From Recovery Wire

The Great Debate: Is Harm Reduction Enabling or Empowering?

Jul 1, 2013  By Dr. Vera Tarman

In the 1980s, I was prescribing methadone to a handful of heroin addicts. None of them really wanted to get clean, but even more than that, they no longer wanted to die. They came to me hopeless, helpless and willing. Methadone gave them the chance to get clean without the horrid physical withdrawal that always accompanied their best intentions to quit opiates. My offer to stabilize them if they stopped using was quickly accepted. Our plan was to get clean and then slowly wean them off the methadone.  In the months of sobriety that it took to wean each person off the methadone would give that person plenty of time to do the work of recovery so that a life without drug use was palatable.

I repeat, almost none of them wanted to get clean when they walked into my office. They just wanted to stop their relentless suffering. If I could have offered them a way to keep using their opiate safely,  most would have chosen that route instead. But the 1980s and early 1990s were tough times; if you kept using heroin or substituted with another drug, and you were kicked off the program. The goal of the program was abstinence: Like it or not, patients had to get clean to keep getting methadone. I had people calling me daily to join up. In the morning, we would listen to the heart wrenching voicemails of people begging to get the next spot on the waiting list. They had heard that someone just been booted off yesterday and could they have that spot?

If YOU were offered the possibility to use your drug of choice safely, would you stay sober?

One morning I received a fax from our College of Physicians and Surgeons that governs the methadone program in Ontario. I looked at the missive in disbelief: a profound shift in policy had occurred, it seemed to me overnight.  I was instructed to move from an abstinence based policy to a more harm reduction focus. This floored me: It meant that if a person was still using heroin or another drug, I was to continue them on the program. The harm, the reasoning went, that was created by discharging using addicts back into their previous lifestyle risking overdose, disease incarceration, and poverty was much worse than the harm of continually serving them. After all, what harm could there be to provide methadone as well as other medical care and counselling that came along with it? Certainly abstinence was still a goal, but there were other goals just as important: Lets keep the person alive first so that perhaps one day they will choose abstinence over using.

I had heard about harm reduction ventures in the past: the Vancouver East side needle exchange and the European countries that were rumoured to give controlled amounts of daily heroin to their addicts. Methadone maintenance was itself a form of harm reduction, though we practiced it with the main goal of securing abstinence. As I sat looking at the policy directive,  I immediately pictured my patients who would hear the news from me later that day. One of them, an articulate woman who had just run out of all the warning letters and was on her last trial after months of repeatedly slipping, had finally got one month clean.  She, like so many of my patients, had not really wanted to get clean. They wanted to stop the suffering of the consequences of the drug: the loss of house, family, money, health and self esteem, and now the loss of a treasured spot on the program. They each reached a bottom that hurt more than sobriety.

If you were offered the possibility to use your drug of choice safely, would you stay sober? I told this patient the news. I had seriously debated withholding the information, but knew the futility of this; someone would find out and broadcast the changes to everyone in the clinic. She lit up when she heard the news and asked the inevitable question, “Are you telling me that if I use my drug safely (i.e., less often, smaller amounts), I will be allowed to keep using and stay on the methadone program?” I nodded glumly. Her sobriety ended that night.

This scenario was repeated throughout the parade of patients I saw that week. Methadone became the drug that “enabled” them to keep using but not every day and not having to use their very last dollar to maintain a lifestyle of using: The rent could be paid, food was still on the table, and then the reward of getting the drug when you wanted, rather than when the body dictated, now existed. There were some addicts who complained bitterly that it was better when they were not ‘allowed’ to use. Despite doing well in sobriety, when they were given the choice to use, they found that they could not resist.

There now lays lies a continuum of care in the addictions field, from abstinence to harm reduction. On the one end, are the doctors, (such as myself), who actively encourage abstinence. We argue that the choice to use should not be in the addicted person’s hands, since informed choice requires a sound mind that is not encumbered by the disease of addiction. We emphasize that the primary characteristic of addiction is denial: A person in denial about their addiction will always think they can control their drug use in a safe manner – the next time. They are not likely  to get that moment of lucidity, that can break through the denial, until something happens that forces that recognition. We call that the moment “hitting bottom”, and any interventions that softens that critical moment enables the addict to continue using. Addiction is the disease of always wanting more and more and more, with no end in sight. If interventions keep the end at bay, we are not helping those who are addicted, only prolonging their disease of addiction.

On the other end of the treatment spectrum are the harm reduction clinicians who quite rightly say that their treatment promotes empowerment for the addict.The person is encouraged to take responsibility to make up their own mind to stay clean or to use and risk death. When addicts shrug and say that they are not ready to make that choice, these clinicians will identify their clients as ambivalent or pre-contemplative. I call that ambivalence the denial of addiction, and anything that allows this denial to continue is ultimately not empowering, but destructive and mis-directed.  Harm reduction proponents also claim that their approach is more humane, and argue that the “tough love” approach does not work for the majority of people. They are right: All addicts, active or sober, should get the same level of professional care.

Since that epoch changing moment of the late 1990s and in treating thousands of addicted clients, I have come to observe that there are three types of addicts seeking recovery. The first third are those who want to get abstinent. They will do so regardless of the intervention. They recognize their addiction and know they have to get abstinent, whether they get help from others or not. Another third are those who don’t want to stop using drugs, regardless of the consequences (health, financial, or otherwise) or the interventions. If the treatment program does not interfere with their using, they will access the service, but if it obstructs use, they will drop out to continue to use. The last third are the undecided, those who are swayed by the consequences of their use or the interventions offered and will choose whatever is easiest. If stopping means access to care, then they will stop. If continuing to use does not affect access to care, or actually makes it safer to use (through the use of clean needles, and medications to mitigate the withdrawal), then why stop?

My impression is that the early days of professional treatment served the abstinent minded individuals best. It was also instrumental in persuading the undecided to get clean. It decidedly did not help the recidivist addicts who were discharged from these early programs only to get jailed, sick, or to die. Current times gives compassionate and empowering care to the addicted who continue to use, and allows the undecided third to remain in their indecision – which typically means to continue to use. The abstinent addicted person get addict gets shortchanged by lack of support, often sitting in contemplative groups where other addicts debate the pros and cons of use, or who try to moderate their drinking or drugging. It can even tempt the most determined teetotaller to question their own need for sobriety.

The shift towards harm reduction shift has many attractive qualities. From the larger societal perspective:fewer deaths occur, less infectious disease can spread, and decreased rates of incarcerations have saved the government millions of dollars. Who can argue with these? But on the individual level, specific to addiction and its characteristic feature of denial, the individual goal of abstinence is often sold out to this larger perspective of societal benefit.

Our societal policies and funding have decidedly swung towards harm reduction in the last fifteen years; CAMH and  many treatment centres now support this model. It is virtually impossible to get public funding for an abstinent based treatment program, making centres like Renascent increasingly rare. I personally feel like a dinosaur at most addiction conferences; I feel as if I am preaching a quaint philosophy of temperance and religious sentiment, both out of fashion these days. Where do these values exist outside of the rooms of 12-step programs?

Will the pendulum swing still further farther? I would be very interested to know what people think about this debate. Like all debates, there are no correct answers. There are only opinions and biases, often based on how an individual’s own experience has informed him or her. What are your experiences?