Topics in Treatment: Abstinence or Harm Reduction?

Drugs and alcohol have been part of the human experience longer than most people realize. Classical and pre-classical literature – dating back to 2000 B.C.E. – contains ample written evidence about the use of opium, cannabis, alcohol, and other intoxicants for religious and casual purposes. Archaeological evidence shows humans used alcohol and hallucinogens as early as the Neolithic Period (12,000– 2,000 B.C.E.). And although history books make only occasional mention of opium addiction and excess alcohol use, it’s safe to assume that as long as humans have known about intoxicants, there’s been a segment of the population whose use was, to use a modern clinical term, disordered.

Yet it wasn’t until the 20th century that an organized approach to problem drug use or drinking appeared. In the 1930s in Akron, Ohio, the now-famous Bill W. and a small group of acquaintances devised Alcoholics Anonymous (AA). This approach is now is now virtually synonymous with addiction recovery. AA began as a group to help people recover from alcohol addiction, specifically: hence the name, Alcoholics Anonymous. However, since its formation, it’s branched into many different iterations, such as Narcotics Anonymous (NA), Marijuana Anonymous (MA), and CA (Cocaine Anonymous).

These various groups follow the 12-step model introduced by AA. The specifics details change from group to group, but they all share one common philosophy: a fundamental prerequisite of recovery is total abstinence from the drug of choice. Whether it’s alcohol, opioids, cocaine, or benzos, it doesn’t matter. To be in recovery, in the language and criteria of 12-step programs, an individual must completely stop using the intoxicant that causes them problems.

That’s also been the approach of most contemporary approaches to treatment: abstinence is a prerequisite for recovery. However, a group of alcohol addiction experts on the West Coast may be changing this paradigm.

A Different Approach

An alternative approach to the treatment of alcohol and substance use disorders is gaining momentum around the country: it’s called harm reduction. Although the term has fallen out of favor and treatment providers often focus on medication-assisted treatment, we think the history of harm reduction – including its new applications – are an important topic to address.

This post will discuss harm reduction in relation to alcohol use and alcohol use disorders, with a focus on the work of researchers at the Harm Reduction Research & Treatment Lab (HaRRT), a special program at the Harborview Medical Center at the University of Washington in Seattle. The team at HaRRT published a study this year that compared the effects of a harm reduction program for alcohol use disorders against the effects of a traditional, abstinence-based program.

We’ll talk about that study in just a moment. First, we’ll define what we mean by harm reduction. According to Harm Reduction International, “There is no universally accepted definition of harm reduction.”

Instead, there’s a set of principles and a group of primary goals behind the concept

Harm Reduction: Core Principles
  1. Respecting individual rights. Using drugs does not mean people forfeit their human rights. Harm reduction means treating people who struggle with alcohol and drug use with compassion and dignity.
  2. Commitment to Evidence. Harm reduction means approaches to alcohol and drug treatment must be based on evidence that show them to be practical, safe, and effective. They must also be cost-effective in diverse social, economic, and cultural settings.
  3. Commitment to Social Justice. The harm reduction movement stresses access to treatment services  for all. No person should be excluded from access because of their race, gender, gender identity, sexual orientation, occupation, or economic status.
  4. Reducing Stigma. Harm reduction means meeting people where they are in their recovery or addiction journey without judgment. The underlying philosophy is to respect people who seek treatment and offer treatment where and when they’re willing to accept it.
Harm Reduction: Primary Goals
  1. Keep people alive and encourage change. Harm reduction approaches recognize that protecting the health and well-being of people with drug or alcohol use disorders should be a priority. They seek to facilitate positive changes in individual lives and in entire communities, no matter who the individual is or how small the community might be.
  2. Reduce harm caused by law and policy. The harm reduction approach challenges laws, both national and international, that criminalize drug use. It challenges any policy that denies treatment or  discriminates on the basis of class, race, or gender. It also challenges laws that force mandatory minimum periods of incarceration for possession of drugs.
  3. Offer alternatives. The harm reduction approach advocates an increase access to high-quality, evidence-based treatment programs that do not require abstinence for participation. Participation in treatment should be voluntary. While abstinence is the goal for many people who enter treatment, it should be seen as an individual choice rather than imposed as the sole option for entering treatment. Abstinence should not be the only metric for treatment success.

When you hear the phrase harm reduction in relation to treatment for alcohol and/or substance use disorders, that’s what it means: improving the lives of people with alcohol or drug problems without requiring abstinence, without stigmatizing them, and without punishing them for having what is now widely accepted as a chronic, relapsing disease.

Harm Reduction in Action: The HaRRT Study

The stated mission of the HaRRT Center is:

“To work collaboratively with substance users, community members and organizations to develop, conduct, evaluate and disseminate evidence-based interventions that help to reduce substance-related harm, improve quality of life, and promote social justice and racial equity for affected individuals and their communities.”

In 2018, HaRRT researchers decided to put their theories to the test. They conducted a randomly controlled trial of 168 participants with alcohol use disorder (AUD), comparing a harm reduction approach to treatment with a traditional, abstinence-based approach to treatment. Over three months, researchers tracked and questions participants in three areas: alcohol use, alcohol-related problems, and alcohol use disorder symptoms. They also administered urine tests to all subjects, although they did not advocate abstinence over harm reduction.

Here’s what they found:

Compared to control group (abstinence) participants, harm reduction participants:

  • Decreased alcohol use by 66%
  • Decreased alcohol-related problems by 71%
  • Reduced alcohol use disorder symptoms by 63%
  • Showed a 20% decrease in positive urine tests for alcohol

Let’s be clear here: the idea that a harm reduction approach yields positive results should not be surprising. Harm reduction has been at the core of Medication-Assisted Treatment (MAT) for years. It’s been at the core of methadone programs for close to five decades. But those programs focus mostly on opioid use and heroin addiction. This study focuses on using the harm reduction approach to individuals with alcohol use disorders. It’s a new wrinkle, both for the treatment of alcohol use disorders specifically and the application of harm reduction to addiction treatment in general.

The results are encouraging.

Harm Reduction Improves Lives

The topic of harm reduction touches on a question that’s fundamental to the current state of addiction treatment:

Does recovery require total abstinence?

We do not have a definitive answer to this question. We will, however, make this affirmative statement:

Treatment for opioid use disorders does not require total abstinence.

We know this through scores of studies on the effects of MAT and methadone programs over the past fifty years. We also know it from results we see every day in our own work. MAT enables people to heal, rejoin their communities, return to work, and engage in life-changing, life-saving treatment for substance use.

What the study we discuss in this post causes us to ask is this:

If a harm reduction approach to AUD reduces alcohol use, reduces symptoms of AUD, and reduces alcohol-related problems, then should abstinence be required for treating AUD?

As we move forward as a society, one thing we have to grapple with is the problem of addiction. Previously – and for logical reasons – professionals and lay people alike assumed successful recovery from addiction meant complete, total, and sustained abstinence. The idea that one does not have to become completely abstinent from alcohol or drugs to be in recovery from alcohol or substance use disorders challenges long-held assumptions.

They’re difficult assumptions to let go of. But we have to admit that what we’ve been doing so far has not been entirely successful. The statistics tell the story in black and white.

So what can we do?

If our goal as physicians, nurses, therapists, and addiction counselors is to improve lives, and harm reduction demonstrably does that, then as difficult as it may be, we need to challenge our assumptions. The very least we can do is engage in open debate on the subject. Beginning with this question: since harm reduction is a viable approach to the treatment of opioid use disorders,  should we also consider it a viable approach for alcohol and other substance use disorders, as well?