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Drugs: Harm reduction versus abstinence programs?

2015

I am curious to hear about your experiences in the field of Child and Youth Care around the efficacy of either harm reduction or abstinence policies in programs. I was at a lecture the other week by an agency who primarily focused on harm reduction, and this left me with many questions.

To begin with, I would like to praise the harm reduction approach. I recognize that it moves addiction away from being a moral and criminal issue, it does not expect abstinence which may be unrealistic for many youth, and it can create a more tolerant, accepting atmosphere that may allow an individual to be willing to listen to different perspectives (Denning, Little, 2012). I believe that for many young people who are experimenting with drug and alcohol use, long-term consequences, punishment, and forced abstinence are difficult to implement, diminishes their autonomy which is a primary function of adolescence (Steinberg, 2014) and can create unnecessary power struggles. In addition, from a 12 step model, only the alcoholic or addict themselves can determine whether or not they have this as a condition (Alcoholics Anonymous World Services, 2001).

However, there are some environmental, biological, and genetic components to the development of addiction which I believe were overlooked in the presentation I was at recently. During adolescence, when the prefrontal cortex is developing through myelination and synaptic pruning, repeated experiences, damage, and overuse of the reward systems are particularly influential, and can create long-term consequences (Steinberg, 2014). In addition, although addiction and alcoholism as a disease are debateable, there is evidence of genetic and biological predispositions (Benios, 2007). For many who are born with this predisposition, the idea of harm reduction is enticing, but the application may backfire if the individual suffers from a mental obsession, an abnormal reaction of the body, and the theory of a spiritual malady (Alcoholics Anonymous World Services, 2001).

So my questions to those of you who have practical experience with either or both of these approaches are: What strategies have you witnessed as being effective or not effective? Is it possible to create an environment of harm reduction while including information about abstinence programs that describe alcoholism/addiction as a disease? At what point is intervention helpful or intrusive?

Thank you in advance. I appreciate your time and experiences in this area.

Holly Tilden

References
Alcoholics Anonymous. (2001). Alcoholics anonymous (4th ed.). New York, NY: Author.
Benios, T. (2007). Predisposition for addiction. In Scientific American Mind, 18, 13. doi:10.1038/scientificamericanmind0607-13b
Denning, P., Little, J. (2012). Practicing harm reduction psychotherapy: An alternative approach to addictions (2nd ed.). New York, NY: Guilford Publications.
Steinberg, L. (2014). Adolescence (10th ed.). New York, NY: McGraw-Hill.
...

We have to remember that addiction, while being a bio-psycho-social disease, is still just as equally a moral, spiritual and criminal problem. Those of us who work in the dual-diagnosis field become quickly aware that efforts to strip away those factors move people toward incomplete recovery. Emphasizing the moral and spiritual bankruptcy of addictions does not have to involve shaming, but a signing level of embracing a moral code and spiritual direction that is incompatible with addictive behavior is absolutely imperative to successful long-term recovery. We move toward what we worship, addictions are a disordered form of worship, and treatment that does not include attention to the moral, legal and spiritual aspects of addiction and recovery is as anemic as most strictly secularists modifies of treatment.

As for harm reduction, we know from chemistry that the brain will continue to crave something it is continuously exposed to. The harm reduction model makes treatment professionals feel better about themselves for not looking like their me talk stereotype of the old-time confrontational addictions counselor,and it communicates to the client that the life they want can accommodate less sacrifice and more compromise with the demons they say they want to beat. HR moves the consequence line out to far. I prefer the approach of "Total Abstinence with reasonable grace." Clients of mine who understand that their brains, once addicted, cannot regulate desire as rigorously as they could prior to addiction, tend to be more motivated than clients who are given the pass to define success as "less use"..... show me one wife who wants her husband's cheating problem to be addressed with Harm Reduction, versus Total Abstinence. Healing in the moral and spiritual dimensions requires acknowledging a form of right and wrong, and if on some level the behaviors prompted by addictions are considered "wrong", allowance for partial Abstinence is also wrong. Harm Reduction was an overcompensation for the unnecessarily rigid application of Total Abstinence, and it sacrificed some essential qualities NE essay to fully address the soul of the addicted person.

Scott A. Knapp
Cleveland, Ohio
...

Holly,

Simply put, everyone is different.

For some “compulsive” drinkers reduction would not be recommended; in some situations abstinence is necessary. I agree with the AA quote “, only the alcoholic or addict themselves can determine whether or not they have this as a condition”. To get to that understanding, education is required.

Hope this helps.

Peter Hoag
...

Thank you both for your responses.

I appreciated what you said about the need for education, and allowing the individual a chance to determine this for themselves, Peter.

Scott, I respect your approach around "Total Abstinence with reasonable grace", and healing the emotional and spiritual aspects of the soul of the addicted person. That was really well-written, so I read it a few times. :)

I am still curious about your opinions around when an intervention is about saving their lives or when it becomes intrusive?

Holly
...

Hello Holly,
 
I am a second year student at Mount Royal University. I am in Child and Youth Care Counselling and I am completing my full year practicum at a treatment facility for youth with addictions. These youth are recommended to the program through Alberta Health Services, Alberta Alcohol and Drug Abuse Commission. This specific program is abstinence based, but over the time the staff have realized that having an only abstinence based program was keeping the youth from telling them the truth about what is going on. If the youth went on a home visit and used, they would come back and try to hide it because they were scared of being discharged, and this effected their treatment negatively. Because they were no longer being honest about what they were going through.
 
They have since changed to a harm reduction but still strive for abstinence. The youth have mentioned that they enjoy having the support there if they do slip up and use again to help them get back on the wagon, and to stay sober. This has also opened up a lot of honesty between the youth and staff. The communication around why they used and if that was really the best choice, do they have tools that they could have used instead, if not what can the staff do to help you gain tools to prevent you from slipping again has become very open. This helps the youth to know that no matter what happens they are being supported and it is a feeling that some of these youth have not had before. They are unaware of what its like to slip yet still have people there that care and are willing to still help you.
 
This also links into attachment, because if the staff are still there for the youth, the staff can show the youth what a healthy relationship is, but if the youth is showing no interest in possibly being abstinent there is a conversation around if this treatment is the right type of treatment for them. So you need a balance.
 
So I do believe that it is possible to have a harm reduction environment while pointing towards abstinence.

Melissa Evans
...

Hi Holly,

I'm currently completing my practicum in a community-based group home and our team often utilizes the Harm Reduction approach. We have teens ranging from 12-17 who are currently using drugs such as crystal methamphetamine, cocaine, crack, and other various drugs. We have become aware of some of the triggers our youth have that lead them to using drugs and typically we will try to recognize and prevent this as much as possible (aiming for abstinence!). With that being said, when our youth tell us they're going to use and that we cannot stop them, we accept this and have a discussion with them. We often start by asking what drugs they plan to use, where they plan to be and who they plan to be with. We will then evaluate each situation (i.e. are they planning to mix drugs? are they going to be out in public or in a house? are you going to be with people you trust or at a party?). Assessing each situation we try to eliminate the most dangerous aspects (sometimes this can really test your morals...) - such as asking them not to mix drugs and to stick to one drug for the evening. We give them the option to choose which drug will give them the power to stay away from others at the same time.

Looking at your points regarding the developing brain, this is our way of lessening (hopefully) the damage they are causing while maintaining the relationship and hoping for further progress. We use these conversations as education opportunities, as you asked, and do our best to provide as much knowledge as possible. Our teens often know the repercussions but potentially don't fully understand the impact it may have yet. This is why I believe Harm Reduction can be useful; because it has the potential to lessen the damage until the teen is ready to face their addiction. Like you said, the teen has to see this as a problem within themselves!

This type of approach certainly leaves room for back lash even within our profession. There are many individuals and caseworkers who do not value or appreciate this approach and it's important to tread carefully with it as well. Some flaws to this approach are that some individuals will say that this makes you liable and that you've condoned the behaviour if something were to go wrong. While I disagree with this, I can also understand where the idea comes from as it could be hard on the conscience as well as your record if a problem did arise. I have a current story of a youth that may be valuable to some of your questions:

We have a youth addicted to crystal methamphetamine and one of his biggest risk factors is that he likes to mix this drug with various other drugs at a time (i.e. cocaine, crack, marijuana). Recently we've created a visual calendar in his room where we write down goals for him regarding AWOLing and drug use. Throughout the week we simply write "yes" or "no" beside each category but avoid giving any specifics, so that our youth does not become discouraged or tempted by the name of drugs staring him in the face. With the idea of Harm Reduction in mind, we do not count marijuana in our "drug use" category since this is what we as a team (including caseworker) have determined as his "safe" drug. This is not to say that we all condone marijuana, in fact many of our team members have strong opposing views to marijuana, but we have to remember that we are looking through our Harm Reduction lenses.

Just last week this youth made a goal to not AWOL for 3/7 days and not use "hard" drugs (anything other than marijuana) for at least 2/7 days. Our youth not only made his goals but EXCEEDED them. He told us that he felt supported and because we were able to understand where he was coming from instead of expecting abstinence right away, he had many sit down discussions with us when he was feeling tempted. He often left these discussions feeling better and rarely used or went AWOL afterward. While these goals may seem small to others this was HUGE progress for him. He gets treats at the end of each week for completing his goals as well, so this part also involved a reward system. It should be noted that he has recently called his addictions counsellor and began seeing her regularly again - he is not ready for detox but he says that within time he may feel that he is able to take it on.

I have a deep love for the Harm Reduction approach but I can also understand the fears surrounding it as well as the scientific evidence that shows the possible damage that it could cause. I should note that I don't have experience with an abstinence approach when it comes to teens and addictions, and I'm certainly open to hearing any feedback regarding this approach that has been successful in your personal work or within research as well.

Thank you for your time,

Courtney Penner
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