Different Strokes for Different Folks

This addiction treatment field has had major conflicts about abstinence versus harm reduction or moderation management. This controversy requires some closer scrutiny.

 

While it is clear that the dispute has its roots in the view of substance use disorders as unidimensional conditions (see my August 2015 column titled “What’s Wrong with Our View of Substance Use Disorders?”), it would be both inaccurate and pejorative to assume that advocates of these different approaches are not people of good integrity. For many, giving up our beliefs is very difficult. The source and persistence of these disputes may be summed up by a quote from Friedrich Nietzsche, who opined that, “Conviction is a greater enemy of truth than lies” (1886/1996).  

The choice of strategies to respond to people with substance use disorders is dependent on two issues: the kinds of outcomes desired and the type and severity of the substance use disorder. For example, if the goal for people addicted to opioids is reduced criminal behavior, vocational stability, and enhanced family and social functioning, it appears that the use of methadone or buprenorphine is appropriate. However, such pharmacotherapy would be a flawed choice if the goal is total abstinence from opioids. While I would prefer an abstinence model for all opioid addicts, experience has demonstrated that for some, psychosocial treatment alone has not been effective. Clinicians committed to total abstinence as the only path to recovery often have opposition to either the approaches of harm reduction or moderation management. Some definitions are in order here.

Moderation management (MM) is a secular, nonprofit organization providing peer-run support groups for anyone who would like to reduce their alcohol consumption or achieve “controlled drinking” (“What is,” n.d.). MM was founded in 1994 to create an alternative to Alcoholics Anonymous (AA) and similar addiction recovery groups for nondependent problem drinkers who do not necessarily want to stop drinking, but moderate the amount of alcohol consumed to reduce its detrimental consequences.

MM was founded by Audrey Kishline, who was always careful to point out that MM was not intended for “alcoholics” but rather for “problem drinkers”—read “misusers” or “abusers”—and in her book said that those who were already sober were not encouraged to try MM (Kishline, 1995). Many opponents of MM cite Kishline’s vehicular manslaughter charge in the of killing a twelve-year-old girl and her father in an alcoholic blackout as an indictment of the program itself, but at the time of the car crash, Kishline was a member of AA as well as other abstinence programs. By January of 2000, Kishline publicly recognized that despite MM’s philosophy and methods, for her, at least, it wasn’t working. She posted a message to an official MM e-mail list, saying that she had concluded that her best drinking goal was abstinence, and that she would begin attending AA, SMART Recovery, and Women for Sobriety meetings, while continuing to support MM for others (Walker, 2015).

Harm reduction (HR) refers to policies, programs, and practices that aim primarily to reduce the adverse health, social, and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption (IHRA, 2015). HR benefits people who use drugs, their families, and the community. HR seeks to reduce dangers posed by risky behavior through management of those behaviors, rather than abstinence, using cognitive behavioral tools that emphasize practical problem-solving to help problem drinkers achieve and sustain moderate, controlled alcohol use. 

Interestingly, HR has been the most common approach for substance use disorders practiced in all of the English-speaking countries except the United States. In fact, until recently it was opposed by the federal government. However, when looking at the definition of HR, it becomes clear that for some individuals to achieve the goals of reducing harm to self or others, abstinence must be the harm reduction strategy because it is the only way for them to reduce harm.

It is clear that MM and HR are similar. In point of fact, both have been used for a long time without any objection primarily because these strategies have not been labeled as “MM” or “HR.” If we go back to the my column in the August issue of Counselor, which spoke of the problem of viewing substance use disorders as a single, unitary phenomenon, we understand that we have a range of severities within this group. At the most severe end of the continuum we have “substance dependence” as defined in the DSM-IV or “substance use disorder, severe” as defined in the DSM-5 or people who are truly addicted. While total abstinence may be preferred for opioid dependent individuals wherever possible, for those unable to achieve abstinence after repeated attempts, the use of pharmacotherapy with agonist drugs is indicated, as are needle exchange programs. In both interventions, we have reduced the harm to the individual and others.

When looking at the other end of the severity continuum, risk reduction through psychoeducation is appropriate. Examples of this last strategy have been employed for a long time in DUI programs in which the majority of offenders are not addicted (Sack, 2015). The goal for these offenders is to change their behavior so that they do not drive impaired or use at all when driving. Since the majority of offenders have either a low severity of substance disorder or may not even be diagnosable as having a substance use disorder—that is, meeting zero or one of the DSM-5 diagnostic criteria for a substance use disorder—a harm reduction approach as just described is entirely appropriate.

If we are to move away from the unidimensional view of substance use disorders, we need to reexamine the concept of abstinence-based treatment. Some of these programs are opposed to the use of pharmacotherapy, particularly agonist medications, and for those individuals who have a substance use disorder of mild or possibly even moderate severity, where the most clinically appropriate intervention is one of harm reduction or moderation management, they would not be appropriate.

I am a firm believer that, as long as we are unable to able to help everyone with a substance use disorder, we do not have the ethical or moral right to simply dismiss any approach, strategy, philosophy or treatment that has some proven efficacy and will do no harm. In working with an alcohol-dependent person who cannot conceive of staying sober for the rest of his or her life, even one day at a time, strategies such as drinking less, putting off the time to the next drink or trying abstinence or a very limited period are steps toward permanent sobriety. These are harm reduction strategies and may be the only path by which that individual can achieve lasting sobriety. By the same token, providing needle exchange services to IV drug users may result in their considering abstinence and entering abstinence-based treatment.

There are many paths to recovery and no one is clearly superior to any other when considering the severity of the substance use disorders and the outcomes desired. If it achieves the goals, it is the right way—there is no one way to recovery! Each of us, regardless of philosophical orientation, has something to share with the other, and each of us has something to learn. An epithet I saw on a tombstone should be our guiding principle: “Rather than being known as a person who had the courage of my convictions, I would prefer to be known as a person who had the courage to change my convictions.”

International Harm Reduction Association (IHRA). (2015). What is harm reduction? Retrieved from http://www.ihra.net/what-is-harm-reduction

Kishline, A. (1995). Moderate drinking: The moderation management guide for people who want to reduce their drinking. New York, NY: Three Rivers Press. 

Nietzsche, F. (1996). Human, all too human: A book for free spirits. (R. J. Hollingdale, Trans.) Cambridge: Cambridge University Press. (Original work published 1886). 

Sack, D. (2015). DUI: A sign of addiction? Retrieved from http://blogs.psychcentral.com/addiction-recovery/2014/11/dui-a-sign-of-addiction/

Walker, R. (2015). Remembering Audrey Kishline, the founder of moderation management. Retrieved from http://www.thefix.com/content/remembering-audrey-kishline

“What is moderation management?” (n.d.). Retrieved from http://www.moderation.org/whatisMM.shtml