Harm Reduction Drug Policies Throw the Baby out with the Bathwater
Harm reduction is the drug policy favoured by the UK government and most European governments. You can add Canada, Australia and New Zealand to that list too. As the name suggests, it is not focused on abstinence (as is common in the US treatment system) but on helping addicted people to remain as safe as possible while they continue using. For injecting drug users in particular, harm reduction (or harm minimization as it is also known) can be approached in a number of ways.
First — pharmacotherapy. In other words — using drugs to treat drugs. Pharmacotherapy uses two broadly different types of drugs. Agonists, and antagonists. Sometimes it uses a combination of the two. Strictly speaking an agonist is any chemical that binds to a receptor site in place of a neurotransmitter and directly activates those receptors.
An antagonist is any chemical that binds to a receptor site, but which can’t stimulate those receptors, and which blocks other substances from doing the same, which is why they are often referred to as ‘blockers’.
Agonists (or partial agonists) such as Methadone and Buprenorphine have traditionally been used in harm reduction initiatives, in order to reduce the need for illicit opiates like heroin by partially mimicking their effect. They stimulate the same (or similar) receptor sites in the brain as the drug of abuse (heroin). These drugs helps to quell cravings when they are prescribed at a high enough dose and are longer acting than illicit opiates which (in theory at least) makes them a safer alternative. This practice is known as ‘replacement therapy’ or ‘maintenance therapy’ because it replaces the drug of abuse and maintains the addictive behaviour in a safer and more manageable context. Critics of maintenance therapy however, would say that the only thing it maintains is the addiction.
Antagonist drugs used to treat substance use disorders are used as blockers. A blocker negates the effects of the illicit opioid (or alcohol) by binding to certain opioid receptor sites and neutralizing the high. Antagonists which are commonly used include medications like Naltrexone (a partial blocker) which can even be fitted under the skin as a subcutaneous implant making it fiendishly difficult (although not impossible) to remove. Naloxone (a full blocker) is used to reverse the effects of overdose, and is carried by paramedics and others who are in regular proximity to active opiate users.
Today the preferred medication used in pharmacological interventions for heroin users (in the US at least) is a combined agonist/antagonist called Suboxone. Suboxone is a combination of buprenorphine and naloxone. The reason it is a frontline medication in the treatment of opioid dependence, is because the naloxone component significantly reduces the risk of overdose and gives it far less abuse potential than Methadone or purer forms of buprenorphine like Subutex. (Subutex has gradually replaced methadone in the UK as the preferred treatment, but unlike suboxone, it can still be smoked or injected when crushed).
Needles Exchanges & Safe Injecting Sites
Another mainstay of harm reduction policy involves support services such as needle exchanges programmes (NEP’s) and safe injecting sites (SIS’s). Safe Injecting Sites are focused predominantly on reducing the risk of overdose which occurs when the user is shooting up unsupervised. They are literally small medical clinics with professional nursing staff, that provide clean works (syringes and other injecting equipment).
Needle exchange programmes are similar (often mobile) clinics, which also hand out clean syringes and dispose of used ones, thus reducing the spread of BBV’s (blood-borne viruses) like HIV and Hepatitis C.
Some people — typically more conservative people — might say that needle exchanges and safe injecting sites encourage drug use. Whilst this is understandable, such people are perhaps unfamiliar with the imperious urges that addicts suffer from. Urges that would see them gladly use a dirty needle to get through the hellishly unrewarding and meaningless moment of ‘now’, only to have a leg chopped off at some point ‘later’ (due to an infected abscess for example). This is an entirely reasonable bargain for an addict. For them, this conundrum is like jumping off a cliff to escape a tiger; perfectly reasonable under the circumstances and completely unaccompanied by any rational thought process. Therefore, needle exchanges are (arguably) an indubitable force for good. They reduce the spread of blood borne viruses and thus reduce the existence of unnecessary suffering.
What Harm Reduction Policy Doesn’t Take into Account
On the other hand, there is such a thing as necessary suffering. Necessary suffering is unavoidable whenever strenuous effort is required to comprehensively deal with a situation. If we are going to comprehensively deal with the addiction epidemic which has blighted our society, then we need to wrestle with this fact.
Abstinence-oriented recovery (as the name suggests) involves total abstinence from the drug of choice and all other mind-altering substances which might cause relapse. (It is worth noting in passing, that drugs such as Prozac and other anti-depressants do not fall into this category because they do not pump the brains reward system. Whilst they may create dependence they do not create addiction — a difference I discussed in a previous article).
The end goal of abstinence oriented recovery is to STOP USING DRUGS … for life … one day at a time. This approach has multiple benefits which not are not lauded by the academic highbrows or the intelligentsia. And it is for this reason that such benefits are noticeably absent from testing in the scientific arena, and indeed, in official governmental policy.
The benefits of ‘full recovery’ (by way of abstinence) have for the most part, been discovered experientially by the ordinary lay public. Mutual aid groups like Alcoholics Anonymous and Narcotics Anonymous have blazed their trail in more or less total obscurity. They have an institutional lack of desire to promote their own programmes. Indeed “attraction rather than promotion” is an enshrined tradition of all 12 step fellowships. Essentially it means this: NOBODY TAKES YOU SERIOUSLY WHEN YOU BANG ON AND ON ABOUT HOW GOOD YOU ARE AT SOMETHING! So if you want people to become abstinent and reap the benefits of such a life — let them come to you!
In the UK it has also long been postulated that the primary motivation behind governmental initiatives to promote MMT (Methadone Maintenance Therapy) was not to ‘save addicts’ but to reduce crime. Methadone was used as a heroin substitute to lure heroin addicts away from using illicit street heroin and ‘maintain’ them in a lifestyle where they were comfortably medicated and presumably (or so the theory goes) no longer buying or selling drugs and committing other associated offences to fund their habits. These acquisitive crimes (most often burglary and shoplifting) cost insurers in certain postcodes a fortune and swelled the prison population. But this policy was built upon the ludicrously naïve belief that you can replace a more dangerous and highly enjoyable drug with a ‘safer’ but not so enjoyable drug.
But if we had actually talked to real addicts and asked them — what would they have said? They would have told us that methadone didn’t really give them enough of a buzz to make up for the cherished powder. They would have told us that they often used heroin on top of their methadone or that they preferred to sell it because even a small amount of heroin which actually got you euphoric was better than a drug which made your body feel better, but not your soul. They would’ve told us how they abused their subutex by crushing it, and smoking it or injecting it — because it gave them a better hit that way.
If you think about it — it’s bloody obvious. Which addict have you ever met who went to his dealer and said, “Hello dealer, I would like to procure some slightly less enjoyable drugs from you today, please.” Nobody. Because addiction is about constantly seeking a higher high — not a lower high. This is why Methadone and Subutex don’t really cut it, and never will. And suboxone is much the same.
Abstinence vs Harm Reduction
Abstinence, from opiates at least, carries risk. In the early 2000’s there were a spate of deaths (particularly amongst young people) who were leaving treatment completely abstinent, but who were not yet possessed of real recovery skills because their treatment period (usually 28 days) had been too short to engender any significant neurological re-wire. Consequently, when encountering the ‘real world’ with all its triggers and temptations — many relapsed. Due to their prolonged abstinence and reduced tolerance to opiates many overdosed and died. This forced flagship abstinence-oriented 12 Step treatment centres like Hazelden (which later merged with The Betty Ford Centre) to revise their abstinence policies, and in 2012 Hazelden’s Chief Medical Officer introduced maintenance medication (suboxone) for the first time.
This is unfortunate in my view, because whilst harm minimization policies arguably work to keep people alive (at least those at the extreme end of the spectrum with regard to substance use disorder) they do very little to assist with changing the psychological conditions which created the addiction in the first place. Yes, they save lives in the short term, but in the long term the risk remains the same. An opioid addicted individual is an individual who continues (for as long as he is addicted) to be at risk of overdose. So the problem has not been removed – it has been postponed. And the motivations for this kind of policy? Well, it’s called ‘ass-covering’. No individual (or institution) wants to take the risk. Their usual answer, is that it would be better for people to remain on a substitution programme for life – than to risk overdose and death. Well I beg to differ.
Surely life is about the quality as much as the quantity. It is about having a life worth living, not merely elongating our existence in the least painful manner. Instead of a living death wrought by clunky chemical compounds (legally prescribed or otherwise) surely abstinence and existential growth is worth that risk? The ripple effect that full recovery can have upon families and communities for generations to come is untold — it is exponential.
Today my existence is vital, alive and full of meaning. But all of this would have been utterly impossible without abstinence. I know people won’t agree with this because it is not the fashionable thing to say, but that is none of my concern. I am only relaying my experience, my hope, and my ideal.