Sunday, December 8, 2013

MMT and 12-Step Groups: Stigma Persists

In his latest contribution to the academic literature, William L. White and colleagues turn their focus on 12-Step participation among patients in methadone maintenance treatment (MMT). Rates of self-reported Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) attendance were very high; however, participants frequently reported that their MMT status prevented them from taking part in many of the "key ingredients" of the groups that most members take for granted. When asked about the experience, nearly half of all respondents who had attended NA or AA reported that they had "received negative comments about methadone use" and nearly "a quarter (24.4%) reported having had a serious problem within NA or AA related to their status as a methadone patient."

The following table from the report details the "frequency with which respondents faced particular challenges":

Table 4: NA and AA Responses to MMT Patient Status                                NA            AA

Response to MM Patient Status:                                                                         (n=228)     (n=142)

Received negative comments about methadone use                                                43.0%     45.1%

Were pressured to reduce the dose of methadone                                                  21.9%     23.2%

Were pressured to stop taking methadone                                                             32.9%     34.5%

Were denied the right to speak at a meeting because of being
in methadone treatment                                                                                         14.5%      14.1%

Were denied the right to become a sponsor because of being                                  8.8%        9.9%
in methadone treatment

White and colleagues implemented this small study at not-for-profit opioid treatment program (OTP) in the Northeastern US. A total of 322 respondents answered a 53-question survey about their participation in recovery support groups. Of the 322, 259 (80.4%) reported a primary affiliation with a recovery support group. Of these, 88.8% reported it to be in some way a 12-Step group. Importantly, 66% of respondents reported past-year NA/AA participation, with 88-89% reporting the group was "helpful".

Despite these figures, the authors found MMT patients had low rates of participation in the "key ingredients" that seem to be critical influencers of long-term recovery outcomes: having a home group (50%), having a sponsor (26%), sponsoring others (13%), attending 12-Step social events (23%), and active step work (21%).

Anecdotally, we see a lot of patients at Alltyr who have a hard time finding a place in the local 12-Step scene. We even began compiling a list of medication-friendly meetings in the Twin Cities as we learned about them, but the stigma associated with maintenance is still prevalent. Could it be that we are on the verge of another breakthrough in medication acceptance? After all, there was a time when you weren't considered "sober" if you were on antidepressant or antipsychotic medications (but now, as Dr W likes to say, you're more likely to be referred to the psychiatrist by your sponsor than by anyone else). We would be interested to hear reader stories about this experience - or opinions on the topic. Are things changing - or not?

See the full paper by White, et al., here:


  1. This is an important article. I think that you will find with broader research there is a greater stigma regarding any maintenance and even other meds than is found in this paper. In the new Green Book published by Hazeldon, there is this: “for some mental health disorders, medications such as antidepressants are needed. These aren’t addictive chemicals and so professionals, as well as AA and NA, accept that we can take them and still be considered clean and sober (abstinent).” For me, this statement demonstrates the bias and is a weak attempt to mitigate.

    I think the stigma goes way beyond the 12-steppers. Even the DSM5 adds the qualification of "on Maintenance therapy" to the "in remission" category. One would expect 12-step programs to at least be more understanding, but my own experience is that they are not. I wonder if they will ever get sued for the overdose death of someone who ceases their OMT on the advice of a sponsor?

  2. I would be interested in hearing more on why a 21st century treatment program would want to facilitate referral to a 20th century treatment paradigm? I don't mean for the question to be rhetorical, as I have come to think that the 12 step's insistence on "once and addict, always an addict" was antithetical to modern concepts of medical treatment of addiction. Am I thinking about this wrongly?
    M. Whiting, MD

    1. Interesting point, Dr Whiting, and a question I often hear asked. Considering the potential benefits of an active peer-based sober-support system, recovery-oriented community groups can be immensely helpful for some. At present, the most common, widely available and easily-accessed of these groups are the 12-step programs. In Minnesota alone, there are literally hundreds of AA or NA groups DAILY. Until the other groups (Health Realization, SOS, SMART, etc.) become more widely available, this will continue to be the case. In the meantime, work to challenge the misconceptions and stigma associated with MMT and buprenorphine maintenance will have to occur from within the organization. Hopefully, articles like this one by Bill White will continue to call attention to the problem and result in more momentum toward a paradigm change.

    2. Referral to self-help groups is firmly grounded in 21st century empiricism.

    3. This will sound argumentative, so I apologize in advance, I am truly seeking how best to think about this as I am in the process of helping start a SUD treatment program.
      I have come to see addiction as a condition that responds admirably to medical treatment it bothers me to think about having anything to do with an organization that does the equivalent of telling a diabetic that they are only treating their disease when they are off all their medications. I can't imagine a diabetes support group that would not welcome a medical professional into their midst. I cannot imagine a diabetic support group that would serve donuts - I constantly hear from my opioid patients that if you want to meet other uses (current uses) go to NA or AA. It would seem to me that an SUD treatment program would do best with its own support group, and individual physicians treating SUD would do best with referrals for individual counseling. When talking specifically about opioid addiction, I have trouble seeing a role for NA/AA anymore. I do see the concept still possibly useful for alcohol addiction in those cases where the individual is not suitable for medical management.
      But again, this is not meant to sound as if I am trying to have the final word as I always have more to learn. I am interested in any response.

    4. From what I understand NA world service has made a statement regarding views of MTT (opioid agonists in general) in bulletin #29 and AA world service has expressed no opinion on the subject. I see the bulletin posted by NA to be problematic, and would feel hesitant to refer a client to NA.
      With that said each AA/NA group is autonomous, for the most part, creating a culture of it's own. The autonomy of groups allows for cultures to grow that are highly accepting of MTT and cultures that are highly judgmental and everything in between. Compiling a list as Ian indicated is extremely helpful to client's who choose to participate in self-help groups.
      It truly comes down to each individual case, client preference, available resources, etc (not referring can be just as harmful if indicated and vise versa...).

  3. Perhaps the patients should consider attending Free Thinkers meeting. They are usually more open, although you might find one individual in the group that will not agree with methadone as recovery. .

    Worldwide Agnostic A.A. Meetings‎
    The publication of this list has not been authorized or endorsed by Alcoholics Anonymous World Services, Inc. ... Freethinkers of the Valley (non-prayer format)

    Here is the links on Free Thinkers in Alcoholics Anonymous Google,or.r_cp.r_qf.&bvm=bv.57967247%2Cd.eW0%2Cpv.xjs.s.en_US.rPdE4CKmgI4.O&biw=1054&bih=547&ech=1&psi=N9CpUt6JFo7ykQfRyYHQAg.1386871402876.3&emsg=NCSR&noj=1&ei=N9CpUt6JFo7ykQfRyYHQAg

  4. Sorry I do not know if I clicked in the Publish Button or I had some other glitch.
    Any way there are several Federal Court Cases stating that forcing anyone to go to AA or NA by any government agent such as Judge, parole probation. The SMART Recovery website has most of the cases explanation. T

    In 2011, the State of Florida Department or Correction was suite by Council for Secular Humanism. Florida DOC was contracting with a outright Christian Organization to provide a number of substance use treatment Services.

    Their is one case which was decide in 2001 DeStefapnos vs Emergency Housing Group (a homeless program). This case give guidelines and states clearly that no public funds (federal, state, county or bed tax like the have in Florida) can be use to promote AA or narcotics anonymous.

    DeSTEFANO v. EMERGENCY HOUSING GROUP INC, Docket No ... › Caselaw › United States › US 2nd Cir.‎
    Apr 20, 2001 - Findlaw provides DeSTEFANO v. EMERGENCY HOUSING GROUP INC,

    Nevertheless this case have fallen on deaf ears. Even if the Treatment staff are knowledgeable of the case they have ignore it. This gives me the impression that this resitance to change is a characteristics of religion

  5. Am sorry I keep having problems. He is the new case this was published in Counselor Magazine. This is the page in the magazine with the explanation.

  6. In Scandinavia we have seen the 12-step approach in substance abuse treatment expanding for the last twenty years. I did a small survey based on Whites papers and a study by David Frank
    among Danish and Norwegian patients in treatment with buprenorphine or methandone. Even the Norwegian health authorities acknowledge these patients as "drug free", they are experiencing the same stigma in 12-step groups as described by White and Frank. My guess is that the confusing concept of "addiction" contributes to this, besides the arguments made by White and colleagues.


Comments are welcome.