Abstinence vs. medication-assisted treatment: Traditional 12-step programs embrace a new model

Photo illustration: Yahoo News

In this series, Yahoo News takes a closer look at the current opioid epidemic, its roots and demographics, the increasing acceptance of medication-assisted treatment as a supplement to 12-step programs and the remaining obstacles to combating widespread addiction. This series also highlights ways in which the current crisis is unexpectedly forcing a larger shift toward treating addiction more like other chronic illnesses. 

Though the FDA approved buprenorphine back in 2000, most addiction recovery programs, with their abstinence-based treatment models, were slow to adopt it. But the growing number of opioid-related deaths — particularly among addicts who relapsed shortly after completing or dropping out of rehab — has made the drug’s success increasingly impossible to ignore.

The Minnesota-based Hazelden Foundation, now Hazelden Betty Ford, has been one of the country’s leading providers of both residential and outpatient drug and alcohol treatment since it was founded in 1949 — just 14 years after Bill Wilson and Bob Smith held the first Alcoholics Anonymous meeting in Akron, Ohio.

Nearly 80 years later, AA’s signature 12 Steps, codified in the 1939 book “Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered From Alcoholism,” is still considered the gold standard for addiction treatment around the world.

Hazelden chief medical officer Marvin Seppala, MD, told Yahoo News he was worried about pushback when, in January 2012, he first proposed incorporating the use of medication-assisted treatments into Hazelden’s historically abstinence-only, 12-step-based program for opioid addiction. But while the decision provoked some backlash within the addiction community, Seppala said he was pleasantly surprised by the response from Hazelden staff.

At an initial training forum at the Hazelden headquarters, Seppala said roughly 100 counselors were asked to raise their hands if they’d ever had an opioid-addicted patient who died of an overdose after leaving treatment.

“Almost all the hands in the room went up,” Seppala recalled. “We said, ‘We’re really trying to do something about this.’” Once presented with the research data, Seppala said, it didn’t take long for the Hazelden staff to get onboard.

“When you can harness the passion of a group of counselors, healers to do something that makes sense to help their patients, they’ll do that, they’ll pursue that,” he said.

Seppala said he’s starting to see the rest of the addiction treatment world follow. When speaking at the National Association of Addiction Treatment Providers conference in 2013, he said, there was “a lot of resistance to what we were doing. A lot of people thought we were going down the wrong path.” But when he addressed the conference again this past spring, Seppala said, “the bulk of people were really supportive of what we’re doing. There’s been a shift.”

Phoenix House, which has more than 120 residential and outpatient rehabilitation programs in 10 states, has also incorporated the use of medication into its services for opioid addiction treatment.

There are still some holdouts within the treatment community, such as the Abstinence-Based Treatment Alliance, which lists actor Matthew Perry — a recovering abuser of opioid painkillers — on its board of directors. Many recovering addicts choose to abstain from using medication in rehab, so Phoenix House segregates patients on buprenorphine in separate counseling groups.

This separation is “sometimes necessary,” explained Phoenix House chief medical officer Andrew Kolodny, because recovering addicts in abstinence-only programs “tend to have a very negative view” of medication-assisted treatments.

“Patients who are on [buprenorphine] can sometimes be given a hard time by their peers that, ‘You’re not really clean, you’re still on the drug,’” Kolodny said. “That’s why it’s helpful to have a group where people can be open and out.”

Seppala elaborated on this mentality, explaining that critics “think giving someone a drug like buprenorphine, which is a partial opioid, could prevent someone from real recovery.” But, he said, the rationale of the drug’s opponents is “mostly philosophical ... not based on the science that supports better outcomes of using these medications, which is why we did it.”