How do you know when Medicating becomes Self Medicating?

A recent blog in the After the Party Magazine  has raised some very pertinent questions about the issue of co-morbidity in alcoholics and addicts seeking recovery via 12 step groups and suggests the extent of this co-morbidity is much higher than may have been anticipated.

This blog raises important issues but ultimately may leave more questions than it answers?

The blog starts “You hear it in 12-step meetings all the time—people who were once on psych meds discovered they didn’t need them after getting sober and doing the steps. Now they’re evangelizing at every meeting in town about how their problem was really just spiritual. Maybe they were never mentally ill to begin with or maybe the steps really did banish their mental illness right out of their brains. But for me, and plenty of others I know, this isn’t the case.”

The author then continues ” If anyone has any questions about psychiatric meds AA has an official stance that’s in a pamphlet called The AA Member—Medications and Other Drugs. ”

I referred to this pamphlet on Monday’s blog Can you be Sober and in Recovery while on Medication?

As I mentioned then the pamphlet appears to be alerting AA members to the reality that certain members “must take prescribed medication for serious medical problems. However, it is generally accepted that the misuse of prescription medication and other drugs can threaten the achievement and maintenance of sobriety”.

As the author notes this pamphlet states ” “No A.A. member should ‘play doctor’; all medical advice and treatment should come from a qualified physician.”

It also states that “Some of us have had to cope with depressions that can be suicidal; schizophrenia that sometimes requires hospitalization; bipolar disorder, and other mental and biological illnesses.

“A.A. members and many of their physicians have described situations in which depressed patients have been told by A.A.s to throw away the pills, only to have depression return with all its difficulties, sometimes resulting in suicide.

“We have heard, too, from members with other conditions, including schizophrenia, bi-polar disorder, epilepsy and others requiring medication, that well-meaning A.A. friends discourage them from taking any prescribed medication. Unfortunately, by following a layperson’s advice, the sufferers find that their conditions can return with all their previous intensity. On top of that, they feel guilty because they are convinced that ‘A.A. is against pills.’ It becomes clear that just as it is wrong to enable or support any alcoholic to become readdicted to any drug, it’s equally wrong to deprive any alcoholic of medication, which can alleviate or control other disabling physical and/or emotional problems.”

The author then suggest that ” roughly 70% people I meet in AA are on meds. A lot people are quiet about it because they don’t want the backlash…”

Is the prevalence of people taking medication in 12 step groups this high? Or is this a sample bias?

Perhaps many of the people I know in AA have simply been keeping quiet about it? I am not convinced that this figure is accurate, based on my own observations?

If this figure is representative then what co-occurring conditions are these recovering people medicating?

There are obviously a host of co-occurring conditions  that recovering people suffer from – from physical, such as back pain, to epilepsy, to anxiety disorders to depression, bi-polar, borderline personality disorder, post traumatic stress disorder, schizophrenia …in fact the list goes on.

Is it  thus reasonable of us in AA and other 12 step groups to expect that all members are medication free or that the 12 steps can treat all co-occurring conditions?

It has been suggested in a AA survey  that over 60% of recovering individuals in 12 step groups seek outside professional help for co-occurring difficulties which suggest that the trajectory of alcoholism and addiction is not straightforward and includes other co-occurring problems which may add to the severity of psychological symptoms experienced.

A very pertinent question is whether these co-occurring conditions are parallel problems or are additional problems that affect one’s addiction recovery.

By this I mean if one suffers, as I do, from PTSD, do PTSD symptoms also add to relapse vulnerability, for example. I can say for myself that the two times I have had issues with relapse have been prompted by manifestation of PTSD symptoms, such as flashbacks.

For me, at least, my co-occurring condition of PTSD affects my recovery from alcoholism and substance addiction. It is inseparable – in fact my PTSD and childhood maltreatment has contributed to my addiction.  Although it doesn’t necessarily follow that my choice of  treatment, e.g. 12 step recovery will straighten out all the factors that contributed to this addiction.

Equally the 12 step and associated fellowship and program for living may help manage this condition too?

I have not relapsed in a decade so the 12 steps etc must be helping with co-occurring conditions as these conditions have to potential to prompt relapse?

I will explain this further, below, in relation to the various sponsors I have had in recovery.

I do not medicate for this condition nor have I sought outside help although I  have considered outside help many times. Perhaps I am edging closer to that.

Equally I believe the process of recovery has helped me recover from PTSD, has made me aware of triggers, etc.

How prevalent is PTSD in addiction? Do others suffer in recovery from this co-occurring condition too?

Approximately 35% to 50% of people in addiction treatment programs have a lifetime diagnosis of posttraumatic stress disorder (PTSD), and 25% to 42% have a current diagnosis (Back et al., 2000; Brady, Back, & Coffey, 2004; P. J. Brown, Recupero, & Stout, 1995; Cacciola, Alterman, McKay, & Rutherford, 2001; Dansky et al., 1996;Jacobsen, Southwick, & Kosten, 2001; Mills, Lynskey, Teesson, Ross, & Darke, 2005;Ouimette, Ahrens, Moos, & Finney, 1997).

Is this the case in 12 step groups?

In order to examine the extent of co-morbidity in recovery I will briefly run through some of the sponsors I have had in recovery, and their co-occurring conditions – self acknowledged or not.

First sponsor – bi polar, not medicated, but also treated via outside professional help – accepts that he will occasionally have very dark days as part of his recovery. His choice is not to medicate as he feels it is a chemical straightjacket although he accepts the right of others to take medication for this condition.

Second sponsor – borderline personality disorder – not medicated – has sought professional outside help.

Third sponsor – no co-occurring conditions  – but would suggest his religiomania contributes to his absolute conviction that recovering people do not need medication of any sort that God can heal everything.

Fourth and fifth  sponsors both PTSD but not fully acknowledged nor treated outside of 12 steps.

All in long term recovery of 12 plus years.

From this very small survey it is clear that there is a common co-occurrence with other conditions, acknowledged or otherwise. There is also extensive childhood abuse of various types.

All of them have not or do not take medication. They may be in some way also be treated by the 12 steps.

I have also sponsored a person with  schizophrenia who needs to take medication because of returning psychosis if he fails to take medication.

What I am saying is that some individuals with obvious co-occurring conditions also choose not to medicate as well and feel their general “recovery” is treated by the steps and fellowship, often together with outside help. Having a co-occurring condition does not mean one automatically takes medication for this condition? Many do not?

This is why I queried the “70%” are on meds above. I do not necessarily disagree that those suffering co-morbid conditions is the majority but would query why so many take medication?

Are some of these on medication assisted treatment to curb urges and cravings too?

In terms of so-called co-occurring disorders such as anxiety and mood disorders such as generalized anxiety disorders (GAD) and major depression (MDD), research has shown that these symptoms often dissipate in the early weeks of recovery.

This had led researchers like Mark Shuckit to call these substance induced disorders and to suggest that co-occurring disorders such as GAD and MDD are distributed in recovery populations as they are in normal population at around 15% prevalence.

This is why I think some 12 steppers are “anti med” as they often see the symptoms of GAD and MDD dissipate in early recovery and thus believe the steps are treating these disorders successfully.

Although these disorders are but temporary substance induced disorders for many, however, for 15%, at least, these conditions of  GAD and MDD are possibly what they suffer from too in recovery.

Regardless of that caveat if we add this 15% to up to 50% who suffer PTSD and the possibility of the occurrence of other conditions such as borderline, bi polar, etc we get closer to the 62% figure of AA respondents that an AA survey in 2012 states  received some type of treatment or counseling, such as medical, psychological, spiritual, etc., (and 82% of those said it played an important part in their recovery from alcoholism).

Whether these conditions require medication is a matter for the person and their sponsor in discussion with medical professionals and not some layperson “medical expert” as often abounds in AA and other 12 step groups.

The issue here is not simply co-morbidity  but whether this co-morbidity is an intrinsic part of the aetiology of addiction from a vulnerability to a relapse  factor. In other words, have other conditions meshed into the overall condition of addiction? Can they be treated by the same treatment?

Regardless,  they often have to be treated  separately.

To conclude it seems that 12 step groups need to appreciate that co-occurring conditions, self acknowledged or not, play an important part in recovery and relapse as well as in the aetiology of addiction.

How effectively the medication used can be dissected from the condition of addiction is still debatable for many?

In short, many feel being on medication impedes full recovery.

How we define full recovery is open to question? Recovery can be measured using many variables related to quality of life. If medication using members feel their lives are steadily improving then who are we to judge?

Equally just because one suffers a condition does not inevitably mean it must be medicated, some of the examples above have “treated”  their co-occurring conditions via the 12 step program of recovery.

I think ardent fans of the right to medication should appreciate that there is a valid counter argument – they may have the same rights to their point of view as the author of this  blog?

All of us has the right to think as they wish and to express their views also.

Live and Let Live may be apropos, we all have the right to be wrong, Love of others is our code.

Alcoholics are such absolutist thinkers, all or nothing, black and white thinkers at times. Recovery is also considering others and their points of view?

Personally speaking if I sponsor, I take it on a case by case basis.

I have had only one sponsee out of 7 who has been on medication.

It is for sponsor, sponsee and family as well as medical professionals to contribute to the debate on continued medication.

My lasting concern, however is the 70% figure cited in this blog. It does not tally with my experience of recovery.

Another part of the AA pamphlet cited also warns,

“Experience suggests that while some prescribed medications may be safe for most nonalcoholics when taken according to a doctor’s instructions, it is possible that they may affect the alcoholic in a different way…”

Again this seems to be alerting us to the question when is medicating actually self medicating?



This has been my main experience with medication, that those taking them do not always look completely sober.

In order to recovery fully perhaps we have to be fully sober first?

I will continue this discussion in Part 2 of this blog when I discuss also whether considering alcoholism purely as a “spiritual malady” complicates this argument.

In the DSM manual 75% of the disorders contained therein have emotion dysregulation at the centre of their condition. I believe alcoholism and addiction also have although not acknowledged.

Insted DSM states the emotional dysfunction seen in addiction is the result of some of co-morbidites mentioned above. I disagree.

Is it not about time we got our heads together and agreed on what the hell we suffer from?

Isn’t addition an emotional disorder in it’s own right compounded by other co-occurring conditions?

Then we will be in a position to discuss how the 12 steps can treat this condition and related conditions of emotion dysregulation?

The main issue for the blog addressed, is that the author, and many others, cannot understand how a spiritual malady has anything to do with their other conditions, when, in reality, alcoholism is another type of disorder, similar to that with which it often co-occurs .

More on this later…








Can you be Sober and in Recovery while on Medication?


In a recent blog from the Recovery Research Institute

by  Brandon G. Bergman, Ph.D. 

It was suggested that a survey of almost 300 long-term AA members (average time in recovery 13 years), more than half felt medication to resist alcohol cravings/urges was or might be a good idea, and 17% did not think it was a good idea, but were “OK with it”.

Obviously if these AA members have a respect for the Traditions of AA they would have been responding to the survey as individuals in recovery? As Tradition 10 of Alcoholics Anonymous states:-

“Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.”

This is a very important point. I do not write this blog as an AA member but as a researcher and recovering alcoholic/addict who seeks to combine  neuro-psychological research with the experiential insights I have been given as the result of recovery, albeit with 12 step recovery. I do not speak for AA nor would I wish to. I believe the traditions can be incorporated in our daily recovery like the 12 steps. The traditions are there to protect us from ourselves and gives us guidelines for interacting with the wider world.

Being drawn into public controversy is not good I believe for the health of AA or the recovering individual within AA.

I mention this also because in this article, the author appears to suggest that AA’s  membership has an  official position on Medication-assisted treatment (MAT), including opioid agonists (e.g., Suboxone) and antagonists (e.g., Naltrexone and its monthly depot formulation Vivitrol).

Is this actually the case or is this statement misleading?

I will leave you to decide that? The   official position on MAT is that of the AA pamphlet The A.A. Member — Medications and Other Drugs – which this author suggests “appears to be one of skeptical tolerance”.

Personally I have read through the pamphlet and see no mention of MAT whatsoever.

The pamphlet appears to be alerting AA members to the reality that certain members “must take prescribed medication for serious medical problems. However, it is generally accepted that the misuse of prescription medication and other drugs can threaten the achievement and maintenance of sobriety”.

Among some suggestion listed in this pamphlet are

“• No A.A. member should “play doctor”; all medical advice and treatment should come from a qualified physician. • Active participation in the A.A. program of recovery is a major safeguard against alcoholic relapse. • Be completely honest with your doctor and yourself about the way you take your medicine. Let your doctor know if you skip doses or take more medicine than prescribed. • Explain to your doctor that you no longer drink alcohol and you are trying a new way of life in recovery….”

The pamphlet proceeds to warn

“From the earliest days of Alcoholics Anonymous it has been clear that many alcoholics have a tendency to become dependent on drugs other than alcohol. There have been tragic  incidents of alcoholics who have struggled to achieve sobriety only to develop a serious problem with a different drug. Time and time again, A.A. members have described frightening and sobriety-threatening episodes that could be related to the misuse of medication or other drugs.”

Experience suggests that while some prescribed medications may be safe for most nonalcoholics when taken according to a doctor’s instructions, it is possible that they may affect the alcoholic in a different way. It is often true that these substances create dependence as devastating as dependence on alcohol.

I can not see a “skeptical tolerance” or even a mention here of MAT.

The author then suggests that “broader anti-medication messages may be pervasive” within AA membership.

Although he slightly contradicts this by citing a survey “of almost 300 long-term AA members (average time in recovery 13 years), more than half felt medication to resist alcohol cravings/urges was or might be a good idea, and 17% did not think it was a good idea, but were “OK with it”. That would be a majority are “ok with it”?

The actual study concluded that “it did not find strong, widespread negative attitudes toward medication for preventing relapse among AA members. Nevertheless, some discouragement of medication use does occur in AA. Though most AA members apparently resist pressure to stop a medication, when medication is prescribed a need exists to integrate it within the philosophy of 12-step treatment programs.”

So why say it anti-medication views are pervasive based on this study?

However, one could say they are indeed pervasive based on the next study.

The author then states, “However, in a follow-up survey  with about 130 participants from Project MATCH 10 years after they began the clinical research study, only 16% agreed that 12-step members say it is acceptable to take medications to address drinking problems.”

I found this passage a little confusing so looked at the original survey abstract which states “In general, client perceptions were not favorable about the use of such medications.”

The author then proceeds to mention NA’s  official position “on individuals receiving MAT is welcoming on the one hand, while on the other, is explicitly restrictive and conveys a clear divide between members who are “clean” (i.e., “in recovery”) and those who are “on drug replacement therapy” (i.e., attending meetings but are not “in recovery”).”

NA’s “official position” is outlined in the pamphlet – NA groups and Medication

Drug Replacement

By definition, drug replacement is used for a different reason than prescribed medications for mental or physical health. This distinction makes drug replacement a separate issue for us in NA. When it comes to those who participate in drug replacement, it is helpful to remember that our Third Tradition clearly states that membership in NA is established when someone has a desire to stop using or when they choose to become a member, not when they are clean. No matter what the issue, groups are still charged with the goal of welcoming each person who walks into a meeting.

Some NA members are confused or even intolerant of those on drug replacement due to what they see as a contradiction between drug replacement and the NA principle of complete abstinence.

Some of us are fearful when those on drug replacement want to share or speak on behalf of NA. It may be helpful for all of us to remember that many addicts on drug replacement eventually do get clean, stay clean, and find a way of life they thought was unobtainable before coming to NA. This process doesn’t always occur when an addict attends his or her first meeting—getting and staying clean is often a decision that’s made after attending many meetings over a period of time.

Because NA a is program of complete abstinence, groups do sometimes limit the participation of members on drug replacement to ensure the clarity of the NA message. Yet, we must balance this limited participation with the idea that membership in NA comes with a desire to stop using, not abstinence.

As the Tradition Three essay in It Works: How and Why, reminds us, “Desire is not a measurable commodity. It lives in the heart of each member. Because we can’t judge the sole requirement for membership, we are encouraged to open wide the doors of our meetings to any addict who wishes to join.”

Opening our doors to these members means that groups take the time to discuss this issue and find ways to make everyone feel welcome. Each group is autonomous, and a group’s conscience will ultimately determine the level of participation of those on drug replacement.

Some groups may decide to encourage those on drug replacement to serve as coffee or tea makers, or as a clean-up person, instead of holding leadership positions. These commitments may encourage a desire for complete abstinence through allowing these members to feel a part of NA.

The reality is that some groups already permit those on drug replacement to share and lead meetings, while others do not. Although we may not endorse this level of participation, we can simply acknowledge what exists and consider ways to encourage every member to get clean and find the hope and recovery that are possible in NA. The real question groups are left with is how to honor the NA philosophy of complete abstinence and still welcome addicts in our groups and meetings.

What is most important is that we don’t let our fears get in the way of our group’s ability to carry the NA message of hope and freedom. The only requirement for membership is a desire to stop using. Tradition Three One of the most challenging aspects of this issue is that while an NA group is free to ask those who have used that day to refrain from sharing in the meeting, groups don’t decide what “using” means for an individual member. The use of medication is an issue that many members have strong personal feelings about, but a group is not there to enforce, endorse, or oppose members’ personal opinions.

Any member—those who take medication and those who feel taking medication is inappropriate—has a responsibility to not represent their personal feelings and opinions as the opinions of Narcotics Anonymous as a whole. In NA, we purposely attract people who are ill, unstable, and in need of help. Our challenge is to continue to practice tolerance, patience, and love, so that we create an atmosphere in which those who want to recover can do so.

Many of us have watched as NA meetings become weighed down by disruptions, controversy, and negativity around this issue. Yet, when these challenges are addressed through incorporating the spiritual principles of our program, groups often become stronger and more focused as a result. Recovery is often a demanding process with many ups and downs, and NA groups tend to experience similar challenges. Yet, it is these struggles that allow us to grow as individuals and as groups.

Narcotics Anonymous is here to help addicts find a new way of life, and joining NA means becoming a part of a lively and diverse fellowship. As our First Tradition reminds us, “Our relationships with one another are more important than any issue that may arise to divide us.” Keeping this in mind allows our groups to best serve all addicts seeking recovery in NA.”

However, as the author notes in reference to William White’s observations , “there are no empirical studies of how MAT patients engage with NA or, in parallel, NA members’ perceptions and attitudes toward MAT. In an informal qualitative assessment of MAT-focused online discussion forums (e.g.,, however, he found that some individuals receiving MAT have had positive, live-saving experiences in NA, though the majority experience was one of feeling rejected, confused, or angry, sometimes leading individuals to seek support elsewhere.”

The author concludes that “the medication-skeptical culture in professional 12-step-oriented treatment programs and systems appears to be in transition. Cutting-edge, front-line organizations like Hazelden Betty Ford recognize the power, and evidence, in both linking individuals to MHO-based recovery supports, as well as the need to address opioid use disorders with a comprehensive biopsychosocial approach.”

“They are currently studying pilot outcomes of this new integrated treatment that uses MAT to help patients get into recovery emphasizing 12-step MHO engagement, with an eventual gradual taper once long-term, stable recovery is achieved. It is unclear whether this type of attitudinal shift is also taking place within the community-based 12-step MHO groups themselves.

In the meantime, the limited available data suggests individuals receiving MAT are likely to encounter concerns or outright opposition from 12-step MHO members (with greater anti-medication attitudes in NA). They and their providers and family/friends should be prepared for this. The field would benefit from research studies of MAT patients’ quality of life recovery outcomes, MAT patients’ attitudes about NA, NA members’ attitudes about MAT, and whether and how MAT patients can successfully navigate anti-medication sentiment during their 12-step MHO participation. Also, specific research questions around different opinions about agonists versus antagonists would have important implications on clinical practice. Finally, there are a host of non-12-step MHOs that the field knows far less about from an empirical perspective, like SMART recovery, which, for example, officially supports legally prescribed, evidence-based MAT.”

It is worth noting that AA also has no opinion on treatment centres either. What happens at HalezdenBettyFord is not the concern of AA.

The results of their study or prospective studies do not necessarily have any bearing on 12 step groups either.

There are a number of hugely important issues raised in this article, which is indeed timely.

In part 2 of the is blog I will attend to these points and another article recently posted in the After the Party Magazine.

In order to get to the bottom of this debate we have to ask ourselves some serious questions such as

What is that I suffer from as an addict (what are the underlying conditions)?

How are these underlying mechanism “treated”by 12 step recovery processes? What is recovery?

How would this treatment or recovery be helped or hindered by continued use of MAT – i.e. when is short term use ok and long term not (how do we draw he line between recovery and choosing an easier softer way which does not arrest our condition but may contribute to it’s continued trajectory?)

There may be no hard and fast answer to the last question.

I am not sure we have arrived at a comprehensive theory of addiction which links the cognitive affective mechanisms which mediate the impaired neurobiology of addiction.

As such we seem to rely on neurobiological accounts which have a focus on paradigms such as craving and cue reactivity etc when these are always mediated by factors such as stress and emotion dysregulation?

To conclude we need to ultimately consider recovery tools which address the emotion and stress dysregulation which maintain this disorder and prompts carving and relapse.

Whether MAT straightjackets or facilitates this process to wellness is ultimately the question.

My craving dissipated with full acceptance of my addictive disorder.

Ultimately it is a very personal question too!?

This is often for individuals, and their sponsors and home groups to decide not by “official positions” – to decide for themselves what is in the best interest of recovery within individual groups at a micro level not the macro levels that researchers want 12 step groups to comment on.

Researchers may also consider that it is not always fear that prompts anti medication debates but real concern that certain individuals are engaged in a recovery process. Not to be engaged in a recovery process or reluctant to be has obvious consequences also.

AA and other 12 step groups are ingenious in their structures  that flow from from the 12 steps, to the 12 traditions to the 12 concepts for World Service to help what is essentially group of, at times, fear based control freaks to live properly together, to recover, together. They achieve in that  human terms is the equivalent of learning how to  herd cats!

They are truly remarkable. They are also there to protect us from the however well meaning opinions of others, or otherwise, in the outside world!

The outside world often has not got a clear idea of how these structures protect our recoveries. AA is a network of indepedent groups, a federation in the true sense, of emotionally vulnerable people who only want to help others like them.  This is in fact how these fellowships  grow and recovery

Within these structures we try not take other people’s inventories but only our own. We try not judge but be tolerant of. Groups take their own inventories but not other groups’. in an ideal scenario anyway!

If individuals do not feel welcome in these meetings there are often other groups where they will.

I am stating this because there is an idea of 12 step groups as a monolith when the opposite is true. The liberties of 12 step groups far exceeds any other groups I have ever known. No one is in charge of AA or other groups and it is enshrined in our concepts, traditions and steps that we all,  AA and other 12 step groups included, have the right to be wrong.

It is via our own individual and group consciousness that the best direction that most suits others in need is sought.

We recover by helping others recover.

But ultimately we all have to consider as NA states ” What is most important is that we don’t let our fears get in the way of our group’s ability to carry the NA message of hope and freedom.

We do this I believe by “love and tolerance”  and by showing 12 step recovery to those who may not yet have it.

All our efforts thus must be to facilitate this for others, even if that is facilitated by a group conscience that seems at odds with the acceptance of MAT but hopefully not with our traditions of service.