Harm Reduction Strategies and Palliative Care

Harm reduction Strategies are all the rage in government health circles. That's where tax payer money is going. The adherents of this religion are in the ascendent and have been for a long time.  It is important to understand that this all has followed on the success of abstinence strategies and spiritual programs that proved addiction was a treatable and curable disease.   It's further not seen purely as an 'individual' treatment as with 'alcoholics anonymous' which was aimed solely at the individual alcoholic.  Harm Reduction Strategies are principally a 'public health program', not a traditional 'therapy' per se.  In traditional medicine 'harm reduction strategies' have been called 'palliative care'.  There is nothing new or sexy in the model despite the 'spin doctors' sales propaganda.
I first studied "Harm reduction' as a Community Medicine resident 25 years ago in my Public Health program.  My Family Practice and Psychiatry training were principally aimed at curative or ameliorative strategies and principally concerned the individual.  We learned and practiced 'harm reduction' and 'palliative care' but only as a 'last resort.' They were never proposed as the 'principal' treatment or 'alternative treatment' or 'primary treatment'.  They were an approach to care when it was thought in most cases 'death was inevitable' and all we could do was to make the person 'comfortable'.
Harm reduction strategies are exceptionally good public health.  Unfortunately they are often 'spun' as the best thing for a patient.  However, it's important to note that patients with addiction are by nature fairly psychotic.  By the standards of the community they are clearly out of touch with reality.  They drink and drug themselves to death and cause major societal concerns and the courts even let them off crimes because their reasoning was impaired.  Indeed the modern MRI shows that reasoning deficits last after a person stops the subtance of abuse approximately 3 months.  Experienced addiction personnel note that the greatest vulnerability for relapse, ie recurrence of the psychotic behaviour, last for at least a year or more.  During this time a person's capacity to judge the 'safety' for themselves of a substance of abuse is subjectively at great variance to the objective reality of friends, family and society at large.
Given this I have actually wondered if addicts shouldn't be assigned lawyers to help them make decisions about their health care in face of the increased pressure on impaired individuals to accept 'harm reduction' which is clearly more beneficial for the community.
Harm Reduction is a Public Health measure that 'colludes' with the patients insaniety about their ability to practice doing heroin 'safely' or drinking 'safely' or smoking 'crack' safely.  The very term 'harm reduction' doesn't suggest 'safely'.  Palliative care was a much more honest term and is used for all other areas of medicine.  So why not in addiction.
In medicine we have a term called 'treatment of choice'. This refers to the treatment that has the highest likelihood of success.  Harm reduction strategies by comparison have the least likelihood of success for the individual however from a public health perspective they may have the greatest appeal.
If there are two programs available, one which is 'curative' and 'abstinence' based for addiction therapy, and one which is 'harm reduction' the former therapy is more costly whereas the latter is 'cheap' by comparison.  In the treatment of appendicitis, surgery is the treatment of choice for the individual however surgeons, surgical theatres, OR nurses, aseptic fields and anesthestists are all terribly expensive.  If one doesn't have surgery a harm reduction approach to appendicitis is to just give antibiotics. This is surely better than nothing and some people indeed get better with this approach alone.
The key here is that 'harm reduction strategies' are cheap.  The principal fear of an insurance monopoly is that the economists and investors would eventually see that the greatest profit lay not in 'curative' therapy but in 'harm reduction' therapy.  Ultimately 'no therapy' becomes harm reduction.  Beurocrats have long known that their greatest rewards come when the emperor has no clothes. In this case, it's the patient.
Never forget that from a public health perspective 'euthanasia' is a 'harm reduction' strategy because it reduces 'harm' to the community.
It's further to be remembered that only the doctors, nurses, health care providers, and not the 'administrators' or 'economists', have codes of ethics that mandate caregivers to put the well being of the individual at least on par with the concerns of the sometimes 'for profit' insurance concerns.
I was trained in harm reduction and palliative care over a quarter of a century ago. I've practiced it ever since. I was further trained in curative and restorative and rehabilitation models and always opt to offer these first.  Some 'harm reduction' and 'palliative care' models actually buy time for an individual waiting to get the 'treatments of choice'.  However increasingly I see 'harm reduction' presented as a 'superior model'  or an 'equal' but 'alternative' model and certainly those 'promoting it' are considered sexier and get paid far more than those in the front lines providing scientifically proven therapeutic care.
This was always a point of contention with the government when it was noted that alcohol and drug counsellors with greater training and equal experience were paid far less than the people selling alcohol in the Canadian government controlled outlets.  Given that our government benefits from the taxes on sales I"m not surprised they want to keep people drinking to the very last sip.  That was the experience we had with the government around smoking until decades after all the 'harm reduction' strategies were used up and the government had moved it's tax base elsewhere did definitive legislation come in that helped individuals and public together.
I just read of the latest harm reduction strategy. It's called "MAP" a rather cute acronymym. It's basically a 'drink your way into sobriety' program like the new 'shoot heroin safely program.'
I express my cynicism because my colleagues who promote them and get such accolades never mention how 'cheap' these services are and also don't care to mention that they are getting the money for these programs from 'therapy' and 'health care' programs that were not specifically allocated for 'public health' or 'law enforcement'.  Indeed, Drug Court is a highly effective 'harm reduction' strategy I fully support but it's funding doesn't detract from family medicine.
The fact is that all the 'tools' in the 'tool box' are what are needed however the 'celebration' of 'harm reduction' and the spin doctoring around it sends a very questionable message to children, and the community at large.  Something about 'palliative' care' never did this.  Mind you I've been highly suspicious of government and beurocratic language since the same folk in the 60's gave us the 'Peace Missile'.  What concerns me is that we will one day have to pay more taxes to clean up after the priorization of harm reduction programs just as we all paid more taxes to clean up the excessive missiles which now are the reason for the excessive costs of security. Government bearocracies have a long documented love for short term success projects that have long term negative consequences.  Their favourite is spend our way out of debt, a political harm reduction program that is causing Greece and others like it a little concern to put it nicely.
There's something to be said for competition in health care insurance.  Harm reduction is necessary and certain harm reduction programs like drug court, and methadone maintenance,  are highly beneficial.
The WHO supports harm reduction but only as a stepping stone to abstinence.  I don't see that being the agenda of many of the programs that are promoted as really 'sexy'.  They seem unfortunately to be putting today's problem off till tomorrow.  That sounds to me like 'let's make the  children and grand children"  pay for the government's spending schemes.  Harm reduction is simply palliative care. Is there a plan as the WHO would demand that these approaches ultimately lead to abstinence or is this just a way to have the government get more of the highly lucrative turf of alcohol marketting and street drug dealing. Great public health but please don't say 'it's for the patient's own good' without ensuring that poor girl or boy has a lawyer representing him.