Throwback Sunday – Pessimistic Paternalism

blank signI’m doubling up this week with two posts on harm reduction from December 2006.

I’ve written often about the subtle bigotry of low expectations, these two posts illustrate that concern. (I like my reference to “pessimistic paternalism disguised as compassionate pragmatism.”)


Debate on abstinence

A horrifying excerpt from a debate in a British treatment provider magazine. (It’s at the bottom of both pages.) I don’t completely understand the context–whether they are debating a “motion” in a binding way for the specialty society that publishes the magazine or if it’s a devise for a magazine column.

One of the participants proposed that detox is dangerous due to the possibility of reduced tolerance and unintentional overdose in the event of a relapse. Harm reduction advocates used to argue that they represented a needed choice philosophy in working with addicts. The is the worst kind of pessimistic paternalism disguised as compassionate pragmatism–and there’s nothing representing real choice.

…Detox can be dangerous and is not very often successful. Death rates are higher in recently detoxed patients.

Many people request detox but we need to recognise that maintenance is a very worthwhile option. Maintenance patients need our support – including psychological support – and harm reduction has to be our goal.

The NTA says rehab providers have to provide mechanisms for rapid referral into maintenance programmes. Getting people off drugs is dangerous.

Bill Nelles,founder of The Alliance,said: ‘Let’s take the morality out of drug treatment and put the humanity back in’. Judy Bury [GP] said it is our job as GPs to keep people alive until they are ready to change.

There’s not much evidence for long-term effectiveness of detox,but it can reduce tolerance. People cannot do abstinence when they walk in the service. The move toward abstinence-based treatment is dangerous and will increase drug-related deaths.


“Recovery Impatience”

Lowering_The_Bar_Cover_2010.09.22Let’s hope that the concept of “recovery impatience” does not catch on. Keep in mind that this is in the context of a country with a big emphasis on methadone and 60% of the methadone recipients have expressed a preference for abstinence based treatment.

“We are now seeing the emergence of a culture of “recovery impatience”: the demand for people to move quickly to a drug-free lifestyle while denying the significance of other factors – such as low income and life in neglected communities – which make rapid achievement to a drug-free life impossible for the majority,” she said.

“The combination of totally unrealistic expectations, along with the demonisation of drug users, is having a trickle-down effect on practice, with “firmer” responses becoming more acceptable.

“We are in danger of harking back to the days when those seeking treatment were labelled as feckless and chaotic, deemed as having given up their right to be involved in their own treatment or to be treated with the dignity, respect and quality of care afforded other vulnerable groups in society.”

One thought on “Throwback Sunday – Pessimistic Paternalism

  1. OOHHH….Thanks for the posts, but these harm-reduction folks INFURIATE ME ( so sorry in advance for the long comment) …
    The unfortunate thing, at least in my opinion, is that the overriding ideas of addiction as a choice and the “moral model” are culprits in their philosophy, even as they mouth the opposite. There is no thought process that a cancer, diabetes or (thank God by now) HIV researcher should stop working toward cure rather than just coping with the disease (shoot, even the common cold). Doctors would not deal in that manner with patients either…. “Well, since you refuse to stop smoking, we’ll just stop the chemo… You can just be a little cancerous”. However, since, in allot of minds, addicts are either worthless sinners or people who choose to keep using, harm reduction makes more sense to them. I see allot of clinicians get sick of clients taking too long to “get it” (choice) or atone (sin). In turn, they just say “fine, we’ll give you a little bit to get you out of society’s hair”. “Don’t be Ridic!” (Doris Dowling as Gloria, “Lost Weekend” 1945)
    It’s crazy to me that, even after all the empirical data supporting abstinence and comprehensive care (Project MATCH was in 1994 for God-sakes!), even a great number of clinicians and faculty members do not believe it works… eventually. Sorry y’all, abstinence-based recovery is not easy, it may take a bunch of tries, it may cost insurance companies more money, the pharmaceutical industrial complex may not make crazy money from it for decades, you may not be able to get your friend in recovery to have just one at your wedding, and, yup, %15 of the population can’t smoke weed, even if it’s legal nation-wide (ummm… like cigarettes and booze… hint hint), BUT IT WORKS…. deal with it.
    Even if the progress to it is slowed, abstinence should be the goal. One of my mentors in recovery and addiction counseling, with over 30 years free from heroin, got sober with a two-year wean using a methadone program. However, it included full 12-step program participation with accountability, social service assistance and drug testing for other substances. That program was based not on harm-reduction, but increasing self-efficacy (getting societal gains and tangible progress), while decreasing the dope. This was/is few and far between. “Def but Def” (Doris Dowling as Gloria, “Lost Weekend” 1945)
    OK, I feel better now … have a great Sunday y’all…
    Shiba P. (est. 5.20.2005)


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