Drug and Alcohol Findings asks the big question about harm reduction and exposes the fault lines.
What is a harm reduction service for?
Just one issue for you to ponder, but a (the?) big one, because surely the first thing any organisation should be clear about, is what it is there to achieve. The answer seems self-evident – to reduce harm. But what counts as harm, and whose harm? According to the UK Harm Reduction Alliance, harms may be to health or social or economic in nature, and may affect individuals, communities, or whole societies. That opens the way to taking opposing stances in the name of harm reduction, from prioritising the health of drug users to (if need be) sacrificing this to promote other social objectives and avoid costs. In the UK there are indeed different interpretations of harm reduction, each seemingly ‘self-evident’ to their adherents. In 2012 the UK government’s “roadmap” to a recovery-oriented treatment system subjugated “All our work on combating blood borne viruses” to the national strategy’s “strategic recovery objective”, arguing that, “It is self-evident that the best protection against blood borne viruses is full recovery”. What ‘full recovery’ entailed was never spelt out, but what it did not entail was clear; out of the mix was continuing drug use of the kind which might prompt needle exchange attendance and remaining in opioid maintenance prescribing programmes.
For the UK Harm Reduction Alliance and partners including the UK Recovery Federation, all this was not all self-evident. Their response transformed the government’s Putting full recovery first title in to Putting public health first, challenging the “ideologically-driven hierarchy” which places full recovery at the top, with “any other achievement marked as inferior”. That theme was trenchantly taken up by the Australian Injecting & Illicit Drug Users League. Concerned that the nation’s harm reduction orientation was under threat from UK-style “new recovery”, they attacked the UK government’s roadmap, insisting “Harm Reduction is the goal – not a step along the ‘road to recovery’ or the path to ‘freedom from dependence’.” This formulation echoed their core belief that harm reduction is the “principle paradigm upon which drugs policy should be based. All other approaches (eg demand reduction, supply reduction) can have validity only where there is strong evidence that they are appropriate, practical and equitable means of reducing drug-related harm.” In other words, they reversed the primacy order so self-evident to the UK government, subjugating treatment and recovery to harm reduction, not the other way round.
These polarities are endemic in debates about methadone maintenance and allied approaches for heroin addiction, seen as both treatments for addiction and harm reduction while dependence continues. A recent UK attempt to reconcile these objectives complained that “the protective benefits [ie, harm reduction] have too often become an end in themselves rather than providing a safe platform from which users might progress towards further recovery”, and was prepared to see this progress pursued even if it “will sometimes lead to people following a potentially more hazardous path, with the risk of relapse”. At the same time, “preservation of benefit” was seen as a legitimate reason for continuing treatment; not least among those benefits is the preservation of life and health.
It makes it hard to imagine collaboration and integration. We’re supportive of harm reduction as long as it IS treated as a step along the road to recovery.
Check out his whole series that are organized as a matrix.
6 thoughts on “Harm reduction is the goal – not a step along the road to recovery”
Great minds; I spotted this too and scribed something. Reminds me of the Methadone and the Hall of Mirrors paper where, depending on your point of view, methadone can represent wildly different things to different groups.
What’s missing for me in the above assessment is any consideration of what opiate dependent people want when they access services. They don’t need to be passive recipients of what’s on offer. Most of them, I believe, don’t want reduction of harm, they want something much more transformational.
I agree completely
The harm reduction argument only makes sense in terms of population medicine, from the perspective of the mountain top, and when the rubrics are narrow. On an individual level, harm reduction becomes something else entirely. “Along the way” people can have terrific consequences. So can their families. The addict is never the neat little package these arguments lead us to believe.
From the experiences in my family, our opiate addict kept going back and forth on Suboxone because it was perceived as the softer, easier way (it wasn’t). While on this path, she graduated from a huge pill addiction to IV heroin, because she could no longer get enough pills. “Harm reduction” was always her trap door to escape treatment and recovery. As a family, we — and most especially the children — went through years of a particularly gruesome hell.
Some might argue, “Well, she’s alive today!” But she’s only alive, because as a family, we intervened and then began working as a recovery team. We got her to commit to a year of treatment and top-knotch transitional housing (professionally run) and continue today as a team. Before we did this, she’d spend two hours in the bathroom trying to find a vein.
Suboxone never accomplished any of this. It just allowed the the addiction to continue running the show and terrorize the entire family.
I believe in raising the bar, setting behavioral expectations, and remembering that this is a family disease.
Here, here. I fear this post may have gotten a lot of likes because people didn’t read past the headline.
I shared this to show that there’s a culture of harm reduction that is about more than just health and part of it is framing addictive drug use as a lifestyle choice. There’s also a tribe of workers who seems to derive some vicarious nonconformity/coolness from their association with using addicts.
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