As addiction professionals created the modern treatment sector, harm reduction strategies were viewed with skepticism. The opioid epidemic has forced a re-evaluation of harm reduction’s place in the treatment toolbox. This article takes a further step by suggesting that treatment professionals should view themselves part of the public health world.
History
From a historical perspective we can identify 3 distinct periods for how traditional addiction treatment viewed harm reduction philosophy.
The first followed the introduction of clean needle distribution programs from Europe and the United Kingdom. Avoidance, rejection, and demonization characterized this period, which reflected some of the worst excesses of America’s drug war. Harm reduction was conflated with drug legalization and the third rail of drug policy, “protecting youth,” managed to keep harm reduction practices confined to outlaw status.
This period was followed by a second era during which harm reduction responses to the HIV/AIDS epidemic allowed for movement out of the shadows, and a realization among addiction professionals that in certain circumstances adherence to ideological purity was trumped by on-the-ground necessity. During this era, which lasted until the 2020 presidential election, there was a gradual warming toward harm reduction as the growing opioid epidemic required expanding and retooling the national substance use disorder treatment system. This entailed finally accepting medication-assisted treatment as legitimate, and the proliferation of easily available naloxone distribution. The adherence to a strict abstinence ideology was decreasing since, after all, for someone to recover they must remain alive.
Current Practice
A third period was inaugurated when President Joe Biden sent his initial drug policy priorities to Congress. For the first time, the White House was not just using the term harm reduction, but embracing it. Soon after, $30 million in targeted grants were awarded to treatment organizations and a network of research institutions received grants to study the implementation of harm reduction strategies. In addition, a national harm reduction technical assistance center was established to facilitate the integration of harm reduction into traditional treatment programs.
So far, traditional treatment professionals and programs demonstrate only a limited understanding of harm reduction as a public health philosophy. As viewed within the treatment community recently, harm reduction is seen largely as a mechanism to get people into treatment/recovery. The idea of assisting a drug user for increased safety without facilitating a path to abstinence is viewed as a violation of recovery culture and ethically questionable.
There is a pervasive belief, often unstated, within the traditional treatment and recovery communities that all people experiencing significant negative sequelae from alcohol or drug use must want help and that help must be abstinence.
For true harm reduction practitioners, the phrase “meeting someone where they are at” is central to an avoidance of any judgement and an acknowledgement that a person’s decision to use drugs must be respected. This idea of active, non-intervention is anathema to most treatment and recovery professionals.
Traditional programs stop short of this kind of full-throated embrace and limit their harm reduction activities to Narcan distribution and outreach to local harm reduction agencies. This form of “harm reduction lite” allows programs to claim adoption of harm reduction practice without getting hands dirty with active drug users.
Addiction treatment programs historically have sought clients who are “treatment ready.” This meant that persons seeking care had to demonstrate some level of motivation, however weak. In treatment, a major goal is to strengthen that motivation and help clients to internalize incentives to remain abstinent.
Potential clients demonstrating no interest in stopping their drug use are rejected, although many might respond affirmatively if asked whether they would like to do something about their drinking/drug use.
Looking Forward
Assuming that harm reduction acceptance will continue to grow and not swept away with a succeeding federal administration, we need to rethink our basic assumptions. As motivational practices taught us to not wait for someone to “hit bottom,” so perhaps harm reduction practices will show us that humane care does not have to always lead to abstinence.
Recent statistics indicate that the opioid epidemic is now a fixture of American life. Despite enormous federal and state spending, overdose death rates remain historically high. To suppress the epidemic, we need a “wholesale” strategy, not treatment alone, which is essentially a retail approach.
The COVID-19 epidemic taught us that any attempt to treat our way out of an epidemic is a fool’s errand. To turn the tide, we needed public health strategies such as masks, social distancing, and avoidance of mass gatherings.
Nationally, we have thousands of treatment organizations. The number of true harm reduction programs is likely in the low hundreds. If we could encourage treatment programs to incorporate more substantial harm reduction activities in their mission, the result could over time significantly impact the overdose mortality rate.
If treatment providers could roll up their sleeves and get out into the street or the shelter to bring public health practices to those sick and suffering from substance use disorder, many lives could be saved.
John de Miranda, EdM, CRC, is executive director of Peninsula Health Concepts in San Mateo, California.