Is It Harm Reduction-or Harm Continuation?
Peter O’Loughlin

Principal, The Eden Lodge Practice

Abstract:

From a long career in treatment services, this author has first-hand experience in the practice of harm reduction and the consequences of applying it – which are not always positive.  This author suggests ways of bringing greater clarity to the whole arena. The abandonment of abstinence as a goal in UK treatment practice is scrutinised with the conclusion that it could best be described as ‘harm continuation’. The interaction between national treatment bodies and ‘Whitehall’ (the UK government) and the enforced reconciliation of treatment needs and political interests is appraised and found wanting.  Some hope is seen in scientific and pharmacotherapeutic current advances, whilst at the same time recognising the ongoing effectiveness of 12-step fellowships (albeit difficult to scientifically measure) and its ready correlation with the transtheoretical model.  This author concludes that British practice facilitates continued drug/alcohol use – whether intentionally or consequentially – and that statistical smoke screens mask the process, a process which if not corrected is likely to increase rather than decrease society’s problems.

Keywords: Harm Reduction, harm continuation, treatment, addiction, dependency.

In the beginning

It is more than likely that the concept of harm reduction has existed since shortly after we discovered substances that could change the way we were feeling. Ever since man first trod grapes and enjoyed the temporary euphoria that subsequently arose from their fermented juices, there has been the realisation that the effortless, sometimes euphoric, altered states of consciousness arising from using ‘elixirs’ could produce unpleasant side effects. Not surprisingly, some found these side effects so unpleasant they chose to ingest more of the potion/substance in an effort to cope with the mental and physical disturbances experienced. Thus they sought to ‘reduce’ the harm brought on by the substance with ‘self medication’. The rest, as they say, is history, with those in less enlightened times who became addicted to alcohol held up to ridicule, scorn and disgust; in fact, it was only as short a time ago as the 1950s that alcoholics were classified by the British Government as ‘vagrants’.

One of the most notable and possibly disastrous attempts at harm reduction (although that may not have been its original intention) was attempted back in the 1880s when a German scientist managed to isolate and extract the active ingredient of the coca plant and presented the world with cocaine. It was initially used for the medical purpose of local anaesthetic, the credit for which is attributed to the experiments carried out by William Halstead. Dr Halstead was a co-founder of the John Hopkins Medical School, a man frequently referred to as the ‘Father of American Surgery’.  It was he who in 1884 carried out the first nerve blocking operation using cocaine instead of a general anaesthetic. Dr. Halstead’s enthusiasm for this ‘wonderful substance’ led him to self experimentation with a view to establishing if surgery could be carried out with its use. Unfortunately, these experiments led to his addiction to cocaine - an addiction that was to jeopardise his career and lead him to use morphine as a ‘safer’ alternative, a habit which remained for the rest of his life, but presumably, one that he felt was less harmful.

Conversely, in the same year, Sigmund Freud published his now infamous paper ‘Uber Coca’ (1) extolling the virtues of cocaine as a ‘cure’ for asthma, wasting diseases, syphilis, andalcohol and morphine addiction. Like Halstead, Freud succumbed to the addictive properties of cocaine, but not before he had persuaded a close friend that this ‘elixir’ would cure his morphine addiction. His friend subsequently became the first recorded European cocaine addict.

Neither Halstead nor Freud was alone in promoting the use of cocaine. On the contrary, the medical journals of the day were fulsome in their praise of cocaine as the answer to a variety of problems, with just a few voices of dissent and caution. Needless to say, the use of cocaine became widespread, and there is well documented history of the subsequent epidemic of addiction (2) and explosion in crime (3). The latter was due to the fact whilst at that time it was not a prohibited substance; it was not free. Addicts, both men and women, sold their bodies, robbed, and stole to fund their habit - facts that are conveniently overlooked or forgotten by pro-legislation drug groups. At least they have the courage of their convictions as compared to covert groups who masquerade as drug treatment agencies and tout so called harm reduction techniques for the ostensible and ‘compassionate’ reasons that it will reduce crime, unnecessary suffering, degradation, and deaths. Utopia beckons!

Clarity, rather than confusion

Before proceeding with the pros and cons of harm reduction, it might help to make it clear that whenever and wherever the word addiction or addict appears, it is done so deliberately. Dependency is allegedly the less pejorative and preferred description and isconsidered less stigmatising. It is interesting to note that ‘dependency’ was substituted for addiction after much discussion among members of the American Psychiatric Association (APA) (4), and its use subsequently was voted on by a majority of one. There were no clinical or scientific reasons for this change, nor for that matter is there any now. From those perspectives, the use of ‘dependency’ is hopelessly inaccurate. The change was motivated entirely by the politically correct attitude that it was less pejorative.

 A more realistic approach to changing the perception that addiction is a disease rather than a stigma is to increase, in lay terms, the awareness of the general public and the media of the evidence and facts:

• That addiction is a disease of the brain, body, and spirit.
• That no one sets out to become addicted.
• That anyone who includes in their lifestyle toxic and mind altering drugs, including alcohol, can quite easily develop what is referred to as Substance Abuse Disorder. (SAD) 
• That some are more vulnerable than others.
• That there is a very fine line between SAD and addiction.

Surveys consistently show that the excellent ‘awareness campaigns’ run by the Partnership for a Drug Free America (PDFA) are helping the general public to understand that addiction is a disease and, of equal importance, to accept it as such (5). In addition, treatment agencies around the country report that whenever and wherever these campaigns are run, the numbers making enquiries about treatment services increase dramatically. Thus in seeking to minimise, if not entirely eradicate, through facts rather than semantics that addiction is a disease, PDFA is making a positive contribution to harm reduction. They are not only removing the stigma concept, which not infrequently prevents people from seeking treatment, they are also bringing more into treatment.

SAD is presented in DSM-1V as ‘a condition’. This author suggests that it is more accurately described as ‘a process, leading to dependency’. Dependency is a condition which applies to anyone on any form of medication, inasmuch as they are ‘dependent’ on their medication to alleviate their presenting symptoms. Toxic, mind altering substances, temporarily achieve a similar end for those seeking an altered state of consciousness without effort. The resulting transient, ‘switching off’ effect is discovered to be highly desirable; so, not unnaturally, the process is repeated as a perceived antidote to stress, worry, anxiety, and depression. In many cases it is a process that is indulged in to enhance feelings of euphoria and sexual desires, and so a dependency is formed upon the drug(s) of choice. Addiction, on the other hand, includes the fact that there is loss of control over the use of the drug(s) of choice. A very interesting debate has developed with the American Journal of Psychiatry (6), submitting a very strong argument for reverting back to the correct description in future DSM issues. This author would add that he has yet to meet an alcoholic or addict who did not have an aversion to reality and therefore believes that the use of euphemisms to describe their condition subliminally encourages and facilitates that aversion. For that reason alone, euphemisms are more likely to delay addicts from coming to terms with the reality of their condition and delay seeking treatment, thus hindering their chances of successful recovery. Such euphemisms could be regarded as permitting harm to continue rather than reduce it.

What is harm reduction?

Harm reduction is defined by the British-born, Australian based International Harm Reduction Association (IHRA) as follows (where italics appear, they have been chosen by the author):

Policies and programmes aimed at reducing the adverse health, social and economic consequences of drugs. It can include (a) abstinence or reduction in consumption of drugs; (b) prevention of transmission of HIV diseases among injecting drug users; (c) use of less harmful drugs in place of more damaging ones. Based on evidence from many countries around the world, harm reduction programmes have proven to be effective in preventing HIV infection among injecting drug users. Effective harm reductions are not limited to the provision of sterile injecting equipment but must also include other components such as AIDS awareness raising and education among drug users and their sex partners, provision of barrier methods to prevent sexual transmitted diseases, drug dependence treatment and rehabilitation, treatment of sexually transmitted diseases and other health services: and access to voluntary and confidential counselling and testing. Moreover local communities, including the drug using community itself, must be mobilised and participate fully for such package of measures to work. No single element of this package will be fully effective if practised on its own. Harm reduction programmes do not promote drug use and can be implemented in countries alongside programmes on primary prevention of drug use and demand reduction (7).

The above could be described as entirely holistic and an acknowledgement that there is no cure for addiction, whilst recognising that the majority of those afflicted, notwithstanding the ongoing mental, physical, and spiritual damage they are inflicting on themselves and others, are likely to continue using.  On that understanding it would be hard to reject such an all-encompassing vision if it were adhered to in its entirety, which includes the goal of abstinence and subsequent recovery for those who are addicted and, as the originators point out, not in a ‘pick and mix’ combination.

However, in the UK, in accordance with the politically expedient, convenient, and revised policies and strategies of the National Treatment Association (NTA), the goal of abstinence has been abandoned. In its place there is ‘educating’ of addicts (who by definition have lost control over their consumption) to reduce it.  This policy has permitted the introduction of programmes that not only contradict the spirit of the IHRA definition but seek to fragment the component parts, whilst simultaneously ignoring the wealth of scientific and medical evidence. The research clearly shows that in the cases of addiction, any reduction in use is purely transient and that sooner or later the original pattern of consumption is reinstated. As such, the UK approach is more worthy of being described as ‘harm continuation ’. Running parallel with this travesty, we have NTA funded ‘drug treatment agencies’ promoting with local councils the establishment of Drug Consumption Rooms (DCRs). These have been described by one prominent agency as ‘offering a warm and welcoming environment where clients under medical supervision  can safely ingest drugs.’ By any definition that has to be regarded as facilitating if not actually promoting drug use, a further contravention of the IHRA definition.

Notwithstanding their failure to adhere to the fundamental IHRA concept of harm reduction, NTA claims to advance harm reduction, by their methods, via the following statements:

National and international evidence consistently shows that good-quality drug treatment is highly effective in reducing illegal drug misuse, improving the health of drug misusers, reducing drug-related offending (8).

The above is then reinforced by the following:

Effective, well delivered treatment improves the health and social functioning of individual drug misusers, reduces the risk to public health resulting from the spread of blood-born viruses and improves the safety of community by reducing re-offending amongst drug-misusing offenders. (9)

Note the total absence of any reference to abstinence.

Success for the strategy is claimed on a number of issues, the first of which is the increased number of addicts in treatment. The statistic is a somewhat simplistic measure, unaccompanied as it is by the numbers who are ‘maintained’ on methadone, do not re-offend or indeed any other meaningful statistics, such as numbers discharged drug free (DDF). Nor is there any independent monitoring of sustained reduction in use, all of which would give a clear indication of how either or both the above statements translates into reality. However, the report does include the following claim: ‘Overall drug related crime is reducing as treatment increases.’ That claim is considerably at odds with Home Office statistics, which for the final quarter of 2005 showed an increase of 21% in such offences. Nor, unfortunately, is that alarming increase a blip or one off since increases were also recorded in the previous two quarters of that year, resulting in an overall increase for 2005 at 16% (10).

Written enquires to the NTA by this author, also dated June 2006, about this apparent anomaly together with enquiries as to the ‘favourable effects’ on blood borne diseases, Hepatitis C, and HIV etc. remain unanswered to date.

Anomalies seem to feature strongly in reports of claimed success of the Harm Reduction strategies promoted by the NTA - strategies which they continue to insist are ‘evidence based’. A more recent statistical report issued by the National Drug Treatment Monitoring Service (NDTMS) (11) and publicly claimed in both the national and industry press by Health Minister Caroline Flint and Chief Executive of the NTA, Paul Hayes, as evidence of how successful the strategies are is a case in point.

The NDTMS report highlights 4 primary objectives for the strategies, none of which include abstinence; however, they do include ‘reduction in harm’. There are also secondary goals which include the laudable objective of getting drug users into employment. Unfortunately, there is no explanation of how employers are to be persuaded to employ habitual drug users. Further, there is no explanation of how this tacit sanctioning of continuing illicit drug use can help addicts into employment. Nor, for that matter, are we offered any statistics as to numbers or percentage of clients who have achieved either a sustainable reduction in harm and/or are gainfully employed, or both.

The statistics we are offered and on which claims for success are based are, as might be anticipated, the numbers ‘in treatment’ (apparently these have exceeded targets), the number who have been discharged, and the numbers who have completed 12 weeks treatment and also discharged. We are advised that the latter ‘is the point when sustainable change begins to become achievable’. The nature of these changes are not disclosed nor are we advised if or what ‘sustainable changes’ have actually been achieved, but it seems that they too have exceeded targets.

Apart from those omissions, one would have thought that as the majority of evidence indicates that it is at this time that changes become achievable, there is an increased need for support, in order to avoid relapse. Rather than discharging clients, a work oriented programme of recovery would be beneficial. Notwithstanding their claim to use only ‘evidence based practice’, this somewhat important part is not utilised.

Close perusal of the creative accounting criteria used to establish the numbers in treatment reveals that if someone turns up just once, they are counted as being ‘in treatment’. If nothing more is heard from them during the year in question, they are considered as ‘discharged’ - an interesting use of semantics for those who are normally referred to as ‘drop outs’.

The most significant anomaly from this report comes with the omission of the statistics for the North West of England, a major area which separate research shows contains no less than 8% of all clients in structured drug treatment services in England.  We are informed that the reasons for such an important and substantial number being omitted are ‘that details of drug use are missing for a large portion of clients registered in this region’. We are also informed that ‘where such details have been collected they may be subject to systematic bias’. (Sic.)

In itself the foregoing might be understandable were it not for the fact that in the preceding August a report by researchers at John Moores University of Liverpool (12) appears to take a completely polarised view, inasmuch as the researchers quite categorically stated that their reasons for selecting the area omitted by NDTMS was influenced by the fact that the North West is the only area in England that has consistently collected treatment outcome data between 1996 and 2004/5.

The above study, rather than suggesting that ‘numbers in treatment’ is a measure of success, concludes that increasing such numbers is associated with an increased number of ‘drop outs’, a fact, which together with its realistic phrasing, is omitted from the NDTMS report (presumably because drops outs are classified as ‘discharged’). It also brings into question the validity of using ‘numbers in treatment’ as a legitimate basis for claiming success. A further highly significant statistic in the John Moores study referred to the number DDF, which for the year in question was an abysmal 3.5%. It is apparent that this report offers a far clearer assessment of outcome treatments for the ‘Harm Reduction’ strategies than that published by the NDTMS. Whether that is by accident or design is speculative. What is crystal clear is that ‘Harm Reduction’ drug treatment, Whitehall style, is not working despite the ever increasing amount of taxpayers’ money being invested and notwithstanding facile and disingenuous claims to the contrary.

One can only conclude that the architects of this particular corruption of the IRHA definition of Harm Reduction are not familiar with Einstein’s definition of insanity, but they appear to have a strong familiarity with ‘Alice in Wonderland’s ‘what I tell you three times is true’. Nor for that matter have they encountered the works of William James, psychologist and philosopher (1842-1910) who said: ‘Truth may be defined as ‘that which is ultimately satisfying to believe’.

The author was so incensed by the widely publicised misleading claims made for the ‘success’ of the current strategies and the sanitised NDTMS report that he was moved to put his concerns in writing, wherein he concluded that had the NDTMS published the numbers DDF and included ‘drop outs’, the result would have been more a more realistic but politically unacceptable report. Whilst some satisfaction came from having these concerns and comments subsequently published in the ‘Featured Spot’ in the comments section of the UK publication Drink and Drug News (13),  the NTA, NDTMS, and the DoH have not sought to challenge his comments or conclusions, nor those of John Moores research.

The insistence on continued use of strategies that are clearly not working is all the more disturbing when Home Office statistics show that a high percentage of those on Drug Treatment Orders (DTOs) continue to re-offend. Year on year, these appear to be increasing rather than decreasing, with the latest figures at a staggering 92%. In a further attempt to obtain an explanation of  how, with all the claimed success of the strategies employed, this deplorable situation has come about, this author wrote an open letter to DDN (14), pointing out the tremendous discrepancies between such claims and raised a number of rigorous questions regarding the efficacy of the interventions being used. Given the obsession of the NTA with box ticking forms that indicate the achieving (or otherwise) of seemingly meaningless targets, this author also asked why the important and relevant objective of reducing the harm caused by re-offending did not appear to have a corresponding target. The question was also raised of why the universally preferred, abstinence-focused treatment for those who had been diagnosed as clinically ‘dependent’ was not being used.

To date there has been no direct response from the relevant parties. There was, however, a joint response from two prominent academics (15) who informed this author that using what they referred to as ‘reconviction rates’ is a ‘crude measure’ to judge the effectiveness of the treatment strategies since it failed to take into consideration ‘the characteristics of offenders’. They further pointed out that neither did this ‘crude measure’ take into consideration ‘the reductions in the frequency of offending’. They also kindly pointed to their own research wherein they found ‘considerable reduction in the frequency of offending for those on DTOs’. No doubt, with the assurance that they will be robbed less frequently, the latter fact will come as a welcome relief to victims of drug related crime. Seemingly, this miraculous advance is due to the quality and type of treatment employed and therefore has nothing at all to do with the fact that street prices in Europe of the most popular drugs are at their lowest levels ever, thereby reducing the number of occasions addicts have to go to ‘work’ in order to continue feeding their habit.

The respondents went on to point out that there is no reason to suppose that abstinence would lead to a reduction in reoffending, whilst choosing to ignore the strong probability that those who are abstinent and in recovery are less likely to reoffend than those who are still using.

On a more positive note, there can be no denying the advances that have been made in both scientific and pharmacotherapy approaches to harm reduction. The scientific approach continues to seek for the definitive gene that predisposes some to addiction, presumably with a view to find the ‘magic bullet’ that will neutralise it. Other scientific research has shown how the brains of addicts are ‘different’, together with the actual changes that take place in the brain with the onset of addiction. It is to be hoped that this dedicated work will eventually provide us with a solution.

The drug manufacturing industry has produced a variety of drugs which, to all intents and purposes, alleviate the cravings of addicts. Apart from the fact that the long term effects of the most recent drugs are yet to emerge, it is questionable whether or not any of these drugs will satisfy the psychological and emotional cravings of addicts for the experience of the high or the oblivion that many addicts consciously or unconsciously seek. In the interim Carl Jung’s prescient comments are worth recalling:

Science has no answer to this problem, psychotherapy alone is useless, what is required is a spiritual experience (16).

The terms ‘spiritual experience’ and ‘spiritual awakening’ are referred to in the simple programme of recovery offered by 12 step fellowships which millions of men and women of differing cultures, nationalities, and beliefs throughout the world, whether they be Christian, Muslim, Hindu, Buddhist, agnostic, or atheists, have found to be a lasting solution to their problem. It is defined as a personality change sufficient to bring about recovery from addiction: a change that appears to have different and varying manifestations. Many of the experiences appear to be educational rather than religious, inasmuch as they occur or develop, sometimes slowly, over a non-specific period of time. What is apparent from observation of those who have found this ultimate to be the ultimate form of harm reduction is a sweeping and far-reaching alteration in their reaction to life and the problems of living, which in turn permits them to live a healthy, productive, and satisfying life, alcohol and drug free.

The 12 step programmes appear to have borrowed extensively from medicine, psychiatry, and religion. It is also noted that the steps are based on the collective experiences of the first 100 sober members of Alcoholics Anonymous (AA). 12 step fellowships have been the subject of praise and criticism. On balance, the overall picture is favourable. However, researchers who have concluded that addicts who attend meetings regularly, together with appropriate interventions for those with co-morbidity issues, have a greater chance of a lasting recovery than those who do not and confess to being unable to identify any ‘scientific’ reasons for their undoubted success. This author, who has made a close perusal of the 12 steps, noted that unlike most programmes, it has no dates or specified period of time in which the programme is to be completed, thus members are free to choose when or to what extent they engage with the individual steps. Readers who are familiar with the transtheoretical model of behaviour change (17) will be aware that the framework and the progression through each stage, likewise, have no time limitations imposed.

Also of interest is the fact that the processes that members undergo as they progress through the steps bear a remarkable similarity to those found in the various stages of the transtheoretical model; therefore, each of the steps is not only compatible with the model, which also has withstood considerable critical examination, it fits very elegantly into it. This author has found that correlation to be of considerable help in bringing about change in many of his clients, among whom are a considerable number of alcoholics and addicts who had been judged by others as ‘not ready’. Somehow, they appear to have ‘become ready’ through what could be described as the most effective form of harm reduction.

Conclusions

This author is of the opinion that what is ‘passed off’ as harm reduction in the UK is, in reality, a process that facilitates the continued use of toxic, psychoactive drugs. Whether or not that is the intention is open to speculation. What is indisputable is the fact that it is simply not working insofar as the rehabilitation and recovery of addicts and alcoholics are concerned – an outcome which includes relinquishing criminal activities, living in a safe and stable environment, and, in the fullness of time through gainful employment, becoming a self supporting member of society. Further, the architects of this disaster persist in hiding their failure by the time consuming and expensive process of producing sanitised statistics (which do not in anyway aid recovery but do enable politicians to claim success in achieving meaningless targets), meaning that the scourge of addiction currently damaging our society is likely to escalate.

© Peter O’Loughlin.  January 2007.The Eden Lodge Practice, Beckenham. BR3 3AT. UK.

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