all came tumbling down. And I had gotten into trouble, because they were company credit cards, and they wanted the money back! So, all of the sudden my wife found out that not only do I have a pain pill problem, but we’re $50,000 short, and I wasn’t very ethical in the way I got the money, because it really wasn’t my credit, it was my company’s credit card.

JB: So addiction made you do things you wouldn’t do otherwise?

XYZ: Absolutely. I lied to people, I took money from people, I ran up credit cards tens of thousands of dollars, and really put my family in serious jeopardy at that time. But buprenorphine took away that whole obsessive-compulsive need for pills, made me feel better, and took away all the withdrawal symptoms at the same time. I didn’t worry about it.
To be honest, I was such a hypochondriac before. I haven’t been sick in years now. I haven’t had a backache or headache that ibuprofen didn’t cure [since starting recovery]. I was fortunate it was all in my head. I would milk any little thing. I had two knee operations that probably could have been healed through physical therapy, but I was all for surgery, because I knew I’d get pain pills.

JB: That’s the power of addiction!

XYZ: Yes. Finally I did some research about buprenorphine, online. Actually, I had some good family members, who did some research and brought it to me, because they were concerned for me, and they brought it to me and said, “Hey, there’s a medicine that can help. Call this number,” and I found places out there that would do it [meaning Suboxone], but my concern was the speed that a lot of them were doing it. A lot of them said, OK come in, and we can evaluate you, and after a week you’ll be down to this, and after a month you’ll be down to this.

This was in 2005. And when I asked them what their success rate is, it wasn’t very high. It was something like twenty percent of the people who were doing it [succeeded]. So when I’d finally gotten a hold of “X,” [receptionist for Dr. H], she saved my life over the phone. Because she said, you can come tomorrow, and she said that whatever it takes, they’ll work with you. And I felt good about going to a place where it wasn’t already determined how long it would take. Because I already knew how I was feeling after I would come off of opiates. I didn’t want to do that again.

I saw Dr. H. and felt better within twenty-four hours, although it took a little while to get the dosage right. I think we started off at a lower dose, then we went up on the dose and it kept me so level. I had no symptoms. It cured my worst withdrawal symptoms, my stomach and my bowels.

There’s always a kind of stigma in the rooms [12-step recovery meetings] because I’d been in NA for a little bit of time then [he’s speaking of stigma against medication-assisted treatment]. You realize who [among addicts in NA] is die-hard, one way to do recovery, and who is willing to be educated about some things and understand that there’s more than one way to skin a cat.
And I was fortunate that I had a sponsor at that time, and still do, who was willing to learn about what exactly it was, and not make me feel guilty about it. It wasn’t necessarily the way he would do it, but he was a cocaine addict, so he didn’t understand that whole part of it.

He said, “Your family’s involved, you’ve got a doctor that’s involved, your doctor knows your history. If all these people, who are intelligent, think this is an OK thing, then who am I to say it’s not going to work?” He was open-minded. And there are not a lot of people I would trust right off the bat [in recovery], that I would tell them. [that he’s taking Suboxone]. I’ve shared it with some people who’ve had a similar problem, and told them, here’s something that might help you. I always preface it with, [don’t do] one thing or another, you’ve got to do them together. You have to have a recovery program and take this medicine, because together it will work. Look at me. I’m a pretty good success story.

One of my best friends in Florida called me, and I got him to go see a doctor down there, and he’s doing well now. He’s been on it almost eleven months now and no relapses.

To me, it takes away the whole mental part of it, because you don’t feel bad. For me, it was the feeling bad that drove me back to taking something [opioids] again. Obviously, when you’re physically feeling bad, you’re mentally feeling bad, too. It makes you depressed, and all of that, so you avoid doing fun things, because you don’t feel good.

Once I trained myself with NA, how to get that portion of my life together, to use those tools, not having any kind of physical problems made it that much easier to not obsess.

JB: So, how has your life improved, as a result of being on buprenorphine?

XYZ: Well, the most important thing for me is that I’ve regained the trust of my family. I was the best liar and manipulator there was. I’d like to think of myself as a pretty ethical and honest person, in every aspect of my life, other than when it came to taking pills.

JB: So, you regained the trust of your family, felt physically better…

XYZ: I gained my life back! Fortunately, I had enough of a brain left to know it had to stop. Once I started on buprenorphine, it gave me back sixteen hours a day that I was wasting. That’s when I decided I really don’t want to jeopardize my recovery, by going out and looking for a job again [he means a job in corporate America, like he had in the past], because I’ve got this thing, this stigma…they’re going to check a reference and I’m screwed. I’m not going to get a job doing what I was doing for the same amount of money.

My brother had enough faith in me that it was worth the risk of starting this business [that he has now] together. My wife and I started on EBay, making and selling [his product], and slowly grew it to the point that, three years later, I’m going to do over two million dollars in sales this year, I’ve got [large company] as a client, I’ve got [large company] as a client, I’m doing stuff locally, in the community now, and can actually give things back to the community.

JB: And you employ people in recovery?

XYZ: Oh, yeah. I employ other recovering addicts I know I can trust. I’ve helped some people out who have been very, very successful and have stayed clean, and I’ve helped some people out who came and went, but at the same time, I gave them a chance. You can only do so much for somebody. They have to kind of want to do it themselves too, right?

JB: Have you ever had any bad experiences in the rooms of Narcotics Anonymous, as far as being on Suboxone, or do you just not talk to anybody about it?

XYZ: To be honest, I don’t broadcast it, obviously, and the only other people I would talk to about it would be somebody else who was an opioid addict, who was struggling, who was in utter misery. The whole withdrawal process…not only does it take a little while, but all that depression, the body [feels bad]. So I’ve shared with those I’ve known fairly well. I share my experience with them. I won’t necessarily tell people I don’t know well that I’m taking buprenorphine, but I will let them know about the medication. Even though the information is on the internet, a lot of it is contradictory.

It’s been great [speaking of Suboxone] for someone like me, who’s been able to put a life back together in recovery. I’d tell anybody, who’s even considering taking Suboxone, if they’re a true opioid pill addict, (I don’t know about heroin, I haven’t been there), once you get to the right level [meaning dose], it took away all of that withdrawal. And if you combine it with going to meetings, you’ll fix your head at the same time. Really. I didn’t have a job, unemployable, my family was…for a white collar guy, I was about as low as I could go, without being on the street.
Fortunately I came from a family that probably wouldn’t let that happen, at that point, but who knows, down the road… I had gotten to my low. And that’s about it, that’s about as much as I could have taken.

It [Suboxone] truly and honestly gave me my entire life back, because it took that away.

JB: What do you say to treatment centers that say, if you’re still taking methadone or Suboxone, you’re not in “real” recovery? What would you say to those people?

XYZ: To me, I look at taking Suboxone like I look at taking high blood pressure medicine, OK? It’s not mind altering, it’s not giving me a buzz, it’s not making…it’s simply fixing something I broke in my body, by abusing the hell out of it, by taking all those pain pills.

I know it’s hard for an average person, who thinks about addicts, “You did it to yourself, too bad, you shouldn’t have done that in the first place,” to be open minded. But you would think the treatment centers, by now, have seen enough damage that people have done to themselves to say, “Here’s something that we have proof that works…..”

I function normally. I get up early in the morning. I have a relationship with my wife now, after all of this, and she trusts me again. Financially, I’ve fixed all my problems, and have gotten better. I have a relationship with my kids. My wife and I were talking about it the other day. If I had to do it all over again, would I do it the way I did it? And the answer is, absolutely yes. As much as it sucked and as bad as it was, I would have still been a nine to five drone out there in corporate America, and never had the chance to do what I do. I go to work…this is dressy for me [indicating that he’s dressed in shorts and a tee shirt]

JB: So life is better now than it was before the addiction?

XYZ: It really is. Tenfold! I’m home for my kids. I wouldn’t have had the courage to have left a hundred thousand dollar a year job to start up my own business. I had to do something. Fortunately, I was feeling good enough because of it [Suboxone], to work really hard at it, like I would have if I started it as a kid. At forty years old, to go out and do something like that…

JB: Like a second career.

XYZ: It’s almost like two lives for me. And if you’re happy, nothing else matters. I would have been a miserable, full time manager, out there working for other people and reaping the benefits for them and getting my little paycheck every week and traveling, and not seeing my wife and kids, and not living as well as I do now.

I joke, and say that I work part time now, because when I don’t want to work, I don’t have to work. And when I want to work, I do work. And there are weeks that I do a lot. But then, on Saturday, we’re going to the beach. I rented a beach house Monday through Saturday, with just me and my wife and our two kids. I can spend all my time with them. I could never have taken a vacation with them like that before.

JB: Do you have anything you’d like to tell the people who make drug addiction treatment policy decisions in this nation? Anything you want them to know?

XYZ: I think it’s a really good thing they increased the amount of patients you [meaning doctors prescribing Suboxone] can take on. I’d tell the people who make the laws to find out from the doctors…how did you come up with the one hundred patient limit? What should that number be? And get it to that number, so it could help more people. And if there’s a way to get it cheaper, because the average person can’t afford it.

The main thing I’d tell them is I know it works. I’m pretty proud of what I’ve achieved. And I wouldn’t have been able to do that, had I not had the help of Suboxone. It took me a little while to get over thinking it was a crutch. But at this point, knowing that I’ve got everybody in my corner, they’re understanding what’s going on…it’s a non-issue. It’s like I said, it’s like getting up and taking a high blood pressure medicine.

I originally interviewed this patient in 2009, for a book that I wrote. Since that time, he and his family have moved to the west coast, but I’ve stayed in contact with him. He’s been in relapse-free recovery for over eight years, he’s still on Suboxone, and still happy. He has excellent relationships with his wife and children, and his business has thrived and continues to grow.

He’s an excellent example of how a recovering addict’s life can change with the right treatment. For this person, Suboxone plus 12-step recovery worked great.

The Differences Between 12-Step Recovery and Other Group Therapies

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It struck me that some of my readers may not know that 12-step meetings are run differently and have different norms of interaction than other support groups. While it’s true each group has the freedom to run its meetings as it sees fit, most follow AA’s Twelve Traditions as a pattern for interaction.
Physicians, therapists, or educators of any kind would not be allowed to talk to any group to educate them about anything. If such a person is a member of a 12-step group, he/she is welcome to talk only about her personal experience, strength, and hope. In fact, in Alanon, if there are members present who are also members of AA, NA, GA, or any other 12-step group, they are asked to keep that to themselves, as it can distract from the focus of the meeting.
In 12-step meetings, there’s no therapist or counselor in charge of the meeting. Instead, there’s a chairperson, a member of the 12-step program who opens and closes the meeting. This person is in charge only in the sense that she guides, rather than controls, the meeting. Some chairpersons guide more than others. For example, some chairpersons will interrupt a member who’s sharing something that can be harmful to the group. This could mean interrupting a “drunkalog” (long pointless sharing that glamorizes drinking or using drugs). Other chairpersons let the meeting run its course, believing that a Higher Power is always in control. The chairperson is responsible for starting and ending the meeting on time.
Members don’t give advice to each other. Or at least, experienced members of Narcotics Anonymous and Alcoholics Anonymous don’t tend to give advice to each other. Instead, members share their own experiences. They tell about what worked for them, and what didn’t work. The topic is often about how to get through situations without using drugs or alcohol, but may also be about how to live with difficult life situations, and still retain one’s serenity.
In group therapy, members are encouraged to give advice, or feedback, to other members. Some treatment centers believe that alcoholics and addicts must be confronted, so that denial can be broken through. Twelve-step meetings don’t take this stance. Instead, members offer their own experience, freely and without expectations. It’s a subtle difference, but important. Other 12-step members don’t assume they know what another person should do about life decisions; they simply offer their own experiences.
Twelve-step meetings are free. Most group therapy costs some amount of money.
No record of attendance is kept at 12-step meetings. A person is considered to be a member of Narcotics Anonymous when that person says they are a member. The only requirement for membership is a desire to stop using drugs.
Twelve-step groups don’t promote themselves. One of their twelve traditions says that new members should be gained by “attraction, rather than promotion.” However, some group have websites for group members, and some groups do advertise times and locations of local meetings as public service announcements.
Twelve step meetings are held in slightly different ways in different areas of the country. In some places, meetings range from fifty minutes to an hour and a half. At “speaker” meetings, one person tells their story of addiction and recovery for the whole hour, traditionally telling “what it was like, what happened, and what it’s like now.” At other types of meetings, all persons present are offered a chance to share or pass to the next person. In some meetings, members who wish to share raise their hands and are called on by the meeting chairperson. In group therapy, all members are usually expected to say something during the session, but at NA or AA, no one is coerced to speak.
Problems are shared at meetings, but the emphasis is on solutions. Most good meetings don’t allow the meeting to become a dumping ground for negative experience. The emphasis of meetings is on solutions to problems. In most meetings, sharing about specific drugs is discouraged. NA members are encouraged to share about what they are feeling, and what kind of help they need to remain abstinent from all drugs.
Overall, the mood of 12-step meetings is one of humbleness, where one recovering addict shares what worked for her with the rest of the group, without expectations and with humility. By contrast, in group therapy, feedback or advice is usually given by other group members. But an addict’s tendency with such an approach is to ask, “Who are you to be telling me what to do?” Narcotics Anonymous meetings recognize that advice and feedback often grates on addicts, and their meetings are constructed differently. Other member’s experiences are offered as learning opportunities.
Twelve step members aren’t perfect, to say the least. Many members are wrestling with serious mental and emotional problems. Sometimes members do lapse into advice-giving and preaching, but most lose this tendency to try to control others as they progress in their own recovery.

12-Step Recovery and Medication- Assisted Treatment: Mutually Exclusive?

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I’m surprised and disappointed by all the negative comments to my blog from medication-assisted treatment (MAT) advocates who strongly criticize my article on excuses people use to justify not attending 12-step recovery.

Actually, the blog entry is a re-run, from about a year and a half ago, when it didn’t get much attention at all. I first wrote the piece years ago, for patients with all sorts of addiction, and not specifically those in medication-assisted treatments. Most of my readers have interpreted the blog to be targeted at MAT patients. I guess that’s not unreasonable, since my blog is dedicated to opioid addiction and its treatment with medication.

I’m surprised that some MAT advocates, who must have endured much discrimination and misunderstanding, are equally judgmental and biased against 12-step recovery.

Hear this: 12-step recovery is an evidence-based treatment. I’m preparing a blog with all of the study references so those who are open-minded enough can read them, and make a more informed judgment of 12-step recovery. Each time the American Society of Addiction Medicine holds their review course, there’s a lecture on 12-step recovery and the literature that supports it, just like there’s a lecture on methadone and buprenorphine for treatment of opioid addiction.

I’m sorry people have had bad experiences with 12-step recovery, but to use one bad experience as an excuse to denigrate 12-step meetings in their entirety is no different than saying because one person overdosed and died from methadone, it’s dangerous and should be outlawed.

For the record, I’m not in favor of forcing anyone to go to 12-step meetings if they don’t want to. Patients in my Suboxone practice have to do some kind of regular counseling, and they have their choice of seeing an individual counselor in my office, seeing their own therapist, going to 12-step meetings and documenting their attendance, or going to an intensive outpatient program at a local treatment center. About one-third of the new patients pick 12-step meetings because that’s the cheapest option, and that’s fine with me. At the opioid treatment programs where I work, I don’t force patients to go to 12-Step meetings. In situations where patients can’t stop drinking alcohol, I will recommend AA as an alternative to try before I have to recommend inpatient drug rehab, but those patients also have the option to attend the group meetings held at our OTP. However, one the OTPs doesn’t have any group meetings, so I’m more likely to recommend AA. That’s in Boone, and from what I hear, there’s no NA up there.

My office Suboxone patients give me a unique view. I inherited a group of about 30 patients from another Suboxone doctor. She was well-loved and well-known in local 12-step meetings, and any AA or NA member who got addicted to opioids after they were in recovery were referred to her. When she retired, I got most of those patients. Some of these patients had many years of sobriety from other drugs when they got put on pain pills for some reason, and they developed a secondary addiction to pain pills. After they got on Suboxone, they continued to go to their recovery meetings as usual.
I’m starting to realize that these patients may be rare. They’re comfortable with being on Suboxone and equally comfortable going to and participating in 12-step meetings. I enjoy them very much, and they’re easy to treat, since they’ve already had recovery experience.

These patients don’t share in meetings about buprenorphine, because that’s not their problem. These patients go to meetings to learn how to live a happy life without getting high. They talk about how to get through difficult life circumstances without losing their serenity, sanity, or sobriety. For them, the fact they are on a maintenance dose of medication is a non-issue. They aren’t looking for opinions or advice about their methadone or Suboxone dose.

If you are at a place in your life where you feel you must share about medications, I agree 12-step probably isn’t going to work for you, unless it’s MA (Methadone Anonymous).

It sounds like many MAT advocates have been to some very bad 12-step meetings. I hate that, but it’s not the norm. For example, 12-step members aren’t supposed to give advice, but only share what worked for them. In Alanon, one of my favorite 12-step groups, the readings at the beginning actually tell attendees not to give advice or comment on what other members have shared, but only about what you are going through and what is working or has worked for you.

It breaks my heart to hear an NA member castigate a newcomer to the group for being on methadone or Suboxone. It also breaks my heart when patients on medication-assisted treatment put down 12-step recovery. I always think to myself, “Oh if you only knew how much this helps some people, you wouldn’t talk bad about it…”

Maybe that’s just human nature.

Excuses for not going to 12-step meetings:

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Some people collect stamps. I collect reasons for not going to 12-step meetings:

I’m too busy.
I don’t have a car.
I don’t have a license to drive my car.
Gas is too expensive.
I hate cigarette smoke.
I can’t smoke at meetings.
I don’t have childcare.
I won’t know anyone.
I might know someone.
I hear that it’s really a cult.
I’d have to drive too far.
All they talk about is drinking.
They sell drugs at the meetings.
The meetings are too depressing.
The people at meetings are too happy.
I get my recovery at church.
Meetings are too far away.
Meetings are too close and I’ll know people there.
My probation officer won’t let me go because of my curfew.
Going to meetings makes me want to drink or use drugs.
I have social phobia and don’t feel comfortable in groups.
I don’t want to hear a bunch of other people’s problems.
I don’t want to tell a bunch of strangers my personal problems.
The only time I ever think about drugs or alcohol is when I’m at a meeting.
The people there are a bunch of fakes, lying about being clean/sober.
The last time I went, the men wanted to hook up with me sexually.
The last time I went, the women wanted to hook up with me sexually.
I got into recovery to have a life, and going to meetings just interferes with that.

And…my all-time favorite: I don’t want to get addicted to meetings. I just love that excuse…you may be snorting dangerous pills, alienated your friends and family, be nearing financial ruin, but none of that bothers you as much as the possibility you may get addicted to going to recovery meetings.

I’m not unreasonable. I know some of these excuses have some merit, like lack of childcare. But I also know there’s usually a way to overcome these barriers. People in active addiction often overcome great challenges to continue to getting their drugs. They create clever and imaginative solutions. Similarly, people can get to meetings if they want to do so.

I’d rather hear real reasons for not going: it’s scary and humiliating to admit you are addicted. It takes tremendous courage to walk into a 12-step recovery meeting for the first time, and it takes courage to continue to go to meetings. Meetings aren’t always pleasant or convenient.
But this form of recovery has worked for millions of people in a few hundred countries. It’s been around for seventy-seven years. What other drug addiction recovery programs have been in existence for that long? Twelve- step recovery isn’t a flash in the pan, and it has multiple clinical studies to show that it works. And it’s the best deal in town, since it’s free. So even though it can be intimidating to start going to meetings, the benefits are worth the effort.

Is it possible to recover without going to 12-step meetings? I believe so, yes. But I think it’s harder and takes more time and energy. I imagine the difference to be like hacking your way through a dense forest rather than taking a wide and well-worn path through the forest.

Twelve step programs aren’t the only recovery option and may not work for everyone, but please don’t tell me it doesn’t work for you until you’ve tried it.

Does 12-Step Recovery Really Work?

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I recommend 12-step meetings to my patients, because we have evidence these meetings work, at least for some patients. Studies of AA’s effectiveness, obviously difficult due to the anonymous nature of the program, have been conducted since 1945.

A metanalysis of thirty-three studies, done from 1945 until 1990, shows a positive association between the frequency of AA meetings attended by an alcoholic and increased abstinence from alcohol. In other words, an overall summary of these studies shows that the more AA meetings attended, the more likely the alcoholic stayed sober. (1) However, there were two of the thirty-three studies that showed a negative association, meaning that more AA meetings was associated with less time of sobriety. At times, organizations that oppose Alcoholics Anonymous quote one of these two studies and give no information about the other twenty- nine studies.

Of course, it may be that alcoholics who are more motivated to stay sober go to more AA meetings, and the number of meetings attended was thus a marker of commitment to sobriety. Was it the degree of motivation of the person, rather than the AA program, that produced the better outcomes? Later studies done in the 1990s controlled for the degree of personal motivation,  and still showed a positive correlation between number of meetings attended and sobriety. (2)

Later studies looked not at the number of AA meetings attended, but rather the degree of involvement of alcoholics in the AA program. These studies showed the degree of involvement in AA correlated higher with longer time of alcohol abstinence than did the number of meetings attended. Multiple studies, looking at outcomes other than abstinence from alcohol, have found that AA attendance was also associated with emotional well-being, serenity, and finding purpose in life. (1)

AA has never claimed to have all the answers or solutions. (3) Strangely, most alternatives to twelve step recovery use as their main selling point, “Not like Alcoholics Anonymous.” I have read books authored by people who seem quite bitter that AA did not “fix” them, as if AA had some obligation to do so. Twelve step recovery programs don’t force membership on anyone. In fact, the only way to become a member is to say you want to be a member.

So… if 12-step meetings help, great.

If not, then don’t go.

They have helped about two million people worldwide, but they don’t work for everyone. Thankfully, there’s more than one path to recovery.

1. Tonigan, J. Scott, “Alcoholics Anonymous Outcomes and Benefits,” in Recent Developments in Alcoholics, Volume 18, Research on Alcoholics Anonymous and Spirituality in Addiction Recovery, edited by Marc Galanter and Lee Ann Kaskutas. P 357-372.
2. McKeller J, Stewart E., Humphreys k, “Alcoholics Anonymous and positive alcohol-related outcomes: cause, consequence, or just a correlate?” Journal of Clinical Psychology, 2003, April, 71 (2) p 302-308.
3. Alcoholics Anonymous, 4th ed., (often called the “Big Book of Alcoholics Anonymous”) Alcoholics Anonymous World Services Inc., New York City, 2001, p 164.

 

12-Step Meetings Are Not the Same as Group Therapy

Before I actually went to some open 12-step meetings, I thought they would be like group therapy meetings. However, 12-step meetings have basic differences from group therapy meetings.

Twelve-step meetings are free. Most group therapy costs some amount of money.

Members don’t give advice to each other. Or at least, experienced members of Narcotics Anonymous and Alcoholics Anonymous don’t tend to give advice to each other. Instead, members share their own experiences. They tell about what worked for them, and what didn’t work.  The topic is often about how to get through situations without using drugs or alcohol, but may also be about how to live with difficult life situations, and still retain one’s serenity.

In group therapy, members are encouraged to give advice, or feedback, to other members. Some treatment centers believe that alcoholics and addicts must be confronted, so that denial can be broken through. Twelve-step meetings don’t take this stance. Instead, members offer their own experience, freely and without expectations. It’s a subtle difference, but important. Other 12-step members don’t assume they know what another person should do about life decisions; they simply offer their own experiences.

In 12-step meetings, there’s no therapist or counselor in charge of the meeting. Instead, there’s a chairperson, a member of the 12-step program who opens and closes the meeting. This person is in charge only in the sense that she guides, rather than controls, the meeting. Some chairpersons guide more than others. For example, some chairpersons will interrupt a member who’s sharing something that can be harmful to the group. This could mean interrupting a “drunkalog” (long pointless sharing that glamorizes drinking or using drugs). Other chairpersons let the meeting run its course, believing that a Higher Power is always in control. The chairperson is responsible for starting and ending the meeting on time.

No record of attendance is kept at 12-step meetings. A person is considered to be a member of Narcotics Anonymous when that person says they are a member. The only requirement for membership is a desire to stop using drugs.

Twelve step meetings are held in slightly different ways in different areas of the country. In some places, meetings range from fifty minutes to an hour and a half.  At “speaker” meetings, one person tells their story of addiction and recovery for the whole hour, traditionally telling “what it was like, what happened, and what it’s like now.” At other types of meetings, all persons present are offered a chance to share or pass to the next person. In some meetings, members who wish to share raise their hands and are called on by the meeting chairperson. In group therapy, all members are usually expected to say something during the session, but at NA or AA, no one is coerced to speak.

I tell my patients about these differences, because many people who really need the guidance and support that 12-step meetings don’t go, because of their mistaken opinions about meetings.

They think they will be made to speak at an NA or AA meeting, and don’t want to go for that reason. Other patients say if they hear people talking about drugs it will make them want to use drugs. Other people say they “don’t want to hear everybody else’s problems.”

Problems are shared at meetings, but the emphasis is on solutions. Most good meetings don’t allow the meeting to become a dumping ground for negative experience. The emphasis of meetings is on solutions to problems. I explain that in most meetings, sharing about specific drugs is discouraged. NA members are encouraged to share about what they are feeling, and what kind of help they need to remain abstinent from all drugs.

Overall, the mood of 12-step meetings is one of humbleness, where one recovering addict shares what worked for her with the rest of the group, without expectations and with humility. By contrast, in group therapy, feedback or advice is usually given by other group members. But an addict’s tendency with such an approach is to ask, “Who are you to be telling me what to do?” Narcotics Anonymous meetings recognize that advice and feedback often grates on addicts, and their meetings are constructed differently. Other member’s experiences are offered as learning opportunities.

Twelve step members aren’t perfect, to say the least. Many members are wrestling with serious mental and emotional problems. Sometimes members do lapse into advice-giving and preaching, but nearly always lose this tendency to try to control others as they progress in their own recovery.

There’s a reason 12-step recovery has been around for seventy-five years. Many other recovery methods have attained a brief popularity, only to fade away within ten or twenty years. Twelve step recovery has helped millions of people worldwide, continues to grow, and will be with us for a long time to come.

Excuses for not going to 12-step meetings:

Some people collect stamps. I collect reasons for not going to 12-step meetings:

I’m too busy.

I don’t have a car.

I don’t have a license to drive my car.

Gas is too expensive.

I hate cigarette smoke.

I can’t smoke at meetings.

I don’t have childcare.

I won’t know anyone.

I might know someone.

I hear that it’s really a cult.

I’d have to drive too far.

All they talk about is drinking.

They sell drugs at the meetings.

The meetings are too depressing.

The people at meetings are too happy.

I get my recovery at your church.

Meetings are too far away.

Meetings are too close and I’ll know people there.

My probation officer won’t let me go because of my curfew.

Going to meetings makes me want to drink or use drugs.

I have social phobia and don’t feel comfortable in groups.

I don’t need to hear a bunch of other people’s problems.

I don’t want to tell a bunch of strangers my personal business.

The only time I ever think about drugs or alcohol is when I’m at a meeting.

The people there are a bunch of fakes, lying about being clean/sober.

The last time I went, the men wanted to hook up with me sexually.

The last time I went, the women wanted to hook up with me sexually.

I got into recovery to have a life, and going to meetings just interferes with that.

And…my all-time favorite: I don’t want to get addicted to meetings. I just love that excuse…you may be snorting dangerous pills, alienated your friends and family, be nearing financial ruin, but none of that bothers you as much as the possibility you may get addicted to going to recovery meetings.

I’m not unreasonable. I know some of these excuses have some merit, like lack of childcare. But I also know there’s usually a way to overcome these barriers. People in active addiction often overcome great challenges to continue to getting their drugs. They create clever and imaginative solutions. Similarly, people can get to meetings if they want to do so.

I’d rather hear real reasons for not going: it’s scary and humiliating to admit you are addicted. It takes tremendous courage to walk into a 12-step recovery meeting for the first time, and it takes courage to continue to go to meetings. Meetings aren’t always pleasant or convenient.

But this form of recovery has worked for millions of people in a few hundred countries. It’s been around for seventy-seven years. What other drug addiction recovery programs have been in existence for that long? Twelve- step recovery isn’t a flash in the pan, and it has multiple clinical studies to show that it works.  And it’s the best deal in town, since it’s free. So even though it can be intimidating to start going to meetings, the benefits are worth the effort.

Is it possible to recover without going to 12-step meetings? I believe so, yes. But I think it’s harder and takes more time and energy. I imagine the difference to be like hacking your way through a dense forest rather than taking a wide and well-worn path through the forest.

Twelve step programs aren’t the only recovery option and may not work for everyone, but please don’t tell me it doesn’t work for you until you’ve tried it.

 

Story of a Recovering Addict

Following is an interview that I did with a recovering addict. He now has over 13 years in recovery, and has a master’s degree in addiction counseling.  His history demonstrates how NA can help an addict, and illustrates some of the main tenants of 12-step recovery.

JB: What kinds of drugs did you use?

ML: Everything. I shot cocaine, Dilaudids, heroin, quarter-grain morphine tablets, and always alcohol. Alcohol and marijuana were just a given. They were daily.

JB: Can opioid addicts get clean just using NA?

ML: Yeah. My sponsor did, and other people [have].

JB: What percentage of people in NA used opioids?

ML: Back in1982, when I entered recovery, it seemed like seventy-five percent of people in NA used opiates. Then in the 1980s, more people addicted to crack came into NA, so now I’d estimate about fifty percent or less. But there’s no numbers [statistics kept by NA].

JB: How else has NA changed?

ML: Back in the early days of NA, most addicts hit a low bottom, before coming to NA, but now, with the growth of treatment centers, drug courts, information on the internet…when my father told me I had to leave the house unless I got help, I looked in the phone book and there were only two numbers to call for help. I called the Council on Alcoholism and got directed to AA. There’s been such a growth in [addiction treatment resources]. Every family has had experience with some kind of addiction. There’s more acceptance and knowledge now. People get to NA before they hit the kind of bottom that I did. That’s a good thing.

JB: How effective is NA? Some people say that only two percent of people who go to a twelve step meeting stay clean. What do you say to that?

ML: (laughs) I’d like to know where they got their numbers.

A lot of people get their start in NA and find other means to recover…other fellowships, churchs,…it’s an individual thing. It depends on what kind of living situation the individual is in, how willing the individual is [to get clean], and what kind of recovery the people at those [NA] meetings have. It depends on how deeply they get involved in that fellowship [NA].

In my case, I went to meetings for more than a year, but I didn’t work any steps. But I stayed clean, by going to meetings and getting support from the people at the meetings. Then I moved away and didn’t have that support. It didn’t take long for me to relapse. I was around old friends I used with, old sights and sounds…It takes more than just going to meetings to be successful. There are always exceptions, though. Some people have stayed clean for years that way.

In my case, the seed was planted. I wasn’t at a point where I could honestly look at my situation. So after I skinned my ass up [experienced consequences from using drugs], I went to inpatient treatment and then a halfway house. Plus meetings [Narcotics Anonymous and Alcoholics Anonymous]. I had a little more honesty, a little more willingness. But that second time, I didn’t work all the steps. I had three and a half years clean, got to the fourth step, and I relapsed. That relapse happened when my priorities shifted from going to meetings five or six times per week to relationships, working twelve hour days, hunting and fishing. Looking back, being surrounded by people in recovery was carrying me along.

It wasn’t long. I hadn’t experienced the change that comes from working all of the steps. It was only a matter of time before the self-deception set in. How in the hell could I talk myself into thinking I could sell dope, without using it? I was dissatisfied with my job, went traveling, and met “X.” He knew I’d hauled dope out of Florida in the past, for my brother in law. He asked about my connections and asked if I could help him move some kilos. I told him I still knew a few people, but I can’t be handling the stuff. I talked myself into believing I could sell that stuff and not use it. Insane.

That led to two and a half years in state prison. This put me in a controlled environment. I knew enough about recovery and the twelve steps and the change that can happen. I’d heard enough about it that I reached out and asked people I knew in NA to get me some [recovery reading] material. That was in 1988. They didn’t have as many 12-step meetings or substance abuse programs [in jail] then like they have now. I had to reach out and ask for help. I paid “Y” [an inmate] a candy bar so he would allow me to have an NA meeting in his cell, because it was the biggest. I paid a candy bar to him each meeting. He’d never been to a meeting in his life. This was in the county jail.

When we both got to state prison, they had NA meetings there. He got real involved. He got clean and is still clean today! He has twenty-one years in recovery, works in construction, and travels the world. I went to an AA meeting a few years ago, when I was visiting a town in Alabama, and it turned out he was speaking that night. He pointed to me and said, “That man is one of the reasons I’m here.” (At this point, ML tears up and takes a pause).

I had regular correspondence with friends, who sent me recovery literature. There was a “black market” step working guide. I used it and that’s the first time I did a “fearless and searching moral inventory” of myself. I didn’t have anyone to do my fifth step with [this is the step where the addict admits to God, himself, and another human being the exact nature of his wrongs].

At this point, I was in the county jail, about to go to state prison. This guy from Minnesota was in jail for thirty days for old warrants. It turns out he had a few years of recovery. He heard my fifth step and guided me through step seven. He mentioned his dad got [was sentenced to] forty years for murder. In the late 1970’s, when I was bringing cocaine out of Miami, the guy who set me up with the Columbians was named “Z”. I would meet him in a field [to exchange drugs] and he had a young boy with him. The guy who heard my fifth step was his son!

I’d been going in the front door of this state prison for six years, as an NA member, bringing meetings to the prisoners. Now I was in that prison. I progressed on through the steps, and experienced a change in my being…a real deep change that I can’t put into words. I recognized it was the beginning of a change that would continue to occur over a lifetime.

I relapsed once more, after nearly ten years clean. I got away from people in recovery, quit doing all the things I’d done on a regular basis, like prayer and meditation, meetings, contact with people in recovery. That relapse lasted a year. I was rescued by the Macon County Sheriff’s Office. I knew I was going to die. I was waiting for the overdose, the gunshot, whatever. I had no hope.

An addict always has the potential for relapse. I don’t care who they are, where they are, how long they’ve been clean or whatever. But once I experienced change on a deep level, mentally, emotionally, spiritually, and then used drugs again…you’re not the same addict. You don’t have the hustle. You can’t be as thoughtless, selfish, and solely self-focused as you were, before you experienced that change. I knew I couldn’t use drugs successfully, and I knew it was going to kill me. But when I lost that support, when I pushed away that foundation, that God of my understanding…That allows self-deception. It might be only momentarily, but you forget. You forget who you are, and if you’re where substances are available, you’re deceived.

JB: How’s your recovery now?

ML: Awesome. If you’d asked me in 1999 how I’d be doing now, I wouldn’t have gotten close. My life today is better than it’s ever been. I’m extremely blessed and grateful to be where I’m at today. I’m blessed to have the work, the people, a wonderful fiancée … I’m blessed to be able to share my life with the people I have in my life.

JB: What kind of work do you do?

ML: I work as a counselor. I work in a jail’s substance abuse treatment program. Looking at what they have available in jails now…fully staffed treatment programs, right in the county jail! From having to pay a candy bar to hold a meeting to where they have whole dorms in the county jail to treat addiction…the change has been awesome to see.

            This addict, ML,  described how his recovery progressed over time, and how he had setbacks and relapses. Obviously, given the morbidity and mortality of active addiction, treatment professionals and addicts prefer relapse-free recovery, but for many, relapse is part of the recovery process. Many fortunate addicts are able to get back into recovery, before catastrophe occurs.

ML is also a good example of how 12-step recovery meetings can help. Addiction treatment professionals should always inform addicts seeking recovery about these meetings, and encourage addicts to go to at least a half-dozen meetings, before deciding if 12-step recovery is right for them or not.

There are many recovering opioid addicts who used 12-step resources or other counseling to become completely opioid free and were able to get through both the acute physical opioid withdrawal and the more prolonged post-acute opioid withdrawal. Therefore, it does appear that drug-free recovery may be a reasonable goal for some opioid addicts who are motivated to do the work of recovery. For addicts who find the spiritual theme of 12-step recovery unacceptable, secular recovery groups are available.

            12-step recovery is free, widely available, and proven to work. It’s still the best deal in town.

Suboxone: Miracle Drug or Manacle?

Yesterday in my office, I saw patients for whom I prescribe buprenorphine (better known under the brand name Suboxone). It was not my typically pleasant day. Usually, I see the positive changes occurring in the lives of my patients: they are getting families back, getting jobs or better jobs, getting health and dental care needs addressed, and overall feeling happier and more productive.

 But yesterday I had two patients who were bitter about being on Suboxone. Both were having great difficulty tapering off of Suboxone. Both had also been reading materials on the internet that described the hopelessness of ever tapering off this medication.

 This frustrates me for several reasons. First, not everything you read on the internet is correct. Second, people don’t appear in my clinic requesting Suboxone for no reason. All of my Suboxone patients were addicted to opioids before I ever prescribed Suboxone. Even assuming no patient ever gets off Suboxone, it’s still so much better than what they were doing before. Third, I’ve never said it’s easy to get off Suboxone. It can be done, but it’s still an opioid. When you stop opioids, you will have withdrawal. There’s no way around that. 

Overall, most people say withdrawal off Suboxone is easier than other opioids. But people and their biochemistries are different, and I accept that some people have a worse withdrawal than other people. I’ve had a few people say methadone withdrawal was easier than Suboxone withdrawal. I have to believe that’s their experience, but I think that’s unusual, and not the experience of most people. 

Some doctors think patients on maintenance medications, like methadone or Suboxone, should always stay on these medications, given what we know about the rates of relapse and even death for patients who leave these programs. And some patients have continued sub acute withdrawal symptoms for weeks or months off opioids, and just don’t feel right unless they are on maintenance medications. These people seem to do better if they stay on maintenance medication. 

And on the other hand, many people are able to taper off opioids and remain off of them, and lead happy, healthy lives. I keep thinking about two groups of recovering opioid addicts who do well off of all opioids, on no maintenance medications: members of 12-step recovery groups, and recovering medical professionals.

 Off the top of my head, I can think of a dozen recovering opioid addicts who are members of Alcoholics Anonymous or Narcotics Anonymous, and who aren’t on any maintenance medications. They feel fine, and have been abstinent from opioids for years. If you don’t believe me, go to an open Narcotics Anonymous meeting. Ask the recovering addicts there if they have been addicted to opioids in the past. Chances are that around a fourth of the people you talk to are recovering from opioid addiction. There may be a few people who are on methadone or Suboxone, but many are completely free from opioids.

 Look at doctors in recovery. Opioids were the drug of choice for many addicted doctors, and they are “real” addicts, having used remarkable amounts of opioids before getting into recovery. But doctors have one of the highest rates of drug-free recovery. This isn’t because we are so smart or special, or because we have Charlie Sheen’s tiger blood. It’s because we are held tightly accountable by our licensing boards. If we want to practice medicine, we have to participate in recovery. Licensing boards often hold our licenses hostage unless we do the work of recovery. This may mean three to six months of inpatient residential treatment, after a medical detoxification. It may mean four recovery meetings per week for the first five years of recovery, along with monthly random drug screen, and a monitoring contract for five years.  (1,2)

If every addict seeking recovery could have that degree of treatment and accountability, I suspect relapse rates would be uniformly low. Sadly, that’s just not possible for most opioid addicts, because of financial constraints, and because there’s less leverage with most people than with licensed professionals. 

Not all opioid- addicted doctors do great off opioids. Many have multiple relapses, and would probably be much healthier and happier if they got on maintenance medications like methadone or Suboxone, but isn’t allowed – at present – by the licensing boards in most states. Again, one type of treatment doesn’t work for everyone.

 My point is that it is possible for many people to get off Suboxone, and live a happy drug free life. And for other people, lifelong maintenance is probably the best and safest option. At present, we don’t have a way to predict who might do well off of Suboxone (or methadone). We do know that a taper should be slow, and probably takes four to six months for a taper to give best results.

 I believe in Suboxone. It’s saved many lives, just like methadone has. I wouldn’t prescribe it if I didn’t know it works. I think what I’ve been hearing and reading is a normal backlash against the unrealistic expectations many people had for Suboxone. It’s been called a miracle drug, but it’s not. It’s still an opioid, and there is still a withdrawal when it’s stopped. It’s a great medication for many people. It can allow many opioid addicts to get their lives back and enjoy a normal life, except for having to take a daily dose of Suboxone. But isn’t that still drastically better than active addiction? 

  1. Ganely, Oswald H, Pendergast, Warren J, Mattingly, Daniel E, Wilkerson, Michael W, “Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000,” Journal of Addictive Diseases, Vol 24(1) 2005.
  2. McLellan, AT, Skipper, GS, Campbell, M, DuPont, RL, “Five Year outcomes in a cohort study of physicians treated for substance abuse disorders in the United States,” British Medical Journal,2008;337: a 2038.

Use of Prescription Monitoring in Suboxone Patients

I enthusiastically use my state’s prescription monitoring program. This database is available only to physicians who have applied and been approved for access. It records all controlled substance prescriptions filled by a patient, the prescribing doctor, and the pharmacy where they were filled. This means it records prescriptions for opioids, benzodiazepines, anabolic steroids, most sleeping pills, and prescription stimulants. Any prescription medication with the potential to cause addiction will be listed. Medications such an antibiotics, blood pressure medication, etc, aren’t controlled substances, and aren’t list on the website. 

I use this database in several ways.

It can help me decide if a new patient is really addicted to opioids, and appropriate for treatment

If a new patient has a urine drug screen that’s negative for all the opioids, and has no record of getting prescriptions for opioids, I’ll have to see objective evidence of addiction before starting to treat him with Suboxone. But if the urine is negative, and I see monthly oxymorphone prescriptions (sometimes missed on urine drug screens) have been filled, it’s more likely this patient is appropriate for Suboxone treatment. Rarely, a misguided, misinformed person might claim to be addicted to opioids in order to be prescribed Suboxone. This happened once to me, with a patient who was addicted to Xanax, and was convinced Suboxone would cure her. I referred her to more appropriate care.

Using the database can help detect a relapse sooner

Most of the patients in my Suboxone practice (around 80%) are pill takers, not heroin users. When they relapse, it tends to be to prescription opioids, obtained from a doctor unfamiliar with their history of addiction. I check each patient on the state’s database just prior to each visit, and if there are medications on the site I didn’t know about, that will be the main topic of our visit. New medication on the database doesn’t always mean a relapse, so I need to listen to their explanation.

 When it does mean a relapse, the patient and I decide what to do next. Often, the patient decides to allow me to call the other doctor, agrees to increase her “dose” of counseling, and possibly her dose of Suboxone, if it was an opioid relapse. If there are repeated relapses, I may decide Suboxone, as an outpatient, doesn’t provide the support a patient needs. Then, I refer to another form of treatment. Usually this means to a long-term inpatient drug rehab, or to an opioid treatment center, where the patient comes to the clinic every day. Either way, I believe I’m able to address a relapse more quickly using the database.

 Frequently, Suboxone patients get prescriptions for benzodiazepines. That’s a problem for me. For a person without addiction, benzodiazepines can be helpful, mostly used short-term. But for people with addiction, they usually cause problems, sooner or later. People with a previous addiction to any drug, especially including alcohol, need to regard prescription benzodiazepines as high-risk medications.

 I try to be flexible, too. If a traumatic event has occurred in the life of a patient, I may OK benzodiazepines short-term, provided I can see the patient more often and have good communication with the doctor prescribing the benzodiazepines.

  I also have to remember the body reacts the same to a mixture of opioids and benzos, no matter why they’re taken.  Even though Suboxone is safer than methadone, it’s still not safe when mixed with benzos, when taken for any reason.

If this sounds wishy-washy, that’s because it is. So many situations arise in the lives of patients that one hard and fast rule just doesn’t exist. That’s the art of medicine.

 Is the patient filling Suboxone on time?

The database also shows me when patients are filling the Suboxone prescription. If I write a prescription today, but the patient doesn’t fill it for two weeks, what’s going on there? Has he relapsed for several weeks? Did he have a stockpile of Suboxone from a previous prescription? Was he unable to afford it until now? All these questions and their answers are important to guide treatment.

 It makes me happy.

It warms my heart to see a patient who had a long list of opioid prescriptions from multiple doctors before starting Suboxone, then after entering treatment, see only Suboxone. This occurs in the majority of my patients.

My state’s prescription monitoring program is one of the best tools to help patients that I’ve ever seen. I believe it’s saved many lives. I think it’s just as important as drug screening for my Suboxone patients. Of course, the best tool for recovery is the counseling. I prefer 12-step recovery, as that provides ongoing support even after Suboxone treatment, but any kind of counseling helps. The patients I see doing the best are the ones involved in both formal counseling, in group or individual settings, along with 12-step meetings.

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