Abstinence and harm reduction

Two sides of the same coin

Drug users come from all walks of life, and all have different stories and different journeys. Similarly their aspirations and the way in which they are going to achieve them vary. But pretty nearly all, at some time, want abstinence.

After the initial honeymoon period, most drug users want abstinence almost every day of their using careers – certainly 57% of drug users accessing treatment services for the first time said that abstinence was the only change that they hoped for against 15% opting for harm reduction.

The problem of course is that only about 5% of heroin dependant patients each year achieve durable abstinence.

For those who attempt abstinence but then relapse, there is the sense of shame and failure which can provoke even more drug use, and the very real risk of loss of tolerance leading to overdose.

So why is it so difficult to achieve, and once achieved, why is abstinence so difficult to sustain? Many people who have never  experienced addiction ask these questions, and faced with the awful consequences of a roaring drug dependency (which we all know and which I will not therefore repeat) it does seem perverse that someone would go through the uncomfortable business of a detox, and then “fecklessly” relapse.

So it may be worth considering the reasons behind this apparent paradox. I would begin by patronisingly suggesting that most drug users don’t actually want the full consequence of abstinence; what they want is an end to the

  • chaos
  • the daily worry and reality of feeling sick,
  • being pursued by debt collectors,
  • the police,
  • the chronic pain and
  • unhappiness of lost relationships,
  • children taken into care and so forth,
  • the daily obsession with needing first the money and then the drug,

just to feel normal – abstinence is seen in only one half of its reality – the riddance of all that is wrong with drug use. But of course abstinence has two halves, it also demands the riddance of all that is right with drug use.

Drug users are very good at what they do – for most of their adult lives (and often longer) they have become skilled in resourcing their habit by whatever means – they are socially bonded to a peer group or partners who are usually also drug using.

All that they have known for years has drug use at its core. And drugs of course also feel good – if they didn’t, we wouldn’t have the problem.

“Heroin is a sensory deprivation tank for the soul where there is no sense of pain, no regret or shame, no feelings of grief or guilt, no depression and no desire. Insensible stillness and peace disperse fear and suffering.”

Many of our patients are carrying around a burden of pain from early life traumas, and indeed from the consequences of their drug using – how tempting it must be to slip back into that state which Pink Floyd so succinctly described as “comfortably numb”.

The consequences of full-on drug using are indeed horrible, they soon drive the merits of drug use into the distant memory.

But the consequences of abstinence soon resurrect those memories, leading to the inevitable question: “Wouldn’t it be nice if I could just use occasionally? Just get all the merits, without a dependency.”

In a way, this what a methadone script offers. Daily methadone keeps the chaos of full-on heroin dependency at bay, but still allows (assuming the modern nonpunitive treatment model) occasional use with relative impunity.

So apparently the harm reduction model affords a safe haven both from the chaos, and from which the patient can occasionally indulge his habit without most of the negative consequences.

We all recognise the enormous gains in reduction of morbidity and mortality which good harm reduction programmes have delivered, and must put an end to the pathetic Jurassic arguments that seek to polarise the abstinence versus harm reduction phoney war.

Abstinence without the safety net of harm reduction when someone falls off the wagon is dangerous. But equally Harm Reduction must entertain the realistic hope that one day, abstinence can be achieved.

Because methadone programmes are not perfect. Many studies have seen substantial reductions in drug use accompanied by worrying increases of alcohol consumption.

Poly drug use is now far more common than single drug use, and methadone alone is often not enough in complex cases.

And I suspect that the majority of those in harm reduction programmes, whether they are using occasionally or not, will sooner or later prefer to not be dependant upon a drug (be it a safer prescribed pharmaceutical or not), a doctor, a pharmacist and a drug service. They would like to lead what they perceive as “normal” lives, and have their independence back.

Abstinence philosophy and the 12 steps
Earlier I referred to patients ultimately seeking independence from drugs and drug services. We often hear them say “I just want my life back”.

There is nothing wrong with being dependant on methadone, purely in the narrow sense of dependency: diabetics are dependant of insulin medication, but they too would rather not be. It is inconvenient, its availability is a permanent source of concern, and travel arrangements can be awkward.

But for insulin diabetics, there is no choice – for the drug or alcohol addicted, there is a choice. And every day that they have not returned to abstinence is almost a choice to be dependent.

That can be a hard to accept – that one would choose to stay dependant. Even for the veteran who has detoxed on a number of occasions, who has moved past denial to taking full responsibility for the consequence of his drug using but just cannot stomach the constant fight to maintain abstinence, to admit to yourself that you just can’t do it is a very uncomfortable admission.

There is that self-efficacy in all of us that needs to be free and independent; “If you are not master of your own destiny, some other bugger is”.

Abstinence is therefore a seismic shift in personal philosophy – it is a symbolic reversal of dependency on drugs and a self-serving life where that dependency and need is at the centre of all relationships, to independence.

And the realisation of that independence demands the acceptance of responsibility for everything in your life, and bestows the freedom to appreciate it. It also demands, for most people, the acceptance that you will never be able to regain control.

This is what is referred to in 12 Step programmes (e.g., or as otherwise called, Narcotics Anonymous, Cocaine Anonymous, Alcohol Anonymous) as “the acceptance of powerlessness”. Paradoxically, there is something fundamentally liberating in the acceptance of powerlessness – for it means that you never have to struggle with control again. You just don’t try.

Many heavy drinkers are content to agree that their drinking is adversely affecting their lives in some way, and that they have difficulty with control – most are content to be described as “problem drinkers”, but because they can go for a few days without a drink, or don’t drink first thing in the morning, or whatever other prejudice they have, they are therefore not “alcoholics”.

Most have friends who drink as much or more than they do, and are apparently well, and it is that which validates their continued drinking.

Most therefore would like to reduce their drinking because they know it is harming them, but they just can’t – it is the continued argument with “not being a real alcoholic” that enables the drinking to continue.

They cannot visit their heavy drinking friends and say “Don’t give me a drink because I am drinking a little bit too much”.

But once you cross the Rubicon and define yourself as an Alcoholic, someone who is powerless to maintain control, that definition empowers you to deny alcohol consumption.

This concept of the powerless addict is central to the 12 Step philosophy. Once accepted, it is a lifetime status – it is a status that defines the person. It doesn’t have to, and indeed should not permeate every corner of a person’s life, but it is of central relevance wherever mind affecting and addictive substances and your life might meet.

And it begins to take on a spiritual dimension as well – not necessarily a religious dimension, although for many in the Fellowships (Narcotics Anonymous, Cocaine Anonymous, Alcoholics Anonymous etc) religion is important.

But belief is extremely powerful: it does not have to justify itself, it just is. Belief, as they say, moves mountains, and if you accept that you are powerless over something, then a belief that something else can restore you to sanity is extremely powerful.

The 12 Steps are a belief system – they demand belief in the concepts in the Big Book, and that adherence to the Steps and fellowship will keep you sober.

This arbitrary belief system is very difficult for many to accept – indeed it is often very off putting to those early contacts with 12 Step groups.

But even the most secular of us have beliefs when it comes to politics, natural law, philosophy or whatever – to adopt a new belief system that offers a way out of the curse of dependency should not be beyond any of us.

12 Step attendance has been subject to many studies, although for obvious reasons it does not lend itself to scientifically rigorous analysis. But it is evident that it is as powerful in maintaining abstinence as any other modality, be it drug, CBT or whatever. And 12 Step groups are available the world over, free of charge.

Source; Morse, Gordon. NETWORK A national newsletter on substance misuse management in primary care. 16 Dec, 2006.

Part two

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