David got up from his folding chair. Several people reached out to shake his hand or slap him on the back as he passed. Everyone in the room knew how tough it was to achieve that first month of sobriety. But as the little red medallion was handed to him, the question that had haunted him for the last month flashed across his mind: “Am I a fraud?”
David had a secret. After years of failing to kick his addiction, he had finally been prescribed Suboxone, a pill to ease his cravings and help him recover. The pill helped. For the first time since engaging in heavy heroin use, he was managing to stay clean. But David knew that many in the recovery community would not consider him truly sober if they knew he was taking medicine. “Most people look at Suboxone and think you are cheating, that you are getting high somehow, that you are taking the easy way out,” he told us. “There is this junkie pride where you are supposed to go through detox and withdrawal. Suffer it out. Cold turkey.”
As David walked back from the podium, he felt confused and alone. Should he trust his doctor, who had told him that Suboxone was an effective way of treating opioid addiction and akin to an antidepressant? Or his peers, who preached complete abstinence, even from medication—and honesty, no secrets, as the only pathway to recovery? In the support group people had shared their darkest secrets as part of the 12 Steps to recovery. Some had told the group that they had been molested as children. One had even confessed to David that he had committed a murder. “But I didn’t even feel comfortable to say that I was on Suboxone,” David said.
Eventually, David stopped taking Suboxone, part of his on-again, off-again relationship with the treatment. “I guess that sense of isolation and loneliness led me back to the kind of people that I was getting high with, led me back to the streets and the drugs,” he said. “Everybody needs their tribe.”
For many people, that tribe comes at a great cost. Health authorities and medical researchers widely consider medication-assisted treatment (MAT) with methadone or Suboxone the most effective way of treating opioid addiction, which in 2016 affected some two million people across the United States. Yet in the midst of a national opioid epidemic, only a fraction of addicts receives MAT. In response, President Donald Trump recently vowed to expand access to MAT, which can be expensive and difficult for patients to obtain. The push, sorely needed as it may be, faces an obstacle that is beyond the abilities of the federal government to remedy. The real barrier may not lie in a lack of resources, but in the very way America still thinks of addiction, thanks to a decades-old 12 Step philosophy that has left a new generation of addicts out in the cold.
It was pitch black outside and the sun would not rise for another two hours. Michael Dever, a skinny 34-year-old in horn-rimmed glasses, black hoodie, and black pants, was already in his car, driving to a methadone clinic in the east end of Louisville on a January morning, just as he had most mornings for the last seven years. This is his routine. “I’ve tried to separate it from my person. Because this is just something I have to do,” he said. “It enables me to live a normal, stable life and get up and go to work every morning and be productive, and not be on heroin shooting up three or four times a day.”
The Crossroads of Louisville methadone clinic is situated on a dead-end road. Two large spotlights shined on the parking lot, making the ground look glassy in the light rain, as Michael made his way hastily towards the clinic. On busy days, when clients are called five at a time, and lined up against a wall festooned with inspirational quotes, Michael almost feels like he is in prison. Today, the nurse only called Michael, went over his dose, and dispensed 16 mg of methadone in a small plastic cup. Michael swallowed the cherry-flavored shot and rinsed with water. “That’s how it’s supposed to run, so it doesn’t interfere with your day so much,” he said. “But it doesn’t happen like that every day. It rarely happens like that, actually.”
Michael can deal with the hassle of getting the medicine. What he finds harder to live with is the suspicious attitude people take toward it. On the walls of the clinic, large posters address some of the myths that feed that attitude. One is that it is just a replacement drug—that patients on methadone are just trading one addiction for another addiction. “That’s not true at all,” Michael said sharply. “Methadone-assisted treatment is nothing like a heroin addiction. It’s not even close.”
The misconception stems from the fact that most medications for treating addiction, like Suboxone and methadone, are opioid-based. With the correct prescription, an addict’s compulsive behavior, loss of control, constant cravings, and other hallmarks of addiction will usually vanish. But if you take too much, you will get high. The idea that MAT is just a replacement drug has been debunked countless times by medical organizations, including the U.S. Department of Health and Human Services (HHS).
Nonetheless, Michael has been told that he is still a junkie, not only by people in the 12 Step meetings he used to go to, but also by friends: “They look at you like you are still using, that you are not sober, that you are basically still living the life of a drug addict, when you are not.” Michael has come to terms with the fact that he will probably have to take methadone for the rest of his life. He hates the stigma associated with his medicine, but he knows that he needs it to function.
The effects of MAT have been studied by health authorities and medical experts for over five decades, and the evidence in favor of the treatment method is overwhelming. One 2017 review of 19 studies, published between 1974 and 2016, found that when people received medication-assisted treatment, their overall risk of dying from an overdose went down by more than 50 percent. HHS affirms that long-term MAT has the best track record for controlling opioid use and saving lives.
But MAT is still greatly underused. One study from 2017 found that less than one in four patients diagnosed with opioid dependence or abuse received the combination of MAT and psychosocial treatment that clinical guidelines recommend. Furthermore, this figure does not include undiagnosed addicts or addicts without health insurance. The actual percentage of recovering addicts on MAT is likely much lower.
A visit to the men’s detox ward for the Healing Place in Louisville—a facility that is based on A.A.’s 12 Step method—points to one of the causes. Twenty-five beds are positioned side by side in an open room, smelling of sweat and detergent. A man lay sprawled on his mattress with his pants down to his knees. Another rested with a sheet over his face. The drapes were drawn, the room lit only by the ambient glare of fluorescent tubes. There was no sense of time in here. Scattered around the room were several copies of one tome: The Big Book of Alcoholics Anonymous.
For nearly 30 years, this facility has played a vital part in the city’s social work. The Healing Place provides food and shelter to up to 700 people every day; the bulk are in the recovery program, some are in detox, and the rest are homeless people coming from shelters or from the streets. For addicts who want to kick the habit, but cannot afford expensive rehabs, there is almost nowhere else to go.
Fifteen years ago, when Michael was just 20 years old, his parents forced him to go there to wean himself off his growing addiction to opioids. He stayed for only one night. Early next morning, he staggered out the door and walked for miles back to his house. Neither the interior of the detox ward, nor its philosophy, has changed much since. The recovery facility believes in full abstinence, so before they do anything else, patients must spend their first 24 hours to nine days in the ward detoxifying themselves from whatever substance they are on: alcohol, heroin, painkillers—or medication-assisted treatment like methadone or Suboxone.
Heaps of faded sheets were piled at the end of the room. Depending on the drug used, withdrawal symptoms can include severe sweating, nausea, and diarrhea. “It’s just absolutely horrible. It’s like a cold and a flu combined times ten,” said former resident Keenan Beckhart, who now holds the title of gift officer of the development team. Yet, apart from mild pain relievers, patients are not allowed to use any medication. The staff members, most of whom have been through the program themselves, have limited medical training.
At lunch in the detox ward, everyone got the same thing: two pieces of wheat toast wrapped in foil with slices of cold turkey. The irony was almost too thick. One guy stirred a big pot of gray porridge with a texture like wallpaper paste and doled out portions for those who had the strength to eat. Most stayed in bed.
On the wall hung photographs of about 200 people who had previously been through the program. The Death Board, as it is called, is a memorial, meant to honor former patients, and to serve as a gloomy reminder of what can happen to current patients if they relapse. Adam Harmon, a young man with a scruffy brown beard, had been a resident at the Healing Place for almost a year before he became a peer-mentor. “I was in the program with him… and him… and him…” he said, pointing to the small photographs of men who had overdosed and died. “Twelve people that I know have died within the last 11 months.”
But what is accepted with grim resignation at the detox ward is a source of deep dismay for medical experts. “Detox without MAT is potentially dangerous,” said Bachaar Arnaout, an assistant professor of psychiatry at Yale School of Medicine. “An overwhelmingly majority of people end up relapsing after detox. It’s a gamble with lives.”
When patients go through detox, their tolerance decreases drastically. If they fall off the wagon and take the dose of opioids they were used to, or even a lower dose, this can be enough to shut down vital body functions. This is especially the case today, Arnaout said, because the opioid epidemic is largely driven by fentanyl—an opioid up to 50 times more potent than heroin.
Both national and international studies have shown that detoxing without medication is associated with increased risks of mortality. HHS does not recommend going through serious opioid withdrawal without medication such as Suboxone or methadone. The health authorities in Canada—a nation that is facing a similar
public health emergency—go even further and strongly recommend against detoxification without MAT.
“One wonders whether it would actually be safer to continue using drugs,” Arnaout said, “rather than attending programs that do not lower the risk of relapse, but result in lowered tolerance, and thereby an increased risk of overdose.” He hastened to add that he did not advocate abstaining from treatment. “But my point is that people should have access to the treatment that works.”
The official stance of the Healing Place is that recovery is different for everyone, and that, for some, MAT might be the right solution. Yet they are very clear that MAT is not compatible with their methods. “Our program works just fine without Suboxone or methadone,” said Keenan Beckhart. “And if you are willing to change your life and get off of Suboxone or methadone, you are more than welcome to come in here.”
The patients that make it through detox typically start their new lives as residents at the Healing Place. They go to church, take classes on fundamental life skills, and participate in A.A. meetings. More than 40 weekly 12 Step meetings are held at The Healing Place. As you reach the end of the program, you are not only sober—you are also equipped to go out and live a normal life, Beckhart said. “At a Suboxone clinic you learn how to take Suboxone and to stay on Suboxone. The same with methadone,” she added. “We don’t do that here. We teach fundamentals of life.”
The recovery facility is funded mostly by donors and the state of Kentucky. The main contributor in 2016 was Kentucky’s Justice & Public Safety Cabinet, which donated
$500,000. Adam Bisaga, a professor of psychiatry at Columbia University Medical Center, strongly believes that programs withholding effective treatments, intentionally or unintentionally, should not receive public funding: “Public resources, especially when limited, should be steered towards the most effective interventions.”
Alcoholics Anonymous was founded 83 years ago, 330 miles northeast of Louisville, in Akron, Ohio. Prohibition had recently been lifted, and alcohol consumption was on the rise. In 1935, Bill Wilson and Bob Smith, a stockbroker and a surgeon, started A.A., and formulated 12 principles to guide alcoholics to sobriety.
Today, with an estimated two million members, A.A. is deeply ingrained in American culture. In 2012 the Library of Congress designated the founding text—The Big Book—as one of 88 “Books that Shaped America.” The organization is, in many ways, the bedrock of American addiction treatment. In 2016, 73 percent of all treatment facilities used the 12 Step approach.
Over the course of nearly a century, the 12 Steps have helped millions of people quit alcohol, pills, and needles—and given them a place to share and heal. But Clay, a public information coordinator at Alcoholics Anonymous, is fully aware that people receiving MAT do not always have the chance of benefiting from the fellowship. Instead, many feel excluded by their peers. “There are people in A.A. that have an orthodoxy,” Clay acknowledged. “They think that A.A. must be this. So yes. These things are going on. There is no orthodoxy in A.A., but there are people who believe that.” Clay’s comments offer a rare window into an organization that is known for its secrecy. He works at A.A.’s headquarters in New York City, and, as an active member, has asked to be identified only by his first name.
A.A.’s official stance is that it has no opinion, positive or negative, on MAT. But it will not interfere if groups exclude people on Suboxone or methadone: “That’s the one thing we can’t do. Because, we have no authority,” Clay said, referring to the unyielding principle that every A.A. group is self-governed and fully autonomous.
To Bisaga of Columbia University Medical Center, that is not a valid excuse: “It is unacceptable that A.A. does not have a position, because they do not want to adjust to change. They are still functioning the way they did, when they were born in the 1930s,” he said. Bisaga, the author of Overcoming Opioid Addiction, is co-director for the organization PCSS-MAT, which advocates for MAT. “It is unfortunate that they don’t have a clear stance in line with all professional medical organizations, including the WHO,” he added.
A.A.’s founders stated that its methods are meant for alcoholism only. But today the popular 12 Steps are used in treating everything from compulsive gambling to sex addiction, and dozens of organizations have sprung from A.A. In the early 1950s, when people struggling with drugs started knocking on A.A.’s door, Narcotics Anonymous was established. With an estimated 67,000 meetings a week, it is by far the largest of the organizations that follow A.A.’s model.
Clay said that people who mainly have a drug problem ideally should seek help at an organization like Narcotics Anonymous. However, that may not help a recovering opioid addict on MAT. Because, unlike A.A., N.A. does take a stance on MAT. In the eyes of Narcotics Anonymous, people in recovery are not clean before they abstain from all drugs—including Suboxone and methadone. And so N.A. advises its member groups not to let individuals on MAT share at meetings, be speakers or sponsors, or hold any trusted positions within the organization.
This stance was made clear most recently in an official N.A. pamphlet from 2016, drawing from the 1996 Bulletin no. 29“Regarding Methadone and Other Drug Replacement Programs.” In this text, a phrase appears that will sound familiar to David, Michael, and countless other addicts in recovery: “Our program approaches recovery from addiction through abstinence, cautioning against the substitution of one drug for another.”
Arnaout, the professor at Yale School of Medicine, urged Narcotics Anonymous to change its view on MAT and encourage its members to seek treatment: “It would be appropriate if they said: ‘We are here to support you, but you should see someone in the health care system, too.’”
Bob, who works in public relations for Narcotics Anonymous World Services, confirmed that some groups may discourage people from actively participating. “Because that goes against our core tenant of complete abstinence,” he explained. Bob, like Clay, has asked not to have his last name published. A member on medication-assisted treatment is not officially clean, according to N.A.’s definition. “Hopefully it will be a goal for them, and their doctor, not to take medication for the rest of their life,” Bob said.
Bisaga does not agree. For some people, he said, the only way to stay alive is to stay on medication for the rest of their lives: “If we do not accept that, we’ll just continue to have people dying.” Bisaga regards it as a great loss that N.A. does not embrace MAT: “We do really want people to have medication, but we also want people to benefit from the recovery community.”
The loss is especially felt in places like Louisville, where the opioid epidemic runs deep. About the time that David Hockenbury and Michael Dever began experimenting with drugs—when they were angry teens in baggy clothes and Timberland boots, their hair spiked with gel—a big story in the world of health was the under-treatment of pain. Chronic pain, long neglected, was taken up by patient advocates, who demanded better treatment options. Pharmaceutical lobbyists quickly picked up on the trend, pushing for wider prescriptions and the use of more potent opioid-based products. The initiative was embraced by Kentucky’s coal miners and other manual laborers.
The first time the boys experimented with pills was when David’s girlfriend gave them some of her mother’s Xanax. It didn’t take much of an effort to find more. At parties, David and Michael would nose around in cabinets overflowing with Xanax, Valium, Klonopin, and Benzos of all shapes and sizes. They would take out the powder, snort it, and fill the empty pill cases with sugar. Michael and David could not see that they were part of a vast epidemic spreading in their town, their state, and all across the country.
When they both landed themselves in the hospital—20-year-old David after a car crash, 17-year-old Michael with a stomach condition—they were sent home on heavy opioids. First Percocet. Then OxyContin. Every chemical was stronger than the previous one. And when their hospital stashes diminished and cravings kicked in, they turned to the street.
Little by little, news coverage of pain treatment gave way to stories about the millions of Americans who were becoming dependent on opioids. Crackdowns were launched. Prescription opioids became less accessible, and much more expensive. Suddenly 80 mg of OxyContin had a street price of $60.
For David and Michael, rowdiness turned into violence and weapon charges as a drug-filled lifestyle led them into more serious crime. That was also when they began to seek out a cheaper, more efficient option: heroin. Their lives followed a by-now familiar trajectory. There were blackouts and overdoses, visits to the hospital; there was jail time.
The opioid crisis had its origin in the rural heart of America, but is now spreading to the cities. From July 2016 through September 2017, overdoses increased by 30 percent across the country. The Midwest, Appalachia, and New England are losing the most lives to the epidemic. In 2016, Kentucky had the fifth-highest rate of death due to drug overdose.
There still aren’t many support groups beyond A.A., and few places in Louisville provide a sanctuary for people on MAT. Medically Assisted Treatment To Recovery (MATTR) was founded in August of last year as a response to people on MAT feeling excluded from other recovery groups. At a meeting at the boardroom of the Morton Center addiction facility in January, four pale women found seats at the large table. “Before you say congratulations, I just want to say that I’m not pregnant,” one said. “I’m just really, really constipated.” Others restlessly scratched their arms and necks. Numbness, tingling, trouble concentrating—all are common side effects of the Suboxone they take, along with constipation.
The meeting was led by co-founder Andrea Jones, and the group was eager to share. “Hi, I’m Diana. My sobriety day is 12 22 2017,” said a young woman wearing sweatpants and a washed-out Batman t-shirt, absentmindedly scratching the inside of both elbows with blue polished nails. (The names of the MATTR attendees have been changed.) It was her first day on Suboxone, and the decision to start taking it had not been easy. “I was so confused. Because so many people were already judging and telling me not to do the treatment. I didn’t know how to think.”
The medicine was audible in the slow, soft croak of her voice. It usually takes a few days for the body to adjust. But today, for the first time in a long while, she had not thought about running off and doing drugs, she told the group. “I want to be open about it,” she said. “And this is like one of the only places I can be open about it.”
Next, Jessica, a petite woman with a bun of brown curls and large golden earrings, shared her story. An addiction to heroin and methamphetamine had brought her here. “I went from smoking weed a little bit every day to being five months pregnant with my second daughter, shooting up in a gas station bathroom, begging God to just let me die.” She stopped and took a deep shuddering breath. “MAT saved my life.”
The others nodded in sympathy and thanked her for sharing. Samantha, the young woman with the swollen belly, took over. She was pretty, but the sickly pallor of her skin and her expressionless face made her resemble a mugshot. In a slow Southern drawl, she told the group that her boyfriend broke up with her when he found out she was on Suboxone. “He said that I’m just getting on MAT to get legal, cheap high.”
Some 12 Step meetings openly prohibit the use of MAT. But more often, these women were shamed out of meetings by other participants. They were told that their all-important sobriety date was false and that they were not truly sober. Jessica was even kicked out from a meeting when the other participants learned that she was on Suboxone. “People are just uneducated about it. For one, it’s not a high. If anything, I’m exhausted,” she said, sinking back in the large office chair. “But it slows my brain down enough to let me do what I need to do that day.” Her voice thickened and tears welled in her eyes.
Diana’s voice rose: “I shouldn’t have to worry about this. I’ve literally drawn myself into an anxiety attack because I don’t know how the world will react to this.” They had all had close friends, even family, question their medicine. “I may be on something to maintain me,” Diana added. “But I’m not gonna abuse it. There’s a difference between abstinence and sobriety. You’re doing something to recover. That counts.”
She delivered the last statement with defiance, as if trying to convince someone.
When N.A. member Amber suggests to people on MAT that they get off of their medicine, she does so politely. She has talked to people like the women from MATTR, and advised them against maintenance drugs: “I would encourage you to get off of Suboxone,” she said, reminding them that it can be bought off the streets and used to get high. Amber, who has also asked to be identified by her first name, had tried Suboxone herself, but said she felt that her doctors pressured her into taking it. They would tell her that if she just took this medication, she would not need to get high anymore. To Amber, however, it felt like “substituting one drug for another,” as she said. Today, she is one of many N.A. and A.A. members who have a clear stance on MAT: “You don’t need to be on Suboxone.”
But to many addicts on MAT, like David and Michael, this approach feels like cruel and needless banishment. With the help of methadone, Michael has been sober since last summer. David, after years of relapses and recovery, recently chose to quit A.A. and find a support group open to everyone—including people on MAT. Today, he has been sober for over a year. Still, last fall he decided to wean off medication again. Prescriptions and visits to the doctor cost him almost the same as rent. But that was not the only reason. The negative opinions toward MAT among his peers in A.A. continued to bother him: “Coming from this absolutist black-and-white recovery community, where you had to be totally abstinent and off of everything, I still had pressure in my own mind to get off MAT.”
The hunt for complete abstinence still haunts many of the people they know—or have known. “If five years ago there was no stigma attached to MAT and if it was accessible and affordable, I think a lot of our friends would probably still be alive,” Michael said in January in a Starbucks on the outskirts of Louisville.
“How many people have died that we were friends with?” he asked David, who was calmly sipping a bottle of orange juice.