Bill White, Marc Galanter, Keith Humphreys and John Kelly have noticed some trends in the coverage and public health responses.
Public health responses have focused primarily on 1) suppression of illicit opioid markets, 2) public education on opioid addiction risks, 3) prescription medication disposal campaigns, 4) opioid-focused physician training and prescription monitoring, 5) new non-opioid protocols for non-cancer pain management, 6) introduction of abuse-deterrent opioid formulations, 7) increased legal access and distribution of naloxone (Narcan®) for overdose intervention, and 8) efforts to expand access to addiction treatment—particularly medication assisted treatment (MAT).
But there’s a troubling omission. What is it?
As long-tenured addiction researchers, the authors have supported these efforts, but have been struck by the scant attention given to the role recovery mutual aid organizations such as Narcotics Anonymous (NA) can play and are playing in the national response to opioid addiction. If NA is mentioned at all in public or policy discussions of opioid addiction, it is as a fleeting reference to its existence as a post-treatment referral option, or, more frequently, in criticism of its alleged hostility toward maintenance medications in the management of opioid addiction.
The writers identify 11 misconceptions about NA that contribute the neglect of this story:
Misconception 1: NA is a treatment for opioid addiction and other substance use disorders.
Misconception 2: NA meetings and the NA program are not widely accessible.
Misconception 3: NA suffers from a lack of members in long-term recovery. (Variations: There are no “oldtimers” in NA like those found in AA. There is too much street culture in NA. Opioid addicts should be referred to AA rather than NA because AA has a stronger recovery culture. I referred a client to NA, and they were offered drugs at their first meeting. Don’t most NA members have criminal backgrounds? My clients would be offended by the profanity at NA meetings.)
Misconception 4: Opioid-dependent youth should not be referred to NA due to concerns about its effectiveness and safety.
Misconception 5: NA does not effectively serve women, ethnic minorities, and other historically disenfranchised populations
Misconception 6: NA is anti-treatment.
Misconceptions 7: People addicted to opioids do not seek help from NA due to its stance on maintenance medications. People in medication-assisted treatment for opioid addiction should not be referred to NA due to NA’s attitudes toward maintenance medications.
Misconception 8: People with a co-occurring psychiatric illness should not be referred to NA because they will be encouraged to cease using their medications.
Misconception 9: People should not be encouraged to attend NA unless they have a pre-existing religious orientation that would make a Twelve-Step program acceptable to them.
Misconception 10: NA (Twelve-Step) involvement is another form of dependency (one addiction for another) that personally and politically disempowers its members, compromises quality of life, and perpetuates social isolation within a drug-oriented social network.
Misconception 11: NA does not have a role in reducing the social costs of opioid addictions nor in other social contributions
What do they see as the most neglected story in opioid addiction?
There is a pervasive pessimism about the long-term prospects of recovery from opioid addiction. Tens of thousands of NA members in long-term recovery from opioid addiction stand as a living refutation of such pessimism. That fact is the least told story in the public media and in professional discussions of opioid addiction.
This paper perfectly captures a recurring theme of this blog. I’m grateful they’ve shone a light on this story that is omitted from the current narratives about the opioid crisis.
A message for the recovery advocacy movement to promote?
It would seem that this makes the case for more recovery advocacy efforts to get this story out there, right? Especially with Bill White said the following in his post introducing the paper, “Tens of thousands of NA members in long-term recovery from opioid addiction stand as a living refutation of such pessimism.”
So, where are they? Why aren’t advocacy groups countering pessimism with this particular story?
Well, sharing this particular story gets complicated. (This story is often present, but in a vague or generic way that omits any reference to a drug-free path.)
According to the paper, NA “publications define the NA program as one of complete abstinence, including abstinence from maintenance medications used in the treatment of addiction.”
The current recovery advocacy movement is so committed to affirming MAT and other paths to recovery that celebration of a drug-free path is often viewed as divisive and stigmatizing. (Some of this advocacy emerges from grassroots, some from federal funding, some from media narratives and some from professional interests.)
It’s also becoming a difficult to discuss topic in professional settings. For example, I attended a speech and panel with Michael Botticelli and the University of Michigan and an audience asked about the the place of drug-free treatment in policy and advocacy. While Mr. Botticelli was very polite, the question was met with condescension and head-shaking (literally) by other expert panelists and it was responded to as though it were a manifestation of ignorance and stigma.
Media reports and comments from “experts” give the impression that opioid addiction (heroin, vicodin, etc.) is a near hopeless condition and that the only hope is maintenance on other opioids (buprenorphine and methadone).
Some of these reports acknowledge that there are people who achieve drug-free recovery, but imply that they are extremely rare. It almost sounds like everyone’s heard of them, but no one’s seen one—like unicorns.
We know this isn’t true.
We want people to know that opioid addicts can achieve full recovery without opioid maintenance drugs. And, it’s not rare or unusual when people get the right kind of help.
This post received several angry messages via comments, facebook and email.
Why? Is the unicorn message exclusive? Does it put down other paths to recovery? Here are a few of the messages from the site.
We’re not here to argue that medications like buprenorphine and methadone are bad, or that our path to recovery or one form of treatment is better than another.
. . .
We believe that all addicts should have reasonable access to the full array of evidence-based treatment and recovery support services, including MAT, detox, outpatient treatments, long-term residential, case management, peer support etc.
. . .
We have no interest in ranking recovery, declaring one form as superior to another or invalidating any path to recovery–someone achieving recovery with the assistance of medication or through a faith community is not inferior to any other form of recovery. Any addict achieving recovery, whatever their path, is cause for celebration.
Further, any addict who has not yet sought or achieved recovery is deserving of respect.
So, it doesn’t rank paths to recovery, says all recovery should be celebrated and even argues for access to MAT.
This begs the question of whether there’s room for inclusion of this particular message in the current recovery advocacy movement (particularly with the influential role of government funds) without push-back from other advocates that this message contributes to overdose deaths and stigmatizes MAT patients.
I’m not suggesting the inclusion of this message and exclusion of other messages. But, is there room for advocates to say, “Saving lives with naloxone is great, but what comes after the overdose rescue?” or “Maybe some of that $1.1 billion should go to helping people who want drug-free treatment.” or “You know, there are tens of thousands of people in drug-free recovery from opioid addiction in NA alone. Most of them probably got inadequate treatment. Imagine what’s possible if we provided access to drug-free treatment of adequate quality, intensity and duration? Maybe we should advocate for that too.”