How Moderation and Harm Reduction Can Support Abstinence

Seattle Counseling Services, a nonprofit agency dedicated to the lesbian, gay, and transgender community runs a weekly group called “Meth Madness.” Meth Madness is a support group open to users even if high or tweaking. Attendees talk in safe surroundings with current and former meth users. Trained counselors offer support and teach how to stay hydrated and take care of veins, how to keep your teeth, and how to avoid contracting Hep C or HIV. The Meth Madness group created a surprising demand for abstinence-based treatment. Meth users who came for six months or so wanted help to quit meth entirely. Demand for help was so high that the agency started an abstinence-based treatment program. Dirty Words “Moderation,” “harm reduction” and “control” seem like dirty words to many of us. The thought of trying to control their drinking seems like sheer madness to those in long-term recovery. Moderation makes much more sense to those starting out, trying to figure out what to do about the problems they are experiencing. Our failure to include moderation and harm reduction among our treatment protocols limits the options available to persons facing problems. Such lack of options means overdrinkers and drug users continue longer at dangerous levels. Abstinence Exclusive It is sad but well known that most people wait a long time to get help for drug or drinking problems, and that most people relapse after addiction treatment. There is ample research-based evidence that we could reach people sooner and help relapsers minimize harm from use. Unfortunately most treatment centers focus exclusively on abstinence and 12-step facilitation. Many people believe that offering abstinence-based treatment is incompatible with moderation or minimizing harm. Research shows that programs designed to control or to minimize harm can lead participants to choose abstinence. Not Ready for a Name I am conce ed that AA facilitation and abstinence-only programs may unintentionally act as barriers that prevent many from seeking help. Though deeply grateful for my own 12-step experiences, I recognize that 12-step concepts such as “disease” and “powerlessness,” or relying on a “Higher Power,” and labels such as “alcoholic” or “addict” are hard for many to swallow. Yet more than ninety percent of the treatment programs in the United States are dedicated to abstinence and twelve-step facilitation. Many people who drink too much are unable to get help because they are not ready to be labeled or consider lifelong abstinence. 12-steppers conveniently say they have not hit bottom. Dead Drunk We used to believe that people had to hit bottom before they were willing to do anything about their drinking. Now we know that hitting bottom may be too late. For many, Dr Phil suggests, bottom is “six feet deep.” Research by William R Miller (of Motivational Interviewing fame) suggests that overdrinkers are willing to do something about their drinking, but before they opt for abstinence they would like to try to control their drinking. It seems natural to them to try moderation before choosing abstinence. If we help them try to moderate some will succeed and some will fail and some will opt for abstinence. What is important is that people face their problems sooner when moderation is an option. I would like to see abstinence-based treatment centers offer local programs for controlling or moderating drinking. Do Something About Your Drinking Offering local programs for moderating drinking will allow more people to face their drinking problems sooner. Miller’s tools for reducing drinking are offered in his research-based book Controlling Your Drinking. His program helps people who are experiencing problems with their drinking consider how much they drink, name the problems they experience, and make a decision to “do something about their drinking.” Participants go on to assess their levels of drinking in comparison to other Americans, and consider how likely they are to moderate. Participants are encouraged to take a two-week break from drinking, learn to track their drinking and estimate blood alcohol concentration, and set goals for safe drinking. Over a four-to-six week period they practice slowly reducing their alcohol consumption to a problem-free level and keeping it there. Research participants were followed for a period of three to eight years after completing the program. Outcomes from Miller’s research program are encouraging but not rosy. Something Positive Miller’s researchers found that in the year before follow-up about 15% (one in seven) had maintained complete moderation throughout the year (drinking less than 3 standard drinks per day and less than 10 drinks per week). Another 23% (almost one in four) reduced their drinking significantly to an average of 14 drinks per week but still experienced occasional alcohol-related problems. Another one in four (24%) had been totally abstinent for the previous year. Unfortunately more than one in three (37%) continued to drink at heavy and harmful levels. On the other hand almost two out of three (63%) were able to do something positive about their drinking by trying moderation. For one in four, starting with moderation lead them to choose abstinence. The Harm Reduction Effect When treatment programs limit their focus to abstinence they miss a second opportunity: to effectively help those who relapse. Reports of typical relapse rates suggest that more than 2 out of 3 relapse after treatment. Some reports put the rate as high a 9 out of 10. But this news may not be a bad as it sounds. I believe that a harm reduction effect occurs as a result of abstinence-based treatment. I believe this because about six years ago I heard a radio interview with a man from Califo ia who talked about why Califo ia offered free chemical dependency treatment to anyone who wanted it. Staying Out of Trouble The state found that significant money was saved when it offered free treatment. However, most of the people who went through treatment did not remain abstinent. But those who went through treatment got in less trouble and made few demands on social services. Califo ia saved money because over all there were fewer trips to the emergency room, less domestic violence and child abuse across the state, and fewer arrests and incarcerations. Such savings occurred even though most who went through treatment went back to using alcohol and other drugs. Unintentional Harm Reduction I concluded that going through treatment has an unintentional harm-reduction effect. That makes me wonder what would happen if treatment centers intentionally taught harm reduction to persons going through abstinence-based treatment? After all, addiction is defined as a “chronic relapsing disease,” so it makes sense that people should learn how to minimize harm in case of relapse. I don’t believe that learning about harm reduction will make someone more likely to relapse any more than having a plan in case of fire will cause a fire. Still many are afraid to teach harm reduction. The Safest Thing Some people object to harm reduction (or moderation) because they believe that it promotes or condones drug use. Harm-reduction educators point out that abstinence is offered as one of many options in harm reduction and is recommended as the safest thing to do. But they accept that, in spite of the risks, many people choose to use alcohol and other drugs. Harm-reduction educators teach the safest ways to use alcohol and drugs, how to minimize use, avoid drunk driving or contracting Hep C and HIV, how to plan for safer use, and how to avoid harming their family (don’t use in front of the kids). They help individuals and families stabilize as they reduce or eliminate risky behaviors. And just as in the Seattle Meth Madness group, many users who come for harm reduction decide they want help to stop entirely. Many go to treatment and succeed in maintaining abstinence, but of course some relapse. Alumni Support for Relapsers Given the high rates of relapse after treatment it seems sensible to teach harm reduction as part of treatment. Teaching abstinence-only practices can isolate the relapsed user for prolonged periods of harmful use. This is dangerous to the person who relapses but also dangerous to their children, partners, families, and communities. I would also like to see treatment centers offer harm-reduction groups and support to alumni who have relapsed so they are less isolated and have structure that helps them make positive changes. Alumni programs should offer help and support to all their alumni—not just those who are successful at staying abstinent. More Interest In Treatment Services What would happen if treatment centers across the country accepted the natural patterns of addiction (that people want to try control before trying abstinence, that many who try abstinence end up continuing to drink and drug, that sustained abstinence is a great goal but one that some never reach)? What would happen if treatment centers offered moderation classes to those who want to try doing something about their problems, 12-step facilitation and other options for those seeking abstinence, included harm reduction education in treatment, and offered harm reduction support for alumni? I believe treatment centers would see increased interest in their services. Problem drinkers and druggers would get more effective help sooner and many would choose to become abstinent. People experiencing relapse would stay safer, and as Califo ia found, this would significantly reduce the costs to communities. It is time to accept that moderation and harm reduction are research-based and clinically-effective practices that often lead to abstinence. I would like moderation and harm reduction to be the bookends of the abstinence services currently offered. Treatment centers that do embrace moderation and harm reduction will be extremely popular, will make more money, and save any number of lives. Please forward this article to key people in your treatment community. For more information, contact Crossroad Recovery Coaching director Alida Schuyler at coachalida@gmail.com Copyright 2011 Crossroads Recovery Coaching, Inc.