Harm Reduction and the Clothing Police

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



Image result for marijuana on cap in rhinestones

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 to allow patients to use drugs on the premises? 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?

15 responses to this post.

  1. Posted by Daniel Strickland on December 3, 2017 at 1:52 am

    Sobriety is an asymptote. I am not sure that pot smoking is any riskier than benzo use, and the former may be safer, especially in the context of MAT. On the spectrum of Harm Reduction, I am closer to the end that supports life over overdose.


  2. Every outward expression is a reflection of what was once inward repression.
Response to the treatment of a young girl who wore a hat into a drug treatment program that was emblazoned with a marijuana leaf and caught flak for it.
You are her physician and not her mother. She is young as you stated, and as you well know, the prefrontal cortex doesn’t quite adequately develop until, in some cases the early 30’s and, I would venture to guess, even later in some. With that said, I don’t think that her choice of attire, whether it be emblazoned with a marijuana leaf or a liquor bottle, is a reflection of her commitment or lack there of to your program no more than it’s an endorsement of her support for the product.
Her wearing that hat into your clinic is no different than her pulling into your parking lot in a late model shiny Mercedes Benz or having a bottle opener on her key chain or a brand new tattoo of a syringe emblazoned on her forearm. I see symbols of my patients’ past routinely in my practice and it would be very easy for me to cast a judgmental glance or make an offhanded remark about it in passing to the patient but to do so is to violate the very premise within which, as physicians, we operate; namely, to provide a safe, non-judgmental supportive environment for our patients. An environment where they can express themselves within the confines of their own unique and individual style without fear of being belittled or disparaged or shamed for their past or the expression of their style. She wasn’t naked or scantily clad nor was she smoking a blunt in your lobby or acting in any way that wasn’t in keeping with a person there to get help and pursue her journey towards a clean life.
Her hat, in a different context, would carry an entirely different meaning once you heard the story. I had a patient who I was treating with MAT for a heroin addiction. On a routine visit, he shows up with a brand new tattoo of the chemical structure of morphine on his left calf. I recognized it as an opioid and inquired as to why on earth he would choose, of all things, to permanently emblazon an opioid on his skin. He retold the story of his mother’s struggle with breast cancer and how, in her final weeks of life, morphine was the only thing that brought her both comfort and peace. I looked at his new tattoo in a completely different light.
The fact that your patient chooses to express her individuality with a symbol of her past should have no bearing whatsoever on her commitment to her path forward and, while I can understand how this symbol could and did evoke a negative visceral response from you, it should in no way undermine or slant your determination or approach in how you choose to proceed in continuing to help her as a young girl with a young mind in a complicate world that she just beginning to comprehend. She likely gave no more thought to the wearing of that hat as an endorsement of drugs than you did in not being able to restrain yourself from a knee jerk reaction to a symbol you interpreted as defiance and disrespect—you reacted as if she had just slapped your face!
I don’t think anyone can blame you for your response. After all, we spend a career trying to educate patients and steer them towards a path of non-dependence on drugs and to have someone flippantly display a symbol of what would appear to represent a drug endorsement in our office is, at the outset, seemingly incomprehensible and untenable. I understand where those feeling come from and how this visual could generate the response it did. But what I also realize in treating my patients struggling to regain a sense of normal in a world that is no longer experienced through the lens of chemicals, is that just because they have chosen to pursue their new path doesn’t mean they have to forget the symbols that led them there in the first place.


  3. Reblogged this on My Sharing Blog.


  4. Posted by michaelwalker on December 3, 2017 at 1:38 pm

    I’s almost like saying you hate Trump, so if she had a Trump shirt on you would still confront her? A marijuana leaf is a symbol of drug use, you stereo typed it already., for all you know that was a support mechanism for it becoming legal etc.. it can mean many different things to her..for all we know smoking it might cure some cancers for Petes sake..thats the problem now days with Doctors they bring in their Political, Money, and all kinds of other views into the office and their patients suffer.


    • Huh? I don’t think you read the blog post…


      • Posted by michaelwalker on December 3, 2017 at 5:57 pm

        I thought I did I guess LoL , you said you were conflicted on it, yet you still stereo typed Marijuana as a bad thing, I realize you took a second look at it of course, (Good for you!) yet the feeling or perception must still be in the back of your mind… And I mentioned, quite a few doctors involve these feelings or views in their practice, Even though it looks bad with her hat on, it is because of how people perceive other’s and their believe’s in their own mindset. We should never judge anyone I guess, we might not interpret the true meaning behind the hat.

    • I take issue with that sweeping over generalization of doctors. I am about as non-judgmental as they come when it comes to delivering evidence-based medicine to my patients. I am paid on my medical knowledge not my social opinions. You unfairly and incorrectly stereotype ALL doctors into your narrow-minded view of us. I invite you to come spend a day in my office and I believe you’ll retract your comment after the first hour spent with me.
      Judge not what you do not yet understand


      • Posted by michaelwalker on December 3, 2017 at 6:03 pm

        Well for one, I did not say ALL Doctors, and actually did not mean that if you took it that way, I did already post a reply that said quite a few of them.. I could tell by your post that your one of the Good One’s and they are hard to find , at least in my area. But what I do say is still true, it’s is not all doctor’s thats for sure, so I apologize on that post, I meant to imply the one’s that do bring those views into the office setting.. I had a doctor that used my name and called me Governor for instance when I came in, because my states governor has the same last name. And this Governor is not well liked. I make my point right there.

  5. Posted by SUE TISON on December 3, 2017 at 6:55 pm

    Dead on once again Dr. J. (for Jana)!!! I have come to believe that just like reducing teen pregnancy the success in the abstinence idea was not a huge success. A very rudimentary comparison, of course. Opting for alternate methods of care delivery and education that might be seen as “collateral damage control” may be the way to reach the many who just cannot make the leap from active addiction to recovery.
    Yeah, the hat would have irked me too–but I think I could overlook the fashion statement with a clean urine drug screen. Just another way to look at it-choose the battles worth the work to win.
    You do amazing things!


  6. Posted by Maximilian Alexander on December 4, 2017 at 4:19 am

    It’s a reasonable request to ask patients not to wear drug glamorising attire in an addiction recovery clinic. Drug rehabs and halfway houses have similar, and even more stringent rules on the topic.


  7. Posted by JM on December 4, 2017 at 2:33 pm

    I live in a state with medical cannabis. From my patient observations and experiences, those patients who use cannabis usually are much more stable in my MAT program. Drug screens are usually unremarkable except the THC. They tell me that when they smoke, they don’t crave opioids, meth or benzos. I embrace it as a harm reduction strategy and encourage some of my patients to get their medical cannabis card. Smoking pot, having the munchies and watching a movie at home vs shooting up meth and taking a handful of benzos then doing god knows what, you tell me, what is the better scenario?


    • Posted by nspunx4 on December 10, 2017 at 3:59 pm

      IF one accepts medical marijuana the same as any other prescription medication (in states where it is legal) then what is the difference from a doctor who has a lunesta pen and a Zyrtec notepad?


    • I think you’ve set up a logical fallacy by implying the only two choices for someone in recovery on MAT are smoking pot and munching on the couch or shooting up meth and taking benzos…


  8. People just blow my mind nowadays. Being young just is not an excuse for something like this. I don’t care who you are, you do not wear clothes that promote/glamorize drugs while going to drug treatment. I don’t buy the “it was her only hat” argument either. She knew damn well she had it on but didn’t have enough sense to realize that it was very inappropriate. Maybe I’m unempathetic or just out of touch with today’s societal norms but IMO there is no excuse!


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