(Twenty-fifth in a series of topical blogs based on chapter by chapter excerpts from Opiate Nation. Translation into most languages is available to the right.)
I’ve heard a saying: “The chains of habit are too weak to be felt until they are too strong to be broken.” And just like chains, some habits are stronger and deadlier than others. Conversely, healthy habits can be just as strong and powerful – but instead of bondage, they bring freedom to live our lives to the fullest.
In The Power of Habit, Charles Duhigg says, “Habits are a three-step loop: The cue, the routine, the reward. They become automatic beginning with a cue that triggers a routine and a craving for a clear reward. Craving is an essential part of the formula for creating new habits…You can never truly extinguish bad habits. So in order to change a habit, you must keep the old cue and deliver the old reward (that you are craving), BUT insert a new routine.”
Duhigg says this is why AA has been the largest and most successful method of habit change in the world. Their techniques help those struggling with addiction to use the same cues, and still get a reward, while shifting the routine. These are built into the AA system of meetings, companionship, accountability, and service which helps members do something in place of drinking or using every night. Creating habits of relying on, and benefitting from, community and the 12-steps becomes automatic for people with addictions. When stress or catastrophe happen, the learned response for seeking support and help will get them through. A young recovering opiate addict told me: “Going to my 12-step meetings was a new routine I had to learn to replace my old routine of drug-seeking behaviors.”
Tracey Helton Mitchell’s message in The Big Fix is that “In the end, I found that for me, there was no Big Fix.” Her life changed incrementally as her behaviors changed and new habits were formed. The beginning of those changes started for her in prison through a forced period of detox and sobriety. If we do anything for a long enough period of time, it becomes an automatic behavior.
When people begin forming or changing habits, they are inevitably surrounded by temptation. So, it is essential to create an environment that is supportive of the new, healthy routine. This is where a focused accountability group is so important. Being part of, and accountable to, a community of like-minded people is what will help our resolve in fighting our demons, whatever they may be.
But alcoholism and certain drug addictions are also more than a habit—they are physical and psychological addictions, both body and mind craving the release or rush they will receive. For opiate addiction in particular, there is a very prolonged physical addiction. Modifying habits is therefore only part of the solution and is best used in conjunction with Behavioral Therapy/Counseling and Medication Assisted Treatment (MAT). The statistics tell us clearly: Successful recovery for opioid addiction in 12-Step programs alone is approximately 10-15%; with MAT it is 50-60%. On the other hand, using MAT alone, physical addiction may be controlled, but without establishing new habits like the 12-Steps, the options are either to stay on medication indefinitely or risk relapse.
Currently, there is one significant drawback to AA/NA/HA meetings when it comes to MAT. Many of the groups are so focused on the original philosophy of alcoholism being a “moral failure,” that they may openly reject MAT as part of a valid recovery or simply stigmatize those who use medication. Our son and several of his friends found this true, especially a decade ago. The result has caused many to drop out of the group due to shame and to relapse.
NIDA (Nat’l Institute on Drug Abuse) says that “Treatment of chronic diseases (like addiction) involves changing deeply rooted behaviors (habits) – and relapse doesn’t mean treatment has failed.” As we now know, on average it takes 4-5 recovery attempts and 8 years to gain one year of sobriety from opioids. I believe this discouraging statistic is gradually changing for the better as more physicians, therapists, and recovery programs recognize the need for MAT along with behavioral therapy and an ongoing solid 12-step group.
Let’s encourage those struggling with addiction to use all the tools available to build a new and healthy future. More in-depth information in the articles cited below may be of help. Learning new, healthy habits brings freedom. But freedom has a price—in any setting, in any context, in any situation–eternal vigilance:
The condition upon which God hath given liberty to man
is eternal vigilance; which condition if he break,
servitude is at once the consequence of his crime.
–John Philpott Curran, c. 1790
Benefits of 12-Step programs for opioid addiction: Providers Clinical Support System – December 6, 2017
12-step programs are not just for individuals with alcohol addiction. Studies have found that persons addicted to alcohol, drugs, or both have better chances of recovery as they attend more 12-step meetings and participate in more 12-step activities. Parts of the 12-step program are especially helpful for those recovering from drug abuse.
- Service: One of the most beneficial 12-step activities is doing service in AA (Alcoholics Anonymous) or NA (Narcotics Anonymous). The 12-step belief in “giving back” to one’s community through service work can very valuable later in recovery for both drug and alcohol-addicted persons.
- Support: The supportive social networks provided by 12-step programs are also beneficial for recovery, and can help recovering addicts to surround themselves with a supportive and nonsubstance-using environment.Individuals struggling with addiction may have become socially isolated or only have friends in circles where the temptation to use drugs is high. 12-step meetings’ social support and the opportunity to connect with other people that do not endorse substance use may be very beneficial.
12-Step programs along with other therapies
Patients who choose to attend 12-step meetings may also see a therapist regularly. Therapists may use a method called “12-step facilitation” to help patients get the most out of their separate 12-step meetings.
12-Step Programs and MAT
Many 12-step programs are not supportive of the use of medication-assisted treatment (methadone, buprenorphine, or naltrexone). Because these medications are opioids, those who receive help from MAT are often not considered fully abstinent, or “clean,” from drug use. Despite the proven benefits of MAT in helping people recover from opioid addiction, the 12-step model’s understanding of the addiction recovery process isn’t always open to the use of methadone or buprenorphine.
Many 12-step programs teach that addiction is mainly a moral and spiritual failing, best treated by improving one’s behavior and spirituality. In contrast to this way of thinking, methadone and buprenorphine treatment programs are based on a “medical model” of addiction – teaching that biological factors determine addiction. This medical model teaches that addiction is a chronic (long-lasting) disease, similar to life-long diseases like diabetes. In this model, addicts benefit from medical treatment just as diabetics benefit from insulin. Because many 12-step programs are based on the moral-spiritual understanding of drug addiction, and not the medical model, those who find help with MAT may have difficulty reconciling the two views and participating in 12-step programs. The morality-based teachings of 12-Step treatment programs, often shared by patients and their communities, can conflict with the medical model of understanding addiction and can make MAT seem like an illegitimate treatment option, despite its proven benefits.
Witbrodt, J. and L. A. Kaskutas (2005). “Does diagnosis matter? Differential effects of 12-step participation and social networks on abstinence.” Am J Drug Alcohol Abuse 31(4): 685-707. Ries, R. K., Galanter, M., & Tonigan, J. S. (2008). Twelve-Step Facilitation: An Adaptation for Psychiatric Practitioners and Patients. In M. Galanter & H. Kleber (Eds.), Textbook of Substance Abuse and Treatment (4th ed.) Arlington, VA: American Psychiatric Publishing.Frank, D. (2011).
Meetings & Medication? Combining Narcotics Anonymous Attendance with Buprenorphine Treatment
Recovery Research Institute (2015)
“Despite the conflicting viewpoints on medication use between 12-step groups and buprenorphine programs (in this study) there appears to be a benefit in attending meetings among patients also engaged with medications…each additional Narcotics Anonymous (NA) meeting attended per week was associated significantly with a 2% increase in the odds of treatment retention and a 1% increase in the odds of abstinence at 6 months. Negative attitudes toward buprenorphine may begin to shift as medication-assisted treatment becomes more widely accepted as an evidence-based treatment for people seeking recovery.”
Do Drug Dependent Patients in Alcoholics Anonymous (rather than Narcotics Anonymous) Do As Well? Recovery Research Institute (2014)
Drugs, Brains, and Behavior: The Science of Addiction (July 2020)
12-Step Programs for Drug Rehab and Alcohol Treatment (2021):
The Success Rate of AA for alcohol abuse: