Harm reduction vs recovery: the false dichotomy
By Katy MacLeod -Crew Training and Outreach Coordinator
I opened up my email the other week with my DS daily snippet courtesy of Drugscope landing in my mailbox. I flicked through the top stories and for the first time (well at least in a few days) I got really fired up about something. I came across this:
“A team including one of the researchers responsible for the original finding have queried the interpretation of the highly influential report from a national Scottish study that most drug users starting treatment wanted to become abstinent. On the basis of in-depth interviews, they caution that it is just not that simple.”
What is the role of harm reduction when drug users say they want abstinence?
Neale J., Nettleton S., Pickering L.
International Journal of Drug Policy: 2011, 22, p. 189–193. Located here
The original report it discusses What are drug users looking for when they contact drug services: abstinence or harm reduction? (McKeagney et al), recruited participants from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. “ The research identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying ‘abstinence’ as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited ‘reduced drug use’, and 7.4% cited ‘stabilisation’ only. Less than 1% of respondents identified ‘safer drug use’ or ‘another goal’, whilst just over 4% reported having ‘no goals’.” Full report found here
Having recently attended the Mckeagney/Peele debate, I observed a bit of a backlash on harm reduction with some claiming that it interfered with recovery. Neil Mckeagney even suggested that the majority of drug services are focused on reducing harm and as a result are not focusing enough on recovery. As Stanton Peele clarified, Neil (and many others attending) actually mean abstinence when they say recovery. (For more info on the debate view our blog entry.)
Having mostly worked in abstinence-based services previously, I found this claim in stark contrast to the reality of working in drug services. If anything I feel it is the other way about; we promote abstinence and often add harm reduction as an afterthought. This is certainly true in my experience when you consider psychostimulant use. In Scotland we are pretty good at harm reduction for injecting use. There is good access to needle exchange in many areas and there is a lot more invested in education for workers with regards to injecting use. I don’t think the same can be said about psychostimulant use. Don’t get me wrong, there are some wonderful services out there that are doing this, e.g Incite in Aberdeen, NHS Harm reduction teams, etc. However I don’t think it is prioritised across the general drugs field. This may have something to do with the dominance of opiates when looking at problem drug use in Scotland. I would argue that our problematic psychostimulant users of today could be our problematic opiate users of tomorrow if not given the right support and advice when they need it.
In delivering training across Scotland for Crew, there is often a harm reduction section of the training. Often I am faced with pretty limited discussion from workshop participants around practical harm reduction tips. Responses generally slide toward tips for stopping or at least reducing use. This is overlooking a significant percentage of psychostimulant users who do not wish to stop, or, are not ready to yet. Because people are much more likely to be using psychostimulants recreationally, harm reduction is really crucial for this user group. Recreational use doesn’t mean use isn’t problematic. People may well be taking risks. With much more social acceptance of psychostimulant drug use, the risks and harms often get overlooked.
Of course this doesn’t mean that we can only approach people with ways of cutting down. This is part of harm reduction for sure, but looking at some of Miller and Rollnick’s suggestions within Motivational Interviewing, presenting people with a menu of options is more likely to get them to do something. In this menu of options there could be techniques to cut down their use, control their use or at the very least, use with the minimum impact to health possible.
I get really frustrated about the suggestion that harm reduction is somehow separate from recovery or prevents someone from achieving abstinence. At Crew we support people to reduce, stabilise or stop. We always promote abstinence as a choice but we also tell people about safer ways to use if they are determined to use. Is this not what being person centred is all about? Working within that person's goals? With some major advancements in the drugs field, it seems crazy to me that Crew often gets viewed as slightly “edgy” or radical. Our stance is really very simple: we neither condemn nor condone substance use. We see substance use as a public health issue not a moral issue. This doesn’t mean we are pro drugs!
Of course we would love to see people leading a happy fulfilling life without the use of mind-altering substances but we also recognise that people can and do use substances safely, look at alcohol! We probably all know people who use safely and then those who use to excess. We recognise that people engaging with harm reduction may have made that first vital step on the road to recovery. Many people are calling for a review of drugs policy and as we have mentioned before, the war on drugs could be described as flogging a dead horse. Crew supports an open and frank discussion with regards to drug policy. We come from a neutral place as we recognise that legal and illegal drugs have both positive and negative aspects to use. Our learned colleagues at Transform have described many models for regulation in their book Blueprint for Regulation which don’t involve opening the flood gates and legalising everything.
The report: what is the role of harm reduction when drug users say they want abstinence? helps us to clarify. When people are talking about abstinence, we find they often mean different things. Many of the people surveyed actually didn’t mean complete abstinence. They wanted to abstain from their problem drug but perhaps continue using other substances on a recreational basis. Surely this is evidence that there is a need for harm reduction to sit within recovery. We need to recognise that recovery is personal and will not mean abstinence for every individual. At Crew we define recovery as “stopping problematic use”. For many of our clients this does involve complete abstinence but for others they may return to recreational drinking for example.
Taken from the Road to Recovery:
“ For too long, debate in Scotland has centred on whether the primary aim of treatment for people who use drugs should be harm reduction or abstinence. We fundamentally disagree with the terms of this debate. We do agree with the United Nations Office on Drugs and Crime, which said in a recent report that "harm reduction is often made an unnecessarily controversial issue, as if there were a contradiction between treatment and prevention on the one hand, and reducing the adverse health and social consequences of drug use on the other. This is a false dichotomy. They are complementary.”
At Crew we fully support this statement. Much time can be lost getting caught up in the debate and as a result we can lose focus of what’s important- facilitating and sustaining recovery. Being one of the pioneers of harm reduction in psychostimulants, Crew sees no separation between our harm reduction work and our recovery work. Crew’s National Director John Arthur is at the forefront of the Recovery Agenda with his work through the Scottish Drugs Recovery Consortium.
At Crew we apply a stepped care approach. Its key elements are that it is easily accessible, person centred, is proportionate to wherever someone may be in their substance use and crucially doesn’t wait until people become problematic users before engaging with them. Crew are showcasing our stepped care approach at our National event in March. Over the last 2 years Crew have been focusing on the recovery support part of our approach. This involves ongoing support to build recovery capital following drug counselling. Support is provided in groups and one to one sessions. Crew facilitates SMART recovery and wellbeing groups in collaboration with other agencies such as Simpson House and with people in recovery. We also offer waiting list support for our drug counselling. For more information on our recovery services, visit our website http://www.crew2000.org.uk/services/support-services/recovery-work.html
Looking back at the Abstinence or Harm Reduction report (McKeagney et al, 2004), one thing we do agree with is that recovery is a process and that “harm reduction may form an essential element of transitional support” within that process. Turning to the role of harm reduction report (Neale, 2011) we also firmly agree with the statement “If researchers do not probe for cannabis, alcohol or tobacco, interviewees will probably not think to mention them”. At Crew we find this extends to anyone working with users of drugs and it is something we hear time and again from front line workers. If we continue to only have an opiate focus when looking at problem drug use, we are missing a whole sphere of drug use. With the emergence of trends such as new psychoactive substances and Scotland being named the cocaine capital of the world (World Drug report, 2010), it is crucial we give more focus to psychostimulants. . If you or your team need to get up to date with the latest trends in substance use, check out our training courses at http://www.mindaltering.co.uk/training Equally if we only focus our services at the problem end of drug use, we will never break the cycle. Surely then, the key to success with preventative spend is more emphasis on effective early interventions.
Harm reduction is one thing that can be done with all drug users regardless of their goals. Giving users safety advice doesn’t interfere with recovery; very often it is harm reduction that engages someone in seeking further treatment. We firmly acknowledge that a drug free life should be promoted as an option but also see the damage of not acknowledging that complete abstinence isn’t always a user’s preferred option. When offering harm reduction support in a recovery orientated service, we feel it can only be a good thing. Ultimately it saves lives.
Crew’s National Director John Arthur will continue to explore this debate in his presentation Harm reduction vs recovery- the false dichotomy at our National event, full details and to book visit http://crewsus2012.eventbrite.com/
