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A Cultural Approach to Addictions Treatment: Harm Reduction

A. Tom Horvath, Ph.D., ABPP, Kaushik Misra, Ph.D., Amy K. Epner, Ph.D., and Galen Morgan Cooper, Ph.D. , edited by C. E. Zupanick, Psy.D.

We cannot escape the influences of the society that we live in. For example, television commercials normalize alcohol use and contribute to increased drinking among young people (Snyder, Milici, Slater, Sun & Strizhakova, 2006). Some popular music reifies the drug culture and encourages illicit drug use. People are bombarded every day by advertisements that promote pharmaceutical solutions to nearly every health problem. People demand a quick-fix to their health concerns. Busy physicians respond to these demands with prescription tablet in hand.

teens drinking on beachAddiction is certainly a cultural problem. To treat addiction at this level we must examine not only how society affects individuals, but also how addicted individuals affect society. The social costs of addiction are enormous. We all pay the price for addiction. Addiction contributes to higher healthcare costs, crime, premature deaths, destruction of property, lost productivity, and many other losses (to list of personal costs).

A harm reduction approach to addiction operates from the premise that many individuals with addiction problems may never achieve lasting abstinence. Harm reduction accepts this unfortunate fact. Therefore, it seeks to limit the harm to addicted people. At the same time, harm reduction decreases the cost of addiction to society as a whole. In some cases, a harm reduction approach serves to keep addicted persons alive long enough for recovery to begin.

A harm reduction approach to addiction stands in opposition to treatment approaches that insist upon abstinence. Many individuals faced with the proposition of complete abstinence refuse treatment of this sort. A harm reduction approach considers some positive change is better than no change at all. When we consider abstinence the only acceptable recovery outcome, positive change is limited. This is because individuals refusing abstinence will make no change at all. Harm reduction seeks to maximize positive change by reducing harm to addicted persons without insisting upon abstinence.

One example of a harm reduction approach is the advent of nicotine replacement products. Tobacco products create a vast cost to society. For individuals who cannot break the nicotine addiction, several nicotine replacement products are available. These include gum, patches, lozenges, and inhalers. These products do not totally eliminate the risks associated with nicotine use such as cardiac problems and hypertension. However, they significantly reduce the harm of nicotine addiction by eliminating the delivery of nicotine in the dangerous forms of smoking or chewing tobacco. Cigarettes and chewing tobacco contain not only nicotine but also toxic, cancer-causing agents as well.

Smoking tobacco products not only harms the individual smoker but also puts others at risk. Designated, no-smoking areas represent another type of harm reduction. Designated non-smoking areas protect non-smokers from exposure to smoke. Another type of harm reduction is tobacco regulation and anti-smoking campaigns. These are intended to reduce harm to society by reducing the number of people who become addicted to cigarettes.

A controversial harm reduction approach is heroin (methadone) maintenance programs (HMPs). The primary risks to individual heroin users is overdose and health risks associated with sharing needles (HIV, Hepatitis). The primary cost to society of heroin addiction is crime. HMPs curtail both the risk to heroin users, and the cost to society. Oral medications in controlled doses (such as methadone) reduce risks to heroin addicts, and reduce costs to society. Research shows that individuals in HMPs are more likely to remain in addiction treatment. They are also less likely to use street drugs, and less likely to have other negative consequences of addiction. Critics of heroin maintenance programs argue that HMPs are expensive and that rehabilitation reduces crime more than maintenance. Proponents point out that heroin maintenance programs are typically less expensive than prison. Research suggests that heroin maintenance programs are cost-effective due to savings in the criminal justice system (Lintzeris, 2009).

Needle exchange programs reduce harm by providing clean needles and syringes to IV (injection) drug users. Because syringes usually require a prescription, IV drug users often reuse syringes and share needles with each other. This contributes to the spread of infectious diseases such as HIV and Hepatitis C.

Similarly, safe injection sites provide sterile injection equipment in a medically supervised environment. Other names for these harm reduction facilities include supervised injection facility; safer injection facility (SIF); drug consumption facility (DCF); or medically supervised injection center. At these locations, medical personal monitor individuals who go to these safe injection sites to inject their own drugs. If a drug user develops respiratory distress or heart failure (i.e., overdose), they can receive immediate medical attention. Critics argue that safe injection sites encourage drug use. Supporters argue that they do not increase levels of drug use. In fact, safe injection sites decrease risky behavior while increasing access to addiction treatment services. These sites are located in countries around the world. At the present time, Australia, Canada, Switzerland, Germany, Spain, and the Netherlands offer some version of this harm reduction approach.