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Addiction: Harm Reduction vs. Abstinence

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Tiffany Barnett

on 5 April 2014

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Transcript of Addiction: Harm Reduction vs. Abstinence

Addiction: Harm Reduction vs. Abstinence
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?

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

Harm Reduction
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
Canadian Addiction Statistics
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.
Harm Reduction vs. Abstinence
What are 12-Step Programs ?
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
12 Step Approach to Treatment
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
When Abstinence is Appropriate
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
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
4 Principles of Harm Reduction
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
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

Pros and Cons of Zero Tolerance Programs
Pros and Cons of Harm Reduction
Harm Reduction and Abstinence
Gradualism: Building the Harm Reduction-Abstinence Continuum
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
Basic Principles
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.
Basic Components
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
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
Complementary, Oppositional or Something In-Between?
Benefits of Abstinence
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.
Types of Drug Treatment
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
Gabor Mate - What is Addiction?
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
Zero tolerance is ideal but not practical
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
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%
Zero tolerance is expensive
and has negative consequences
Disadvantages of Abstinence
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
Thank You !
Questions or Comments?
Benefits of Harm Reduction
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
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
Benefits Extending Beyond the Individual
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
Drug related crime
Loss of productivity
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
Opposition to Harm Reduction
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
Advantages of Harm Reduction
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
Something In-Between
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
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
Final Thoughts
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
12-Step Programs: AA and NA
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
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
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