Recently, I have seen yet another wave of anti-12 step promotion via various digital formats and blogs. The various talking point involve, “AA is not evidence-based”,”AA has incredibly low success rates,” and a variety of cultural criticisms and safety warnings. Time and time again I run across people who quite suddenly demand that I offer evidence of AA, when I speak affirmatively about it. As such, I have decided to assemble, once again, a solid collection of openly accessible articles that I generally consider the evidence base for 12-Step efficacy.

I usually take the time to qualify the challenges of researching a self-selecting group, with anonymous members, and the ethics that prevent RCT study generally. I also try to outline some of the statistical maneuvering that is used to get around this. For the AA skeptic, the minute you begin to explain these things, there is a, “Tsk, tsk! Sounds like you are trying to make excuses!” So, for the purposes here, I will simply let the authors of the various articles speak for themselves. All of these article are openly accessible and do not exist behind paywalls.

I am also not going to break down these articles and explain them one by one. This is intentional and for a very simple reason- All too often, someone will demand evidence of AA efficacy, who then don’t bother to read the article offered in any serious way. Why? The answer is because they are not truly interested in the evidence for AA. They are interested in confirming their own biases to prove or disprove the 12-Steps. By not breaking down these articles, I am filtering out those types unwilling or uninterested in learning about 12-Step research. Additionally, we are all adults and we can all do our own homework.

Let’s Begin

Keith Humphreys, Ph.D., Janet C. Blodgett, M.Sc., and Todd H. Wagner, Ph.D.

Kelly JF¹, Bergman BG¹, Fallah-Sohy N¹.

Jane Witbrodt, M.P.H,^*,1,4Jennifer Mertens, Ph.D.,²Lee Ann Kaskutas, Dr.P.H.,¹Jason Bond, Ph.D.,¹Felicia Chi, M.P.H.,² and Constance Weisner, Dr.P.H., M.S.W.^2,3

Lee Ann Kaskutas, Dr.P.H.

John F. Kelly, PhD

John F. Kelly, Robert L. Stout, Molly Magill, J. Scott Tonigan, and Maria E. Pagano

John F. Kelly, Ph.D., Robert L. Stout, Ph.D., Molly Magill, Ph.D., J. Scott Tonigan, Ph.D., and Maria E. Pagano, Ph.D.

John F Kelly,Keith Humphreys, and Marica Ferri

John F. Kelly,^*M. Claire Greene, and Brandon G. Bergman

Yu Ye¹ and Lee Ann Kaskutas^1,2

Stephen Magura,^a,**Joseph McKean,^bScott Kosten,^b and J. Scott Tonigan^c

J. Scott Tonigan, Elizabeth A. McCallion, Tessa Frohe, and Matthew R. Pearson

My Thoughts

Undoubtedly someone, somewhere, will parade this post out and decry it’s contents. I just want to ensure that if this is the manner in which you came across this post, then do yourself a favor and read the above articles.

Additionally, others will say there are other or better articles out there: There are literally thousands of peer-reviewed research articles on AA. I chose these articles because I often refer back to them in my own work, and because they are accessible to the general public. I encourage folks to respond in the comment section and link additional articles they may feel warrant additional consideration. Please make these articles available to the public, if paywalled, by using a Google Docs Folder and providing a link to it.

You’ll notice many of these articles go back quite a few years. This is a source of frustration to me: open, publicly accessible research on AA has been available for over a decade now. Anyone can find research on AA, and yet, even among professionals, researchers, and clinicians, I still hear the blanket statement “AA is not evidence-based.” These statements are usually accompanied by the assertion that anyone who defends AA (even from a research perspective), is somehow supporting “folk wisdom,” and is merely being “reactionary” and “cult-like.” My personal recovery experience does involve AA, which worked well for me. But this isn’t why I defend AA. Scientifically, I defend AA because there is good evidence to do so. Period.

The Questions Everyone Wants to Know

1.
Q: Is AA for everyone?
A: Absolutely not. Everyone should explore if it is right for them. Fortunately there is an AA meeting going on nearby, right now. It is free, and requires no commitment to check it out. We should encourage everyone to find out if it is right for them.

2.
Q: Should treatment be more than AA.
A: Yes and No. 12-Step groups are the only guaranteed resource post treatment. Virtually every client will be able to access a 12-step group, no matter where they go. They should be oriented to the program during treatment. Additionally, TSF is, in fact, an evidence-based modality. And finally, ALL treatment of any positive repute should do MORE than simply teach the steps. If they don’t, then I would question their model (and the cost, since you can literally get the same thing for free.)

3.
Q: What about “the God thing.”
A: See number 1

4.
Q: What about NA and their beef with MAT?
A: If you are on medication, I would suggest you try out several other meetings, like CA, and OAA which has no such qualms. Also, there are *some* 12-Step meetings specifically catered to those on pharmacotherapy. Look around, offer these to your clients if you’re a clinician.

5.
Q: What about rape culture, patriarchy, and WASP criticisms?
A: Re: Rape Culture- There have been incidences. This does not mean that the rooms are any more dangerous than anywhere else. These incidences have also been greatly magnified by the internet, and by the anti-12 Step proponents. Though people in the rooms ALL have checkered pasts. Part of the value of the rooms is the fact they accept everyone as is and makes no judgement about an individual’s past. The more dangerous element is 13th stepping which happens to BOTH men and women. This is why it is suggested not to date for a while, and you should probably not date people from the rooms. Part of the problem here is that early relationships in recovery excite the brain along the same reward pathways as substances. Clients should be educated about this and sponsors should discourage dating, not because the literature says so, but because it is part of being responsible to the community. If one is still uncomfortable, take a friend to an open meeting to get the feel of the group.

Meetings vary greatly by regions, towns, even parts of the country and across the various groups (NA, AA, CA) etc. One will have to deliberately try out several meetings in order to make an informed decision about whether or not 12-step groups are for them.

Re: Patriarchy- 12-steps, particularly AA, use the Big Book. It is a historical document, the language and format are heavily gendered. You will have to decide for yourself if this is a barrier to attending. Other groups may use more modern literature.

Re: WASP- Some groups are heavily populated by white people. However, this varies a lot. There is no definitive way to determine whether one will feel comfortable until they try out a few different meeting places and groups. It is not so much an ethnocentric group, as it is a class-centric group generally geared toward working and middle-class people. The highly educated may struggle, those with cognitive challenges may struggle, and (surprisingly) those who are highly religious may struggle. Still, none of these are bars to engagement.

Changes I Would Personally Make to 12-Step Groups

Before someone says “Yeah, but, what about…” I will say this:

NO: People should not be mandated to 12-Step groups. It isn’t good for the dynamics of a self-selecting community to have people forced into these groups. I would change this. Asking for attendance cards to sign at the BEGINNING of the meeting, and letting the people who do not want to be there go on their way is probably the best way to handle this.

NO: I don’t agree with NA’s ban on the participation level of people on medication. I believe it violates the traditions. NA does NOT speak for the whole of 12-step members. Particularly other fellowships like AA and CA. The great thing about 12-Step groups is that you can find other groups if you do not like a particular one.

YES: The 12-Steps are hard, and they may look intimidating for a variety of reasons. However, each step builds on the last one. And you do not work them alone, or without support from the group. Trust this process.

YES: If you have significant trauma, co-occurrence, or a history of abuse, you should also be engaged in therapy. The steps are rigorous, and they stir up a lot of uncomfortability. You should know this ahead of time. The steps ARE NOT therapy. They are designed to help you overcome a SEVERE issue with substances.

In Closing
12-step communities offer tremendous benefit to individuals and to local communities. The benefits far outweigh any negatives. You will need an open mind, and multiple exposures to groups and such exposure should be encouraged by clinicians. Taking someone’s word for it, or not going because of something you read on the internet is probably not going to provide you with enough experience. You will have to see for yourself. But, the evidence that it will help, is quite good, and the likelihood you will make life-long friends is high. Do not let prejudice stand in the way of finding out for yourself what it is all about. Although, to some degree, 12-step groups are a reflection of their collective members, individual members are not always healthy people. It helps to keep this in mind. The person in the front row who says something offensive may be on day 1 of their journey. It may not reflect the group as a whole, and definitely not indicate the value of 12-Steps as a whole. “Principles before personalities” is the key. Tolerance is needed and should be cultivated by anyone who attends on a regular basis. It is one of the values of recovery.

I am a huge advocate for the five-year care paradigm. I have written about it extensively, including a STAT news article early this year and a piece with Dr Robert Dupont among others.  Put simply, the five-year recovery paradigm is a call to reorganize our care system around the fact that people who reach five years of recovery have an 85% chance of staying in recovery for the rest of their lives. Addiction was a leading cause of death even before the COVID-19 pandemic, destroying communities and costing vast sums of money. Expanding the number of Americans in long term recovery would be a game changer in America. We must focus on long term recovery for everyone with a severe SUD.

The frequent criticism I hear back is that we cannot afford to help everybody.  

Why do we ask this question about how we treat persons with substance use conditions? This is not a criticism we hear about other chronic medical conditions. We are not triaging persons with heart disease, diabetes or cancer and deciding which ones get full care and who gets palliative care. We need to ask some hard questions about how services are being deployed and for whom we stop care for at less harm rather than focusing efforts at getting everyone into treatment and recovery. A look at access to care for marginalized communities might give us a hint at that.  

Where does the mentality of triages and rationed services lead? In the US, what history shows us is that it has leads to care durations well below the minimum effective dose in lower intensities than necessary. We intervene at later stages in the condition to help people than we do with other chronic conditions where we have adopted an early intervention mindset. We typically wait until adulthood to address SUDs, often delaying help until after the person has had significant legal or medical problems that stem from the condition. Adolescent care for moderate to low-income families is hard to get. Here in Pennsylvania, we have lost most of our programming for young people, it may be true in other states as well. Addiction typically takes hold in our young people, yet we delay interventions for years and allow the condition to worsen – and then, after incarcerating people we say don’t have the money to help them, at least those in the bottom tier of the socioeconomic system.   

Who are the worthy drug addicts and who are the unworthy drug addicts?  How does bias against persons with substance use conditions, so prevalent among health professionals influence outcomes?

What happens when we decide a person, or a marginalized group has too far to go to get recovery and we do not think  that they can make it?  What history shows us is that we provide less care and less opportunity to obtain and sustain recovery and greater barriers to obtain help. Such determinations very likely have a whole lot more to do with the biases within our care institutions than the potential of persons with substance use conditions to get better.

Serious questions need to be asked about how the Pygmalion Effect plays out in who gets care and where the resources go. One of the things we see is that recovery community organizations – programs run by and for people in recovery scramble for scraps while groups perceived as more worthy like academic or law enforcement associated groups get the lion share of the limited resources. These are structural biases that emanate from stigma against persons with SUDs.

We should be looking at a addiction from an entirely different lens and considering what we have to gain by focusing on trauma resiliency. One area we need to look at more deeply building out a care system that fosters the “better than well” and community recovery as a public health intervention. Instead of focusing on an acute service infrastructure. We should consider the three key component parts of a theoretical model of recovery as articulated by UK researcher David Best and they include:

Recovery capital – personal and social resources – the journey of growth
Social identity and social contagion in recovery – the role of friends and connections
Therapeutic landscapes of recovery – the role of location

We can and should have a national conversation on the economics of recovery and addiction, there is not doubt that we would find that not only is addiction our most profound public health problem, but it is also our greatest opportunity to save lives, restore communities and save vast sums of money. This conversation must start with the premise that everyone is worthy of help and that we cannot afford to do anything other than to develop a system of care focused on recovery with equitable access for everyone. 

Everyone is worthy, and we cannot afford to do anything less than focusing a system oriented to long term recovery for everyone who experiences an addiction.

Let’s start with that basic premise.

What do patients want when they come to treatment? My own experience suggests simple things: relief of emotional pain; a healed life; to be a better mum, dad, partner, human being; to let go of shame; to have a job and to be free from the Groundhog Day experience of addiction. Modest goals.

Some people set specific goals in terms of their substance use. Wanting to control use is common. In my practice, most have set the goal of abstinence. How common is this?

DORIS

A large-scale Scottish study DORIS (Drug Outcome Research in Scotland) undertaken by academics at Glasgow University was published in 2004. Researchers suggested that the majority (57%) of those coming to treatment wanted to achieve a goal of abstinence. The finding was both welcomed and condemned depending on perspective. “Of course, that’s what people are going to say,” was a commonly heard response from detractors. It all became a bit political. Some felt that, for opiate use disorder in particular, such a goal was both unrealistic and dangerous.

For these people, DORIS seemed like an attack on harm reduction and on MAT (medication assisted treatment), the prevailing treatment mode. I remember thinking that even if the proportion seeking abstinence is not as great as 57%, it’s still true that some do want to be free from illicit and prescribed opioids. And, of course, there is the fact that there already are many people in the UK and elsewhere in long term recovery from opiate addiction – so it’s clearly been achievable for them. Why can’t our systems accommodate many needs and goals?

Independent Expert Review on ORT

There’s been an unhelpful stigma about methadone programmes which has largely failed to bend to the weight of evidence on the harm reduction benefits of being in MAT. It’s not all about stigma though. I remember taking evidence from families for the Independent Expert Review on Opioid Replacement Therapies in Scotland a few years ago. It was a bruising experience. 

The venue was a Scottish Families Affected by Alcohol and Drugs (SFAD) conference. Here’s the thing: families did not like methadone. I listened to dozens of frustrated and angry delegates on the subject. As a prescriber, I came away feeling responsible for the perceived sins of all clinicians. 

But these views had little to do with stigma – what I heard behind the anger was family members’ views that the sort of treatment we were delivering did not go far enough. Back then, what was on offer was not doing enough to help our patients and their families reach their goals, something confirmed when the review was published.

To be honest, as both a harm reductionist and a supporter of recovery, I was less interested in getting involved in the polarising debates that came out of the DORIS study, than in finding answers to the questions: how have recovering people done it and how can we help to make the process safe and more successful? 

What do service users and their families want?

Ten years after DORIS, a small qualitative study by Sarah Thurgood and colleagues from Leeds took a nuanced look at what service users and their families wanted from treatment and found that they placed weight on abstinence and ways of maintaining abstinence. That’s what ‘being better’ was about for them it seems. It chimed with my experience with the SFAD conference delegates – they had higher ambitions for those in treatment than they felt treatment was delivering.

Thurgood and colleagues found that the challenges around defining what constitutes a ‘good outcome’ are considerable. Abstinence can seem like an absolute term (though there are various views on what it actually means) and in any case it gives little indication of life quality. 

Recovery, on the other hand, may encompass more complex domains such as “physical, biomarker, psychological, psychiatric, chemical dependence and family, social and spiritual”, so it can also be difficult to pin down.

In this study, six focus groups involving 24 service users and 12 family and friend members were recruited from a broad range of treatment modalities and recovery journeys. 

Although an attempt was made to recruit those currently on MAT, there were difficulties with engagement. However, a significant number who did participate in other groups had been on opiate replacement in the past.

Twenty ‘outcome elements’ were identified and categorised into sub-themes. The numbers mean we have to be careful about generalisation, but the purpose of this type of research is to look at themes and detail, which is valuable in a different way. The numbers were good for a qualitative study.

What did they find?

On abstinence: 

“Many felt that stopping substance use was a prerequisite of effective treatment and created a virtuous circle of feeling better, which in turn helped to motivate more effort to make change.”

On ORT: 

“The use of medication, such as methadone, was discussed and especially so in the court-mandated rehabilitation group. It was felt that substitute prescriptions masked the problem and were simply a parallel addiction… The use of methadone can support an individual in a controlled and managed way. It can also reduce the risk of injecting behaviour. However, SUs felt that even with these benefits, their end goal was to be free of heroin and any substitute drugs.”

Other domains

The researchers found dramatic improvements in health and that these “naturally happened with abstinence.” Service users found structure and activity important when recovering from addiction, relationships improved, but at the same time they had to let go of using and drinking friends. Participants also developed coping skills to deal with cravings.”

Perhaps mindful of the reaction to the DORIS study, the researchers reinforced the value of other outcomes that recovering people may achieve earlier on.

“The weight given to abstinence, strongly supported by family and friends, may be controversial. Of course, this does not mean that other outcomes, which some may consider less ideal, are not worthy achievements.”

Given the differing goals patients set for themselves and the sometimes aligning and sometimes opposing public health imperatives, we need a range of options laid out to service users coming for help. This should stretch from outreach and needle exchange to rehab. This does happen to some extent, but is patchy and not very joined up. It’s not just about having the options though; it’s about having a vision that people can and do move on into abstinent recovery.

Service users don’t always get what they want from services and that can be because expectations are unrealistic or that it is going to take time to get where they want to go. Sometimes though it is because what the service user wants and what the addiction worker thinks the service user wants are mismatched. 

Great or low expectations?

There are earnest and caring practitioners who believe that MAT is best when entered into for life. There are some convincing public health reasons why this view is held, but could it also be limiting for individuals who don’t want this? It is undoubtedly true that some of the time our expectation of what people can achieve is set too low. I’m thinking of the David Best study of the UK drug workers who estimated only 7% of their clients would ever recover. (Long term remission rates are much, much higher).

As I write I’m remembering a medical colleague (from a different city) who told me at a MAT clinic that to stay sane and prevent burnout, it would be better for me to accept that nobody was ever going to recover. This advice was too late in coming; by the time she told me, I’d already met hundreds of people who were in abstinent recovery from opiate addiction. 

It is also clearly possible to be in recovery through MAT. People can and do reach their goals on opiate replacement therapy. New options like Buvidal (long-acting injectable buprenorphine) have changed the landscape for the better. If someone reaches their goals on MAT, then there is much to celebrate and little more to be said. But I’m thinking of those who have different goals or who are not able to achieve what they want from what we have on offer – where the system is not flexible enough.

The voice of lived experience

In this regard, service users and recovering people have found a voice. They have found it in lived-experience recovery organisations (LEROs), service user groups, national organisations, and in the recovery advocacy movement.

Recovery advocates are not shy about speaking up and there is evidence that they are being heard. In addition, it seems to me what we now have activists who call for improvements in harm reduction services, but also for access to treatment options focused on recovery, like rehab. 

We need to be aware that one of the reasons we have a recovery movement at all is the very thing I’m writing about: service users and their families were not getting what they wanted from our services. Some voices may sound angry and baying. There is a reason for this. It’s easy to get defensive when we feel we are going the extra mile for our patients, but we really need to listen and open up conversations. 

Equal partners or ‘clinician knows best’?

Quoted in the Telegraph a while back, Professor David Haslam, then chair of the National Institute of Health and Care Excellence (NICE), said British patients should become more assertive and see themselves as “equal partners” with their doctors, with legal rights.

“I think it is essential for the future of the health service and for the future health of the nation that patients understand their conditions, their treatments and work with their health advisors so they can have the best care,” he said.

Ironically Professor Haslam was talking about accessing evidence-based medication, but the points could equally apply to accessing Recovery-Oriented Systems of Care (ROSC) which sets the bar high with regard to recovery– that’s what the evidence tells us some people want after all – and uses evidenced interventions to help patients get there. 

I wonder how many of us working in the field could list the elements of ROSCs if asked. We do need to support the service user’s expectation of what is achievable, let them be equal partners, and we need to deliver the sort of active interventions to make it happen. Enacting ROSCs would help – the intention is laid down in policy but getting it to work has proved difficult.

What did the Leeds researchers find?

I’ve digressed – back to the Leeds study. Broadly speaking they found that the desired goal in their sample of service users was abstinence from psychoactive substances. A second tranche of outcomes was about achieving changes that maintain the abstinence goal. 

A third tranche, and seen rather as a bonus, were the positive benefits of abstinence, for example, improved health. “We believe that practitioners will find it helpful to be mindful of the ‘being better’ goals while recognising that the day-to-day business of therapy often means negotiating small steps along the way to the desired goal.”

Although some of the participants had experience of MAT, this paper would have been strengthened by having input from those currently on MAT. There’s a risk of bias and of hearing only one part of a story, but, on reflection, I think the emerging themes are still relevant for debate in 2021. Who can say, particularly in light of our drug and alcohol related deaths, that we could not do better in treatment? 

Here’s the essence of this paper in a sentence.

In general, it is fair to say that SUs [service users] look for tough criteria to define ‘being better’ – perhaps tougher than their practitioners.

Thurgood & colleagues

It’s time to raise the bar.

Neil McKeganey, Zoë Morris, Joanne Neale & Michele Robertson (2004) What are drug users looking for when they contact drug services: abstinence or harm reduction?, Drugs: Education, Prevention and Policy, 11:5, 423-435, DOI: 10.1080/09687630410001723229

Sarah Thurgood, Helen Crosby, Duncan Raistrick & Gillian Tober (2014) Service user, family and friends’ views on the meaning of a ‘good outcome’ of treatment for an addiction problem, Drugs: Education, Prevention and Policy,21:4, 324-332, DOI: 10.3109/09687637.2014.899987

I have been thinking Don Coyhis this week. For those who do not know of him, Don Coyhis is the founder of White Bison the American Indian/Alaska Native recovery community organization. Last year he received the distinguished lifetime achievement award at the Faces & Voices America Honors Recovery Award Dinner. He certainly deserved that award. It was a great honor simply to spend time with him on that night, which was also one of the most memorable nights of my own recovery journey.

One of things he talked about was how when federal funding came to support the work of White Bison. Federal grant officers were concerned at the time that their methods were not evidence based in ways that traditional services are defined. White Bison told the grant officers that they had several thousands of years of evidence on what worked in their community. Ultimately, they were allowed the latitude to serve their community as they saw fit, as it was recognized that they were the experts on their own community.  White Bison flourished.

This is profound. The experts on recovery community are people who live in the recovery community. I suspect that providing space for the recovery community to define and support its own members is a key ingredient in other recovery community organizations success as well. We must remain ever cognizant of this as we move to integrate peer recovery support services into our care infrastructure or we will lose the vital role and central function these services have in supporting long term recovery nestled within community.

As I have written about in recent weeks, community is fundamental to recovery for all of us. As Americans, we should be thinking about investing in measures to strengthen community in the broadest sense. Americans belong to fewer organizations, know our neighbors less, meet with friends less frequently, and even socialize with our families less often than ever before. It has broad negative implications for our health and wellbeing. The book Bowling Alone Collapse and Revival of American Community published in 2000 focused on the loss of social capital. In 2018, Senator Ben Sasse also focused on the loss of community as a central societal challenge in his book Them – why we hate each other and arrived at similar conclusions about what is happening and what we need to do to change it. I can’t think of anything more important to fix for our collective future as a nation.

Strengthening recovery community is a critical element in the revival of American community. Recovering people become engaged citizens which benefits all society. As Bill White, Pat Taylor and Carol McDaid note in there 2010 paper Recovery and Citizenship, we become involved in volunteerism, with our own families and reconnect with meaningful activities as citizens. Citizenship is central to the recovery identity.

Fundamentally:

1. People in recovery are the experts on what is needed to develop and strengthen our own communities.
2. There are broad societal reasons why we should be nurturing community in America right now.
3. The recovery community is a key element in reviving American community.

We must avoid defining peer recovery services as similar to counseling – delivered in units on an individual or group level defined externally by others. Funders, even when well-intentioned could actually do harm to us and become a barrier to our work if not mindful of our expertise. The fact is the recovery community itself is the healing agent and the peer professional is more an ambassador of recovery than a service element. We must remain diligent and nurture recovery community and keep community “baked into the recipe” of peer services or we will lose the essence of the work we will do to activate and engage citizens in community.

After-all – we are the experts on what is needed in our own communities and what we have can help restore American community. This kind of service is central to our identity, all we are asking is for the recognition that we are the experts on our own needs. Doing so will help heal America.

[first posted March 18, 2020]

And just like that, overnight all of our worlds have changed. I already miss things that I did without a second thought less than two weeks ago before COVID-19 took hold. I am sure I am not alone in that. All of us are reeling from unprecedented change and disorienting events occurring wholly outside of our control. For many of us in recovery, this is not the first, second or third time when our worlds have come crashing down around us.

Every one among us have faced immobilizing fear and found our way back into life. We know about overcoming adversity, resilience and service to others. There are few communities better prepared to do the next right thing than the recovery community.  We have experience that can support our own wellness and help those around us. This is exactly what is needed right now.

We are generous community because we have experienced need. We are a humble community because we have experienced life bringing us down, at times as a result of our own doing. We know what it means to be down and out and need to ask for help and as a result, we are there for others. We pay it forward.

Many people are asking me how they can help in this time of crisis. One way we can do this is practicing social distancing and helping keeping COVID 19 from spreading. We must be good citizens and do our part to not spread this virus. A whole lot of lives depend on all of us doing are part in this effort. We should model it for the rest of society.

It also means taking care of ourselves. Taking care of ourselves physically, mentally and spiritually is really important right now. It is a really high stress time and one of the most important things we can do is to keep ourselves in recovery. Each of us is worth that effort. Many who love us are counting on that.

It then means taking care of our families, and then trying to help those around us. I see a lot of groups putting meetings on line, taking the crisis seriously and jumping into action to take care of each other. This is a basic tenant of recovery, and for many of us it is central to our identity.

So what should we do now?

I think we should do what the recovery community does best – service to others, the sharing of hope and the importance of living one day, one hour or one minute at a time when life is difficult. Because what we do have control over is how we react to the events occurring around us. We have valuable experience and tools in our toolboxes. Start thinking about those around you who may need help and check in on them on the phone of through media regularly. This is our chance to be part of the solution.

Let’s focus on what we know best and put it into action. This is our time to model self-care, hope, resilience, good citizenship and service to others.

Let’s do exactly that and show the world how we really are a community of consequence at a time when what we have to contribute has never been needed more.

This really can be our finest hour. Let’s make it so.

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Imagine this scenario. You get the terrible diagnoses of cancer, like addiction, it is terminal if left on its dreadful course unimpeded. You are in the depths of despair, facing everything this terrible diagnosis means for your life.

The treating professional turns to you and says “recovery is possible. It is POSSIBLE you might survive this, it does HAPPEN.”

I would not be reassured by such a scenario, and the truth of the matter is that people beat cancer every day. This is a result of an advancement in science, a commitment to fund care and a dedication to follow multiple pathways of care, people who get that diagnosis survive. This occurs because the care team never gives up and keeps working until they hit on the combination of care needed for the person to move into remission. In respect to cancer, the truth of the matter is that the death rate from cancer in the US declined by 29% from 1991 to 2017. This occurred in large part due to a commitment to study outcomes over the long term and to fund care.  What this means for a person sitting in the chair learning that they have cancer is that the treating professional knows which treatments have the best chances of getting you into and sustaining them in remission for five years. They also know that there is wide variation in what works for whom. This means that they use multiple treatments and combinations of care to achieve remission

We know that addiction recovery is a probable outcome given the proper care and support they need 85% of the people who stay in recovery for a period of five years stay in recovery for the rest of their lives. 

Let’s start using more accurate language:

Recovery is the probable outcome for people with substance use disorders when they provided proper care and support.   

We need to focus on long term recovery as our focus of all addiction policy. Let’s study long term recovery and support multiple pathways and service strategies. Let’s do a moon shot, national focus on recovery so that in twenty years we can say that we reduced deaths from addiction dramatically, just like we did with cancer.

That starts with framing our discussion with the proper language of recovery as the probable outcome when people get what they need to get to get better and acknowledging we are a long way from achieving a system that provides that focus for all Americans.

So please stop saying recovery is possible and let’s focus on recovery being probable if we move towards recovery focused policy so we change our care systems to reflect the needs of persons seeking help with a substance use disorder.  

Addiction to alcohol or other drugs is not always easy to recover from. However, there are many pathways to recovery, including through treatment. One group of patients does far better than most other groups. In fact, their results are so impressive that many commentators have urged us to learn from what’s different about their treatment and follow-up to see if we can transfer learning and experience. This group, claim researchers, sets the standard for addiction treatment. Indeed, it represents gold standard addiction treatment. Who are this group? They are doctors.

In 2009, in the Journal of Substance Abuse Treatment, Robert DuPont and colleagues published a study that looked at how addicted doctors were cared for in the treatment system and also what their outcomes following treatment were.

The numbers were large. 906 physicians admitted to 16 different state Physicians’ Health Programmes were followed up for five years or longer.

Treatment

The authors accept that doctors generally come to treatment with more resources than the average patient, but they also point out the hazards that doctors face which potentially increase relapse risk. (Exposure to drugs in the workplace.) What was quite different about doctors in the USA is that they generally have access to specifically designed assessment, treatment and monitoring programmes (Physicians’ Health Programmes). These programmes typically evidence long term abstinence outcomes of between 70 – 96%. Since this paper was written a Practitioner Health Programme has been well established and reports similar results. Here’s what the researchers of the 2009 paper say:

For these reasons, the PHPs appeared to represent one of the most sensible and evidence-based approaches to addiction currently available. We reasoned that an examination of this novel care management approach might provide suggestions for optimally organized and delivered addiction treatment — real-world treatment at its best. If there were clear evidence of positive results from this form of care, the findings might provide guidance for improving mainstream treatment efforts.

The features of the Physicians’ Health Programme model

• Doctors sign binding contracts
• Abstinence is the goal
• Weekly doctor-specific mutual aid groups
• Attendance at 12-step mutual aid groups (AA, NA, CA etc)
• The regulatory boards are often avoided if doctors comply
• Extended care (five years)
• Recovery often starts with an active/planned intervention
• This is followed by an intensive residential (or out-patient)
  rehab period, usually three months long
• Withdrawal from work during treatment
• Active monitoring and care management
• Active family engagement
• Mental & physical health needs assessed
• Active management of relapse
• Random drug and alcohol tests over the five years

The study

16 PHPs participated in the national survey which looked at all admissions (intention to treat) over a six-year period. The case records and lab results of 904 doctors were studied. Most (86%) were male with an average age of 44. Two thirds were married.

Drugs of choice

What drugs were problematic?

The primary drugs of choice reported by these physicians were alcohol (50%), opiates (33%), stimulants (8%), or another substance (9%). Fifty percent reported abusing more than one substance, and 14% reported a history of intravenous drug use. Seventeen percent had been arrested for an alcohol or drug-related offense, and 9% had been convicted on those charges.

ORT

And what about our first line treatment for opiate addiction? How many of the hundreds of opiate- addicted doctors ended up on methadone? That would be just one, or to put it another way, 0.001% of the sample.

Work

72% of the doctors got back to work. When they looked at doctors who successfully completed the programme, this rose to 91%.

Overall outcomes

Specifically, of the 904 physicians followed, 72% were still licensed and practicing with no indications of substance abuse or malpractice, 5 to 7 years after signing their contracts. In contrast, the PHP process appears to have moved approximately 18% of these physicians out of the practice of medicine through loss of license or pressure to stop practice.

Of the 904, 180 (19%) had a relapse episode and were reported to their licensing boards. However, only 22% of these had any evidence of a second relapse— generally indicating that the intensified treatment and monitoring were successful in maintaining remission.

Nuggets

• This was the largest sample of doctors ever followed and over the longest period
• Doctors use in a similar fashion to everyone else
• 78% of doctors did not have a single positive drug test over the years of monitoriing
• Outcomes did not differ by drug of choice, opiate addicted docs did as well as alcohol dependent docs
• IV drug users did as well as everyone else
• 50% of the doctors were polysubstance abusers
• This research is in keeping with literature before and since

What does this mean for treatment in general?

If we applied the principles and standard of treatment that doctors get to other patients, would we see improved outcomes overall?

Whatever the differences from other populations experiencing SUDs [substance use disorders], it is likely that the successful treatment of physicians with SUDs has important implications for SUD treatment in general. For example, if physicians were found to have significantly better outcomes than other groups when treated for diabetes or coronary artery disease, this would be of great public health interest.

Raising the bar?

‘Recognizing that SUDs are biological disorders with major behavioral components (just like diabetes and coronary artery disease), the relatively high level of success exhibited by physicians whose care is managed by PHP is important with respect to the potential for success in addiction treatment generally. Indeed, the observed rate of success among physicians directly contradicts the common misperception that relapse is both inevitable and common, if not universal, among patients recovering from SUDs.’

They go on to say:

‘Indeed, rather than being a defining characteristic of addiction, the “ inevitable relapse” may be a defining characteristic of the acute care model of biopsychosocial stabilization, which offers an opportunity for recovery initiation but lacks the essential ingredients to achieve recovery maintenance.’

Making all treatment gold-standard

The paper has some suggestions to transfer learning and improve addiction treatment outcomes:

1. Adopt the contingency management aspects of PHPs
2. Offer frequent random drug testing
3. Create tight linkages with 12-step programmes and abstinence standards
4. Active management of relapse by intensified treatment and monitoring
5. Continuing care approach
6. Focus on lifelong recovery

Reflections

The fact that only one doctor ended up on opiate replacement is a remarkable finding. Are there double standards inherent here? Why do doctors so readily turn away from an evidence-based intervention, one they are very happy to prescribe for patients?

The expectation is that doctors will make the journey to abstinent recovery, but there seems to be a much lower expectation of their patients. Some argue this is just realistic, but does such ‘realism’ result in poorer outcomes? Is there a mismatch between professional expectations and client goals? Safety considerations have to be paramount and harm reduction at the heart of everything – but when a patient sets abstinence as a goal, could we do better at helping them get there?

I don’t think there’s much doubt that we could get better outcomes for our clients by raising the bar, increasing the intensity and duration of treatment, actively referring to mutual aid and thinking much more about the bridge from treatment to recovery community support, which is one of the keys to long term recovery.

Should doctors really get better treatment and follow up than the rest of the population? Can we narrow the gap?

—

DuPont, R., McLellan, A., White, W., Merlo, L., & Gold, M. (2009). Setting the standard for recovery: Physicians’ Health Programs Journal of Substance Abuse Treatment, 36 (2), 159-171 DOI: 10.1016/j.jsat.2008.01.004

This blog was previously published a few years ago. It has been lightly edited.

Keith Humphreys nails an elusive and important truth:

Thinking about what it means to advocate publicly for recovery. To me, this means showing that recovery is not only possible for persons with substance use conditions, but that given the proper care and support, recovery is the probable outcome for persons with a substance use disorder. As a person in long term recovery, I can’t think of many things that mean more to me than changing our care systems to expand help and reduce discrimination. We can save lives, resources and communities by focusing resources on getting people into and retaining them in recovery.

I think like many people in recovery, I have lost more people I love to addiction than every other way that people can die combined. I have also seen people who seemed to be on the path of recovery fall back into destructive behaviors. In the next breath, I will say that after three decades of working with people with addictions in our public care system, I have seen that people can get better than well – that recovery can lead to dynamic changes and dramatic reductions in criminal justice involvement and the use of healthcare services, increased productivity and civic engagement. I hope we all work together to reduce the former and expand the latter.

Over the last year or so, I have been thinking a lot about what it means to advocate for recovery and how one goes about doing so in a way that helps the community. I don’t hold myself out as an authority on this issue. I am just a guy who has spent a lot of time thinking about the topic and seeing really great examples of what I consider people who are “walking the talk” of recovery advocacy. Unfortunately examples also abound of what my colleague Jason Schwartz wrote about recently in his post titled “Recovery Celebrities?” I really hope other people are thinking about this as well, because a great deal of damage can be done by people with personal agendas driven by ego and aspiration and it really should be discussed constructively within the recovery space.

It is my humble opinion that recovery advocacy is:

• Consensus building around things that support recovery for everyone at the expense of no other group (do no harm)
• Modeling what we want people to do (walk the talk)
• Servant leadership – sharing power, putting the community first and helping others to grow and thrive. In servant leadership, the “leader” exists to serve the people not the other way around.
• About the community and not about the advocate
• Understanding the consequences of what is being advocated for to avoid unintended consequences.
• Never advocating for what we want at the expense of other groups just as we would not want other groups to do so to us.
• Honoring all pathways of recovery
• Service with humility and integrity
• Modeling inclusion, compassion, resiliency and hope
• “Pulling each other up” in constructive ways so we all do a better job and not get ourselves into trouble
• Not shaming, belittling or bully people or working behind their back to get our own agendas past

We know that fame and notoriety can be intoxicating. This is a particular risk for people in recovery. Those of us operating in the public space to advocate for others are at greater risk for harm because the work can be intoxicating.  History is replete with examples of public figures in recovery using drugs and alcohol after proclaiming themselves in recovery or some other bad thing like stealing money or getting arrested. This harms all of us.

For readers – please read this post as a humble effort to contribute to the common good, I am not holier than thou, I am simply a person trying to contribute to the greater good. Thoughts welcomed.