This is a long post, but I think it is very important to read. It would be great if this is in fact the truth because NA groups have for so long crucified those of us on MMT. I have always said I think the ideal treatment plan would involve an even mixture of ORT and NA.
NA & 12 Steps Programs are for the mental aspect of our addiction while ORT is for the physical aspect of our addiction.
ORT without the therapy is useless because then you will NEVER have a chance of real recovery because the reasons behind our addiction are still there.
For those of us who weren't able to do a 12 Step or other type of recovery program because of the physical side effects of our addiction, that is where ORT comes in.
One without the other doesn't work on the whole aspect of our addiction, therefore we need both methods to work together before finding true recovery from our addiction to opiates.
I got the article from
The field of opioid addiction treatment is no stranger to controversy. Since the introduction of methadone as part of the harm-reduction approach to treatment in the ‘60s and ‘70s, the field has had to contend with persistent stigmatization and many false myths about this clinically proven recovery technique. But there has also been a long-running schism about methadone occurring within the recovery community itself — one that has perhaps been equally if not more damaging to addicts seeking recovery: the divide between those who believe in medication-assisted addiction treatment and the attitude among some in the 12-Step recovery community that if you’re still taking a drug, you’re not really in recovery.
The good news is this divide appears to have narrowed significantly in recent years. More and more members of 12-Step programs now accept and recognize the validity and value of medication-assisted opioid treatment programs (OTPs). There seems to be a greater awareness emerging that, for many addicts, recovery might not be possible at all without methadone maintenance Therapy (MMT) and other forms of medication-assisted treatment.
Talking to both sides
To investigate the current status of this long-running controversy, Behavioral Health Central recently invited representatives on both sides of the issue to give BHC readers an update on current attitudes towards methadone maintenance therapy (MMT). On the medication-assisted side, we spoke with Ira Marion, Director of Government Relations for the Department of Psychiatry and Behavioral Health at the Albert Einstein College of Medicine, which operates a large Community Mental Health center that treats more than 3,250 patients for opioid addiction. Marion is also the co-chair of a statewide group working to transform methadone treatment in New York State; Board President of the New York State Association of Alcoholism and Substance Abuse Providers (ASAP); First Vice President of the American Association for the Treatment of Opioid Dependence (AATOD); Board President of the Institute for Professional Development in the Addictions; and on the Board of Directors of COMPA (New York State Coalition for Opioid Treatment).
Marion says that indeed, early on, tension between the medication-assisted treatment movement and 12-step groups was a problem, and that some addicts undergoing MMT treatment felt less than welcome at NA meetings and, to a lesser degree, some AA meetings as well. This often became a serious barrier to recovery for many, as such groups can be a critical source of support. “Early on, as methadone treatment expanded and developed, the recovery community and particularly the 12-step community had a philosophy of total abstinence. I think it’s articulated most in Narcotics Anonymous,” he says.
However, Marion has noticed a marked change in recent years. “But I believe that has changed over time,” he explains. “One of the deans of recovery, William White, spoke at the last AATOD Conference in New York City, and said, ‘I got it wrong. Methadone maintenance treatment, when it’s part of a program of addiction treatment and recovery, is a valid pathway to recovery.’ And he’s written extensively about that recently and I think that the attitudes have changed in many arenas and they are continuing to change.”
In Marion’s view, it’s a critically important development that the drug-free recovery community now increasingly supports or at least accepts members on MMT, because the treatment is designed to work in combination with counseling and support group attendance. Without that component, chances of a full recovery may be severely compromised. “Taking methadone does not, in and of itself constitute recovery,” Marion explains. “People need to change the way they live their lives. If you continue to live a life of deceit and lies and addiction to other drugs or alcohol, you’re not in recovery simply because you may participate in a methadone program kind of more as a harm-reduction approach to treatment. But if you work a program of recovery that may be either Miller’s or the 12 Steps themselves, I don’t see methadone in any way as invalid in that process.”
Attitudes in NA have begun softening
On the 12-Step program side of the issue, we spoke with two representatives of Narcotics Anonymous, the world’s largest member-run, self-help support group for drug addicts. They include Bob Stewart, Marketing Manager for NA World Services, and Jane Nickels, NA’s Public Relations Manager. And while the 12 Traditions under which NA operates (which were adapted from those developed by Alcoholics Anonymous founder Bill Wilson) forbid the group from holding or expressing positions publicly on outside issues, the two do report that they’ve noticed a softening of attitudes in recent years towards members who may be on MMT — a trend NA World Services may have played a role in through its education efforts.
“NA as such has no opinion on outside issues, including medication. The membership — individual members — may have opinions, but NA as an organization does not,” Nickels first explains. But she goes on to describe how NA World Services — which in accordance with the 12 Traditions does not manage or lead NA but merely offers support services to local groups — offers materials intended to help members better understand the role of MMT in opioid addiction treatment and prepare them to welcome new members who may be on methadone. “With the propensity toward medication-assisted treatment, NA World Services has produced publications to help members get a better understanding that these folks who may come to meetings to see if this is where they belong may come in on medication,” she explains. “We have no opinion, and our job is to welcome them to see if this is where they want to recover.”
All of this is not to say that NA newcomers on MMT may not still encounter some hard-line attitudes among some members. Some old-timers may continue to hold an uncompromising belief in NA’s complete abstinence approach, but there does seem to be a growing understanding and acceptance emerging for the fact that such therapy is often a necessary stage along the road to being completely abstinent. This trend has no doubt also been bolstered by the fact that an increasing number of older members may themselves have recovered through the aid of MMT.
Marion adds that robust support, research, outreach and education efforts by government agencies and advocacy organizations have also played key roles in helping change attitudes, both within the recovery community itself and in society at large. “I think it’s become more enlightened, and I think that NIDA has done a great job of publishing the science related to the brain disease of opioid addiction,” Marion explains. “I think SAMHSA and SECAD have certainly supported that notion and ONDCP as well. And I think as we hear this from our federal partners, and as AATOD and the National Association of OTPs start to partner with Therapeutic Communities of America and other advocacy groups, you’re going to see that change expand. And as recovery advocates start talking about this as well.”
Many myths and misconceptions remain
Still, methadone remains subject to many popular myths — some of which border on conspiracy theory — and Marion finds he still has to devote considerable effort to debunking such false beliefs, which can impede community acceptance of the therapy. “One myth is that dolophine — which is one of the trade names for methadone — is named after Hitler,” says Marion. “In fact, methadone was developed in the ‘30s in Germany as part of a bunch of experiments. It’s not named after Hitler. The name most likely comes from its use in pain. French for pain is ‘dolor’ and ‘-phine’ means ‘end,’ so ‘ending pain’ is probably where the name came from.” Marion goes on to relate some other notable myths about methadone in popular culture. “That methadone is ‘bourbon for scotch;’ that methadone cheats people; that it controls people; that it’s simply a way for folks to make money. People refer to methadone as ‘liquid handcuffs;’ that it’s simply the programs that are profiting over people’s dependence; and that it trades one for the other. But the science, it completely belies all of that.”
The evidence is, in fact, irrefutable that methadone and other forms of medication-assisted treatment are effective at helping opioid addicts recover and live normal, productive lives. “There’s a long, 40-year-plus history of methadone treatment that has proven it to be an effective — probably the most effective — modality,” Marion says. “I don’t think we have the data yet on Buprenorphine, but I think it seems to be as effective for many of the people taking it as methadone. But methadone treatment in approved programs and with counseling and other support services has proven to be probably the most effective treatment — some folks would say the gold standard for opioid addiction medicine treatment.”
Opioids’ distinct effect on the brain
The many misunderstandings, myths and suspicions about medication-assisted therapy as a treatment for addiction are perhaps rooted in a lack of understanding for precisely how opioids affect the brain. Unlike alcohol and many other drugs, opiates produce distinct changes in brain chemistry that can make stopping use not only exceedingly difficult, but also physically dangerous and potentially life-threatening. To the layman, it may seem as though addicts simply lack willpower, and ought to be able to stop the same way an alcoholic or smoker stops — by simply ceasing use and with support, toughing it out until the urges go away. But opiate addiction works in a fundamentally different way. It was for this reason that methadone, which was originally developed to try to separate morphine's pain-killing capabilities from its debilitating cognitive effects, came into use as a treatment for opioid addiction.
“The philosophy behind it is basically that we know addiction to opioids affects the brain,” explains Marion. “I don’t think we know who gets affected or for how long one must take opioids before marked changes in brain chemistry occur, but the philosophy is that we need to normalize brain chemistry. We need to occupy the receptor sites that heroin has occupied and has disrupted, so that folks will feel normal, not crave opioids and be able to work a program of addiction treatment.”
Today, methadone has been joined by newer medications such as Buprenorphine and Buprenorphine with Naloxone, developed in an effort to provide a safer alternative to methadone as it is a very powerful drug that can be dangerous if not prescribed and used correctly. All are intended to satisfy the brain’s cravings for opioids to allow recovery efforts to unfold without severe cravings or withdrawal symptoms.
Misconceptions about NA are also common
One of the reasons that members of 12-step programs such as Narcotics Anonymous may have harbored distrust over the years towards MMT is that NA itself predates the development of medication-assisted therapy by decades. In fact, in a perhaps somewhat ironic twist, NA itself dates back to a time when suspicion of drug users was so extreme that the group itself was illegal in many places. Bob Stewart explains: “In the ’50s there were laws in place in many states that prohibited known addicts from gathering together. In fact, it was against the law. In the state of New York, they had what was called the Rockefeller law which said that if any two people who were known, registered addicts met publicly, they could be arrested. So, if you look back at our history, the proliferation of growth in that state was stunted because, quite frankly, you could be arrested if you met together. So they met in hospital rooms quietly, privately. But there was no public offering of meetings unless you left that state and went next door to Connecticut or New Jersey. You couldn’t meet in New York, and in the ’50s, we had meetings that were under surveillance by the police consistently.”
In spite of those early suspicions about the group, NA soon convinced authorities that it could be a powerful partner in its efforts to stamp out drug use and abuse, and soon began to gain a modicum of popular acceptance. But nonetheless, NA, like methadone treatment, still suffers from many popular misconceptions and myths to this day. Among the most common is that it’s a group solely for heroin addicts.
But in this day and age, NA, with the expansion of drug abuse to many other substances — and increasingly to prescription drugs — welcomes users of any drug who wish to stop using, as it has always done. “Our name says Narcotics Anonymous, but that’s one of the biggest myths because anyone is welcome to attend NA and become a member of NA regardless of the drug used,” explains Nickels. “Right now, there are a lot of prescription medications that members have become addicted to, but they’ve never used heroin. We have a lot of young people and young people’s literature, and they’ve never used even narcotics. But the name in 1953 came about because everything, every drug, including marijuana, was considered a narcotic. That’s one of the myths.”
A further irony is that NA’s own tradition of anonymity makes it difficult for group members to disabuse the public on many of these myths and misconceptions, and to tout its successes. “What happens is, because of the tradition of anonymity, those who are receiving the most benefits from recovery are prohibited from proclaiming it and advocating it the way the public wants them to advocate it,” explains Nickels.
Medical community needs to be better educated
However, the group does try to play an active role in educating the medical field about drug addiction and its work. Surprisingly, it is often among this professional and supposedly well-educated and medically informed population that it finds the most alarming lack of knowledge. “NA World Services conducted a medical roundtable in San Antonio in 2007, and we brought in five physicians for the members to be able to talk to these physicians and gain some information,” says Nickels. “And of all of the five physicians, if they stated if they received two weeks of addiction training, that was the high end. Most of them received maybe four hours. One of NA World Services’ concerted efforts has been to educate medical professionals about NA being a community resource and an adjunct if they have a patient who needs it.”
NA World Services frequently sends representatives to such professional medical conferences as part of their outreach and education efforts, and frequently finds a similar lack of awareness about drug addiction and NA in the medical profession. It’s a problem NA works to address through such outreach, but Nickels says they can’t do it alone — that information about drug addiction needs to become a bigger part of medical training. “Recently, this past July, a colleague and I went to the Family Physicians Resident and Student Conference that’s held yearly. There were 700 residents and students. What was really surprising to me was the number who did not know what Narcotics Anonymous was and why we were there. I could probably say of everyone who stopped [by our booth], I believe five had heard of Narcotics Anonymous, because they needed to take addiction training in their medical school. So I believe there needs to be more education. I know we’re trying on our end.”
Coming together in common cause
It’s a problem the addiction treatment community as a whole also knows all too well. And while it’s reassuring to report that, within the treatment and recovery community itself, mistrust and misunderstanding between advocates of medication-assisted therapy and the 12-Step, drug-free recovery movement seem to be on the wane, the next frontier for both sides now appears to be working together on better educating the medical community and society as a whole. In that regard, it is perhaps timely and fitting that old and outdated internal divisions now seem to be rapidly becoming a thing of the past.
BHC Interview with Ira Marion
BHC: Let’s start first with perhaps a brief history of methadone maintenance therapy and perhaps you could describe some of the main philosophies behind this treatment modality.
IM: Well, most people know that methadone maintenance treatment was developed in New York at what is now Rockefeller University by Dr. Vincent Dole and his team, which consisted of Dr. Marie Nyswander, also a psychiatrist and a physician that worked in Lexington, Kentucky; and Dr. Mary Jeanne Kreek who’s still at Rockefeller doing research in addiction treatment. Methadone was developed as a result of a need to look at addiction medicine and the possibility that drug-free therapies were not available widely enough to deal with what was then an epidemic of heroin addiction in New York and also an epidemic of Hepatitis B.
Methadone treatment expanded rapidly in the early ‘70s, and in 1972 was approved by the FDA as a valid treatment for opioid addiction at that time, mainly heroin. And it has expanded worldwide, all over eastern and Western Europe; now in China, Vietnam, former republics of what was then the Soviet Union. Russia still does not use methadone medication.
Methadone is a full opioid agonist, unlike most recently approved treatments for opioid addiction, Buprenorphine and Buprenorphine with Naloxone, which is a partial agonist treatment. Methadone, because it’s a full agonist and because in the wrong hands it could become a dangerous medicine, has been causing mortality and morbidity in the pain world of late because of its use of the treatment of chronic pain.
But methadone treatment is controlled now by the Substance Use and Mental Health Services Administration’s (SAMHSA) Center for Substand Abuse Treatment(CSAT), which requires programs to be accredited by an approved accreditation agency. It’s also regulated by the Drug Enforcement Administration, and most states have a state methadone or a state opioid treatment authority that regulates, and states regulate methadone treatment. There are also some localities that regulate methadone treatment as well.
So there’s a long 40-year-plus history of methadone treatment that has proven it to be an effective — probably the most effective — modality. I don’t think we have the data yet on Buprenorphine, but I think it seems to be as effective for many of the people taking it as methadone. But methadone treatment in approved programs and with counseling and other support services has proven to be probably the most effective treatment — some folks would say the gold standard for opioid addiction medicine treatment.
The philosophy behind it is basically that we know addiction to opioids affects the brain, and I don’t think we know who gets affected or for how long one must take opioids before marked changes in brain chemistry occur, but the philosophy is that we need to normalize brain chemistry. We need to occupy the receptor sites that heroin has occupied and has disrupted, so that folks will feel normal, not crave opioids and be able to work a program of addiction treatment.
And that program generally is group, individual and family counseling, depending on where and what the individual needs of the individual patient are. It could be a 12-step program — working that program. It could be that the person does very well because they already have a vocation and employment and they just needed medication to deal with this opioid craving, which generally contributes greatly to relapse.
So I think that’s the philosophy — normalize brain chemistry, normalize endocrine function, normalize the kinds of disruptions that result in withdrawal symptoms, psychological as well as physical, when a person’s first coming off opioids, and allow that person to be amenable to treatment.
Also opioids, particularly heroin, at least half the people end up using heroin intravenously and so you have all the infectious, sexually-transmitted infections, and blood-borne pathogens that go along with injecting heroin — hepatitic C now, HIV, hepatitis B. And so the idea is to stop the use of needles. Methadone is effective orally; it’s effective for 24 to 36 hours in almost everyone. And it allows people — it doesn’t cause highs and lows so folks can be amenable to working a program.
BHC: What’s the average amount of time that a patient undergoes methadone maintenance therapy? Is there any sort of a set schedule for it? Is it something that some people may have to do for life? Help us understand that a bit.
IM: I think ideally that’s an individual decision that’s usually made by the patient and the treatment program or the physician who’s prescribing the medication. I think there are people who are able to take methadone for a year, or two years or three years. And their desire is to be medication-free and they work that program. I think that others will require methadone for long periods of time and even for life.
I think that the rules and regulations that govern methadone in many states and federally make it difficult — not so much federally anymore, since the regulations were changed in 2000 and I believe 2001. But methadone maintenance treatment, which is directly observed therapy in bricks-and-mortar clinics, can be disruptive to fully recovered individuals or individuals who are in long-term recovery. And so, going to a clinic every day or three times a week or twice a week can be onerous, and that in and of itself makes folks think about terminating treatment — even prematurely terminating treatment — because of the restrictive nature of the treatment itself.
But essentially it’s an individual decision as to how long folks stay on methadone. If you look at the data, there’s a blip at three years of treatment, so that you can kind of surmise that folks after three years of successful treatment try to taper their dose down to zero. Some are able to do that and remain drug free in the community, even for a year or two years. Inevitably, if they’re not prepared properly, craving comes back and relapse possibilities exist. Some folks are able to stay drug free for the rest of their lives. Some folks decide that they need residential treatment after methadone and succeed post-residential treatment. I don’t think there’s a pattern or a timeframe that you can grab onto. A percentage of people that we know succeed at becoming eventually drug free as opposed to taking methadone for indeterminate amounts of time.
BHC: What are some of the most common myths or misunderstandings about MMT?
IM: Well, there are lots of them. I mean, there are the bizarre ones — that methadone was invented by the Nazis, that methadone gets in the bones. I actually had a great PowerPoint on the myths about methadone, but there are a number of street myths about methadone — it rots your teeth. It’s a kind of medication that I think is truly subject to street lore, if you will, and I don’t know if I’ve got a ton of myths that it’s more addictive than heroin, etc. And these are the kinds of myths that prevent people from entering effective treatment.
In fact, they are myths. They’re totally, just totally not real. These are some of the reasons that methadone is not available for treatment in Russia now, where there are some four million heroin addicts who are suffering.
That methadone is bourbon for scotch; that methadone cheats people; controls people; that it’s simply a way for folks to make money. People refer to methadone programs and methadone as “liquid handcuffs;” that it’s simply the programs that are profiting over people’s dependence and it trades one for the other. But the science, it completely belies all of that.
And what’s so fascinating, I think, about that is that there is always a little bit of truth in some of these things. One myth is that dolophine — which is one of the trade names for methadone that dolophine comes from — that it’s named after Hitler. In fact, methadone was developed in the ‘30s in Germany as part of a bunch of experiments. It’s not named after Hitler. It most likely comes from its use in pain. French for pain is “dolor” and “-phine” means end, so ending pain is probably where the name came from.
I guess there are lots of these kinds of myths that one could go over and talk about, but there’s no scientific evidence to say that for example methadone has any impact on bones or teeth or physical health at all. That it’s fattening. That patients gain weight. But of course when you’re living a life as a heroin addict on the street and you’re not eating properly, you might be thin and even emaciated. A new lifestyle where you’re eating well, inevitably results in some weight gain. I would guess if you eat properly and you exercise properly, you won’t gain weight. Methadone also has a myth about sexual dysfunction associated with methadone that it has an impact on the libido. And in fact, some people do have sexual dysfunction, but often it’s a factor of age, health status and possibly of the methadone dose itself.
BHC: Ira, for some years there has been some tension between the 12-step recovery community and methadone maintenance treatment providers, with the attitude perhaps in the recovery community that only total abstinence from any drug can begin the path towards recovery. Does this attitude continue to exist? And if it does, what would you say to those who hold this view and perhaps express it toward those who come to them for support in recovering from opioid addiction?
IM: Well, I think early on as methadone treatment expanded and developed — and we now have more than a quarter of a million people in methadone treatment programs across the nation, almost all of the states — the recovery community and particularly the 12-step community had a philosophy of total abstinence. I think it’s articulated most in Narcotics Anonymous. I think AA (Alcoholics Anonymous) is far more accepting of medications. And rarely, even in drug-free treatment programs, do you find people who do not need some medication or another on a maintenance level, like behavioral health medications, mental health medications — antidepressants for example.
But I believe that has changed over time and one of the deans of recovery, William White, spoke at the last AATOD Conference in New York City, where I also was interviewed by Behavioral Health, and his Plenary Address (we had a Recovery Plenary) basically said, “I got it wrong.” That methadone maintenance treatment, when it’s part of a program of addiction treatment and recovery, is a valid pathway to recovery. And he’s written extensively about that recently and I think that the attitudes have changed in many arenas and they are continuing to change. And I think that White will help foster that change since he himself once felt that methadone and assisted treatment in general were not valid pathways to recovery.
I would also just add that taking methadone does not, in and of itself constitute recovery — that people need to change the way they live their lives. If you continue to live a life of deceit and lies and addiction to other drugs or alcohol, you’re not in recovery, simply because you may participate in a methadone program, kind of more as a harm-reduction approach to treatment. But if you work a program of recovery, that may be either Miller’s or the 12 Steps themselves, I don’t see methadone in any way as invalid in that process.
BHC: So you would say the attitude has become a little more enlightened in recent years in that area?
IM: I think it’s become more enlightened, and I think that NIDA has done a great job of publishing the science related to the brain disease of opioid addiction. I think SAMHSA and SECAD have certainly supported that notion and ONDCP as well. And I think as we hear this from our federal partners, I think as AATOD starts to partner and as the National Association of OTPs starts to partner with Therapeutic Communities of America and other advocacy groups, you’re going to see that change expand. And as recovery advocates start talking about this as well.
Faces and Voices for example. Lisa Torres, a major advocate for methadone treatment and a lawyer currently on methadone herself, was the Chairman of the Board of Faces and Voices of Recovery for two years. About a year ago, I think she left the Board.
So this enlightenment has gone — I don’t know what the right word is — it’s expressed itself in various traditionally abstinent organizations and ways.
BHC: Is it do you think, also spreading to the society as a whole? Do people undergoing methadone maintenance therapy still face, let’s say, considerable discrimination in looking for a job or housing or those kinds of things?
IM: I think we have a long way to go. I think that the media has continued to publish bad news. And there is lots of bad news that is associated with the word methadone. I think it has not yet enabled patients, for example, who are in recovery and are taking methadone medication, to openly disclose that, even though we all — those of us who run treatment programs and who work in this world — know many, many people who are leaders in their professions and their fields who are afraid to disclose.
You don’t see the kind of disclosure that you see when celebrities say, “I went into treatment and I am now working a program of recovery.” I think when that starts to happen and people are willing to take those chances, you’ll see some of those general societal stigmas break down. But I don’t think we’re there yet. I think we have a long way to go.
BHC: Ira, with parity legislation now having gone into effect as of the first of the year and with more people having greater access now to care for addiction, what guidelines would you give to caregivers and those who want to get into recovery to consider when trying to determine whether methadone maintenance therapy is the right approach for their situation?
IM: Well, I think that right now given the regulatory structure of methadone treatment, first of all, I think methadone treatment should be paid at parity and should be fully insured. And I think this parity legislation and national healthcare reform anticipates that, and hopefully the bills that passed the House and Senate when they get reconciled and a bill hopefully gets signed, methadone maintenance treatment will be a full partner with other treatment modalities at parity in that legislation.
I think the decision to enter methadone treatment is still an individual decision. You need to, like all treatments, work the program and take advantage of the services that programs offer. I am not sure whether there is a formula as to when you would recommend medication-assisted treatment for opioid addiction, as opposed to trying to enter a treatment program whose eventual goal was for you to be drug free. I think treatment should be individualized and I would like to see — and what we are trying to do in New York State — is to transform the system to have a single outpatient system of care where any outpatient drug treatment program, or for that matter residential drug treatment program, offered the plethora of approved medications for addiction. So if you were opioid-addicted and you entered a residential treatment or intensive outpatient program or a traditional outpatient program, medication was part of the treatment plan when it was indicated, and you were assessed based upon your individual needs. If you had relapsed several times from attempted ‘drug-free’ treatment, you might be offered buprenorphine as a medication, buprenorphine with naloxone, or methadone, or make a decision as to which two might be best for you.
I think that the future is a single outpatient system of care that is in healthcare reform at full parity, not isolated methadone treatment programs that are kind of out there on their own in a silo, and then over here there are drug-free treatment programs, and somewhere there are these fellowships that are either part of those programs or aftercare-like referrals. I think we need to integrate all these things so that there isn’t a debate as to whether it’s methadone or buprenorphine or drug-free.
BHC: Anything you would like to add in closing that we haven’t covered here about this?
IM: I think that methadone treatment in 45 years has proven to be a more widely available treatment than, for example, therapeutic community treatment, simply because of the available number of slots and beds. I think obviously the fellowships and drug-free treatments are important components, and individuals make choices about treatment based on individual needs. And it’s important that assessment and evaluation and referral be done without regard to an individual program’s need to fill slots or to make profit or what have you, but based on the individual patient’s needs. I think we’re seeing in this country a for-profit behavioral health system grow up, because governments at state and federal levels don’t want to fund treatment programs.
So, in regards to methadone, for example, most of the new slots that have developed in the past ten years have been for-profit slots that have taken the place of what was not-for-profit funded entities. And I think it’s important for state and local governments to come back to the arena of funding programs, to do good and take out that profit incentive — not that for-profit programs can’t be just as excellent and top-notch as those in the public sect.
BHC: Well Ira, I really want to thank you for joining us today.
IM: Well, it’s my pleasure and I hope I have added something to the dialogue.
BHC Interview With Bob Stewart and Jane Nickels of Narcotics Anonymous World Services
BHC: Let’s start by getting a little bit of background and history.
Bob Stewart: A brief history of Narcotics Anonymous is that Narcotics Anonymous was founded in 1953. We experienced marginal growth for about 30 years and then there was an explosive growth period following the publications of its primer, the book Narcotics Anonymous, in 1983. Today, there are currently 153,000 Narcotics Anonymous meetings weekly in 130 countries and we are currently translating into 65 languages.
BHC: That’s tremendous. Tell us about how it came to be. Who were the original founders that got together and decided to create Narcotics Anonymous?
BS: One of the cofounders who I can speak of was a gentleman by the name of James Kinnon. He and a group of other members of Alcoholics Anonymous who were recovering addicts felt that there was a need for a fellowship that would address the needs and identification for addicts coming into the rooms that couldn’t identify [with AA] and that were walking out. And they formed the nucleus of a group in the summer of 1953, came up with the first set of bylaws, and formed the first meeting, which started in August of 1953.
BHC: Let’s talk about some of the main philosophies behind Narcotics Anonymous — what a person who may be thinking about joining Narcotics Anonymous should know about the organization in order to make a decision and how to find out more information to attend.
BS: First of all, Narcotics Anonymous is a 12-step-approach fellowship, utilizing the 12 steps. It’s a sponsor/mentor-based fellowship where one addict — the therapeutic value of one member helping another — is a key core incentive. It’s an abstinence-based program — complete abstinence from all drugs. There are no membership dues or fees required. The only requirement for membership is the desire to stop using and to recover from the disease of addiction.
Jane Nickels: If someone was interested in attending, they may want to go on the na.org website. They would find literature there, like, “Am I an addict?” or, “Welcome to NA.” And they’d also find meeting schedules for their various locales throughout the world.
And meetings have identifications of either open or closed. An open meeting is open to anyone — members or non-members, family, friends, professionals. So they might want to try an open meeting to see if this is for them.
BS: A piece of literature that’s online is a pamphlet entitled Information about Narcotics Anonymous. If they read that particular item, they will get a historical, philosophical and demographical overview of our fellowship in that one piece of literature.
BHC: Could we talk about what you think some of the misunderstandings about Narcotics Anonymous might be, and what they might be misunderstanding about the idea of privacy versus wanting to talk about the program itself?
JN: NA has spokespersons like Bob and myself, and we’re located at the international headquarters, NA World Services. However, our members refrain from interviews because there is a tradition in NA that speaks of anonymity at the level of press, radio and film. So they are reluctant to engage in any kind of interview.
Oftentimes, when there is a world convention (we had one in Barcelona) I, as a spokesperson for Narcotics Anonymous could go on filmed media. There are various television stations and they wanted human interest stories to accompany the information like you’re asking. And the members were filmed [with] first name, last initial over their shoulder, and they were never disclosed as full face. So there is a way to train our members and a way to train media so that interviews can happen. But it’s difficult sometimes to work with membership who are not used to dealing with any kind of interview.
There are more myths, I think, probably especially when you mention narcotics addiction and Narcotics Anonymous. Our name says Narcotics Anonymous, but that’s one of the biggest myths because anyone is welcome to attend NA and become a member of NA regardless of the drug used. Right now, there are a lot of prescription medications that members have become addicted to, but they’ve never used heroin. We have a lot of young people and young people’s literature, and they’ve never used even narcotics. But the name in 1953 came about because everything, every drug, including marijuana, was considered a narcotic. That’s one of the myths. Bob, you want to add to that?
BS: No, that covers it. The myth that we’re solely heroin addicts — that’s long been debunked because of the range of what addicts find themselves addicted to today. And as Jane said, our membership is a wide variety of different abuses and everybody is welcome to come and see if this is what they want.
BHC: At Behavioral Health Central, we initially launched primarily for clinicians in the behavioral health field, and since then we’ve expanded our news and resources and information to include caregivers and patients in recovery and so forth. And so, in light of healthcare reform that’s coming up and the parity legislation as I mentioned, our goal is to provide information and resources so that each person entering recovery can work with their caregivers and providers to determine the course that might be best for them. So, if someone is coming in and not quite sure, is there a certain type or a certain readiness that you need to have in order to be successful in NA? Can you describe how you counsel people to determine if they’re ready for it?
JN: Honestly, Robin, we don’t counsel. NA operates on the premise of the therapeutic value of one addict helping another, and it’s really through a process of identification. So if someone walks into the rooms and thought they were misunderstood — “You never had it so bad as me. I lost my house, my job, my family because of this addiction,” more than likely there are members who would be able to say, “Welcome.” Because many of the members have already walked the same path but are now recovering. So there’s no counseling, it’s really just members helping other members learn how to live without the use of drugs, and become productive, responsible members of society.
The other component piece is that NA as a whole has traditions and these traditions are guiding principles on how we should function — the organization, the members, the groups, the meetings, the structure. And one of them is NA as such has no opinion on outside issues, including medication. The membership, individual members, may have opinions but NA as an organization does not, and with the propensity toward medication-assisted treatment, NA World Services has produced publications to help members get a better understanding that these folks who may come to meetings to see if this is where they belong may come in on medication. We have no opinion, and our job is to welcome them to see if this is where they want to recover.
BHC: Then is there a certain time frame that they would have to transition off of medication-assisted therapy is they decided to make NA their course for recovery?
JN: We don’t set guidelines. That’s between the medical professional and their patient. They would naturally, because it’s an abstinence-based program, hear from individual members in their town that you have to be off medication. But that’s an opinion. There are equally meetings where the members recognize that they may decide to stay or they may not decide to stay — they’re getting stable, they’ll support them, be their mentor, And hopefully at some point, the person on medication will make the decision that they want to learn how to live an abstinence-based life too. But we don’t offer any guidelines as to when that should happen.
BHC: If we can, if it’s known, let’s go back to when NA was founded and when the principles were established. Since abstinence is also the premise behind AA, this might sound like an obvious question, but for those who may ask, what is the idea or what is the reasoning for an abstinence-based approach?
JN: Honestly, I don’t know. I believe that in 1953, one, it was illegal for addicts to even be seen together and meeting together. And there were no pharmaceutical adjuncts at the time because there was no treatment for addiction per se. It was like an addict was shunned from society. They had to be cloistered, and the only way they could recover was based in abstinence and that was refraining from the use of any drugs and alcohol.
And I believe that in our primer that Bob mentioned, that we published in ’81, we recognized the disease of addiction back in 1981 as a physical, mental and spiritual disease. And then through medical studies and the growth of substance abuse within the U.S. and the science [of addiction], they actually then added it to the DSM-IV. And from there, there was more research from NIDA and SAMHSA, and brain studies that really saw that there were effects on the brain that medication could assist. But in 1953 it was a different world.
BHC: And so let me just make sure I understand clearly. You had said it was illegal for people in recovery to meet?
BS: In the ’50s there were laws in place in many states the prohibited known addicts from gathering together. In fact, it was against the law. In the state of New York, they had what was called the Rockefeller law which said that if any two addicts that were known, registered addicts met publicly, they could be arrested.
So, if you look back at our history, the proliferation of growth in that state was stunted because, quite frankly, you could be arrested if you met together. So they met in hospital rooms quietly, privately. But there was no public offering of meetings unless you left that state and went next door to Connecticut or New Jersey. You couldn’t meet in New York, and in the ’50s, we had meetings that were under surveillance by the police consistently.
We talk about not being under surveillance at anytime but there was a time in our history when we quite frankly were under surveillance. We had to deal with stigmatization a lot longer than the alcoholics had and it is still out there today. We are trying to overcome a lot of it and we’ve come a long way and there are no laws now that say that we can’t meet, but there are countries in the world today still where addicts cannot meet publicly.
BHC: Any in particular that come to mind?
BS: Where NA meetings were being held and were shut down by the law in particular countries.
BHC: What reasoning do they give?
JN: It’s against the law in the country to be an addict, so to recover from addiction would be breaking the law.
BS: If you come forth and announce that you’re an addict, you’ve broken the law and you can be arrested.
BHC: Were there actually arrests in the 1950’s here in the U.S.?
BS: Absolutely. In San Fernando Valley where the first meeting was founded, one of the cofounders went to the local police captain after about a year of their existence and said, “Listen. Here’s what were trying to do: We’re trying to use the tenets of these 12-steps and we’re trying to abstain from using. We’re clean, we’re productive, and we have jobs now. Is there any way that we can curtain some of this surveillance that’s going on?” And after having a sit-down with the police captain, it was finally agreed that they would call off the dogs and allow these people to meet and try to recover.
BHC: I guess because back then the science wasn’t known that addiction was a disease and they thought it was a moral issue. Is that correct?
BS and JN: Absolutely.
JN: And it’s been a long struggle. It’s more stemming the tide now in the U.S. with the effort of outside organizations to recognize recovery and recognize that it’s not a moral issue, but that’s probably gained momentum in the last ten years. Up to then, many folks held that it was a moral issue. In fact, Rob and I attended Recovery Month Planning Partners, and in an annual kick-off luncheon with Seattle Police Chief Kerlikowski who’s now the new Drug Czar, he explained publicly there up to ten years ago he really believed addiction was a moral problem. That they were weak. But through education he realized it was a disease.
BHC: Even now in recent interviews where I’ve asked a specialist how they think that the parity legislation will improve care for behavioral health and they said, “Well, it’s interesting. We can educate providers but there’s still a stigma, even a cultural stigma that needs to be overcome because people even among their families don’t want to talk about it, because in many places it’s still being considered a moral issue.” And so, what do you think it’s going to take so that parity will have the positive impact that we want it to?
JN: Truth is I don’t know.
BHC: What have you seen in trends? Has stigma lifted enough that you’ve seen a steady increase in the growth of membership in NA?
JN: I don’t think stigma affects the growth because of the tradition of anonymity. Members attend meetings — everyone’s equal regardless if you’re a top brain surgeon or if you’re homeless. There’s an equality among the members and the principles of anonymity are adhered to, so society at large doesn’t know that you’re attending.
So stigma hasn’t — in fact, that’s probably some of the rationale [behind the fact] that many recovering persons within certain professions would not want to publicly state their recovery, because their profession might stigmatize them if they publicly proclaim that.
BS: One of the issues that we’re confronted with is that with the education of the public about the value of recovery and what it means for society, there is also the hue and cry that people come forth to advocate, but what happens is, because of the tradition of anonymity, those who are receiving the most benefits from recovery are prohibited from proclaiming it and advocating it the way the public wants them to advocate it.
BHC: Let’s transition for a moment into educating providers. Again, going back to the issue of parity legislation going into effect in January and healthcare reform really pushing the idea of a patient-centered medical home where the primary care physician will be much more in contact with other sub-specialists — so it might be addiction specialists and so forth — but the primary entry for the person to get into recovery more and more will be the primary care physician. How familiar is the primary care physician in understanding what NA is in order to educate their patients about what options they have for recovery support?
JN: More than likely they have very little information. NA World Services conducted a medical roundtable in San Antonio in 2007, and we brought in five physicians for the members to be able to talk to these physicians and gain some information. And of all of the five physicians, if they stated if they received two weeks of addiction training, that was the high end. Most of them received maybe four hours. One of NA World Services’ concerted efforts has been to educate medical professionals about NA being a community resource and an adjunct if they have a patient who needs it.
Recently, this past July, a colleague and I went to the Family Physicians Resident and Student Conference that’s held yearly. There were 700 — this was a slightly smaller year probably based on economy — number of residents and students. What was really surprising to me was the number who did not know what Narcotics Anonymous was and why we were there.
I could probably say of everyone who stopped [by our booth] — we offer literature information about NA, membership demographics, and respond to questions — of all those that chose to stop, I believe five had heard of Narcotics Anonymous, because they needed to take addiction training in their medical school. So I believe there needs to be more education. I know we’re trying on our end.
BHC: Well, interestingly, this sort of goes hand in hand with one of the concerns with healthcare reform, and that is that if we are successful in achieving access for the 87 million people that don’t have healthcare coverage right now, there would not be enough primary care physicians. Most countries have about a 50/50 blend, where 50 percent of their physicians are primary care and 50 percent are sub-specialty. I understand that after this graduating class in 2010, our ratio is going to be about 20 percent primary care compared to sub-specialty and one of the reasons why is because medical schools really aren’t incentivized to produce the ratio of physicians that their community might need.
Some are being proactive —I know at the University of Colorado, in the rural areas of their state, there is a shortage of primary care providers there and so they’re opening up more access to primary care students who are interested in serving rural populations. But because the funding comes from big pharma and from manufacturers who produce technology related to sub-specialties and so forth, that there really is not a drive for primary care. And so I would imagine that that would in turn also mean that there’s probably not a drive to educate primary care about areas that they currently don’t interact with commonly.
I think that’s going to have to change because, as they said at the Rosalynn Carter Mental Health Symposium this fall, almost everybody is comorbid these days, and if we’re going to treat the whole person, then we’re going to have to include these courses in the care process. I guess, then, campaigning to medical schools and to the primary care associations who communicate to primary care providers to educate them about addiction. Does NA offer any sort of CE opportunities for physicians to learn about them?
JN: Continuing Education Credits, is that what you’re asking?
JN: Following the Family Physicians Conference or during it I spoke to the program organizers and basically stated that I understand you want research-based workshops. I approached them saying, “Would you like to have a workshop about what the Narcotics Anonymous program is, so that you could educate these family residents, even though there are not going to be the efficacy studies that you want?” And they were more than willing to work with me to help the medical residents.
We try to attend as many medical conferences as we can. We also attend the Rural Institute, which is primarily with those providers — primary, mental health — who work in rural America. So we’re hoping this next conference cycle that the voting constituency for NA World Services will hold another medical round table.
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Methadone; A Flicker Of Light In The Dark
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