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Dr. David Fawcett

What is Harm Reduction?

Harm reduction incorporates both principles and strategies that are designed to reduce the risk inherent in the use of substances or other behaviors, including financial, legal, emotional, and physical health consequences. A variety of strategies are employed, including techniques to make use safer, to help people better manage their use, and to mitigate potential harm from the circumstances of using itself (such as tainted drugs or used paraphernalia). Harm reduction recognizes that the use of substances and behaviors is a complex phenomenon and that different approaches are useful depending on the individual.

Harm reduction also includes important principles about persons who use drugs or mood-altering behaviors, primarily meeting people “where they are at.” For example, some individuals may not think they have a problem at all, while others might want to continue their use while making it safer. Someone else might recognize they have the beginning of a problem but would prefer to cut back or better manage their overall use. Harm reduction proposes that such behavior is complex and that the quality of life for individuals and communities may be more important than abstinence.

Finally, harm reduction employs an attitude of non-judgment about such behaviors and the people who engage in them. This is important because compulsive activity – whether involving substances and/or behaviors – is highly stigmatized, and this gets in the way of many people seeking help for themselves or loved ones.

Most treatment professionals are accustomed to working with people for whom the use of drugs or high-risk behaviors has become highly problematic, that is, people for whom simply cutting back or trying to impose control is no longer an option because their behaviors have become addictive. This is not a moral judgment but a diagnosis based on specific behavioral criteria. While some view the term “addiction” as stigmatizing and harmful in itself, I believe it is important to recognize that problematic use of drugs or behaviors for some individuals can cross a line beyond which attempts to mitigate or control use will be futile. In such cases, abstinence is required.

That said, it is also important to recognize that many if not most people who engage in drug use, porn use, or even casual hookups are not addicted. For them, demanding abstinence without a more thorough assessment of their behavior will likely result in them turning away from any help at all.

What Are Some Harm Reduction Strategies?

Harm reduction strategies for substances include any number of methods to reduce risk and potential harm. These could include asking someone to purchase a lower quantity of drugs or alcohol in order to ultimately use less. Many people who act out compulsively will keep using until they run through their supply. Similarly, one might set a time limit to stop use after a period of time, although the rush of dopamine involved in intensity addictions like amphetamines, sex, and pornography makes interrupting the behavior much more difficult. Other methods include choosing the least harmful mode of ingestion or having some drug-free days or weeks. Finally, numerous studies show that needle exchange programs not only reduce drug-involved harm, they significantly limit the transmission of HIV, Hep C, and other blood-born concerns.

Harm reduction for behavioral disorders can be useful as well. Someone viewing excessive pornography, for example, might benefit from increased awareness about their patterns of use. Instead of just trying to totally stop, asking someone to track their online activity could be helpful, noting time spent, feelings before and afterward, and other observations. There are even built-in settings on most devices that can give us instant updates on how much screen time was spent on any given app. Such information can be a useful reality check, since many individuals who are spending time in the “bubble” of porn or other forms of online stimulation lose track of time.

Other harm reduction techniques for sex include something as simple as carrying condoms or, for anyone at risk for HIV exposure, taking PrEP (Pre-exposure prophylaxis medication). Someone who is trying to break a habit of one-night stands might want to implement a dating plan in which they meet someone first for coffee and, through a series of meetings, progressively move toward physical intimacy. Harm reduction principles can even be applied if someone has a lapse or slip. By far the most benefit from such an unfortunate event comes with a non-judgmental review of what happened so that other, more proactive steps can be taken to avoid a repeat occurrence in the future.

Are Harm Reduction and Abstinence-Based Recovery Compatible?

In my mind, harm reduction and abstinence-based recovery are certainly compatible. It is a mistake to think of harm reduction and abstinence as black-and-white opposites. For example, I believe that simply going to a 12-step meeting is, in effect, an act of harm reduction. Having worked for many years with individuals who combined powerful amphetamines, such as meth, with sex, I choose to combine harm reduction and abstinence. I understand that relapse can be almost inevitable in the process of recovering from meth. When such a relapse occurs, it provides useful information about underlying patterns of triggers and cravings and the opportunity to practice new skills. Essentially, we are practicing harm reduction on the way to a client-identified goal of abstinence.

Discerning Next Steps

Meeting people where they are at is a basic principle of good clinical practice. Many people truly question whether their behavior has reached a point that abstinence is the only solution. If someone seeking information or assistance is told that the only option is abstinence, there is a high probability that they will turn around and leave, not getting any assistance at all. The tension arises, of course, when someone whose behavior has actually progressed beyond any semblance of “casual” into “problematic” or addicted. If this person is in denial about the reality of their situation, they are likely to fight any intervention, especially suggestions of abstinence. In such cases, challenging and working through that denial is essential to help the individual come to terms with their behavior. As that occurs, harm reduction approaches can be helpful.

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