It’s time to abandon the assumption that total abstinence is essential if you’ve been addicted to a drug
They repeat the words in chorus during almost every Narcotics Anonymous (NA) meeting I’ve attended: “A drug is a drug is a drug.” It means that if you’ve used one drug, experienced problems with it and quit, you can’t use any other drug without problems.
But is this true? It’s one of those comforting mantras that’s rarely challenged in some circles. But there’s a kernel of danger contained within those words, waiting to unleash itself on people most at risk.
Marijuana or alcohol or heroin, for example, produce quite different effects in our brains. Their use fulfills different purposes for people, many of whom might have trouble finding physical or mental health care otherwise (although most people can use drugs or alcohol without major problems). We have tools to help determine where we fall on that spectrum.
The concept of “a drug is a drug…” borders on pseudoscience, with little evidence to support it. In fact, preliminary research indicates these ideas might actually cause more harm for people who have experienced substance use disorders (SUDs).
Denial of Vital Medications
NA promotes a position targeted directly at people on medication-assisted treatment (MAT) with methadone orbuprenorphine (Suboxone). “Bulletin 29” suggests that MAT patients aren’t really in recovery; they’re simply replacing one addictive drug with another. And while NA encourages MAT patients to attend meetings, they discourage us from opening our mouths—perhaps because MAT allows many people to reclaim control of their lives without working NA’s program?
Even people in treatment or “long-term recovery” (a term which carries significant baggage) show a remarkable ability to control their medication intake. Many methadone patients are able to work their way up to earning take-home privileges, which requires a tremendous amount of self-control and abstinence from street drugs.
Unfortunately, patients who test positive even for THC can be denied those privileges.
Dr. Merrill Norton of the University of Georgia’s School of Pharmacy explained at a 2015 conference that many MAT patients use cannabis to treat chronic pain which can’t be treated effectively by other means during methadone or buprenorphine treatment. This suggests that many MAT patients could benefit from medical use of cannabis. He also cites long-term treatment retention rates of 59 percent and 50 percent for methadone and buprenorphine, respectively. This far outperforms the 5-10 percent success rates demonstrated by 12-step programs.
Chronic pain patients, even those with a history of problematic substance use, shouldn’t be denied medications that can improve their health because of misinformation. Addiction shouldn’t be confused with physical dependence. Most people who use opioids for more than a few weeks will likely develop physical dependence, but most don’t develop problems or become addicted.
Pseudoscience as Social Control
It’s important to note at this point that distinctions between “medical” and “street” drugs are largely arbitrary.
Many of the drugs which are presently illegal to possess in the United States have pharmaceutical-grade counterparts, which are legal with a prescription. Examples of such drug “pairs” include heroin and OxyContin, or methamphetamine and Adderall. This arbitrary distinction suggests an element of social control by government agencies and the pharmaceutical and treatment industries—those who determine which drugs are medicines and which have “no medical value,” and those who profit from such decisions.
Many of the very worst harms related to drugs—arrests, incarceration, stigma, unsafe using practices, lack of quality control and dosing information—are caused by the prohibition of certain drugs, rather than the drugs themselves.
Switching From Riskier to Less Risky Drugs
In some cases, substance users will replace a more potentially dangerous drug, like heroin, with a less dangerous one, like marijuana. They’re both illegal in most states, but many people who have previously experienced problems with heroin find that marijuana gives them a sense of ease that “fills some of the holes” opioids did.
The risk profile for cannabis is certainly lower than that of heroin. The risk profile of alcohol, when you take into account the additional harms inflicted on heroin users by the prohibition of that drug, is arguably lower, too. This is a harm reduction approach to substance use and, for many people, it’s incredibly successful.
Even though all drugs, legal or illegal, carry some potential risks, the person’s quality of life should be used as a primary factor for their definition of “recovery.”
Micha*, developed problems with opioid pain pills which had a major impact on her health. She’s since found less potentially harmful ways to cope: “I drink nearly every day. most days that consists of one beer, but one-to-three times a week I’ll get pretty drunk. I feel like it’s a social thing for me. And the single beer will be more of a de-stressor when getting off of work or winding down after a long day.”
She sometimes takes kratom, an opioid-like plant in the coffee family. “Sometimes I want to stop taking it but most of the time I don’t find that it’s an issue.” Her main concern is that the long-term effects of kratom use aren’t well-known, although it’s considered less potentially addictive than other opioids. I used kratom to taper off methadone, but after jumping off, I quickly returned to heroin, which led me to buprenorphine, which has helped my opioid use disorder and mental health issues.
Kenneth Anderson, Influence contributor and executive director at Harm Reduction for Alcohol (HAMS) explains: “It is very common for people to quit one problematic substance, such as heroin, and moderate another substance such as alcohol, particularly if they have never had a problem with alcohol in the first place. We see people doing this in our HAMS group all the time. Although there are some people who switch from an opioid addiction to an alcohol addiction, this strikes me as the exception rather than the rule.”
“We don’t actually know [how common “cross addiction” is] because studies of people quitting one substance and moderating another are non-existent,” he continues. “However, research does prove that people who quit an addiction are less likely to start a new addiction than those who do not quit their first addiction.”
Continuing to Use the Same Drug, With Fewer or No Problems
Harm reduction approaches to problematic drug use don’t just involve switching to less risky drugs, however. Many HAMS participants who have used alcohol problematically move on to drinking with fewer or no problems. And the concept holds true for so-called “hard” drugs.
Carolyn, a key player in her regional harm reduction movement, was able to moderate her use of heroin after previously developing problems with heroin and crack.
“I feel that everything I was taught about drugs has been wrong,” she says. “Last year, when I used heroin multiple times over the course of a year, nothing awful happened. I didn’t fall into a full-blown relapse, I didn’t crave, I learned from it and moved on with my life without having to go sit in 12-step meetings and repent—or even inform most people in my life.”
“I’m lucky that I have a treatment team that supports my decisions regardless,” Carolyn continues. “They may check my use, if I’m being honest about something and expressing my own concern about what I‘m doing, but they don’t just immediately assume that all substance use is harmful. They agree that there are times where substance use may be the healthiest option for me.”
Programs like NA attempt to scare people with SUDs with language. One example from the literature:
“We lived to use and used to live. Very simply, an addict is a man or woman whose life is controlled by drugs. We are people in the grip of a continuing and progressive illness whose ends are always the same: jails, institutions and death.”
But this just isn’t the case for everyone. Consider that about half of people who use drugs of any kind problematically will “mature out” of it by the age of 35, mostly without formal help or treatment. Do you suppose that more than a small minority of them are then abstinent from all drugs—legal and illegal, prescribed and non-prescribed—for the rest of their lives? Of course not.
Many reduce and moderate their use, many switch to different substances, prescribed or not prescribed, and many use these drugs without experiencing further problems.
Further Examples of How Abstinence-Only Narratives Cause Harm
The “drug is a drug…” position is one of the pillars on which abstinence-only models are built. But these programs show limited success, whereas MAT demonstrates measureable improvements in almost every area of quality of life. We might even view switching from problematic substance use to moderated, less harmful substances as a form of self-medication, one which fills gaps the medical and treatment communities fail to provide.
Abstinence-only thinking becomes dangerous when people buy into ideas which allow them to rationalize a return to harmful use. They’ve been taught that all drugs are bad, which can become a self-fulfilling prophesy. Research has shownbelief in the disease model of alcoholism to predict the likelihood of a return to problematic drinking, for example.
Doctors are frequently scared to prescribe pain to patients with legitimate needs, and are especially wary of prescribing controlled substances (opioids, benzodiazepines, ADD/ADHD meds) to patients with a history of problematic use of anysubstance.
This has devastating effects and—in the absence of evidence that prescribing these medications will result in a relapse to harmful use—can cause long-term health consequences. It leaves those who are hurting, suffering mentally and physically, with no means of relief. These are our most at-risk people. Denying them medications can drive them to underground markets, which are unregulated and carry far greater potential for harmful effects, including incarceration or overdose.
“I have always felt that the most damaging parts of my drug use were not the drugs themselves,” Carolyn says. “It was the legal consequences. The stigma of being a user and feeling worthless and hopeless as a result. It was that my family was taught to hate and fear me by society and addiction treatment programs.”
Read more from The Influence:
Some 12-step programs like Alcoholics Anonymous (AA) hold positions that some “non-addictive” medications, like psychiatric medications, are safe. But by their own admission, AA’s literature admits this doesn’t prevent members or sponsors in autonomous AA groups from pushing the potentially devastating advice that all medications are harmful.
Even years after I stepped away from 12-step programs, I still retain the thinking that I need to be on as few medications as possible. I’m cautious which medications I take, even though I know I require them to function. This has caused harm to my long-term mental health and productivity.
Sammi, now 21, was prescribed benzos at age 12 for childhood bipolar disorder. This led to developed physical dependence, but not problematic use. Sammi later had problems with other substances.
“During high school I developed a problem with opioid pain medications and sleeping pills,” Sammi explains. “Later I developed a problem with crack cocaine. I was able to stop using crack by self-medicating with opioids and support from a network of friends who are willing to meet me where I’m at. Now I’m able to moderate my opioid use—which feels more like medicine which makes me feel normal than recreational use.”
Sammi still misused sleeping pills to cope with psychosis until it was possible to find adequate mental health treatment. “I’m now diagnosed with schizophrenia, bipolar, and dissociative identity disorder. Occasional opioid use and self-harm still help me cope with symptoms when they become unmanageable, but I don’t consider those nearly as harmful as my previous problematic drug use or behaviors. In some ways I find they actually improve my health and coping during extreme depression and chronic pain episodes.”
Transcending Traditional Recovery Narratives
As we have seen, plenty of available data and ample anecdotal evidence contradict abstinence-only positions. There’s actually little evidence to support the abstinence-only narrative and some to suggest that switching to less harmful drugs can improve quality of life.
There are some people who can’t go back to their preferred substance in moderation. I certainly can’t with opioids. Sometimes I feel like minor alcohol use (usually one or two beers a few times a week) helps keep more problematic use in check. More than five years after I quit using heroin every day and switched to MAT, drinking has never caused me to relapse. I never drink too much or want to use opioids after drinking.
Ultimately, the terms of a person’s “recovery” should be set by them, with medical or therapeutic advice as they deem necessary. Pseudoscience and outdated mantras do nothing to encourage healthier lifestyles.
Abstinence from certain drugs is an absolutely legitimate personal choice, and one that should be respected. But abstinence should never be imposed on others. For many people, using a harm reduction approach that includes less problematic substance use can improve health and quality of life.