Can Harm Reduction and Abstinence-Based Models Constructively Co-Exist?

    What does it mean to be “in recovery” from a substance use disorder?

    In theory, it seems a straightforward enough question—one that should have a more-or-less universally accepted answer. In reality, finding a definition that is satisfactory to everyone under the drug-user health umbrella is like seeking a syringe in a haystack. People’s answers are often inseparable from how the concept of recovery was introduced to them.

    “Recovery” as presented to someone at a 12-step group or rehabor who is merely passively ingesting the traditional public viewis much different from the idea passed along to people who use syringe services or are active in the harm reduction movement.

    These two divergent versions⁠—one emphasizing abstinence from all illicit drugs and alcohol as an essential aspect of recovery, the other viewing each incremental step towards a healthier, less chaotic lifestyle as a goal in and of itself⁠—are often viewed as incompatible.

    The Betty Ford Institute Consensus Panel, for example, defined recovery as a “voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship,” with sobriety categorized as “abstinence from alcohol and all other nonprescribed drugs.” This definition is often seen as being in direct conflict with one of the key principles of harm reduction, as outlined by the Harm Reduction Coalition, which “establishes quality of individual and community life and well-beingnot necessarily cessation of all drug useas the criteria for successful interventions and policies.”

    Unfortunately, viewing these two visions of recovery as competing is a hopelessly ineffective strategy.

    Most of the burden of coalescing these two recovery paradigms must fall upon the shoulders of those advocating for abstinence-based recovery.

    If the United States is ever to have the faintest hope of ending the current overdose crisis and giving people with substance use issues the quality, evidence-based healthcare that they deserve, we must learn to view these definitions as complementary, not contradictory.

    And in order for this to work, most of the burden of initiating the coalescence of these two recovery paradigms must fall upon the shoulders of those advocating for abstinence-based recovery. More specifically, governmental institutions and the addiction treatment industry must initiate this change and begin incorporating harm reduction practices into their currently abstinence-based frameworks.

    To be clear, I’m not placing the responsibility for bringing together abstinence-based and harm reductionist recovery models at the feet of the Hazelden Betty Fords or traditional treatment-supporting politicians out of some sort of antipathy towards them.

    In fact, I personally owe my quality of life, and very possibly my life itself, to Hazelden Betty Ford. It was at their Center for Youth and Families where I got sober a decade ago. I am also grateful that Congress and state legislatures have at least seen fit to finally begin providing the overdose crisis with the attentionthough certainly not yet the resourcesthat it deserves.

    I place responsibility with politicians and treatment industry titans because they, along with the media, control what is still the dominant recovery paradigm in the US. Traditional treatment programs also receive the lion’s share of the funding and therefore⁠—unlike their harm reduction counterparts⁠—have the scope to expand and diversify.

    As such, they have the power to change the mainstream recovery conversation to one that includes evidence-based, harm reductionist principles.

    When I was ushered into sobriety through a Minnesota Model, 12-step-based treatment facility, I thoroughly internalized the notion that abstinenceor at least the continual pursuit of abstinencewas a prerequisite for living a life free of addiction.

    Despite routinely warning me of the dangers of engaging in “black and white thinking,” treatment staff never addressed the grayscale approaches to substance use disorders found in harm reduction. Moderating your use was presented not as a viable option if you didn’t desire abstinence, but as a delusion of the addicted mind.

    In these spaces, “Go out and try some controlled drinking and using was never a recommendation offered in earnest, but a rhetorical device to “prove” the individual’s powerlessness over a drink or drug.

    “Come back to us when you hit rock bottom” is not a public health strategy. It is medical malpractice.

    In retrospect, the complete absence of any instruction in the principles and practice of harm reduction in my treatment experience is jarring, but not altogether surprising. The traditional abstinence-based model of recovery was intentionally designed to create a sense of unity and purpose, but only for those who faithfully adhere to its precepts.

    This conception, which seeks to bestow upon its membership the camaraderie and urgency of those trying to save one another from a sinking ship, can be quite successful for those who buy into it. Unfortunately, it provides very little for those who lack the desire or capacity to achieve abstinence.

    It is worth noting that, in the 10 years since I was in its care, Hazelden Betty Ford has incorporated the use of medication-assisted treatment (MAT) with drugs including buprenorphine and naltrexone for clients with opioid use disordera development that would once have seemed unthinkable. Still, the deployment of MAT in its facilities is explicitly framed as a bridge to their ultimate goal of “a stable recovery based on the Twelve Steps and abstinence from opioids.”

    Similarly, while syringe services programs (SSPs) are slowly gaining acceptance among some Republican politicians at federal and state levels in the wake of the injection drug use-fueled HIV outbreak in Scott County, Indiana, the partial ban on funding for SSPs remains in Congress. Very little of the money coming out of federal and state legislatures to address the overdose crisis is being given to harm reduction-centered organizations.

    At this point, with scores of thousands of deaths every year, it should be painfully clear that any treatment modality or conception of recovery which fails to take care of those who don’t rigidly adhere to it and alienates broad swaths of people who use drugs is unsustainable.

    “Come back to us when you hit rock bottom” is not a public health strategy. It is medical malpractice. And the biggest players in Washington and the addiction services industry need to realize this.

    “Our idea of recovery … is that any positive change is recovery.”

    Fortunately, there already exists a version of substance use disorder recovery that incorporates abstinence as one of a range of positive outcomes based on the desires and capacities of drug users themselves. This is evidenced, for example, by the involvement of many people in abstinence-based recovery in the harm reduction and drug policy reform movements—including in leadership positions.

    This inclusive vision of recovery is currently being practiced by a number of innovative providersperhaps none more successfully than the Missouri Network for Opiate Reform and Recovery.

    “Our idea of recovery is piggybacking off of [harm reduction pioneer] Dan Biggs’ idea of recovery, which is that any positive change is recovery,” Executive Director Chad Sabora told Filter. “It may not look like the recovery that you’re used to hearing about, but it is recovery.”

    Sabora and his colleagues accordingly provide a mixture of harm reduction and peer recovery support services to people with substance use disorders in the Greater St. Louis area. Missouri Network for Opiate Reform and Recovery operates an SSP, distributes naloxone and refers individuals who wish to go to abstinence-oriented treatment. The organization’s Recovery Community Center holds everything from 12-step meetings to harm reduction trainings and even acupuncture.

    Sabora’s personal journeywhich saw him transform from an exclusive advocate of abstinence-only recovery, based on his own experience, to an avowed champion of harm reductionist principles who also maintains a strong toehold in the 12-step communityis instructive. These ostensibly opposing viewpoints can co-exist in a mutually beneficial fashion, as long as impacted people are empowered to make their own choices and pursue whatever works for them.

    “We all have the same goal,” Sabora said of abstinence-based recovery proponents and harm reductionists. “Our goal is to keep people alive. If we worked in unison, we’d have a lot more success.”

    Photo adapted from Jens Lelie on Unsplash

    • Drew is a freelance writer who covers HIV and drug policy, as well a multitude of other issues related to public health and social justice. He has worked in AIDS advocacy for a number of years. He lives in Washington, DC.

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