The Move Away from Abstinence Based Addiction Treatment

Richard Taite’s self-serving article contains numerous untruths and mischaracterizations, and I welcome the opportunity to clear up the record.

Addiction treatment is changing, and must; it’s just not changing fast enough. The misuse of heroin and prescription painkillers (collectively classified as opioids) has been labeled an epidemic by the Centers for Disease Control, and people are dying in record numbers from overdose. Here at the Hazelden Betty Ford Foundation, we’ve seen a pronounced increase in the numbers of opioid-addicted patients. This population also has unique problems -- like hypersensitivity to pain -- that often undermine their ability to remain in treatment and ultimately achieve long-term abstinence. Our response to these unique challenges combines all of the best available treatments for opioid dependence, including Twelve Step programs, specific psychotherapies and certain medications, to give those with opioid dependence the best chance for lifelong recovery.

Our new program for opioid dependence, the Comprehensive Opioid Response with Twelve Steps (COR-12), provides certain medications (Suboxone or Vivitrol, not methadone) for some patients. These medications are evidence based, reduce the risk of overdose death, increase engagement in treatment and are extremely beneficial in preventing opioid use when prescribed correctly for the right people. Our program has resulted in more patients staying for full treatment and a reduction in overdose death upon relapse after treatment. These patients experience the same joy and heartache of early recovery, whether on medications or not. Our goal is to engage them long enough in recovery-based activities that they can ultimately go off the medications. This is being realized every day in our outpatient settings as these patients dramatically change their attitudes, start to witness the real gifts of recovery and transition off medications.

Some see medication assistance and abstinence as diametrically opposed. We do not. Even when medications are part of our protocol, abstinence is still the objective. The medication, in those cases, is simply a part of the path to abstinence. We call it COR-12. But one also might call it the “Third Way” because it strikes a reasonable, common-sense balance grounded in the Twelve Steps and based on abstinence, while also utilizing the safest, life-saving medications that keep these patients engaged in recovery long enough to achieve long term sobriety.

Our commitment is absolutely to abstinence, and always will be. Using medications conservatively and according to the evidence, as we do, does nothing to compromise that commitment. Any characterization of our approach as “harm reduction” is simply inaccurate and uninformed.

We have chosen to use everything at our disposal to treat opioid addiction, due to the escalating crisis and high death rate. We remain absolutely committed to Twelve Step recovery, in fact even more so having witnessed these people engage in recovery and reclaim their lives. We are doing research on our method and the early results are very encouraging. We hope other programs will do the same, use the science and the spiritual, provide these medications, engage more people in treatment, save lives and ultimately help more get into long term recovery.

Marvin D. Seppala, MD
Chief Medical Officer, Hazelden Betty Ford Foundation

I applaud anyone who takes steps to regain control of their lives. I am an alcoholic, I quit completely. My neighbor went from pain pills to heroin. Her use became very destructive. Thank she went from heroin to methadone to marijuana.
It is not a perfect solution but it is a better life than the one where heroin had total control. She is not a risk with the law. She doesn't need to sleep with strange men to pay for her pot habit but she did when heroin was her preferred drug.

I do not understand why abstinence proponents find harm reduction such a terrible thing. They live one day at a time, why is it wrong for people to regain control of their lives one step at a time until they get to where they (not other people) want to be.

I am a masters student in Addiction Studies and I've been in MAT recovery for 4 years and two months exactly. Recovery with buprenorphine plus therapy has turned my life around for the better. I don't know why anyone in the addiction treatment profession would want to take tools out of the addict's arsenal. For example, buprenorphine is not a cure-all; it is a tool that works for some opiate addicts. The day I started buprenorphine was the day I stopped obsessing over opiate medications. I noticed that my withdrawal symptoms were gone immediately, but I didn't notice that I had stopped obsessing over pills until the next day when I noticed I had a lot of time on my hands that I wasn't used to. Buprenorphine was the tool I needed to stop my abuse of opiates and therapy was the adjunctive tool which helped me understand why I was susceptible to opiate addiction in the first place.

Outside of my own experience there are studies showing the efficacy of buprenorphine in opiate addicts. For example: http://archpsyc.jamanetwork.com/article.aspx?articleid=1107433 Where are the studies backing up treatment for opiate addicts based on 12 step models?

My other question is about the consequences of abstinence-based treatment. How many opiate addicts have gone into abstinence-based treatment, detoxed off opiates, maintained a short period of sobriety, were kicked out of their treatment program because they slipped or relapsed, and overdosed when they took their normal fix which was now too much for their level of tolerance?

The answer is: far too many. A treatment system which says, "You messed up. You're out. Come back when you're ready to work at sobriety," is allowing many addicts to slip through the gaping cracks. Such a high threshold for treatment is killing addicts, especially opiate addicts. On the other hand, harm reduction says, "Progress not perfection." (I am very aware of the irony.)

After all, does anyone win a prize at the end of a long life if abstinence is maintained as opposed to treating addiction with a medication? No! The prize is living a long life not cut short by failing at abstinence. Let's give addicts the chance to live and work toward progressive goals that may include abstinence. The special club is for those who survive addiction! Not just for those who survive addiction through abstinence.

Why is it so many 12-step folk are adamant that their way of recovery is the only way?

I was a Narcotics Anonymous member for 8 years. In that time I worked the steps multiple times, held multiple service positions, worked under the guidance of my various sponsors, stayed away from relationships for the first year of recovery, attended on average one meeting a day. Despite all this, I relapsed. Multiple times. I call it "relapsing on the program", and according to the basic text, it can't happen. But talk to many relapsed members and you'll get a more accurate picture. In those 8 years in NA, the most clean time I achieved was 18 months.

And every time I relapsed, I relapsed HARD. I was so convinced of my powerlessness over my addiction, that every time I picked up I was totally at the mercy of my disease, that I had to hit a new rock bottom, that it became a self-fulfilling prophecy. So every time I picked up, my relapses became more life-threatening, as I let myself sink deeper in the hope it'd help me eventually stay clean. How backwards is that? Some members even suggested to me that I might need a stretch in jail to "get recovery".

I'm one of the fortunate ones though. After 8 years in NA with mixed success, I had the insight to question the program and how well it had worked for me over the years, especially given I had followed the program's direction to a tee. I realised that, despite my intermittent periods of clean time, I had essentially been forced to restart my life every time I got clean. I had really achieved very little in terms of life achievements. Because of my various sponsor's directions and the fact I was perpetually in early recovery, I hadn't studied, worked, and I'd stayed out of intimate relationships. All I really had to show for my clean time was a bunch of plastic keytags and a couple of exercise books full of step work. Nothing I could put on a resume.

So I left NA and went on Suboxone. In hindsight, short of trying to get clean in the first place, this was the best decision I made for my recovery. It's been 3 years since I put a needle in my body, I'm about to graduate university, I'm in a stable, loving relationship with a healthy, non-addict partner. I have my own apartment, and I run my own small business. In short, I've achieved more in these 3 years than I did in the whole 8 years in NA.

For a program that espouses the virtues of being honest, open-minded and willing, NA is extremely closed-minded to the benefits of medication like Suboxone. A member could win the Nobel Prize and still be looked down on if they were on Suboxone. It's for this reason I don't attend NA while on Suboxone.

Maybe I need to take inventory, but there is still some resentment that nobody in NA ever said to me "mate you've been trying to get this program for 8 years and keep relapsing. Maybe it's time you tried something else". I know people in NA who have been trying to "get the program" and stay clean for decades, and nobody in the program suggests they try medication, or SMART recovery, or a different program. Many people die trying to get clean the NA way. I thought the definition of insanity was making the same mistake and expecting a different result?

12-step abstinence based treatment doesn't work for everyone. In fact, studies show it only works for approximately 5% of people. The thousands of people I saw come into the rooms of NA, then leave within 6 months, is evidence enough for me that figure is accurate. And, like Richard who wrote this article, that 5% are always so adamant that the program works for everyone, and that there's no need for any alternative approaches to recovery.

I hope for the day that 12-step fellowships are more open-minded to alternative approaches to recovery. But I don't see that day coming anytime soon, sadly.

Access to opiate replacement therapy is by far the most successful intervention for opioid dependence.

The article's author blithely dismisses "replacing one drug with another," as if any "drug" is inherently bad.

Opiate replacement therapy saves countless lives. A rabid adherence to the dogma of purity and abstinence has led to thousands of needless deaths by overdose. These tend to occur during the inevitable relapse after a period of abstinence wherein the opiate addict's tolerance has been significantly reduced.

The author mentions evidence-based treatment at the end, but then decides to completely disregard all the evidence around MAT throughout the rest of the piece?

This is one of the problems currently facing the field AND in really helping people recover. Betty Ford and Hazelden, trailblazers and leaders in the field of addiction, embracing MAT should be a huge cue that there is significant evidence of efficacy.

The contradiction between the importance of implementing multiple modalities, but then claiming only 1 - abstinence-based 12 step - is the answer should not go unnoticed.

This is where the field is truly lacking. Many are slowly embracing the fact that 12-step programs are not the only answer, but they merely tack on additional modalities to 12-step. The modalities are not used as evidence dictates works best, but almost superficially, with 12-step still being the center.

So why this insistence on holding on to 12-step with its 5% efficacy rate? It's just dogma. The field is full of that 5% where 12-step worked incredibly well, highlighting its usefulness for that small population, but we need to truly embrace individualized treatment, which means evidence-based treatment modalities that can and will differ by individual. Slapping a one-size-fits-all abstinence-based 12-step model on everyone goes beyond doing a disservice to patients, it can actually cost them their life.