Let's Abandon the Assumption That If You've Been Addicted to a Drug, Total Abstinence Is Essential

Jun 20 2016

Let’s Abandon the Assumption That If You’ve Been Addicted to a Drug, Total Abstinence Is Essential

By Jeremy Galloway

June 20th, 2016

They repeat the words in chorus during almost every Narcotics Anonymous (NA) meeting I’ve attended: “A drug is a drug is a drug.” It means that if you’ve used one drug, experienced problems with it and quit, you can’t use any other drug without problems.

But is this true? It’s one of those comforting mantras that’s rarely challenged in some circles. But there’s a kernel of danger contained within those words, waiting to unleash itself on people most at risk.

Marijuana or alcohol or heroin, for example, produce quite different effects in our brains. Their use fulfills different purposes for people, many of whom might have trouble finding physical or mental health care otherwise (although most people can use drugs or alcohol without major problems). We have tools to help determine where we fall on that spectrum.

The concept of “a drug is a drug…” borders on pseudoscience, with little evidence to support it. In fact, preliminary research indicates these ideas might actually cause more harm for people who have experienced substance use disorders (SUDs).


Denial of Vital Medications

NA promotes a position targeted directly at people on medication-assisted treatment (MAT) with methadone or buprenorphine (Suboxone). “Bulletin 29” suggests that MAT patients aren’t really in recovery; they’re simply replacing one addictive drug with another. And while NA encourages MAT patients to attend meetings, they discourage us from opening our mouths—perhaps because MAT allows many people to reclaim control of their lives without working NA’s program?

Even people in treatment or “long-term recovery” (a term which carries significant baggageshow a remarkable ability to control their medication intake. Many methadone patients are able to work their way up to earning take-home privileges, which requires a tremendous amount of self-control and abstinence from street drugs.

Unfortunately, patients who test positive even for THC can be denied those privileges.

Dr. Merrill Norton of the University of Georgia’s School of Pharmacy explained at a 2015 conference that many MAT patients use cannabis to treat chronic pain which can’t be treated effectively by other means during methadone or buprenorphine treatment. This suggests that many MAT patients could benefit from medical use of cannabis. He also cites long-term treatment retention rates of 59 percent and 50 percent for methadone and buprenorphine, respectively. This far outperforms the 5-10 percent success rates demonstrated by 12-step programs.

Chronic pain patients, even those with a history of problematic substance use, shouldn’t be denied medications that can improve their health because of misinformation. Addiction shouldn’t be confused with physical dependence. Most people who use opioids for more than a few weeks will likely develop physical dependence, but most don’t develop problems or become addicted.


Pseudoscience as Social Control

It’s important to note at this point that distinctions between “medical” and “street” drugs are largely arbitrary.

Many of the drugs which are presently illegal to possess in the United States have pharmaceutical-grade counterparts, which are legal with a prescription. Examples of such drug “pairs” include heroin and OxyContin, or methamphetamine and Adderall. This arbitrary distinction suggests an element of social control by government agencies and the pharmaceutical and treatment industries—those who determine which drugs are medicines and which have “no medical value,” and those who profit from such decisions.

Many of the very worst harms related to drugs—arrests, incarceration, stigma, unsafe using practices, lack of quality control and dosing information—are caused by the prohibition of certain drugs, rather than the drugs themselves.  


Switching From Riskier to Less Risky Drugs

In some cases, substance users will replace a more potentially dangerous drug, like heroin, with a less dangerous one, like marijuana. They’re both illegal in most states, but many people who have previously experienced problems with heroin find that marijuana gives them a sense of ease that “fills some of the holes” opioids did.

The risk profile for cannabis is certainly lower than that of heroin. The risk profile of alcohol, when you take into account the additional harms inflicted on heroin users by the prohibition of that drug, is arguably lower, too. This is a harm reduction approach to substance use and, for many people, it’s incredibly successful.

Even though all drugs, legal or illegal, carry some potential risks, the person’s quality of life should be used as a primary factor for their definition of “recovery.”

Micha*, developed problems with opioid pain pills which had a major impact on her health. She’s since found less potentially harmful ways to cope: “I drink nearly every day. most days that consists of one beer, but one-to-three times a week I’ll get pretty drunk. I feel like it’s a social thing for me. And the single beer will be more of a de-stressor when getting off of work or winding down after a long day.”

She sometimes takes kratom, an opioid-like plant in the coffee family. “Sometimes I want to stop taking it but most of the time I don’t find that it’s an issue.” Her main concern is that the long-term effects of kratom use aren’t well-known, although it’s considered less potentially addictive than other opioids. I used kratom to taper off methadone, but after jumping off, I quickly returned to heroin, which led me to buprenorphine, which has helped my opioid use disorder and mental health issues.

Kenneth Anderson, Influence contributor and executive director at Harm Reduction for Alcohol (HAMS) explains: “It is very common for people to quit one problematic substance, such as heroin, and moderate another substance such as alcohol, particularly if they have never had a problem with alcohol in the first place. We see people doing this in our HAMS group all the time. Although there are some people who switch from an opioid addiction to an alcohol addiction, this strikes me as the exception rather than the rule.”

“We don’t actually know [how common “cross addiction” is] because studies of people quitting one substance and moderating another are non-existent,” he continues. “However, research does prove that people who quit an addiction are less likely to start a new addiction than those who do not quit their first addiction.”


Continuing to Use the Same Drug, With Fewer or No Problems

Harm reduction approaches to problematic drug use don’t just involve switching to less risky drugs, however. Many HAMS participants who have used alcohol problematically move on to drinking with fewer or no problems. And the concept holds true for so-called “hard” drugs.

Carolyn, a key player in her regional harm reduction movement, was able to moderate her use of heroin after previously developing problems with heroin and crack.

“I feel that everything I was taught about drugs has been wrong,” she says. “Last year, when I used heroin multiple times over the course of a year, nothing awful happened. I didn’t fall into a full-blown relapse, I didn’t crave, I learned from it and moved on with my life without having to go sit in 12-step meetings and repent—or even inform most people in my life.”

“I’m lucky that I have a treatment team that supports my decisions regardless,” Carolyn continues. “They may check my use, if I’m being honest about something and expressing my own concern about what I‘m doing, but they don’t just immediately assume that all substance use is harmful. They agree that there are times where substance use may be the healthiest option for me.”

Programs like NA attempt to scare people with SUDs with language. One example from the literature:

“We lived to use and used to live. Very simply, an addict is a man or woman whose life is controlled by drugs. We are people in the grip of a continuing and progressive illness whose ends are always the same: jails, institutions and death.”

But this just isn’t the case for everyone. Consider that about half of people who use drugs of any kind problematically will “mature out” of it by the age of 35, mostly without formal help or treatment. Do you suppose that more than a small minority of them are then abstinent from all drugs—legal and illegal, prescribed and non-prescribed—for the rest of their lives? Of course not.

Many reduce and moderate their use, many switch to different substances, prescribed or not prescribed, and many use these drugs without experiencing further problems.


Further Examples of How Abstinence-Only Narratives Cause Harm

The “drug is a drug…” position is one of the pillars on which abstinence-only models are built. But these programs show limited success, whereas MAT demonstrates measureable improvements in almost every area of quality of life. We might even view switching from problematic substance use to moderated, less harmful substances as a form of self-medication, one which fills gaps the medical and treatment communities fail to provide.

Abstinence-only thinking becomes dangerous when people buy into ideas which allow them to rationalize a return to harmful use. They’ve been taught that all drugs are bad, which can become a self-fulfilling prophesy. Research has shown belief in the disease model of alcoholism to predict the likelihood of a return to problematic drinking, for example.

Doctors are frequently scared to prescribe pain to patients with legitimate needs, and are especially wary of prescribing controlled substances (opioids, benzodiazepines, ADD/ADHD meds) to patients with a history of problematic use of any substance.

This has devastating effects and—in the absence of evidence that prescribing these medications will result in a relapse to harmful use—can cause long-term health consequences. It leaves those who are hurting, suffering mentally and physically, with no means of relief. These are our most at-risk people. Denying them medications can drive them to underground markets, which are unregulated and carry far greater potential for harmful effects, including incarceration or overdose.

“I have always felt that the most damaging parts of my drug use were not the drugs themselves,” Carolyn says. “It was the legal consequences. The stigma of being a user and feeling worthless and hopeless as a result. It was that my family was taught to hate and fear me by society and addiction treatment programs.”

Read more from The Influence:

The Worst Place to Die: How Jail Practices Are Killing People Going Through Opioid Withdrawals

The Scientology-Based “Re-Education” Program for American Prisoners, Sponsored by Goldman Sachs

…and follow us on Facebook and Twitter.

Some 12-step programs like Alcoholics Anonymous (AA) hold positions that some “non-addictive” medications, like psychiatric medications, are safe. But by their own admission, AA’s literature admits this doesn’t prevent members or sponsors in autonomous AA groups from pushing the potentially devastating advice that all medications are harmful.

Even years after I stepped away from 12-step programs, I still retain the thinking that I need to be on as few medications as possible. I’m cautious which medications I take, even though I know I require them to function. This has caused harm to my long-term mental health and productivity.

Sammi, now 21, was prescribed benzos at age 12 for childhood bipolar disorder. This led to developed physical dependence, but not problematic use. Sammi later had problems with other substances.

“During high school I developed a problem with opioid pain medications and sleeping pills,” Sammi explains. “Later I developed a problem with crack cocaine. I was able to stop using crack by self-medicating with opioids and support from a network of friends who are willing to meet me where I’m at. Now I’m able to moderate my opioid use—which feels more like medicine which makes me feel normal than recreational use.”

Sammi still misused sleeping pills to cope with psychosis until it was possible to find adequate mental health treatment. “I’m now diagnosed with schizophrenia, bipolar, and dissociative identity disorder. Occasional opioid use and self-harm still help me cope with symptoms when they become unmanageable, but I don’t consider those nearly as harmful as my previous problematic drug use or behaviors. In some ways I find they actually improve my health and coping during extreme depression and chronic pain episodes.”


Transcending Traditional Recovery Narratives

As we have seen, plenty of available data and ample anecdotal evidence contradict abstinence-only positions. There’s actually little evidence to support the abstinence-only narrative and some to suggest that switching to less harmful drugs can improve quality of life.

There are some people who can’t go back to their preferred substance in moderation. I certainly can’t with opioids. Sometimes I feel like minor alcohol use (usually one or two beers a few times a week) helps keep more problematic use in check. More than five years after I quit using heroin every day and switched to MAT, drinking has never caused me to relapse. I never drink too much or want to use opioids after drinking.

Ultimately, the terms of a person’s “recovery” should be set by them, with medical or therapeutic advice as they deem necessary. Pseudoscience and outdated mantras do nothing to encourage healthier lifestyles.

Abstinence from certain drugs is an absolutely legitimate personal choice, and one that should be respected. But abstinence should never be imposed on others. For many people, using a harm reduction approach that includes less problematic substance use can improve health and quality of life.

*These interviewees chose to use pseudonyms to protect their privacy.

Jeremy Galloway is harm reduction coordinator at Families for Sensible Drug Policy, program director at Southeast Harm Reduction Project, co-founder of Georgia Overdose Prevention, and a state-certified peer recovery specialist. He lives in North Georgia with his wife and three cats. He writes and speaks regionally about drug policy reform, harm reduction, his experiences, and the importance of including the voices of directly impacted people in policy decisions.

  • Ya think?

  • makeaasafer

    So glad to see someone pushing up against the “Abstinence ” Model and 12 step dogma form 1935. WOO HOO. Keep up the good work.

    • Susanjones2007

      Actually, NA wasn’t started until much later. Tom Caton has a great deal of positive things to share about it. AA doesn’t share the position taken by NA or this article.

      • Voice of Reason

        Neither does NA

  • Unhappy Psychologist

    Maybe new ways of thinking based in science and critical thinking are what we need to help people with addictions, as it’s pretty apparent that the old ways aren’t working.

  • Unhappy Psychologist

    Unhappy Psychologist • a few seconds ago
    Maybe new ways of thinking based in science and critical thinking are what we need to help people with addictions? It’s pretty apparent that the old ways aren’t working.

  • Babalon777

    Thank you for pushing up against the outdated victim blaming rhetoric of 12 steps & abstinence mandatory ideals, Both of those dogmas are non science/health based and I believe harm addicts more than help, As a longtime IV heroin addict, I felt nothing but stigma, and being pressured into telling myself Im weak and I NEED “a higher power” to help my life because Im not strong enough to do it myself….that attitutde HARMS …keep up the awareness and open mind 🙂 🙂

    • SusanJones2007

      Interesting thought. If I could have managed my drinking, I woouldn’t have needed harm reduction or anything else. For this alcoholic, abstinence is the best plan. I don’t consider 12 Step to be victim blaming. I am not a victim at all.

      If you can recreationally use IV heroin, you wouldn’t be an addict.

  • hr williams

    By far one of the best articles I’ve read that makes total sense and I wished every doctor,mat clinic and all addicts would open mindedly read

    • tranquility

      I believe many of the things, the author of this article wrote may be true and i also believe that he has not really understood what NA is about, and is not really openminded himself.

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  • Voice of Reason

    For some people – me included – using no drugs is easier than moderating drug use. I couldn’t do it. I tried various combinations of drugs, frequency, dosage, etc, and the only thing I found that provides me with the quality of outcomes that I’m seeking is abstinence.

    When viewed in isolation, none of the specialist drug treatment options work well for everyone. That’s why we need a range of options available in the community for people who use drugs. And that range of options needs to be able to accommodate a variety of treatment goals. If MAT doesn’t work well for you, find something else. If AA/NA doesn’t work well for you, find something else. However, just because it doesn’t work well for you shouldn’t mean you get to attack it or the people for whom it is providing quality outcomes.

    • tranquility

      I feel likewise. Thank you.

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  • Eevie

    Put addicts in life situations they are happy in and most give up their addiction.

  • Heather

    Thank you for this article. I’ve been on Bupe for 11 years and will probably take it for the rest of my life. I would have hoped that after this many years, access to the drug would be easier to get, but it seems that idiot lawmakers just keep putting more obstacles in the way of those that need it (they did pass some recent laws that should be helpful though). They’re so worked up about diversion, despite the fact that most of us became addicted to opiates through pill diversion in the first place, and really who gives a crap if heroin addicts have illegal access to Bupe? If it’s keeping them off heroin for a few days or permanently, that should be considered a win. It’s much safer than any of the drugs addicts take in it’s place.

    I can’t smoke weed or use any drugs at all because my bupe doctor drug-tests me. It’s so stupid. Smoking pot is a totally different thing in my view. It’s no worse (better even) than drinking alcohol. So I can drink till I fall over if I want to (I don’t though) but I can’t smoke a joint because I’d risk losing my bupe. That makes sense, right? If someone slips up and uses drugs, take them off bupe so they can fall head first into a total relapse.

    I really hate these idiot lawmakers, and the pharmaceutical companies too, who have decided that Suboxone needs to be sold in godawful blister packs that slide in and out of hard plastic containers. There’s an incredible amount of unnecessary waste because of those changes. What makes Suboxone so much more dangerous than any other drug that kids can get ahold of? There are plenty of drugs that will harm someone who takes it unprescribed, but they don’t require bomb-proof packaging. Jeez. So now my pharmacy refuses to fill my prescription in the amounts I need because they want me to only get it in whole package increments (15 pills in the 8 mg and 30 pills in the 2mg). What I need is 75 2mg and 15 8mg (my insurance will only pay for 90 pills, but I prefer the 2mg.) That requires that they cut up the blister pack though and they’ve refused to that for me anymore.

    Sorry I’m rambling about stuff that has nothing to do with your article, but I do agree with your article. 12-step programs are like a religious cult, filling addicts’ heads with nonsense that doesn’t work for the majority of people who try it. And they’re making Suboxone patients’ lives harder in many ways. I really think it’s mainly about money for them. If addicts take Suboxone and are able to stay off pills or heroin, they won’t need to keep going in and out of rehabs until they overdose and die. They don’t need rehab at all actually. The Suboxone *is* the rehab. I’ve never had any treatment and I’ve been on Sub and off pills for 11 years now. I stopped smoking weed after about 4 years of being on Suboxone, around the time my doctor started thinking drug-testing was important, lol.

    Keep speaking out, please. We need more people like you telling the truth.

    • Nick Name

      “That makes sense, right? If someone slips up and uses drugs, take them
      off bupe so they can fall head first into a total relapse.”

      That is correct, if the slip does not make the ‘sky fall’ the system itself will. I have a buddy I met along the way that is labelled a ‘chronic relapser’ so what do his parents that are brainwashed by the system do ? They keep making him live in these sober living places so when he finally gets sick of it and drinks at a bar he gets kicked out and becomes homeless instead of just going home like a normal person and going to bed. Over and over the same thing. Treatment center > sober living house > he gets sick of it and drinks becomes homeless by design > back to treatment center.

      Its a long story but I watch how they make the self forfilling prophecy come true over and over again with this guy.

      The amount of money spent on his treatments easily could have bought a modest house.

  • Katela

    12 Step programs are God cults.

  • 8daycure

    I’m a little curious, Jeremy…if your thesis has any value at all, then how much heroin are you able to safely inject now?

  • tranquility

    While this article has many good points and should not be discarded, i should note that the author clearly hasn’t got a grasp on what NA is about and what its views (which are quite diverse) are. Throwing bulletins like this (bull29) at addicts who are still suffering, can be very harmful, too. Also NA doesn’t claim to be the only way or option to deal with substance use. Openmindedness is about allowing different options and programs to coexist, so that every addict might find what is right for him. NA is about the desire to stop using drugs. Not about stopping to use “a” drug, but all drugs. It is about abstinence. But by no means is NA for everyone who has a problem with a substance. Just for those who discovered they cannot deal with substances at all and who want to quit everything.

  • Nick Name

    i had a seroius problem with Xanax and the benzos, I had no idea what withdrawal was when I was prescribed and started taking them till the first time I missed a doctors appointment and ran out. I was also prescribed Adderal , I was dependent on that too and I would drink with those pills every day. I was in bad shape.

    Long story short I went to many treatment centers and was told the usual total absence thing but I found I could still drink once in a wile without problems besides waking up with a hangover.

    I liked going to the AA but it got to where I felt like a phony keeping my twice a month drinking outings a secret. I stopped going even though I do think it helped me.

    Drugs like Xanax and the ADHD drugs screw me up and cause me to crave alcohol, to me taking drugs without drinking is like a pizza without cheese, but if I don’t seem to have a problem going out for beers once in a wile.

    I still have alot of friends in AA and miss going, I just don’t want to hear that how much time do have thing cause to me my recovery date is six years ago when I got off those pills not two weeks ago the last time I went out for beer.

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