The recovery community says it offers refuge from opioid addiction. But it’s still hostile to lifesaving addiction medications 

The last time Mark Palinski went to a Narcotics Anonymous meeting, he was asked to leave and never come back. He stills remembers the argument: All he had done was advocate for the use of the “gold standard” treatment for opioid addiction, a common medication called buprenorphine. 

To Palinski, buprenorphine is a godsend. It helped him finally beat opioid addiction decades after he was prescribed Vicodin for a schoolyard kickball accident, leaving him hooked on painkillers at age 11. Buprenorphine, often known by the brand name Suboxone, is regulated, safe, and available for pickup at his local pharmacy. And instead of forcing him to white-knuckle his way through withdrawal, it left Palinski free of the cravings, sweats, nausea, and anxiety typically associated with quitting opioids. “It saved my life,” he said. 

But much of Narcotics Anonymous, and the addiction recovery world more broadly, sees buprenorphine differently. To the leaders of the meeting that Palinski attended years ago in Ohio, it was a mind-altering substance no better than heroin or fentanyl. When participants acknowledged taking addiction medications as prescribed by their doctors, group leaders told them they weren’t yet “clean.”

“Somebody would just outright tell them: You’re just replacing one drug with another, you need to get off that shit,” Palinski said. “Eventually, I spoke up and said: Hey, is anyone in this room a medical professional? Do any of you have the ability or the licensing to prescribe, or give people medical directions? Three people came up to me and said: You’re going to walk out, and you’re not coming back here.” 

As the death toll of the national drug crisis has climbed as high as 110,000 annually, much of the U.S. has grown more accepting of long-stigmatized but highly effective addiction medications like buprenorphine or methadone, which can reduce risk of overdose by more than 50%. The rise of ultra-potent fentanyl has made these medications not just the best option for quitting illicit opioids, but, experts say, the only realistic one. 

But a STAT investigation shows that thousands of the institutions that claim to offer refuge from opioid addiction are among those most hostile to lifesaving addiction medications. In dozens of interviews, former Narcotics Anonymous participants and residents of sober living homes, detox facilities, and rehab centers described a culture that ignores medical consensus and silences dissent. Given the 12-step philosophy’s emphasis on anonymity, many spoke only on that condition. But nearly all said the system often forces people attempting to quit drugs to make a stark choice: basic medicine or a supportive community. 

In recovery housing programs, residents are evicted if “caught” taking methadone or buprenorphine. In rehab and detox facilities, residents are only admitted if they aren’t taking either medication or pledge to quickly wean off. In Narcotics Anonymous chapter meetings, people who take methadone or buprenorphine are told to sit in the back row or are barred from speaking. Others are barred from leadership roles and instead asked to prepare coffee before meetings, or clean up after. Still others who take medication are first welcomed with open arms, only to be told by a sponsor months later that they must quit. 

The hostility to medication reflects a decades-old Narcotics Anonymous aspiration: abstinence from all “mind-altering” substances. Historically, that mandate hasn’t just applied to dangerous illicit drugs like heroin or fentanyl, but also to regulated, effective medications that are chemically opioids, like methadone and buprenorphine. Even as science and public opinion increasingly embrace the medications, much of the 12-step community has not budged in its definition of abstinence. 

Most current Narcotics Anonymous participants are reluctant to speak publicly about the organization, given the program’s tradition of anonymity. In recognition of this principle, STAT offered an anonymous interview to a member of Narcotics Anonymous leadership. The organization did not respond to the offer or to STAT’s multiple requests for comment. 

Evidence regarding Narcotics Anonymous is mixed, said Keith Humphreys, a Stanford professor and former White House drug policy advisor who studies addiction. Some people “definitely benefit” from the program, he said, while cautioning that the benefit is not universal and there is little high-quality research regarding long-term outcomes for N.A. participation, especially in the fentanyl era.  

“It’s easier to change your health behavior of any kind when you’re with other people who are trying to do the same thing and are supportive of you,” he said. “And at the same time, these opioid agonist therapies are pretty darn effective, and a lot of people in N.A. don’t like them. So that’s a genuine conflict.”

Despite dozens of studies underscoring the effectiveness of methadone and buprenorphine, authorities with the power to curtail anti-medication bias have not taken action. The federal government has never enforced a requirement that addiction treatment facilities receiving taxpayer funds offer medication. Accreditation organizations that certify rehab programs and provide training for addiction treatment professionals continue to green-light abstinence-only approaches while training a new generation of anti-medication drug counselors. 

“Historically, the leaders in policymaking are the product of the old school of addiction treatment, which is 12-step recovery,” said Patrick Kennedy, a recovery advocate and former Rhode Island congressman who used buprenorphine to treat his opioid addiction. “That’s why a supermajority of quote-unquote ‘addiction treatment’ is based on the 12-step model. That’s a legacy that’s hung on, obviously, for far too long.”

Hostility to medication is not universal, however, and certain corners of the recovery world have seen a recent cultural revolution. Many N.A. chapters now tolerate methadone or buprenorphine, and an increasing share of rehab facilities and sober living homes recognize the medications as an essential element of recovery. 

But in many communities, recovery strategies rooted in a strict “abstinence-only” philosophy remain the default. One government survey of over 14,000 substance use treatment facilities showed that over 40% did not offer methadone or buprenorphine.  

Narcotics Anonymous, which holds more than 70,000 meetings worldwide, has doubtless helped millions of people. Its only requirement for participation is that those who join have a desire to one day “become clean,” and it defines itself as a fellowship — not addiction treatment, per se, but a peer support group centered on abstinence. 

But its opposition to addiction medications can yield calamitous results. One recent study found that people who seek recovery from opioid addiction without medications are significantly more likely to overdose and die than those who don’t seek treatment at all. 

“I think N.A. has done more harm than good,” said Kim Gannon, a Yale Ph.D. candidate in health policy and management who participated in Narcotics Anonymous for years but has since come to question the program’s values and effectiveness. “Not only as it exists and as it forms the minds and philosophies of its individual users, but also the way that it has infiltrated drug treatment. I would not be surprised if Narcotics Anonymous has caused more deaths than it has prevented.” 

Widespread hostility

While anti-medication programs are increasingly seen as incompatible with modern medicine, interventions rooted in the “12-step” ideology made famous by Alcoholics Anonymous remain the default response to addiction. Programs like Narcotics Anonymous are where parents send children; where judges send defendants; where religious leaders send congregants; and where bosses send employees. 

Narcotics Anonymous is not alone in its hostility to medication. And while many recovery organizations in the U.S. enforce de facto bans through word of mouth, others, like the Salvation Army, enforce written policies that underscore their ideological opposition to methadone and buprenorphine.

Though the England-based Christian charity is best known for its homeless shelters and delivering disaster aid, the Salvation Army also bills itself as the “largest provider of residential drug and alcohol abuse treatment” in the United States. But it bans methadone and buprenorphine at nearly all of its 122 rehabilitation facilities nationwide.

The organization is currently the target of a federal lawsuit originally brought by a Massachusetts resident who says the organization evicted him after he took buprenorphine as prescribed by his doctor. 

“Salvation Army employs a blanket prohibition on methadone and buprenorphine for people with opioid addiction, thereby denying thousands of people access to the lifesaving medicine that is considered to be the standard of care for treating opioid use disorder,” said Janet Herold, the legal director of Justice Catalyst law, the nonprofit advocacy group that brought the lawsuit. “No one should be forced to choose between accessing publicly available and sometimes court-ordered housing and services and taking lifesaving medication.”

In a statement, a spokesman for the Salvation Army declined to comment on the pending court case. He also declined to address the organization’s attitude toward addiction medications, writing that the residential programs provide “an environment that is designed to help participants live healthy, fulfilling lives, generally at no cost to them.”

But in a court filing, the organization made clear that it sees methadone and buprenorphine no differently than it sees far more dangerous illicit drugs.

“The policy prohibiting use of intoxicants or mind-altering substances, including illicit drugs, alcohol, and narcotic or addictive prescription medications (including certain medication-assisted treatment medications, including methadone and buprenorphine), is based in part on The Salvation Army’s long-standing religious beliefs against use of such substances,” the organization’s attorneys wrote. 

And while certain national groups, like the National Alliance for Recovery Residences, support the use of addiction medications, many lesser-known facilities across the country remain hostile.

In one recent government survey, 751 federally certified addiction treatment facilities reported that they do not provide methadone or buprenorphine and do not admit people taking either medication. A separate study found that just one-third of outpatient mental health facilities in drug-ravaged states offered medication treatment for opioid addiction. Still more research found that more than half of recovery residences in Florida, long known for shoddy rehab facilities and patient brokering, prohibit buprenorphine.   

One rehab provider, Segue, directly states on its website that it allows medications prescribed by a doctor — except for buprenorphine and methadone.

“Segue provides abstinence-based housing, so we do not allow mind-altering medications like Suboxone and methadone,” the website says. “If you or your loved one is currently on an opiate replacement medication, we can work with you and your medical providers to safely help you to become abstinent from mind-altering substances.”

There is remarkably little oversight of sober living houses or addiction-treatment providers. No federal standard prohibits addiction treatment that bans the standard-of-care medications — nor is there a hard rule that facilities offering rehab services must offer them. 

On paper, the Substance Abuse and Mental Health Services Administration requires sober living facilities receiving certain federal grants to allow medications for opioid use disorder. But the language is nonbinding and is routinely ignored. As a result, the U.S. government spends billions of dollars each year on addiction treatment out of step with evidence-based medicine. 

“It is another unfortunate circumstance where we find very rigid systems that are very categorical, and by being so categorical, they close the doors,” said Nora Volkow, an addiction psychiatrist and the director of the National Institute on Drug Abuse. “I have been with patients who respond very well to buprenorphine but want to be able to go to group therapy, to Narcotics Anonymous — they are rejected. They are placed in this bind: whether to discontinue the buprenorphine, which is helping them, or to let go of their support systems.” 

‘No easier, softer way’

There is a common saying in 12-step recovery circles: “There is no easier, softer way.” 

The phrase implies that recovery will require sacrifice and pain, and that those pursuing any other approach will fail. But when it comes to opioids, there is an easier, softer way: medications that have been in use for decades whose express purpose is to quell those withdrawal symptoms, enabling even longtime opioid users to quit. 

Palinski, known to friends as “Murk” thanks to a repeated spelling error at a local Starbucks, experienced over a decade of addiction to prescription opioids and made over a dozen attempts at abstinence-based recovery. He said his first time taking buprenorphine was “the best [profanity] feeling I’ve ever felt in my life.” 

“My mind thought that I had the opiates in my system, and that I had already gotten high, but I felt absolutely no intoxicating effect,” he said. “All of a sudden, I felt like all of the things I needed to work on in my life — it felt like I could do them. It was life-changing.” 

Narcotics Anonymous language remains unsympathetic to Palinski’s experience. And in literature distributed at chapter meetings as well as online, the organization makes clear that its attitudes toward medication have shifted only slightly, if at all. At its recent World Convention, Narcotics Anonymous devoted significant time to the question of medication-assisted treatment, lamenting that “there is a prevailing belief that the only hope for the addict is long-term treatment with medication.” 

“Within the context of NA and its meetings, we have generally accepted principles, and one is that NA is a program of complete abstinence,” according to one pamphlet last updated in 2016 and distributed frequently since. “By definition, medically assisted therapy indicates that medication is being given to people to treat addiction. In NA, addiction is treated by abstinence and through application of the spiritual principles contained in the Twelve Steps of Narcotics Anonymous.” 

Other language makes clear that people who are abstinent from illicit drugs like heroin or fentanyl, but take buprenorphine or methadone under a doctor’s supervision, are welcome in meetings, but are not considered “drug-free.” The pamphlet underscores that even though many chapters remain hostile to those taking addiction medications, chapters are free to choose their own practices. 

“NA may be compatible for addicts on medically assisted protocols if they have a desire to become clean one day,” the pamphlet reads. 

Other literature makes the organization’s stance even more explicit: That NA participants on methadone or buprenorphine are considered to be “using” on par with those who use drugs like fentanyl.  

“Members on drug replacement programs such as methadone are encouraged to attend NA meetings,” according to one referred to as Bulletin 29. “But, this raises the question: ‘Does NA have the right to limit members (sic) participation in meetings?’ We believe so. While some groups choose to allow such members to share, it is also a common practice for NA groups to encourage these members (or any other addict who is still using), to participate only by listening and by talking with members after the meeting or during the break. This is not meant to alienate or embarrass; this is meant only to preserve an atmosphere of recovery in our meetings.”

‘True recovery’

The National Institute on Drug Abuse defines recovery as “a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential.” 

Narcotics Anonymous and other recovery groups, however, have stuck by their original threshold: Participants are only deemed to be “clean” when they abstain from mind-altering substances, which, in their view, include prescription medications like buprenorphine.

Many people in recovery disagree, arguing the definition of “true recovery” should be about their overall health and happiness, not whether they’re consuming medications of a particular chemical class. Palinski stressed that he does not abstain from all substances — but has eliminated drug use he considers to be unsafe, and measures his recovery by his happiness and fulfillment.  

“I drink coffee, and it alters my mind and my mood,” Palinski said. “My idea of recovery is me doing well. I’m living a better life, I’m safe, I’ve eliminated all the risky things I was doing. That’s recovery for me.” 

Narcotics Anonymous was founded in 1953 in Los Angeles as an Alcoholics Anonymous offshoot. And while the program has flourished in decades since, there is little research regarding its effectiveness in the modern era, since the synthetic opioid fentanyl came to dominate the country’s drug supply and sent overdose rates skyrocketing. 

Separately, good-faith debates about addiction medications do remain. Some patients, like Palinski, begin taking methadone or buprenorphine expecting to take them forever as a consistent treatment for a chronic condition. The American Society of Addiction Medicine and many addiction doctors generally discourage discontinuation, citing poor outcomes, including increased risk of death. Nonetheless, others begin methadone or buprenorphine with the intent of one day tapering off, either to avoid side effects or simply because they’re no longer necessary. But there is no debate about their broader effectiveness at helping people quit illicit opioids and avoid overdose.  

And while public health experts see 12-step fellowships’ hostility to methadone and buprenorphine as harmful, implementing full access to addiction medications at every sober living home, rehab center, and detox facility may be easier said than done. 

Banning the medications outright is “totally irresponsible,” said Percy Menzies, the president of Assisted Recovery Centers of America, a chain of transitional living facilities based in St. Louis, but “the practical challenges of somebody bringing in an abusable drug are considerable.” 

Broad lack of access to addiction medications, and some participants’ intermittent use of illicit drugs, can lead to black markets or barter systems when residents come home with a 90-day supply of buprenorphine. The medication can fetch $5 or more per dose — though it is increasingly available in long-acting injectable form. Eventually, Menzies said, “The houses say: Enough is enough, I can’t take this anymore.” 

‘Not your mother’s drug supply’

To quit OxyContin or even heroin without the aid of methadone or buprenorphine was always a longshot proposition. But as the nation’s drug supply moved from prescription drugs, then to heroin, then to fentanyl, experts say opioid users’ odds of successfully quitting cold-turkey nosedived from slim to virtually none. 

Critics of Narcotics Anonymous and much of the recovery community’s opposition to medication say that the community has not shifted its philosophy accordingly. The organization’s nature also lends itself to selection bias, said Gannon, the Yale researcher: Those who remain sober against all odds often wind up in leadership roles, often leaving an older generation to shepherd a younger one. 

But while the older generation managed to quit comparatively weaker opioids, like prescription painkillers or even heroin, the younger generation is faced with the prospect of quitting constant fentanyl use — meaning that attempts to white-knuckle through weeks of agonizing withdrawal can bring disastrous results. 

“This is not your mother’s drug supply,  you know?” Gannon said. “Given the potency of fentanyl and the extent to which it adulterates some drugs in the supply, I don’t think the old guard really understands how much of a gamble they’re taking.”

In light of the organization’s anti-medication bias, many addiction doctors, researchers, and people in recovery have begun to question the 12-step philosophy — and whether its most basic rules are at odds with strategies known to promote recovery and save lives. 

The resistance to Narcotics Anonymous has spread and grown increasingly organized. Groups that actively oppose the Narcotics Anonymous philosophy, or help people in recovery transition away from 12-step groups, exist in large numbers on Facebook, many with thousands of members. 

Palinski, who once participated in chapters across Ohio and now North Carolina, is now involved in a group called Medication-Assisted Recovery Anonymous, which facilitates in-person meetings in 37 states. 

The vast majority of MARA members come upon the organization only after engaging with Narcotics Anonymous, Palinski said. But despite their similarities in name, the organizations are radically different. 

MARA meetings read a version of the 12 traditions, including language modified to stress their acceptance of addiction medications and eliminate mentions of god. Other language, included in MARA’s recently-published book of traditions, notably excludes the famous 12-step passage admitting powerlessness over one’s addiction. Notably, MARA also allows “cross-talk” — participants directly engaging with one another during meetings — which is prohibited in most traditional 12-step settings. 

And while Narcotics Anonymous says its only requirement for participation is “a desire to one day become clean,” MARA says its only requirement is “a desire to live a safe lifestyle.”

Palinski’s Friday meeting has been running for years and typically draws between 10 and 25 people. Besides the network of in-person meetings, MARA runs 21 virtual meetings per week and an active Facebook group with over 2,500 members. 

“There are people out there that are like me, and need that sense of community and support,” he said. “And I know they’re not getting it.” 

STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.