The applause rang out in the drab
meeting hall across the river from 
David Hockenbury's hometown of Louisville, Kentucky. David's heart was pounding, and he felt his cheeks flush under the gaze of
the large group gathered there on a spring night in 2016. It had been 30 days
since he had last flexed his arm, found a vein, and spiked it with a dose of
heroin—and now, in a ritual common to many Alcoholics Anonymous groups, he
was being called on to receive his first sobriety chip.

David got up from his folding chair.
Several people reached out to shake his hand or slap him on the back as he
passed. Everyone in the room knew how tough it was to achieve that first month
of sobriety. But as the little red medallion was handed to him, the question
that had haunted him for the last month flashed across his mind: "Am I a
fraud?"

David had a secret. After years of
failing to kick his addiction, he had finally been prescribed Suboxone,
a pill to ease his cravings and help him recover. The pill helped. For the first time since
engaging in heavy heroin use, he was managing to stay clean. But David knew that
many in the recovery community would not consider him truly sober if they knew
he was taking medicine. "Most people look at Suboxone and think you are
cheating, that you are getting high somehow, that you are taking the easy way
out," he told us. "There is this junkie pride where you are supposed to go through
detox and withdrawal. Suffer it out. Cold turkey."           

As David walked back from the podium, he felt confused
and alone. Should he trust his doctor, who had told him that Suboxone was an
effective way of treating opioid addiction and akin to an
antidepressant? Or his peers, who preached complete
abstinence, even from medication—and honesty, no secrets, as the only pathway
to recovery? In the support group people had shared their darkest
secrets as part of the 12 Steps to recovery. Some had told the group that they
had been molested as children. One had even confessed to David that he had committed a murder.
"But I didn't even feel comfortable to say that I was
on Suboxone," David said.

Back in his folding chair, he turned
the small A.A-engraved token over in his needle-scarred hand, and the last bit
of pride he had felt over his accomplishment was stifled by the paradox of his
situation: The medication that gave him a fighting chance at escaping
addiction was also what held him back from truly belonging to the support group
he desperately needed to stay sober.

Eventually, David stopped taking
Suboxone, part of his on-again, off-again relationship with the treatment. "I
guess that sense of isolation and loneliness led me back to the kind of people
that I was getting high with, led me back to the streets and the drugs,"
he said. "Everybody needs their tribe."
 

For many people, that tribe comes at
a great cost. Health authorities and medical researchers widely consider
medication-assisted treatment (MAT) with methadone or Suboxone the most
effective way of treating opioid addiction, which in 2016 affected
some two million people across the United
States. Yet in the midst of a national opioid epidemic, only a fraction of
addicts receives MAT. In response, President Donald Trump recently 
vowed to expand access to MAT,
which can be expensive and difficult for patients to obtain. The push, sorely
needed as it may be, faces an obstacle that is beyond the abilities of the
federal government to remedy. The real barrier may not lie in a lack of
resources, but in the very way America still thinks of addiction, thanks to a
decades-old 12 Step philosophy that has left a new generation of addicts out in
the cold.

It was pitch black outside and the
sun would not rise for another two hours. Michael Dever, a skinny 34-year-old in horn-rimmed glasses, black hoodie, and black pants, was already in his
car, driving to a methadone clinic in the east end of Louisville on a January
morning, just as he had most mornings for the last seven years. This is his
routine. "I've tried to separate it from my person. Because this is just
something I have to do," he said. "It enables me to live a normal, stable
life and get up and go to work every morning and be productive, and not be on
heroin shooting up three or four times a day." 

The Crossroads of Louisville
methadone clinic is situated on a dead-end road. Two large spotlights shined on
the parking lot, making the ground look glassy in the light rain, as Michael made his way hastily
towards the clinic. On busy days, when clients are called five at a time, and lined
up against a wall festooned with inspirational quotes, Michael almost feels
like he is in prison. Today, the nurse only called Michael, went over his dose,
and dispensed 16 mg of methadone in a small plastic cup. Michael swallowed the
cherry-flavored shot and rinsed with water. "That's how it's supposed to run,
so it doesn't interfere with your day so much," he said. "But it doesn't happen
like that every day. It rarely happens like that, actually."

If he comes in a few hours late or if
the line is longer than usual, his hands will go clammy, as the synthetic
opioid substitute dissolves from the receptors that they have been blocking and
craving starts to kick in.

Michael can deal with the hassle of getting the medicine.
What he finds harder to live with is the suspicious attitude people take toward it.
On the walls of the clinic, large posters address some of the myths that feed that attitude. One is that it is just a replacement drug—that patients on methadone
are just trading one addiction for another addiction. "That's not true at
all," Michael said sharply. "Methadone-assisted treatment is nothing like
a heroin addiction. It's not even close."

David Hockenbury is one of many recovering opioid addicts who has felt pressure to abstain from medication: "There is this junkie pride where you are supposed to go through detox and withdrawal. Suffer it out."Photographs by Katrine Jo Andersen and Cecilie Maria Kallestrup

The misconception stems from the fact
that most medications for treating addiction, like Suboxone and methadone, are
opioid-based. With the correct prescription, an addict's compulsive behavior,
loss of control, constant cravings, and other hallmarks of addiction will
usually vanish. But if you take too much, you will get high. The idea that MAT
is just a replacement drug has been debunked countless times by medical
organizations, including the
U.S. Department of Health and
Human Services
 (HHS).

Nonetheless, Michael has been told
that he is still a junkie, not only by people in the 12 Step meetings he used
to go to, but also by friends: "They look at you like you are still using, that
you are not sober, that you are basically still living the life of a drug
addict, when you are not." Michael has come to terms with the fact that he
will probably have to take methadone for the rest of his life. He hates the
stigma associated with his medicine, but he knows that he needs it to function.

The effects of MAT have been studied
by health authorities and medical experts for over five decades, and the
evidence in favor of the treatment method is overwhelming. One 2017 review of 19 studies, published
between 1974 and 2016, found that when people received medication-assisted
treatment, their overall risk of dying from an overdose went down by more than
50 percent. HHS affirms that long-term MAT has the best track record for controlling opioid use
and saving lives.

But MAT is still greatly underused. One study from 2017 found that less
than one in four patients diagnosed with opioid dependence or abuse received
the combination of MAT and psychosocial treatment that clinical guidelines
recommend. Furthermore, this figure does not include undiagnosed addicts or
addicts without health insurance. The actual percentage of recovering addicts
on MAT is likely much lower.
 

A visit to the men's detox ward for
the Healing Place in Louisville—a facility that is based on A.A.'s 12 Step
method—points to one of the causes. Twenty-five beds are positioned side by side in an open room, smelling of
sweat and detergent. A man lay sprawled on his mattress with his pants down to
his knees. Another rested with a sheet over his face. The drapes were drawn,
the room lit only by the ambient glare of fluorescent tubes. There was no sense
of time in here. Scattered around the room were several copies of one tome: The Big Book of Alcoholics Anonymous.

For nearly 30 years, this facility
has played a vital part in the city's social work. The Healing Place provides
food and shelter to up to 700 people every day; the bulk are in the recovery program, some are in detox, and the rest are homeless people coming
from shelters or from the streets. For addicts who want to kick the habit, but cannot
afford expensive rehabs, there is almost nowhere else to go.
 

Fifteen years ago, when Michael was
just 20 years old, his parents forced him to go there to wean himself off his
growing addiction to opioids. He stayed for only one night. Early next morning,
he staggered out the door and walked for miles back to his house. Neither the
interior of the detox ward, nor its philosophy, has changed much since. The
recovery facility believes in full abstinence, so before they do anything else,
patients must spend their first 24 hours to nine days in the ward detoxifying
themselves from whatever substance they are on: alcohol, heroin, painkillers—or
medication-assisted treatment like methadone or Suboxone.

Heaps of faded sheets were piled at
the end of the room. Depending on the drug used, withdrawal symptoms can
include severe sweating, nausea, and diarrhea. "It's just absolutely horrible.
It's like a cold and a flu combined times ten," said former resident
Keenan Beckhart, who now holds the title of gift officer of the development
team. Yet, apart from mild pain relievers, patients are not allowed to
use any medication. The staff members, most of
whom have been through the program themselves, have limited medical training.

At lunch in the detox ward, everyone got the same thing: two pieces of wheat toast
wrapped in foil with slices of cold turkey. The irony was almost too thick. One guy
stirred a big pot of gray porridge with a texture like wallpaper paste and
doled out portions for those who had the strength to eat. Most stayed in bed.

On the wall hung photographs of about 200 people who had previously been through the program. The Death Board, as it is
called, is a memorial, meant to honor former patients, and to serve
as a gloomy reminder of what can happen to current patients if they relapse.
Adam Harmon, a young man with a scruffy brown beard, had been a resident at the
Healing Place for almost a year before he became a peer-mentor. "I was in the
program with him... and him... and him..." he said, pointing to the small
photographs of men who had overdosed and died. "Twelve people that I know have
died within the last 11 months."
 

But what is accepted with grim
resignation at the detox ward is a source of deep dismay for medical experts.
"Detox without MAT is potentially dangerous," said Bachaar Arnaout, an
assistant professor of psychiatry at Yale School of Medicine. "An
overwhelmingly majority of people end up relapsing after detox. It's a gamble
with lives."

When patients go through detox, their
tolerance decreases drastically. If they fall off the wagon and take the dose
of opioids they were used to, or even a lower dose, this can be enough to shut
down vital body functions. This is especially the case today, Arnaout said,
because the opioid epidemic is largely driven by fentanyl—an opioid up to 50 times
more potent than heroin.

Both national and international
studies have shown that detoxing without medication is associated with
increased risks of mortality. HHS does not recommend going through serious
opioid withdrawal without medication such as Suboxone or
methadone. The health authorities in Canada—a nation that is facing a similar
public health emergency—go even further and strongly recommend against detoxification
without MAT.

"One wonders whether it
would actually be safer to continue using drugs," 
Arnaout said, "rather than attending programs
that do not lower the risk of relapse, but result in lowered tolerance, and
thereby an increased risk of overdose." He hastened to add that he did not
advocate abstaining from treatment. "But my point is
that people should have access to the treatment that works."
 

The official stance of the Healing Place is
that recovery is different for everyone, and that, for some, MAT might be the
right solution. Yet they are very clear that MAT is not compatible with their
methods. "Our program works just fine without Suboxone or methadone," said
Keenan Beckhart. "And if you are willing to change your life and get off of
Suboxone or methadone, you are more than welcome to come in here."

The patients that make it through
detox typically start their new lives as residents at the Healing Place. They
go to church, take classes on fundamental life skills, and participate in A.A.
meetings. More than 40 weekly 12 Step meetings are held at The Healing Place. As
you reach the end of the program, you are not only sober—you are also equipped
to go out and live a normal life, Beckhart said. "At a Suboxone clinic you
learn how to take Suboxone and to stay on Suboxone. The same with methadone,"
she added. "We don't do that here. We teach fundamentals of life."

The detox ward at the Healing Place in Louisville, Kentucky.

The recovery facility is funded
mostly by donors and the state of Kentucky. The main contributor in 2016 was
Kentucky's Justice & Public Safety Cabinet, which donated
$500,000. Adam Bisaga, a professor of
psychiatry at Columbia University Medical Center, strongly believes that programs
withholding effective treatments, intentionally or unintentionally, should not
receive public funding: "Public resources, especially when limited, should be
steered towards the most effective interventions."

Alcoholics Anonymous was founded 83
years ago, 330 miles northeast of Louisville, in Akron, Ohio. Prohibition had
recently been lifted, and alcohol consumption was on the rise. In 1935, Bill
Wilson and Bob Smith, a stockbroker and a surgeon, started A.A., and formulated
12 principles to guide alcoholics to sobriety.

Today, with an estimated two million
members, A.A. is deeply ingrained in American culture. In 2012 the Library of
Congress designated the founding text—The Big Book—as one of
88 "Books that Shaped America." The organization is, in many ways, the
bedrock of American addiction treatment. In 2016, 73 percent of all treatment facilities
used the 12 Step approach.  

Over the course of nearly a century,
the 12 Steps have helped millions of people quit alcohol, pills, and
needles—and given them a place to share and heal. But Clay, a public
information coordinator at Alcoholics Anonymous, is fully aware that people
receiving MAT do not always have the chance of benefiting from the fellowship.
Instead, many feel excluded by their peers. "There are people in A.A. that have
an orthodoxy," Clay acknowledged. "They think that A.A. must be this. So yes. These things are going
on. There is no orthodoxy in A.A., but there are people who believe that."
Clay's comments offer a rare window into an organization that is known
for its secrecy. He works at A.A.'s headquarters in New York City, and, as an
active member, has asked to be identified only by his first name.
 

A.A.'s official stance is that it has
no opinion, positive or negative, on MAT. But it will not interfere if groups
exclude people on Suboxone or methadone: "That's the one thing we can't do.
Because, we have no authority," Clay said, referring to the unyielding
principle that every A.A. group is self-governed and fully autonomous. 

To Bisaga of Columbia University Medical
Center, that is not a valid excuse: "It is unacceptable that A.A. does not have
a position, because they do not want to adjust to change. They are still
functioning the way they did, when they were born in the 1930s," he said.
Bisaga, the author of Overcoming Opioid
Addiction
, is co-director for the organization PCSS-MAT, which advocates
for MAT. "It is unfortunate that they don't have a clear stance in line with
all professional medical organizations, including the WHO," he added. 

A.A.'s founders stated that its
methods are meant for alcoholism only. But today the popular 12 Steps are used
in treating everything from compulsive gambling to sex addiction, and dozens of
organizations have sprung from A.A. In the early 1950s, when people struggling
with drugs started knocking on A.A.'s door, Narcotics Anonymous was established.
With an estimated 67,000 meetings a week, it is by far the largest of the
organizations that follow A.A.'s model.

Clay said that people who mainly have
a drug problem ideally should seek help at an organization like Narcotics
Anonymous. However, that may not help a recovering opioid addict on MAT.
Because, unlike A.A., N.A. does take
a stance on MAT. In the eyes of Narcotics Anonymous, people in recovery are not
clean before they abstain from all drugs—including Suboxone and methadone. And
so N.A. advises its member groups not to let individuals on MAT share at
meetings, be speakers or sponsors, or hold any trusted positions within the
organization. 

This stance was made clear most
recently in an official N.A. pamphlet from 2016, drawing from the
1996 Bulletin no. 29 "Regarding Methadone and
Other Drug Replacement Programs." In this text, a phrase appears that will
sound familiar to David, Michael, and countless other addicts in recovery: "Our
program approaches recovery from addiction through abstinence, cautioning
against the substitution of one drug for another." 

Arnaout, the professor at Yale School
of Medicine, urged Narcotics Anonymous to change its view on MAT and encourage
its members to seek treatment: "It would be appropriate if they said: 'We are
here to support you, but you should see someone in the health care system,
too.'"

Bob, who works in public relations
for Narcotics Anonymous World Services, confirmed that some groups may
discourage people from actively participating. "Because that goes against our
core tenant of complete abstinence," he explained. Bob, like Clay, has
asked not to have his last name published. A member on medication-assisted
treatment is not officially clean, according to N.A.'s definition. "Hopefully
it will be a goal for them, and their doctor, not to take medication for the
rest of their life," Bob said.

Bisaga does not agree. For some
people, he said, the only way to stay alive is to stay on medication for the
rest of their lives: "If we do not accept that, we'll just continue to have
people dying." Bisaga regards it as a great loss that N.A. does not embrace
MAT: "We do really want people to have medication, but we also want people to
benefit from the recovery community."

The loss is especially felt in places
like Louisville, where the opioid epidemic runs deep. About the time that David
Hockenbury and Michael Dever began experimenting with drugs—when they were
angry teens in baggy clothes and Timberland boots, their hair spiked with gel—a
big story in the world of health was the under-treatment of pain. Chronic pain
, long neglected, was taken up by patient
advocates, who demanded better treatment options. Pharmaceutical lobbyists
quickly picked up on the trend, pushing for wider prescriptions and the use of
more potent opioid-based products. The initiative was embraced by Kentucky's
coal miners and other manual laborers.

The first time the boys experimented
with pills was when David's girlfriend gave them some of her mother's Xanax. It
didn't take much of an effort to find more. At parties, David and Michael would
nose around in cabinets overflowing with Xanax, Valium, Klonopin, and Benzos
of all shapes and sizes. They would take out the powder, snort it, and fill the
empty pill cases with sugar. Michael and David could not see that they were
part of a vast epidemic spreading in their town, their state, and all across
the country.

Michael Dever has accepted that he'll probably be on methadone for the rest of his life: "It enables me to live a normal, stable life and get up and go to work every morning and be productive, and not be on heroin shooting up three or four times a day."

When they both landed themselves in the hospital—20-year-old David after a car crash, 17-year-old Michael with a
stomach condition—they were sent home on heavy opioids. First Percocet. Then
OxyContin. Every chemical was stronger than the previous one. And when their
hospital stashes diminished and cravings kicked in, they turned to the street.

Little by little, news coverage of
pain treatment gave way to stories about the millions of Americans who were
becoming dependent on opioids. Crackdowns were launched. Prescription opioids
became less accessible, and much more expensive. Suddenly 80 mg of OxyContin
had a street price of $60.

For David and Michael, rowdiness
turned into violence and weapon charges as a drug-filled lifestyle led them
into more serious crime. That was also when they began to seek out a cheaper,
more efficient option: heroin. Their lives followed a by-now familiar trajectory. There were blackouts and overdoses, visits to the hospital; there was jail time.

In 2009, the number of Americans who
died from an overdose surpassed the number who died from being shot. 
In 2011, overdoses surpassed deaths by car
accidents.

The opioid crisis had its origin in
the rural heart of America, but is now spreading to the 
cities. From July 2016 through
September 2017, overdoses increased by 
30 percent across the country. The Midwest, Appalachia, and New England are losing the most lives to
the epidemic. In 2016, Kentucky had the fifth-highest 
rate of death due to drug
overdose.

There still aren't many support
groups beyond A.A., and few places in Louisville provide a sanctuary for people
on MAT. Medically Assisted Treatment To Recovery (MATTR) was founded in August
of last year as a response to people on MAT feeling excluded from other
recovery groups. At a meeting at the boardroom of the Morton Center addiction
facility in January, four pale women found seats at the large table. "Before you say congratulations, I
just want to say that I'm not pregnant," one said. "I'm just really, really
constipated." Others restlessly scratched their arms and necks. Numbness,
tingling, trouble concentrating—all are common side effects of the Suboxone
they take, along with constipation.

The meeting was led by co-founder
Andrea Jones, and the group was eager to share. "Hi, I'm Diana. My sobriety day is 12
22 2017," said a young woman wearing sweatpants and a washed-out Batman
t-shirt, absentmindedly scratching the inside of both elbows with blue polished
nails. (The names of the MATTR attendees have been changed.) It was her first
day on Suboxone, and the decision to start taking it had not been easy. "I was
so confused. Because so many people were already judging and telling me not to
do the treatment. I didn't know how to think."

The medicine was audible in the slow,
soft croak of her voice. It usually takes a few days for the body to adjust.
But today, for the first time in a long while, she had not thought about
running off and doing drugs, she told the group. "I want to be open about it,"
she said. "And this is like one of the only places I can be open about it."

Next, Jessica, a petite woman with a
bun of brown curls and large golden earrings, shared her story. An addiction to
heroin and methamphetamine had brought her here. "I went from smoking weed
a little bit every day to being five months pregnant with my second daughter, shooting
up in a gas station bathroom, begging God to just let me die." She stopped and
took a deep shuddering breath. "MAT saved my life."

The others nodded in sympathy and
thanked her for sharing. Samantha, the young woman with the swollen belly, took
over. She was pretty, but the sickly pallor of her skin and her expressionless
face made her resemble a mugshot. In a slow Southern drawl, she told the group
that her boyfriend broke up with her when he found out she was on Suboxone. "He
said that I'm just getting on MAT to get legal, cheap high."

Some 12 Step meetings openly prohibit
the use of MAT. But more often, these women were shamed out of meetings by
other participants. They were told that their all-important sobriety date was
false and that they were not truly sober. Jessica was even kicked out from a
meeting when the other participants learned that she was on Suboxone. "People
are just uneducated about it. For one, it's not a high. If anything, I'm
exhausted," she said, sinking back in the large office chair. "But it slows my
brain down enough to let me do what I need to do that day." Her voice thickened
and tears welled in her eyes. 

Diana's voice rose: "I
shouldn't have to worry about this. I've literally drawn myself into an anxiety
attack because I don't know how the world will react to this." They had all had
close friends, even family, question their medicine. "I may be on something to maintain
me," Diana added. "But I'm not gonna abuse it. There's a difference
between abstinence and sobriety. You're doing something to recover. That
counts."

She delivered the last statement with defiance, as if trying to convince someone.

When N.A. member Amber suggests to
people on MAT that they get off of their medicine, she does so politely. She has talked to people like the women from MATTR, and advised
them against maintenance drugs: "I would encourage you to get off of Suboxone,"
she said, reminding them that it can be bought off the streets and used
to get high. Amber, who has also asked to be identified by her first name, had tried Suboxone herself, but said she felt that her doctors
pressured her into taking it. They would tell her that if she just took this
medication, she would not need to get high anymore. To Amber, however, it felt
like "substituting one drug for another," as she said. Today, she is one of
many N.A. and A.A. members who have a clear stance on MAT: "You don't need to
be on Suboxone."

But to many addicts on MAT, like David and Michael, this approach
feels like cruel and needless banishment. With the help of methadone, Michael has been sober since last
summer. David, after years of relapses and recovery, recently chose to quit
A.A. and find a support group open to everyone—including people on MAT. Today,
he has been sober for over a year. Still, last fall he decided to wean off
medication again. Prescriptions and visits to the doctor cost him almost the
same as rent. But that was not the only reason. The negative opinions toward
MAT among his peers in A.A. continued to bother him: "Coming from this
absolutist black-and-white recovery community, where you had to be totally
abstinent and off of everything, I still had pressure in my own mind to get
off MAT."

The hunt for complete abstinence
still haunts many of the people they know—or have known. "If five years
ago there was no stigma attached to MAT and if it was accessible and
affordable, I think a lot of our friends would probably still be alive,"
Michael said in January in a Starbucks on the outskirts of Louisville.

"How many people have died that we were friends with?" he asked
David, who was calmly sipping a bottle of orange juice.

Both of them looked distant. Losing a friend had long ceased being an extraordinary event.

"Jesse, Mike, Muff." 

They counted on their fingers, but
ran out of fingers to count. 

"Burford, Kyle."

"Who'd you say?"

"Noodle."

"Oh, yeah. Noodle."

"And Devon?" 

"And then the people I know from A.A. It's an even larger number,"
David said.

"Jon." 

"Yeah, and Erica, she died that same day," David said quietly. He
was the one who talked her into going to A.A., where she eventually decided to
stop taking methadone. She relapsed and died. 

He shrugged. "I lose count. I think
it's at least 30. And at least 15 of my close, close friends."

"I mean really, it's just me and you and two other friends from our
old group that are still alive," Michael said. 

If everybody needs a tribe,
most of theirs is gone.