Meetings & Medication? Combining Narcotics Anonymous Attendance with Buprenorphine Treatment

While medication assisted treatment (i.e., buprenorphine, methadone) is an accepted & effective treatment for opioid use disorder, there is still some argument against its use among people who support a total abstinence model of recovery.

12-Step programs, such as Narcotics Anonymous (NA), which follow a philosophy of complete abstinence, do not prevent attendance by people on medications, though they may limit participation in meetings by these members.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

12-Step programs, such as Narcotics Anonymous (NA), which follow a philosophy of complete abstinence, do not prevent attendance by people on medications, though they may limit participation in meetings by these members. For example, some Narcotics Anonymous (NA) groups may encourage members on medications to not speak during meetings and participate solely through listening (see here).

Since active participation in meetings can improve outcomes over attendance alone (see here), people taking buprenorphine or methadone may miss out on some of the benefits conferred by participating in meetings. It is unknown however, if the conflicting philosophies of Narcotics Anonymous (NA) and medication assisted treatments may result in negative effects such as stigmatization, discrimination, or encouragement to discontinue their medications against medical advice.

HOW WAS THIS STUDY CONDUCTED?

This analysis included 300 opioid-dependent African Americans beginning buprenorphine at one of two outpatient programs.

READ MORE ON STUDY METHODS

Both of these programs originally followed abstinence-based treatment models but adopted buprenorphine treatment as part of a city-wide initiative to expand services before this study began.

Both programs encouraged NA (or other 12-step meeting) attendance while some participants were required to attend an on-site meeting by their counselor. Abstinence from opioids and cocaine was defined as zero days of self-reported use in the past 30 days and a negative urine test for the specified drugs, while treatment retention was self-reported.

For the qualitative portion of the study, 20 patients (10 from each of the two outpatient programs from which study participants were recruited) were interviewed 3 months after beginning treatment. Interviews asked about patients’ attitudes and knowledge about buprenorphine and treatment expectations.

WHAT DID THIS STUDY FIND?

In the 6 months after BMT initiation, 86% of participants reported attending more than 5 NA meetings. Over three quarters reported that their counselor required them to attend meetings. Of the 209 participants who attended meetings while in BMT, only one third disclosed their BMT status to members. Among those who disclosed their status (n = 68), one quarter reported that someone at a meeting encouraged them to decrease their dose or stop taking buprenorphine all together.

The average number of meetings attended by 6-month follow-up was significantly higher among participants who remained enrolled in buprenorphine treatment (72 versus 37 meetings, respectively). Meeting attendance was also higher among participants who were abstinent from opiates/cocaine at 6 months. The rates of buprenorphine treatment retention and past 30 day abstinence at 6 months were 63% and 33%, respectively.

The number of NA meetings attended was significantly associated with remaining in buprenorphine treatment and with abstinence, even when controlling for variables that might account for both attendance and retention/abstinence (e.g., older age). Specifically, each additional NA meeting attended was associated with a 2% increase in the odds of treatment retention and a 1% increase in the odds of abstinence at 6 months. Being required to attend meetings by a counselor was not associated with retention or abstinence.

Main themes emerging from the qualitative portion of the study were:

Engagement of buprenorphine patients with the 12-step community may be impacted by 12-step members viewing medications as a “crutch” and an inability to be “clean” while still using such medications
Negative reactions to burenorphine use may discourage patients from returning to meetings and may motivate individuals to discontinue buprenorphine after a period of time (e.g., 6 months).
Making the distinction between buprenorpine that is taken as prescribed and buprenorphine that is obtained illegally, understanding the clinical benefit of this medication, and finding meetings with other buprenorphine patients may help BMT patients ignore/avoid negative comments and continue to engage in meetings

This very timely study found that NA meeting attendance did not have a negative impact on buprenorphine treatment retention and was also associated with increased likelihood of abstinence at follow-up.

Despite the conflicting viewpoints on medication use between 12-step groups and buprenorphine programs—which was reiterated by participants in the qualitative study—there appears to be a benefit in attending meetings among patients also engaged with medications.

As noted above, each additional Narcotics Anonymous (NA) meeting attended per week was associated significantly with a 2% increase in the odds of treatment retention and a 1% increase in the odds of abstinence at 6 months. Negative attitudes toward buprenorphine may begin to shift as medication-assisted treatment becomes more widely accepted as an evidence-based treatment for people seeking recovery.

Counselors may play a role in helping patients in buprenorphine treatment maintain engagement in 12-step groups, but this has not been examined empirically. Understanding counselors’ attitudes toward simultaneous use of BMT and 12-step groups is thus important as well.

WHY IS THIS STUDY IMPORTANT

While their philosophies at first glance may appear to be incompatible, NA and buprenorphine treatment are a viable option for many.

This study by Monico and colleagues explores this issue among African Americans with opioid use disorder in Baltimore, Maryland. As a community greatly influenced by the 12-step philosophy and with recent expansion of buprenorphine treatment for low-income residents, Baltimore serves as an ideal location to examine whether the combination of both approaches is possible and even helpful.

Referring patients in buprenorphine treatment to attend Narcotics Anonymous (NA) or other 12-step meetings DOES NOT have a detrimental impact on treatment outcomes. While requiring attendance did not improve abstinence or buprenorphine treatment retention results, patients may benefit from this free and widely available community recovery support resource.

LIMITATIONS

Although the researchers attempted to control for factors that might explain the relationships between Narcotics Anonymous (NA) meeting attendance and better outcomes, the results are correlational (i.e., it is not known if NA meeting attendance actually caused people to stay in buprenorphine treatment and remain abstinence).
There may be concerns regarding generalizability of results given that the sample consisted solely of African Americans in Baltimore receiving free treatment.
Additionally, the study only measured meeting attendance rather than active involvement, which may provide higher quality information on the benefit of NA attendance.

BOTTOM LINE

For individuals & families seeking recovery: Since 12-step meetings are freely available, attending may help increase chances of abstinence and remission. It may be an option to consider as a companion to their medical treatment.
For scientists: More research is needed to understand how disclosing buprenorphine treatment status at a 12-step meeting that discourages medication use may impact meeting attendance, active involvement, and ultimately, substance use outcomes, and what clinical measures might be useful to help patients make the best use of freely available recovery support organizations like Narcotics Anonymous (NA).
For policy makers: Attendance at 12-step meetings does not appear to impede buprenorphine treatment, and along with this medication, may actually enhance outcomes. Given that buprenorphine treatment and 12-step mutual-help groups are two evidence informed approaches to addressing the opioid epidemic, more funding is needed for research studies that examine these approaches in combination.
For treatment professionals and treatment systems: Consider setting aside time in treatment to discuss the issues that your buprenorphine patients may face when attending 12-step groups. Also try to facilitate participation in groups like NA by adapting evidence-based strategies found to be effective among those suffering from alcohol addiction.

CITATIONS

Monico, L. B., Gryczynski, J., Mitchell, S. G., Schwartz, R. P., O’Grady, K. E., & Jaffe, J. H. (2015). Buprenorphine Treatment and 12-step Meeting Attendance: Conflicts, Compatibilities, and Patient Outcomes. J Subst Abuse Treat, 57, 89-95. doi:10.1016/j.jsat.2015.05.005