| Harm Reduction Approaches to Addiction Treatment |
Executive Director’s Column Harm reduction (HR) approaches to addiction treatment are famous mostly for ending up on the front pages of newspapers: tax-payer funded sites for injection drug users to shoot up, supplying heroin to heroin addicts, needle exchanges, and the like. Disciples of abstinence denounce loudly such efforts, but an increasing number of healthcare professionals are touting its benefits. More than simply helping addicts use safely, HR is a collection of strategies and techniques that have in common the idea that successful treatment reduces the harm that drugs cause to the addict, his family, and society. Although HR has a history in many parts of Europe, it is a relatively new movement in North America. Policy and clinical experts have been struggling to understand how HR can work within the American (and Canadian) context, known for its zero-tolerance for drug use. Today, it remains vaguely defined and includes interventions as diverse as training servers in a bar, providing drugs to palliative care patients, implementing controlled drinking programs, and working with clients who relapse in treatment. The Alberta Alcohol and Drug Abuse Commission (AADAC) is typical of the ambivalent attitude. Worried of offending abstinence service providers, AADAC (1999) attempted to assuage them by suggesting that:
The statement describes both HR and abstinence approaches only at the superficial level of drug use, the level that is an affront to prohibition. Indeed, HR literature reports that the approach arose mainly as a response to the growing incidence of HIV/AIDS infection (see, for eg, AADAC, 1999; Marlatt, 1998). Controlling infectious diseases, including Hepatitis, was the main impetus for needle exchange programs. And AADAC (1999) goes out of its way to comment that “harm reduction is not the same as legalization or decriminalization.” Yet the logical inconsistency is obvious: on the one hand, for instance, providing safe injection sites and safe smoking sites (for crack cocaine and crystal methamphetamine), while on the other declaring that possession of controlled substances is a criminal act. I find it amusing to read the various positions of Vancouver policy makers and the federal drug policy makers over the appropriateness of, for example, the North American Opiate Medication Initiative (NAOMI), which provides heroin to heroin addicts. The federal minister of health has publicly announced that heroin is illegal in this country at the same time as Vancouver pushes to continue the project. And now Vancouver City Council (June 14, 2007) passed a motion that approved the objectives and principles of the Chronic Addiction Substitution Treatment (CAST), which will provide free mood-altering prescription drugs to cocaine and methamphetamine addicts, at an estimated cost of $10 million. (The cost of HIV among injection drug users in the notorious Downtown Eastside is $215,852,613 according to a 2004 report.) HR as a response to the moral perspective But the difference in approaches is far more comprehensive, and many believe they are incompatible (see, for eg, Peele, 2004). Two conflicting issues are the moral and epistemological stances. Increasingly, the literature is highlighting current discomfort with prevailing abstinence-based clinical practice that is rooted in a rigid moral and biological reductionist thinking. Typical of the new view is the comment of one service provider: “These [clients] are people who are on a journey…. It’s not right that we only accompany people on their journey if they do it our way” (Editorial, 2001, p. 2). The traditional abstinence program took control of clients, demanding that they behave according to an imposed standard and punished those who did not measure up. Marlatt (1998) thus described HR as a humane approach that avoids the shaming finger of the moral perspective and the deterministic medical perspective. Traditional treatment had demanded behavior for addicts that was never applied to any other health condition. What physician would punish a heart patient or a diabetic for not following his medication regime? But in addictions treatment, the carrot-and-stick approach was so common that many assumed it was the only treatment. The moral influence had demanded prohibition, which had left many addicts marginalized. HR advocates said: ‘Look, we know that people have been using excessively for millennia, and all our efforts at prohibition don’t work. So let’s deal with reality and do what we can to help’. Unlike abstinence approaches to treatment, HR is also concerned with families of addicts and with their communities. A 1999 HR conference provided a series of principles for service providers, one of which emphasized: “Service providers are responsible to the wider community for delivering interventions which will reduce the economic, social and physical consequences of substance abuse and misuse” (Editorial, 2001, p. 2). Advocates of HR thus bring the message that it as a more ethical way to conduct therapy. HR and post-modern epistemology HR is consistently described as “practical” (see, for eg, AADAC, 1999; Marlatt, 1998), and few have commented on its philosophical basis, which is rooted in a post-modern epistemology. It recognizes that programs that set particular standards of behavior (for eg, abstinence as a prerequisite for recovery) or motivations (for eg, determining who is and is not ‘ready’ for treatment) say more about the assumed epistemological stance of program providers than they do about the reality of addiction. The shift to a post-modern epistemology has been a struggle. Until relatively recently, for instance, traditional scientific psychologists have relied on quantitative research studies and often dismissed qualitative studies as being vague and not the proper purview of psychology. Today, however, qualitative research is generally accepted, as psychology has recognized the soundness of its foundations, which were proposed by the philosopher Edmund Husserl and other thinkers. Jerome Bruner (1991) is often cited in psychology as presenting a clear explanation of the new thinking. He points out that much of what we believe to be the ‘truth’ is really an assumption that the traditional scientific method, what Bruner calls “paradigmatic reasoning,” is the only way to enlightenment. With post-modern epistemology, however, we have accepted that “narrative reasoning” is equally valid. Narrative reasoning says that each of us views the world through an individual lens. Given this, it is not realistic to suggest that one’s view is the truth, because what the individual sees is filtered through her unique experiences and physical brain. Qualitative research thus does not concern itself with the ‘truth’ of phenomena, but rather with their meaning. The more lenses through which we view something, the richer the meaning we find. Under narrative thinking, it is thus highly questionable for therapists to set arbitrary standards because this is the particular lens of the therapists, not some absolute truth. Rather than rely solely on ‘experts’, HR invites addicts to contribute to the discussion on treatment, because the addicts’ views are equally valid. In fact, commentators have often called HR a grassroots movement (see, for eg, Marlatt, 1998). Theoretical foundations for HR HR also argues that it is an evidence-based alternative to abstinence. Almost all proponents note studies that show HR has been quantitatively validated and has, in fact, better success rates than abstinence programs.
Two foundational theories support HR: Prochaska and DiClemente’s Transtheoretical Model of Stages of Change (Prochaska, Norcross, & DiClemente, 1995) and Motivation Theory (Ryan & Deci, 2000). In 1984 a group of addictions researchers and clinicians arrived in Scotland attempting to find some model that would offer some way to describe how addicts change addictive behavior. Two of the participants, James Prochaska and Carlos DiClemente, had worked out a model of how smokers quit, and subsequent refinements produced the now famous stages of change model that could be applied to any treatment program. The model was thus not driven by any theoretical underpinning; it was developed by observing how addicts found recovery whether in counseling, 12-step programs, self-management, Minnesota Model, or other strategy. The abstinence approach had raised drug use as the defining difference between recovery and addiction. A single beer, prescribed mood-altering drug, or use of illegal drugs meant relapse. The stages of change model dispelled this myth; in fact, it highlighted two dynamics of recovery that were an affront to abstinence. First, it pointed out recovery was not an either-or event; addicts went through a predictable series of definable stages. Secondly, and most controversial, relapse was a natural stage of the recovery process. Prochaska and DiClemente observed that only a tiny percentage of smokers were able to quit on the first attempt. Despite relapsing, the smokers were serious about quitting and kept trying until they succeeded. Most of us have known people who diet, and we recognize that the vast majority of dieters relapse. Few would condemn them for this because relapsing is the norm for dieters; the key is to try again. The same dynamic is true for recovery. Whereas abstinence outcomes counted relapse as a failure, HR maintained that it was natural and even expected.
Motivation theory recognized that intrinsic motivation is the key to successful recovery. Since the first salvo in the war with the behaviorists was launched in 1971, there has been disagreement between these schools. Motivational theory seems to have won out with the publication of Miller and Rollnick’s (1991) Motivational Interviewing, the highly acclaimed application of motivation research results to addiction treatment. The key finding from motivation research showed that modifying behavior through external punishment and reward obviated internal motivation (Ryan & Deci, 2000). Recall James Frey’s (2003) A Million Little Pieces, in which Frey describes life at Hazelden Treatment Center, the birthplace of the abstinence-based Minnesota Model. Frey’s descriptions focus on how clients must act to avoid being discharged—hardly an inspirational lesson on being motivated for a better life. Treatment outcomes Studies that measure abstinence as the sole criterion of treatment have long since been relegated to library basements where they are collecting dust. In part, there is a political reason for this. Under managed care, treatment facilities must justify their success rates. Because the relapse rate is so high, it is very difficult to convince insurance companies and other funders that their money is being spent productively. Beyond this, however, there is a logic to defining outcomes other than complete freedom from drugs and alcohol. Because HR clinicians do not see drug use as the defining feature of addiction, it accepts clients on methadone and other mood-altering medications, does not discharge clients in treatment for using, and accepts a client where the client is at, rather than set standards of behavior and motivation. The level of drug use is included in outcome studies but only as one outcome measure. Other measures generally include physical health, familial relationships, emotional health, readiness for work or school, and involvement in the criminal justice system. HR studies have also shown that it saves tax dollars. A famous (or infamous) report by the Rand Corporation (Rydell & Everingham, 1994) reported that treatment is 7 times more cost effective than domestic law enforcement method, 10 times more effective than interdiction, and 23 times more effective than the ‘source control’ method. Similarly, the State of California Department of Drug and Alcohol Programs reported that for every dollar invested in addictions treatment, 7 dollars was saved in societal costs (Gerstein, Johnson, Harwood, Fountain, Suter, & Malloy, 1994). One of the most outstanding successes was reported by Project MATCH (1997), an eight-year, $27 million study of twelve-step facilitation (TSF), motivational, and relapse prevention treatment outcomes. It should be noted that participants were not discharged for drinking, despite TSF’s abstinence focus. MATCH reported that 30 percent of participants drank during the first year but without bingeing. A further 20 percent remained sober. But this success may not be transportable to other programs. Although Project MATCH was carefully designed, it has been chastised for, among other things, its vigorous selection methods in which only stable participants were selected. A more representative study may be the Baltimore Drug and Alcohol Treatment Outcomes Study (Johnson, Ahmed, Plemons, Powell, Carrington, Graham, Hill, Schwartz, & Brooner, 2002). This study discovered that participants reduced drug behavior at statistically significant levels over the course of a year. One year after treatment the Baltimore participants in non-methadone treatment, for instance, reduced the number of days they binged from 3.4 days per month from a pre-treatment level of 5.0, although those participating in the methadone program had slightly increased number of using days. Significant reductions were also found in criminal behavior, HIV-risk behavior, and depression. In short, the participants did not abstain from drugs or risky behavior; they simply reduced their unhealthy lifestyle sufficiently to attain statistical significance. Proponents of harm reduction argue that these results constitute a major step to success not only for clients but also for society. In Canada, for instance, the annual per capita cost to deal with the consequences of addiction (excluding nicotine) was $725 in 2002 (Rehm, Baliunas, Brochu, Fischer, Gnam, Patra, Popova, Sarnocinska-Hart, & Taylor, 2006). If one year after treatment, clients use drugs fewer days per month, have fewer health problems per month, engage in fewer criminal activities per month, and so on, this translates into major tax savings and social stability. Harm reduction and political policy Inevitably, HR has confronted the traditional American policy of zero-tolerance. Many tax-funded treatment providers provide evidence-based harm reduction programs, while public policy promotes zero-tolerance and the criminalization of drug use. It is an odd combination that rests uneasily. Canada, a more liberal environment for drug issues than America, also feels a tension between abstinence and harm reduction. The national and provincial governments have unanimously endorsed harm reduction practices. Vancouver, for instance, has safe injection and smoking sites, provides heroin to heroin addicts (with Montreal, as a test city for the North American Opiate Medication Initiative), needle exchanges, and so on. But the governments of BC and Canada also make possession of illicit substances a criminal offence. Vancouver and the surrounding areas are famous for their homegrown marijuana, known as ‘BC bud’. In fact, marijuana is so prevalent that law enforcement officers often do not bother pressing charges for the simple act of smoking a marijuana cigarette. A friend of mine from Singapore and I were touring Vancouver. She wanted to see one of our famous ‘hemp’ shops, where we discovered the cashier happily smoking a joint. In an open letter to the Secretary General of the United Nations, eminent citizens declared, “We believe that the global war on drugs is now causing more harm than drug abuse itself” (Public letter to Kofi Annan, June 1, 1998). The signatories were a who’s who of Nobel Prize winners, heads of state, government ministers, police chiefs, and others. American signatories included conservatives William, F. Buckley, Jr., Milton Friedman, and George Shultz. What raised their concern was the growing awareness that the war on drugs no longer had a moral basis. In the United States, for instance, 58.9 percent of 1998 inmate population had been sentenced for drug violations. The policy of supply and demand reduction also meant that enforcement was eating up most of the drug budgets. Of the federal money targeted to ease addiction, 58 percent went to treatment and prevention in 1970, but by 2000 this had been reduced to 34 percent (Smith, Runnette, Zill, Bergman, Levis, & Hamilton, 2000). Key points of HR approach Principles in the harm reduction literature, as interpreted in America, report that it is:
Works cited Alberta Alcohol and Drug Abuse Commission (AADAC).
(1999). Position on harm reduction. Developments
18(6). Retrieved February 2, 2007 from http://corp.aadac.com/developments/dev_news_vol18_issue6.asp#Position%20on%20Harm%20Reduction
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