Abstinence vs. Harm Reduction redux

Sara McGrail sent a kind comment to yesterday’s post. I thought I’d post her entire comment to make it more visible:

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.


I agree that it is important that we not view all heavy drinking or illegal drug use as addiction. The U.S. had its excesses with this in the 1980s when every kids who’s Mom found a bag of weed in their sock drawer was diagnosed with substance dependence. I also agree that the clinician should not be prescribing goals, however when we offer clients services that are filled with hope and success stories, they choose recovery. (Skeptics should visit our detox facility.) As for the difficulty of raising aspirations within the context of addiction as an illness, I don’t see it. We don’t see hope as incompatible with other illnesses and I don’t see a nonjudgemental review of the diagnostic criteria as harmful labeling. Personally, I think that viewing an addict outside of that framework frames them as self-destructive hedonists, making it more a matter of character than health.

However, I think she’s put her finger on the crux of much of the tension between many HR advocates and recovery advocates. If you view drug users as engaging in a lifestyle choice, recovery advocates look like evangelical temperance zealots driven by moral judgement and panic. If you view it as brain disease characterized by loss of control, then long-term strategies that are focused on controlled use or limited to reducing harm constitute professional neglect–similar to treating only the symptoms of a serious chronic illness when treatments to facilitate full recovery (Even if only for a sizable portion.) are available.

2 thoughts on “Abstinence vs. Harm Reduction redux

  1. Harm Reduction and abstinence have some things in common, the two the spring readily to mind is that neither can actually reduce the harm that has already been caused. Conversley the ongoing ingestion of the drug(s) of choice is likely to increase the severity of addiction, defined here as 1When the pursuit and ingestion of the drugs of choice continue despite attempts to control intake, either by frequency or quantity.2 Or when more is needed in order to achieve the same affect.3 When continued use has a markededly less effect.4 Experience of withdrawel symptoms is treated with the, or similar drug(s)5 Frequency and duration of use is often greater than intended.6 The abandoning of social, work and domestic lesiure activities.7 Continued use despite knowing that it is causing ongoing physical and/or psychological disorders. According to DSM-!V any three of the above in the preceding 12 months equates to addiction, or as they refer to it dependency, a clinically inaccurate description for what is a chronic disorder.Now what is Harm Reduction? alas there is no universal definition, but in view of the above, how can continued use cannot be classified as harm reduction? Continued use cannot reduce the harm already done, but it is likely to aggravate the harm that has occurred.Abstinence is one step up from the hell of addiction, so let’s talk recovery, defined here as learning to live, work and play without the crutch of mind altering substances. Easy? Definitely not! Possible? Yes! Worthwhile? Ask those who are achieving it. Will it reduce the harm that has been caused, unlikely, but it will kick start a healing process, which may also require qualified professional help.Attend 2/3 12 step open meetings a week, with an open mind, for a year, then decide.If on the other hand one prefers to continue to use, let’s remember what Einstein said about insanity: Continuing to do the same thing whilst expecting a different result.


  2. Harm reduction is an excellent approach to working with both dependent and non-dependent drug users. For the former, harm reduction strategies recognise the difficulty in “just stopping” – even when people want to stop, it might take a few tries before they are successful.


Comments are closed.