Who’s Sober in Narcotics Anonymous?

Abstinence-only ideology in twelve-step treatment programs is making it harder for addicts to stay clean.

Anochecer en la escollera III by Ignacio Pinazo Camerlench, 1898. Google Arts and Culture

Dahlia took her first oxycodone at nineteen, months into her first semester as a college freshman. She was curious and a little naive with a penchant for trying her luck — and drug addictions, she thought, were for other people.

“It was the worst kind of stupid mistake,” she said.

What followed was months of chipping pills; oxycodone and codeine. She crushed them in a straw and snorted them in the bathroom before class. But pills were expensive. Heroin was cheap. Within the year she had dropped out of school and graduated to an intravenous heroin habit that she’d wrestle with for the next five years.

At twenty-two, Dahlia entered a four-day detox center and relapsed twenty-four hours after she was released. A few months later she tried a different rehabilitation program, stayed clean for a month, and relapsed again. So began a familiar cycle. Scoring heroin when she had the money, suffering brutal muscle aches, chills, and vomiting when she didn’t.

Exhausted and desperate, Dahlia’s family helped her get into a methadone treatment program. On methadone, Dahlia finally kept off heroin. For the first time in years, she woke up without thinking about her next fix, where the money was going to come from, if the needle was safe, or whether the next batch would be cut with fentanyl, a powerful synthetic opioid that would put her at risk of overdosing or dying.

Six months later, she’s at a Narcotics Anonymous (NA) meeting, hoping for a sober chip — a plastic round emblazoned with the NA logo and a time stamp: Six Months Clean and Serene.

When it comes time for members to celebrate their clean time and receive their sober chips, Dahlia stands. But as she moves to the front of the room, the meeting leader shakes his head. He explains that she’s ineligible for a sober chip as her methadone use means she’s not sober. The group does not acknowledge her clean time.

“I was embarrassed. I was angry. I felt like a failure,” Dahlia said. “Here’s this drug, methadone, that’s been a miracle for me, I haven’t been at risk for overdosing. I haven’t been using needles. I consider myself clean. What have I been doing for the last six months if I haven’t been clean?”

Clean Time

Clean time is an essential element of a recovering addict’s identity. Something to ground you, something to aspire to. The weeks, months, or years accrued become a yardstick to measure your addiction against: Look at what I have achieved; look at all the time I hold away from my demon. Clean time grants a person status, pride, and perhaps most crucially, a rank among others who are also in recovery. Given its deeply personal, often clearly precious status to a person in recovery, what does it mean to have clean time questioned?

For Dahlia and others using medication-assisted treatment (MAT) like methadone to treat their opioid addictions, Narcotics Anonymous meetings can become zones of judgement rather than the support groups they’d hoped for. They report being asked not to share during meetings, being made ineligible for clean-time recognition, or made to feel otherwise ostracized and unwelcome by the group.

All NA groups are considered autonomous and therefore each group meeting is different, but the frequency of complaints about discrimination against MAT patients in NA makes the pattern clear. Narcotics Anonymous as an organization resists full acceptance of medication-assisted treatment patients, often resulting in MAT members feeling rejected or even discriminated against during NA meetings.

In 1996, Narcotics Anonymous World Service Headquarters issued Bulletin no. 29, an organization-wide memo that clarified their position on the use of medication-assisted treatment options. The bulletin rules that each NA group reserves the right to discourage or outright deny members on MAT from sharing during meetings. Also, in order to “preserve the atmosphere of recovery in meetings,” no current MAT member can hold elected service positions within NA leadership.

None of this is to say that individuals using methadone or buprenorphine (also known as suboxone) are necessarily unwelcome in NA meetings. NA is quite explicit in stating that all that is required for membership in NA is a desire to be clean from drugs. Yet just as each group of NA is autonomous from one another, each member of NA is given license to interpret literature such as Bulletin no. 29 as they see fit, leaving individual members of NA to decide how to define MAT users within their community.

As a part of the twelve-step tradition, Narcotics Anonymous does not believe that those members using MAT are abstinent. NA’s definition of abstinent is to be free from all drugs. Therefore, the use of MAT would technically fall outside of total abstinence. However, like other twelve-step programs, NA does make exceptions for medicinal drug use; in a pamphlet titled In Times of Illness, it cautions that “taking medication as prescribed for an illness is not the same as using”. So, what makes MAT different?

When a body used to opioids is deprived of the drugs, it can cause symptoms like severe nausea, shivers, and body aches lasting from three to ten days. People in recovery swap stories about how to alleviate withdrawal: spend the first twenty-four hours submerged in hot water to stop the chills, weed might stop the vomiting, and magnesium helps with the leg cramping. Sometimes just the fear of a terrible, painful withdrawal is enough to keep someone using opioids; buying themselves a bit of normalcy between periods of “dope-sick.”

MAT aims to stop this cycle. Being opioids themselves, methadone, and buprenorphine can fulfill a person’s cravings and stop withdrawal. What’s different is that these drugs are administered in carefully controlled doses in a safe medical setting. When used as directed, the drugs do not produce the same euphoric high that opioids do when abused. Since the opioid user no longer needs to avoid withdrawal and their physical cravings are managed, MAT significantly reduces the risk of relapse.

Methadone is a full agonist, meaning that it stimulates the same opioid receptors as heroin or oxycodone. Buprenorphine, similarly, is a partial agonist, so it partially stimulates and partially blocks opioid receptors in the brain. Because of this, both these MAT methods are often stigmatized as simply replacing one drug for another — substituting heroin, for example, for methadone treatment.

Such is the stance reflected in Narcotics Anonymous literature. Addressing the issue of MAT, NA’s Bulletin no. 29 reads, “Our program approaches recovery from addiction through abstinence, cautioning against the substitution of one drug for another.” MAT is therefore not categorized as a prescribed medication, but as a kind of “swapping out” that perpetuates the user’s drug abuse.

When the medication is used as prescribed, a MAT patient does not suffer the same risks and health damage as someone struggling with an opioid addiction; in particular, they have a much lower risk of dying from overdose. Yet the stigma against MAT means that many addicts are still deprived of this potentially lifesaving medical care.

For some MAT patients, going to an unsupportive NA meeting nearly cost them their recovery. Dan, a thirty-year-old suboxone patient recovering from a ten-year oxycodone addiction, had been doing well on his buprenorphine regimen until a move from Michigan to California left him feeling isolated and anchorless. Fearing he was in danger of relapsing, he decided to attend a Narcotics Anonymous meeting to find support.

Unaware that the meeting he was attending held a negative view of MAT, Dan shared that he was struggling despite his six-months clean on suboxone. They immediately told him that he wasn’t really clean, and his recovery wouldn’t actually start until he was abstinent even from suboxone.

Already in a vulnerable place, Dan took them at their word.

“I thought, hell if I’m not clean then what does it matter?” Dan relapsed less than fifteen hours later with a score of oxycodone he bought off Craigslist.

Dan acknowledges that it wasn’t necessarily the NA group’s reaction that caused his relapse. He’s very clear that to an addict about to relapse, the tiniest excuse to slip up is enough justification. A whole series of factors may have contributed to his drug use: the stress of finding a new suboxone provider, his untreated depression, the judgmental side-eye he’s sure he got from the pharmacist when he went to pick up his suboxone prescription, etc. Yet it’s the reaction of that NA group that sticks with him.

After a few months of opioid abuse, Dan got back onto a suboxone regimen and feels back to normal. He has not gone back to NA.

One Size Fits All

Many MAT patients, like Dan, attribute their return to normalcy — lives led without fear of overdosing, the pain of cold-turkey detoxing, or the crippling feelings of failure, anger, and shame should they relapse — to medication-assisted treatment.

“With methadone, I feel normal — normal like I can make my own choices. I can move forward with my treatment and my life. And I don’t have to see my father cry again because I’m back on heroin. That’s what clean means to me,” Dahlia said.

Those who have found success at taming their addiction with MAT have gained stability and safety, affording them a measure of control that they never had with their previous substance use disorder. Medical authorities such as the National Institute on Drug Abuse, Centers for Disease Control and Prevention, and the World Health Organization all recognize medication-assisted treatment as the gold-standard for addiction recovery. Studies show that medication-assisted treatment significantly reduces opioid-related deaths and can cut the mortality rate among addiction patients by half or more.

Opioids claimed 42,000 American lives in 2016. With the opioid epidemic set to result in a half-million American deaths in the next decade, the stigma against MAT may literally cost thousands of lives.

Yet twelve-step programs such as Narcotics Anonymous set the dominant narrative in the business of recovery. According to a 2013 study by the Substance Abuse and Mental Health Services Administration, twelve-step programs such as NA are used at least occasionally in more than 74 percent of treatment centers in the US. NA alone claims to have 67,000 meetings worldwide.

Hospitals, outpatient clinics, halfway houses, and rehab centers use the twelve-step program as a basis for treatment. TV shows and movies depict twelve-step meetings. Even US drug courts routinely sentence offenders to court-ordered attendance to Narcotics Anonymous meetings as an alternative to mandatory rehabilitation stays or jail time.

By sheer prevalence, NA and other twelve-step programs have become deeply embedded in how we understand the narrative of addiction. By insisting on abstinence-only sobriety, Narcotics Anonymous subtly frames the question of cleanness and abstinence by implying that recovery should be achieved through willpower alone. Within NA, a person may admit that they are powerless over their addiction, but they are expected to have the power to choose abstinence.

Medical evidence dramatically contradicts this notion. According to a survey conducted by Harvard psychiatrist Lance Dodes, twelve-step programs used as the sole recovery method may have only a 5 to 10 percent success rate. Lodes found that this method has a high attrition rate and prevalence of relapse.

Accepting NA’s framing means prioritizing abstinence over the use of a method proven to save lives. With this kind of mentality, the stigma surrounding MAT patients is reinforced, with very real consequences. In 2017, for example, then-US Health and Human Services Secretary Tom Price affirmed the stigma against MAT to justify his support for more twelve-step programs or faith-based rehabilitation techniques.

“If we’re just substituting one opioid for another, we’re not moving the dial much,” Price said.

His statement was met with ire from the medical community, including former US Surgeon General Vivek Murthy, who responded in a series of tweets, “Research clearly shows that medication-assisted treatment leads to better treatment outcomes compared to behavioral treatments alone.” A spokesman for Price walked his statement back, but the comment shows how the stigma against MAT continues to influence policy makers at the highest levels of the country’s health care system.

According to a 2016 Surgeon General’s report, just 10 percent of Americans with a drug use disorder obtain medication-assisted treatment. The report attributes the low rate to severe shortages in the supply of care — shortages that can lead to waiting for weeks or months to receive treatment.

The idea that MAT merely replaces one opioid with another underlies the federal government’s policy of placing caps on the number of MAT prescriptions for fear that the drugs will be diverted and used recreationally. US doctors have strict limits on how many patients they can supply buprenorphine to. Clinics that supply methadone also have a patient cap and recipients must attend the clinic every day, without the option of taking the drug home. Both options limit how accessible the treatment is.

An analysis of 2016 data from the Substance Abuse and Mental Health services Administration by AIDS/HIV advocacy group, amfAR found that of the more than 12,000 drug addiction treatment facilities in the US, only 41.2 percent offered at least one kind of MAT for opioid addiction. Fewer than 3 percent offered all three.

Addiction recovery is not a one-size-fits-all kind of treatment. While MAT is still the most successful medical option for treating opioid addiction, it still may not work for as many as 40 percent of opioid users. Some patients might not respond well physically to the medications, or the medications may for whatever reason fail to keep them from misusing drugs.

Others may find that a twelve-step program such as Narcotics Anonymous does work best for them. They may be seeking an abstinent recovery treatment as well as support from like-minded people. In fact, the sense of belonging, of being shown empathy and support within a recovery community, is why many people choose to attend twelve-step meetings. Given how often recovering addicts are marginalized, having an understanding and supportive community that teaches crucial coping techniques can be critical to an addict’s continued success.

A Path to Recovery

NA has saved lives, no doubt. But allowing a twelve-step model of abstinence-based treatment to nearly monopolize how we define who is and isn’t considered clean and in recovery not only risks further marginalizing addicts for whom abstinence hasn’t worked. It also contributes to a system that denies potentially lifesaving medication to those who may need it most.

Molly, a heroin addict for six years and now in recovery for the past three years, views the fellowship of the twelve-step program as the most valuable part of her recovery. But ultimately it wasn’t enough to get her clean. For the first three years of her recovery she was in an intensive outpatient program that strongly prioritized NA’s twelve-step abstinence approach. For those three years, Molly was caught in a cycle of detox and relapse.

Finally, Molly decided she wanted to make the jump to trying suboxone. When she told her therapist, however, Molly was informed that she was no longer welcome in the recovery group.

Molly was on suboxone for two and a half years and has now been completely free of MAT for nearly a year.

“I had hoped that people in this profession would be more open-minded about maintenance medications. After all, suboxone saves lives” Molly said.

Jamie Engel, who works as program director for a transitional sober living house in the Chicago area and has been working in addiction recovery for nearly seven years, says it doesn’t have to be so antagonistic.

Engel is a longtime advocate of twelve-step programs like Narcotics Anonymous, but also supports his residents using medication-assisted treatment. He believes the ultimate goal for those in recovery should be abstinence but acknowledges the key role that MAT can play for getting patients to that goal.

“I see MAT as giving you back your agency. When you’re in the swings of addiction, you’re not in a place to make any decisions, you just can’t. MAT gives you the control that you need to move towards abstinence,” Engel said.

The role that MAT plays in recovery is personal for Engel. He himself used buprenorphine for ten days as a part of his detox process. But he considers his clean date to be the day he stopped heroin, not the day he transitioned off of his medication-assisted treatment.

Engel stresses the deeply personal nature of one’s clean time and individual method of recovery. For him, being clean means having made the decision to be free from abusing opioids and is not necessarily dependent on one’s total abstinence from drugs as a whole. No one else, Engel says, should be able to determine when an addict is in recovery or when an addict is clean.

Yet like any system comprised of individuals, each autonomous Narcotics Anonymous meeting risks having members express strong opinions against MAT patients’ status, which might alienate or drive those members away.

Such opinions wouldn’t matter as much if alternatives to twelve-step groups were more accessible to those in recovery; members on MAT could simply find another group to attend. But alternative support groups, such as STAR recovery or Women in Recovery, have a tiny fraction of the available NA meetings in the United States.

Even Narcotic Anonymous’ platform of abstinence-only sobriety isn’t necessarily a problem on its own. Many people have found success through the twelve steps. But when abstinence sobriety becomes the dominant recovery narrative at the risk of possible further harm to other treatment techniques, that’s a damaging precedent that should be addressed.

“I’m tired of my friends dying,” Dahlia said. “If we’re all trying to get clean, what does it matter how it’s done?”