This nation is in an epidemic. There are no two ways about it. By now you have undoubtedly heard that more people died of overdose in New York State in 2016 than died of motor vehicle accidents, homicide and suicide, combined. In responding to this crisis, we do not have the luxury of closing our minds to any viable option.
Some people in recovery will tell you that they are alive because someone in their life insisted they “get sober,” which is often a path taken reluctantly at first. They will tell you that without that someone, they may never have decided to abstain from substance use and may have never experienced the joys of recovery. Their decision to choose abstinence –saved their lives.
Others will tell you that they struggled in abstinence-based programs, were never able to achieve total abstinence, and frequently felt like they failed; a feeling that fueled the addiction. Some found a therapist or a program that took the time to understand their personal goals and helped them to achieve them. They will tell you that their lives, whether they ultimately abstained or not, were enriched by the experience and that they too have found joy in recovery of their own design.
There are very few terms that evoke more passionate responses than the term “harm reduction.” I understand why. For some people, harm reduction is regarded as approval of destructive behavior. They believe the strategies taken to reduce harm of use allow the destructive behavior to continue, reduce the natural consequences of a person’s choice to continue using, and may cause premature death. For others, harm reduction is a life-preserving strategy. They consider harm reduction strategies to be life affirming and support individuals who choose to continue using to do so with the least risk to themselves and others. They also believe harm reduction strategies may prevent premature death. It is the weight of this life and death debate that evokes such passion. In this article I would like to explore this issue from several different positions and move the conversation from a dichotomous one to looking at the options as more of a continuum.
In abstinence-based programs a person generally stops using all substances, but relapses occur. Continued use can result in the patient being referred to a higher level of care. This practice is based on evidence that addiction impacts the brain in such a way as to interfere with cognition, judgment, goal setting and attainment. It is believed that the person must abstain to learn new skills and even to evaluate his or her own circumstance. There are many programs that work with the person to better adhere to an abstinence goal over longer periods of time.
Harm reduction can mean many things. A harm reduction approach encourages a person to set his or her own goals around substance use, and with information provided by a counselor, identify ways to reduce the negative impact of use. One example of a harm reduction approach is a syringe exchange program. The person chooses to continue using substances intravenously and also chooses to exchange used needles for new ones to reduce the risk of blood born illness. Another example might be abstaining from the substance that is causing the most harm to the person, but choosing not to abstain from another. In harm reduction, the person may or may not choose abstinence from substances as his or her ultimate goal.
There is some empirical evidence to consider. Several treatment approaches are considered effective based on the evidence. They include Twelve Step Facilitation (which promotes abstinence and attendance at self – help programs); Motivational Interviewing (emphasizes individual autonomy and choice); and Cognitive Behavioral Therapy (teaches skills to manage urges and prevent relapse). Each of these have been shown to be effective treatment approaches. Mindfulness, Dialectical and Behavioral Therapy, Seeking Safety and other approaches have also been shown to be effective.1 Some approaches emphasize abstinence while others do not.
There is also evidence to consider from National Institute on Drug Abuse on brain changes due to substance use that indicates that higher cognitive functions are impaired through regular substance use while the reward system is enhanced – leading to increased drive toward using and decrease capacity to use reason and judgment to combat the drive.2 And there is evidence to support the impact of poverty and social situation on use patterns with empirical support for remissions from substance use as conditions change.3
We know that many approaches to treatment are effective and that both client and counselor factors influence the realization of a positive outcome. Success is often tied to a working alliance between counselor and client.4 We know that people who address their substance use and identify that they are in recovery are passionate about their recovery and that their willingness to share their experience and hope is effective in helping others.5 They serve as models to those who continue to experience negative effects from their addiction and represent many pathways to recovery.
How should this inform policy for Substance Use Disorder (SUD) treatment? SUD professionals should provide treatment consistent with the standard of care. People seeking treatment should be informed of the different approaches available to treat substance use. Treatment programs need to be aware that if someone is not responding to an abstinence approach, they may respond better to a harm reduction approach and vice versa. For some, a treatment system that seemed impossible to access may become accessible if abstinence is not a requirement of treatment.
Substance Use Disorder is a chronic medical condition and we need to treat it as such. We need to encourage people to remain engaged in care, even if they relapse or are not strictly abstinent. Supporting people’s treatment and recovery efforts, not discharging because patients show exacerbation of signs and symptoms of their illness, and providing patient-centered and family focused care are the underlying principles of New York State’s prevention, treatment and recovery services.
There are many roads to recovery. We cannot stigmatize the pathway that one chooses to take to recovery simply because it is a road less taken. We are all in this together. We must be open to and embrace less traditional models if there is clear evidence they save lives.
The evidence and our experience points to a comprehensive system of care that welcomes all, supports autonomy and promotes whole person health. The most important thing we can do is to welcome people to treatment, provide them with the care they need and help them achieve recovery.
- The Neural Basis of Addiction: A Pathology of Motivation and Choice. https://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.162.8.1403
- Peter W. Kalivas and Nora D. Volkow American Journal of Psychiatry 2005 162:8, 1403-1413
- Hart, C. (2013). High price: A neuroscientist’s journey of self-discovery that challenges everything you know about drugs and society. New York, NY, US: HarperCollins Publishers.
- Miller William R., and Moyers Theresa B. (2015), The forest and the trees: relational and specific factors in addiction treatment, Addiction, 110, pages 401–413. doi: 10.1111/add.12693
5. Peer Recovery Support for Individuals With Substance Use Disorders: Assessing the Evidence Sharon Reif, Lisa Braude, D. Russell Lyman, Richard H. Dougherty, Allen S. Daniels, Sushmita Shoma Ghose, Onaje Salim, and Miriam E. Delphin-Rittmon Psychiatric Services 2014 65:7, 853-861. https://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201400047