Twelve Step Recovery and Medication Assisted Therapies

by Louis E. Baxter, Sr., MD, FASAM | Jun 12, 2014

"You're not clean and sober if you keep taking that medication from your doctor!"

"You're just substituting one drug for another."

"You are depressed because you are not grateful enough."

These and other statements are often made to 12-step members who are legitimately prescribed and taking FDA approved medications to treat their addictions and other co-occurring illnesses. Unfortunately, this so- called “advice” from well-intended but misinformed members is not founded in scientific or 12-step philosophy and violates a long held 12- step policy of " AA members should not give medical advice to each other." (Read The AA Member - Medications & Other Drugs).

It is well known that AA supports and encourages its members to "follow doctor's orders." In an article published in AA News in 1999, author Dr. Jacqueline Chang wrote that research regarding short-term abstinence showed "other things besides and in conjunction with AA are helpful. These include therapy, counseling, and others like Valium, Antabuse, Naltrexone, and Acamprosate."

Dr. Ruth Fox, the Founder of ASAM, supported MAT. It is well known and documented that she regularly prescribed Antabuse to her family, friends, patients and colleagues to assist them in their recovery from alcoholism.

Further, Alcoholics Anonymous and Psychiatric Medication (September 7, 2010) says that "it became clear just as it is wrong to enable or support any alcoholic to become re-addicted to any drug, it equally wrong to deprive any alcoholic of medication which can alleviate or control other disabling physical and or emotional problems."

Although there is no dispute that abstinence from alcohol and other drugs with potential for addiction is the foundation for sustaining recovery in most instances, there are other cases where MAT, especially for persons with co-occurring illnesses, is essential to obtain and sustain term recovery. 

In the late 1980's it was discovered by NIH that addiction was a brain disease. Since that time, medications with FDA approval have been developed to target those areas of the brain. These medications have shown great efficacy in assisting patients into and sustaining recovery. Every other chronic medical disease employs and encourages the use of medications in concert with life-style changes. Addiction medicine should examine the benefit of following suit.

MAT in addiction treatment is not required for everyone, but used in conjunction with 12- step programs and other biopsychosocial interventions, for those that need it, has shown to be invaluable in appropriate cases.

Louis E. Baxter, Sr., MD, FASAM

Dr. Baxter is the Immediate Past President of ASAM and Executive Medical Director of the Professional Assistance Program of New Jersey, Inc, located in Princeton, New Jersey and Medical Director, of the Division of Addiction Services for the New Jersey Department of Health and Senior Services. He is also an Instructor in Medicine at the Thomas Jefferson School of Medicine in Philadelphia, Pennsylvania.

13 Comments

  1. 13 Yo 16 Sep

    In my not so humble opinion, but I think am pretty accurate. AA and NA unfortunately had been avoiding independent scientific studies. The treatment facilities would state something like "all we need to know about effectiveness (and safety I add) is a God and a Spiritual Program".  Although this may be true (or not) it has never been proven to be true.

     I have sat in too many meeting where I hear claims, (sometimes outlandish and exaggerated one added with quite a bit of embellishment)  for which they have no evidence of its existence nor truth.

     It should be in the best interest of AA/NA to allow independent scientific studies. And stop thinking that our own personal opinions are facts. It is in the best interest of the patient and its members that they should at least be honest with themselves. 

    I suspect that AA/NA might have something to offer, but as long as they continuo with this holy than everyone else attitude, I dare not go or recommended. What is the code of ethics. First do no harm? I can not in good conscience recommend something that operates in the fashion that AA/NA does.

    ----------------------------

    by the way your statement Dr. Baxter

    "In the late 1980's it was discovered by NIH that addiction was a brain disease."

    I guess that NIH is the NIDA main umbrella, but as far as I have been able to find. it is NIDA who has been making this claim. Although I wouldn't have any difficulty if this statement was true. That way we can deal with conditions more with facts.  It is my sense that this claim has not been proven but only repeated.  There are too many researchers who have been refuting this statement science it was brought up by Dr. Leaher and is being promoted by Nora Volkow <for which I have a lot of respect).

    Nevertheless, I believe given all of the research available the best we can truly and honestly say is that "the professions have yet to reach a consensus on this issue" Scott Lilienfeld PhD and Sally Satel MD the book Brainwash make some very compelling arguments that brings this claim in to question.  I follow Richard Dawkins philosophy that says "no amount of wishful thinking changes the facts." We have too many biases a work here.

    While Galileo Galilee has been reported to have said " Eppur si muove"  (still it moves, And yet it moves or  It does move) after he was sentence by the Roman Inquisition. I continuo to assert "This world still looks flat to me!!!".  

     

     

  2. 12 Violetagain 10 Sep

    I appreciated this article.  And I also appreciated all of the comments.  I think it is interesting that one person admits to telling her clients not to discuss MAT in AA/NA without gaining trust from the group first.  Obviously, this is a smart suggestion.  But what does this say about the social and political climate in the rooms of AA/NA?  I have been around AA for twenty years and I have seen very, very little evolution in the way people regard medication.  It is overly simple and obvious to point out the program (which is indeed faith based; please spare me the argument about it being "spiritual") is based on archaic doctrine.  The fellowship can be a wonderful thing; however, it can also be something that works against someone, too.  Esp. someone who is being judged by ignorami for using medication. I am not sure what the solution is here.  But I think articles like this one speak to an iota of evolution.  I just wish I had higher hopes for more of this kind of thing.  I think, without much despair, that AA/NA will mostly dissolve before it evolves. 

  3. 11 Michael Weiner, Ph.D., CAP 30 Jul
    Perhaps the only surprising thing about Dr. Baxter's excellent article regarding the effectiveness of Medication Assisted Therapies (MAT) is that it's still being debated.
    MAT works when it is individualized, accompanied by counseling, support, and is monitored by a physician certified by the American Board of Addiction Medicine (ABAM).
    It occurs to me that deeply rooted resistance toward the use of medication in any stage of recovery has prevented an open discussion. The result may have been that many people could have had a better chance of achieving long term recovery.
    Medications need to openly discussed.  All medications prescribed for a person recovering from an addictive disease should be monitored.
    As recovery progresses people get older. The likelihood that a person with an addictive disease will experience surgeries, pain, stress, panic, anxiety, depression, hypertension, sleep disorder, etc. increases.
    I would like to suggest Medication Monitored Recovery. The best situation would be that every person in recovery has a Primary Care Physician who is ABAM certified.
    At a minimum, an ABAM certified physician needs to be on the recovering person's medical team.
    There are physician groups that have shared medical records. If my ABAM certified physician is part of that group, he/she can review every medication prescribed.
    I would find that physician group very attractive.
    Perhaps we can move toward every physician group seeking a member who is certified by ABAM and toward Medication Monitored Recovery.
  4. 10 Mike D 02 Jul

    Interesting that the only MAT highlighted as prescribed to " she regularly prescribed Antabuse to her family, friends, patients and colleagues to assist them in their recovery from alcoholism." I, for one would like to see how many would prescribe methadone and or suboxone to this same cohort. Frankly, I have been asking this very questions to friends and professional colleagues in the field informally for the past 2 years. From what I can observe, first hand, the answer is pretty much "none."  So it is apparently OK for "us guys" to prescribe these powerful medications to "those guys" but when it comes to someone close to me they are "off the list." What does that imply about these beliefs, prescription meds, and the principles we allege to be promoting????

  5. 9 massive 01 Jul

    This is not true. AA members all over the country do tell their members that  to take medication or not take is not being " sober" . They are filled with "Playing Dr" all the time. Even the AA approved pamphlet you mention here is hogwash. How dare AA , a religious peer support group from the 1930's that is never been updated, tell anyone how to talk to their DR. How arrogant AA is and why are they so arrogant. AA members have no business taking about anything like this. They should say...I have no opinion! I have no knowledge! I am not a Dr  .... I am not a therapist. The day is coming soon when these sponsors will be sued, for all the suicides that have occurred in AA and NA rooms and culture because of this nonsense. 

     

  6. 8 Counselorchick 01 Jul

    Addiction is NOT a disease. 12 step programs are dangerous to acquiring a healthy mind. The only reason why AA wrote and released their pamphlet supposedly advising members to refrain from telling other members that their meds make them 'not sober' is 1) the practice is so widespread and 2 ) they are covering their ass. 

     The Church of BILLshit. Our mission - To Disempower you when you are at your most vulnerable and then to skull-fuck you till the day you die. Our door is always open. Leave your brain at the door and come right in. You cannot trust your own thinking but you can leave the thinking to us. We have no trained facilitators and we spout thought-stopping dogma to keep you coming back. We will, we will Rock You.

  7. 7 Rasha Kowalewski, BS, LADC 01 Jul

    Thank you, Dr. Baxter!  As a licensed alcohol and drug counselor working at an opioid treatment program, I encourage my clients to attend 12-step meetings.  I also encourage them to keep their status as a medication-assisted treatment particpant to themselves--until they establish themselves in the program and cultivate a feeling of trust with their fellows.

     Just as no one can label someone as an alcoholic or addict (only the sufferer can lable themselves), the same is true of sobriety.  I can call someone sober or "in recovery" all day long; if they don't believe it, what does it matter? 

  8. 6 Carlos 24 Jun

    I have been running from 12 Step programs since I hear them "share" at a  treatment facility. "Only 2 or 4 of you (of 100 or so present) will be clean and sober, one year after completion of treatment. I guess they were trying to impressed something on us. I was disappointed not inspired.

    I know a thing or two about statistics, and I told myself "Are you kidding me!!! and you want me to be listening to what you have to say?" Jesus Christ, maybe if I do not pay attention to you I might become at least a coincident, at best a placebo effect if I get clean on my own. From what I understood (am not sure how honest this numbers are either) I heard that 20% of patients who stop using substances do it without treatment. If this is true, and I do understand there are other variables. This may mean, that the 12 Step approach maybe doing worst than placebo. Or even some of the things they believe in or tell people actually may cause relapse rather than recovery  ( I sure like to see a number of studies that would try to answer those questions).

    This wouldn't be the first time that the field of mental health haven't done more harm than good. Back in the early 70s I believe it was the National Institute of Mental Health did a study and found that patients in waiting list were getting better than those who were getting "treatment". That was bound to raise my eye brows

    First I was not sure where they got this statistic from. I suspect that this number maybe a misinterpretation of the Triennial Report done by a non alcoholic Physician which is a member of the board of Alcoholics Anonymous.  Among other things the Triennial Report states that.  Only 4 or 5 persons who attend AA for the first time continue in the program a year later. They are not sure why? but one of my guesses is that they find the program unattractive like I have.  But of course in the mystic mentality of AA/NA member since they believe that unless you are going to meetings, have a sponsor and are not doing the steps you are bound to relapse. Of course they had never done a study, but they claim to be able to make conclusions from the mere observation of their group experience "We have learn from group experience that those who come to meeting regularly stay clean" Of course there seem to be some studies that indicate that it does have some ground in reality, but the numbers are not really that great either. It is not 100% as the statement seem to have implied to me. People who go to meetings regularly, have sponsor and do THE STEPS also seems to relapse regularly.

     As I recall, historically AA sponsors have been known to tell sponsees that they needed to get off their anti psychotic and anti depression medication, if they were expected to recover. If I recall correctly that also cause some problems and it may have been part of the reason why some doctors in recovery started to look at ASAM. Bringing a little sanity on this issues of medications. Keeping sponsors from trying to play doctor (or God).

    I think we need to rethink and redefine what is it meant by RECOVERY. Abstinent is surely not THE only definition. I always thought he had more to do with improving you social and perhaps even economic conditions of the patient. I have wonder if there is such thing as an Ego Syntonic opiate dependent person. I have read both in "Licit and Illicit Drugs" by Consumer Union Report and "Brainstorming" Dr. Solomon H. Snyder (the main researcher who discover the Opiate Receptors in the brain) both states that historically prior to the War on Drugs and the laws (like the Harrison Act) Opiate Dependence was not much of an economic or social.  problem. It is obvious to me that the whole history of Opiate Dependence (nor 12Step history) is not clear and up on the table.

    Researcher have had a problem studding The 12Step Program.  Many of the subjects and facilities avoided the studies on its effectiveness. They claimed that the only thing they need to know about the effectiveness of the program was a God and spiritual program. Recent studies have shown not so great statistics either. Some proponents attempted to "confirm the effectiveness" of the 12 Steps doing poor designs studies and extrapolating where there was no data. And like any other scientific research in any other field studies research is done to confirming and refuting their most beloved theories.

    To be honest, of course, the 12Steps never claimed to be a science (only a society or a fellowship). But its professional proponents did crossed the line into science when they tried to adapted it into a treatment protocol. They never checked to see whether the protocol was safe and effective. And given that 20% of addicts or users seem to quite doing substances on their own without treatment. I have to wonder whether the protocols was outdated before it was even implemented. Why Bogus Therapies Seem to Work  http://www.csicop.org/si/show/why_bogus_therapies_seem_to_work/

    Am sorry, but I need to question why it seem to be that there is a lot more recovery on patients who are treated with Methadone and Suboxone, than in the dominant protocol of the 12Steps. I do not have the data, nor studies to back it up. But if I am to assume (correctly) that not one treatment works for every patients. I surely need to question why is it not use as a option in all facilities to all patients both residential and out patients. Seems like we need to learn more about which treatment works best for which patient. But seem to be clear to me that we should be given patient and honest description of each of the programs and have the patient chose which one they think will work best for him. What a noble idea!!! Why don't we ask the patient what they want? Hester and Miller 2003 "Manual of Alcoholism" stated the data suggest that patient DO have an idea of what may work for them. After all Whose Treatment is it Anyway?

  9. 5 Joseph DeSanto 18 Jun
    This is a concept and decision that needs to be addressed on a patient to patient basis. Most patients I feel will benefit from complete (no addictive prescription medication AT ALL) abstinence and total physical sobriety. But based on personal experience, I have found that it's spiritual sobriety that actually keeps you from the next  (first) drink or drug. I have many patients with chronic pain issues and patients that are in high-risk fields (bartenders, nurses, pharmacists, doctors) that I maintain on  that are transparent with their use with me and their sponsors and partners, and attend 12-step meetings regularly and consider themselves sober. They possess a desire to stop drinking or using, maintain conscious contact with a power greater than themselves,  practice principles aligned with selflessness and good,  and they are helping those who still suffer. To me...THAT is true sobriety.
  10. 4 j. Becker 16 Jun

    How well a medication does work depends, partly, on the acceptance of its use by all those around the patient. Years ago I used Antabuse for the first few weeks of sobriety and compared it to punishing a puppy as soon as he made a mess as opposed to the next mornings hangover. The folks in my group "got it;"no problem. I was also taking antidepressants-a different story. It was obvious that a few members-influential members-didn't "believe in" those, like an article of religion.

  11. 3 Tony Riccobono, MS, LCADC 16 Jun
    I believe we are doing a disservice to our clients when we deny them the benefits of medication assisted therapy as long as it is coupled with some form of counseling or psycho-social support group. It is egocentric and close-minded to think we can treat the problem single-handed.
  12. 2 Peter L. Myers, Ph.D. 14 Jun
    The counseling field is quite dogmatic and resistant to innovation. The subfield of addictions is even more so. Nevertheless, I have noticed amongst my students that there is less resistance to MAT.
  13. 1 Edward Reading, PhD, LCADC 14 Jun

    We need more information like this spread out to addiction professionals...and those in training...

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