The 12 Steps and MAT Can Co-Exist in Addiction Recovery
A controversy currently exists that many believe pits the use of Medication-Assisted Treatment against Alcoholics Anonymous (“AA”) and their Twelve Steps and Twelve Traditions that explain the 24 basic principles of the AA program. Behind this controversy is the national opioid crisis and the existence of differing approaches to treatment and support for recovery from opioid use disorder. In reality, both methods of helping people get into and maintain recovery are essential.
The basic textbook of Alcoholics Anonymous (AA) was first published in 1939 to explain AA’s philosophy and methods. AA’s Twelve Steps and Twelve Traditions book was then written by founder Bill W. to offer an explicit view of the principles by which AA members recover and by which the AA fellowship functions. However, these Steps and Traditions are now used to guide recovery from numerous addictions and behavioral issues including recovery from drug problems/addiction, over-eating, gambling, and more. Twelve Step programs are found widely throughout both the US and the world; in fact, there are currently over 118,000 AA groups meeting in over 180 nations and over 2 million active members worldwide.
Medication-Assisted Treatment, also called Medication for Addiction Treatment, or MAT, is the use of FDA-approved medications in combination with counseling and behavioral therapies, providing a whole-patient approach to the treatment of substance use disorders, most commonly with opioid use disorders. There are some MAT options for alcohol use disorder, but none for most other drugs such as cocaine or amphetamines.
Those in the treatment field are well aware of the existing dichotomous relationship between firm 12 Steppers and some MAT supporters. Each have differing strongly held opinions on treatment and recovery, with some in the former group believing MAT simply replaces one drug for another. This is a dangerously false generalization that is not backed by science. The truth is, both 12 Steps and MAT are effective options to gain and maintain recovery and they can peacefully and synergistically coexist.
National nonprofit organization Shatterproof takes the position that “[Twelve Step] support programs can be an invaluable resource for some people in recovery. But they don’t work for everyone, and 12 Step programs alone are not an adequate substitute for evidence-based medical treatment for addiction.” Although some people do quit drug use on their own, with the help of family or support groups, many more need formal treatment and AA itself makes it clear in the “AA Preamble” that they are not treatment, they are “a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.”
Just as every person is unique, treatment is not one-size-fits-all. Support groups like 12 Steps have proven to be highly beneficial in providing accountability, coping techniques, and the social network that helps reduce relapse. Individuals struggling with addiction may have become socially isolated in their use or only have friends in circles where the temptation to use drugs is high. Twelve Step meetings’ social support and the opportunity to connect with other people who do not encourage substance use may be very beneficial. In addition, the 12 Step belief in giving back to one’s community through service work can be very valuable later in recovery.
Research also shows the effectiveness of MAT, particularly for opioid use disorder, where numerous options exist. The primary medications utilized in the treatment of opioid use disorder, are methadone (an opiate agonist), naltrexone (an opioid antagonist) and buprenorphine (often formulated as an agonist/antagonist combination). Unfortunately, MAT options do not currently exist for patients with most other addictions, with the exception of a few options for alcohol use disorder (naltrexone, disulfiram) and tobacco use disorder (varenicline and nicotine replacement therapies).
MAT programs for opioid use disorder help patients adhere to the recovery process and reduce opioid use and can be more effective than non-medicated approaches. This is due, in part, to how these medications impact the opioid receptors in the brain. These medications vary in their mechanism of action, but all lessen opioid cravings and decrease the likelihood of opioid use. Methadone and buprenorphine products help patients with physical symptoms such as withdrawal.
Importantly, neither the 12 Steps nor MAT are stand-alone replacements for comprehensive treatment for individuals with substance use disorders. Comprehensive evidence-based treatment includes providing a continuum of care based on the patient’s needs, with options including inpatient and outpatient treatment that include individual and group therapy, medical and psychiatric care, family services, and other tailored services delivered by treatment professionals. Treatment that effectively incorporates the 12 Steps and/or MAT provides optimal chance for treatment success.
A study published in The American Journal of Drug and Alcohol Abuse (Volume 44, 2018 — Issue 2) by Dr. Marc Galanter found that greater collaboration between practitioners of MAT and Twelve Steps should be promoted. “Criteria for developing evidence-based approaches for combined treatment should be developed, and research for evidence-based treatment on this basis can be undertaken in order to develop improved clinical outcomes.” He recommends better communication between physicians practicing medically assisted, medication-based treatment and practitioners of Twelve Step-oriented treatments. “Both groups have much to offer, in terms of promoting recovery from substance dependence, and collaboration between the two can improve opportunities for long-term abstinence.”
Some people disagree with what they see as the rigidity of the 12 Step approach; the 12 Steps are 80 years old after all. Others may feel that MAT doesn’t do enough to address the behavioral changes and personal assessment that one needs to make in order to stop abusing substances. The bottom line is that we must accept that, just as with other diseases, addiction has options for treatment and not every option will work for every person. Identifying the best combination of treatment and recovery support services for long-term success is paramount. The health and wellbeing of the patient is the goal and multiple paths to recovery do exist.