September 30, 2021 at 12:13AMMaia Szalavitz
When I kicked cocaine and heroin in 1988, I was told that there was only one way to get better: abstain forever from psychoactive substances including alcohol—and practice the 12 steps made famous by Alcoholics Anonymous. The only alternative, counselors and group members said, was “jails, institutions or death.”
My addiction was so extreme that by the end, I was injecting dozens of times a day. So I grabbed the lifeline I was thrown and attended the traditional 12-step rehab program recommended by the hospital where I underwent withdrawal.
But once I began to study the scientific data on addiction, I learned that these claims were not accurate. In fact, research shows that most people who meet full diagnostic criteria for having an addiction to alcohol or other drugs recover without any treatment or self-help groups—and many do so not by quitting entirely, but by moderating their use so that it no longer interferes with their productivity or relationships.
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There is no “one true way” to end addiction—and the idea that “one size fits all” can be harmful and even deadly in some cases. Until we recognize this and celebrate the variety of recovery experiences, September’s National Recovery Month and similar efforts to promote healing will fail to reach millions of people who could benefit. During an overdose crisis that killed more than 90,000 people in 2020 alone, a better understanding of how people really do overcome addiction is essential.
Unfortunately, rehab hasn’t improved much since I attended in the late 20th century. At least two-thirds of American addiction treatment programs still focus on teaching the 12 steps and promoting lifelong abstinence and meeting attendance as the only way to recover. (The steps themselves include admitting powerlessness over the problem, finding a higher power, making amends for wrongs done, trying to improve “character defects” and prayer—a moral program unlike anything else in medicine.)
Moreover, despite the fact that the only treatment that is proven to cut the death rate from opioid addiction by 50% or more is long-term use of either methadone or buprenorphine, only about one-third of residential programs even permit these effective medicines, and around half of outpatient facilities use them, typically short-term.
Worse: when they do allow medication, most treatment centers also push people with opioid use disorder to attend the 12-step program, Narcotics Anonymous. That creates what can be deadly pressure to stop the meds. The group’s official literature says that people on methadone or buprenorphine are not “clean” and have only substituted one addiction for another.
I have been contacted by more than one family who lost a loved one to overdose because their relative had rejected or prematurely ended medication based on this view. If we don’t start to view recovery more inclusively, we are denying hope and healing to those who benefit from approaches other than the steps.
So, what does a more accurate and expansive view of recovery look like? To me, one of the most helpful definitions was devised by a group known as the Chicago Recovery Alliance (CRA), which founded the Windy City’s first needle exchange. CRA was also the first organization in the world to widely distribute the overdose reversal drug naloxone—and train drug users to save each other’s lives by using it. Naloxone (also known as Narcan) is a pure antidote to opioids: it restores the drive to breathe in overdose victims but must be given rapidly to be effective. (If used in error, it is safe: it won’t hurt people with other medical problems and typically works even if opioids have been combined with other drugs.)
CRA’s approach is called harm reduction, and it defines recovery as making “any positive change.” This means that anything from starting to use clean needles to becoming completely abstinent counts. From this perspective, if someone quits smoking crack, gets a job and reconciles with her family, she counts as being in recovery—even if she stills smokes marijuana daily.
Or, if someone goes from drinking a bottle of Scotch a day to having a daily glass of wine—or from drinking daily to binging only on weekends—these too are positive changes, not just “active addiction.” Here, recovery is a process, not an event. It’s difficult to learn any new skill without trial and error, and this includes developing coping skills to manage or end drug use. For most people, even with behaviors short of addiction, big changes take time.
This broad definition obviously includes people who take addiction medications. Doing so is a positive change because it dramatically reduces the risk of death, even for those who continue to take other substances.
Moreover, those who do quit nonmedical use and stabilize on an appropriate dose of these meds can drive, connect with others and work as well as anyone else. They are not intoxicated or numb—just like people taking other psychiatric drugs as prescribed.
While patients on methadone or buprenorphine remain physically dependent on medication to avoid withdrawal, they no longer meet criteria for addiction. According to psychiatry’s diagnostic manual and the National Institute on Drug Abuse, addiction must include compulsive behavior despite negative outcomes—it’s not simply needing something to function.
Of course, for people steeped in traditional abstinence-oriented recovery, CRA’s “any positive change” definition can be challenging. In the 12-step world, members who have maintained continuous abstinence for many years are revered—the longer their time away from alcohol and other drugs, the higher their status tends to be. The lure of such social acclaim helps some avoid relapse. Granting the status of “recovering” to those who have not quit entirely seems unfair from this perspective.
However, it could save lives. In 12-step programs, people who break continuous abstinence—even for just one day after 20 years—are seen as returning to square one, and their “sober time” and its associated status is completely erased. Research shows that having such a binary view of recovery can actually make relapses more dangerous. That’s because people figure that, since they’ve blown it already, their small slip might as well be a massive spree.
Since most people do relapse at least once, moving away from the idea that only continuous abstinence matters—not quality of life, not the ability to maintain relationships and contribute to society—would likely be healthier for everyone.
But there’s another way to reconcile conflicting views of recovery, which preserves traditional ideas for those who prefer them. That is, simply define it for yourself and let others do likewise. If you’ve heard someone identify themselves by saying, “I’m a person in long-term recovery and for me, that means abstinence,” you’ve seen this idea in practice.
My own perspective has changed over time. From 1988 through 2001, I was continuously abstinent from drugs other than caffeine, including alcohol. Since then, I have used alcohol and cannabis responsibly, without difficulty. However, I have no illusions that I could moderate either cocaine or heroin use—so I continue to avoid these drugs and count myself among the recovering.
Now, though, I suspect that my recovery probably started before my abstinence—when I was taught to use bleach to clean my needles in 1986 and began to fight to get HIV prevention information and equipment to other injectors. That positive change likely helped prepare me for further transformation, including seeking rehab. It almost certainly helped me avoid AIDS.
What really matters is not whether someone recovers via medication or moderation or 12-step programs or anything else. It’s that, like me, most people do get better. And even more of us can if we recognize and support many roads to recovery.
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