Abstinence vs. Harm Reduction – a False Dichotomy

Abstinence vs. Harm Reduction – a False Dichotomy; by Alexander DeLuca, M.D., FASAM, August 2000.

See also:
12 Steps Back – Maia Szalavitz, Brills Content; 2001
Controlled Drinking Debates – Brook Hersey, Rutgers; 2001
Abstinence vs. Harm Reduction Follies 2000 – Alex DeLuca; 2001

On July 10th, 2000, I was fired as Chief of the Smithers Addiction Treatment and Research Center. My offense? No longer supporting the ‘program philosophy of total abstinence,’ according to an unidentified St. Luke’s/Roosevelt Hospital spokesperson as quoted in the New York Times.

Since then, I have been surprised to find myself cast as a speaker for the harm reduction movement. I have received hate mail, solicitations to write books, and multiple requests for interviews to discuss whether abstinence or moderation is the best treatment for alcoholism. This is about as rational as asking whether coronary bypass surgery or medication is the best treatment for heart disease.

To pose harm reduction against abstinence is to make the good the enemy of the best. Drinking problems exist on a continuum, from the very minor to the very fatal. Effective medical response varies from suggestions to cut down or limit alcohol intake to inpatient stays in therapeutic communities lasting months to years. Any textbook of addiction medicine will tell you this.

So why all the fuss? Why when we consider the addictions do we find ourselves discussing philosophy instead of research? Historically, addiction treatment developed not as a medical discipline, but as an outgrowth of the self-help movement epitomized by Alcoholics Anonymous. These are our roots; and the fact that many people who work in the field achieved their own recoveries through AA has complicated our progress towards evidence-based treatment. Rapid developments in our understanding of the brain, new and promising psychological approaches, and significant pharmacological advances have led to a clash of cultures. On the one hand we have a tradition of ‘tough love,’ ‘hitting bottom,‘ ‘confronting denial,’ and avoidance of psychotropic medications. On the other, a more modern and medical approach works directly with ambivalence and motivation, and is often accompanied by pharmacotherapy for the craving, anxiety, depression, and insomnia so common in early recovery.

When talking about addiction, harm reduction carries connotations of permissiveness and of effective but marginalized approaches such as needle exchange and methadone maintenance. Yet in every other field of medicine, harm reduction is the default approach. If a person is overweight and has elevated blood sugar and is at risk of developing adult onset diabetes, a physician might recommend a strict diet and exercise program. But if the patient cannot or will not comply with the recommendations, the physician doesn’t send him away to return when he is ready to accept the diagnosis and be compliant. Rather, the physician might start drug therapy while continuing to work with the patient on his resistance to, or problems with, the diet and exercise regimen. This is harm reduction. We accept the refusal or inability of the patient to do the best thing, and try our hardest to do the next best thing.

The practice of medicine IS the practice of harm reduction. It is a fundamental principle of medical care that the patient has the right to disagree, to be non-compliant, to choose a path or a goal other than the one we might desire for them. The physician’s job is to do everything possible to help such a patient do the best he can, to minimize harm since, at least temporarily, it cannot be eliminated. Only in addiction medicine is it insisted that patients and staff hew to a ‘philosophy’ of ‘total abstinence’ rather than support appropriately individualized goals.

To refuse to work with a patient because he or she will not accept our goals for them, to not inform patients of legitimate treatment alternatives when such exist, to refuse to try legitimate alternative treatments when a particular approach has repeatedly failed because to do so would violate some ‘philosophy’ of treatment, all such behavior constitutes sub-standard medical care. This is true whether it takes place on an alcohol rehabilitation unit or an asthma ward.

9 Comments »

  1. Comment by:
    Medical Website

    Ok Since it talks a lot about addiction let me tell one thing. It's not some thing we can't really overcome . what you need is the willingness and courage plus some well planned consultation.

  2. Comment by:
    sulis

    Thank you so much for posting this. I am researching this topic for a private matter and this is very helpful and informative.

  3. Comment by:
    Matt Hanna

    He's saying there's a double standard in the medical community when it comes to type II diabetes a Doc will reccomend limiting or eliminating sugar and carb intake but this of course rarely ever happens so the Doc will prescribe medication to control blood sugar. It would be awesome if the diabetic would change his/her lifestyle and not require medication just like it'd be great if addicts would stop using drugs completely. This very rarely actually happens though. Addiction is a disease just like any other why would a Doc send a patient away for not complying in addiction treatment when this never happens with other diseases?

  4. Comment by:
    update song

    That's a really great article there. I was looking for various information on Abstinence. But I do personally believe that rather than teaching on abstinence it's better to educate on safe sex. Which I think would be the better option for this matter.

  5. Comment by:
    Mumble

    Your blog keeps getting better and better! Your older articles are not as good as newer ones you have a lot more creativity and originality now. Keep it up! And according to this article, I totally agree with your opinion, but only this time! :)

  6. Comment by:
    Lawrence Rockwood

    Why does the Harm Reduction Movement still not address the the war on pain management. HIV/AIDS is still a valid focus, the narrowness of the Harm Reduction movement still amazes me.

    I want to serve those who are using heroin for pain management, as an LPN, educator, and counselor in the addictions an psych fields for over 30 years, where can I apply? Where can I refer those using heroin for pain management for case management in NYC?

  7. Comment by:
    Bob

    You start out seeming offended when you were fired for not supporting, perhaps even opposing, a corporate policy of total abstinence. Most people who have a problem of addiction have difficultly dealing with moderation. It's either all or nothing. While there is a continum of compulsion, it is probably wise not to tempt fate with moderation.

    If you disagreed with corporate policy you should have resigned and sought employment where your views were shared.

    I also wonder if you are confusing a "physican" that may be in a private practice dealing with many patients with a "physician" employed by a corporation whose mission is to carry out the corporate policy (in this case total abstinence). The physician in private practice has the right and option to counsel, advise, and present alternatives. The physician employed to carry out corporate policy does not. You should not confuse the two.

  8. Comment by:
    ..alex...

    Sheesh, Bob; I’m not confusing anything. Read everything on this site (how about a simple search of the site?) about that incident before gracing me with your paternal advice. I’m not going to bother unloading a dozen links on lazy you. There was no “corporate policy of total abstinence” as I have explained in writing. I am not going to waste one more minute rehashing a very complicated event, that happened over a decade ago, with anyone who has only read one essay about it. Do your own homework if you are interested in actually understanding what happened. Otherwise – ciao.

  9. Comment by:
    ..alex...

    Hi Lawrence,

    You could try the Beth Israel Pain and Palliative Care department in NYC – http://stoppain.org – Re: referrals for pain patients [with or without comorbid substance use disorder(s)].

    You could also visit the Harm Reduction Coalition in NYC – http://harmreduction.org/ – and ask these questions of Allan Clear who is in charge there. He knows everything there is to know about harm reduction, especially in NYC. [Say hello for me if you do visit; Allan has been and is a trusted friend to myself, and to MM in their years of need; he is a true scholar and gentleman, and has one hell of a resource in HRC.]

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