Few discussions within the addictions field have generated more vitriol than the extremely polarized debates between advocates of harm reduction and advocates of abstinence-based approaches to addiction treatment and recovery support. The chasm between these ideological poles has widened over the course of my career, but there is a recent trend toward discovery of common ground within these approaches. Rather than conceiving these philosophies and service strategies in either/or terms, a maturation within all but the most extreme fringes of both camps seems to be producing new models of collaboration. These efforts are based on the premise that individuals may need quite different types of support at different stages of their drug use, addiction and recovery careers. I have just posted a paper on the integration of recovery and harm reduction concepts and practices in the City of Philadelphia. The quotes below illustrate some of this shift in thinking.
[Bridging the harm reduction and traditional addiction treatment worlds] requires openness to the possibility that our worldview and the cherished concepts we use to describe it may need to become subtler, more fine-grained, amended or even discarded; and, that approaches which don't work for one person can, equally, be life-saving for others, when all the time our own beliefs, experiences, perhaps even our entire biography, shouts out that this can't be so." Neil Hunt, in: Recovery and harm reduction: Time for a shared, development-oriented, programmatic approach In R. Pates & D. Riley (Eds.), Harm reduction in substance use and high-risk behaviors. Chichester: Wiley-Blackwell.
While harm reduction can be viewed as an end in itself with afocus on mitigating harm to individuals, families and the community as a whole, harm reduction strategies can also be viewed collectively as a platform or point of access for promoting long-term health, and, for those with severe alcohol and other drug problems, long-term personal and family recovery. If our goal is to promote health and reclaim lives, then we must understand the direct and sometimes circuitous paths through which individuals and families achieve and sustain such health. We must meet each individual and family with fresh eyes in every encounter with a belief that each encounter is an opportunity for movement, no matter how small, towards health and wholeness. -Arthur C. Evans, Jr., PhD, Commissioner, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, 2013
....harm reduction and abstinence-based substance abuse treatment can not only be integrated, but their integration is more powerful than either theoretical framework separately, particularly in terms of patient engagement and retention. Drs. Roy Futterman, Maria Lorente and Susan Silverman, In: Futterman. R., Lorente, M., & Silverman, S. (2004). Integrating harm reduction in abstinence-based substance abuse treatment in the public sector. Substance Abuse, 25(1), 3-7.
We believe that harm reduction provides many clients with hope to improve their lives in ways that traditional treatment services cannot. Furthermore, integrating harm reduction strategies into existing treatment services allows for many more ways to improve the health of clients and improve the public health of local communities. Dr. Alan Marlatt, Arthur Blume and Dr. George Parks, in: Marlatt, G. A., Blume, A., and Parks, G. A. (2001). Integrating harm reduction therapy and traditional substance abuse treatment. Journal of Psychoactive Drugs, 33 (1), 13-21.
Harm reduction and 12-step approaches can be complementary. Drs. Heather Sophia Lee, Malitta Engstrom and Scott R. Petersen in: Lee, H. S., Engstrom, M., & Peterson, S. R. (2011). Harm reduction and 12 steps: Complementary, oppositional, or something in-between? Substance Use and Misuse, 46, 1151-1161.
...those staff that work in needle exchanges can help speed up the process of recovery and can play an active role in directly routing injectors towards recovery. Colin Wisely in: Wisely, C. (2013). The logic of recovery and injection drug use. Journal of Substance Use, 18, 56-64.
Recovery has within it an implicit and explicit goal of reducing harm. Stable recovery is the ultimate harm reduction strategy. Our mantra is "no closed doorways to recovery." We will meet people where they are on any day and support on that day even the smallest steps towards recovery and wellness that the individual is willing to take, all the while affirming their potential for full recovery and our willingness to walk this path with them. Roland Lamb, Director of the Office of Addiction Services, DBHS, Philadelphia, 2013.
We reframe harm reduction within an expanded purpose of?health promotion rather than an end in itself. This occurs?with?a trauma-informed perspective that recognizes the impact that violence and victimization may have onIndividuals' capacity to minimize harm associated with their substance use while partnering with them to strengthen their?capacity to initiate and maintain their recovery.Harm minimization can be viewed as an end in itself or as a first step towards recovery. At New Pathways, we view it as the latter. Eugenia Argires, Program Director at New Pathways, Philadelphia, 2013.
A recovery focused NSP will be driven by a vision that creates a therapeutic space conducive not only to safer injection practices, but also to actively promoting and supporting engagement for long-term recovery from problematic substance use. Ideally, this means making visible recovery successes and articulating a robust, realistic narrative of recovery that is meaningful and appropriate to the injecting population. ...if there is an authentic, realistic possibility of recovery then there is arguably an ethical imperative to promote and provide access to services that deliver recovery oriented change....The Journey towards a full and meaningful life that is recovery can begin in the most unlikely of places. Why not through the doors of a needle exchange programme Stephen Bamber, in Bamber. S. (2010). The role of syringe and needle programmes in a recovery-oriented treatment system. Recovery writing: Volume one, 2009-2010, pp. 48-54.
Traditional harm reduction programs have pioneered low threshold services, but they have often also been characterized by low expectations. Our vision is to expand low threshold services that at the same time elevate peoples' sense of what is possible for them. We do this by exposing them to living proof that recovery is possible even under the most difficult of circumstances, confirming that there are people who will walk this path with them, and offering stage-appropriate services to support people in their journeys from addiction to recovery. Arthur C. Evans, Jr., PhD, Commissioner, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, 2013
Like much of my work in recent years, this latest project is prompting me to critically re-evaluate long-held ideas about how to best serve those not being reached through traditional models of addiction treatment. You can access the new paper by clicking here. If you have experiences with such integration attempts that you would be willing to share with me, please contact me at firstname.lastname@example.org