Harm Reduction in Addiction work - what is that fly in the ointment?

When it comes to assisting those who suffer from addictions, one might say “surely some change is better than none?” So when we hear the term Harm Reduction, we may feel positive. After all, the term implies a change for the better – albeit not complete abstinence.

Certainly, Harm Reduction does offer valuable strategies to reduce dangers in certain substance abuse contexts. However, when we consider the chronic and progressive nature of addiction, we can see that presenting Harm Reduction as a viable alternative to abstinence might give a dangerously misleading message. For sustained, safe, lifelong recovery, there is a strong argument for abstinence-based approaches being far preferable.

What is Harm Reduction and where does it fit into addition work?

Three broad approaches to addressing drug problems in society are Supply Reduction, Demand Reduction and Harm Reduction. Let us briefly review the focus and role of each:

Supply reduction rests on the premise that removing drugs and dealers from our streets will essentially remove drug problems. It is the work of law enforcement personnel and the justice system.

Demand reduction rests on the premise that addicts cannot consistently control their use of substances, and that sustained recovery thus requires abstinence. It is offered by abstinence-based treatment programs and is also the ethos of the 12-Step fellowships such as Alcoholics Anonymous and Narcotics Anonymous.

Harm reduction rests on the premise that if addicts don’t choose to abstain from substances entirely, they can effectively implement ways to reduce the harms of addiction. It is the stance of harm reduction and health outreach programs.

The case for Harm Reduction

A Harm Reduction approach is particularly useful and relevant when another life-threatening health problem – e.g. Tuberculosis or HIV – is the primary concern and imminent risk for the addict. By implementing harm reduction strategies, the impact of drugging on their TB/HIV treatment can be reduced. They are advised, for example, on ways to abstain from drugs the night before a clinic appointment, thus being more likely to attend the appointment and receive their medication. Another example is encouraging alcoholics to have a glass of water or soda between each alcoholic beverage, with the aim of reducing their intake of alcohol.

A further benefit of Harm Reduction strategies is to reduce the immediate health and safety risks of drug use. Examples of this are supplying clean needles, condoms, and safe places off the streets to use drugs.

Clearly, these Harm Reduction tactics do reduce many of the damages related to substance abuse, and can surely sometimes even save lives.

But what is the fly in the ointment?

Addiction is chronic and progressive. This is evidenced repeatedly in addicts’ life stories. Addiction does not just stop one day. Addicts don’t get better at controlling their substance use. Addiction continues and exacerbates until one either enters recovery or the illness reaches a terminal and possibly life-threatening point. The amount of substances used, and the consequences of using, increase over time. These consequences can be extremely severe, resulting in losses in many areas of life. This implies a huge ethical responsibility in how addiction professionals educate and advise addicts. Presenting Harm Reduction as a viable alternative to abstinence can be a risky message for addicts to hear. It implies the belief that addicts can control their drugging, and in essence sanctions their continued use. Taking into account the capricious outcomes which may follow using – even with the best intentions of control – this advice could be extremely dangerous. Add to this the addict’s own ambivalence..

Addicts considering treatment are ambivalent about change. On the one hand they recognise the damages drugs are causing in their lives. On the other hand, their drugs have become central to their lives, and they may long to be able to continue using. For example, an alcoholic may express the wish to be able to simply enjoy only one or two drinks, as she observes others doing, without the loss of control and unpredictable consequences which result when she drinks. The Harm Reduction approach, offering the option to still use the substance they love, will no doubt be very appealing to addicts considering treatment options.

Recovery is a lifelong process. Indeed, it is a lifelong process requiring fundamental changes. A key example of this is altering one’s social circle. Avoiding triggers to relapse will most likely require terminating some connections and creating new ones. For example, this would include ending relationships with friends who abuse substances themselves. Joining a 12-step fellowship and working with a sponsor would also be important. For an addict following a Harm Reduction approach, a firm commitment to these fundamental changes is less likely. After all, they are still using - a case of “one foot in, one foot out” of recovery.

Recovery has implications relating to significant others in the addict’s life. Restitution of family relationships and employment are examples of very positive potential treatment outcomes. There are likely to be - not unreasonable - expectations of abstinence from significant others who have witnessed the chaos of addiction playing out in the addict’s life. Trust has most probably been battered and broken down. Presenting half measures as a feasible treatment alternative may very well lead to the addict failing to find healing in their relationships.

In Conclusion

Harm Reduction has a valuable and necessary role in the addiction field. Lives can be saved by strategies to reduce the harms of substance use in certain contexts. However, promoting Harm Reduction can be a form of institutionalized enabling, by sugar-coating treatment with options that are not helpful for long-term recovery. In terms of finding sustained recovery, abstinence may indeed be a more effective and safer option.

As addiction professionals, we cannot control the choices addicts make about their treatment and recovery path. But we can control the messages we give them. So beware of that fly in the ointment!

Cathy Karassellos | Clinical Psychologist