medication assisted treatment

How AA/NA Structures are Part of the Healing Process

In a recent blog from the Recovery Research Institute http://www.recoveryanswers.org/blog/12-step-mutual-help-and-medication-assisted-treatment/

by  Brandon G. Bergman, Ph.D. 

It was suggested that a survey of almost 300 long-term AA members (average time in recovery 13 years), more than half felt medication to resist alcohol cravings/urges was or might be a good idea, and 17% did not think it was a good idea, but were “OK with it”.

Obviously if these AA members have a respect for the Traditions of AA they would have been responding to the survey as individuals in recovery? As Tradition 10 of Alcoholics Anonymous states:-

“Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.”

This is a very important point. I do not write this blog as an AA member but as a researcher and recovering alcoholic/addict who seeks to combine  neuro-psychological research with the experiential insights I have been given as the result of recovery, albeit with 12 step recovery. I do not speak for AA nor would I wish to. I believe the traditions can be incorporated in our daily recovery like the 12 steps. The traditions are there to protect us from ourselves and gives us guidelines for interacting with the wider world.

Being drawn into public controversy is not good I believe for the health of AA or the recovering individual within AA.

I mention this also because in this article, the author appears to suggest that AA’s  membership has an  official positionon Medication-assisted treatment (MAT), including opioid agonists (e.g., Suboxone) and antagonists (e.g., Naltrexone and its monthly depot formulation Vivitrol).

Is this actually the case or is this statement misleading?

I will leave you to decide that? The   official position on MAT is that of the AA pamphlet The A.A. Member — Medications and Other Drugs – which this author suggests “appears to be one of skeptical tolerance”.

Personally I have read through the pamphlet and see no mention of MAT whatsoever.

The pamphlet appears to be alerting AA members to the reality that certain members “must take prescribed medication for serious medical problems. However, it is generally accepted that the misuse of prescription medication and other drugs can threaten the achievement and maintenance of sobriety”.

Among some suggestion listed in this pamphlet are

“• No A.A. member should “play doctor”; all medical advice and treatment should come from a qualified physician. • Active participation in the A.A. program of recovery is a major safeguard against alcoholic relapse. • Be completely honest with your doctor and yourself about the way you take your medicine. Let your doctor know if you skip doses or take more medicine than prescribed. • Explain to your doctor that you no longer drink alcohol and you are trying a new way of life in recovery….”

The pamphlet proceeds to warn

“From the earliest days of Alcoholics Anonymous it has been clear that many alcoholics have a tendency to become dependent on drugs other than alcohol. There have been tragic  incidents of alcoholics who have struggled to achieve sobriety only to develop a serious problem with a different drug. Time and time again, A.A. members have described frightening and sobriety-threatening episodes that could be related to the misuse of medication or other drugs.”

Experience suggests that while some prescribed medications may be safe for most nonalcoholics when taken according to a doctor’s instructions, it is possible that they may affect the alcoholic in a different way. It is often true that these substances create dependence as devastating as dependence on alcohol.

I can not see a “skeptical tolerance” or even a mention here of MAT.

The author then suggests that “broader anti-medication messages may be pervasive” within AA membership.

Although he slightly contradicts this by citing a survey “of almost 300 long-term AA members (average time in recovery 13 years), more than half felt medication to resist alcohol cravings/urges was or might be a good idea, and 17% did not think it was a good idea, but were “OK with it”. That would be a majority are “ok with it”?

The actual study concluded that “it did not find strong, widespread negative attitudes toward medication for preventing relapse among AA members. Nevertheless, some discouragement of medication use does occur in AA. Though most AA members apparently resist pressure to stop a medication, when medication is prescribed a need exists to integrate it within the philosophy of 12-step treatment programs.”

Why say it anti-medication views are pervasive based on this study?

However, one could say they are indeed pervasive based on the next study.

The author then states, “However, in a follow-up survey with about 130 participants from Project MATCH 10 years after they began the clinical research study, only 16% agreed that 12-step members say it is acceptable to take medications to address drinking problems.”

I found this passage a little confusing so looked at the original survey abstract which states “In general, client perceptions were not favorable about the use of such medications.”

The author then proceeds to mention NA’s official position “on individuals receiving MAT is welcoming on the one hand, while on the other, is explicitly restrictive and conveys a clear divide between members who are “clean” (i.e., “in recovery”) and those who are “on drug replacement therapy” (i.e., attending meetings but are not “in recovery”).”

NA’s “official position” is outlined in the pamphlet – NA groups and Medication

Drug Replacement

By definition, drug replacement is used for a different reason than prescribed medications for mental or physical health. This distinction makes drug replacement a separate issue for us in NA. When it comes to those who participate in drug replacement, it is helpful to remember that our Third Tradition clearly states that membership in NA is established when someone has a desire to stop using or when they choose to become a member, not when they are clean. No matter what the issue, groups are still charged with the goal of welcoming each person who walks into a meeting.

Some NA members are confused or even intolerant of those on drug replacement due to what they see as a contradiction between drug replacement and the NA principle of complete abstinence.

Some of us are fearful when those on drug replacement want to share or speak on behalf of NA. It may be helpful for all of us to remember that many addicts on drug replacement eventually do get clean, stay clean, and find a way of life they thought was unobtainable before coming to NA. This process doesn’t always occur when an addict attends his or her first meeting—getting and staying clean is often a decision that’s made after attending many meetings over a period of time.

As the Tradition Three essay in It Works: How and Why, reminds us, “Desire is not a measurable commodity. It lives in the heart of each member. Because we can’t judge the sole requirement for membership, we are encouraged to open wide the doors of our meetings to any addict who wishes to join.”

Opening our doors to these members means that groups take the time to discuss this issue and find ways to make everyone feel welcome. Each group is autonomous, and a group’s conscience will ultimately determine the level of participation of those on drug replacement.

What is most important is that we don’t let our fears get in the way of our group’s ability to carry the NA message of hope and freedom. The only requirement for membership is a desire to stop using. Tradition Three One of the most challenging aspects of this issue is that while an NA group is free to ask those who have used that day to refrain from sharing in the meeting, groups don’t decide what “using” means for an individual member. The use of medication is an issue that many members have strong personal feelings about, but a group is not there to enforce, endorse, or oppose members’ personal opinions.

Any member—those who take medication and those who feel taking medication is inappropriate—has a responsibility to not represent their personal feelings and opinions as the opinions of Narcotics Anonymous as a whole. In NA, we purposely attract people who are ill, unstable, and in need of help. Our challenge is to continue to practice tolerance, patience, and love, so that we create an atmosphere in which those who want to recover can do so.

Narcotics Anonymous is here to help addicts find a new way of life, and joining NA means becoming a part of a lively and diverse fellowship. As our First Tradition reminds us, “Our relationships with one another are more important than any issue that may arise to divide us.” Keeping this in mind allows our groups to best serve all addicts seeking recovery in NA.”

However, as the author notes in reference to William White’s observations , “there are no empirical studies of how MAT patients engage with NA or, in parallel, NA members’ perceptions and attitudes toward MAT. In an informal qualitative assessment of MAT-focused online discussion forums (e.g., suboxforum.com), however, he found that some individuals receiving MAT have had positive, live-saving experiences in NA, though the majority experience was one of feeling rejected, confused, or angry, sometimes leading individuals to seek support elsewhere.”

The author concludes that “the medication-skeptical culture in professional 12-step-oriented treatment programs and systems appears to be in transition. Cutting-edge, front-line organizations like Hazelden Betty Ford recognize the power, and evidence, in both linking individuals to MHO-based recovery supports, as well as the need to address opioid use disorders with a comprehensive biopsychosocial approach.”

“They are currently studying pilot outcomes of this new integrated treatment that uses MAT to help patients get into recovery emphasizing 12-step MHO engagement, with an eventual gradual taper once long-term, stable recovery is achieved. It is unclear whether this type of attitudinal shift is also taking place within the community-based 12-step MHO groups themselves.

In the meantime, the limited available data suggests individuals receiving MAT are likely to encounter concerns or outright opposition from 12-step MHO members (with greater anti-medication attitudes in NA). They and their providers and family/friends should be prepared for this. The field would benefit from research studies of MAT patients’ quality of life recovery outcomes, MAT patients’ attitudes about NA, NA members’ attitudes about MAT, and whether and how MAT patients can successfully navigate anti-medication sentiment during their 12-step MHO participation. Also, specific research questions around different opinions about agonists versus antagonists would have important implications on clinical practice. Finally, there are a host of non-12-step MHOs that the field knows far less about from an empirical perspective, like SMART recovery, which, for example, officially supports legally prescribed, evidence-based MAT.”

It is worth noting that AA also has no opinion on treatment centres either. What happens at HalezdenBettyFord is not the concern of AA.

The results of their study or prospective studies do not necessarily have any bearing on 12 step groups either.

There are a number of hugely important issues raised in this article, which is indeed timely.

In part 2 of the is blog I will attend to these points and another article recently posted in the After the Party Magazine.

In order to get to the bottom of this debate we have to ask ourselves some serious questions such as

What is that I suffer from as an addict (what are the underlying conditions)?

How are these underlying mechanism “treated”by 12 step recovery processes? What is recovery?

How would this treatment or recovery be helped or hindered by continued use of MAT – i.e. when is short term use ok and long term not (how do we draw he line between recovery and choosing an easier softer way which does not arrest our condition but may contribute to it’s continued trajectory?)

There may be no hard and fast answer to the last question.

I am not sure we have arrived at a comprehensive theory of addiction which links the cognitive affective mechanisms which mediate the impaired neurobiology of addiction.

As such we seem to rely on neurobiological accounts which have a focus on paradigms such as craving and cue reactivity etc when these are always mediated by factors such as stress and emotion dysregulation?

To conclude we need to ultimately consider recovery tools which address the emotion and stress dysregulation which maintain this disorder and prompts carving and relapse.

Whether MAT straightjackets or facilitates this process to wellness is ultimately the question.

My craving dissipated with full acceptance of my addictive disorder.

Ultimately it is a very personal question too!?

This is often for individuals, and their sponsors and home groups to decide not by “official positions” – to decide for themselves what is in the best interest of recovery within individual groups at a micro level not the macro levels that researchers want 12 step groups to comment on.

Researchers may also consider that it is not always fear that prompts anti medication debates but real concern that certain individuals are engaged in a recovery process. Not to be engaged in a recovery process or reluctant to be has obvious consequences also.

AA and other 12 step groups are ingenious in their structures  that flow from from the 12 steps, to the 12 traditions to the 12 concepts for World Service to help what is essentially group of, at times, fear based control freaks to live properly together, to recover, together. They achieve in that  human terms is the equivalent of learning how to  herd cats!

They are truly remarkable. They are also there to protect us from the however well meaning opinions of others, or otherwise, in the outside world!

The outside world often has not got a clear idea of how these structures protect our recoveries. AA is a network of indepedent groups, a federation in the true sense, of emotionally vulnerable people who only want to help others like them.  This is in fact how these fellowships  grow and recovery

Within these structures we try not take other people’s inventories but only our own. We try not judge but be tolerant of. Groups take their own inventories but not other groups’. in an ideal scenario anyway!

If individuals do not feel welcome in these meetings there are often other groups where they will.

I am stating this because there is an idea of 12 step groups as a monolith when the opposite is true. The liberties of 12 step groups far exceeds any other groups I have ever known. No one is in charge of AA or other groups and it is enshrined in our concepts, traditions and steps that we all,  AA and other 12 step groups included, have the right to be wrong.

It is via our own individual and group consciousness that the best direction that most suits others in need is sought.

We recover by helping others recover.

But ultimately we all have to consider as NA states ” What is most important is that we don’t let our fears get in the way of our group’s ability to carry the NA message of hope and freedom.

We do this I believe by “love and tolerance”  and by showing 12 step recovery to those who may not yet have it.

All our efforts thus must be to facilitate this for others, even if that is facilitated by a group conscience that seems at odds with the acceptance of MAT but hopefully not with our traditions of service.

In essence  part of AA and 12 step success is their organisational structures, it is how these groups are organised from the bottom up which keeps us in check. I have never come across a organisational structure, where no one dominates or is in charge, that is actually part of the healing process to such an extent.

We  can recover if we apply these guidelines to our own recoveries first before then considering how to respond to others.

 

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