Abstinence vs. Harm Reduction: a False Dichotomy

Abstinence vs. Harm Reduction – a False Dichotomy; by Alexander DeLuca, M.D., FASAM, originally published: August 2000. Represented with minor reformatting: 2009-01-15.

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

Note:
I am re-presenting this ‘oldie but goodie’ essay (originally written as a NYTimes op-ed article but, alas, not published there) because it bears on issues currently being raised around Obama’s appointments of surgeon general and ‘drug czar.’ See John Tierney’s Drug Czar Controversy for background on the current furor.

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.

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