I spend a lot of time on this blog discussing 12-step programs. But what exactly constitutes a “12-step program”? The term itself is rather vague.
I tend to use this as an umbrella term to describe the group-based, discussion-heavy, and non-medicated treatment style that claims to be the spiritual successor of AA. This approach has been expanded to treat narcotic addiction, nicotine addiction, and any number of other conditions. It has also been adopted very widely, and while it’s common for treatment providers to stay close to AA’s original 12 steps, they also tend to tweak and change and “put their own spin” on the 12 steps as much as they can. What this has led to is a huge variety of treatment approaches that, to an outsider with a critical eye, all appear to share a few core principles that they have taken from the founding tenets of AA. Usually this includes belief in a Higher Power; the righting of wrongs done to others in the past; establishing a social network with other ex-addicts; and a strong moral emphasis on being “clean” rather than “dirty”; and a refusal or demonization of medication.
I write about 12-step programs mostly from my own experience, because as a doctor advocating medication maintenance for addiction, I encounter a great deal of hostility and resistance from the staff. I also witness firsthand the effects that this style of treatment has on my patients, who refuse to stay healthy on maintenance because they believe they are still “dirty”. Most care that fights against medication maintenance do so using a kind of authoritative hair-splitting; they claim that, since buprenorphine affects the opiate receptors, it takes away a patient’s right to be called “clean” or “in recovery”. I would just like to point out the irony of this panicked accusation, seeing as the founder of AA originally made it very plain that excluding anyone on such superficial grounds was very much against the spirit of the organization. You can read Bill W.’s opinion on who should be allowed to be a member of AA here.
Alcoholics Anonymous was founded in 1935 by Bill W. and Dr. Bob as a way to help alcoholics find strength and comfort in community. As part of my education in the field of addiction, I’ve read a large amount of AA literature, including the “Big Book”, considered the central text of the organization. I have reached the conclusion that the original spirit of AA was an unflinchingly inclusive one, and that the founders would not have approved of keeping an addict out of “recovery” based on what other medication they were taking, or what other measures they might be taking to control their alcoholism. Addiction is a disease, and taking regular medication for it should be no more problematic than taking regular blood pressure medication. It certainly shouldn’t be used as an excuse to keep stable and thriving patients out of the nebulous category of “in recovery”.
Yet a great deal of resistance to medication maintenance comes from a widely-held belief that medication somehow violates the principles of AA, and the 12-step programs that have descended from AA. I would argue that this belief is factually wrong, but the factual correctness of a statement like that doesn’t even matter, because every interpretation of the “principles” of AA is equally valid. AA (used here as the flagship example of the 12-step type of program) is a nebulous, widespread organization without a central authority capable of making policy decisions. It is based on a certain amount of written material, all of which is open to interpretation, and there is no one with the authority to call any interpretation right or wrong. It actually resembles many religions in this way.
I would argue that the belief that medication goes against the spirit of AA is widely-held, not because the texts support such an interpretation, but because it has become a sort of canon that has been mixed into the original philosophies of AA and passed on due to tradition and financial advantage. Thankfully, since all interpretations are equally valid, I will tell all my future patients that this ugly and discriminatory policy does not come from a place of authority and should have no power to prevent them from seeking the most effective treatment they can.