We need a bigger recovery “tent”: It’s time to think beyond 12-step programs

Though being fifteen years into rock-solid recovery from opioid addiction, I have intimately experienced a wide variety of treatment modalities, many mandated at the time by the medical board and the courts. Through the treatment I’ve provided as a doctor to thousands of patients suffering from addiction – from the super-rich, to other doctors to the homeless, for all sorts of addictions — I feel certain that there needs to be a Copernican revolution around how we view recovery.

Two of the main components of a healthy and successful recovery program are medications that can greatly assist treatment (e.g., methadone, Suboxone, and, increasingly, psychedelics and cannabis) and peer support. Arguably, these are the two magic ingredients. Unfortunately, due to the ideological vice grip that the at-times cult-like Alcoholics Anonymous (A.A.) has had on the recovery world since it burst onto the scene in 1937, these two critical components are on a collision course with each other.

Time to enter a more modern age

It is worth noting that A.A. was established and took root in 1937, before we had modern medicine, current study designs, neuroimaging, plausible theories of addiction or any medications to help addiction. At A.A. meetings, hundreds of which I’ve been forced to attend, one has very little sense that anything from the modern world has seeped in since 1937, except for more contemporary brands of cigarettes and coffee – the “good drugs.” How is it that this old-fashioned, non-science based, and very religion-y ideology has cornered the market of our modern, medical recovery paradigm almost a century later?

The “twelve step” groups and programs are unquestioningly very helpful to a self-selecting group of people. I’ve had friends solidly recover through A.A. Yet, we need to challenge the ‘abstinence only’ model that A.A. has imposed on tens of millions of us in the recovery community. There are several issues here, such as the Puritanical idea is that if you’ve ever used one intoxicating or potentially enjoyable drug, you can’t ever use a different one for the rest of your life — “One is too many, 1000 is never enough.” If an unhappy youth was addicted to cocaine at age twenty, according to doctrine, he or she can’t safely enjoy a glass of wine with dinner in his or her 50’s. There is no evidence for to support such a draconian rule.

More concerning, according to a hardcore but hardly uncommon interpretation of the 12-step ideology:  you aren’t really in recovery if you are on Suboxone or methadone, or other potentially pleasurable or abusable drug (e.g., valium for anxiety), even if they are prescribed by a doctor and are being used solely to help with your addiction or your mental health.

Medications work

Thousands if not millions have used cannabis to transition off of opioids, alcohol and other deadly drugs, or to minimize their dangerous usage. 

Medications such as Suboxone (buprenorphine) and methadone offer a 50 to 80 percent reduction in overdosages and deaths. These are a critical treatment that need to be made more widely accessible, without stigma or barriers. At my hospital, Massachusetts General, we view the use of these medications, for the disease of addiction, as analogous to the use of insulin for diabetes. No one says, “You aren’t really in recovery from diabetes because you are cheating by taking insulin.” Yet stories abound of people, early in recovery, hanging on by a thread, being shamed at A.A. and N.A. meetings due to their usage of these medications.

Recently, there has been an explosion of interest in, and studies demonstrating, the helpfulness of psychedelics such as psilocybin mushrooms and LSD, to treat a wide variety of addictions, including two of the deadliest: opioids and alcohol. Ironically, the founder of A.A., Bill Wilson, used LSD to facilitate his recovery from alcoholism. He believed it could help with the “spiritual awakening” so critical to recovery.  Yet he still somehow managed to come up with a rigid abstinence-only paradigm.

What about cannabis?

Most Americans have woken up to the fact that they’ve been sold a bill of goods about cannabis and stand behind legalization. Cannabis certainly has its potential harms, especially for teens and pregnant/breastfeeding women, but, for countless other patients, it can be a relatively non-toxic remedy for a wide variety of symptoms and maladies. Thousands if not millions have used cannabis to transition off of opioids, alcohol and other deadly drugs, or to minimize their dangerous usage. I have had great success with this in my practice and this is what harm reduction is all about. In my own struggle with opioid addiction, cannabis was indescribably more helpful than anything else was in alleviating the soul-crushing withdrawal effects from abrupt opioid cessation.

While cannabis can be addictive, it is less addictive than alcohol and opioids, and the quality of the addiction usually tends to be less life-destroying. No one is robbing pharmacies. We are learning more, every day, that the “gateway hypothesis”, which claims that cannabis use leads to other drug use — a foundational talking point of the War on Drugs – has no evidence to support it. For many, cannabis has proven to be a ‘gateway’ off of alcohol, opioids and other drugs, rather than a gateway onto addition. Many people are choosing to be “Cali Sober” – meaning, no drugs except cannabis, and they seem to be doing quite well, though this needs further study.

(Disclaimer: In my practice, I treat active opioid addiction with Suboxone not with cannabis, as there is a far better evidence base for this practice).

We need a bigger recovery tent

If the hardcore denizens of A.A. dismiss methadone and Suboxone – both FDA approved meds — one can only imagine how they many of them may view psychedelics and cannabis. However, times change, and we need to break with the old ideologies when they stop helping many of us. We need to provide a ‘big tent’ for people limping into recovery, so that they feel welcomed. We need to provide a tent that freely includes methadone, suboxone, cannabis and psychedelics.


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It is cruel and dangerous to stigmatize and shame people – many of whom are barely holding it together in early recovery. Further, there is no evidence for the morally stark, abstinence-based mode of recovery. The one credible study I’ve seen, published in JAMA in 2014, showed that “As compared with those who do not recover from a Substance Use Disorder (SUD), people who recover have less than half the risk of developing a new SUD. Contrary to clinical lore, achieving remission does not typically lead to drug substitution, but rather is associated with a lower risk of new SUD onset.”  The hard work of getting yourself into recovery teaches you the tools and coping mechanisms to keep you healthy and safe.

We need a bigger recovery tent, one that incorporates the last century or so of both lived experience and scientific discovery. Clinicians and scientists need to meet people where they are. So does the recovery community. Rather than shunning people, let us embrace them. Getting into recovery from my opioid addiction was the most difficult thing I’ve ever done. The stakes truly are life and death. Let’s welcome all of my brothers and sisters in recovery — from all backgrounds, with different philosophies and definitions of recovery — into our shared goal of a healthy way of being in the world, together, free of the death grip which our respective “drugs of choice” formerly had on us.

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