Sunday, March 31, 2013

Harm Reduction, Abstinence and Public Health

Abstinence first and foremost is a therapy for the individual. It's the 'cure' for addiction. Harm reduction originally was a public health strategy for the benefit of the community. Example - needle exchange - reduces risk of disease transmission. Methadone maintenance - reduces crime and disease spread. The impetus for abstinence was 'healing the individual' and in AA and other such self help group the altruism of 'one drunk helping another'. AA demonstrated that abstinence was a cure whereas prior to the success of these programs alcoholism and addiction were considered untreatable. Today sometime biting the hand that feeds, the harm reduction programs standing on the shoulders of those who have gone before them, are serving more financially rewarding ends that the marginalized human addict often described as a parasite. Harm reduction policies have been promoted as 'saving money from having members jails', reducing health care costs to the community etc. 
I'm all for harm reduction. All physicians are in the harm reduction and 'cure' business. We've individually had no stake in either per se. It's common for us to advise re 'preventative measures', recommending lifestyle changes, going to AA, exercise, diet, less stress, seeing therapists, and then going on to treat the liver disease, heart disease and mental illness that come with the very common 'noncompliance' and 'non adherence to medical regimen'. There is the same problem in the treatment of all chronic illness, heart disease, diabetes, hypertension etc, life style changes are hard and people continue to see the doctor for 'harm reduction' therapy. But no doctor would argue that exercise isn't good for diabetes. 
This is where the problem arises - harm reduction evangelists - usually with some monetary gain in their agenda - criticize the proven abstinence therapies and argue against abstinence Abstinence is 'cure' and the first stage to highly successful recovery which is a state of being 'happy, joyous and free'. The World Health Organization clearly states that harm reduction is valid only as means to abstinence. It's not an 'alternative'. It's not superior. The 'treatment of choice' for addiction is abstinence, no different than the 'gold standard treatment of choice' for acute appendicitis is appendectomy. There are other treatments for appendicitis but they have greater mortality and morbidity. 
The funding for harm reduction over abstinence based treatments reflects a shift away from the care of the individual and a trend to 'blaming the victim' and ultimately justifying marginalization and herding of addicts into a second class citizen role with only 'palliative care' offered (palliative care being another 'harm reduction' strategy offered when there is no cure available). Today though there is a cure for addiction and the rich are still offered this while the poor are increasingly given 'cake' or 'harm reduction' only. In the end ironically, the lucky ones find AA or NA or become involved in some other spiritually based program of abstinence. The longest studies of sobriety and long term success, such as done by Gallanter, show people who are doing well are abstinent, involved in a spiritually based supportive community and recognise that whatever the substance of addiction is was not safe for them personally. 
Personally I get paid more for 'harm reduction' work than abstinence based work mostly because the patients who are in the 'harm reduction' phase of treatment remain sicker longer, need more visits, and are more likely to need more medical and psychiatric services. When I convinced my hypertensives to meditate and get off their anti hypertensive medications I lost them as patients. Cure is rarely as well supported in the industry as 'harm reduction' therapies. I saw this with Herbert Benson's work and Kohlberg's work about heal. 
This doesn't concern me. I don't think there is some huge conspiracy of sickness.  People in recovery come back to see me for brief psychotherapy and short term bouts of medication management.  Indeed they've returned to being in the same category as people who seek help for situational crisis but don't require ongoing support.  The 12 step programs and other spiritual programs of recovery provide that ongoing support and the therapist is then used specifically for advances rather than to just keep the person's head above water so to speak.  Harm reduction therapies all contribute to bringing a person to the point of seeking abstinence if this is at all possible.  Both are vital and the problem only arises when a person is solely invested in one or the other and sees the world with the cognative distortion of either/or black and white thinking. 

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