Death by Degrees?

“Harm reduction” has been defined myriad ways.

The “Godfather of Harm Reduction,” Dan Bigg, referred to it as “the principle of reducing the negative consequences associated with drug use.” The organization he co-founded, the Chicago Recovery Alliance (CRA), uses the phrase “any positive change.” (https://www.thechicagoschool.edu/insight/news/any-positive-change/)

The National Harm Reduction Coalition says that “harm reduction is a set of practical strategies (philosophy and ideas) aimed at reducing negative consequences associated with drug use.”

And all this sounds nice on paper, until you start parsing the words.

First, what does it mean to “reduce the negative consequences associated with drug use”? If we provide clean needles to reduce the spread of HIV and hepatitis, we certainly reduced the negative consequences. But are we really reducing negative consequences if someone switches from heroin to cocaine? Heroin to alcohol? Cocaine to amphetamines? Methamphetamines to cocaine? Really, isn’t the bar quite low when we start considering the negative consequences that are supposedly being reduced?

Plus, what does “positive” mean? According to the American Heritage Dictionary, “positive” as an adjective means, in part: “Measured or moving forward or in a direction of increase or progress.” That means that reducing use is “positive” in the loosest sense of the word. If my drug of choice is alcohol and I’m going from a pint of vodka a day to a half pint a day, that’s progress…I guess. But when you consider the damage that a half pint of vodka each day can do to a body, how positive is that change? Is dying more slowly positive?

Enter cannabis. If alcohol is my drug of choice but now I’m using cannabis instead, the damage to my body is reduced, and that is positive. That’s progress…at least for my liver. But what about the effects of being addicted? I’m still suffering from addiction; my loved ones, my employer, my community are still negatively affected by my addiction. If I’m only using cannabis now, I’m not going to die from alcohol poisoning or liver damage, but the “progress” is LIMITED while I’m actively using substances.

I’ll attest that IS still progress – like changing seats on the Titanic. But what makes anyone think I’m not going back to my original seat? I contend that cannabis is a gateway drug, not necessarily from cannabis to harder drugs for the casual user but from harder drugs to cannabis and BACK to harder drugs for those who suffer from addiction. Addiction is a brain disease, but the addicted brain prefers a certain substance. Drinking to stay away from heroin is only one shot away from heroin. Smoking weed to stay away from alcohol is only one toke away from a shot. And on and on. No one is addicted to a certain substance because addiction doesn’t occur in a silo, so staying away from that substance while using others may be considered “harm reduction,” but is it really?

And what about NARCAN? While I fully accept that saving a person’s life is a good thing, this isn’t really a “change,” as in “any positive change.” NARCAN isn’t “harm reduction” any more than a defibrillator is harm reduction for those suffering from heart disease; it’s “death reduction.” And, while death reduction is a good thing, in and of itself it doesn’t reduce harm at all. It can and does, in some cases, prolong harm. That’s not to say we shouldn’t make NARCAN available; it is to say that we really have to know what “harm reduction” means.

The National Harm Reduction Coalition prescribes eight foundational principles, which you can find here: https://harmreduction.org/about-us/principles-of-harm-reduction/

Principle #8 is that harm reduction “does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with ILLICIT drug use.” (Emphasis is mine.) Does this mean that harm reduction is only for those using illicit drugs? Here’s more parsing: remember that licit drug use – that is, alcohol use – kills more people in the USA every single year than illicit drug use does. Have we simply decided that those whose drug of choice is alcohol don’t merit “harm reduction”?

The bottom line is that, as a theory, “harm reduction” is great. It’s said to reduce deaths, meet people where they are, and encourage recovery. As a real solution to the disease of addiction, however, it requires more definition and the realization from everyone espousing it that “harm reduction” still encounters harm.

In 2003, the first edition of Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol by Patt Denning, Jeannie Little, and Adina Glickman addressed “a powerful alternative to traditional treatment that helps users set and meet their own goals for gaining control over drinking and drugs.” Prior to that, in 2000, Denning and Little created the Harm Reduction Therapy Center, based on their work with gay men in San Francisco in the 1980s, “ground zero for HIV/AIDS before we had effective treatments.” They developed programming for those who “need more than simple ‘just say no’ advice and programs that require you to commit to the goal of abstinence before you’ve even explored the problem. Firmly rooted in the values of self-determination, we meet each person where they are, we accept them wholeheartedly for who they are, and we empower people to define their own problems and discover their own goals.“ (https://harmreductiontherapy.org/about/)

More parsing.

First, the “just say no” campaign had absolutely nothing to do with serving those with substance use disorders. It was a campaign targeted to youth to give them tools to say no to TRYING drugs. Let’s quit pretending we believe it was developed as an answer to those suffering from addiction, as though anyone in the world believed they would wake up one morning and “just say no.”

Next, committing to abstinence before “you’ve even explored the problem” is much easier than it first appears. Follow the Marty Mann test for addiction. That is, “The Test: … For the next six months at least decide that you will stick to a certain number of drinks [uses] a day, that number to be not less than one and not more than three.” If a person can pass the test, abstinence is not a necessity. However, if a person fails this test, the problem has been fully explored and diagnosed by the one person who needs to diagnosis it: the person suffering from addiction. Read more about it here: https://the4csofaddiction.wordpress.com/2023/01/03/the-marty-mann-test-for-alcoholism/.

And, finally, regarding self-determination: if we believe that addiction is the disease we say it is, self-determination doesn’t make that disease go away. Let’s consider any other chronic, progressive, lethal disease, such as cancer or diabetes. Meeting people where they are, accepting them for who they are, and empowering them “to define their own problems and discover their own goals” cannot be done in a vacuum. Recognizing that they suffer from a deadly disease is imperative to getting them better. They can certainly choose not to address that disease or to address that disease only a little, and they should undeniably be treated with unconditional positive regard, as should every person we come across, but acting as though we don’t see the chronic, progressive, lethal diseases they are suffering from isn’t helping anyone, especially not those who are dying.

Yes, let’s absolutely keep more people alive as they struggle with their diseases, but, as the Coalition’s eighth principle states, let’s stop “minimizing and ignoring the real and tragic harm and danger associated” with the chronic, progressive, lethal brain disease of addiction – to illicit and licit drugs.