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Abstinence isn’t for everyone – an introduction to harm reduction
Abstinence isn’t for everyone – an introduction to harm reduction
When we talk about harm reduction, safe injection sites or opioid replacement therapy come to mind for many people. But the concept of harm reduction is much broader and can be applied to any substance at any level of severity. You’re probably familiar with the concept of harm reduction when it comes to food intake, even if you don’t call it by that term. When you choose treats that have less sugar or fat, you are engaging in a harm reduction strategy. When you decide to forgo a second helping of dinner, that is harm reduction.
Harm reduction is any strategy that reduces the negative consequences of substance use. Some examples include consuming a lower alcohol content beverage, drinking water between drinks, eating while drinking, waiting until a certain age before using substances, or using pain management techniques other than medication, such as yoga or meditation. While some people may be willing to quit substances altogether, most people are not. Harm reduction allows all people to engage with strategies that benefit their lives. The key to harm reduction is that any step in a positive direction is a beneficial step.
“The key to harm reduction is that any step in a positive direction is beneficial.”
But shouldn’t some people just stop using substances? Research shows that some people who struggle with substance use benefit from abstinence, particularly if they have found substance use difficult to control over time and have experienced severe consequences such as losing jobs or important relationships.
That being said, the majority of people do well with harm reduction approaches but do not have that option when seeking treatment. Programs that provide the option of reducing or moderating substance use are rare, and many programs require that you abstain or commit to abstinence when entering treatment. This all-or-nothing approach prevents seeking help and is not aligned with up-to-date, evidence-based understandings of addiction treatment.
One of the main barriers to harm reduction approaches — and the reason abstinence is often touted as the gold standard — has been a dominating belief that addiction is a disease. The main premise of the disease model is that people who struggle with substance use have a progressive and irreversible illness that stays with them forever. The research evidence simply does not support this model.
“The research evidence does not support the model of addiction as a lifelong, irreversible disease.”
The longest follow-up study in addiction recovery is being conducted at Harvard Medical School, where they have followed the drinking patterns of a group of males since 1940. Results show that many of the participants have continued to use high levels of alcohol for decades without progressing to a more severe state. Similarly, research studies conducted by the National Institute on Alcohol Abuse and Alcoholism have found that about 75% of people who meet the criteria for an Alcohol Use Disorder no longer do so at a later time. We now know that people who struggle with substance use fall along a spectrum of problems from low to high; it is not a matter of having or not having a disease. Most people on this spectrum tend to ebb and flow in and out of struggles with substance use throughout their lifetime.
What are the benefits of harm reduction?
Abstinence isn’t for everyone:
Many people are not ready or willing to commit to abstinence, especially those on the mild or moderate part of the spectrum who would benefit from harm reduction. Acknowledging that there are numerous pathways to resolution can have implications for drawing more people into treatment. In an analysis of 38 articles with 40 separate samples, Linda Sobell and her colleagues found that 3/4 of the individuals who had recovered from struggles with alcohol use reported that low-risk drinking was part of their recovery. Similar evidence was found for drug use, with nearly half of the combined sample reporting recovery involving some form of continued use.
It provides early intervention:
A second benefit to harm reduction is that it helps people earlier in the process. A common belief is that recovery from addiction requires hitting “rock bottom” and receiving formal treatment. However, programs that successfully create change in the early stages of an addictive process serve to help people who may not yet have experienced negative consequences of use.
Harm reduction is client-centric, which means techniques are tailored to the individual and meet them where they are. Imagine if you were told today that you had to give up sugar forever? Most people would struggle with this goal, but many are open to reducing their sugar intake over time. The same principles apply to substance use treatment. Allowing people to make choices about how and when they make a change offers the best chances for success.
It’s the natural process of change:
Referring back to the sugar example, imagine if the only measure of success for good health was to never consume sugar again? What if you had reduced your sugar consumption to only on weekends, or only on holidays? Surely that would be a measure of success? Yet historically, the only measure of success in substance use treatment has been complete abstinence. This outcome does not consider the multitude of ways that someone can change in a positive direction. Most lasting changes happen in small incremental steps over time.
What are some examples of harm reduction?
Harm reduction can come in many different forms. Here are some ideas of harm reduction you might consider:
- Plan the amount of a substance you will consume in advance and stick to the plan
- Consume lower alcohol content drinks
- Eat and hydrate while drinking
- Purchase cannabis with lower THC content from a regulated provider
- Use cannabis hybrids (THC and CBD) vs pure THC
- Use test strips to ensure your drugs are not mixed with other substances
- Only use drugs when others are present
- Take substance use breaks (for example, dry January or sober October)
- Track your substance use to create more awareness about your patterns
- Work with a coach or therapist to help you understand why you use substances
- Plan activities that do not include substance use
- Only consume substances to enhance pleasurable experiences vs to reduce painful emotions
What does harm reduction look like in practice?
Here’s an example of how someone has benefited from a harm reduction approach:
Jackie likes to relax after work with a few drinks, and sometimes more when she’s feeling stressed out. On the weekends, she often gets together with her girlfriends for nights on the town and boozy brunches. But in the last few years, she feels like these habits have caught up with her. Her hangovers are getting worse, she’s given up some of her nighttime hobbies, her spending on alcohol has been increasing, and she’s been getting anxiety around all of it. In the last few months, Jackie has been working with a coach to implement harm reduction practices. She now considers the low-risk drinking guidelines by sticking to two drinks a night, except for on special occasions. She’s decided to make Mondays to Wednesdays alcohol free days. On the weekends, she’s determined to forgo any day drinking, and when she does meet up with friends in the evenings, she leaves her car at home, so she’s not tempted to drive home after a few drinks.
Jackie never saw abstinence as a realistic option or something she needed. But making these changes in her life has given her a sense of accomplishment and improved her health and mood. As a way to continue to motivate herself, she’s been socking away the money she saves on alcohol and putting it towards monthly massages and pedicures, as well as saving for a vacation she’s wanted to take for a long time.
How can I change my substance use?
If you or a loved one has been thinking about changing your substance use, think about one small change you can make today that would move you in a positive direction. This change could include reducing the amount of substance you use or reducing the harmful consequences of use.
ALAViDA provides a range of support options for anyone wanting to change their relationship with substances, whether that’s through harm reduction or abstinence. Support is accessed through the TRAiL platform, and includes iCBT modules, daily notifications and tracking tools, coach-assisted support, live classes, and facilitated care groups. Access the ALAViDA TRAiL.
Dr. Terri-Lynn Mackay, PhD, is the Clinical Director of Alavida. She leads a team of licensed professionals who practice client-centered, compassionate, evidence-based care. Previously, Dr. Mackay served as the Director of Operations for the Canadian mental health pandemic response, as the Associate Director of Counselling Services at the University of British Columbia, and as an Associate Professor at the University of Nevada, Las Vegas. Dr. Mackay holds a PhD in Clinical Psychology and a Masters degree in Behavioral Neuroscience. Her research has been featured in journals such as Canadian Psychology, Neuropsychologia, Computers in Human Behavior and International Gambling Studies.
Sobell, L. C., Ellingstad, T. P. & Sobell, M. B. (2000). Natural recovery from alcohol and drug problems: Methodological review of the research with suggestions for future directions. Addiction, 95(5), 749-764.
Valliant, G. E. (2003). A 60 year follow-up of alcoholic men. Addiction, 98, 1043-1051.