Recovery and medication for addiction can work hand-in-hand

With the opioid epidemic killing 80,000 Americans per year, the author argues, why would we deny medicine to those who need it? Photo by Drew Angerer/Getty Images.

Andy Brehm’s recent Star Tribune commentary, in which he argues that sober living houses should be able to deny residents who take prescription medication, including for their addiction, lays out a version of recovery that is very familiar to many of us. It relies on the 12-step recovery process and aims to restore health through a spiritual program.  

It’s a beautiful story for many thousands of people and their families, myself included. 

It’s also, unfortunately, just as often a story of how these approaches are incomplete when practiced in a manner that ignores science and refuses to use some of the best tools we have to fight our fentanyl and larger substance use crises. 

Brehm argues that new legislation passed to ensure access to medications for residents of recovery housing is unnecessary and jeopardizes the efforts of sober houses as they work to keep their clients safe. He argues that it limits choices for clients and programs while warning that it will essentially remove access to “the best” way to maintain continuous recovery, a specific flavor of 12-step recovery. 

Like many — but far from all — people within the 12-step recovery community, Brehm sees the use of these medications as something other than recovery. He specifically mentions the ADHD drug Adderall, and benzodiazepines, which are prescribed for anxiety. 

Tellingly, he makes no mention of drugs like buprenorphine — brand names Suboxone, Sublocade, Subutex — which have been shown to be one of the most effective treatments for opioid-use disorder, reducing all manner of negative outcomes including overdose and overdose deaths. 

The 12-step community is far less dogmatic and monolithic about total abstinence today, but some people still maintain that using medications like methadone or buprenorphine, even as prescribed, is the same as using drugs. 

I used to believe this, too. 

I thought that using these medications was just “trading one drug for another,” that a spiritual experience as laid out in the 12 steps of Alcoholics and Narcotics Anonymous was fundamentally impossible when using these substances, and that this was actually a dangerous recommendation peddled from people with no personal experience with substance use or the harsh realities of addiction or recovery. 

I had internalized stigma and misinformation, and like many people in early recovery, the simplicity of these beliefs were a tremendous comfort. 

I believed that the dogmatic philosophy I picked up during my own recovery journey were handed down from the earliest days of AA, and that there was no possible wiggle room in the matter. I was a counselor at Hazelden Betty Ford when they said they would start using these medications, and I nearly quit in protest. 

In the midst of a process of intense introspection I came across this anecdote. 

I share this often, as it highlights the beliefs that AA founder Bill Wilson shared with AA trustee Vincent Dole. 

Dr. Dole and his wife and partner Dr. Marie Nyswander are considered the founders of methadone maintenance programs, having established the first officially sanctioned programs in New York City. 

Bill Wilson — looking out for innovative approaches to helping those still suffering — invited Dr. Dole to be a trustee on the board of AA. 

What I read next had me questioning everything.

My mind broke after I read this. 

Bill Wilson endorsing something similar to methadone?! If the big nicotine-stained pictures of Bill and Bob on the wall at the Alano club had started talking I would have been less surprised. 

More than just finding out that dogmatists have misrepresented the view of AA’s cofounder, I’ve also had a front row seat to the worst addiction crisis we have ever seen. Living through the death brought about first by painkillers, then cheap, pure heroin, and ultimately fentanyl, I’ve come to understand in a painful, visceral way that the status quo is intolerable.

This process and journey has resulted in a complete reframing of my views on what recovery looks like and made me much more supportive of an expansion of recovery pathways. 

Misinformation — especially around medications for opioid use disorder — does nothing but increase stigma and risk for our communities’ most vulnerable people and families. 

It does nothing to address the over 80,000 preventable deaths we are seeing every year from opioid overdoses. This type of oversimplified thinking sidelines medications like buprenorphine, which is one of the most effective tools we have in addressing our national crisis — one that works best when paired with supports like the ones that Brehm discusses.

We tend to hear statements like, “people need to hit bottom” and “they just weren’t ready to put in the work.” These ideas were never in alignment with how recovery works, but they are especially dangerous in the age of our poisoned drug supply. 

Brehm notes — accurately — that there is empirical support for voluntary 12-step participation, but he willfully ignores the data that creates a moral imperative for the widespread availability of medications. 

We have a solid body of data that proves that mutual aid of the type provided in AA and NA is helpful for those individuals who voluntarily pursue it, especially when they have a stable family and work life and minimal mental health or medical comorbidities. However, we also have an absolute mountain of data that shows that without the use of medications like buprenorphine or methadone, treatment for opioid use disorder has worse outcomes than no treatment at all. 

Which means the stigma around medications increases risk for death and suffering. 

Like Brehm, I too am an advocate of freedom of choice and limited government intrusion into personal autonomy. I can think of no greater intrusion of personal liberty than somebody getting between a doctor and a patient. Make no mistake, this is exactly what happens when programs like recovery houses and non-clinical support programs make recommendations around medications. And, unfortunately, the consequences are often deadly. 

It’s easy to pretend these deaths are inevitable — just another loss to the brutality of addiction — but I have to ask, is there another disease wherein ineffective treatment and the resulting bad outcomes are blamed on the patient? Is there another disease wherein anything outside of complete abstinence or perfect adherence to a plan results in a complete cessation of care? 

Would we as a country allow over 80,000 of our daughters, fathers and friends to die every year while leaving our most effective tool unused? 

If we insist that a substance use disorder is a no-fault condition, and that addiction is a disease, we need to actually treat it as such. 

When anyone who is not a trained and licensed provider of medical services starts controlling access to a medication that has repeatedly been shown to reduce risk of overdose death by up to 75%, we have a huge problem. 

And this is what this legislation was aimed at solving. 

Recovery is more complicated than a one-size-fits-all approach. It is intensely personal. It is varied. It is complicated. 

And, our most vulnerable members deserve to be able to receive care from professionals without being subject to rules based on misinformation and stigma. 

I have no problem arguing policy on its merits; in fact, I wish we didn’t need this bill at all. 

But we must start from a place of reason, humility, and an openness to new ideas if we’re going to solve our shared crisis.