(104) Medication Assisted Recovery Anonymous vs 12 Step Groups: Comparing MOUD Stigma Experiences

Background & Introduction: The United States has faced an opioid epidemic for over 20 years, with more than 100,000 overdose deaths in 2021 alone, involving prescription opioids, heroin, and synthetic opioids. While effective treatments for opioid use disorder (OUD) exist, such as methadone and buprenorphine, barriers like prescribing limitations, insurance restrictions, criminal justice policies, and stigma hinder their use. Stigma, particularly, is pervasive and hard to address, as it exists across the general publics' perception, the criminal justice system, and healthcare settings.

Peer support groups, including Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), have also been found to stigmatize medications for opioid use disorder (MOUD). Individuals using MOUD may face exclusion in meetings, impacting their MOUD adherence and increasing relapse risks and overdose. Medication-Assisted Recovery Anonymous (MARA) was formed in 2018 as a non-traditional 12-step group welcoming to individuals on MOUDs. To date, no studies have addressed MARA, and few studies have investigated AA/NA stigma toward individuals taking MOUDs.

This study uses a qualitative approach using interviews and observations to assess whether former NA or AA attendees experience less MOUD-related stigma in MARA and how MARA addresses stigma as compared to AA/NA.

Methods: Instrument Development
The survey was developed from literature reviews, discussions with my dissertation committee, and White et al.'s (2014) study. It included screener questions for eligibility and assessed stigmatic experiences in Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Medication-Assisted Recovery Anonymous (MARA) meetings over the past three years. The interview instrument expanded on survey responses using semi-structured questions about participants' experiences with AA, NA, MARA, and medications for opioid use disorder (MOUD).

Initial observation templates were created for MARA meetings to document discussions and structure, with subsequent templates designed to validate interview themes.

Recruitment and Data Collection
Thirty participants were recruited through snowball sampling from July 2023 to February 2024, with eligibility criteria including being over 18, living in the USA, and identifying as in recovery from opioid use disorder (OUD) with experience in AA, NA, or MARA. Participants received a $5 gift card for completing the online survey. Nineteen follow-up interviews were conducted via Zoom or phone, and interviewees received a $20 gift card for their participation.

Additionally, a convenience sample of three respective online AA/NA/MARA meetings were observed with ethnographic notes taken.

Data Analysis
Interview data and ethnographic notes were analyzed for themes using iterative categorization.

Results: Survey participants were most often white, female, and located across 19 states, with most residing in the South (n=15). Only one survey respondent engaged in AA and MARA, while five participated in NA and MARA; the remaining 24 attended both AA, NA, and MARA. 80% and 83.33% of survey respondents felt uncomfortable disclosing their methadone or buprenorphine treatment to others in AA and NA, respectively, while 93% reported they did not experience any provided examples of stigma in MARA.

Similar demographic and trends concerning stigma were noted for interview participants; 79% expressed discomfort toward disclosing their methadone or buprenorphine treatment to others in AA and NA, while almost 95% did not experience any examples of stigma provided in MARA.

Qualitative data from interviews yielded nine themes:
Participants felt that recovery in AA/NA requires complete abstinence from all substances, while in MARA, individuals define their own recovery; that relapse in AA and NA means using any mind-altering substances, whereas MARA views relapse as a return to problematic use and is part of the recovery process.

Participants perceived AA/NA as having a rigid, one-size-fits-all approach essential for recovery, while MARA offers a flexible and empowering method, viewed as a "tool in the toolbox" of recovery services.

They perceived that recovery in AA and NA relies on a Higher Power, whereas MARA encourages personal power and choice.

Many participants felt that AA and NA are less accepting of medication-assisted treatments (MOUDs), viewing them negatively, while MARA is open and accepting of MOUDs.

Most learned about AA/NA in mandatory treatment settings, while they discovered MARA through online searches or referrals from friends.

Participants often continued participating in AA/NA due to legal or treatment center requirements, but they chose to engage with MARA voluntarily because they appreciated its positive aspects and community.

They believed that AA/NA have a more rigid meeting structure, offering less personalization, while MARA is seen as more flexible, allowing for individual needs.

Participants liked the welcoming nature of AA/NA for newcomers, but they liked MARA for its inclusive, accepting, and supportive community. They felt that MARA provided a safe space for discussing challenging recovery situations and promoting harm reduction.

Critiques of MARA included issues with meeting accessibility, a lack of literature, and potentially triggering practices. Criticisms of AA/NA focused on judgmental attitudes towards MOUDs, stigmatizing language, and perceived hypocrisy regarding less addictive substances.

Conclusion & Discussion: My study sought to determine whether former AA or NA attendees experienced less MOUD-related stigma in MARA and how MARA addresses stigma as compared to AA/NA. Interview participants responded that they experienced less MOUD-related stigma in MARA, as well as less overall stigma in MARA, as compared to AA/NA. MARA's focus on inclusivity and flexibility (e.g., using harm reduction) as opposed to AA/NA's perceived rigidity and one-size-fits all model were described as reasons as to why individuals experienced less MOUD-related stigma. In addition, MARA's stated name and purpose helped participants feel that MOUDs were acceptable to discuss and continue taking, rather than tapering.

Methadone/buprenorphine providers, mental health providers, and court treatment providers should disclose that negative attitudes may exist toward MOUDs and medications exist in AA/NA to their clients before initial involvement to prepare them for possible negative comments or attitudes they may experience in AA/NA settings. Providers to those with OUD should consider referring clients to non-AA/NA groups that provide dual diagnosis support. Healthcare facilities could offer MARA meetings on-site, facilitated by staff for clients to attend.

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Kelly JF, Levy S, Matlack M. A systematic qualitative study investigating why individuals attend, and what they like, dislike, and find most helpful about, smart recovery, alcoholics anonymous, both, or neither. J Subst Use Addict Treat. 2024 Jun;161:209337. doi: 10.1016/j.josat.2024.209337. Epub 2024 Mar 14. PMID: 38492804; PMCID: PMC11090757.

White, William & Campbell, Michael & Spencer, Robert & Hoffman, Howard & Crissman, Brian & DuPont, Robert. (2014). Participation in Narcotics Anonymous and Alcoholics Anonymous and Abstinence Outcomes of 322 Methadone Maintenance Patients. Journal of Groups in Addiction & Recovery. 9. 14-30. 10.1080/1556035X.2014.888883.