Photo by Sushobhan Badhai
Medication-assisted treatment (MAT) is an increasingly popular method for treating addiction. The approach is touted as the most effective way to treat people abusing prescription opioid painkillers like vicodin or oxycodone, as well as street equivalents like heroin. With tens of thousands of people dying every year from opioid overdoses, the public health community—rightly desperate for a way to lower the body count—is looking to MAT as a solution.
However, I believe that there are serious downsides to MAT that need to be discussed. I also believe that spiritual recovery groups offer unique advantages over MAT. Both people who need recovery and the public health professionals committed to serving them would benefit from a greater understanding of what spiritual recovery has to offer—a free, powerful and community-oriented path to enjoying life while clean and sober.
My aim is to further that understanding.
I have been in recovery for six years, have trained as a social worker and worked as a drug counselor for a year. I have experience with Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and Refuge Recovery, though I am not a representative or spokesperson for any of these groups. This essay is based on my firsthand observations.
First off, what is MAT?
MAT is a harm reduction approach to dealing with addiction. Essentially, it works by replacing one drug with another—substituting methadone or suboxone for prescription opioid painkillers or heroin. Methadone and suboxone are prescription opioids themselves, but they are formulated or dosed so they are harder to get high on than opioid painkillers, making it possible for someone to work or go to school while taking them.
Critically, methadone and suboxone are more difficult to overdose on than other opioids. It is possible to overdose on methadone if you take enough, but it is typically given out at lower doses to prevent that. It extremely unlikely to overdose on suboxone. Equally important, switching to methadone or suboxone allows a person to avoid going too deeply into the long, debilitating withdrawals that occur when someone stops using opioids altogether. This means that they can stop taking prescription painkillers or heroin relatively painlessly.
MAT is administered under the supervision of a doctor or a specialized clinic. People on methadone have to go to a clinic every day to get a new dose. Suboxone is more typically prescribed in weekly or monthly allotments.
The goal of MAT is to transition drug users off of prescription painkillers or heroin and onto methadone or suboxone. The later are safer, and people can take them and lead functional lives. This is not an unreasonable approach, and if it’s working for you, good. Carry on.
What does spiritual recovery mean?
Typically, spiritually-based recovery means 12-step groups like AA or NA. AA was the first such group. Founded by Bill Wilson and Bob Smith, AA published its eponymous book Alcoholics Anonymous in 1939. The book was a guide for people who couldn’t stop drinking despite their best efforts to do so.
Alcoholics Anonymous, which was written by Wilson and other early members of AA, explained how the authors themselves had tried and failed to quit drinking for many years. They had only been able to achieve sobriety—and the peaceful state of mind necessary to maintain it—by making a concerted effort to live according to spiritual principles. These principles included letting go of yourself through honest self-examination; taking responsibility for your actions; and helping others.
Specific suggestions for how to do this were outlined in the book and were called the 12 steps. Alcoholics Anonymous promises that anyone who makes an effort to follow the 12 steps can remain clean and sober for life, and more importantly, experience happiness, joy and freedom.
The AA approach has worked for a great many people. Consequently, the 12 steps have since been used as the foundation for other recovery groups, including NA, Marijuana Anonymous and Cocaine Anonymous. In more recent years, Refuge Recovery, a Buddhist-inspired (not 12-step based) recovery group established by the Buddhist teacher Noah Levine, has also become popular. Many people who felt uncomfortable with the theistic language used in AA or NA have found Refuge Recovery’s God-free, meditation-centered approach appealing.
Theistic or not, spiritual recovery groups are often described as religious. However, that mischaracterizes their basic nature. Religions teach a particular set of beliefs and ask their followers to adhere to them. By contrast, spiritual recovery groups teach a set of practices that help you question your beliefs and explore the nature of your individual experience. You’re meant to walk your own path—that’s the only way it really works. This inevitably means letting go of beliefs, not gaining them.
The only real article of faith is that you’re willing to give those practices a try. If you do, something happens. People who commit to a spiritual recovery inevitably become the sort of people who make the world a better place.
It is worth noting that spiritual recovery groups are highly informal—there are no fees, no hierarchy, no membership rolls, no requirements to be there other than a desire to recover. A member is anyone who shows up. It is also worth noting that spiritual recovery groups are, well, groups. For anyone who wants to stay sober, a spiritual recovery group doesn’t just provide a path, but a community to walk it with. This can make the journey far more bearable.
However, the public health community seems to be more comfortable with MAT. I understand that health professionals would prefer a medical solution to addiction, but I believe there is a broader picture that should be taken into account.
The trouble with MAT.
I have three main concerns with the MAT approach. In brief:
- Methadone and suboxone are even harder to detox off of than prescription painkillers or heroin. This means once you start MAT, you’re often stuck with it.
- Methadone and suboxone are powerful, mind-altering substances. Your head might be clearer than if you’re shooting up heroin, but your consciousness is still very much clouded.
- A great many people suffering from addiction are at a point in the disease where they are not able to moderate their drug use long-term. Getting and staying high is the whole point, because that’s the only time they feel okay. MAT doesn’t address this aspect of addiction at all.
Let’s take them in order.
First, and perhaps the most serious: methadone and suboxone are infamous for having a uniquely brutal detox. They are harder to get off of than the drugs they are replacing.
For those unfamiliar with drug use, detox (or withdrawals) is what happens when you stop using a drug after a period of sustained use. Someone detoxing off of any opioid can expect to go through weeks of pain, nausea, sweats, diarrhea, vomiting—the list goes on. I’ve never been through it myself, but I’ve seen people go through it, and it’s awful.
Part of the reason many people keep abusing prescription painkillers or heroin is that they want to avoid experiencing detox. The symptoms are so bad that some drug users would rather risk overdose and death than stop and suffer through them. It’s a rock and a hard place.
Proponents of MAT argue that one of the biggest advantages of methadone and suboxone is that they offer a way to get people off of prescription painkillers and heroin without making them go through withdrawals. They’re right—someone who switches from vicodin to suboxone will experience some detox symptoms, but they will be comparatively mild and won't last. But what happens when that person wants to get off of suboxone?
The bill comes due. I spent four months as a client in two rehabs, and have worked for two rehabs as well. Here’s what I’ve seen: people detoxing off of methadone or suboxone inevitably describe it as the most painful experience of their lives. Those who struggle with addiction are no strangers to pain—and opioid addicts perhaps most of all. The people I’ve watched coming off of methadone and suboxone had all detoxed off of heroin or prescription painkillers before. But universally and unequivocally, they all agreed that withdrawing from methadone or suboxone was harder.
The antidote is in many ways worse than the poison.
This matters because it means that people who start MAT are likely to be trapped on it. Fully detoxing off of methadone or suboxone can take anywhere from months to years. During that time, it is difficult if not impossible to function normally: to work, go to school, be there for your friends and family. In other words, if you want to stop MAT, you have to be willing and able to put your life on hold and experience a level of pain and discomfort even worse than that of heroin or prescription painkiller withdrawal. People do it, but it isn’t easy.
My former 12-step sponsor Norman did it. In his late forties, after 20 years in a methadone program, he detoxed himself off the drug. He told me how, desperate for any distraction from the pain, he would go to AA meetings, two or three times a day. He wouldn’t ever say anything—he was too sick to get the words out—but he would sit in the back, shaking and hallucinating. It took over a year for his symptoms to abate.
That’s what getting off of MAT can look like. I believe that proponents of MAT really need to understand that.
Second, methadone and suboxone are powerful, mind-altering substances, just like prescription painkillers, heroin, alcohol or any other drug of abuse.
Harm reduction—the theory of encouraging users to switch one drug for another, less dangerous one—is a legitimate approach to addiction treatment. Breaking a heroin habit by using cannabis, for example, is a step in the right direction—someone using cannabis is not going to overdose and die. Methadone and suboxone can be similarly useful in that regard.
However, I believe harm reduction works best when it is part of an overall transition to being clean and sober—abstinence from consuming any mind-altering substance. But once you’re on a methadone or suboxone regimen, you’re probably going to stay on it long-term. Someone in a MAT program might well spend the rest of their life with their consciousness permanently affected by a drug: their thoughts clouded, their emotions blunted, their perceptions altered.
Methadone and suboxone might be harder to get high on (although methadone is often a drug of abuse), but they are still opioids that affect the same parts of the brain that prescription painkillers and heroin do.
No one I know who has taken methadone or suboxone would describe the experience as the same as being sober. Norman told me that when he used to take his daily methadone dose at the clinic, he felt like he was “flying out of his mind.” In the words of another recovering addict, “methadone fucks you up.” Suboxone is more subtle, but still dulls your mind.
According the American Society of Addiction Medicine, over 2.6 million American suffer from full-blown opioid addiction. A MAT approach would see most of them prescribed methadone or suboxone. But what is the cost of keeping such a large number of people on powerful, mind-altering drugs indefinitely? I believe it is considerable. Not so much in dollars (although suboxone can be prohibitively expensive), but to the individuals themselves, their families, and society as a whole.
Millions of Americans on methadone and suboxone means millions of Americans who can’t experience the full range of their humanity, not because it isn’t there but because it’s buried under the effects of the medication. Anyone who has ever had too much to drink understands what it means to lower your consciousness with a drug. Is that really something we want to promote as the first option for addiction treatment? No one would argue that people abusing opioids would be better off staying on heroin, but to hold up another opioid as a drastically less harmful alternative is naive and short-sighted.
In our culture, so often our first instinct is to reach for a pill. But I think we do ourselves a disservice by doing so. The alternative—choosing not to try and force our minds to behave a certain way—is where the growth is. We don’t have to numb ourselves to recover. Indeed, we can’t. In my experience, it is the very act of turning towards our pain and our fear that allows us to start getting free.
Third, people who have advanced their addiction past a certain point are often unable to moderate their drug use for any significant periods of time. Getting and staying high is the whole point, because that’s the only way they feel okay.
For almost a century, 12-step writing—beginning with the book Alcoholics Anonymous—has described addiction as a disease, rather than a failure of morals. This has played an important part in the gradual de-stigmatization of addiction, especially since the public health community has embraced this characterization as well.
But importantly, Alcoholics Anonymous and subsequent texts have noted that addiction is a progressive disease. This means that addiction often gets worse the longer a person is caught up in it. I started out smoking weed once a day at the beginning of my senior year in college. A year later, I’d dropped out of law school, and was using all day, every day.
Part of why this happens is that the longer you use drugs, the more drugs you need to take to produce a decent high. The bigger part is that once you find something that makes you feel better, you want to feel that way all the time.
Not everyone who suffers from addiction experiences the same progression, but many do. The degree may vary, but people who abuse drugs and alcohol do so because they like the effect—using gives them feelings of genuine relief and inner peace. This is perhaps the key difference between people who struggle with addiction and everyone else: most people usually feel okay sober. Addicts usually only feel okay high.
If you struggle to feel at ease in your own skin every day, you chase that ease by whatever means necessary. This usually means using more and more.
How does this relate to MAT? While methadone and suboxone do replicate some of the effects of prescription painkillers and heroin, they aren’t meant to provide the same high (although as previously noted, you can absolutely get high on methadone). Consequently, MAT doesn’t offer the same feelings of relief that people struggling with addiction so desperately want.
MAT addresses one barrier to quitting prescription opioids or heroin—the fear of painful withdrawals. However, it completely ignores the larger obstacle—that people abuse drugs because they don’t feel okay sober even after they’ve completed detox. This is what 12-step groups call the spiritual malady. Prescription painkillers and heroin are a temporary solution to that problem—heroin is accurately called a fix. Methadone and suboxone are less effective solutions, precisely because they are less likely to get you high.
In other words, the MAT approach ignores the main reason most people get caught up in addiction.
Addiction recovery offers a tremendous opportunity for emotional, mental and spiritual growth. Spiritual recovery groups like Alcoholics Anonymous, Narcotics Anonymous and Refuge Recovery can put you on a path to a deeper understanding of yourself and the universe. MAT gets in the way of that.
The whole point of spiritual recovery is to become comfortable in your own skin while clean and sober. Complete abstinence from all drugs and alcohol is part of that, but just a small part. Being drug-free is a gateway, not a destination. The larger goal is to get to a place where you don’t want to drink or use, because you no longer need to do so to feel at peace.
This is what 12-step groups call a spiritual awakening, or Buddhists a journey of enlightenment.
I understand that public health and medical professionals are often uncomfortable with spirituality. It isn’t taught in schools and can’t be quantified into neat data sets or reproduced in clinical trials. For the scientific-minded, mention of spirituality often produces a sense of skepticism.
Healthy skepticism is never a bad thing. Indeed, a persistent examination and questioning of reality is how we find the truth. However, I feel that those without firsthand experience in recovery themselves too often often ignore the benefits of a spiritual approach to addiction treatment.
This does a disservice to people who need recovery. By promoting MAT while disregarding spiritual recovery programs, the public health community is ignoring an existing approach to recovery that really works.
How do we know it works? Go to a meeting and ask. In Los Angeles, where I live, there are over 3,000 meetings a week, all of them full of people who are using a spiritual recovery path to transform their lives. They’ll tell you. Then watch how they support each other, see the love and camaraderie and kindness, and you’ll know the truth of their words.
Both spiritual recovery groups and public health professionals see addiction as a disease. But spiritual recovery groups understand that while addiction affects both the mind and body, it is fundamentally a reaction to how people perceive themselves and the universe—and largely beyond the purview of doctors and psychologists (or any other authority). True self-inquiry is something no one else can do for us. What spiritual recovery groups can do is offer us guides for how to conduct that inquiry, and a community to support us along the way.
Conversely, health professionals who view addiction as a disease in more traditional medical terms naturally see medication as the best response. From their perspective, there is nothing wrong with someone being on methadone or suboxone for the rest of their life. Doctors that prescribe such medication tell their patients that they’re clean and sober once they start taking it, as if it were aspirin, not a powerful psychoactive drug. Doctors may think that all their patients need to do is keep taking the medication and maybe do some therapy to be okay.
This saddens me a great deal. The MAT approach stands directly in the way of what spiritual recovery has always offered: a chance to heal from addiction. Spiritual recovery programs teach us that in order to break the cycle of addiction, we have to grow and open up to the true nature of reality. We can’t do this if we’re clouding our minds with more drugs. We don’t have to reach enlightenment to stay sober, of course, but we do want to get on the path—and help others walk it with us.
As Norman would remind me, nothing matters but love and service.
I don’t believe any recovery group is perfect, of course (and AA, NA and all the rest are groups, plural—many thousands of individual groups following common texts). They’re human creations full of messy human relationships. I also don’t believe you need to be in a recovery group to pursue a spiritual path to recovery.
But what I really do appreciate about the people you meet in groups like AA, NA or Refuge Recovery is that they’re some of the only folks out there—in any realm of society—that are saying that if you just make an effort to honestly examine your experience and help others, you’ll be okay. That you don’t have to buy something, take a pill, do anything complicated—just examine yourself and help others. They certainly don’t have the market cornered on that wisdom, or even offer it in it’s purest form, but it’s there, it’s simple, and it’s open to everyone.
Spiritual recovery makes addiction an opportunity—one that shakes us out of our humdrum existence, forces us to confront our suffering, and says “wake up!” What someone chooses to do with this opportunity is up to them: each of us has our own journey and our own path. But if we’re following some sort of spiritual principles, our path has the potential to take us very far indeed.
Norman is the perfect example of how spiritual recovery can transform a life. He was crippled by addiction for decades, spent time living on the streets, had several failed marriages and couldn’t hold down a job. You get the picture.
But then Norman got off methadone and into AA. When I met him in a meeting, early in my own recovery, he’d been sober for almost twenty years, and was no longer the man he used to be. Standing there talking to him, I could feel his compassion radiating outwards. He was always the first person to put his hand out and welcome someone new like myself. He became a father figure to me, bringing me into the middle of the group and walking with me through some hard days.
He’s done the same for dozens of other men over the years, and through them, his love and wisdom have rippled out into the world to touch the lives of countless others. That’s where a spiritual recovery can lead.
However, if our minds are dulled with drugs—even doctor approved drugs like suboxone or methadone—we’re putting a hard ceiling on how far we can really go in our spiritual journey. Maybe some people are okay with that. If so, cool. But I would guess the vast majority of people who are offered MAT have no idea that basing their treatment around medication means that they are limiting how deep their recovery can really be.
It’s none of my business what choice someone makes, but I do care that they make that choice with a reasonable understanding of the consequences.
In passing, I would also like to note the tremendous irony of looking for a solution from the same pharmaceutical companies that caused the opioid epidemic, and the very real, practical issues of cost and access to methadone and suboxone. Methadone is cheap, but dispensed only in daily doses, meaning you have to go to a clinic every day to get another dose. Suboxone is more often prescribed a week or a month at a time, but a month’s prescription plus the cost of the associated doctor’s visit can cost hundreds of dollars or more. The MAT approach means that you’re tethering yourself either proximally or financially to a clinic or doctor for an indefinite amount of time—and living with the knowledge that you’re a day away from devastating withdrawal symptoms if you can’t get your dose.
By contrast, spiritual recovery groups are free, everywhere, and ask nothing more of you than whatever you are willing to give. I’m no more of a poster boy for membership in one of these groups than anyone else—I’ve had an up and down relationship with them. But they’re always there for me when I need them (and when I don’t).
Spiritual recovery offers a way forward. MAT is closer to a holding pattern.
What I’m trying to say boils down to this: I believe that the purpose of this life is to wake up to the nature of reality and our interconnection with one another. I believe that those of us who struggle with addiction get to a place of such pain because deep down, we desperately want to wake up, but don’t know how to do it. I believe that spiritual recovery can help us start to do that. A medication-based approach may provide short-term benefit, but will eventually just get in the way. We can’t run forever, after all.
People have the right to try any approach to addiction treatment they so desire, but they should do so with at least some sense of what that approach means long-term. I understand the public health community’s desire to find a scientifically-based method for treating the opioid epidemic, but I feel that in the rush to anoint MAT as the answer, they are missing the forest for the trees.
Ian is a writer and the founder and editor of Open Heart Beginner's Mind.