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'Opioid Reckoning' calls out the Twelve Steps in an age of fentanyl

Macalester professor's new book is a provocative look at the limitations of today's treatment industry in the face of the modern opioid epidemic. The "reckoning" in Amy C. Sullivan's title stands for the collision between the polite traditions of getting sober in the 12 Steps and the need for ideology-free medical care in the face of a deadly scourge.

ROCHESTER, Minn. — With drug overdose deaths soaring past 100,000 American lives lost in 2020, and with opioid-use disorder patients often experiencing rounds of inpatient treatment followed by relapse, overdose and sometimes death, has the so-called "Minnesota Model" of addiction care fallen short of its celebrated potential to transform lives?

Put more directly, in an age of opioids, is the method embodied within the time-tested traditions of Twelve Steps and Alcoholics Anonymous — an approach pioneered by the state's treatment mecca, the Hazelden Betty Ford Foundation — no longer up to the task?

That's the thorny question raised in "Opioid Reckoning ," a new book published last month by University of Minnesota Press by independent scholar and Macalester College historian Amy C. Sullivan .

A provocative look at the limitations of conventional addiction treatment in the face of the modern opioid epidemic, the "reckoning" in Sullivan's title stands for the collision between the polite traditions of getting sober in the Twelve Steps, and the need for ideology-free addiction medicine in the face of a deadly scourge.

"The key takeaway from the Minnesota model is the need for abstinence and following the program once you leave treatment," Sullivan said in a recent phone interview. "You go to AA meetings and get a sponsor and keep going to AA meetings.

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"It was revolutionary in the time that it was created in the 1940s," she says. "It took inebriates out of the asylum and allowed people to have a space to heal with the care of nurses, peer support and a priest or a pastor. That's what Hazelden created for working professional men."

What "Opioid Reckoning" explores is whether a more successful approach can be found in the trading of AA's self-examination and chemical prohibitions for the more pragmatic approach known as harm reduction .

The Opioid Reckoning, published in 2021 by University of Minnesota Press. free

Harm reduction seeks to stabilize the suffering chemically, then meet patients with empathy and support in all other aspects of their lives. Sullivan traces harm reduction to clean needle, methadone and condom outreach programs targeting HIV and addictions in the 1980s.

An approach that eschews moral judgments in favor of radical acceptance, it's one that advocates the use of fentanyl test strips, never taking drugs alone, and promoting the widespread availability of Narcan, an emergency overdose drug.

"The ideas around Twelve Steps and abstinence have to do with a particular kind of person and a particular kind of place and particular kind of substance," Sullivan says.

"It's helped plenty of people, but it has failed us with the opioid epidemic. All the systems have failed us. The medical system has failed and the insurance system has failed us and the Minnesota Model has failed us. We're not doing enough to stave this off."

From painkillers to heroin to fentanyl

The story of the opioid epidemic begins with a 1990s-era, drug industry-created Pandora's box, one which seeded addictive painkillers throughout the nation's suburbs and small towns using pill mills and pharmacy chains .

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Once prescribers clamped down on 30-day supplies of painkillers, this first wave of the opioid epidemic soon gave way to a flood of cheap heroin in the early 2000s. With the arrival in recent years of illicit fentanyl , compounds which proved cheaper to produce, opiate demand eventually shifted to counterfeit drugs laced with the powerful and deadly narcotic.

While Minnesota has not been among the states hit hardest by opioids, no state has gone unscathed. Pockets of Minnesota have shouldered an outsized impact from opioids, including Minnesota tribal communities and communities of color.

For many, the approach pioneered by Hazelden Betty Ford Foundation — even as modified in some centers to incorporate the use of opiate receptor medications — stands today as a bad fit for a host of marginalized communities, especially given the nature of the drugs themselves.

"If someone is craving a drug and their body is hurting from it, it becomes really, really hard for them to work on the 12 Steps and to talk about how they are powerless and to turn their life over to God," Sullivan says. "It was pretty clear that the situation for treatment was going to have to change."

Among the alcoholism-based tropes of AA that fail to pass muster with opioids, as Sullivan sees it, are the concern that opioid parents trying to save their adult children are "enabling," delaying the needed reckoning with rock bottom. With opioids, rock bottom can mean death.

One change agent profiled in "Opioid Reckoning" is Dr. Marv Seppala, the Mayo Medical school graduate and recently retired medical director for Hazelden.

In 2011, Seppala initiated a COR-12 program at the center, a hybrid treatment using drugs such as Suboxone and naltrexone in combination with Twelve Steps. It was a move that clashed with the longstanding Alcoholics Anonymous model of abstinence-only.

"It was a real battle for him to get the institution to accept the idea of medications for opioid use disorder," Sullivan says of the program, which now uses three treatment pathways for opioid addiction, one of them an abstinence oriented version seeking rapid tapering from addiction medication.

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"The deaths from the epidemic and the overdoses that were happening after patients would leave Hazelden," Sullivan says of COR-12, "really made them reckon with their own stance on medication."

Today on its website , Hazelden says COR-12 has research showing "high rates of continuous abstinence in the first six months after initiating recovery."

It also discourages the original addiction medicine drug that is methadone, however, with the caveat that "people in methadone maintenance programs don't typically have an abstinence orientation ...."

"You need to do the spiritual work because something in you is flawed," Sullivan says of AA. She believes this poses barriers to a woman suffering domestic abuse, or a person of color battling exclusion.

Others cite the unrealistic expectation within Twelve Steps of imposing a contemplative path to recovery upon drug users experiencing homelessness, trauma, generational drug use or the disruptions of the criminal justice system.

"To take someone who has been an active rip-and-run heroin addict for the last five years and assume they are going to be able to engage in a fairly literature-based experience of reading ... the Big Book and completing these workshops on Steps One through Five all in the span of 28 days ... those two are incongruous," opiate programming director Rick Moldenhauer says in Sullivan's book. "They don't work well together."

Yet the AA model remains the default pathway. Sullivan believes this is because health systems do not generally wish to deal with persons suffering addictions, and because methadone dispensation has been racialized and stigmatized, seen as a lesser pathway.

"It's actually not that complicated to treat," Dr. Emily Brunner says about opiate dependency in the book. A St. Paul addiction medicine specialist, Brunner cites research that opioid addictions can be effectively managed 50-75% of the time with Suboxone.

"AA and the 12 Steps have been really powerful for many people," Sullivan says. "They create a community and it's a good program, but .... you can't focus on yourself and your spiritual life if your body is distracted, and you just want to leave treatment."

Get the book

"Opioid Reckoning" by Amy C. Sullivan is available for $25.95 through University of Minnesota Press at www.upress.umn.edu/book-division/books/opioid-reckoning or on IndieBound or Amazon .

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