When I read Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [1], I was surprised to see Twelve-Step Facilitation (TSF) included as an evidence-based behavioral treatment for addiction. I had just done a literature review on the efficacy of 12-step-based interventions [2], and found the evidence insufficient to support the prescription of 12-step groups as treatment. TSF is a standardized form of therapy where professional counselors try to engage their patients in participating actively in 12-step groups, in part by emphasizing 12-step philosophy during therapy sessions [3].

Twelve-step philosophy stipulates that addiction is a spiritual disease born of defects of character, and that 12-step groups are the only cure, involving faith in a higher power, prayer, confession, and admission of powerlessness. In contrast, the National Institute on Drug Abuse (NIDA) defines addiction as a disease of the brain – a medical condition requiring medical treatment [4]. A spiritual disease concept is not the same as a medical disease concept. Twelve-Step Facilitation treats addiction as a spiritual and biopsychosocial disease, retaining the spiritual emphasis of 12-step philosophy [5].

TSF was classified as a professional behavioral treatment in the Surgeon General’s Report. How can a professional, medical treatment be based on a definition of addiction as a spiritual disease? Baffled, I knew I would not be able to understand if I got stuck in bias against Twelve-Step Facilitation. I had studied the research on 12-step groups, but had only dipped my toe into the research on TSF. The Surgeon General’s Report cites hundreds of studies, and over a dozen in support of TSF. So, I did what all good scientists must do: I set aside my bias, knowing that if I want truth, I must assume first that I am wrong and dig deeper.

I conducted a preliminary literature review to investigate the effectiveness of TSF as a treatment, and then examined each of the sources the Surgeon General’s Report cited in support of TSF. I looked at the methodology, results, and conclusions for each. In this article, I define “evidence-based” to mean any treatment supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples. I use “12-step approaches” to refer to all 12-step-based rehab programs, TSF, and 12-step mutual help groups.

The key to understanding research on TSF is to know why the treatment was created in the first place. Researchers had documented an association between 12-step group attendance and abstinence, but association is not causation and research had been limited in several ways:

• Studies evaluating the effectiveness of 12-step groups could not eliminate self-selection bias, which happens when group members are not randomly selected and participants opt in or select themselves, creating biased samples. The people participating in the studies had chosen to participate, and researchers could not determine whether successes observed were due to 12-step participation or qualities in the self-selected participants, such as greater motivation to enter recovery, more resources, or greater receptivity to messages of God, faith and/or acceptance. The people who chose not to participate, or who dropped out of the study, were not always accounted for. Researchers could not determine whether the association they observed between 12-step participation and abstinence was due to the treatment or to the characteristics of the people participating.
• Twelve-step groups have no standardized methods or conditions. Leaders of the groups are often laypeople in recovery from addiction themselves. The quality of social support in the group depends on the people who are participating. The literature is interpreted by the members, who create their own cultures around the interpretation. Twelve-step cultures also pass around other information and advice, which may or may not permeate every group. Each sponsor is a different layperson in recovery from addiction, with different character traits. Researchers could not control for all of these variables all of the time.
• Researchers struggled to maintain rigorous control groups throughout studies. At minimum, to determine whether 12-step groups have effect, researchers needed a no-treatment control group for each study. Ethically and logistically, they could not prevent people in the control groups from receiving treatment or from attending 12-step groups.

Twelve-Step Facilitation was developed by researchers working on Project MATCH, a well-known and extensive study funded by the National Institutes of Health. Project MATCH compared TSF to Motivational Enhancement Therapy (MET) and Cognitive Behavioral Therapy (CBT), seeking to establish what patient characteristics corresponded with the best results for each treatment. The study found there “was little difference in outcomes by type of treatment” based on the primary outcome measures of percent days abstinent and drinks per drinking day [6].

By standardizing methodology for TSF, Project MATCH made some headway on strengthening the quality of evidence, but they did not find a way around self-selection bias and they did not have a control group. Many patients, however, did drop out of the assigned treatments early on in the study. Two researchers later examined the outcomes of the zero-treatment dropout group, and found that “two-thirds to three-fourths of the improvement in the full treatment group was duplicated in the zero-treatment group” [7]. This means that the people in Project MATCH’s treatment groups did not have significantly better abstinence outcomes than the people who dropped out of the study. Importantly, we do not know whether the dropout group sought treatment on their own, and it seems probable that they did. Based on their analysis, none of the interventions in Project MATCH seem to be effective, but without an actual control group the results are equivocal regardless.

Some researchers have sought to re-analyze other parts of the Project MATCH data [8,9], but their findings, while supportive of TSF, are subject to the same methodological limitations of the parent study. Many other studies cited by the Surgeon General’s Report seem to support TSF as effective for improving abstinence outcomes [10–14] and/or for relatively increasing 12-step participation compared to treatment as usual (TAU) [15–20], but none of these studies had control groups. The Surgeon General’s Report cited one source in support of TSF that was actually an article reviewing information about 12-step programs to educate social workers, not an experimental study [21]. The Report also cited a study in support of TSF that examined two active referral interventions, 12-step peer intervention (PI) and doctor intervention (DI), compared to no intervention (NI). The study found that while the active referral interventions significantly increased participation in 12-step groups compared to no intervention, “abstinence rates did not differ significantly across intervention groups (44% [PI], 41% [DI] and 36% [NI])” [22]. This study was the only one cited in the Surgeon General’s Report in support of TSF that approximated a control group, and it does not actually support the efficacy of TSF in increasing abstinence outcomes. The NI pseudo-control group still received a list of 12-step group meeting times and locations, but was not encouraged to attend. The PI group attended meetings twice as much as the NI group, and yet the researchers found no significant difference in abstinence outcomes. The DI group, essentially TSF, was less effective than the PI group at increasing attendance, and again, did not significantly improve abstinence.

My own literature review turned up articles the Surgeon General’s Report did not reference, both in support of TSF [5,23–28] and not supporting TSF [7,29,30], but none of the studies I found had control groups either. Results of my literature review, including my assessment of the Surgeon General’s report sources, were therefore as ambivalent as the 2006 Cochrane Review, a systematic meta-study of all 12-step-based programs that found that, “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems” [31]. A more recent systematic review by the Campbell Collaboration found evidence on 12-step approaches for other drug use disorders to be weak as well, with only 9 studies meeting all of their inclusion criteria. What evidence they did find indicated no difference between 12-step approaches and other psychosocial interventions in reducing illegal drug use, and some evidence that 12-step approaches have higher dropout rates than other interventions [32]. Researchers have not been able to methodologically eliminate self-selection bias, and most often fail to utilize adequate controls in their studies of 12-step groups and TSF.

One study to date attempted to use instrumental variables models, a recently developed statistical method, to determine what percentage of increased 12-step group attendance can be attributed to TSF without self-selection bias [33]. The researchers, Humphries et al. 2014, re-analyzed data from 5 randomized clinical trials, though none of these clinical trials had control groups. They determined that TSF did significantly increase participation in 12-step groups for people who had not previously participated much or at all, though not for people who already had high levels of participation. Their methods were inadequate for determining whether increased participation is causally linked to increased abstinence, or whether increases in abstinence occurred without self-selection bias.

My review answers a question that cannot be answered by simply counting the number of studies apparently supporting or not supporting 12-step approaches like TSF. Are 12-step approaches evidence-based for treating addiction – supported by numerous scientific experiments with rigorous methods that include control groups, randomization of patients to treatments, and bias-free samples? No, 12-step approaches are not evidence-based, because no studies decisively demonstrate their effectiveness. In fact, research on 12-step approaches faces insurmountable obstacles. Practically speaking, researchers cannot ethically design and conduct experiments that eliminate self-selection bias and utilize adequate controls.

In medical science, if a treatment is ineffective or faces prohibitive methodological challenges, the treatment is either revised or abandoned. Twelve-step philosophy prohibits either approach. Twelve-step literature is comparable to the Bible for Christians or the Qur’an for Muslims; if the literature is removed, the identity of the group goes with it. The same basic text has been used for AA since the publication of its “Big Book,” Alcoholics Anonymous, in 1939. Twelve-step literature also explicitly states that, “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average” [34]. Twelve-step philosophy, by taking this position, is asserting that its methods can never be wrong. If the 12 Steps do not work for people, 12-step philosophy explicitly states it is their fault, and that the fault is inborn and irreversible. The 12 Steps and attendant literature, however, are not modified.

Research does support the concept that changing “people, places, and things” and finding a network of people with a culture of abstinence can improve chances of recovery [35]. However, mutual help groups other than 12-step groups do exist that may provide the social support needed by people in recovery. A study by Zemore et al. [36], compared the relative, personal satisfaction of participants in 12-step groups vs. 12-step alternatives: SMART Recovery, LifeRing, and Women For Sobriety. The study did not examine abstinence or drinking/using outcomes among participants, but interviewed all participants on demographics, level of participation in their mutual help group (MHG) of choice, and level of satisfaction and group cohesion they experienced in their MHG. They found that, “despite lower levels of in-person meeting attendance, members of all the 12-step alternatives showed equivalent activity involvement and higher levels of satisfaction and cohesion, compared to 12-step members.” The participants who engaged in alternative MHGs tended to be less religious, and to have higher levels of education and income. The study demonstrates that alternative MHGs not only exist, but are of comparable efficacy in terms of social support. People who are not religious may be able to make 12-step groups work for them as social support if they have no other choices [37], but other options will most often be available.

Social support may be subjectively helpful as an individual seeks medical treatment, but ultimately medical treatment is necessary to ameliorate disorder symptoms. Social support is also not sufficient to prevent addiction from developing. Researchers using statistical analysis to determine whether social support and social networks reduced the odds of developing AUD following stressful life events and chronic stressors, among other disorders, found no statistically significant effect of social support or networks on later rates or effects of AUD [38].

A study in 2001 by Humphreys and Moos [39] found that TSF may reduce health care costs for people in recovery by emphasizing reliance on free 12-step groups, as opposed to cognitive behavioral therapy. Yet their conclusions that the study indicates people should be diverted from CBT to TSF because it is ultimately cheaper amounts to advocating malpractice. TSF itself is not free and is not decisively supported by evidence; twelve-step groups, while free, are not evidence-based or treatment, and other available mutual help groups are equally free options for social support. Even if TSF were demonstrably effective at promoting abstinence for some people, 12-step philosophy is heavily spiritual (specifically Christian-based), so it would be unethical to recommend TSF simply because it might save money.

In Unbroken Brain: A Revolutionary New Way of Understanding Addiction [40], Maia Szalavitz, citing Anne M. Fletcher’s Inside Rehab: The Surprising Truth About Addiction Treatment–and How to Get Help That Works [41], reports that 12-step approaches are “a required curriculum” in 80% of American addiction treatment programs. Many addictions treatment facilities state that that they are 12-step based. Based on my literature review, that means that these facilities are not offering effective, evidence-based treatment.

After extensive research, I assert with confidence that 12-step approaches are not evidence-based treatments. They may be strong recovery support options for people to choose in addition to a medical treatment plan, but 12-step approaches—including TSF—are not established as evidence-based for treating addiction. Due to the methodological limitations identified in this article, I question continuing to spend thousands of dollars, hundreds of hours, and limited expertise on researching a spiritually-based treatment for addiction that cannot be proven to be effective for most people most of the time compared to “spontaneous,” or natural, remission rates. It is time to relegate 12-step approaches to the realm of recovery support services (RSS, as defined in the Surgeon General’s Report) and allocate our research resources to promising treatments that can be studied rigorously and without such crippling methodological limitations.

References

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Laurel Sindewald is a writer and researcher for Handshake Media, Incorporated. Anne Giles contributed to this report.

A version of this report was originally published by The Fix as “AA Is Not Evidence-Based Treatment” on 3/16/17. We broaden the scope, update with the latest research, and provide full citations using APA style guidelines. We will continue to update the report as new research warrants. This report was last updated on 6/23/17.

I felt that paradox of shock and recognition that shadows the human experience of time when I realized I had been writing and researching on addiction for Handshake Media, Inc. for 3.5 years.

Anne Giles and I have worked diligently together on investigating and reporting on addiction. I have felt like a detective, or a mythbuster. Anne, in her work as an addictions treatment advocate, would come across a new concept or quandary, or a common belief about addiction, and she would task me with investigating. While researching and writing for Handshake Media, I have authored 26 articles on addiction and addictions treatment. After hundreds of hours of research over the past 3.5 years, Anne asked me these questions.

What is addiction?

Addiction is a disorder or disease of the brain, of varying severity, that compromises willpower and executive functions, sensitizes the brain’s stress system, and desensitizes the reward system. Addiction is defined by a person’s inability to stop a behavior despite negative consequences.

What causes addiction?

Addiction happens when a combination of risk factors (e.g., genetics, past trauma, attachment style, co-occurring disorders, and a poor socioeconomic support system) coincide with a person’s use of substances or behaviors regularly to cope with stressful situations in place of other emotion regulation strategies.

What treats addiction?

Each person requires a personalized treatment plan based on his or her individual situation, developed in consultation with his or her doctor. Three main components can be listed, however, that are often helpful for most people most of the time for recovery from addiction.

1. Medication-Assisted Treatment (MAT). Foremost, medications are available that directly or indirectly treat the brain problems that develop with addiction. Counseling is not required for treatment of addiction with medications to be effective.
2. Individual or Group Counseling. Adherence to medical treatment in general averages to around 50%, and addiction is likely no exception. Counseling may help people stick with a treatment plan, and to meet their abstinence or harm-reduction goals. People with substance use disorders (the medical term for addiction) may also need assistance with developing new emotion regulation skills and strategies to replace the behaviors and/or substances they previously used when stressed. Dialectical Behavior Therapy (DBT) and Cognitive Behavioral Therapy (CBT) are two treatment options available, and may be especially helpful for people with co-occurring disorders. We don’t know whether counseling directly affects the changes in the brain resulting from addiction, but by supporting abstinence or harm reduction, counseling may play an important part in indirectly affecting those brain changes over time.
3. Recovery Support Services (RSS). RSS is not actually treatment, but may be helpful in supporting people in recovery. Some people find support groups (also known as Mutual Help Groups or MHGs) to be helpful for social support in building a new recovery lifestyle. While 12-step groups are the most common support groups available, they are not for everyone, and they are not the only option. SMART Recovery is a secular, CBT-based support group teaching concrete skill sets to help people reduce or stop any kind of behavior. RSS is not limited to MHGs, however, and may include legal, housing, or nutritional assistance, and help with dependent care.

Is addiction a condition that would benefit from healing? Can it be healed?

Yes, addiction is a condition that benefits from healing because there are brain changes involved that require medications to stabilize, and eventually alter them. The term “healing” also implies an element of long-term care, which is helpful because the brain changes involved in addiction happened over time, and new changes also require time.

Addiction can be healed, and remission is considered stable after 5 years. Much as a habit or learned behavior can eventually be changed, an addiction can be changed too, but requires a deal of time and patience with mulligans and suffering. The brain networks of connection will always be there (one never forgets how to ride a bike or drive a car), but over time other networks will be stronger or will predominate.

Why do some people with addiction behave badly?

I believe people with addictions who behave badly are suffering – in pain – and do not know how to cope with that pain or adequately express it. When they use a substance, their ability to make decisions is further compromised and they are unable to stop or control the behavior. As addiction progresses, they lose more executive function in the brain and are unable to stop or control behavior, whether they are presently using the drug or not.

What might prevent people with addiction who behave badly from doing so again?

I think that first of all, people with addiction require a medical treatment plan for a brain condition involving medication and counseling as individually required. All co-occurring disorders must also be treated appropriately, and past trauma if in evidence. People with addiction may need help with an action plan to regulate emotion when they are upset, instead of using. Many people may require socioeconomic support, legal defense, and job training to have better lives in recovery.

I believe people with addiction also need compassion and forgiveness from those they love, even if harm has been done. Tough love is not helpful, and may worsen a person’s addiction. If a person is constantly focused on repenting for past deeds or making amends, how can he or she focus on the full-time self-care required to prevent a relapse, much less to build a new life worth living? I believe forgiveness frees a person to stop self-punishment for past actions, and to instead practice self-love and self-care.

I know that my position of compassion for people with substance use disorders is fairly uncommon, because unfortunately, addiction often has concussive effects on families and communities for generations. People who are close to people with addictions may be physically or emotionally abused, stolen from, cheated on, molested, raped, or otherwise traumatized – trust broken. People are suffering who did their best to help their loved ones with addiction, over and over, and yet those loved ones behaved incomprehensibly, cruelly, despite all efforts.

The elephant in the room of addiction is raw suffering, and hopeless defeat.

My position comes from these years of research, and hard-won experience, knowing and loving people with one or more addictions who hurt me or other people I love. Yet, while my personal experience tallies with the research I’ve done, it’s the research that I rely on when I report on addiction. Good research is based on careful methodology, transparency about funding and potential bias, and conservative conclusions from carefully-analyzed data. The research I have reviewed, compiled, and reported on pulls together information about hundreds of thousands of cases of addiction. Any experiences I have are singular data points, and only helpful when viewed as a very small, biased sample of the whole, complex picture.

So, what do I advocate after 3.5 years of research and reporting no addiction?

I strongly advocate compassionate delivery of evidence-based treatment, a focus on harm reduction rather than abstinence, dollars allocated toward treatment and not punishment or incarceration, and love-love for people with addiction—never tough-love.

Photo from Maia Szalavitz’s visit to Blacksburg, Virginia

Opioid addiction has been declared a national epidemic in America. President Obama called for $1.1 billion in new funding for opioid addiction treatment and research early in 2016.

Opioids are drugs that relieve physical and emotional pain. Opioids include opiates, which is an older term for drugs derived from opium, such as morphine. Common opioids include prescription painkillers such as OxyContin, hydrocodone, Percocet, methadone and Vicodin, as well as drugs like morphine and heroin. Opioids cause a rush of dopamine in the brain, conditioning the brain over time and altering pathways dealing with pleasure, memory, learning, and decision-making.

With continued use, the human body develops tolerance to opioids, which means the body no longer responds to the drugs unless the dose is increased. A person with a highly developed opioid tolerance may take doses to get high that would be lethal for a person without an opioid tolerance.

Unfortunately, people taking opioids illicitly may have an irregular supply, causing their tolerance to fluctuate. Illegal opioids are also of variable potency, and may be laced with stronger, faster-acting opioids like fentanyl. The combination of fluctuating tolerance and unpredictable potency creates a dangerous situation for people using illicit opioids. For example, someone using heroin whose tolerance has dropped may inject what they think is a manageable dose of heroin, not knowing it is laced with fentanyl; the added potency and reduced tolerance could cause an overdose, and this person could be at risk of dying.

Since 2000, opioid overdose deaths in the U.S. have increased 200%.

Some discussions about opioid maintenance involve black-and-white/good-or-bad thinking. Let’s explore the nuances of how opioid maintenance works for people with opioid addictions.

Why Opioid Maintenance Treatments Are the Best We Have

The opioid epidemic is alarming especially because so many people with families, dreams, and skills – like anyone else – are affected. People with opioid addictions are taxpayers and citizens of many races, religions, and backgrounds; they are people and they are valuable. How can we prevent them from dying?

Addiction is defined by NIDA as a chronic, relapsing brain disease characterized by repeated behavior despite negative consequences. Relapse rates for addiction are comparable to other chronic illnesses, such as diabetes and hypertension.

Given that relapse is likely and given that reduced tolerance is a primary risk factor for fatal overdose, it follows that maintaining tolerance would reduce overdose deaths. Sure enough, scientific research on opioid maintenance shows that stable doses of full or partial opioid agonists (drugs that completely or partially activate opioid receptors) maintain tolerance and reduce risk of death if a relapse occurs.

“If we really want to stop the overdose epidemic, we need to get serious about providing the only treatment known to reduce the death rate by 50 percent to 70 percent or more: indefinite, potentially lifelong, maintenance on a legal opioid drug like methadone or buprenorphine. The data on maintenance is clear. If you increase access to it, death, crime and infectious disease drop; if you cut it short, all of those harms rise.”
– Maia Szalavitz, The public scorns the addiction treatment Prince was going to try. They shouldn’t.

How Opioid Maintenance Works

“The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone’s system can leave them less able to naturally cope with physical or emotional stress…”

– Maia Szalavitz

Two drugs are supported by scientific evidence as effective opioid maintenance treatments: buprenorphine, and methadone. A continuous, prescribed dose of either buprenorphine or methadone prevents people from experiencing withdrawals, stabilizes them in recovery, and reduces risk of fatal overdose. These medications do this by maintaining tolerance to opioids. People who are in opioid maintenance programs are not high when they take doses as prescribed (also because of tolerance), and are quite capable of driving a vehicle, going to work, providing childcare, and otherwise living life. Pregnant women who are addicted to opioids are advised to take buprenorphine (Subutex) to stabilize themselves and their babies until delivery.

Buprenorphine

Buprenorphine is a partial opioid agonist, which means that it binds to opioid receptors in the brain with only partial efficacy compared to full agonists (like morphine, oxycodone, and fentanyl). Effects of buprenorphine also have a ceiling dose, beyond which higher doses have no effect. This ceiling effect also means overdose from buprenorphine is less likely. Buprenorphine also affects the mμ receptor, which reduces the effects of additional opioid use.

Because it is safer than methadone, buprenorphine can be prescribed by physicians as pills or sublingual films, often under the brand names Suboxone or Subutex. Subutex is buprenorphine alone, while Suboxone also contains naloxone, an opioid antagonist. Suboxone was created to discourage misuse. When Suboxone is taken orally as directed, the opioid partial-agonist effects of buprenorphine predominate. If Suboxone is injected, however, the naloxone blocks opioid receptors and prevents the person from getting high. In an opioid dependent individual, the naloxone precipitates withdrawal effects.

Methadone

Methadone is a full opioid agonist, and does not have ceiling effects like buprenorphine. For this reason, it is considered to have higher misuse potential and is only administered by SAMHSA-certified opioid treatment programs, usually methadone clinics. However, a 2014 Cochrane review of studies comparing methadone and buprenorphine determined that people are less likely to drop out of methadone programs.

Given the complexity of addiction, and the complexity of factors uniquely affecting each person, individuals with addiction need individualized treatment. Only the individual, in consultation with one or more physicians well-educated in opioid use disorder and its treatment, may decide.

“Extensive literature and systematic reviews show that maintenance treatment with either methadone or buprenorphine is associated with retention in treatment, reduction in illicit opiate use, decreased craving, and improved social function. … Further work is needed to directly compare each medication and determine individual factors that can assist in medication selection. Until such time, selection of medication should be based on informed choice following a discussion of outcomes, risks, and benefits of each medication.”
–Dr. Gavin Bart, 2012 (Emphasis added)

How Opioid Maintenance Treatments Discourage Misuse

Just as it is impossible to eliminate all supplies of illegal drugs, law enforcement and treatment providers cannot wholly prevent diversion and misuse of buprenorphine or methadone. In fact, in trying to reduce misuse of buprenorphine, authorities have restricted access to buprenorphine maintenance treatment, limiting the number of buprenorphine patients a doctor can treat at any one time.

Still, treatment providers, pharmaceutical manufacturers, legislators, and law enforcement continue to try to limit the potential negative impacts of opioid maintenance treatments. Methadone, for example, is only given in take-home doses if patients can provide drug-free urine for several months.

However, because Suboxone can be diverted to people who were not prescribed the medication, it can still be misused. People who do not have a tolerance for opioids can still get high on Suboxone, up to the ceiling effect. Arguably, it’s a safer high than heroin because it is less likely to cause fatal overdose, but it’s still an illegal high.

In this case, as citizens, we have to weigh the risks of the diversion of partial agonist, buprenorphine, with full agonists like heroin, morphine, fentanyl, and oxycodone. If the goal is to reduce overdose deaths and crime associated with the opioid epidemic, buprenorphine will remain an important tool despite diversion.

Why People Dependent on Drugs Are Not Addicted

People taking medicine for depression, diabetes, and many other chronic illnesses become physically, literally dependent on their drugs to stay healthy. In most of these cases, however, these people are not addicted to their medicines. Even chronic pain patients, who become physically dependent on their painkillers and suffer withdrawals without them, typically do not develop addiction – only 8-12% of chronic pain patients become addicted to pain medication.

Dependence and addiction are very different, and understanding this may sometimes make the difference between life and death. Addiction is defined by persisting in a behavior despite negative consequences. People who are only dependent on a drug suffer withdrawals, and are then free to continue their lives – they do not go looking for more of the drug or persist despite negative consequences. People who are dependent and addicted, however, will continue to seek the drug even after withdrawals are over.

In the case of opioid addiction, people are still at risk for relapse after withdrawals are through, and may die from a relapse if their tolerance drops. To treat opioid addiction, rather than only opioid dependence, opioid maintenance treatment – recommended by the World Health Organization, the Office of National Drug Control Policy, and others to be continued indefinitely, perhaps life-long – is necessary to keep people stable and to prevent fatal overdoses.

How Opioid Maintenance Disrupts Addiction Patterns

Addiction happens when people at risk due to trauma history, mental illness and other factors take a drug which they are predisposed to experience as extraordinarily rewarding. In the brain, when a person has an exciting new experience, the reward system responds with a release of dopamine and other neurotransmitters telling us it’s something we want to do again. Certain drugs are more likely to cause a magnified reward response in the brain, releasing far more dopamine than ordinary experiences.

The reward system helps people to learn which experiences are good and which are bad. Because some people biologically experience some drugs as more rewarding than anything else, they learn to associate the drug, and any cues relating to its use (paraphernalia, locations, people, symbols) with immense reward. Their brains begin to respond to the cues, more even than the drug itself, which reinforces use.

Opioid maintenance does not involve the cues to which people with opioid addictions respond. Commuting to a methadone clinic is very different from shooting up heroin. Receiving one dose of Suboxone from a designated family member is very different from self-administering indefinite pills. The “people, places, and things” associated with use are changed when a person enters opioid maintenance. Opioid maintenance treatment helps keep neurocognitive cravings and physiological withdrawals at bay while the person rebuilds his or her life to remove cues for use.

In this way, opioid maintenance disrupts the addiction pattern of cue > pursuit of drug > use. Essentially, opioid maintenance attempts to replace an addiction with simpler dependence, rather than with another addiction. The difference between physical dependence and addiction is crucial to understanding why opioid maintenance does not replace one addiction with another.

How Opioid Maintenance Supports Healthy Recovery

At this point, it may seem overly simple to say that because opioid maintenance prevents people from dying, it supports lives in recovery. Still, this is a key truth. Beyond keeping people alive, opioid maintenance allows people to find enough stability to build new lives in recovery.

Many people believe that a person must abstain completely from all drugs in order to truly be in recovery. However, if a person in recovery from addiction needed medical treatment for diabetes and were prescribed insulin, that person would certainly not be expected to abstain from insulin for the ideal of abstinence. Nor would a person refuse needed antibiotics on the principle that they must not take any drugs if they are to be in recovery. Opioid maintenance is no different from these examples of medication for medical necessity.

A person in opioid maintenance treatment is not high. The steady dose of a partial or full-agonist opioid basically establishes a “new normal” biologically – biochemically – without which normalcy is disrupted. A person with depression who benefits from an anti-depressant is said to have a chemical imbalance, which is stabilized by the anti-depressant. Similarly, a person with an opioid addiction has a chemical imbalance from chronic opioid use, and may be unstable without some level of continued opioid administration.

People in recovery from opioid addictions will still need to do everything a healthy person must do to survive and succeed, such as keep a job, pay bills, provide child, pet, or elder care, or maintain a household. In order to be stable enough to manage all of these challenges and the attendant stress, people in recovery from opioid addictions need access to opioid maintenance.

To Sum it Up

• People with opioid addictions are at risk of dying. As health professionals, concerned citizens, or families and friends, we owe it to people with opioid addictions to do what we can to prevent this.
• Buprenorphine/methadone maintenance is the only evidence-based treatment that reduces death risk by 50%. To prescribe other treatments without considering maintenance is, frankly, malpractice.
• People are not high when taking buprenorphine or methadone as prescribed. Opioids produce tolerance in the human body, such that consistent doses no longer make the person high.
• Opioid maintenance treatments include measures to prevent or discourage misuse. Buprenorphine, as a partial agonist, has a “ceiling” dose, beyond which further amounts have no effect. Suboxone discourages injection misuse by the action of naloxone, which precipitates withdrawal symptoms in opioid dependent individuals. Methadone is primarily delivered in controlled, daily doses in a clinical setting.
• Addiction is different from dependence. Addiction involves a learned behavior that continues despite negative consequences. Dependence is only the body’s physical adjustment to a drug, and can happen without addiction. Unlike addiction, dependence does not involve persisting in use despite negative consequences.
• Maintenance disrupts addiction because doses are not rewarding and are not associated with addiction cues. People in opioid maintenance programs are receiving their stable doses of methadone or buprenorphine under very different circumstances than their usual addiction-related rituals. By disrupting the patterns of addiction and providing doses that are not rewarding (do not get the person high), maintenance maintains tolerance and dependence without maintaining or creating addiction.
• Indefinite maintenance allows people to focus on improving their lives in recovery. Opioid maintenance treatments allow people to lead lives in recovery without worrying about coping with withdrawal symptoms or risking fatal overdose. In the event of a relapse, people can focus on learning which cues to avoid next time – how to prevent another relapse – rather than recovering from a severe overdose or dying.

Further reading:

Why We Have Wait Lists for Opioid Addiction Treatment

What the Opioid Epidemic Means in Virginia

How Ithaca, NY is Addressing America’s Opioid Epidemic

Addiction or Dependence: A Life and Death Difference

How to Talk with Someone About Getting Help with Addiction

This post was last updated on 10/27/16.

In the 1980s, when addiction science professionals sat down to agree on terminology for the DSM-IV, the room decided by only one vote to call addiction “dependence.” The issue did not rest there. The latest Diagnostic and Statistical Manual of Mental Disorders, DSM-5, labels addictions as “substance use disorders,” because “dependence” does not quite cover what addiction really is.

Dependence is when a person becomes physically reliant on a substance, and experiences withdrawals without it. While dependence often happens as addiction develops, full addiction is much more complex, and is defined by continuing to use drugs or engage in behaviors despite negative consequences.

As an example, physical dependence can happen with many different medications. People who take antidepressants, for example, become dependent on them and undergo withdrawal symptoms if they stop taking the medications. In this case, these patients are dependent on antidepressants but are not addicted to them, and antidepressants are not considered to be addictive.

People in pain go to their doctors for relief, take pain medicine as prescribed, and if they take it long enough, their bodies get used to the medication, expect it, and throw a fit without it. When (if) their chronic or acute pain is over, doctors know to taper patients from pain medicine if physical dependence happens, and to treat withdrawal symptoms to ease the process. The patients may or may not know they are feeling sick because of withdrawal, but if they are otherwise happy in their lives they won’t bother with trying to find opioids illegally on the streets.

They do not persist in using the drug despite negative consequences, which defines addiction. They were dependent on the drug, but not addicted to it.

(Note: Among pain patients prescribed pain medication, only 8-12% develop addiction. Maia Szalavitz reports for Scientific American that “75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.”)

Addiction develops in 10-20% of people when multiple risk factors coincide with drug use (whether prescribed or recreational). If people have genetic predispositions, a history of trauma, and/or mental illness(es), they will be vulnerable to developing addiction. Even for these individuals, addiction takes time as they learn to associate the substance or activity with pleasure or relief, and the absence of the substance or activity with misery.

Individuals addicted to opioids are usually also physically dependent on them. Often a first line of treatment is to enter people with opioid substance use disorders into detox, where withdrawal symptoms may be treated while the person is monitored by medical staff. What happens next unfortunately depends on which doctor is managing the case (not all treatments are equally effective).

But to whatever treatment they are referred, individuals with opioid use disorder are at risk for relapse long after withdrawal symptoms are gone. This is why addictions, or substance use disorders, are very different from physical dependence. Once a person has gone through withdrawals and been abstinent from the substance for a period of time, the body readjusts and is no longer dependent on the substance. But people with substance use disorders still crave the drug.

Moreover, with certain drugs, like opioids, the body builds up tolerance with repeated use, which means the drug no longer affects the body unless the dose is increased. When a person enters a period of abstinence, their tolerance drops substantially.

Sadly, people with opioid use disorders often relapse and die when trying abstinence-based treatment, because they’re still addicted and their tolerance is gone. When they take the opioid at their usual dose, they overdose. What was once an okay amount is now fatal. Buprenorphine and methadone maintenance are recommended to keep people alive by keeping tolerance stable (without being high). Life-long maintenance may be necessary. If a person is tapered or otherwise terminates maintenance treatment, they are at higher risk of fatal overdose.

In the case of addiction, distinguishing between “substance use disorder” and “dependence” is a life and death debate. Understanding that substance use disorders – addictions – are more than physical dependence means we will help these individuals long after withdrawals are gone and for as long as they need treatment.

This post was last updated 5/4/17.

For a long time since Bill Wilson and Dr. Bob Smith founded Alcoholics Anonymous (AA) in 1935, AA’s twelve steps were the standard of care in addictions treatment. AA is a mutual help group for people with alcohol use disorders, guided by standard literature and twelve steps aimed at helping people make amends, develop spiritually, and connect with others in similar situations.

AA’s model has been adopted by other groups such as Narcotics Anonymous (NA), Gambler’s Anonymous (GA), Overeater’s Anonymous (OA), and other variations. In each case, these groups continue to rely on the twelve steps, with minor adaptations, and have been generally known as 12-step support groups.

People in 12-step groups help each other with bits of collective wisdom beyond official literature, including the admonition to change “people, places, things” to remove triggers for use; the acronym HALT, reminding members never to get too Hungry, Angry, Lonely, or Tired; and the serenity prayer:

God, grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
And wisdom to know the difference.

While meeting formats vary, they tend to include members sharing about their experiences and struggles while living in recovery and readings and discussions of the 12-step literature. Twelve-step groups also encourage members to find sponsors to provide advice based on their own recovery experience. Generally, people who have been abstinent for awhile become sponsors for other, newer members.

Many hundreds of people have testified that 12-step support groups saved their lives, and some scientific research seems to support the efficacy of 12-step groups (Humphreys et al., 2014; Witbrodt et al., 2014; Moos & Moos, 2006).

Other people have criticized 12-step groups, pointing to the high rates of dropout, the heavy spiritual and moralistic emphasis, the inconsistent and contradictory logic in its literature, and the variability of groups depending on who is in them. Furthermore, about half of women who have participated in AA have experienced “13th-stepping,” the practice where group members, usually men, target new members, usually women, for dating or sex. In some cases this common practice has resulted in rape.

Despite their limitations, 12-step support groups remain an important part of many peoples’ lives in recovery, particularly if they feel belonging to their group. Research shows that social support is an important part of recovering from addiction. People who are a part of a strong group of people committed to sobriety are more likely to stay abstinent than people surrounded by old friends who may still be drinking or drugging.

Twelve-step groups are not the only addictions support group option, however. For people who want the social support without the spiritual emphasis, other mutual help groups exist, such as SMART Recovery (Self-Management and Recovery Training) and Moderation Management.

The Minnesota Model and Modern Rehab

The ubiquity of 12-step support groups was expanded to treatment in the 1950s by the Minnesota Model, a 12-step-based program developed by two people (not yet trained in addictions) working in a state mental hospital that was quickly adopted by the Hazelden Foundation, one of the oldest and most well-known rehab centers. The Minnesota Model is an intensive program including mandatory 12-step meetings, lectures, and counseling.

Rehab centers like Hazelden provide this type of care for 28-day periods on an inpatient basis. For many people with addiction, inpatient rehab may be their first contact with addictions treatment. Rehab centers have been criticized for high relapse rates, and for not following up with patients following discharge. Research on the efficacy of standard, 28-day rehab programs is notoriously scarce.

Twelve Step Facilitation (TSF)

Much later, in the 1990s, Twelve Step Facilitation was developed as a standardized adaptation of 12-step support groups, intended as an early, individual therapy delivered by a counselor. TSF helps to introduce many of the concepts of 12-step support groups, and encourages patients to engage in support groups following therapy. However, TSF is distinct from AA and other 12-step support groups.

“TSF is not officially related to or sanctioned by AA. It is available as a manual for standardized use by addiction treatment facilitators with a focus on abstinence as a treatment goal. Participation in AA meetings and other official AA activities (such as service and AA social events) is encouraged as a means to that end.” – Nowinski, Baker, & Carroll, 1999.

Some studies have demonstrated that Twelve Step Facilitation has helped people use 12-step support groups to support abstinent lifestyles, though when compared with TSF, cognitive behavioral therapy may be better for long-term support. As a first step toward engagement in 12-step support groups, TSF seems to be helpful and is often used in inpatient rehab settings.

Despite the ubiquity of 12-step groups and programs, scientific studies evaluating how well they work have not yet established, conclusively, whether 12-step-based approaches are effective. Reviews of the literature find mixed results, with some studies finding positive effects, some finding negative effects, and some detecting no statistically significant influence. Studies face methodological challenges (particularly self-selection bias), and most often do not distinguish between 12-step support groups, inpatient rehab, and TSF (perhaps because their content is so similar).

The first mandate of medical treatment is to do no harm. Because some studies have found 12-step programs to be detrimental to people, and because their effects are otherwise inconsistent and inconclusive, 12-step-based treatments cannot be considered to be evidence-based. Evidence-based treatments for addiction do exist, and include cognitive behavioral and dialectical behavior therapies, mindfulness training, and a range of pharmaceutical treatments. Typically, addictions treatments must be individualized, and must account for the type of substance or behavior used, co-occurring mental disorders, and trauma history.

With a scarcity of evidence, treatment providers must decide on a case-by-case basis whether 12-step groups, inpatient rehab, TSF, or some alternative is best for a person in recovery. Twelve-step groups and facilitation do work for many people, but they are not for everyone.

The primary benefit of 12-step support groups and programs is subjective, depending on the quality of the human relationships in a given group and on the importance of spirituality to the person in recovery. Social support is recommended for people in recovery from addictions, but other mutual help groups may provide this without the problematic aspects of the 12-step approach.

After extensive research, the most balanced recommendation I can make is if you are a person in recovery, consult your doctor first, and choose the treatments that work for you. The goal is to create a stable and positive life in recovery, and if a treatment is not adding to this goal, it is not for you. In this case, if the medicine tastes bad, it is bad.

If you are a treatment provider or a drug court judge, please be advised that 12-step groups and programs are not evidence-based, may sometimes do harm, and therefore, if recommended at all, should be one of many treatment and recovery support options offered.

I wrote this post following a discussion with Anne Giles, in which she requested balanced research on the efficacy of and difference between 12-step support groups, inpatient rehab, and Twelve Step Facilitation. The positions I take in this post are mine, and cannot speak for her, or for Handshake Media, Inc. 

The article annotated and excerpted below, published in 2013, offers a conceptual framework through which to apply the findings of neuroscience to addictions treatment. It may be explosively important. Translating its offerings into practical applications will be difficult. The article is lengthy, written in highly technical language, weighs in at 9,300+ words, and cites 182 sources.

My intention is to attempt, however, to do just that. The work by Eric Garland, et al. – new research funding was just announced 9/6/16 –  could have weighty implications for individuals with substance use disorders (SUDs) and for SUD treatment professionals. My intention is to continue writing about addiction and addictions treatment as simply and directly as I can.

To that end, I have excerpted, annotated, added explanatory links to, and re-formatted the conclusion from Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface and intend to link to this post from other writings.

We offer the following speculative, hypothetical account [demonstrating the conceptual framework described in this paper that applies findings of neuroscience to addictions treatment] based on our clinical and research experience using MBIs [mindfulness-based interventions] to treat persons diagnosed with substance use disorders.

When a recovering addict with a history of using drugs to cope with negative emotions encounters a cue associated with past drug-use episodes while in the context of a stressful environment (e.g., walking past a bar after getting in an argument with a work supervisor), this encounter may activate cortico-limbic-striatal circuits subserving drug-use action schemas. [In other words, the encounter may activate brain structures related to feelings, thoughts and behaviors associated with drug use. The authors write, “The urge to seek intoxication from addictive substances is driven, in part, by reactivity to substance-related stimuli [cues] which have been conferred incentive salience [priority importance], and is magnified by negative affective states.” The authors define “drug-use schemas” as “memory systems that drive drug seeking and drug use through automatized sequences of stimulus-bound, context-dependent behavior.”].

After completing a course in mindfulness training, the addict may become more aware of the automatic addictive habit as it is activated, allowing for top-down regulation of the precipitating negative emotional state and the bottom-up [brain structured-based reactivity] appetitive urge. [“Top-down regulation” is not to be confused with “willpower” or  “suppression” which, according to neuroimaging research, actually results in “hypoactivation in cognitive control circuits.” Attempts to suppress urges, paradoxically, result in 1) increased urges, 2) decreased resilience with regard to emotionally stressful events which is correlated with return to use, and 3) depletion of cognitive resources, thus increasing the likelihood of a return to automatic behavior to use vs. conscious behavior to abstain.]

Specifically, the individual may engage in mindful breathing to first disengage from and then restructure negative cognitive appraisals, thereby reducing limbic (e.g., amygdala) activity, autonomic reactivity, and dysphoric emotions related to the stressor. Concurrently, the individual may become aware of when his attention has been automatically captured by the sight of people drinking in the window of the bar, and, through formal mindfulness practice, activate fronto-parietal mediated attentional networks to disengage and shift focus onto the neutral sensation of respiration.

During this process, as sensations of craving arise, the individual may engage in metacognitive [the ability to become aware of, and direct, one’s thoughts] monitoring of these sensations, and in so doing, facilitate prefrontal down-regulation of limbic-striatal activation. [Author Maia Szalavitz uses the metaphor of a “volume control” to explain a person’s ability to up-regulate or down-regulate his or her own inner state.] As mindfulness of craving is sustained over time without drug-use, the sensations of craving may abate, promoting extinction learning to weaken associative linkages between conditioned addiction-related stimuli and the attendant conditioned appetitive response. [If “appetite” for drinking or using is present, but is not satiated with the anticipated reward, the tie between use and the reward lessens over time.]

Once working memory has been cleared of active representations of substance use, the individual may shift attention to savor non-drug related rewards, such as the sense of accomplishment that may arise from successfully resisting the temptation to drink (i.e., self-efficacy), appreciating the beauty of the sunset on the walk home without being clouded by inebriation, or the comforting touch of a loved one upon returning home safe and sober. [“Savoring” is defined by the authors as “selective attention to positive experience.”]

Through repeated practice of regulating addictive responses and extracting pleasure from life in the absence of substance use, the individual may re-establish healthy dopaminergic tone [to replace atrophy resulting from substance use] and foster neuroplasticity in brain areas subserving increased dispositional mindfulness. [“Dispositional mindfulness” is defined as awareness of, and attention to, what one is feeling and thinking in the moment.]

Ultimately, mindfulness may facilitate a novel, adaptive response to the canonical “people, places, and things” that tend to elicit addictive behavior as a scripted, habitual reaction. In so doing, the practice of mindfulness may attenuate [reduce the power of] stress reactivity and suppression while disrupting addictive automaticity, resulting in an increased ability to regulate and recover from addictive urges.

Posts that link to this post:

• Forthcoming

For those beginning to discover they’re doing something they want to stop – or have tried stopping something and are having trouble – SMART Recovery welcomes all. Whether one struggles with alcohol and other drugs, smoking, gambling addiction, Internet addiction, sexual addiction, self-injury, problematic eating behavior, problematic relationships, or issues with other substances and activities, SMART Recovery meetings are the place to gather and talk with people addressing similar challenges.

What science is telling us and we know from personal experience is that we do better making changes with support from others!

If you’re interested in helping your community address its challenges with addiction, I invite you to train to become a SMART Recovery discussion host.

Based on my professional and personal assessment, holding SMART Recovery meetings is the closest we can get to community-wide, evidence-based, group-based addictions recovery assistance using resources already in place.

If we can, as a community, host SMART Recovery meetings every day at different times all over the area, we can provide free, near-treatment-level assistance to our people with addiction challenges. We don’t need to form task forces, write grants, or lobby public officials. We just need community members to do the training and sign up as hosts with SMART Recovery, and for community organizations with buildings to offer spaces for meeting locations.

• SMART Recovery discussion meetings are free and open to anyone in the community.
• Volunteers hosts DO NOT have to be in recovery from addiction to serve. Any community member – from the mayor to the maki maker to the mechanic – can serve as a discussion meeting host.
• While discussion meetings are not generally facilitated by experts or licensed professionals, meetings focus on learning skills termed “tools” and are guided by trained hosts, thus extending the therapeutic value beyond more sharing-oriented support group meetings.

Here’s more information:

• Train to serve as a SMART Recovery discussion meeting host
• Main handout distributed at SMART Recovery meetings (.pdf)
• What a SMART Recovery discussion meeting is like
• Discussion meeting script used for the Blacksburg, VA SMART Recovery meeting at NRVCS (.pdf)
• How to get help for a loved one with addiction in the New River Valley of Virginia
• How to talk with someone about getting help with addiction
• What Ithaca, NY is doing about addiction in its community

If you’d like to experience in-person what a SMART Recovery meeting is like, this meeting is open to all and you are welcome to attend:

Sundays, 4:00 PM, New River Valley Community Services, 700 University City Boulevard, Blacksburg, Virginia.

We’re compiling local recovery support resources here.

If you have any questions, feel free to contact, Anne Giles, [email protected], 540-808-6334.

(If you email me and don’t receive a reply, please check your spam folder. If you don’t see a reply in your spam folder, please phone or text me and we’ll connect that way!)

Hope to join you in volunteering with SMART Recovery!