Addiction: Harm Reduction vs. Abstinence

Addiction: Harm Reduction vs. Abstinence

Harm Reduction

Zero-Tolerance

Examples of Harm Reduction in Canada

Needle Exchange programs

• provide access to sterile needles and other equipment to people who use drugs by ingestion
• purpose is to prevent transmission of HIV/AIDS and Hepatitis
• Lethbridge has a need exchange program

Safe/Supervised Consumption Sites

• legally sanctioned, publicly funded and medically supervised facilities where people can inject or inhale pre-obtained illegal drugs
• purpose is to reduce overdoses, needle sharing,, health impacts that result from injecting drugs in unsanitary conditions and to provide a point of contact with health and addictions services

Methadone Maintenance Treatment

• use is well established, clinically accepted and has demonstrated effectiveness in reducing harm over many decades
• AADAC has been providing methadone maintenance treatment since 1971

• The voluntary prevention of oneself from indulging in activities that provide pleasure
• Can refer to drug or alcohol treatment programs that aim to help the person stop using drugs or alcohol for the rest of their lives
• Many 12-step programs have utilized abstinence as a main component of treatment
• Past 60 years, most traditional addiction treatment programs have been abstinence-based

What is Addiction?

• Refers to policies, programs and practices that aim to reduce the negative health, social and economic consequences that may ensue from the use of legal and illegal drugs
• without necessarily reducing drug use
• It benefits people who use drugs, families and communities
• Focuses on rehabilitation and discourages drug use through education
• Is a practical approach to drug use, recognizing that quitting drugs may not be realistic or even desirable for everyone

Basic Components

Basic Principles

What are 12-Step Programs ?

4 Principles of Harm Reduction

• 12-step applies to a number of self help groups which have grown from the original alcoholics anonymous movement
• A fellowship of men/women who meet regularly to support each other in their efforts to achieve and maintain abstinence

Outreach

• acknowledge substance use and provide explicit educational materials and methods to inform people on how to reduce risk when they use
• may include teaching about safer injection practices and overdose prevention
• connects hard to reach populations such as the homeless and street involved youth with health and addiction service providers
• McMan in Lethbridge has an outreach program

Server Training and Intervention

• responsible beverage training programs
• intended to discourage public inebriation, excessive consumption by adult bar patrons, reduce impaired driving and decrease access to alcohol by minors
• Alberta Server Intervention Programs
• mandatory for all liquor licenses
• helps reduce underage drinking, over-consumption, impaired driving and the risk of violence in and around licensed premises

Controlled Drinking Programs

• targeted to non-dependent drinkers
• offer information and practical strategies to moderate alcohol consumption
• recognizes reduced consumption rather than abstinence as appropriate goals for some drinkers

12-Step Programs: AA and NA

12 Step Approach to Treatment

• The goal of treatment for many service providers is lifelong abstinence from alcohol and substance use
• The initial phase of treatment may require medically supervised detoxification
• Treatment and rehabilitation services vary in their approach, philosophy, principles and goals
• Treatment for the primary addiction may include the use of control-craving drugs, individual cognitive behavioural therapy, group therapy, family therapy, and relapse prevention therapy
• Programs typically offer services such as early identification and intervention, assessment and referrals, medical detoxification, basic counseling, therapeutic interventions, clinical follow-ups and workplace initiatives

• All addiction, no matter the substance, is caused by lifelong physiological, social and psychological disease progress
• Abstinence removes the guilt that is associated with addiction and focuses on the disease instead of the addicted person
• Recovery involves taking responsibility for the disease and making necessary changes in thinking and behaviour
• Personal change may include recognizing denial and other self-defeating behaviours and replacing these negative thoughts with gratitude, honesty, forgiveness and humility.

• the disease model which calls for abstinence as the only acceptable outcome of treatment is not endorsed by AA/NA
• AA/NA literature does not insist on abstinence for all people
• Both recognize the possibility of controlled drinking for some
• Many ideas believed to be attributed to AA/NA may be inaccurate or misconstrued

• Conceptualizes addiction as a disease
• Open to anyone who wants to stop using
• Connects members through regularly scheduled, peer-facilitated meetings
• 12 steps involves a largely spiritual pathway to recovery
• Acknowledging one's powerlessness over drugs
• Engaging in a healing relationship with God as understood by each individual

Pragmatism

• Harm reduction accepts that some use of psychoactive substances is inevitable and that some level of substance use is expected in a society

Humane Values

• No moralistic judgment is made, either to condemn or support the use of substances regardless of level of use or mode of intake
• The dignity and rights of the individual are respected

Focus on Harms

• The extent of a person's substance use is of secondary importance to the harms resulting from that use

Hierarchy of Goals

• Most harm reduction programs have a hierarchy of goals
• The most pressing needs are addressed first

12 Steps Continued

• Most abstinence programs incorporate the 12 steps as an aspect of their programs
• There is a great variation in the ways in which service providers utilize the 12 step in their professional practice with clients
• 12 step programs are based on the disease model which believes abstinence as the only acceptable outcome of treatment

• used to explain the experience of withdrawal when a substance or behaviour is stopped
• includes the presence of the 4 C's
• craving , control, compulsion and consequences

Pros and Cons of Harm Reduction

Types of Drug Treatment

Pros and Cons of Zero Tolerance Programs

Gabor Mate - What is Addiction?

Health and Well-Being Centered Approach

• Harm reduction is a community based, user driven, non-judgmental and are broad based in that they address systems which isolate and marginalize people
• It ensures that people who use psychoactive substances are treated with respect and without stigma
• It meets drug users "where they are at" and responds to their health concerns
• Focuses on the harms suffered by users such s the risk of overdose and HIV/AIDS

Incrementalism

Benefits of Abstinence

• Harm reduction practitioners acknowledge the significant of any positive change that individuals make in their life
• Services are designed to meet people where they currently are in their lives
• Small gains for many people have more benefit for a community than heroic gains achieved for a select few
• People are more likely to take multiple steps rather than 1 or 2 huge steps

Benefits of Harm Reduction

Abstinence-Based or Zero-Tolerance Treatment Programs

• Residential treatment
• Partial hospitalization
• Sober living
• Some 12-step programs
• Group therapy

Harm Reduction Programs

• Community based outreach programs
• Needle exchange programs
• Methadone maintenance programs
• Medically supervised injection sites

• Abstinence doesn't recognize improvements or successful attempts to cut down
• Abstinence criteria may be excessively stringent
• They might not be ready, it does not match their belief system, or it is too difficult to achieve now
• An abstinence-only approach contradicts some current research that suggests moderation is appropriate for some clients
• It is the ideal way, but not practical
• Abstinence is expensive and has negative consequences

• Many experts highlight the physical and psychological benefits of abstinence-based recovery programs.
• Many intoxicating substances have psychological side-effects, and when a patient stops using the substance his overall mental and physical health will improve.

• Harm reduction strategies approach drug use from a realistic and pragmatic public health perspective
• Benefits go beyond the individuals who use these substances, but also to their families and communities
• Harm reduction acknowledges the incremental change that individuals make in their life

Opposition to Harm Reduction

Advantages of Harm Reduction

Disadvantages of Abstinence

Zero tolerance is ideal but not practical

When Abstinence is Appropriate

Zero tolerance is expensive

and has negative consequences

• Abstinence can be harmful for some users
• removing a coping mechanism without offering a replacement which is tolerable to the individual may place one at risk for self-destructive behaviour greater than the use of a substance

• only option is abstinence, which is an ineffective way to reduce use, as it suggests a submission to a symbolic controlling authority
• much of the harm associated with substance use is due to the tendency in our society to deal with substance users in stigmatizing, devaluing, coercive and punitive ways
• prohibiting individuals from using their drug of choice leads to increased drug use
• classic example of prohibiting needle drugs

Harm reduction is open to abstinence as a goal while recognizing

• This goal may not be the goal of all clients
• Emphasis on abstinence as a goal may prevent people from seeking and remaining in services
• Positive changes regarding substance use are valuable
• Addressing substance use may be just one part of helping clients make positive changes
• improved individual and community well-being are important indicators of effective programs and policies

There are three key elements in which harm reduction is problematic

• Harm reduction does not provide the addict with skills to develop a new life while abstinence-based programs do
• Harm reduction does not take individuals out of their environment which gives them a change to change their habits
• Harm reduction does not improve quality of life in the same way abstinence programs do

Benefits Extending Beyond the Individual

• When the client has already made attempts to moderate without success
• When the client names his/her goal as abstinence
• When a client wants to enter an abstinence-based treatment program
• When a client is mandated by an employer or the criminal justice system
• When relationships are at risk, especially for the peace of mind of the partner

• the overall social costs of substance abuse in Canada in 2002 was estimated to be $39.8 billion
• the harsher drug laws appear to increase use of injection drugs resulting in soaring HIV prevalence from 61% to 84%

Canadian Addiction Statistics

• Harm reduction benefits families and communities by :
• helping to break the stigma of drug use
• integrating users into society and increasing employment
• reducing public drug scenes, improving local businesses
• reducing health care and law enforcement costs by reducing
• HIV and Hepatitis
• Hospitalizations
• Drug related crime
• Loss of productivity

Harm Reduction vs. Abstinence

• 47,000 Canadian deaths are linked to substance abuse annually
• Substance abuse costs our health care system $8 billion a year
• 60% of illicit drug users in Canada are between the ages of 15 and 24
• 16.8% of Canadians aged 15 to 64 smoked marijuana or used other cannabis products
• Between 1994 and 2004, the proportion of Canadians who reported having used an illict drug in their lifetime rose from 28% to 45%
• An estimated 640,632 (2.6%) Canadians (15 and older) are suggested to be alcohol dependent
• In Alberta, 85, 524 (3.5%) of the population are suggested to be alcohol dependent
• 5.3% of Alberta students ( grades 7-12) used club drugs in the past year
• Most users of cannabis, hallucinogens and speed began use between 15 and 19 years of age. Users of cocaine and ecstasy tend to have begun use in their twenties
• The vast majority of Alberta youth use alcohol and more than 2.6% have used cannabis in the past year. The most often used illegal drug in both Canada and Alberta is marijuana.

Thoughts?

Gradualism: Building the Harm Reduction-Abstinence Continuum

Harm Reduction and Abstinence

Complementary, Oppositional or Something In-Between?

Oppositional

Complementary

Final Thoughts

Thank You !

• Harm reduction is seen as an approach allowing for a continuum of outcomes, while 12-step approaches do not allow for the same
• Reducing harm lies at one end of the continuum and abstinence at the other end
• The abstinence-only requirement of the majority of treatment programs seen as an ideology wherein "you have to be cured before you can get treatment" and one where "when you need it, you can't get it"
• Harm reduction seen as helping any one no matter what stage of their addiction they are
• The 12-step model can really work for some people, but then there are some people that it's just not really something that's going to work out

• a growing body of literature addresses the integration and compatibility of harm reduction and abstinence-based approaches
• many individuals who are involved in the harm reduction movement are simultaneously involved in a 12-step program
• harm reduction and abstinence actually have a core goal in common
• both aim to help people reduce the harms they experience because of their substance use

• Co-existence of harm reduction and abstinence based programs show potential for their integration to meet complex client needs
• A shift of thinking needs to occur
• Abstinence is no longer the only way
• A potential for partnership does exist and may enhance the availability of options for people experiencing substance use problems
• In some cases, abstinence can be seen as a preliminary step for those who might be able to moderate their use
• For a gradualist continuum to work, not only would the harm reduction field have to modify it's perspective but also the treatment community would need to transform itself as well
• By meshing the two together a more welcoming approach to treatment can be created allowing an atmosphere that is less harsh and judgmental

Questions or Comments?

Something In-Between

References

Thoughts?

• Obviously just harm reduction and just abstinence is not working
• there is no longer any question that the expansion of abstinence-based treatment programs alone will not resolve the issues and problems related to drug use
• not everyone who uses substances are in need of treatment
• not all problems are the result of abuse, dependence or addiction
• not all people who use substances will access available treatment

Disagree

Agree

• Building on a crucial insight of the harm reduction movement must occur
• healing and recovery are more likely to come through the development of a relationship, rather than imposing authority
• Need to create a "treatment mosaic"
• providing patients with a range of therapeutic possibilities as stated in the previous video
• encouraging users to utilize the treatments that resonated best with them
• Gradualist model
• Abstinence oriented programs need to utilize the entire range of existing therapeutic approaches

• Lee, S.L., Engstrom, M. & Petersen, S. R. (2011). Harm reduction and 12 steps: Complementary, oppositional, or something in-between? Substance Use Misuse 46(9). 1151-61.
• Kellogg, S.H. (2003). On "gradualism" and the building of the harm reduction-abstinence continuum. Journal of Substance Abuse Treatment 25. 241-247
• Alberta Health Services (2007). Harm reduction policy background paper. Retrieved from http://www.albertahealthservices.ca/Researchers/if-res-policy-harm-reduction-background.pdf
• Zur Institute (2014). Harm reduction: A growing alternative paradigm in substance abuse treatment. Retrieved from www.zurinstitute.com/harmreduction_clinicalupdate.html.
• Peele, S (2010). What is harm reduction and how do i practice it. Retrieved from http://www.peele.net/what-is-harm-reduction-and-how-do-i-practice-it/
• Chen, P. & Milligan, J. (2014). Abstinence or harm reduction. Retrieved from https://www.problemgambling.ca/en/resourcesforprofessionals/pages/abstinenceorharmreduction.aspx.
• Conway, J. (2009). Harm reduction vs. the disease model of addiction. Retrieved from http://voices.yahoo.com/harm-reduction-vs-disease-model-addiction-3403142.html?cat=72
• Martin, G. (2014). The abstinence versus the harm reduction model of addiction treatment contrasted. Retrieved from http://garethmartin.hubpages.com/hub/The-abstinence-verses-the-harm-reduction-model-of-addiction-treatment-contrasted.
• CAMH (2002). CAMH and harm reduction: A background paper on its meaning and application for substance use issues. Retrieved from http://www.camh.ca/en/hospital/about_camh/influencing_public_policy/public_policy_submissions/harm_reduction/Pages/harmreductionbackground.aspx.
• City of Vancouver (2014). Four pillars drug strategy. Retrieved from http://vancouver.ca/people-programs/four-pillars-drug-strategy.aspx
• Political and Social Affairs Division. (2006). Substance abuse issues and public policy in canada. Retrieved from http://www.parl.gc.ca/Content/LOP/ResearchPublications/prb0615-e.html