Patients in Methadone Maintenance Treatment Face Obstacles and Stigma When Joining 12-Step Groups

recovery winter 2014 jpegIt’s ironic—and disappointing—that patients in methadone maintenance treatment (MMT) who join mainstream addiction recovery groups face considerable stigma and daunting obstacles from professionals and from other patients, rather than the helping hand they might reasonably hope for and expect.

This became evident in the first in-depth survey detailing the experiences and perceptions of MMT patients in Narcotics Anonymous (NA), Alcoholics Anonymous (AA), and other support groups. Although most of the 323 MMT patients surveyed participated in support groups and found them helpful, patients’ rates of taking part in socializing, speaking at meetings, and other functions were much lower, because of negative experiences.

Key interfering factors include restrictions on MMT patients at 12-step meetings, and obstacles that spring from stigma and professional attitudes.  Yet more MMT patients take part in 12-step programs than might be expected, given the problems encountered.

The OTP Survey

The survey took place at Partners in Drug Abuse Rehabilitation and Counseling (PIDARC), an opioid treatment program (OTP) in Washington, DC. Founded in 1971 as a private, not-for-profit facility, PIDARC today has more than 650 patients and 24 counselors, nurses, physicians, and support personnel. Most patients are poor and African American, and report long-term involvement with the criminal justice system. Many have a history of addiction treatment failures and current medical problems.

The Journal of Groups in Addiction and Recovery published the PIDARC article last November. The lead author is William L. White, MA, a prolific writer and a pioneer in the addiction treatment field. Two of the survey’s coauthors, Howard A. Hoffman, MD, and Brian Crissman, are affiliated with PIDARC.

Enrollees’ Characteristics

Volunteers who were at the OTP at a randomly selected time were enrolled in the survey. Characteristics of the 323:

  • 55% male
  • Average age, 53 years; range, 21 to 79 years
  • Average time in continuous MMT: 2 ¾ years
  • Average percentage of days in the past year abstinent from use of alcohol and non-prescribed drugs: about 70%
  • Primary support affiliation: NA, 68%; other (usually church or PIDARC group), 11%; AA, 7%

Participation in Mainstream Groups

PIDARC doesn’t hold 12-step meetings, but a nonclinical staff person, an NA member, strongly encourages involvement in NA meetings.

Most patients (66 percent) took part in NA/AA programs, and most (about 75 percent) found the programs helpful. Yet most didn’t participate in activities:

Activities of MMT Patients
Who Joined Outside 12-Step Programs

Characteristic  Percent Participating
Have a home group 50
Have a sponsor 26
Sponsor others 13
Attend 12-step social events 23
Take active part in step work 21

 

Patients enjoyed the social aspects of NA and AA. Some liked AA because it “provided more structure and had a stronger spiritual base than NA.” Others identified with NA’s drug-focused fellowship; many never had problems with alcohol.

Problems Encountered

One-fourth of participants encountered a serious problem being an MMT patient within NA or AA. An extreme example: At an NA meeting, a patient who mentioned being in MMT was asked to leave and not return.

Problems MMT Patients Encountered in NA/AA

Problem Approximate Percent
Recipient of negative comments
about methadone use
45
Pressured to stop taking methadone 35
Pressured to reduce their dose 25
Denied the right to speak at a meeting 15
Denied the right to be a sponsor or chair a meeting 10

 

Cautioning against generalizing about patients’ negative experiences, the authors pointed out the considerable variation in “the attitudes of NA and AA groups towards medication-assisted treatment [MAT] of addiction in general and methadone maintenance treatment for opioid addiction in particular.”

Don’t Ask, Don’t Tell

It’s hardly surprising that only 34 percent of patients surveyed disclosed their MMT status at NA or AA meetings, and only about 25 percent did so to their sponsor.

A Lost Opportunity

For patients seeking long-term recovery, “12-Step fellowships and other recovery mutual aid groups may provide a source of critical support,” the authors believe. So lack of support is a squandered opportunity to welcome fellow patients into the recovery circle.

Patients need that support, given their long-term outlook. The common idealized view is that MMT is lifelong therapy, but the fact is that most patients do leave treatment, and they do so without support.

To bring reality home, the authors compiled a list of seven “stark realities” that challenge the idealized views of the optimal time in medication-assisted treatment:

  • 80%-100% of surveyed patients expect to end MMT at some point
  • One-year retention rates in MMT are less than 50%
  • Few patients end treatment in a planned manner (11%, in one study)
  • Post-treatment monitoring, support, and early re-intervention are not standard practices
  • Most discharged patients eventually return to illicit opioid use
  • Patients who end MMT face a significantly increased risk of infectious disease and death
  • Most MMT patients who choose to taper don’t successfully complete the process as planned

The authors note that these realities underscore “the more specific role participation in recovery mutual aid groups could potentially play in long-term recovery from opioid addiction.”

12-step approaches to MMT have a history of encountering obstacles. According to the authors, “The stigma and discrimination MMT patients face when seeking participation within mainstream recovery mutual aid groups are, in part, expressions of the larger professional and cultural stigma attached to MMT in the United States.”

In 1991, MMT patients’ negative experiences in support groups led to the creation of Methadone Anonymous (MA), but, according to the authors, MA “is not widely available in the U.S. at the present time.”

What OTPs Can Do

The authors said that because MMT is a substance-specific treatment, but addiction is not a substance-specific disorder, OTPs and other groups need to address patients’ complex patterns of concurrent and sequential drug use. “Increasing patient participation in recovery mutual aid groups may prove helpful in addressing patterns of multiple drug dependencies.”

The authors suggested ways for OTPs to help patients establish links with other mutual aid groups:

  • Develop relationships with NA service committees
  • Host NA meetings
  • Coach OTP patients about taking part in NA/AA
  • Establish protocols for linking with mutual aid groups
  • Co-host programs on MAT and recovery with mutual aid groups
  • Encourage development of local MA meetings and other recovery-support meetings for patients in medication-assisted recovery

In closing, the authors emphasize that support groups may be able to reach out to MMT patients if they falter during the crucial period when they face the “stark realities” of life after they leave the OTP “on current doses of methadone without planned tapering and support for the transition to recovery maintenance without medication support.” They note again that “the risk of relapse is great under these circumstances and remains a lifelong risk; 12-Step fellowships and other recovery mutual aid groups may provide a source of critical support for patients seeking stable long-term recovery during and following discharge from OTPs.”

Reference

White WL, Campbell MD, Shea C, Hoffman HA, Crissman B, DuPont RL. Co-participation in 12-Step Mutual Aid Groups and Methadone Maintenance Treatment: A Survey of 322 Patients. J Groups Addict Recovery.  2013;8(4):294-308. Published online Nov. 8, 2013. doi 10.1080/1556035X.2013.836872.

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