Reckoning harm reduction with Twelve Step recovery: Who’s “in the room(s)”?

By Kim Gannon and Emily Pasman, guest authors

Twelve Step programs are ubiquitous in the US substance use disorder (SUD) treatment landscape. For many, they provide a powerful forum of life transformation, fulfillment, and purpose. We are two such people: two statistically rare cases (Dodes & Dodes, 2015) who have successfully found long-term recovery from SUD via Twelve Step participation. While we have benefitted personally from these programs, we cannot ignore the lives they put in jeopardy by stigmatizing people who use medications for opioid use disorder (MOUD) and harm reduction strategies. Without large-scale structural and cultural change, Twelve Step communities will continue to harm those they intend to help.

To bring awareness to this tension, we recently authored a commentary entitled Knowing or not knowing: Living as harm reductionists in Twelve Step recovery in the Journal of Substance Use and Addiction Treatment. In it, we begin by describing our journey from drug use to Twelve Step meetings, often called “the rooms” by attendees. Then, we outline our path to embracing harm reduction and non-abstinence recovery pathways. Some of what brought us to harm reduction was academic; we immersed ourselves during graduate school in the overwhelming literature supporting harm reduction over abstinence-only modalities (Barnett et al., 2020; Paquette et al., 2022; Wakeman et al., 2020). Some, however, was much more personal: dozens of our friends and community members have died of overdose in the past few years alone. Beyond grief, rage, and gratitude for our own lives, these experiences have provoked deep reflection and interrogation of our own biases and those of the communities we are a part of.

Editor's note: The authors of this guest post were interviewed by our colleagues at the Peer Recovery Center of Excellence for the April 2023 episode of the "Recovery Talk" podcast. We invite you to listen to that conversation here. 

As graduate students in public health and social work, we frequently find ourselves in dialogue about power and privilege. When wrestling with the way institutions exert influence, we are presented with a common question: “Who’s in the room?” Who are the voices that are heard, privileged, and acted upon in decision-making circles? Historically, the answer is us. Even in 2023, abstinence is still perceived as the “right” (or only) way to recover from SUD, and those who can attain it are elevated in social, clinical, and political circles. We wrote this piece, however, to bring attention to those who are not “in the room(s)”: those kept out due to stigma, and those who died from gatekeeping in the very communities that saved our lives.

To be part of the solution, we offer several suggestions. Individual Twelve Step members can work to deconstruct their own biases and to vocalize their support for non-abstinence pathways in meetings, including by directing people who use MOUD and harm reduction to supportive people and groups. At the meeting level, groups can adopt policies that proactively state support for other pathways in a reading at the beginning of meetings, similar to the Alcoholics Anonymous “safety card” (Alcoholics Anonymous, 2022). Moreover, clinicians can clearly communicate the risks and benefits of Twelve Step participation to their clients, as well as offer themselves as a resource to help navigate messages from “the rooms” that may not support clients’ goals. However, without policy change – including removal of meeting attendance requirements from criminal-legal and treatment settings, changes to Twelve Step literature, and oversight to hold groups accountable for harmful messages they spread – these changes will not suffice.

Harm reduction philosophy promotes the inherent worth and dignity of the individual, regardless of their drug use. Twelve Step philosophy aims to be of maximum service to others, particularly those suffering from SUD. These philosophies are more than compatible, and combined they can be unstoppable. But we cannot achieve this unity without a major reckoning within Twelve Step communities. And as people lucky enough to be “in the room(s),” we must dedicate our lives to making it happen.

References

Alcoholics Anonymous. (2022). Safety card for A. A. groups. https://www.aa.org/safety-card-aa-groups.

Barnett, M. L., Barry, C., Beetham, T., Carnevale, J. T., Feinstein, E., Frank, R. G., de la Gueronniere, G., Haffajee, R. L., Kennedy-Hendricks, A., Humphreys, K., Magan, G., McLellan, A. T., Mitchell, M. M., Oster, R., Patrick, S. W., Richter, L., Samuels, P. N., Sherry, T. B., Stein, B. D., … Vuolo, L. (2020). Evidence based strategies for abatement of harms from the opioid epidemic. Washington, DC: Legal Action Center.

Dodes, L., & Dodes, Z. (2015). The sober truth: Debunking the bad science behind 12-step programs and the rehab industry. Beacon Press.

Paquette, C. E., Daughters, S. B., & Witkiewitz, K. (2022). Expanding the continuum of substance use disorder treatment: Nonabstinence approaches. Clinical Psychology Review, 91, 102110. https://doi.org/10.1016/j.cpr.2021.102110

Wakeman, S. E., Larochelle, M. R., Ameli, O., Chaisson, C. E., McPheeters, J. T., Crown, W. H., Azocar, F., & Sanghavi, D. M. (2020). Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Network Open, 3(2), e1920622. https://doi.org/10.1001/jamanetworkopen.2019.20622

ATTC’s Pearls of Wisdom: Address Challenges with a Collaborative Spirit and an Eye on the Big Picture

By Pamela Woll, Southeast ATTC, based on interviews with Center leadership.

In SAMHSA Region 4, the Southeast ATTC has learned that overwhelming challenges call for openness, broad vision, collaboration, creativity, flexibility, and a willingness to reach out at every level for ideas that will help us build hope and support recovery.

Region Four has eight states—Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee—six of which have not chosen Medicaid Expansion.  Many are under-resourced, particularly in their large rural areas.  

Our field is overstretched and underfunded, struggling to serve a large population with complex combinations of physical and behavioral health conditions, often exacerbated by the effects of deprivation along the social determinants of health.  The individuals we serve are also graced with significant strengths, many of which have been overlooked or minimized most of their lives, rather than harnessed in service of health, well-being, and recovery.

Sometimes it seems as if our field aches for a simplicity that will never be supported by reality—a “one-and-done” training or treatment model that will “check all the necessary boxes,” set everyone on the right course, and turn the tide of conditions that are killing people, destroying families, and overwhelming communities.

From our society and from our own history, the field has inherited:

• persistent stigma toward people with behavioral health conditions;
• harsh terminology that helps keep the stigma alive;
• deficit-based treatment approaches;
• a focus on acute care, even for chronic conditions;
• a hierarchical relationship between clinician and client;
• belief that people who have trouble recovering “just need more pain in their lives”;
• ignorance of the role of trauma in behavioral health conditions and the potential for retraumatization in treatment;
• dismissal of recovery and recovery support as an afterthought, separate from treatment; and
• a siloed system in which the work of treatment is kept separate from that of other critically important systems and communities in the lives of the people we serve.

The past 30 years have seen a blossoming of innovative models and frameworks that are helping us understand the limitations of our inheritance and the true nature of behavioral health.  These include chronic-care approaches, recovery-oriented systems of care (ROSC), trauma-informed care, strength-based models, a focus on health equity, culturally appropriate approaches, integrated health models, and public health approaches to behavioral health.

These approaches fit together well.  They are related, compatible, and capable of helping our field address the complexity we face.  But they are not quick, simple, or inexpensive to implement.

So what does a small-but-mighty ATTC do with all this?  Here are some things we have found helpful:

• With eight states that are significantly different in their needs, we are eclectic in our approaches.  We are not resigned to the fact that one size does not fit all—we love it.
• We have worked hard to cultivate diverse partnerships throughout the region, the ATTC Network, the larger field, and beyond.  We listen with minds and hearts and strive to treat our partners with consideration and respect.
• With our state partners, we have looked at how we can work together as a region, using existing resources and working to bring more resources into the states.
• As valuable as the SSAs are in guiding our vision, we seek a broader perspective on the needs in each state and the region.  We gather information from key informants on every level, e.g., practitioner and provider organizations, schools of SUD studies, faith-based alliances, community and advocacy groups, culture-specific constituencies, ROSC councils, and recovery community organizations.
• We use and contribute to the body of resources and processes developed to dispel the old myths, help providers adopt evidence-based practices, and pave the way for the innovative models that will help the field transform systems, approaches, and human lives.
• We have learned that the strengths of our staff and our region offer opportunities we cannot afford to ignore, e.g., our Faith and Minority-to-Priority Initiatives that have been sources of inspiration and progress.

We have also learned that we are responsible for keeping our hope, our spirit, and our love of service alive.  We cannot be “hope carriers” if we lose hope, and we cannot be of service—truly of service—if we are not wholehearted in our approaches.

All we have to do is look and listen—to our constituents, at our events, in the feedback we receive, and in our invitations from potential collaborators—to be reminded that the work we do really does elevate providers and help them save lives, heal families, and make communities stronger.

And then we remember how grateful we are.

NIATx in New Places: Research and Innovation in Professional Coaching with NIATx

By: James H. Ford II, PhD, FACHE, LFHIMSS

Dr. Jay Ford is an associate professor in the School of Pharmacy at the University of Wisconsin-Madison. His teaching and research focus on the dissemination, implementation, and sustainment of organizational change in multiple healthcare environments, including acute care, behavioral health, and long-term care. He was also a member of the team that helped to develop and launch the NIATx model in 2003. We caught up with Jay recently to find out how he’s using NIATx in his work today.

What’s one “aha!” moment that you remember from the early days of NIATx?

It was probably one of the first times working with the Jackie Nitschke Center in Green Bay. I realized that the change team understood the importance of ensuring they set up a way to sustain the changes and improvements they'd made, even if the staff who were critical to the change left the organization. It was a sign that the model was getting legs and would be sustainable.

Do you have a favorite NIATx principle in the NIATx model?

Yes, and it's probably evolved a little bit. I would say my favorite one is NIATx principle 1, understand and involve your customers. But what’s also grown in favor is the principle of getting ideas from outside the organization–and that can mean organizations inside or outside the field.

Which NIATx principles or approaches were considered the most revolutionary for those first organizations that tried the NIATx model?

Again, NIATx principle 1: Understand and involve the customer. I remember a change leader in South Carolina telling us about the barriers she encountered when she called local agencies in the role of a client seeking treatment. It was eye-opening. Another example I often use when explaining the principle is the story of a phone ringing non-stop when someone called a treatment agency for an appointment. And lo and behold, when the change team investigated, they discovered that the line was still connected to an empty office with no phone.

How are you using the NIATx model today?

I'm using parts of it in my research focused on coaching. How do we assign that external facilitator to work with an organization? Sometimes the best coach isn't the engineer or scientist but the nurse, the counselor, or a trained NIATx coach. As we move outside addiction treatment and into new settings such as nursing homes, you may also need a clinical champion or clinical coach to move forward.

A current study I am working on is a continuation of the work I've been doing with Mark McGovern in Washington state that studied the use of the NIATx model to reduce waiting time for medications for people with co-occurring disorders.* We are now in year one of a five-year NIDA grant that is recruiting specialty addiction treatment clinics, FQHCs, and primary care clinics^**. The study employs a measurement-based stepped implementation-to-target approach within an adaptive trial design to improve access to MOUD. In addition to a new internal facilitation implementation strategy, we’re using different components of the NIATx model, a variation of the NIATx Change Leader Academy, and an adaptation of external coaching with a virtual site visit.

Another example of NIATx in my research is my work with Bryan Garner on substance use treatment and HIV. In this project, we walk the HIV service organizations through three phases: preparation, implementation, and sustainment. The coach is still involved, but their focus depends on the organization's journey through the three phases.

I am also working with a UW-Madison infection disease specialist Chris Crnich on a project that targets improving antibiotic utilization in nursing homes. A coach connects with the nursing homes directly on and around antibiotic utilization, so we're primarily using the coaching component of NIATx in this study also.

Any other thoughts on how NIATx has evolved over the years in your research?

What I’ve found over the years is that the NIATx model is a simple, easy-to-use model that can be adapted and applied in many kinds of organizations. Coaching is the most effective implementation strategy to introduce the NIATx model. How coaching is delivered has also evolved in the last 20 years. We started with a more intensive coaching approach – quarterly in-person site visits and bi-weekly calls over an extended period (often 18 months). Although project or situation specific, coaching now often involves an initial site visit (in-person or virtual) and coaching calls tailored to organizational needs delivered over a shorter period. Despite how coaching has changed, I prefer the active role of working directly with healthcare organizations leads to a deeper understanding of how to best tailor the NIATx model and builds lasting connections that contribute to successful implementation and sustainment of organizational change.

Sources cited:

Ford, J. H., 2nd, Rao, D., Gilson, A., Kaur, A., Chokron Garneau, H., Saldana, L., & McGovern, M. P. (2022). Wait No Longer: Reducing Medication Wait-Times for Individuals with Co-Occurring Disorders. Journal of dual diagnosis, 18(2), 101–110.

Ford, J. H., 2nd, Cheng, H., Gassman, M., Fontaine, H., Garneau-Chokron, H., Keith, R., Michael, E., & McGovern, M. P. (2022). Stepped implementation-to-target: a study protocol of an adaptive trial to expand access to addiction medications. Implementation science: IS, 17(1), 64. https://doi.org/10.1186/s13012-022-01239-y  PMCID: PMC9524103

About the author:

James H. Ford II, PhD, FACHE, LFHIMSS, Associate Professor, UW–Madison School of Pharmacy. Dr. Ford received his BS (1983) in Health Systems Engineering from the Georgia Institute of Technology in Atlanta, GA; his MS (1989) in Industrial Engineering from the University of Tennessee in Knoxville, TN, and his Ph.D. in Industrial Engineering (2004) from the University of Wisconsin, Madison WI. His dissertation examined how employee participation in and information about organizational change and their perceptions about change self-efficacy and coping skills influenced commitment to and behavior toward change. Read Dr. Ford’s full bio.

ATTC’s Pearls of Wisdom: The Legacy and Future of the NIATx Model and the Great Lakes ATTC

 By Todd Molfenter, PhD, director of Great Lakes ATTC, MHTTC, & PTTC

How can I successfully make “organizational change?”

This is the fundamental question that started the NIATx movement. Simply stated, NIATx is a set of tools and techniques used to make organizational change: whether it be improving the admissions process, implementing an evidence-based clinical practice (like MOUD!), improving linkages between health systems of care, or hiring more staff. And change is not easy!

The NIATx change model was developed to make us better at facilitating change in organizational settings. 

Over the past 20 years, the NIATx model has been part of numerous research trials, applied by more than 3,000 organizations, and is now supported by over 60 peer-reviewed publications. 

What’s more, the NIATx approach has been a key ingredient in the Great Lakes ATTC's mission to promote both knowledge of evidence-based practices and how to implement them.

So, what have we learned over the past 20 years?

1. Leadership Motivation Matters

Yes, we know leadership is important and we can’t forget that. Some of the new information we have learned comes from the Motivational Interviewing field. Not only is it important to have a leader that commits to supporting the change, but it is important to clarify why. For example, if asking the question, “Why do you want to implement contingency management in your organization?” make sure to integrate the reasons why into the implementation approach. Furthermore, make sure the desired goals are met, and remind the executive leader of these reasons should team motivation and executive buy-in begin to wane.

2. Champions Save the Day

It is not only Marvel movies where heroes save the day. In change management efforts, the champions are the heroes. They are the people that keep projects moving forward and provide critical internal promotion and marketing for the project. In addition to clinical champions, sometimes it is critical to have champions from the medical, technical, and administrative ranks to make a project a success.

3. The Power of External Incentives

We are all busy, stressed people, and these conditions have only become more acute as labor shortages limit the number of hands available. This is where external incentives in the form of reimbursement or funding support, expectations of key payers, community pressure, licensure expectations, etc. will aid in making sure that the change initiative is a success and becomes a priority among the many other priorities being faced. Look for and embrace external incentives.

4. Easy, Easy

Easy to implement, easy to maintain. Every ounce of extra effort by already overburdened staff becomes a disincentive to make the targeted change. This means great effort should go into making the change as easy as possible to implement and maintain. A simple planning tool is to make sure that a change will result in no extra effort by the staff who are to apply the change. If the change requires more work, relapse to pre-existing behaviors is almost guaranteed.

5. “Nothing About Us Without Us”

This is a commonly quoted phrase from the recovery community. Why is that? Well, because if you plan changes for that community without their input a) you will probably get it wrong, and b) even if you get it right, they likely are going to be very unwilling to implement the change. And they’re right. In this era of community engagement, community participatory research, and the like, you need to understand the desired change the community is seeking to implement as well as how they want the process to occur. The first NIATx principle is to gain the voice of the customer. The customer is anyone who is the recipient of the intended change. Take the time to understand their wishes and success will be more likely.

The Great Lakes ATTC has taken the lessons learned from NIATx and combined them with the emerging implementation science movement along with classic engineering principles to address the pressing and emerging issues in addiction treatment and recovery. 

In our region, this approach has helped us make impressive gains in addressing the opioid crisis and making recovery-oriented systems of care a customary practice. 

The NIATx model has been a key tool for supporting the ATTC Network’s mission over the past decade, and we look forward to the challenges and successes that lie ahead.

About the author:

Dr. Todd Molfenter is the deputy director of the Center for Health Enhancement Systems Studies at UW–Madison. He is also the director of three SAMHSA-funded technology transfer centers: the Great Lakes ATTC, MHTTC, and PTTC.  

Todd’s research specialty is implementation science, which studies methods to promote the use and uptake of evidence-based practices into routine practice. Todd helped to develop and refine the NIATx model of process improvement and has directed several multi-state studies focused on organizational and systems change. He has also guided hundreds of change teams on effective use of NIATx tools and techniques.   

Todd is the 2020 recipient of the Bollinger Academic Staff Distinguished Achievement Award, awarded by the UW-Madison College of Engineering for excellence in research.