A recently published article in the Journal of Substance Use and Addiction Treatment frames 12-step groups, Narcotics Anonymous in particular, as purveyors of stigma.
Our patient was a 33-year-old man with an all-too familiar story: After transitioning from heroin to fentanyl, he had overdosed twice in the past year. He entered the treatment center where we are addiction medicine physicians, and he started medications for opioid use disorder (MOUD). The buprenorphine began to stabilize him. Clinically, he made significant progress: his mood improved, his cravings were controlled, and for the first time in years, he was hopeful. And yet, from the moment he arrived, he was adamant: he wanted to be off buprenorphine before discharge. His sponsor told him that using buprenorphine made him “unclean.”
S. Klein, J. Franco and A. Scioli, Shattering the STIGMA: Talking openly about MAT in 12-step recovery programs, (2025), https://doi.org/10.1016/j.josat.2025.209829
In 35 years around treatment and recovery, I’ve never heard anyone refer to anyone else as “unclean.” Of course, NA members frequently use the term “clean” and may use the expression “not clean”, but I’ve never heard “unclean.”
Setting that aside, the article points to a real problem but misplaces responsibility.
Mutual aid options for people using opioid agonists are too limited.
It’s been 23 years since buprenorphine was FDA-approved to treat opioid dependence, and millions of Americans (a minimum of 4 million unique individuals, see here and here) have been treated with agonists over that period of time. Yet, we are still waiting for a thriving mutual aid fellowship comparable to AA or NA.
Some professionals (prescribers in particular), researchers, and advocates seem to have spent those years waiting for NA to change its stance toward opioid agonists.
I understand, respect, and share the wish that people on agonists be able to easily enjoy the same benefits that some people with AOD problems find in AA and NA. If and when that happens, NA’s beliefs will be irrelevant, because its benefits are readily available elsewhere.
What I find frustrating is the lack of cognitive empathy these groups extend to NA. Instead of trying to understand the factors that contributed to the development and maintenance of their positions, many dismiss their views as anti-science, backwards, superstitious, and stigmatizing.
It’s really not that hard to understand their position.
- NA formed during a period when people with addiction were abused and neglected by medical, legal, and public health systems. (Often harming in the name of help.) They self-organized to recover and help others recover.
- There’s a long history of purportedly safe medications becoming problems for people with addiction.
- There’s a long history of professional helpers focusing on outcomes that are not aligned with recovery (or the goals of the person with the addiction), like symptom reduction, reduced disease transmission, reduced arrests, reduced ER use, etc. Many NA members and their loved ones might view those low expectations as manifestations of stigma.
- Many NA members have lived experience with agonist MOUDs as part of their addiction rather than part of their recovery. (See here and here.)
- Drug addicts were once told that they, as a group, and their needs fell outside of AA’s “singleness of purpose” and, unless also alcoholic, they could not be members of AA. They, therefore, had to start their own fellowship.
- NA has its own definition of recovery for their fellowship, but they are not engaged in any policy advocacy and do not engage in any activity to prevent access to care with medications.
- The opioid crisis and ensuing overdose crisis that have centered agonist treatments were precipitated by iatrogenic opioid use disorder. These prescribing initiatives were often accompanied by similar appeals to compassion, science, and commitment to all patients.
There’s no recognition of any of that in the article.
There’s no call for treatment professionals and prescribers to integrate this context into their advocacy for patients.
There’s no call on paid treatment professionals to do a better job developing community and social support for their patients on agonist treatments.
Our 33-year-old patient and thousands of others aren’t “not sober.” They are committed to recovery. The recovery community should honor their journey and embrace them with the fellowship they deserve. It’s time to move forward with compassion, science, and an unwavering commitment to supporting all individuals, and their families, on their paths to recovery.
S. Klein, J. Franco and A. Scioli, Shattering the STIGMA: Talking openly about MAT in 12-step recovery programs, (2025), https://doi.org/10.1016/j.josat.2025.209829
Instead, they frame the ~250,000 Narcotics Anonymous members who are lay people, gathering in their free time, charge nothing, receive no funding, and do no lobbying, as agents of stigma who lack sufficient compassion, reject science, and are insufficiently committed to the recovery of all people with drug problems.
A lot of criticism has been directed at NA over the 23 years since buprenorphine was FDA-approved (often by people who are paid in dollars or status for publishing or presenting) — conference presentations, federal summit panels, reporting that frames NA as waging a “war on recovery“, and academic papers framing NA as stigmatizing, anti-science, irrational, or irrelevant.
Imagine if, instead of all that effort demanding these unpaid nonprofessions solve their patients’ needs, they put that effort into supporting, organizing, and developing mutual aid for those >4 million people on agonist treatments. Imagine what a group like Medication Assisted Recovery Anonymous (MARA) might be with that energy and commitment.
Recovery Review 