Addiction Professional, December 27, 2018
Attending Narcotics Anonymous (NA) meetings had reinforced Alan Wartenberg, MD's recovery for years, until the early 1990s when he started overseeing medical services at New England programs that offered methadone treatment. The reaction the internist says he then received from some members of the NA fellowship ran the gamut from uncomfortable to downright menacing.
“I was 'outed' at meetings, by members who were saying people were killing people with these drugs,” recalls Wartenberg, who has served as a consulting physician for facilities such as Meadows Edge Recovery Center in Rhode Island. “At one point I was even threatened, by a 19-year-old,” he says with a tone of bewilderment.
At a time when a deadly opioid crisis rages and treatment professionals respond with an ever-warming embrace of the evidence-based agonist medications methadone and buprenorphine, attitudes in the most prominent mutual-support group for individuals with opioid addiction are much slower to change.
Professionals and advocates interviewed by Addiction Professional describe a scenario in which individuals attending NA meetings might not even know from meeting to meeting how their use of these medications will be looked at in their home group—even in those groups that hold a comparatively welcoming attitude toward individuals on medication-assisted treatment (MAT).
They add that treatment programs that recommend or even mandate 12-Step meeting attendance as part of a recovery plan often have no idea how receptive local meetings are to members on MAT. Some individuals are likely to encounter NA members who will aggressively urge them to stop taking agonist medication, suggesting it is not compatible with true recovery (a notion that contradicts how groups such as the physician-based American Society of Addiction Medicine define recovery).
“This creates a hierarchy, a notion of 'I'm better than you,'” says Brandee Izquierdo, director of advocacy and outreach at the national organization Faces & Voices of Recovery. “I don't think NA has sat down long enough to flesh this out.”
For its part, NA acknowledges that the topic has caught the attention of those at the highest level of governance in the worldwide organization.
“NA World Services has heard through member delegates of geographic areas in the Fellowship and from professionals that we have vocal members who do not welcome those on medication to treat addiction,” says Jane Nickels, a member of NA's public relations team. In response, she says, the organization's World Board has encouraged a fellowship-wide discussion of MAT as it relates to NA, with plans in the works to issue new literature on the topic after NA convenes for its 2020 conference.
The question remains as to whether this response is sufficient or rapid enough, when some NA group members may be persuaded to believe they would be better off quitting the medications that science considers their best defense against returning to dangerous use of heroin or prescription painkillers.
Adhering to tradition
As with Alcoholics Anonymous (AA), NA explicitly states as part of its organizational philosophy that it does not express opinions on issues it considers outside its focus on 12-Step recovery. That includes medical issues such as MAT.
NA spokespersons, however, also referred Addiction Professional to a published pamphlet written for health professionals who prescribe medication for addictions. The language in “Narcotics Anonymous and Persons Receiving Medication Treatment” clearly depicts a separation between members who receive MAT for opioid addiction and those who don't.
The pamphlet defines the term ”clean” as typically referring to “being free of all drugs, or abstinent. However, an addict who is not clean is free to attend meetings; we hope through attendance at meetings addicts will gain a sense of belonging and identification with other recovering addicts.”
Another section of the pamphlet states, “Our hope is that those who receive medication to treat addiction will come to meetings and listen to people who are recovering. … NA offers a community and a lifestyle that support staying clean, and NA may be compatible for addicts on medically assisted protocols if they have a desire to become clean one day.”
Wartenberg says this plays out largely in a scenario in which individuals on MAT are encouraged to attend meetings but not actively participate. “They need to keep quiet and listen,” he says.
He adds that in an unscientific canvassing of NA groups in the Boston and Providence, R.I., areas, he found that around three-quarters of them followed to the letter an NA position that holds that any individual still taking an opiate is still considered to be using.
Wartenberg sees this mindset as damaging to individuals, at a time when they could benefit greatly from a fully supportive community of peers in recovery who would reward them for their progress in stopping their heroin or prescription opioid use.
“These are folks who haven't gotten a lot of standing ovations in their life,” he says.
He says AA once held a similar stance toward medication treatments for alcohol dependence, such as disulfiram (Antabuse), but he has witnessed a softening of that position over the years. Meanwhile, he sees NA as “doubling down” on the notion that MAT falls short of true recovery. One clear reason for the difference in philosophy, he believes: There are no “substitute” drug treatments for alcohol in the alcoholism treatment arsenal—nothing analagous to methadone or buprenorphine.
As a result of NA's perspective, “If we have patients who really want to take part [in a 12-Step fellowship], we tell them, 'Go to an AA meeting,'” Wartenberg says. He has said to patients, “When they say the word 'alcohol' in the meeting, you think 'all drugs.'”
Nickels, the NA spokesperson, says the organization also takes no official position on members' use of the opioid antagonist Vivitrol, or on their use of psychotropic medication. She says all of these matters are seen as falling under Tradition Ten of NA's guiding principles, which states, “Narcotics Anonymous has no opinion on outside issues; hence, the NA name ought not to be brought into public controversy.”
Should members disclose?
Another approach backed by Wartenberg, who admits that his own initial medical training was strongly anti-methadone, involves not revealing one's medication status when participating in an NA group. This in fact does not conflict with NA's own stance, as NA World Services “has no opinion on self-disclosing for those who receive MAT,” the NA spokesperson said in comments e-mailed to Addiction Professional.
But the founding president of SMART Recovery, the best-known alternative support group organization to 12-Step based groups, believes that encouraging people not to reveal such information (in a setting where they otherwise are expected to be honest) can be psychologically damaging.
“I was at an MAT talk at an ASAM conference, where a speaker advised that professionals tell patients not to admit taking medication, and I found that scandalous for clinical and ethical reasons,” says Joe Gerstein.
Gerstein, a physician, adds that in the 3,000-plus SMART Recovery meetings he has facilitated, “I have never heard a discouraging word about appropriately prescribed medications.”
For some individuals, then, alternatives to 12-Step support might be preferable to a situation in which a person might be welcomed to an NA meeting one week, only to feel isolated next time because a new group leader with a contrary opinion has taken over.
Encouraging a dialogue
Faces & Voices of Recovery's Izquierdo, who says she has been open about her work in the NA fellowship and has been criticized by some members for language she uses outside the group, would like to see a meeting of the minds on the MAT issue.
“We need to do some kind of workshop that discusses how to merge the ideas of accepting harm reduction and MAT while staying authentic to the fellowship,” Izquierdo says. “It's hard to advocate when members of the recovery community are battling each other.”
In the meantime, Wartenberg believes it is important for professionals in facilities such as opioid treatment programs (OTPs) to warn their MAT patients of what they might encounter in NA. At the extremes, they may be told that buprenorphine and methadone represent a profit-driven ploy to enslave patients—a legal drug trade of sorts.
“There are OTPs that mandate that patients go to NA,” Wartenberg says. “They don't have a clue.”
Yet Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD), which represents OTPs, says the programs with which he is familiar don't mandate 12-Step attendance for that very reason, over concerns about members' perspective on medications.
“I've heard in open meetings comments that if you are on medication, you have not achieved recovery,” Parrino says.
This mindset creates something of a self-fulfilling prophecy, Wartenberg says, when regulars at NA meetings see an MAT patient stop attending meetings after just one or two visits. This reinforces their view that the person on MAT is not doing well, and would see better results with total abstinence, he says.
For Wartenberg, the path he chose was to disengage from NA in his own recovery. He became involved in trying to organize “Methadone Anonymous” groups as an alternative to NA in some programs where he worked. However, “We never got to a real critical mass,” he says, with membership rising initially but then falling off.
Izquierdo has taken a different approach, choosing to stay in a fellowship that she still would like to see make more progress toward embracing the science.
“In the beginning I thought, 'Maybe I'll explore another pathway,'” she recalls. “But if I leave NA, it would be like leaving an old neighborhood. If your neighborhood goes bad, are you part of the problem because you're leaving it?”