Peaceful Coexistence

aaaagetting along

For years, I’ve asserted that patients on medication-assisted treatment for opioid addiction can find benefits in twelve step recovery meetings. Many of my readers have disagreed with me, vehemently at times. I was surprised and pleased when one of them forwarded me a reference to an article in the Journal of Substance Abuse Treatment that showed participation in 12-step recovery increased retention in buprenorphine treatment. (Thank you Zac). Of note, coercing patients to attend 12-step meetings was not found to be helpful. [1]

I know 12-step meetings work for my buprenorphine patients because I’ve seen it. However, I do think I have unusual patient population in my office-based buprenorphine practice.

I inherited many of my patients from a doctor for whom I worked for several years, until he retired in 2010. He was well-known and well-respected in the recovery community of the city where we worked.

Some people, already in recovery from alcohol addiction, were members of Alcoholic Anonymous when they sought treatment for chronic or acute pain conditions. These patients were prescribed opioids for pain by doctors who underestimated the risk of developing opioid addiction, in these patients with a personal history of addiction to another substance. Some of these patients were dismayed to discover they developed addiction to opioid pain pills, meaning they were misusing them by taking too many and running out early, or having obsessions and compulsions to take ever more pills.

Baffled and angry, those patient sought care from my doctor friend. He started buprenorphine and got them off the pain pills, and directed them back into 12-step recovery.

When he retired, I was fortunate that many of them followed me to my new practice.

Around twenty-five percent of my office-based buprenorphine patients are in this category. Most still go to 12-step meetings, though the frequency of meeting attendance varies widely. Some patients go a few times a month, and some a few times per week. I have one patient who goes two times per day. My patients have varying levels of attachment to the 12-step meetings and their participation at the meetings. All of them say they learn and are reminded of important tools of recovery. They say applying concepts like acceptance, tolerance, and kindness enhances the quality of their lives.

These patients, with very few exceptions, are doing very well in their recovery. They are also delightful people.

For these patients, being on medication like buprenorphine has stopped being as issue. Most of them say they know their recovery is better since starting buprenorphine. They don’t tell people they’re on medication, but neither do they hide it. They don’t really care what other members of 12-step meetings think about their medication; it works for them and improves the quality of their lives, while not causing euphoria or the compulsion to take more and more of their medication.

Let’s present 12-step programs as options for our medication-assisted treatment patients on methadone or buprenorphine. As this study shows, and as I see in my own practice, these two options can benefit our patients. Also, as I tell my patients, you can’t beat the price of 12-step meetings, since they are free.

I know 12-step fellowships aren’t for everyone. Though 12-step fellowships don’t endorse one religion over another, these fellowships are intensely spiritual. Not all people are comfortable with such things, or are uninterested in the spiritual side of life. But for those who don’t object to spirituality, or even enjoy or embrace it, 12-step meetings can be a haven of recovery.

1. Monico et al, “Buprenorphine Treatment and 12-step Meeting Attendance: Conflicts, Compatibilities, and Patient Outcomes,” Journal of Substance Abuse Treatment, May, 2015.

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11 responses to this post.

  1. Posted by Deb on July 12, 2015 at 9:17 pm

    Thanks for this. I counsel MAT patients and my concern here is that 12 Step meetings encourage complete honesty with self and others. Many patients do not feel comfortable sharing about their treatment because it negates their abstinence to misinformed or miseducated fellow group members and therefore fosters secret-keeping, which goes against the program. I am glad there are online meetings for MAT patients, but suspect they’re not as beneficial as gatherings in the flesh.

    Reply

    • It’s up to the patient, whether they feel staying quiet about medications amounts to secret keeping. I tell patients that if medication gets them high and they misuse it, it’s probably important to share about it. If it doesn’t get them high, I don’t believe they are keeping secrets. After all, in the actual 12-step meetings, participants are not encouraged to spew all their secrets. Meetings are a place to share experience, strength and hope. The fourth step stuff is intended to be shared with a sponsor or spiritual advisor in Step Five. Of course, meetings do vary, and what’s considered “overshare” in some areas may not be seen as overshare in another region.

      Reply

  2. Posted by Alan Wartenberg MD on July 13, 2015 at 2:23 pm

    Jana, perhaps you DO have an unusual population, and I am not saying that 12 step programs have no role, or that I haven’t had patients who have benefitted from it, but you have to know that there are people who are highly ambivalent about their MAT who are dissuaded from continuing it by people in 12 step meetings (including their sponsors), as well as people who are harassed in very nasty ways – not being allowed to speak at meetings because they are still “high” or “still using,” they cannot go on commitments, they do not receive sobriety recognition and this list goes on. I know there are meetings where their leadership has chosen not to follow national policy (in NA, it IS policy – publication 49, I think), and people can and do hide their use of MAT. However, this flies in the face of an ‘honesty program’ (although I have patients who do fine with it, especially within AA rather than NA). I must tell you that for every patients I have had who benefitted, two or three were lost to MAT and dropped out because of the influence of 12 steppers.

    Reply

    • And this article shows data that for some MAT patients, who are enthusiastic about 12-step recovery, participation improves retention in treatment. I do think you’re right about AA being less concerned with medication that NA, though. In AA, the focus is strictly on alcohol…even though 70-plus percent of AA members also used drugs other than alcohol.

      Reply

  3. My experinece is that most clients, especially if their clinical team supports and understands and is not critical of other paths that alos support recovery, can manage the ‘dialectric” and find a way to coexist using whatever tools work for them. Im near a lage city and most AA/NA meetings in this area are not so spiritually focused but for those who need a total repieve from that the AA Agnosica (see their website) and growing Athesistic/Agnostic AA movement can be helpful both on-line and live meetings.

    http://www.waaft.org

    Reply

  4. Posted by Joy Auren on July 13, 2015 at 4:57 pm

    I have found 12 meetings keep me grounded. I am reminded that recovery is possible and that I’m not alone. I don’t share that I’m on methadone but, if asked I don’t hide. Service work keeps me honest. It feels so good to encourage someone just coming in the doors or someone who is coming bk. After a relasp. Having as much support as you can is the best kind of meds! Peace

    Reply

    • Posted by Alan Wartenberg MD on July 13, 2015 at 5:06 pm

      Joy, if you are in NA, and they are allowing you to do service work, they are violating NA policy. That’s great, as long as the current leadership is around, but I have seen people in your position suddenly facing a very hostile new leadership of a meeting, literally demanding that they return their sobriety coins (I always wondered if they have a ceremony a la Dreyfus of stripping his rank and breaking his sword), and no longer even allowing them to speak at meetings. I am not disagreeing with the value of some 12 step recovery principals and practices (I was “in the Halls” for 20 of my now 37 years of recovery), but pointing out that there are some very serious limitations. Any clinician who refers their patients without preparing them for the possibilities, even rehearsing some role plays of how to handle them, is not necessarily doing their patients a service.

      Reply

  5. Posted by razorx on July 20, 2015 at 4:08 pm

    I am trying very hard these days to figure out just what my recovery is and how to continue with it. I find myself half angry most of the time. And why? because i am taking Buprenorphine for my opiate addiction and I was lead into the NA program by my Dr. I liked much of it. But, I held the Secret. The Medicine secret. I had friends there. I held a service position, I sat outside these meeting with friends as they All at one time or another had Judgemental, Close minded things to say about thoses “poor Addicts on that Stuff”. After three years my secret was out. Only took a week but in this town of 50.000,they all new..Warmth left the room for me. .. I left last August.

    I know what there book says, Im Not clean in the fellowship of NA. This Med Saved MyLife. As I watch others die.Die because there afraid to use a medicine. ..

    As much as Drs or other professionals in the treatment world would like to see MAT and the step world come togather, it may not be possible until more understanding happens in Trad recovery rooms. I guess the best thing for people to do is to come out first thing and have others know your on bupe. But what about privacy? … sorry for the vent, im very very pro suboxone, i see it change lives every week in my clinic and the other clinic i chair a sub support group. Yup, Two Sub support groups in one town. One 12 step based mostly, the other sub education. Wonderful. .I want people to be proud of there sub recovery and lives, not to feel the shame and guilt that they Will feel in thoses rooms. So much more to this, but uno, I must agree With Both Drs here who have commented.

    They both bring up very good points. ..And ill say this, after I left NA, days turned to weeks,then months…..nobody called..no tex…..Nothing..and THAT told all i needed to know..

    Im Clean Enough this day and the last 1648…and counting. ..

    Reply

  6. Posted by christy sayer on August 14, 2015 at 7:53 pm

    I am new to this blogging thing and dont know how to ask you a question directly. I signed up for your blog and got email confirmation but now how do i post a question about my own subject?

    Reply

  7. This is the only topic I’ve disagreed with you Dr. Burson. I think rather than putting patients at risk of being shamed or having them lie by omission to be accepted we need to work on organizing new meetings or utilizing meetings like SMART and Lifering. How can a person be dishonest in a program of rigorous honesty? Also simply hiding ones use of medication and the success of it builds shame and doubt in the patient. I don’t understand the insistence of continuing to promote these meetings when we’re supporting science based and evidence based treatment. Mixing the two is like trying to mix astrology and astronomy. On one hand we have a medication which has been proven very effective and in the other hand we have a treatment approach which claims the only path to recovery is a supernatural force. That is not evidence based. Also speaking of evidence the Cochrane Collaboration reviewed all the literature and found 12 step facilitated treatment to be ineffective. The World Health Organization has also published a paper coming to the same conclusion. When Dr. George Valiant of Harvard studied AA to prove it’s effectiveness he found a success rate of 10% but he also found a natural recidivism rate of 10% in patients with no treatment at all. He also found the AA group had a higher mortality rate and more days of binge drinking. The only positive aspect of the meetings is the support of peers in recovery but the groups scorn those who think that way because they claim it’s all about the steps and a higher power. It has always baffled me how anyone could support a model for change which tells you you’re powerless, you are unable to make decisions for yourself responsibly, and you must believe in a supernatural force which guides you, even if it’s a supernatural rock. The worst thing for me is that their model for treatment hasn’t changed since it was developed in 1935. I’m very suspicious of an organization who’s purported goal is to help others yet disregards any advances which have been made and is focused more on converting a person to their beliefs than exploring other avenues in which they might be more successful in helping their members.

    Reply

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