Can Harm Reduction and the Disease Model of Addiction Coexist?
We hope you enjoy this article from one of our guest writers, Gerald “Jerry” Shulman. Treatment Solutions is honored to have Jerry contributing to our blog. Jerry is a pioneer in the field of substance use and dependency and we thank him for putting his good name behind our company. Look for more from Jerry in the coming weeks. Also be sure and sign up for one of our CEU approved seminars led by Jerry.
The problem with the above is not with the answer, it is with the question. The way the question is worded assumes that all people who use substances comprise a population composed of similar individuals, while in reality we find people experiencing a range of substance use patterns and problems. Some definitions are in order.
Harm reduction is the process of reducing harm to the individual or society without necessarily reducing or eliminating the substance use. Examples of such strategy are drinking low risk amounts, changing the drinking pattern such as not drinking and driving or taking prescribed psychoactive medications only as prescribed.
In contrast, the disease model describes a disease, disorder or illness which is progressive, fatal and incurable. It is also described as a chronic, relapsing brain disease, for which there is currently ample evidence, and for which the only reasonable intervention is total abstinence. These two positions initially appear to be totally incompatible until one looks at the different patterns of use and the best way to do so is to divide the population of users by degree of risk.
There are individuals who make low risk choices characterized by drinking low risk amounts, not drinking in high risk situations (e.g., driving or operating machinery), using prescribed psychoactive medications only as prescribed and no use of illicit drugs. We will refer to this as “Risk Phase 1. Their use results in no problems and there is no significant increase in tolerance. The harm reduction strategy for this population is to continue to make low risk choices, or said another way, no change from the current pattern.
In this next phase of risk, Phase 2, individuals are beginning to use substances in a high risk manner such as drinking high risk amounts and making high risk choices (drinking enough to be impaired when driving) or misusing prescribed medication. In this phase, individuals may develop social dependence and we see the onset of state dependent learning. The individual may begin to have problems such as a single DUI or missing work but as yet without consequences but does not meet diagnostic criteria for substance abuse or dependence. A harm reduction strategy for these individuals is to return to Phase 1, return to making low risk choices. .
People in phase #3 present a more complex picture. In this phase we find the development of psychological dependence, the substance use is more integrated into the person’s life, there is state dependent learning, high risk choices become more important than relationships and we find the individual defending his or her use choices. This phase tends to correspond to substance abuse or substance dependence without physiological dependence.
Individuals in this phase manifest substance-related health or impairment problems, blackouts and drinking to cure hangovers. While return to low-risk drinking choices may still be possible, only about 50% may be able to do so and the individual may require outside help to change choices. The critical issue here is that continued use likely to lead to Phase 4 (see next) and the safest choice at this point is total abstinence.
Phase 4 represents the most severe pattern of use and corresponds to the diagnosis of substance dependence with physiological dependence. In this phase we see physical addiction, withdrawal, compulsion, loss of control and increasing tolerance. The substance use now results in more negative, more severe outcomes than in Phase 3 up to possible institutionalization or death. Since return to low-risk choices no longer possible, the only rational response requires total abstinence, which usually requires outside help to achieve and maintain.
For many clinicians who hold to the disease model of addiction, the idea of harm reduction is repellent because they think of it as applied to those people that find their way into treatment. However, on average, these patients in treatment are in treatment because they have the most severe substance use disorders and its resulting problems (e.g., legal, employment, medical, family). They are generally in Phase 3 or 4.
For those in Phase 3 harm reduction (trying to return to a lower risk pattern of use) may be hazardous and for those individuals in Phase 4, harm reduction is inappropriate and contraindicated. However, for those in Phase 4 who are in the Precontemplation Stage of Change, a non-abstinence approach such as reducing amount or frequency of use, is sometimes employed as an intermediate goal.
Returning to the original question of whether harm reduction and the disease model of addiction can coexist, the answer is a definite “yes” and is clearly related to the degree of risk or problem severity of the substance user. While the only totally safe alternative for every drinker/user is abstinence, people in Phases 1 and 2 are unlikely to choose abstinence, and by forcing them into this position we risk the opportunity to apply harm reduction strategies to halt the progress of the problems and thereby reduce the harm to the individual or society.