The Grey Area: Medication-Assisted Treatment and Recovery

In the face of this opioid epidemic, I’ve been thinking a lot about harm reduction, and in particular the use of medications like Suboxone (buprenorphine) to assist with addiction. In the years I’ve been in recovery, I’ve witnessed a significant amount of tension around the issue of medication-assisted treatment. My own thinking around this subject began in 2009 when a clinic providing Suboxone opened on Main Street in the small city where I lived. Suboxone was not a new drug at this point, but the presence of people using Suboxone became more common, and tensions arose. The community I was a part of was rather traditional in its assumptions and approach toward recovery. Essentially, recovery meant total abstinence from mind-altering substances. With the presence of another option, the community was forced to confront the definition of what it meant to be “clean” or “sober” or “in recovery”. The folks taking this other route challenged this clear-cut definition by staking a claim on the same language to talk about their experience. And rather quickly, a large grey area emerged.        

What I witnessed was a strong reaction to that grey area. People in recovery, like humans in general, don’t do well with ambiguity. We like clarity, we like when things are well defined, and when they aren’t, we have slippery-slope minds that take us directly to worst-case scenarios. The response I saw to the emergence of medication-assisted treatment in my community was threaded with a lot of fear. Would medication replace or render obsolete the 12-step model so many of us held dear? Would our status as people in recovery lose its meaning? How will we find common ground? I too had to confront questions like these, so I don’t mean to diminish this kind of concern. I think these questions are important for us to ask. But I think we need to ask them with open hearts and without fear coloring the answers at which we arrive.

I’d be lying if I said there is no grey area for me with regard to the issue of harm reduction and medication-assisted treatment. I can say confidently that I am a proponent of anything that helps people live healthier lives. I think people should have access to clean needles and safe places to use if they can’t stop at the time being. I think Narcan should be available over the counter and present in all places where folks get high. I think taking Suboxone is leagues better than injecting heroin. The place where I run into tension, however, is that I believe all people, no matter how bad it got, can reach a place where there is no need to reduce harm because there is no harm being done. I believe we can get so free of addiction that things like Suboxone are no longer necessary. This, at least for me, is ultimate goal of recovery.

At this point, you might be thinking, “well, duh. The whole point of harm reduction is to get people to that place where they are capable of living without substances.” And my response is, “yes, that’s what harm reduction would look like at its most effective. But what does it look like on the ground?” I can only speak to my own experience, but what I have heard about in theory does not always align with reality. My sense is that we have some work to do before we can say that medication-assisted treatment is effective in getting people to a place where harm reduction is no longer necessary. I think we can do a better job of helping people move from harm reduction to harm negation, if this is what the person desires.

My main challenge with the idea of recovery through medication is that it has the potential to encourage patterns of behavior and ways of thinking that actually interrupt the process toward harm negation. I say it “has the potential” because I don’t think this is always the case, it may not even be the most common situation, but it has been absolutely true in my experience of walking alongside people taking this particular path. Personally, I have not seen much success, meaning I have not seen people successfully move from medication-assisted treatment to abstinence.

When I say “patterns of behavior” and “ways of thinking”, I am attempting to drive right to the root of addiction, as I understand it. Here it is important to acknowledge my own assumptions and definitions of addiction and recovery. In many of the pieces I’ve written, I’ve spoken about my belief that addiction is the result of our attempt to seize control over the way we feel and shape the way we perceive the world and our place in it. If what is real is too painful, and drugs provide a way to feel control and cope with that reality, then you are dealing with addiction in the way I am trying to define it. All kinds of physical and emotional suffering arise from addiction, but this suffering stems from the root, and I believe if we are going to combat our addictions, we can’t just clip the branches; we need to go deeper. 

The thinking behind medication-assisted treatment is that it provides enough space from drugs and alcohol to begin getting to the root causes, which eventually allows an individual to live without medication. I am totally on board with this idea. My sense, however, is that medication-assisted treatment is often mistaken as the solution to the problem. If my thinking around addiction is at all in line with reality, the solution to addiction rests in finding new ways confronting and coping with our challenges. From this perspective, no matter how I look at it, replacing our narcotics with safer forms of narcotics does not encourage this work. Getting our drugs from doctors may be safer than getting them from the corner, but we are still seeking drugs. Taking a pill is far better than injecting dangerous drugs, but we still dealing with reliance on drugs. Moving away from the illicit drug trade is good, but we are still in possession of a substance with street value, and still in contact with our old connections. Again, all of these things may be steps in the right direction, but we are still behaving and thinking the same way, and we can't settle on this as a destination. We need to go further than this, and I'm not sure the doctors prescribing the medication are going to take us there. 

I have a suspicion that at least part of the appeal of medication-assisted treatment is that it provides a middle ground between active use and total abstinence. It is a way to have our cake and eat it, too. I think we can all understand this appeal, but the problem is that it’s not a long term solution, and doctors aren't making this clear. If we want to get free of addiction, we will eventually have to go through the work of changing our behaviors and thinking, and medication becomes a problem when it allows us avoid that work. And this is exactly the place where we can have an impact in the lives of individuals who do choose medication-assisted treatment and do honestly want to reach a place where they no longer need it.

As I consider this opioid epidemic and how to combat it in my community, I am left wondering whether treatments like Suboxone might be more effective if we were more willing to meet people where they are on their paths. I wonder if getting over our fear of the grey area medication creates might be the first step in helping those who want to move from harm reduction to harm negation. Science is going to continue illuminating more and more about addiction, drug makers are going to continue creating new drugs and pushing them in our direction, and people are going to continue developing new paths toward recovery. We can confront these facts by crossing our arms and pretending like we have all of the answers, as if our chosen path is the only path, or we can be open to the unfamiliar and try to be helpful.

If we greeted people who are on the path of medication-assisted treatment with more kindness, open-mindedness, and support, we may be able to help make harm negation a possibility for them. If instead of splitting hairs over what it means to be in recovery, we became more committed to showing them how we live day to day without the need for substances, that space provided by medication may be enough to get people to the real work of changing the ways they think and behave. Medication-assisted treatment isn't going anywhere, so we face a choice. We can continue closing people out, or we can say, "I honor your path, and I want you to know that there is more." No matter which way we go, I know one thing for sure: if we are unwilling to meet people where they are, we are going to end up doing more harm than good.