Harm reduction and abstinence

TheStar.com – comment – Harm reduction and abstinence
April 22, 2008. Winnie Siu, Community Editorial Board

Last week, my friend Tony Gizzie of the Community Editorial Board wrote an article arguing against a harm-reduction approach to drug and alcohol addiction. He claimed that harm reduction, which can be defined as interventions that decrease harms associated with substance abuse (with or without abstinence as a long-term goal), is “ineffective in the long term.”

I can admit that my evangelical Christian background biases me to a world view that places emphasis on the rightness or wrongness of actions rather than their consequences. Two years ago during a medical school interview, I was asked to argue against the merits of a needle-exchange program. I was able to rattle off a list of reasons why harm reduction was inferior to traditional abstinence programs.

At the top of my list was the issue of whether a needle-exchange program would tacitly legitimize illegal intravenous drug use. And what would become of the surrounding neighbourhood? Surely it would be vulnerable to drug-dealing, prostitution, crime and violence.

More importantly, I continued, harm-reduction programs do not address the root cause of the addiction, be it mental health, domestic violence or social issues. I concluded by saying that money invested in harm reduction could be more prudently spent in abstinence programs.

Two years later, I am not so sure.

It’s not that I believe those arguments are no longer valid. Rather, it is because I have come to realize, slowly and painfully, that complete abstinence may be out of reach for some. The all-or-nothing approach of abstinence advocates neglects the needs of many substance users who may fall somewhere in between.

Much of the problem with the public perception of harm reduction involves the definition of “success.” If abstinence is the only measure, harm reduction, by definition, will never measure up. If, however, we can evaluate success by using a variety of criteria, then harm reduction may prove to be a legitimate form of intervention.

For example, a number of research papers have shown that a supervised injection facility in Vancouver reduced the sharing of needles, decreased public drug use and decreased the number of publicly discarded syringes. Furthermore, the facility was not associated with an increase in injection drug use, crime or public disorder.

Dr. Stephen Hwang, a research scientist at the Centre for Research on Inner City Health at St. Michael’s Hospital, compares supervised injection sites with other medical interventions that mitigate the harmful effects of an illness but do not cure the patient. Such interventions, he argues, are accepted by the government, physicians and society.

He also states that concern over harm reduction “may be partially allayed by an understanding that harm-reduction strategies are intended to complement, rather than replace, more traditional means of treatment. In addition, pragmatic efforts to mitigate the adverse health consequences of a harmful behaviour need not be construed as a sanctioning of the behaviour itself.”

And while it is true that more research is needed as to whether harm-reduction strategies confer equal or even better health outcomes than abstinence programs, the supporting evidence for abstinence programs is paltry as well.

Alcoholics Anonymous, widely heralded as proof of the efficacy of abstinence, does not provide definitive statistics on its success rate. Committed to anonymity, AA does not keep official records of its attendance or membership so it is impossible to know exactly what proportion of those who have attended meetings now abstain from alcohol.

A resolutely abstinence-based drug and alcohol rehabilitation facility I visited last year admitted that it does not measure success or failure by relapse. Instead, its research department looks for evidence that there is a mean decrease in the quantity and frequency of substance abuse post-treatment. That sounds suspiciously like harm reduction to me.

All said, I am still not sure where I stand on harm reduction. I know that abstinence is the ideal.

But the demons of addiction that chase a significant proportion of our society testify to the fact that we don’t live in an ideal world. Our approach to drug and alcohol rehabilitation must recognize this also.

Winnie Siu is a medical student.

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