On the false dichotomy between harm reduction and abstinence
A report from the wild world of academic medicine
It’s conference season, and I’ve been traveling and presenting recently, which is enlivening and motivating while also being a bit of a slog. I thought I’d check in with some reflections from behind the scenes, so to speak. Drug policy, crime and punishment, urban policies—these are all hot topics these days, and I’ve come across some nice scholarship and clear thinking that I hope can be helpful for getting past superficial divisions.
A few weeks ago, I flew into Dallas-Fort Worth for the American Society of Addiction Medicine. This, as I’ve plugged in my interview of Brian Hurley, is a very good conference, especially by virtue of being refreshingly interdisciplinary, with nurses, doctors, counselors, psychologists, harm reduction activists, and more coming from a variety of practice backgrounds and settings. It is the kind of conference that makes it entirely worth it to haul oneself to a convention center hotel. There was an enormous, glassed-in, aggressively air-conditioned atrium, topped by the Lone Star. It wound up being a nice place to chat with colleagues.
Because of the diversity of viewpoints, and the clear and present stakes of the crisis, there is useful friction at ASAM between people who meaningfully disagree on important issues. There is also, however, useless friction as well. One issue that comes up commonly at ASAM, and which is reflective of the field at large, is the false dichotomy of “abstinence vs harm reduction.”
Allow me the latitude to assume you get at least the outlines of this issue. You already understand, I think, that this is a long-running (pseudo-)debate. Yes, “abstinence” means total cessation of substance use and “harm reduction” implies acceptance of continued use at some level. But please don’t let this imply that they are somehow mutually exclusive approaches. I think it’s useful to reflect on why that is the case. Even if you already believe that this is a false dichotomy, clearly, we need to think hard about how to get the message across effectively.
I’ve been thinking about this because of a very good, brief presentation by Dr. Elizabeth Salisbury-Afshar, a physician, policy expert, and currently associate professor at U Wisconsin. This is an important message that many folks have tried to articulate in a variety of ways. Nevertheless, I found her presentation quite clear in a refreshing way.
Imagine harm reduction as a continuum. There is a broad array of strategies that can be used to try to mitigate the negative consequences of substance use. Abstinence is on that continuum!
Abstinence is a harm reduction strategy. It is the ultimate harm reduction strategy, in a way, and one that I use myself.
But the other strategies exist along an interconnected continuum. If anything, the figure makes it look like those categories are too isolated, but in fact they are interconnected dimensions that individuals might move through at different points in their lives, and also that institutions might present in various ways, dynamically, to different people. People take different pathways to resolving substance problems, and people often take progressive steps along the way. Making attempts with one strategy might provide some feedback and knowledge that helps to get to the next stage.
This is a complicated issue. Harm reduction exists, in various forms, across the individual, clinical, social, community, and legal domains, just to name a few. SAMHSA’s (The Substance Abuse and Mental Health Services Administration) “Harm Reduction Framework,” which Salisbury-Afshar is drawing upon, conceptualizes harm reduction as a set of services, an approach, and a type of organization, all at once. There are six pillars, 12 principles, and six core practice areas. This is a necessary level of complexity for a serious and multifaceted topic. But it is complex!
Belying that complexity, people use the words “abstinence” and “harm reduction” as shorthand for a whole mess of strategies, approaches, and organizing philosophies, all jumbled together. This is where we get into trouble. The result is equivocation and talking past one another. E.g., people annoyed about the perceived permissiveness of a given city policy about, say, public drug use and disorder, gripe about “harm reduction.” People chafing under one-size-fits-all abstinence-only policies in treatment centers gripe about “abstinence.” These are different issues, in very different social domains (public policy and law, vs. medical treatment). The words don’t refer to monolithic concepts or approaches, but they are often treated as if they are warring camps, like political parties.
If you want to see how recovery and harm reduction are not in opposition, just look to people who are supportive of (or in!) long-term, abstinence-based recovery, who are also supportive of (or doing!) harm reduction. There are plenty of people like this. One great example is Jason Schwartz, who runs a (non-Substack) blog called Recovery Review. In a series of posts, he’s written about “recovery-oriented harm reduction.” (The big quote on the sidebar of his blog is “It’s important to meet people where they’re at, but not leave them where they’re at,” which I quite like.) His whole 3-part series is worth reading in full. Among several good points, he emphasizes how substance use problems are not the same thing as addiction, and he argues that recovery and harm reduction should remain different constructs.
What’s really going on here when people bicker, in superficial ways, about abstinence versus harm reduction? It makes me think of Jonathan Haidt’s “moral foundations theory.” Haidt argues that we are “groupish” by nature and tend to assort ourselves into different collectives that prioritize different moral foundations, which then separate from one another by vicious divisions. Particularly relevant to this topic, liberals tend to emphasize “care” (caring for others and preventing harm) as well as “liberty” (individual freedom and autonomy), whereas conservatives tend to value “loyalty,” “authority,” and “sanctity” (i.e., vs “degredation”). This theory has been critiqued extensively, I hasten to say, but for our purposes it provides a useful rough approximation of the core issues. If “harm reduction” and “abstinence” simply become proxies for these rough and sweeping moral values—care vs authority, say—and thus proxies for a bigger culture war, we are losing sight of the actual issues at stake that are specific to addiction and recovery.
It doesn’t have to be that way. We can transcend the supposed dichotomy. Please don’t let these imperfect words/categories/labels—“abstinence” and “harm reduction”— become crude proxies for a bigger culture war. The starting point is to see the many responses to drug harms as an interconnected spectrum, and to look for the complexity and connections rather than differences.
This is not separate from the individual work of flourishing, by the way. Hatred, delusion, and division are not great for flourishing. It takes some work, but resisting false dichotomies and unnecessary divisions is part of the emotional work of staying engaged in this issues and being a person in the world in 2024.
I didn’t like that Dallas hotel at first. I wound up finding the good in it. This is, at once, a genuine report of good recent experiences, a plea to the conference gods that it continues to be so, and an active practice of looking for connection rather than division. I really believe this is possible.
Thanks for being here. More soon. I have new podcast episodes in the work and other posts to publish coming up shortly. In the meantime, keep in touch. I always love to hear from you folks.
Part of the problem I have with the abstinence talk is that it often seems to presuppose that abstinence itself is a good in its own right rather than being a tool that can help people lead a good life -- no different in kind than medication assisted treatment or spirituality -- something that can benefit some people but isn't a goal in itself or necessarily the best means for everyone.
And yes, if all you mean is the idea that some people would be better off doing no drugs of a given kind than sure it's not incompatible with anything but that's just not what people are reacting to when they push back on the abstinence approach. Yes, we need to avoid just falling into affiliative groups and should try to speak preciscely but at the same time that doesn't mean we should ignore the fact that often when people speak about abstinence or harm reduction they are importing a broader background value system.
I mean, think of it by analogy to politics. Yes, I don't like the way politics has become all affiliative and vibe rather than policy based. But at the same time, you shouldn't ignore the fact that you do understand that a certain kind of rhetoric does predict that a politician is likely to behave in ways you don't like.
When confronted with a less than wonderful hotel, one can take an abstinence approach of checking out, but, as your post implies, there are softer, gentler ways of reducing harm: cognitively reframing the experience to focus on the good, lowering expectations, deciding to take a bath rather than braving the jacuzzi, etc. In all areas of life, we´re constantly navigating the abstinence/harm reduction continuum and there´s no one right answer for every question. I´m grateful for the range of harm reduction options, cause otherwise my partner would of long ago divorced me.