Stanton, you have deep unresolved pain

typesI’m not a fan of either of these high profile addiction experts, but Stanton Peele’s recounting of his meeting with Gabor Maté illuminates a lot about both men and their approach to addiction. It also helps in understanding the conceptual boundaries of harm reduction, at least as Peele sees them. The boundaries are more rigid than I would have imagined.

Seeking common ground with Gabor, I noted his work with psychedelics as a chance to teach people how to manage drug experiences. But he told me that teaching people competency in drug use is the last thing on his mind. I emailed him in March this year:

I DO like this title—Substance Use Competency. It is interesting to play that idea out—including dealing with people’s traumas (without allowing them to grow to life-overcoming proportions) while also actually teaching them to manage substance use (as you are doing in Mexico). Perhaps we can combine around this.

Gabor responded by rapping my knuckles:

We are not teaching substance use competency with this process. The goal and process is to help people shed the physical and psychological patterns of old trauma, so that they are no longer trapped in the past. If successful, substance use is no longer an imperative. [My emphases.]

The last thing in the world Maté wants people to do is to take drugs as a normal part of life experience. In this way, he is no more a harm reductionist than Nancy Reagan.

Hmmm. Like I said, I’m no fan of Maté, but the goal of eliminating substance use as an imperative puts one in the same category as Nancy Reagan? Count me in that club.

Throwback Sunday – Pessimistic Paternalism

blank signI’m doubling up this week with two posts on harm reduction from December 2006.

I’ve written often about the subtle bigotry of low expectations, these two posts illustrate that concern. (I like my reference to “pessimistic paternalism disguised as compassionate pragmatism.”)


Debate on abstinence

A horrifying excerpt from a debate in a British treatment provider magazine. (It’s at the bottom of both pages.) I don’t completely understand the context–whether they are debating a “motion” in a binding way for the specialty society that publishes the magazine or if it’s a devise for a magazine column.

One of the participants proposed that detox is dangerous due to the possibility of reduced tolerance and unintentional overdose in the event of a relapse. Harm reduction advocates used to argue that they represented a needed choice philosophy in working with addicts. The is the worst kind of pessimistic paternalism disguised as compassionate pragmatism–and there’s nothing representing real choice.

…Detox can be dangerous and is not very often successful. Death rates are higher in recently detoxed patients.

Many people request detox but we need to recognise that maintenance is a very worthwhile option. Maintenance patients need our support – including psychological support – and harm reduction has to be our goal.

The NTA says rehab providers have to provide mechanisms for rapid referral into maintenance programmes. Getting people off drugs is dangerous.

Bill Nelles,founder of The Alliance,said: ‘Let’s take the morality out of drug treatment and put the humanity back in’. Judy Bury [GP] said it is our job as GPs to keep people alive until they are ready to change.

There’s not much evidence for long-term effectiveness of detox,but it can reduce tolerance. People cannot do abstinence when they walk in the service. The move toward abstinence-based treatment is dangerous and will increase drug-related deaths.


“Recovery Impatience”

Lowering_The_Bar_Cover_2010.09.22Let’s hope that the concept of “recovery impatience” does not catch on. Keep in mind that this is in the context of a country with a big emphasis on methadone and 60% of the methadone recipients have expressed a preference for abstinence based treatment.

“We are now seeing the emergence of a culture of “recovery impatience”: the demand for people to move quickly to a drug-free lifestyle while denying the significance of other factors – such as low income and life in neglected communities – which make rapid achievement to a drug-free life impossible for the majority,” she said.

“The combination of totally unrealistic expectations, along with the demonisation of drug users, is having a trickle-down effect on practice, with “firmer” responses becoming more acceptable.

“We are in danger of harking back to the days when those seeking treatment were labelled as feckless and chaotic, deemed as having given up their right to be involved in their own treatment or to be treated with the dignity, respect and quality of care afforded other vulnerable groups in society.”

you are still valued and respected

charles outreach accept

DJ Mac directs us to an interview with a English recovering harm reduction advocate, Kevin Jaffray.

He shares a little of his own experience of fighting and, eventually, entering recovery. [emphasis mine]

Speaking as someone who came into abstinence kicking and screaming – thankfully with my health intact – after a number of chaotic years in addiction, I have to say with my hand on my heart that I would not have got this far if I had not spent a number of years being educated around the risks of my chosen lifestyle and gently guided through the years of chaos with a non-judgemental and non-enforced guiding hand of harm reduction. Those who reached out to me during that time carried me through some of the most destructive years of my life and kept me safe when no one else took the time to care. So being alive and healthy is actually quite a significant positive outcome in my opinion.

meet them where they are atMy own personal experience is how I became involved in carrying a message that there is a way out should you choose to take it and if not, you are still a valued and respected member of the community who deserves to be treated the same as every other member of that community, if not with more respect and due attention.

I’m struck by the repeated references to change and care. He repeatedly asserts that the goal is change and how critical care was for him. He doesn’t reference and harm reduction services, but keeps coming back to care.

It’s interesting, when he talks about his experience of the harms of addiction, he’s not just talking about infections, diseases or near-death experiences–he talks about living with addiction.

The years I spent living with addiction and all its related issues, as did my family and everyone who came close to me over the years. Addiction is not an isolated issue and its ripple effect can be as far reaching as it is deep.

There are those among us who can use safely and those who can remain recreational users. I take my hat off to them and have a, some might say controversial but, very real respect for them and an underlying jealousy if I’m honest. I was not one of them and the result was years of unadulterated chaos everywhere I went. Years of feeling like I did not belong anywhere, years of searching for connection, and years of battling stigma and isolation.

The feelings I lived with for those years were almost debilitating and I became trapped in a cycle of addiction where the pain of being was overwhelming and the substances dulled the pain of being, not a nice experience in any way, shape or form. Don’t get me wrong, I had some amazing times on substances but the effect it was having on my loved ones and significant others eventually added to the pain and became part of the downward spiral. I ended up alone and destitute.

All the needles, safe injection rooms and naloxone in the world won’t reduce those harms–but human connection and recovery can. I’m sure there are interventions I could not join him in, but there is a lot of common ground here to build from. Reading his experience and reflecting on Dawn Farm’s work makes me proud that we offer safe, compassionate, nonjudgmental recovery-oriented care.

His suggestions for people who want to help?

Support your local mutual aid groups; if there aren’t any, think about starting one up. Join online forums and add your voice to the already existing campaigns. Run events in your area. Get out there in your community and talk to people, find out what’s missing. Look for the deficits and fill them. Your community can always be improved. Asset map your community, don’t try and reinvent the wheel, just build more spokes from what is already there.



Vancouver, Insite and HIV infection rates

haart_guideI recently stumbled onto this blog post with a very interesting observation about Vancouver, Insite and HIV infection rates.

Vancouver has seen a marked decrease in the incidence of AIDS/HIV and those who promote harm reduction sites point to the injection site called Insite as proof of success but they are wrong. The reduction of HIV/AIDS in British Columbia is because it is the only province that offers highly active anti-retroviral therapy (HAART)  free of charge and aggressively promotes its use.

“. . . the most compelling data to date demonstrating the soundness of the “treatment as prevention” theory, an approach conceived at the B.C. Centre for Excellence in HIV-AIDS and now being embraced worldwide.

“Treatment as prevention . . . is so successful, from Zimbabwe to Abbottsford, that policy-makers now talk openly about the possibility of freezing the epidemic in its tracks and creating an AIDS-free generation.”

I don’t agree with all the sentiments on this blog post, and I don’t understand the writer’s concept of “redistributing harm”, but , with all the discussion of Insite and Vancouver, I’ve never seen anyone discuss HAART and it’s impact on infection rates.

“looking past these behaviors”

Lowering_The_Bar_Cover_2010.09.22This article got me thinking about the bigotry of low expectations and the importance of continuing to assert that every addict should be offered treatment services that provide a path to full recovery, not just symptom or harm reduction.

If it’s not suicide or drug overdoses doing the killing in psychiatric patients after all, how does that change the way we see severe mental illness? For one thing, it jerks this sort of disease back into the world of everyday misery. Society is excellent at sealing off the deep end, so to speak. Because this kind of illness is behavioral and has to do with the very ways in which we experience the world, it becomes easy to put the brakes on empathy. The study suggests that psychiatric patients are mostly dying in normal ways, albeit in hyperdrive: living life fast but miserable.

Hartz et al’s study also suggests that anti-smoking and other public health campaigns have effectively bounced off the mentally ill, perhaps in part because doctors are looking past these behaviors. “Some studies have shown that although we psychiatrists know that smoking, drinking, and substance use are major problems among the mentally ill, we often don’t ask our patients about those things,” Hartz says. “We can do better.”

via How Mental Illness Kills | Motherboard.

Recovery and Harm Reduction

English: Liberty Bell in Philadelphia
English: Liberty Bell in Philadelphia (Photo credit: Wikipedia)

Bill White has a new paper on Recovery and Harm Reduction in Philadelphia. Here’s a quote he offered in a blog post introducing the paper:

Traditional harm reduction programs have pioneered low threshold services, but they have often also been characterized by low expectations.  Our vision is to expand low threshold services that at the same time elevate peoples’ sense of what is possible for them.  We do this by exposing them to living proof that recovery is possible even under the most difficult of circumstances, confirming that there are people who will walk this path with them, and offering stage-appropriate services to support people in their journeys from addiction to recovery. Arthur C. Evans, Jr., PhD, Commissioner, Philadelphia Department of Behavioral Health and Intellectual disAbility Services, 2013

This reminds me of posts I’ve written about “recovery-oriented harm reduction” over the years. 

From one of those posts:

Recovery is all about freedom. The freedom to live one’s life in the way one chooses without being a slave to addiction or being controlled by treatment or criminal justice systems.

This is the key. We’ve struggled mightily with maintaining a professional culture that is focused on recovery. It often conflicts with human nature and the instincts of professional helpers, so we have to accept that it will be a constant struggle. On the subject, we contributed to this paper.

I’ve been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

  • an emphasis on client choice–no coercion
  • all drug use is not addiction
  • addiction is an illness characterized by loss of control
  • for those with addiction, full recovery is the ideal outcome
  • the concept of recovery is inclusive — can include partial, serial, etc.
  • recovery is possible for any addict<
  • all services should communicate hope for recovery–recognizing that hope-based interventions are essential for enhancing motivation to recover
  • incremental and radical change should be supported and affirmed
  • while incremental changes are validated and supported, they are not to be treated as an end-point
  • such a system would aggressively deal with countertransference–some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients

I’ve also admired Scott Kellogg’s writing on gradualism. Here’s a quote from a story about him a few years back:

A Gestalt-trained therapist, Kellogg holds some views that seem to place him closer to the harm reductionist’s way of looking at substance use and recovery. He questions treatment center practices that appear to profess abstinence at the risk of losing many clients before they can start making progress. He states his belief that “there’s a crisis in our treatment world because many people don’t like treatment.”

Yet he also says his perspective goes against the tenets held by many harm reductionists. He is most impatient with the attitude in some needle exchange programs and similar initiatives that “we would never tell people what to do.” Offering a shower, a sandwich and a clean needle and then repeating the process time and again are fine in the short term, but at some point you need to help build a life after you’ve saved one, he suggests.

The surgery was a success, but…

1368951062alarabalaanPublic health workers are declaring their harm reduction approach a success:

Harm reduction — not a war on drugs — has reduced illicit drug use and improved public safety in what was once Ground Zero for an HIV and overdose epidemic that cost many lives, says a 15-year study of drug use in Vancouver’s impoverished Downtown Eastside.

The report by the B.C. Centre for Excellence in HIV/AIDS found that from 1996 to 2011, fewer people were using drugs and, of those who were, fewer were injecting drugs, said Dr. Thomas Kerr, co-author of the report and co-director of the centre’s Urban Health Research Initiative.

“A public health emergency was declared here because we saw the highest rates of HIV infection ever seen outside of sub-Saharan Africa — in this community. At the same time, the community was being levelled by an overdose epidemic,” Kerr said after presenting his findings to members of the group affected at a community centre in the heart of the neighbourhood.

Vancouver took a public health approach to the crisis, opening the country’s first supervised injection site in 2003, and Kerr said the statistics show that approach was successful.

Kerr goes on to pull the scientific evidence card, casting critics as stupid, unethical and indifferent to death:

“We have a federal government that ignores science in favour of ideology, and people are sick and dying as a result,” Kerr said.

“When we’re dealing with matters such as life and death, I think we’re obligated to base our decisions on the best available scientific evidence. I think it’s unethical to do otherwise.”


There was some disappointing news for health officials in the study.

There has been only a slight drop in mortality rates among the city’s illicit drug users, who have a death rate eight times higher than the general population.

What’s that saying? The surgery was a success, but the patient died.

Now, I’m not saying that law enforcement is a better approach and I’m not saying that reduced disease and crime are unimportant, they are important. However, one of my concerns about public health approaches is that they are often designed to serve the public rather than the individual. When the death rate is only slightly affected, and addicts are still using and homeless, who’s best served by these outcomes of reduced disease and crime?

Harm reduction is not enough. In and of itself, it is not bad.

It’s just bad when the public and professionals declare victory while addicts continue to suffer terrible quality of life.

How much money was spent to achieve these outcomes? How else might that money have been spent?

Why not recovery?

The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke
Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?

Establishing residence in hell

English: Naloxone HCl preparation, pre-filled ...
Image via Wikipedia

Saving lives is good an important, but something about this feels like building an addition on a house in hell.

Naloxone is a medication administered usually by injection which rapidly reverses the effects of opiate-type drugs such as heroin, including the respiratory depression which can cause what are normally referred to as ‘overdose’ deaths. … The 16 pilot projects trained 495 carers (family members, partners and other carers) to respond to an overdose using basic life support techniques, and all but one also trained them to administer naloxone.

Saving lives is a good thing, but what else might be done to prevent overdoses? Why this?

Yesterday’s post asked, “at what cost?” What are the costs of this to the family members?

Missing the point

The American Journal of Public Heath (behind a paywall) has a new study looking at 2 year trajectories of residents in a “wet shelter”.  The found that the residents reduced their drinking by 40%.

Reducing drinking in these cases is a very good thing.

To me, there are several important questions but the first might be, “then what?”

Do we pat ourselves on the back that they are housed and drinking less? Mission accomplished? Or, do we view this gradual change as a start and continue to move them toward recovery?

If we’re talking about the latter, I have no quarrel with a program like this, in principle. (I say, in principle, because, in the context of scarce resources, my bias will probably be that funds would be better spent on improving treatment access and services.)

The study and coverage of it makes me bristle a bit because it responds to and refutes an “enabling hypothesis” that a housing first approach will increase an alcoholic’s drinking. This seems like a bit of a straw man.

Maybe I’m an outlier among people who are concerned about these kinds of programs, but my concerns are:

  1. That this kind of program does nothing to address the individual’s alcoholism. (Not that it would make it worse.)
  2. That it’s a palliative response to a treatable condition.

The study does address #1 to an extent. My response is that drink counting doesn’t tell you a whole lot about alcoholism, particularly with very severe cases. Addiction’s impact is so multidimensional to the individual and the loss of  control extends so far beyond drinking that it’s dot as though a 10% reduction in drinking equals a 10% improvement. Several analogies come to mind, for one, if your’re in chronic and severe pain and the pain is reduced by 10%, is that success? Does it equate to a 10% improvement in well being? Not necessarily. Sometimes, small improvements in a symptom are accompanied by disappointment and depression that this might be as good at is gets. The person may still be disabled. The pain may still be severe enough to interfere with sleep, relationships, other pleasures or participating in activities that are associated with wellness.

Again, I welcome improvement, IF it’s accompanied by an effort to continue moving in the direction of recovery.

My concern about the palliate approach is that it’s based on the assumption that these people can’t get well. This assumption often rests on other assumptions:

  • That they’ve had access to treatment before and have not responded.
  • That they don’t want recovery.
  • That treatment is too expensive.

The problems with these assumptions are that:

  • They probably never got treatment of the appropriate duration and intensity.
  • Context is important in wanting recovery. Does the person see living proof that recovery is possible? Does the person work with helpers that express hope and optimism about their capacity to recover? Is help of adequate intensity and duration available on-demand?
  • Treatment and recovery support doesn’t have to be expensive.
    • Arguments based on costs and savings are arguments within the economic monoculture and deserve re-examination. (Hospice is probably much cheaper than cancer treatment too, does that make it the right thing to do?)

There’s a way in which this is two things at once. An aggressive attempt to meet the basic needs of some very vulnerable community members, AND a form of abandonment by lowing expectations and offering no hope for recovery and wellness. (There was no reference to recovery  or gradual movement in the direction of abstinence in the article.)