Abstinence vs. harm reduction

Though this writer presents herself as having no attachment to a particular treatment approach, she’s clearly a harm reduction advocate. However, she does a good job making the both/and argument and recognizes that motivation and client preferences often change frequently.

What she fails to address is that context and the culture of services have enourmous influence on the addict’s choices and motivation. Does the system subtly and patronizingly discourage abstinence as unrealistic? Does the system reject and judge clients who are unwilling to embrace lifelong abstinence? Does is offer unwaivering hope for full recovery and honestly review options with clients?

Drug-free treatment has historically failed to accept addicts who were not ready to embrace abstinence and harm reduction providers too often define the addict by their illness and place so much emphasis on accepting them as they are that there is no emphasis on what they can become. We know that radical transformation is possible–we see it every day. A system should accept and provide services to support incremental change, but it must not damn them with low expectations, it must not be satisfied with reducing risk for harm, and must offer hope and support for full recovery.

I have to confess, I have no little trouble fathoming how on earth we have ended up here, once again engaged in the obsessive navel gazing that is the debate about whether the focus of treatment should be abstinence or maintenance?

Its just not a question that I can identify with, because people experiencing drug treatment need the opportunity to choose the interventions that work best for them. This might change through someone’s drug using career, with needle exchange, drop in, prescribing, inpatient and community detox and residential or community rehabilitation services coming into play at different points for different people. Sometimes, as we know, people will not move through these interventions in any convenient linear mapable way, but may well drift in and out of treatment over a protracted period of time

Of course as long as they stay for at least 13 weeks we’re all absolutely cool about it.

So is the aim abstinence? Yes. Is it maintenance? Yes. Do we need Harm Reduction? Yes. Is prevention important? Yes.

There is no right or wrong answer and really there should be no debate about this. There is no “one size fits all” solution to the problems people who use drug face. I have as little time for people who say everyone needs a script as I do for those who say everyone needs to go to a fellowship group.

One thought on “Abstinence vs. harm reduction

  1. Hey, thanks for blogging my blog – and you’re right, I am an exponent of harm reduction. I totally agree with your assertion about raising expectations – as long as those expectations that we strive for are the clients and not just the service’s or the worker’s. For me, the difficulties in raising aspiration in any sustainable way while labelling the individual an addict or considering their drug use solely an illness are manifest The context and orientation of services is as you say, critical. While the impetus for change is directed from a political level, its all too easy to negate the choices made by the individual. A focus on criminalising or pathologising drug use is problematic and shifts the emphasis away from individual aspiration, hope and recovery. This is sadly the environment within which many services operate – and in my view a continuing block to a full menu of useful interventions (and particularly those focussed on reintegration) for many individuals experiencing problems with substance use.Harm reduction is a dynamic philosophy that I do not in any way see being in opposition to abstinence. Good harm reduction requires at its core a recognition of individual volition and self direction as well as an understanding of the impact of environment and culture on the choices available. However the philosophy of harm reduction is vulnerable when there is a shift in the definition of harm from an individual one to a societal or political. Community wide gains from harm reduction are best achieved incrementally through numerous successful individual interventions rather than centrally mandated programmes. Centrally funded harm reduction initiatives need to be cautiously managed to ensure the drive for acceptance of the philosophy (ie through attaching crime outcomes) does not overpower the individual intervention. These comments are of course specifically relevant to the UK situation where harm reduction has been accepted for some time. Where harm reduction is less well developed, different approaches may be more appropriate.Going to feed the dog now. Have a grand weekend.Sara


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