Addiction is a problem that has plagued people since humans started using psychoactive substances. It’s a problem that affects you both physically and mentally. Its tendrils reach deep into your brain, causing chemical imbalances and psychological shifts that can take years of commitment to recovery order to overcome. The problem with addiction is that it’s a chronic disease and it lingers even after your last dose has long since left your system. Addiction can be rooted in past traumas, psychological issues, and even genetics. Plus, once it takes hold of you, it branches out, affecting multiple aspects of your life.
With a disease that is so complex, there are a variety of treatment modalities and therapy options that are currently used to help addicted people. Many of them reflect core philosophies that they rely on to pursue the goal of leading people struggling with addiction to a more productive life. However, sometimes those philosophies are at odds with one another.
What Is 12-Step?
The 12-step program was pioneered in the 1930s by Bill Wilson and Dr. Bob Smith when they formed Alcoholics Anonymous. Both founders were both recovering alcoholics that dedicated their lives to helping other people escape from alcoholism through community, accountability, and spiritual pursuit.
The philosophy of the 12-step program can be summarized by six main pillars:
- Admitting that your addiction is beyond your control.
- Recognizing that a higher power can give you the strength to overcome your addiction.
- Examining past errors with the help of an experienced member, called a sponsor.
- Making amends for those errors and wrongdoings.
- Learning to live your life under a new code of ethics.
- Helping others along that same path to spiritual healing and recovery from addiction.
The roots of the 12-step program come from a variety of different places. The most obvious one is the Oxford Group, a Christian fellowship that was the precursor to Alcoholics Anonymous, which Bill Wilson attended. It was a group designed to help people better themselves spiritually, specifically by overcoming sins and moral weak points that they were struggling with.
However, it’s also backed by a couple of medical and psychological powerhouses of the 20th century. The first is Dr. William Silkworth who was a doctor that closely studied alcoholism and was among the first scientists to conclude that addiction is a disease. In a 1937 paper titled, “Alcoholism as a Manifestation of Allergy,” Silkworth criticized the idea that alcoholism just is a bad habit or moral failing and how physicians had historically treated it, saying:
“…alcoholism has been considered a vice within the control of the relatively few individuals concerned and not as a disease entity in its more subtle and damaging aspects; and all that has been expected of the physician has been the administration of sedatives, purges, and emetics to control acute stages.”
During a few of Wilson’s stays in the hospital caused by his alcoholism, he was treated by Dr. Silkworth. After Wilson started working with other alcoholics and started forming AA, Silkworth encouraged him to treat alcoholism as a disease.
Rowland Hazard, another member of The Oxford Group and latter AA, had another encounter with another significant scientific mind of the time before Bill Wilson had achieved sobriety. He was sent to Zurich to be treated for his own alcoholism by Dr. Carl Jung. However, Jung wasn’t able to treat him successfully and discharged him. Despondent, Hazard asked if there was hope, and Jung replied, “No, there is none — except that some people with your problem have recovered if they have had a transforming experience of the spirit.”
This surprising reply may have formed the basis for the 12-step program’s eventual emphasis on spirituality. Hazard attended the Oxford Group and achieved sobriety. Then he brought a man named Ebby Thatcher, who would then bring Bill Wilson.
Are the 12 Steps Effective?
Though the 12-step model was influenced by a few scientific minds, it wasn’t founded based on any intense scientific studies. The 12-steps were formulated by recovering alcoholics that were mostly businessmen in their day-to-day life, though Bob Smith was a surgeon. Still, could a program conceived in the 1930s be effective and relevant in today’s addiction epidemic?
The popularity of the 12-step model is undeniable. There are meetings in every state and most major cities. It’s spread all over the globe and even into most addiction treatment centers. Still, some criticize 12-step for being unscientific and having a lack of data to back it up.
However, the National Institute on Drug Abuse (NIDA) lists the 12-step model under evidence-based behavioral therapies, saying that it “increases the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups, thereby promoting abstinence.”
Studies into the effectiveness of AA and other groups produce mixed results. A 2009 review that looked at four trials studying AA’s effectiveness found that two were positive, one was negative, and one was inconclusive. Without other treatment options, 12-step programs might not be ideal for everyone.
Though the 12-steps philosophy isn’t effective for everyone on its own, it has shown to be a valuable tool in conjunction with other addiction treatment methods like cognitive behavioral therapy. It also seems to be especially useful as an aftercare program.
What is Medication Assisted Treatment?
Medication-assisted treatment, or MAT, is the use of medications approved by the U.S. Food and Drug Administration to treat drug and alcohol addiction. Typically, these medications prevent withdrawal symptoms and cravings, allowing users to stop using illicit, illegal, or dangerous drugs.
Other drugs designed to reverse overdose or discourage drug use can also fall under the category of MAT. There are currently only a few FDA-approved drugs available for MAT and they are primarily used in the treatment of addiction to opioids like heroin and prescription pain relievers. Some can be used to treat alcohol addiction.
Opioids work by altering your neurochemistry and the way your brain communicates with pain receptors. If you become dependent, your brain will rely on the opioid to maintain the new neurochemical balance.
Without it, you will start to feel uncomfortable withdrawal symptoms.
MAT medications work to normalize brain chemistry without making you intoxicated or “high” like the illicit drug would or feel debilitating symptoms like withdrawal would.
They also relieve psychological cravings that would cause you to seek heroin or other potentially dangerous opioids during treatment.
MAT drugs used in treatment for alcoholism work in similar ways but they can also discourage alcohol use by triggering uncomfortable symptoms when the user drinks.
MAT Medications
The medications that are currently being used to treat opioid and alcohol addiction include:
Methadone
Methadone is an opioid that is used to treat pain and opioid dependence. It’s among the most controversial MAT medications because it requires very long-term treatment and can cause withdrawal symptoms of its own. Methadone works by binding to the same opioid receptors that other drugs like heroin attach to.
When methadone is used carefully, it can relieve withdrawal symptoms and cravings without causing sedation or powerful euphoric effects like other opioids. Methadone maintenance can take as little time as a few months and as much time as several years. Some use methadone indefinitely over their lifetime. Even with prescribed medical use, Methadone will eventually cause dependence and requires its own detoxification period to stop using. Additionally, methadone withdrawal is said to be particularly uncomfortable.
Buprenorphine
This is another opioid used to treat illicit opioid addiction. Like methadone, it suppresses opioid withdrawal by binding to the same receptors in the brain as heroin does but it has weaker effects that help users avoid both withdrawal symptoms and developing an addiction to the replacement. However, it can also cause dependence and needs a significant weaning period to detox.
Buprenorphine can also be combined with naloxone, a drug that stops opioids from binding to receptors and stops overdose. The combination is sold under the name Suboxone, and it is less potent than other MAT opioids. It is generally more useful during withdrawal detoxification.
Naltrexone
This is the only MAT drug that’s used for both alcohol and opioid addiction treatment. Instead of binding to receptors to stop cravings and withdrawal, naltrexone stops you from feeling euphoric or sedative effects. The idea behind this therapeutic use is to remove the psychological reward from taking opioids or drinking alcohol.
However, one of the major criticisms of this treatment is that it doesn’t promote med-compliance. If a patient skips a few doses, they can achieve a high. It’s most effective in people that have already gone through detoxification.
Disulfiram
This is another drug used for treating alcoholism that is designed to disrupt the psychological effects of intoxication and euphoria. However, instead of blocking the effects, it causes intense nausea and vomiting when combined with alcohol in your system. However, it has the same pitfall as naltrexone in that it doesn’t encourage med-compliance.
Acamprosate
This is a drug that is used after alcohol detoxification that is said to lessen alcohol cravings. It has shown to be ineffective when used on its own without other therapies.
Is MAT Effective?
Medication-assisted treatment has shown to be effective in reducing the harm of a life of active addiction and allows people to live independent and productive lives.
“According to the Substance Abuse and Mental Health Services Administration (SAMHSA), “MAT provides a more comprehensive, individually tailored program of medication and behavioral therapy.” MAT has shown to improve patient survival rates, keep patients in treatment for longer, decrease criminal activity associated with illicit drug use, and increase a person’s ability to gain and keep jobs.”
– SAMHSA
However, unlike a clinic, MAT often emphasizes the use of counseling and therapies in conjunction with medication to achieve true abstinence and lasting sobriety in the long run.
What is the Controversy?
A woman currently being treated with long-term MAT decided to go to a 12-step meeting. After meeting some people and telling them a little about her story, she was told that she wasn’t really in recovery. She felt unwelcome and a little disheartened. This a real story based on an actual encounter, but it may describe similar experiences all over the country in places where MAT is utilized.
Unfortunately, the history of MAT and the use of indefinite MAT treatment has caused some to dismiss MAT altogether. It conjures up images of methadone clinics that attract drug dealers and lead to some of the worst opioid withdrawal symptoms. In many scenarios, medication doesn’t assist treatment, it replaces it.
People are sometimes put on medications to block withdrawal symptoms without being given the tools to cope with stressors. Underlying issues are never addressed and the result is a lifetime of being on replacement medications.
Plus, it could complicate medical conditions, procedures, and even pregnancy that might occur later in life. To some, total sobriety is the only viable option for true recovery.
On the other hand, many people go through addiction treatment without medication over and over again without success. Frequent relapse increases the likelihood of overdose. If you gain sobriety for a certain amount of time, you might take a dose that you are no longer tolerant to and overdose.
You may also cut ties with known sources of illicit drugs like heroin and the supply you come across in your relapse is a gamble, possibly containing deadly opioids like fentanyl. People who are treated with MAT are often people who didn’t have success in traditional treatment methods. It helps people live more productive lives away from illicit drug use which can cause a range of problems like disease, overdose, and crime.
Twelve-step programs have historically emphasized complete sobriety, with good reason. It has always been the best option in dealing with addiction. Plus, it remains the best option to this day and should be the first response in most cases. However, is there room for compromise in cases where a person is a frequent relapser, whose disease of addiction seems to resist traditional evidence-based treatment methods? Should practitioners of the 12-step model examine their commitment to non-medicated abstinence?
Personal Treatment
The relationship between medication-assisted treatment and traditional treatment options like 12-step programs may not be as polarized as they seem. NIDA has outlined 12 principles that make for the most effective treatment options, a few of them offering insight into the MAT vs 12 step debate.
First, one of the major cornerstones of effective addiction treatment is that it’s tailored to a person’s individual needs. Addiction is complicated and no two treatment approaches are exactly alike. Some people have co-occurring mental disorders, some have experienced past traumas that lead to addiction, and some addictions are so deeply rooted that even the best care and treatment will often fail to fully prevent relapse.
According to the NIDA, for treatment to be effective, it needs to address multiple needs simultaneously. That means it’s usually not enough to put someone on medication to help them avoid withdrawal symptoms and then send them on their way.
Addiction often comes with other mental disorders, health concerns, financial trouble, social problems, and a variety of other potential issues.
For treatment to be successful, it has to address medical, psychological, social, vocational, and legal needs.
That being said, 12-step programs aren’t enough for most people either. It offers help in spiritual and social needs but it’s may not be equipped to treat some psychological or medical needs. The best approach to addiction treatment is to go through a full continuum of care, addressing a person’s needs as an individual. In addiction treatment, you should sit down with clinicians and your therapist to create a treatment plan that conforms to your needs rather than trying to use a one-size-fits-all method.
“Finally, NIDA recommends a combination of medication, counseling, and behavioral therapies for many patients. Medications like suboxone can help a person stabilize their life and remove themselves from a lifestyle of substance abuse. Meanwhile, counseling and behavioral therapies can help them get to the root of their addiction, addressing underlying issues and learning to cope with stress in a positive way.”
– NIDA
Through treatment, they can also build up problem-solving, social, and vocational skills that can lead them to a better life. Once you’ve built up a foundation for a productive life free from active addiction and illicit drug use, you can be weaned off of the medication.
Though many people can go through addiction treatment and achieve lasting sobriety without the use of replacement medications like suboxone, it is a viable option for people who suffer from chronic relapses.
Therapies and Services Combined with MAT
- Cognitive-behavioral therapy
- Individual therapy
- Group therapy
- Relapse prevention
- Family sessions
- Addiction education
- Necessary medication to treat co-occurring disorders
Outpatient treatment also offers MAT clients benefits that are used in an inpatient or residential settings. Among them are:
Outpatient MAT Benefits
- Substance abuse education
- Cravings and triggers management
- Life skills
- Individual therapy
- Family therapy
- Group therapy
- Mental health treatment
- Cognitive Behavioral Therapy (CBT)
- 12-step programs
- Transitional living facility referrals (including sober living homes)
- Relapse prevention training
- Anger management
- Random drug testing
- Spirituality
The National Institute on Drug Abuse and Addiction recommends that clients allow at least 90 days or three months for the best chance at recovery.
Suboxone treatment should be administered by a medical professional, such as a doctor, nurse, or physician assistant. According to the website Drugs.com, a dose of 8mg/2mg Suboxone sublingual film is recommended on the first day of treatment. For the second day, it is recommended that the dosage is increased to 16mg/4mg sublingual films.
The website for Suboxone says the medication can be prescribed at the beginning of a client’s treatment or it can be given to jump-start the maintenance phase of treatment. In that phase, the client has no withdrawal symptoms, no uncontrollable cravings, and minimal-to-no side effects. The website also advises that the medication be discontinued after a maintenance period, which should be made during the client’s treatment plan. This maintenance period is when some in opioid/opiate addiction recovery begin to abuse the drug. This is yet another reason why clients must be tapered off the drug safely and properly.
