Harm Reduction and the Clothing Police

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“Oh I know that’s not a marijuana leaf on your cap!”

I had just ushered a young lady into my office. She entered treatment the week before, and I wanted to check on how she was feeling. When I called her from the waiting room, I noticed a rhinestone design on her cap with one part of my brain. I like bright sparkly things, so it caught my eye. But by the time we walked the short distance to my office, it dawned on me what the design was, and I confronted her about it.

“What? Yeah, it’s marijuana. Sorry. I didn’t even think about it.”

“What part of you thought it would be OK to wear clothing promoting drug use to your drug addiction treatment program?” I continued.

Usually I’m more complacent about clothing our patients wear. Some programs have minimal dress codes: no pajamas, nothing too revealing, must wear shoes, no obscene tee shirts… I’ve never gotten too worked up about clothing, thinking that as long as they came into the building, it was a victory.

But for some reason, on that day, I went a little nuts. What can I say, I have bad days too.

My patient was apologetic, but said it was the only cap she had. I told her she could turn it inside out, which she did without hesitation.

Before you are tempted to write in about how marijuana is really a medication and will be legal someday, let me tell you this: I don’t care. I’d feel the same way if I saw a large, legal, liquor bottle outlined in sequins, or a big sequined Opana pill on a shirt. It’s a symbol of drug-using culture.

Today, I’m conflicted. One part of me still thinks it’s not OK to wear clothing promoting any kind of drug use, and this includes alcohol. After all, we are treating patients in whom drug use has caused significant problems. Some of them could be triggered by symbols of drug culture. Is it too much to ask our patients to think about the message they send with their clothing?

Other addiction treatment professionals endorse similar ideas. If our patients are to return to mainstream society, don’t we have an obligation to educate them about traits that may still associate them with active drug use?

For example, is it possible my patient wasn’t aware of the message she sends with her bedazzled marijuana cap? If my patient wanted to go for a job interview, for example, would wearing this cap work against her? Maybe it depends on the job, but overall I would say the cap would hurt her chances of being hired.

On the other hand, if we view the situation with a harm reduction eye, isn’t it good enough at this point that my patient is getting treatment for her addiction? If a patient wants to get help for some aspect of addiction, isn’t that good enough? Maybe it’s unreasonable to expect a patient in treatment for a short time to start viewing her wardrobe with a recovery-oriented eye. Maybe such issues can be addressed later, in counseling, or maybe not, but perhaps I should concentrate on more important issues. Like helping her get through the day without illicit opioids.

A harm-reduction model would recommend meeting that person where she is now, in her THC-wearing mindset. Harm reduction is an idea that says any change that reduces the risk of drug use is success, and that we need to accept her as she is. We should respect our patient’s choices and help in any way she is willing. Any reduction around the risk of her addiction is an acceptable goal, even if it doesn’t conform to what I may view as “real” recovery.

The question is, or course, where do we draw the line? If it’s OK to wear clothing glamorizing drug use, is it OK to allow patients to tell glamorized stories of drug use in the waiting room?  Is it OK for patients to use drugs on the premises? What about dealing drugs?

I endorse harm reduction principles, but have come to realize I have limits. The longer I’ve been doing this job, the more enthusiastically I approve of harm reduction principles. However, I still draw the line when one patient’s behavior affects the other patients. That’s why I won’t tolerate drug dealing on the premises, patient violence (against other patients or staff), or drug use on OTP grounds. But that’s a hard call to make, and it’s a decision best made at case staffing with input from other staff.

Harm reduction is a difficult idea for many of us. What one person sees as harm reduction, another sees as enabling. Here are some other quotes I’ve heard from other people. I’d like to give credit, but my memory’s not that great.

“Don’t allow the perfect to be the enemy of the good.”

“The enemy of the best is the good.”

“It’s OK to meet a person where they are, but it’s not OK to leave them there.”

“I don’t promote drug use. I don’t promote car accidents either, but I still think seatbelts are a good idea.”

“Dead addicts don’t recover.”

Readers, any thoughts?

 

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3 responses to this post.

  1. Posted by James Cioe on December 28, 2015 at 11:45 am

    It’s all good! Happy New Year.

    Jimmy Cioe, LADAC, CSAC, CPSS –Program Coordinator-Recovery Initiatives

    Governor’s Institute on Substance Abuse 1121 Situs Court – Suite 320 Raleigh, NC 27606

    Office) 919-256-7414 – Fax) 919-990-9518

    Front desk) 919) 990-9559

    Blog/twitter/newsletter sign-up: http://recoverync.org/

    http://www.governorsinstitute.org

    LinkedIn:

    linkd.in/1vkDT

    Reply

  2. Posted by William Taylor, MD on December 30, 2015 at 3:31 am

    There is a great temptation to be glib or funny in this business, both for providers and patients. “trying to be cute” is a more charitable interpretation than “promoting drug use”. For me, I try to be mindful (not always successfully) that this disease has caused profound heartbreak for many; being flippant runs the risk of reopening very painful wounds for people.

    Reply

  3. Posted by Mikael on January 16, 2017 at 7:31 am

    Hello,

    “If my patient wanted to go for a job interview, for example, would wearing this cap work against her? Maybe it depends on the job, but overall I would say the cap would hurt her chances of being hired.”
    Going to the origins of harm reduction, it is important to remember that the economy is controlled by the ruling class. The ruling class does not support THC-centric wardrobes because it threatens the alcohol-centric marketplace. We can probably safely assume that a Bud Light cap would not hurt her chances of being hired as much as a THC cap. More broadly, look at places like Greece, Detroit, Argentina, and Puerto Rico, where hedge fund managers have 100% control and austerity measures are in place. Thus, in San Juan, while the people need San Juan-centric measures, they can’t get them because the ruling class want the funds for their own pockets. For your patient with the flashy cap, drug use didn’t ruin her, but poverty and the war on drugs (including anti-TCH-wardrobe mantras) could ruin her.

    “Is it too much to ask our patients to think about the message they send with their clothing?”
    Harm reduction is also about helping patients hold onto their language and culture. The truth is that commodification promotes addiction to sugar, alcohol, and tobacco. The truth about the cap is that it confronts prejudice about THC. Overall, harm from ethanol is 72, heroin 55, crack 54, and cannabis 20, with 100 the highest, per a 2010 Lancet study (http://www.reuters.com/article/us-drugs-alcohol-idUSTRE6A000O20101101). Navajo and other tribal peoples emphasize the importance of the land, water and mountains; air is medicine. The message her sends is that THC is ok, which is probably not an ideal mindset, but it is less harmful than saying ethanol is ok. Ethanol is the only drug on the planet you have to justify not taking.

    Reply

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