To whatever degree harm reduction has gotten mainstreamed, it still hasn’t budged the meaning of “treatment” and how we measure it, at least if you’re using methamphetamine or cocaine. Treatment means abstinence; abstinence is measured by peeing in a cup.
This is partly because the Food and Drug Administration has not yet approved any medications for stimulant use disorder (SUD), so the binary of abstinence versus use is more intact compared to opioid use disorder. It’s also because stimulant withdrawal is so poorly understood by researchers and clinicians. And it’s because SUD treatment is mostly housed inside the criminal-legal system, where its success is determined with urinalysis results that are binary by design. No one in a position to strip bodily autonomy from stimulant users is going to factor in whether they’re using less than before, and it’s unheard of if the stimulant is meth.
An analysis of 13 studies on pharmacological interventions for SUD, at a “wide range of treatment facilities,” is one of very few where researchers looked at reduction in addition to abstinence. They found that while abstinence is associated with the greatest clinical improvements, reduction in use is associated with enough improvement to be considered a valid outcome. The new study, funded by National Institute on Drug Abuse, was published in Addiction on January 10.
“If somebody is working towards trying to be abstinent, but they’re struggling with that, this is a hopeful sign that we can see meaningful improvement along the way,” NIDA Deputy Director Dr. Wilson Compton told Filter. “Because the study also clearly shows that abstinence has more clear association with the positive outcomes than reduced use. But the real new information is that reduced use was so strongly associated with the improved outcomes as well.”
If you’ve been using meth or cocaine less than four days a month, it isn’t necessarily a big jump to go a month without it.
Abstinence has always been the treatment goal assigned to stimulant users whether they want it or not, but belief that it represents a bigger change than reduction in use isn’t necessarily true. The Addiction research, for example, quantified reduction as moving from high-frequency use (5-plus days per month) to low-frequency use (1-4 days per month) over a 30-day period, which makes the results a bit complicated.
If you’ve been using meth or cocaine less than four days a month, it isn’t necessarily a big jump to go a month without it. This means that the people who made it into the “abstinence” category were likelier to be people whose SUD complications weren’t as severe as those who landed in the “reduced use” category. Meanwhile, you could have gone from injecting an eight-ball of meth every day to just stirring a teensy bit into your coffee on the weekends and not even have made it into the reduced use category in the first place; the data would show you’d made no change.
“Abstinence is an easier thing to quantify,” Compton said. “Because when you say ‘reduced use,’ the question is always, ‘Well, how much does the reduction have to be before you see an improvement?’ And abstinence is pretty straightforward. So I understand the appeal of an abstinence measure.”
The researchers evaluated improvement according to clinical indicators drawn from the Addiction Severity Index. These include other illicit drug use; alcohol use; legal status; psychiatric status; and status of interpersonal relationships. The original ASI also has medical status and employment/financial support status, but the authors didn’t include those on the grounds that they “tend to stay stable over a short period of time.”
Short data-collection periods are the universal downfall of research on SUD treatment outcomes. A 30-day window probably isn’t representative no matter which part of your life you’re looking at, but employment status is something drug users do tend to find subject to sudden changes. The study authors did not respond to Filter’s request for comment.
If people wanted something even easier to measure than abstinence, and also more relevant to stimulant users specifically, there is an obvious one.
A recurring argument against using reduction as a research metric is that it’s is a difficult thing to measure. People lean on this argument both because it’s true and because it tends to preempt questions about how difficult, exactly, but nothing’s easier to measure than abstinence and so none of the rest really matters. Urine drug screens will always be quick and easy to read.
“If you cut back from smoking two packs a day to smoking one-and-three-quarters packs a day, obviously that’s a reduction,” Compton said. “But is that enough to see your risk of lung cancer or your risk of heart disease or your asthma problems or all the other issues related to tobacco use to be reduced?”
If people wanted an objective metric that was even easier to measure, and also more relevant to stimulant users specifically, the obvious one would be criminal-legal system involvement—especially if measured on the scale of years rather than weeks. Instead we keep saying the harms of stimulant use are medical, and cite the death data that’s deeply mischaracterized or cardiac strain that wouldn’t be statistically significant if we weren’t looking for ways to present cocaine and meth use as bad.
The publication years of the 13 studies selected average out to around 2010, and don’t include anything more recent than 2017. The “wide range of treatment facilities” doesn’t refer to the environments most drug users probably call to mind, but to clinical trials treating SUD with various psychiatric medications or muscle relaxants. But none of this is unusual, nor will it prevent the research from hopefully having a positive impact.
It’s worth pointing out the places where SUD research could be a bit more representative, because almost no one ever does it, but this doesn’t mean the Addiction research isn’t very good news for stimulant users. It is. So is the fact that NIDA is actively supportive. The utility of research like this is that it’ll be a supporting citation for eventual change at the policy level, rather than something that impacts present-day stimulant users one way or the other.
Photograph courtesy of Kastalia Medrano