Is “controlled drinking” or “harm reduction” a legitimate goal for treating persons with substance u
It has become increasingly evident that the moral model’s focus on abstinence as the beginning and ending point of treatment, has resulted in the need for a more humanistic, accepting and flexible treatment modality. The harm reduction approach fills this need by differentiating itself from the more authoritative, judgmental and exclusionary treatment modalities. It honors the client’s prerogative to define his or her own harm reduction goals and it does not require drug users to label themselves as addicts, in turn reducing stigmatization. as a result, client retainment is improved, treatment is sustained and the therapeutic relationship is effectively strengthened.
Before determining if “harm reduction” or “controlled drinking” is a legitimate goal for treating persons with substance use disorders, the tenants of the harm reduction model and the definition of what it means to be legitimate should be clear. The harm reduction model of substance use disorder treatment is an approach that combines a number of interventions whose primary goal is to decrease individual and societal damage regardless of the client’s past or present level of abstinence (Brocato & Wagner, 2003). By altering the drug users' behavior, environment and conditions, the harm reduction model seeks to reduce the associated harms and risks while improving the health of the individual and the safety of the society (MacCoun, 1996). The harm reduction model may essentially be broken down into five primary principles: it is humanistic in that clients are treated with dignity and respect regardless of their present level of substance abuse; it is pragmatic in that it attempts to control and reduce the risks and harms inherent in the drug use behavior; treatment is a collaborative effort between the client and the therapist; the priority is reduction of individual and social harms as opposed to eliminating the actual drug use; it incorporates the unique needs and characteristics of the client and as well as the community during the process of prioritizing goals (Riley et al, 1999).
The definition of legitimacy varies slightly among dictionaries, for example, Merriam-Webster online dictionary (2009) defines legitimacy as “conforming to recognized principles or accepted rules and standards,” while Random House dictionary (2009) defines legitimacy as being “in accordance with the laws of reasoning; logically inferable.” Therefore the topic question by definition is asking whether or not the harm reduction model is a reasonable and logical therapeutic approach that conforms to the recognized principles and standards of acceptable patient care. Regardless if the health care practitioner is an M.D., PhD. or an M.F.T., by following the principles of the Hippocratic Oath, the standard of patient care is likely to be adhered to. Research has shown that there is strong support within the psychotherapy community to structure patient care around the tenants of the Hipporcatic Oath (Marzanski, Coupe & Musunuri, 2006). According to Allen (2006), the standard of patient care is considered both legally and ethically non-negotiable. Health care practitioners are duty-bound to work with patients with the understanding that they are infinitely valuable and thus anything short of conforming to the recognized principles and standards of acceptable patient care is insufficient (Allen, 2006). To help determine if the harm reduction model is a reasonable and logical strategy to undertake in treating substance use disorders, the results of alternative approaches that primarily focus on abstinence should be gauged for their level of success and failure.
Research has found that abstinence focused treatment approaches such as the moral model have greatly contributed to an “upward trend in drug use among virtually every age group; a steady supply, decreased cost, and increased purity of street drugs; mounting emergency room visits and deaths from overdose and drug use-related diseases such as HIV/AIDS and hepatitis; and continued drug-related crime (Bilger, 2005).” An overwhelmed Judicial system struggling to keep up with the backlog of drug related court cases and overcrowded prisons is the direct result of a largely ineffective abstinence focused treatment philosophy (Jensen, Gerber & Mosher, 2004). Clearly the evidence seems to indicate a failure on the part of the established abstinence focused treatment approach to significantly reduce the individual and societal consequences of drug use. The legitimacy of the harm reduction approach is ultimately dependent on the results of competing models in that following the standard of patient care implies utilizing the most effective and least harmful treatment strategy available to accomplish the treatment objective (The Gale Group, 2004). Without a strict adherence to the recognized principles and standards of acceptable patient care, legitimacy by definition is not possible.
The harm reduction model which does not regard abstinence as a necessary means to treatment, is fully compatible with the research supported efficacy of cognitive-behavioral therapy and motivational enhancement therapy, as both therapeutic approaches view abstinence as just one of many possible goals and not necessarily the most important (Marlatt, Blume & Parks, 2001). By increasing the client’s level of confidence in their ability to effectively disengage from behaviors that help maintain their drug use, self-efficacy is established and associated harms are reduced (Bandura, 1995). However, if the client has poor self-efficacy, it may result in an increased likelihood of “engaging in more dangerous drug consumption practices (Bandura, 1995).” During the process of changing the drug users destructive and maladaptive behavioral patterns while increasing his or her motivation for change, great care is taken not to stigmatize the client through labeling. This is in part accomplished by not requiring drug users to proclaim themselves as addicts in order to receive treatment (Marlatt, Blume, & Parks, 2001). The potential ability of the harm reduction model to incorporate proven therapeutic approaches such as cognitive-behavioral therapy and motivational enhancement therapy, and then to apply those approaches through innovative programs such as needle exchange, in my opinion helps to further the legitimacy claims of the harm reduction strategy.
Hypodermic needle exchange programs have gained an increased level of popularity and acceptance within the last decade (Bayes, 2007) as research has revealed that it is economically feasible (Bigler 2005), increasingly accessible (Bayes, 2007), and clinically efficacious in treating substance use disorders (Ritter, 2000). Evidence suggests “in the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programs and outreach programs (Ritter, 2000).” Bigler (2005) argues in his article entitled “Harm Reduction as a Practice and Prevention Model for Social Work,” that although the government expenditure on drug control has increased exponentially in the last 20 years, the goal of widespread abstinence has largely failed to materialize (Bigler, 2005). In 2000, the United States spent in excess of $19 billion in an attempt to manage the effects of drug use disorders. Taking inflation into consideration, this exorbitant sum represents nearly a tenfold increase in government spending from 1985 to 2000 (Brocato, 2003). The economic feasibility argument of the harm reduction model suggests that by altering the therapeutic process to encourage risk minimization as opposed to use elimination, destructive behavior would be curtailed, in turn lessening the financial expenditure necessary to combat the societal consequences of drug abuse.
The notion that we should focus more on the personal and societal consequences of drug abuse as opposed to the drug taking behavior itself, may at first seem backwards and counterproductive to some. However, by examining the model’s efficacy, it is clear that this therapeutic approach has proven itself to be quite useful in dealing with a population who may or may not view their drug dependency as an illness and abstinence as an unmanageable and seemingly unattainable goal. In helping to demonstrate the efficacy of the harm reduction model, the article entitled “Making the Case for Harm Reduction” by Bayes (2007), focuses on heroin addicts in Canada who successfully lessened their heroin consumption and related negative consequences on society by legally acquiring methadone through government sanctioned programs. The study suggests that as a result of the harm reduction model, sexually transmitted diseases such as AIDS and hepatitis were curtailed, overdoses reduced, and public displays of drug induced illicit behavior decreased (Bayes, 2007). The strategy of employing outreach programs for harm reduction has proven to be both popular and effective as of the 3.5 million needles distributed via the syringe exchange program in British Columbia, over 3.5 million needles were returned, in turn significantly reducing the possibility of exposure to HIV and other blood-born infections commonly associated with hypodermic drug use (Bayes, 2007). In evaluating the efficacy claims of the harm reduction model, the high exchange rate of used and potentially contaminated needles for sterile ones as part of the needle exchange program provides qualitative reinforcement along with the meta-analytic support that highlights the ability of outreach programs to “manage a host of consequences, from diminishing risks for developing fetuses in pregnant women to reducing the social costs of criminal behaviors to support addiction (Bayes, 2007).” Unfortunately Bayes (2007) does not provide hard data to support the effectiveness of outreach programs or the harm reduction model in managing all the issues that he addresses such as improving the health of developing fetuses to specific social costs of drug related criminal behaviors.
Limited client accessibility to therapy is a major determinant to the sustainability of treatment as geographical and cultural barriers may often stunt motivation, as seeking therapy exceeds the logistical capacity of clients and their social support network (Bayes, 2007). However, the harm reduction strategy expands accessibility through outreach programs for mobility challenged and high-risk populations. Improving accessibility to treatment for “hard-to-engage populations, namely, injection drug users, prostitutes, and homeless users (Brocato, 2003),” is not only logical and reasonable; it is an indicator of harm reduction model legitimacy in treating substance use disorders. As part of the approach, clients work with therapists in a non-confrontational, supportive and educational manner, which in turn helps to increase the probability for continued client participation and ultimate goal attainment (Brocato, 2003). In evaluating the evidence supporting the harm reduction model’s client accessibility claims, the strategy of employing outreach programs appears to be effective in establishing therapeutic contact with individuals who may otherwise fail to receive treatment via more authoritative and exclusionary treatment modalities.
There have been a number of harm reduction developments in recent years in the area of drug substitution therapy. An important development has involved substituting a dangerous and harmful drug such as heroin and cocaine for a safer and more manageable alternative substance such as methadone and naltrexone. By reducing the overwhelming cravings for the illicit substance, use is curtailed and a decrease in harm on both the individual and societal level is likely to occur (Babrova et al, 2007). The growing interest in pharmaceutical solutions to the drug use problem is evidenced by the expanded media coverage awarded to the harm reduction strategy and the breakthroughs that continue to evolve the field of substance use disorder treatment. For instance, the LA Times reported on October 10th, 2009 that a cocaine vaccine had been developed which blocked the drug effect’s on the brain but did little to keep users from wanting the drug. The findings suggest that the vaccine is better suited in preventing relapse in recently abstinent users as opposed to current users (Martell, 2009).
Another form of drug replacement therapy is the process of ingesting a substance that effectively limits the physical effects of the more harmful illicit drug. For example, Disulfiram or Antabuse as it is marketed in the United States, can produce a ”statistically and clinically significant contribution to treatment outcome in alcoholism by limiting the psychological effects of alcohol consumption (Brewer, 1992). The argument is that if the alcohol user is struggling to “achieve sobriety, the supervised administration of Disulfiram is warranted (Fuller & Gordis, 2004). Additional research in the form of longitudinal studies with large sample populations is needed to help determine the long-term physical effects of drug substitution therapy.
Opponents of abstinence based treatment approaches believe that regardless of the treatment strategy, any type of risk compensation that attempts to make drug use safer will inevitably increase participation (MacCoun, 1998). The belief is that the harm reduction treatment approach in particular should not be implemented when “the drug problem may be near a point where modest perturbations favoring greater use can be multiplied into large changes in use (Caulkins, 2009).”At the root of this argument is the notion that if personal harm was reduced, it would result in an increased prevalence of drug use and consequently increased societal harm in terms of health care costs and violent crime (Brocato, 2003).
Evidence that does not support the use of the harm reduction model appears to be focused on alcohol as opposed to other substances such as marijuana, cocaine, hallucinogens and opiates. In a study conducted by Gual, Bravo, Lligoña, and Colom (2009), reported in the article “Treatment for Alcohol Dependence in Catalonia: Health Outcomes and Stability of Drinking Patterns over 20 Years in 850 Patients,” results suggest that when comparing controlled drinking to abstinence, the latter is associated with a lower mortality rate, fewer alcohol-related problems and substantially better psychosocial functioning. The study asserts that the harm reduction model, which utilizes the concept of controlled drinking to combat alcoholism, is rarely successful in the long-term and extremely difficult to sustain (Gual et al, 2009). In the case of alcoholism, abstinence is the “most stable drinking outcome achieved and is associated with fewer problems (Gual et al. 2009).” In evaluating the counter evidence to the legitimacy of the harm reduction model in treating substance use disorders, it appears that alcohol may be the exception as “controlled drinking” may fail the alcoholic in the long-term, resulting in a return to heavy drinking with continued distress and an increased level of mortality. It is unclear why alcoholics do not respond as well to the harm reduction model as do other substance abusers. Perhaps it has something to do with alcohol’s accessibility, and cultural embedded ness that makes alcoholism so difficult to manage. Although further research is needed to determine why alcoholics are unlikely to achieve a comparable level of harm reduction as opposed to other substance users. The 20-year length of the Gual et al. (2009) study provides strong longitudinal support in countering the effectiveness and sustainability claims of the harm reduction model.
Skeptics of the harm reduction model’s legitimacy argue that through the construction of a harm reduction plan that attempts to moderate substance use, it effectively constitutes a formal approval of use by the health care professional and thus a certain level of responsibility for any future trauma or damages (Carroll, 2009). Responsibility to the well being of the patient is a fundamental component to the notion of proper patient care (Allen, 2006), as a result, it is understandable how Carroll (2009) can argue against the legitimacy of the harm reduction model and it’s focus of treating the resulting harm instead of the actual drug use. After all, distributing needles to hypodermic heroin users may see seem counter-productive to attaining the ultimate goal of abstinence, however, when the focus is on reducing the actual harm that results from the drug taking behavior, as opposed to achieving abstinence, then in fact the harm reduction model is a legitimate approach in treating substance use disorders. In my opinion, the construction of a harm reduction plan that rejects the abstinence focused notion of continued substance use as a client disqualifier, is neither a formal approval for continued use nor an acceptance of responsibility by the practicing clinician. The therapeutic strategy of enabling the client to determine his or her own harm reduction goals, in theory helps to insulate the therapist from accusations regarding the consenting of further drug use. Although the sanctioning of drug use is a compelling argument in countering the legitimacy claims of the harm reduction approach, it is not empirically supported and thus more vulnerable to interpretation and refutation.
The theoretical shift away from treating the actual drug use, to the more encompassing treatment plan of focusing on the consequences that result from the drug taking behavior itself, is a significant paradigm shift in the treatment of substance abuse and dependency. By establishing a flexible and open treatment approach that is nonjudgmental (Marlatt, Blume, & Parks, 2001), and based on client education, empowerment and motivational support, the therapeutic relationship may be strengthened as clients become increasingly involved in the construction and maintenance of their own unique treatment plan (Willer & Miller, 1976). The question as to who should hold the prerogative in the therapeutic relationship to define and set harm reduction goals, is for a number of reasons best relinquished to the client. Research has clearly shown that greater client involvement in the goal setting process lead to significantly greater client satisfaction and goal attainment (Willer & Miller, 1976.
The process of strengthening the therapeutic relationship and building a professional bond based on trust and mutual respect is in part, conveying to the client that they are welcome to receive treatment regardless of their motivation or degree of drug use and dependency. As part of the harm reduction strategy, clients are offered treatment regardless of motivation (voluntary or mandated) or belief regarding the problematic nature of their substance use disorder (Noordsy, Schwab, Fox, & Drake, 1996). The non-exclusivity and flexibility of the harm reduction model presents the possibility of treatment to many individuals who may often be disqualified by traditional abstinence based therapeutic programs on the basis of relapses and refusal to label their drug use as an addiction. For the most part, abstinence focused treatment plans are “generically applied, dogmatically interpreted, and presented with moral overtones, which have led many people with substance use disorders to avoid or reject traditional treatment (Donovan & Rosengren, 1999).”
It is clear that as no two drugs are alike, no two substance users are alike either. To assume that the harm reduction model is applicable to all individuals as well as to all substances is misguided and potentially detrimental to the client. Although the success rate of the harm reduction model appears to fluctuate across substances, the goal setting process in which the client is allowed the responsibility of determining his or her own harm reduction goals is a tremendous tool to encourage initial participation, continued involvement and eventual goal attainment. By working with the client in a collaborative relationship as opposed to a hierarchical relationship based on critique and consequences, the therapeutic relationship is strengthened through a process of client education, empowerment, and motivational support.
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