NONABSTINENCE PROGRAMS SEEM TO WORK FOR MANY ALCOHOLICS AND ADDICTS

YOUR TODDLER throws tantrums - whose does not? - so you give him time-outs,
speak sternly, cancel a dessert. But not every time he acts up. Like most
parents, you choose your battles and skip some.

That's the thinking behind providing shelter for chronic alcoholics or drug
addicts without requiring that they abstain or enter treatment.

It's called "harm reduction." It makes sense to keep people alive until,
one day perhaps, they sober up. In the meanwhile, they are prevented from
dying on the streets.

Most of us have a hard time with the measures and implications of harm
reduction. Beyond our tendency to moralize and blame victims, no one wants
to encourage deadly habits.

Naturally, the approach has opponents in the substance abuse treatment
field, where a single-minded insistence on abstinence has saved millions of
lives. Tempers flare when reformers suggest a more flexible approach may
help others.

We in the public ponder this carefully, then bang our fist on the table and
shout, "It's not right." Certain social problems, from alcoholism to AIDS,
churn our stomachs and, often, cloud our thinking about remedies.

Witness the debate over whether, as research now suggests, some problem
drinkers can be helped at an early stage by being taught to moderate their
intake rather than abstain totally.

"It's splitting the field apart," said Jeffrey Hon of the National Council
on Alcoholism and Drug Dependence.

Edward DeBerry of the National Resource Center on Homelessness and Mental
Illness, based in upstate New York, says of the non-abstention treatment
program: "In the public's mind you're encouraging abuse."

His federally funded center neither endorses nor opposes the concept, but
DeBerry says the harm reduction model, long popular in Europe and
Australia, has caught on here because "many people came to the conclusion
that the heavy-handed approach has not worked."

That's why in the helping professions, from ministers to psychologists,
have counseled people to stop their most damaging behavior before
attempting to quit addiction to alcohol or drugs. Increasingly, and usually
on a case-by-case basis, some social workers are beginning to take the same
approach.

Deciding to countenance evil in order to avoid harm constitutes a major
shift in dealing with problems where the traditional approach has been,
"No, don't, stop." The philosophy is to "meet people where they are," in a
common phrase, rather than issuing mandates, and work from there.

Take programs which exchange clean needles for used ones for addicts who
shoot drugs into their veins. The idea is to prevent them from sharing
needles, a major cause of spreading the AIDS epidemic.

Fears that needle exchanges encourage additional drug abuse have gone
unrealized, according to the Center for AIDS Prevention Study at UC-San
Francisco. But risky behavior, such as sharing dirty needles, has declined.

After four years of public needle exchanges in San Francisco, the rate of
HIV infection among intravenous drug users has, at the least, not gone up,
said Delia Garcia, of the city's AIDS office. The exchanges are also a time
when addicts ask about other health problems, with many - often pregnant
women - volunteering for rehabilitation.

Naturally, people who treat addicts have their reservations. In 1987, when
the idea was still new, several former addicts who worked in drug programs
in Harlem laughed at the idea.

They told me that scheming drug users would simply sell the needles for
drug money. Attitudes may have changed, given the continued AIDS epidemic.

"Since their clients are in and out of treatment, counselors don't want to
see them get HIV while they're out," said Kelly Knight, a University of
California researcher who volunteers in a San Francisco exchange for women.

Some clients serve as adjunct public health workers by exchanging other
addicts' needles, which still reduces the number of potentially infected
needles on the streets. Last year, the city programs exchanged 2.2 million
needles.

The commitment to gain trust over time while reducing the most immediate
source of danger also guides long-term outreach to certain groups.

With pink and blue tattoo-covered forearms, a bright red crew-cut and a
silver bone through his nose, Kyle Ranson of the San Francisco AIDS
Foundation seems a natural for his work with runaway, homeless youths in
San Francisco. He may spend months, even years, getting to know some of
these teens and young adults before suggesting they go home or stop selling
sex or using drugs.

"You have to meet the kids where they're at," Ranson told me. "Some are
ready to stop. With others we try to keep them alive long enough so they
reach the point where they will stop."

In the meanwhile, his group runs writing and art workshops and other
activities such as regular barbecues in Golden Gate Park, which tap the
runaways' creativity. Many begin to feel their lives are worth saving.

Some proponents are ambivalent. "Oftentimes, I just feel like I'm
encouraging these kids to continue using drugs," said Sara Parks Urban of
the long-established Larkin Street Youth Center.

The center even has a Hustlers Support Group where young male prostitutes
eat pizza, warn each other about abusive customers and, often, recover
their dignity.

"If they know someone's concerned about them, who knows, maybe in five
years they'll get off the street," said Roger Hernandez of the Larkin center.

The approach appears to be working. He said that 71 percent of Larkin 's
clients have left the streets, usually for families, treatment or a group
home.

Absolute proof that harm reduction efforts work can be elusive since it is
hard to run controlled research trials with such transient groups such as
runaways, addicts with AIDS or street alcoholics.

But other indications, and common sense, suggests it can help. For years in
Minnesota, chronic alcoholics who have been treated but have relapsed
repeatedly are often referred to "wet" or "damp" shelters rather than
another round of expensive care.

With a room, meals and case management, they are in less danger and cost
less in terms of panhandling, crime and emergency room visits, reported
Cynthia Turnure, director of the state's chemical dependency program.

Honolulu has a similar shelter and there are dozens more, some of them
among the 60 or so federally funded Safe Havens, transitional housing of
the last resort for chronically homeless.

Typically, residents cannot drink on the premises. Though they may do so
elsewhere, they are held accountable for their behavior and can be evicted
for violations.

"There is good anecdotal evidence that if they have a safe place to stay,
they will cut back on their drinking or drug use," said Deirdre Oakley, of
the Policy Research Institute, who has visited dozens of such facilities.

And as professionals in the fields reiterate, little happens with an
alcoholic or addict until he or she decides they want to get better.

Much of addiction treatment consists in getting people to that point.
Advocates of wet shelters say that's their aim as well with chronic
alcoholics.

"A lot of people can't grasp the concept that you can accept where they're
at and still encourage them to go into treatment," said Donna DeMaria of
the Homeless Action Committee in Albany, N.Y., which runs one such shelter.

"When you start giving people some compassion, a support system, have them
feel a part of community, and they start feeling good about themselves,
that might start them thinking about making a change."

Consider a final example of harm reduction in practice, that of working
with addicts or alcoholics who have AIDS. Some case managers, notably in
New York City or San Francisco, no longer insist these clients stop drugs
and alcohol in order to qualify for housing or other benefits.

In such programs, abstinence and recovery remain a priority, but not a
requirement. Many counselors consider the approach more realistic as the
epidemic shifts into other groups such as addicts who shoot drugs with
needles.

The goals are several: keep the person alive, prevent him or her from
spreading HIV through risky actions, and enlist the person as a partner.
Mandating abstinence can drive some away and increase the chances they will
infect others.

The urgency of certain health situations, such as AIDS or addictions,
requires we sort through comforting notions of right and wrong in order to
best save lives. It is easy to preach sternly about what "these people"
should do. It is much harder to rethink our traditional, emotion-laden
responses.

©1998 San Francisco Examiner