Harm Reduction versus Abstinence Only

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I’ve heard the harm reduction versus abstinence -only debate about addiction treatment many times, not only at addiction medicine conferences, but also in my own head. In the past, I thought abstinence from all addictive drugs was the only true recovery from addiction. As I’ve aged, I’ve traveled far into the harm reduction camp, having seen people with addiction die from their disease when perhaps more could have been done to save them.

A wise mentor of mine once said try not to argue with people who aren’t actually in the room with you, so I’ve committed the debate to writing.

Following is an imaginary debate between two addiction treatment professionals. One professional believes harm reduction measures are worthwhile because they can keep drug users alive and healthier, even if they never completely stop using drugs. The other professional feels harm reduction cheats a drug user out of full and happy recovery, which she believes is seen with complete abstinence from all drugs.

First, they chat about needle exchange:

HR: I fully support needle exchange programs. They have been proven to reduce transmission of infectious diseases, including HIV and hepatitis. Why wouldn’t we want to help people avoid getting these potentially devastating diseases?

AO: Because giving out needles sends the wrong message. It says we are OK with people injecting drugs, and that we are willing to make it easier for them to do so. Appearing to condone drug use in any way sends the wrong message to young adults, who may be considering using drugs for the first time. Stigma towards drug users can be harmful, but perhaps stigma serves a good purpose if it discourages people from doing dangerous things like injection drug use.

HR: Studies do not show needle exchange increases the likelihood that people will start using drug intravenously. Easily available clean needles are not enough to convince a person to start injecting drugs. Besides, even if you have little compassion for the drug user, for every case of HIV we prevent with needle exchange, we save our society countless dollars in medical care. That’s just one disease. When you consider the health burden and medical costs of transmission of hepatitis C, it’s even more reasonable.

Even the ultra-conservative Mike Pence, the former Governor of Indiana and our future Vice President, changed his mind on needle exchange after an outbreak of HIV occurred in a rural community among people injecting opioids.

Besides being morally right, needle exchange makes financial sense.

AO: No, it doesn’t. It sends a message to drug users that we’ve given up on them. It says we don’t think they will ever be able to live without injecting drugs. In a way, it infantilizes them. By making drug use easier, we may cheat them out of trying to become clean and sober.

AO and HR move to the topic of medication-assisted treatment of opioid addiction with methadone and buprenorphine:

HR: First of all, medication-assisted treatment (MAT) is harm reduction only so far as all treatment should reduce harm. MAT is a good treatment in itself, and isn’t necessarily just a stop on the journey of recovery.

I fully support medication-assisted treatment. We have fifty years of studies that show people who are addicted to opioids are less likely to die if they enroll in methadone maintenance or buprenorphine maintenance. It is one of the most heavily evidence-based treatments in all of medicine, and it is endorsed by many professional agencies, such as the Institute for Medicine, Substance Abuse and Mental Health Services Administration, the World Health Organization, and the American Society of Addiction Medicine.

We have study after study showing how opioid addicted people have a better quality of life when on medication-assisted treatment with methadone. We have more information about methadone because it has been use in the U.S. much longer than buprenorphine, which was approved by the Food and Drug Administration in 2002, after the Drug Addiction Treatment Act of 2000 was passed.

Opioid-addicted people enrolled in methadone treatment are more likely to become employed, much less likely to commit crime, and more likely to have improved mental and physical health. They receive addiction counseling as part of the process of treatment.

We think buprenorphine has the same benefits, though there have been fewer studies than with methadone. We do know the risk of opioid overdose death is much lower when an opioid addicted person is treatment with buprenorphine, too.

Because medication-assisted treatment is so effective, it should be considered a primary treatment of opioid addiction, and not only a harm reduction strategy.

AO: With MAT, opioid-addicted people may be harmed more than if they continue in active addiction. It is no different from giving an alcoholic whiskey. Methadone is a heavy opioid that’s difficult to get off of. The opioid treatment programs that administer methadone don’t try to help these people to get off of methadone, because they make more money by keeping them in treatment. These patients are chained to methadone with liquid handcuffs forever. It’s also expensive over the long run, and patients have to agree to many restrictions put on them by state and federal governments.

HM: Methadone and buprenorphine treatments are not like giving an alcoholic whiskey, because the unique pharmacology of these medications. Both medications have a long half-life, and when patients are on a stable dose, they feel normal all day long without cravings for illicit opioids. This frees them from the unending search for drugs that occupies much of their days. Instead, they can concentrate on positive life goals.

Also, even after an opioid- addicted person stops using opioids and endures the acute withdrawal, he will usually feel post-acute withdrawal. This syndrome, often abbreviated PAWS, can cause fatigue, body aches, depression, anxiety, and insomnia. It’s unpleasant. Many people in this situation crave opioids intensely. We think this occurs because that person’s body no longer makes the body’s own opioids, called endorphins.

Endorphins give us a sense of well-being, and without them, we don’t feel so good. When humans use opioids in any form, our bodies stop making endorphins. In some people, it takes a very long time for that function to return. In some cases, it may never return. We can’t yet measure endorphin levels in humans, so this is a just theory, but one borne out by years of observation and experience.

Methadone and buprenorphine are both very long-acting opioids. Instead of the cycle of euphoria and withdrawal seen with short-acting opioids, these medications occupy opioid receptors for more than twenty-four hours. It can be dosed once per day and at the proper dose, it eliminates craving for opioids, and eliminates the post-acute withdrawal, which is so difficult to tolerate.

We often compare opioid addiction to diabetes, because in both cases, we can prescribe medication to replace what the body should be making.

And yes, methadone is difficult to taper off of, but most of the time it is in the patient’s best interests to stay on this medication, rather than risk a potentially fatal relapse to active opioid addiction. Some patients are able to taper off of it, if they can do it slowly.

Do you think of a diabetic who needs insulin as being “handcuffed” to it? Do you think the doctor who continues to prescribe insulin is just trying to make money off that patient? Why is it wrong to make money from treating addiction, but not other chronic diseases?

AO: What about all of the former opioid-addicted people, now in 12-step recovery, who are healthy and happy off all opioids? Why are these people doing so well, even though they had as severe an addiction to opioids as the patients in opioid treatment programs?

HR: We don’t have all the answers to this question. One form of treatment, even medication-assisted treatment, won’t be right for every patient. Maybe the support that a 12-step group can provide got these people through the post-acute withdrawal. We don’t have much information about these recovering people, obviously due to the anonymous nature of that program.

If these people feel OK off all opioids, that’s great. They don’t need medication. But don’t prevent other people who do benefit from medication-assisted treatment to be helped with methadone, and buprenorphine.

Besides, not all opioid-addicted people want to go to 12-step meetings. Do treatment professionals have the right to insist everyone go to these meetings, even if patients don’t like them?

AO: Medications cheat patients out of full abstinent recovery. Methadone and buprenorphine blunt human emotions, and make it impossible to make the spiritual changes necessary for real recovery. Methadone and buprenorphine are intoxicants, and they prevent people from achieving the spiritual growth needed for full recovery. You keep these people from finding true recovery, and condemn them to a life of cloudy thinking from these medications.

HR: Various people assert patients on maintenance methadone and buprenorphine have blunted emotions and spirituality, but there’s no evidence to support that claim. How can you measure spirituality? If spirituality means becoming re-connected with friends and loved ones and being a working, productive member of society, then studies show that methadone and buprenorphine are more likely.to assist patients to make those changes.

Physically, studies show patients on maintenance methadone and buprenorphine have normal reflexes, and normal judgment. They are able to think without problems, due to the tolerance that has built up to opioids. They can drive and operate machinery safely, without limits on their activities. Contrary to popular public opinion, patients on stable methadone doses are able to drive without impairment.

However, if that patient mixes drugs like sedatives or alcohol with methadone, they certainly can be impaired. That’s why patients should not to take other sedating drugs with medication-assisted treatments.

People with opioid use disorder are far more likely to make significant and healthy life changes if they feel normal, as they do on medications like methadone and buprenorphine. If they chose abstinence, many times they feel a low-grade withdrawal for weeks or months, and this makes going to meetings and meeting life’s responsibilities more difficult.

Remember: dead addicts can’t recover. Far too many opioid- addicted people have abstinence-only addiction treatments rammed down their throats. Most of these patients aren’t even told about the option of medication-assisted treatment, which is much more likely to keep an opioid drug user alive than other treatment modalities.

Too often, people addicted to opioids cycle in and out of detoxification facilities over and over, even though we have forty years of evidence that shows relapse rates of over 90% after a several weeks’ admission to a detox facility. We’ve known this since the 1950’s, and yet we keep recommending this same treatment that has a low chance of working. And then we blame the addict if he relapses, when in reality he was never given a treatment with a decent chance of working!

Medical professionals, the wealthy, and famous people are treated with three to six months of inpatient residential treatment, and they do have higher success rates, but who will pay for an average opioid user to get this kind of treatment? Many have no insurance, or insurance that will only pay for a few weeks of treatment. For those people, medication-assisted treatment can be a life-saving godsend. It isn’t right for every opioid-addicted person, but we do know these people are less likely to die when started in medication-assisted treatment. After these people make progress in counseling, there may come a time when it is reasonable to start a slow taper to get off either methadone or buprenorphine, but first we should focus on preventing deaths.

AO: Given the time, money, expense, and stigma against methadone and buprenorphine, it should be saved as a last resort treatment. If an opioid-addicted person fails to do well after an inpatient residential treatment episode, then MAT could be considered as a second-line treatment. Let’s save such burdensome treatments for the relapse-prone opioid-addicted people.

HR: It seems disingenuous to claim stigma as a reason to avoid MAT when you are the one placing stigma on this treatment.

I could go on for many more pages, so let’s stop here. You get the idea.

In the past, harm reduction and abstinence were considered opposing views. I’ve heard some very smart people say this is a false dichotomy, and that in real life, these views are complementary.

I like this newer viewpoint.

 

Any form of treatment should reduce harm. If a patient achieves abstinence from drugs, then that’s the ultimate reduction of harm. Also, harm reduction principles can help keep drug users alive, giving them the opportunity to change drug use patterns later in life. As I’ve said above, dead addicts don’t recover. Let’s give people more choice and more opportunities to transition out of drug use, if that’s what they desire.

 

Let’s do a better job of working together in the coming year!

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19 responses to this post.

  1. A realistic and compelling potential dialogue between the two camps, assuming that the basis for the AO position is truly born of a belief that abstinence only, is a superior form of opiate treatment, to medication assisted treatment. Unfortunately, I have found it, relatively, easy to convince colleagues that MAT, combined with traditional 12 step treatment, to be superior to the statistical realities of an early death and the abysmal results of an abstinence only treatment philosophy.
    The other problem, we must be faced, is the underlying refusal to see the truth, when doing so, will adversely impact my position with my employer or my employer with their program census. We can’t deny that patients treated on methadone or buprenorphine, do not need to spend 30, or more, days in an expensive inpatient treatment program. The notion of stabilization versus detox, is a scary one for treatment program administrators that see empty beds, in the midst of today’s opiate epidemic. Perhaps, that is why the conversation is so difficult. The conversation cannot take place, if the colleague has left the room many years ago, to protect their financial stability.
    It’s not shameful. Human nature calls for us to do well, however, in this case, the result, too often ends in an unnecessary and premature death. If we don’t name the elephant in the living room, than we will continue to fail our patients. It is our duty, to give those who have trusted us with their lives, to use the very best studies and evidence, in our evaluation of treatment planning and allow patient centered treatment, to really be patient centered. All patients, and their families, deserve to be given a fair analysis of the studies and the results of those studies.
    There may be great hope in buprenorphine implants, to eliminate diversion and to allow patients to focus on their recovery, regardless of the setting of that treatment programming.

    Reply

  2. Posted by Lynn Lightwell on January 2, 2017 at 7:11 am

    A particularly excellent post, of your many valuable insights. Sharing with others…

    On Sun, Jan 1, 2017 at 8:08 PM, Janaburson’s Blog wrote:

    > janaburson posted: ” I’ve heard the harm reduction versus abstinence > -only debate about addiction treatment many times, not only at addiction > medicine conferences, but also in my own head. In the past, I thought > abstinence from all addictive drugs was ” >

    Reply

  3. Posted by Don Flattery on January 2, 2017 at 9:33 am

    We are in the midst of an all-out epidemic and should not ignore any tools in the treatment “tool box”. Save the life first and then focus on therapeutic needs to achieve an abstinent life.

    Reply

  4. Posted by Steve S on January 2, 2017 at 12:28 pm

    Jana, great summary of a debate that I have almost daily and have pretty much stopped because of the futility of trying to change the nature of cognitive bias. It’s like trying to change the minds of an anti vaxxer or climate denier but perhaps even more difficult since many in the abstinence only camp have been there for decades, run AO treatment facilities so not only have a vested financial interest but as a result of their AO policies never get to sit in my seat and see the amazing transformations in the lives of so many.
    I have invited AO docs to my facility to see these changes first hand but have never been taken up on my offer.
    It’s unfortunate that some of the loudest AO voices teach the new generation of ADM docs and perpetuate the AO philosophy.
    I think we need to address the other elephant in the room, and that is paternalism. Many ADM docs and counsellors are themselves in recovery and look at their own non medicated paths and wish to extrapolate it to everyone else. But as you so accurately noted, one size doesn’t fit all.
    I always have the same discussion with the third year Med students who rotate thru my service as you presented but you did a much better job of it, so I’m going to give your virtual debate to them as one of their required readings.

    Reply

  5. Posted by Alan Wartenberg MD on January 2, 2017 at 4:50 pm

    I am at the point where I have decided that trying rational approaches to abstinence-only folks (who are overwhelmingly 12 step oriented, though the majority of people I know with 12 step orientation are NOT abstinence only) is a waste of time and the equivalent of a religious/ideological argument, which is based on faith rather than logic or evidence. Pretending that there are rational arguments to be had with people whose viewpoints, if enacted into law or regulation (which they are) are killing people every day (or more charitably, not saving them from killing themselves). But a worthy effort nonetheless, Jana!! Happy New Year to all.

    Reply

  6. Posted by dominique simon on January 2, 2017 at 6:51 pm

    Thank you for your piece. This is the first time I have ever seen anything compared to MAT other than less treatment….in your statement: “Medical professionals, the wealthy, and famous people are treated with three to six months of inpatient residential treatment, and they do have higher success rates, but who will pay for an average opioid user to get this kind of treatment?”

    It is frustrating to never see MAT compared with solid drug-free treatment. Instead, it is compared with no treatment or just an hour a week of therapy. But here you seem to be saying that 3-6 months of inpatient would work better.

    I would certainly think so, but because of poor funding for substance abuse treatment, we don’t actually compare MAT with comprehensive drug-free treatments of long duration. It is simply never studied.

    So the conversation goes on as you have written.

    As someone who has been on MAT and who now lives sober and clean without it, I can tell you there are a lot of us out there, and we’re not all the 12 step “freaks” that so many paint us as being.

    A supportive group process is integral to success, as is a healthy living and work environment, solid counseling, mental health psychotropics, exercise, decent nutrition and sleep hygiene.

    I would love a study that compares 6 months of this to MAT. If we could show it works, perhaps the funding would follow.

    Reply

  7. Posted by Icecutter on January 2, 2017 at 7:02 pm

    As a 15 year MAT patient, I am encouraged in some of the changes in attitude we are seeing in politicians now. Just the other day, Governor Chris Christie spoke out about evidence-based treatment in such an informed way that it gave me much hope for MAT becoming the primary treatment offered to suffering addicts. When even politicians, conservative ones at that, start speaking up about MAT, we can see that real progress is being made.

    Reply

    • Thanks for sharing. As the owner of an outpatient program with 36 years of recovery, I found that buprenorphine saved my life in 2004, after a shoulder surgery and auto accident left it frozen and me dependent on norco. We have twelve years of MAT experience in our full service, abstinence based outpatient program. I’m able to share my experience with our patients and their families. Took a year to get past the shame, but it has been a clear asset to eliminate the anhedonia that stole my recovery, while I battled to be “abstinent only” for four months. Interestingly, buprenorphine’s anti-inflammatory and anti-cortisol properties are an extra bonus, health wise. There are many more, in the field, who are paralyzed by fear and shame. Many of my colleagues have had similar experiences and our politicians need to hear that there is an enhanced form of treatment available. Good for Chris Christie.
      Another great topic Jana.

      Reply

  8. Im not a fan of the “vs”. terminology we see in these type of dialogues. What works for some does not help others and vice versa. All addiction TX seems to have risks and benefits that are unique to the individual’s process and point in their journey.

    We can embrace HR principles and full support MAT at the same time we can honor and support those for whom an abstinence approach has been their path. With Depression we see many who benfit from meds, others who use exercise or nutrition, psycho-therapy, mindfulness, the list goes on. Many will try all or some of these things over time. One is not “better”.

    A good clinician offers all these tools and supports choice of the client while pointing out when something might need to be considered, added, or “tried”.

    With substance use disorders most people utilize many different resources over time. So IMO all resources have merit and should be offered to see what the clients needs and wants and most importantly to help assess with what they get traction.

    Most decent informed HR folks have no issue if a client chooses or finds 12 steps or the goal of abstinence to be useful, and that rarely happens until lots of attempts at controlled use/drinking have been tried anyway, just as most decent informed abstinence supporting professionals also recognize that for many MAT is useful and life saving.

    Reply

  9. Posted by Max (Tom) Alexander on January 7, 2017 at 5:43 am

    Hi Jana.

    I’m a big fan of your writing.

    I wrote an article that got published on The Fix that touches on the personal toll of those who feel compelled to achieve abstinence when they’re not ready. It finishes with the statement that “you can’t get clean once you’re six foot under”. Would be interested to get your thoughts.

    Kind regards,

    Max Alexander.

    https://www.thefix.com/defense-suboxone

    Reply

    • I read your article and I encourage all readers of my blog to read it, too.
      Wow.
      Very powerful examples of why we shouldn’t mess with a treatment that’s helping someone.
      Though I’ve never heard of an NA meeting that asks members to identify what medications they are taking. That’s sad.

      Reply

    • Posted by Max (Tom) Alexander on January 9, 2017 at 2:50 am

      Yes. A euphemism if there ever was one.

      Reply

      • I really hate it when people misuse language to mean the exact opposite of what the words really mean. Very Orwellian. I do not believe doing what you’ve described is in accordance with the spiritual principles that Narcotics Anonymous embraces. But then, each group is given the freedom to do what they want. Group actions are guided by group members.

  10. Posted by Helena on January 19, 2017 at 11:00 pm

    Excellent read! I agree that it should be Abstinence v. Harm Reduction, but more like Abstinence AND Harm Reduction working together. One would think that it is common knowledge that not all addicts recover the same way, some thrive just fine with abstinence and others work better with medication like methadone, but unfortunately the debate is still extremely divided.I work with a lot of at-risk youth who use intravenous drugs, and one night I was asking them what they thought on the issue. One youth made a point that they felt that abstinence only approaches make them feel “dirty” and “ashamed” of who they are, and that their drug use makes them in to this horrible person (of course, this was only one particular experience with 12-step programs that turned out to be negative), and they prefer the Harm Reduction approach because it allows people to accept themselves and their choices for what they are, and it truly keeps people from getting hurt (a relapse/fentanyl overdose or contracting HIV). While I’m more on board with the Harm Reduction approach, I still like to engage abstinence only when the client requests to do so and it works for them.

    Reply

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