HARM REDUCTION AND ABSTINENCE

Last week, my friend Tony Gizzie of the Community Editorial Board
wrote an article arguing against a harm-reduction approach to drug
and alcohol addiction. He claimed that harm reduction, which can be
defined as interventions that decrease harms associated with
substance abuse (with or without abstinence as a long-term goal), is
"ineffective in the long term." I can admit that my evangelical
Christian background biases me to a world view that places emphasis
on the rightness or wrongness of actions rather than their
consequences. Two years ago during a medical school interview, I was
asked to argue against the merits of a needle-exchange program. I was
able to rattle off a list of reasons why harm reduction was inferior
to traditional abstinence programs.

At the top of my list was the issue of whether a needle-exchange
program would tacitly legitimize illegal intravenous drug use. And
what would become of the surrounding neighbourhood? Surely it would
be vulnerable to drug-dealing, prostitution, crime and violence.

More importantly, I continued, harm-reduction programs do not address
the root cause of the addiction, be it mental health, domestic
violence or social issues. I concluded by saying that money invested
in harm reduction could be more prudently spent in abstinence programs.

Two years later, I am not so sure.

It's not that I believe those arguments are no longer valid. Rather,
it is because I have come to realize, slowly and painfully, that
complete abstinence may be out of reach for some. The all-or-nothing
approach of abstinence advocates neglects the needs of many substance
users who may fall somewhere in between.

Much of the problem with the public perception of harm reduction
involves the definition of "success." If abstinence is the only
measure, harm reduction, by definition, will never measure up. If,
however, we can evaluate success by using a variety of criteria, then
harm reduction may prove to be a legitimate form of intervention.

For example, a number of research papers have shown that a supervised
injection facility in Vancouver reduced the sharing of needles,
decreased public drug use and decreased the number of publicly
discarded syringes. Furthermore, the facility was not associated with
an increase in injection drug use, crime or public disorder.

Dr. Stephen Hwang, a research scientist at the Centre for Research on
Inner City Health at St. Michael's Hospital, compares supervised
injection sites with other medical interventions that mitigate the
harmful effects of an illness but do not cure the patient. Such
interventions, he argues, are accepted by the government, physicians
and society.

He also states that concern over harm reduction "may be partially
allayed by an understanding that harm-reduction strategies are
intended to complement, rather than replace, more traditional means
of treatment. In addition, pragmatic efforts to mitigate the adverse
health consequences of a harmful behaviour need not be construed as a
sanctioning of the behaviour itself."

And while it is true that more research is needed as to whether
harm-reduction strategies confer equal or even better health outcomes
than abstinence programs, the supporting evidence for abstinence
programs is paltry as well.

Alcoholics Anonymous, widely heralded as proof of the efficacy of
abstinence, does not provide definitive statistics on its success
rate. Committed to anonymity, AA does not keep official records of
its attendance or membership so it is impossible to know exactly what
proportion of those who have attended meetings now abstain from alcohol.

A resolutely abstinence-based drug and alcohol rehabilitation
facility I visited last year admitted that it does not measure
success or failure by relapse. Instead, its research department looks
for evidence that there is a mean decrease in the quantity and
frequency of substance abuse post-treatment. That sounds suspiciously
like harm reduction to me.

All said, I am still not sure where I stand on harm reduction. I know
that abstinence is the ideal.

But the demons of addiction that chase a significant proportion of
our society testify to the fact that we don't live in an ideal world.
Our approach to drug and alcohol rehabilitation must recognize this also.