It seems to be human nature to go to extremes; especially when something shows promising results. Harm reduction has been shown to save lives and therefore should be celebrated and implemented. However, it seems that harm reduction has become the entire conversation about recovery; specifically, the support of Medication-Assisted Treatment (MAT).
Alex Pentland, a professor studying human behaviour at MIT, said, “When we see people in our peer group play with an idea, our behaviour changes. That’s how culture is created.” In essence, we gravitate to the standards of those around us. This brings up some questions about recovery culture. What effect does harm reduction have on recovery culture? Obviously, it saves lives, and that’s essential for the recovery process, but are there other effects that we should be aware of?
In exploring some of these other effects, I came across Steven Scanlan, a Board-Certified Psychiatrist specialising in Addiction Medicine, who wrote an article in 2010, titled “Concerns Behind the Miracle,” in which he pointed out that implementing Suboxone (one of the medications used for Medication-Assisted Treatment in the Harm Reduction Model) for more than a month can lead to a “strong dependence.” Dr. Scanlan also mentions Suboxone’s potential to numb an individual’s feelings. These types of things need to be considered when implementing a treatment model such as medication-assisted treatment. If such adverse effects aren’t considered, it’s possible for a widespread model, such as MAT, to undermine the recovery culture: by not providing support for adequate feeling (a developmental task of recovery) and healing (many individuals with an addiction suffer from trauma; feeling is essential for healing trauma).
Is it possible that while MAT, specifically Suboxone, has been shown to save lives in the short-term, it might have counterproductive results in the long-term? According to this recent research paper by Dr Katherine Herlinger & Professor Anne Lingford-Hughes, “More recently, a study of individuals prescribed long-term opioid agonist treatment reported enlargement of the right caudate nucleus, and reduced volume in the right amygdala, anterior cingulate cortex and orbitofrontal cortex. These changes were reportedly more pronounced in those with longer duration of OUD.”
The amygdala is our emotional processing centre and is responsible for regulating our emotional reactions. Reduced volume in the amygdala has been shown to affect one’s ability to control inhibitory (unwanted, or “goal-irrelevant”) actions. One thing I found appealing in the research paper by Herlinger & Lingford-Hughes is that there is “potential for structural changes to return to normal after a month of abstinence.” This is also highlighted in a different section of the research paper, “Of growing interest has been the effect of OST (opioid substitution therapy) on cognitive functioning.
One meta-analysis of methadone-maintained individuals reported neurocognitive deficits in working memory, attention, cognitive flexibility, and other areas compared with controls. In another study both methadone and buprenorphine users exhibited deficits in visuospatial working memory which were strongly correlated with higher mood and anxiety symptom scores. This highlights the potential need to pursue abstinence-based therapy in OUD.” What is so interesting about this is that I never hear about it in the mainstream discussion around opioid use disorder.
When I think about Alex Pentland’s point about how we mirror what we see, I become concerned that the loss of an abstinence-based culture may lead to fewer long-term benefits. So, how can we ensure that individuals on long-term MAT get the rich social connections and resources that an abstinence-based approach may provide?
I believe the answer lies in the practice of discernment. If there is no discernment, then everyone is a good or bad candidate for Harm Reduction, or MAT. This is a problem because treating everyone as such isn’t necessarily appropriate for their recovery, or congruent with their goals. An extreme example of this is at a clinic in Pennsylvania, where an individual sued the clinic’s owner, manager, and doctor for “keeping him reliant on Suboxone.”
It’s important to acknowledge that MAT can help a significant number of people but it’s also important to acknowledge when it isn’t helpful (e.g., if an individual begins to misuse it). This boils down to providing individuals with the best path for their stated recovery goals. Can we say, in all honesty, we are providing individuals with the treatments and resources that will lead them to their desired outcomes?
If we look at drug overdoses over time, we can see that drug overdose deaths have quadrupled since 1999, despite a small drop in 2017, according to the Center for Disease Control and Prevention. I think it’s important that we acknowledge it’s time to look at other evidence-based treatments, as opposed to solely MAT. Nutrition, or the lack thereof, is an often-overlooked aspect of addiction treatment and yet has been shown to be correlated with craving and the potential for relapse.
I think it’s time we admit this (the harm reduction) initiative can be used as a stopgap while we look for ways to build recovery capital. Dr. Gabor Mate put it this way, “We can’t just hand out more and more medications. We have to look at the stresses that, on a social level, affect people.” Another way of saying this is in the words of Recovery Historian, William White: “Our focus should be not on what professionalised services we can offer members of this community, but on how we can support the development of resources within this community that diminishes its members’ needs for professionalised services.”
Having this dialogue is important, especially when we are the ones responsible for giving the most reliable and honest information to individuals seeking our support. If an individual wants to pursue abstinence or doesn’t want to risk side effects, I would like to be able to offer them the tools and support necessary to do so. Conversely, if an individual doesn’t want abstinence but does want to improve their life, I also want to offer them relevant tools and resources. This type of integration requires a restructuring of priorities: from the necessity of surviving to growing. It’s about coming back to the power of recovery communities and the individuals who make them: what do they want to achieve and are we offering what we know to be the best way to help them do that?
Dylan Lundgren is a TEDx Speaker and Addiction Recovery Advocate.
Commentary – David McCartney
Dylan Lundgren gives us much to consider in his guest blog. He posits that there may be potential unintended consequences, cultural and practical, of shifting emphasis and goals from recovery to harm reduction and he is concerned that we do not always discuss the whole picture when we prescribe MAT. I think there is some truth in this – I don’t recall having many, if any, conversations about possible cognition, bone metabolism and immune system side effects from methadone, but while these seem trivial compared to the (potential) ‘side effect’ of death from untreated opiate use disorder, patients do have the right to have a better understanding of all the risks and how they might be mitigated, albeit balanced against the benefits.
The question of what treatment helps an individual to achieve what goal and with what degree of safety is pertinent. I work with those seeking abstinent recovery, but there are risks here too which need to be understood and conveyed. Research has arguably focused too much on reduction of harms at the expense of whether individuals and their families achieve their goals and flourish, but it may also be true that we do not accurately communicate risks to individuals pursuing abstinence.
The suppression of feelings by opioids is one of the reasons people use them. In clinical practice we sometimes see negative emotions related to past trauma surfacing during detox. At times, this is so overwhelming that it becomes intolerable, and we will discuss with the patient re-titration back onto an opioid. Buprenorphine, in my experience, is much less sedating than methadone and may better allow psychological therapy work to be undertaken to help support the individual and address the trauma. (As therapists tell us, it’s important to be able to feel uncomfortable feelings in a way that is sustainable and doesn’t lead to unhealthy coping mechanisms)
As I’ve written before, I believe we need to create a recovery culture in harm reduction services and a harm-reduction culture in recovery-oriented services. The key to this is to have people with lived experience engaged in both.
Finally, the aim of relying less on professionalised services through the development of lived experience/recovery community resources seems to me to be a sound one. Addiction is disempowering; relying on professional services can also feel that way. Mutual aid and LEROs (lived experience recovery organisations) allow people to take control of their own destiny, plus or minus professional support. Who can argue with that?