Harm Reduction


I just read a wonderful book, “Coming to Harm Reduction Kicking and Screaming: Looking for Harm Reduction in a 12-Step World,” by Dee-Dee Stout. The book is as delicious as its title. The first part of the book describes a little bit about what harm reduction is, and the latter parts of the book are interviews of treatment professionals. Half are from the “old timers” of harm reduction, including Bill Miller of Motivational Interviewing fame, and the famous Alan Marlatt. The other half of the interviews are from “12-stepping harm reductionists.”

It’s a fascinating read. These professionals describe their mental journey from believing abstinence-only recovery should be the goal for every addicted person, to believing whatever works is a much more practical approach. I’ve made a similar journey in my own mind, so I can relate.

Lately I’ve been reading, thinking, and talking to other professionals about harm reduction. This is an interesting topic because it inspires very strong feelings on both sides. Indeed, just the fact that there are two sides is somewhat remarkable. Who wouldn’t be enthusiastic about harm reduction?

It turns out that these two innocent words are laden with veiled meaning. A harm reductionist’s definition of the term may be something like, “Strategies for drug users and drug addicts, intended to reduce the harm caused by drug use.” But an anti-harm reductionist may see the term to mean, “Strategies which may reduce some harm to drug addicts, but that also prevent them from finding real recovery from drug addiction.”

The desire to get into recovery exists on a continuum. Some addicts want to stop all drugs and learn to live life drug-free. Those patients may embrace abstinence-only addiction treatment and feel comfortable with that approach. Other people may want to stop problematic use of one drug, but see no need to stop another. I see this often at my opioid treatment program. Some people want to quit opioids because of all the negative consequences, but don’t have any desire to stop marijuana, since they can’t see that it causes them any problems.

Other addicts don’t wish to stop using drugs at all, but prefer not to develop some of the negative consequences.

Here are some examples of harm reduction strategies:
 Needle exchange programs (NEPs). Clean needles are distributed to intravenous addicts, sometimes exchanged for used needles. NEPs have been shown to reduce transmission of HIV, and of other infectious diseases. Additionally, patients are less likely to get skin infections like cellulitis and abscesses when new needles are used
 Distributing information about safe injection practices. This can involve things like telling IV addicts about strategies like never using alone, and staggering injection times so that if one person has an overdose, the other one can summon help or use naloxone. It may include instructions on how to use a test dose, in case the product is higher purity than expected.
 Safe injection sites. You won’t find these in the US, but Canada and European nations have sites staffed with medical personnel where intravenous users can come to inject. If they have an overdose, personnel are immediately available to revive them.
 Naloxone kits. These kits can revive people who have had opioid overdoses. I have written much about them in the past, and it’s becoming more main stream to distribute these kits to opioid addicts and their families. Some pain management doctors and OTP doctors also prescribe these kits for their patients, in case of an overdose.

An astute observer will notice I did not list medication-assisted treatment among harm reduction strategies. This is because treatment of opioid addiction with methadone and buprenorphine should be considered a primary and definitive treatment of opioid addiction, not merely as one stop along the road of recovery. Some patients may wish to transition to drug-free recovery in the future, but it shouldn’t be required. Many patients will do better with less risk of relapse if they stay on MAT.

A false dichotomy between the ideas of “abstinence-only” and “harm reduction” proponents has been set up. Instead, we should view all treatment options as complementary to each other. All evidence-based addiction treatment options should offer improved quality of life for the people who use them.

Why not offer options to people who want to reduce the risk of drug use?

As a person with a strong twelve-step background, I found it difficult to embrace all of the harm reduction measures when I entered this field ten-plus years ago. Time, experience, and the medical literature have been my teachers, along with vivid human examples. Most of all, my patients have revealed to me how recovery from addiction rarely happens in a miraculous flash. Mostly, it involves small changes over long periods of time, with some setbacks along the way.

7 responses to this post.

  1. Posted by Cheryl on June 15, 2015 at 10:07 pm

    Thank you Dr. Burson! I would also suggest great readings by Dr. Patt Denning and Jeannie Little, LCSW- both Over the Influence and Harm Reduction Psychotherapy.


  2. I am so excited to read this book review… and mind blown I haven’t heard about this book before! Even I have softened towards the 12 steps over the past year or so. I think we need to have everything in our arsenal that’s possible. There are many MAT patients who have been rejected and hurt by 12 step groups, but there are also many who benefit from the mutual support as well.

    I’m heading to Amazon from here to order this!


  3. Posted by nspunx4 on June 16, 2015 at 4:09 am

    I feel opioid addiction is a medical problem that requires medical treatment in most cases.

    Harm reduction with methadone and Buprenorphine should be available for patients not yet ready to enter full treatment programs such as they do in some European countries.


    • Posted by blackdickpu(ssie)rple on June 18, 2015 at 10:31 am

      i’m from poland.It is the other way,first all other options like therapies and facilities,then methadone,which i am at now


  4. Posted by Owens, Deborah EAP [JJCUS Non J&J] on June 16, 2015 at 1:06 pm

    Have you viewed this FREE online conference that started last Friday and goes a few more days. They had an excellent speaker yesterday talking about blending 12 step with MAT.



  5. Posted by rex on June 16, 2015 at 6:50 pm

    Im with Zac nere, I too cant believe this book has slipped past me. Great post on harm Reduction Dr B.. As someone who has tried na with bupe, i understand all that can go wroug. Even after being there 4 years when I “came out”you would have thought id killed someone..but times seem to be changing all around. Yes wouldnt it be great if every addict could be drugfree.. Maybe someday..hmmm…


  6. Posted by Diana Goodwin on June 16, 2015 at 9:26 pm

    Thank you for another excellent blog post, Dr. Burson. All patients should have access to a full menu of evidenced-based treatments and harm-reduction measures, including access to medical-grade heroin and a safe, medically supervised setting where they can go to inject. I would rather have my son safely maintained on heroin, if need be, than “scoring” in a back alley somewhere where no one will call for help if he OD’s.


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