In the substance use disorder field, harm reduction aims to minimize the negative consequences of using mood altering chemicals without requiring their cessation. Harm reduction has evolved as a key strategy in public health, particularly in areas like, sexual health, and environmental impact. Advocates tout it as a compassionate and rational approach to societal challenges. Critics have raised concerns about its limitations, unintended consequences, ethical dilemmas and mixed messages. This article explores harm reduction, examining its assumptions, and challenges its application for the real alcoholic.
The War on Drugs and Harm Reduction
(1) The term "war on drugs" was popularized by the media after a press conference, given on June 17, 1971, during which President Richard Nixon declared drug abuse "public enemy number one". He stated, "In order to fight and defeat this enemy, it is necessary to wage a new, all-out offensive…” Earlier that day, Nixon had presented a special message to Congress on "Drug Abuse Prevention and Control", which included a call for devoting more federal resources to the "prevention of new addicts, and the rehabilitation of those who are addicted." Unfortunately, that message did not receive the same media attention as the term "war on drugs.”
Thus began the push to punish pushers and users. Harsh penalties were enacted for use and distribution of drugs. Congress and the courts jumped on this proverbial bandwagon. It was as if we had convinced ourselves that the way out of the addiction problem was through criminal prosecution. Even though we had a failed legislative solution to alcoholism through the enactment of the eighteenth amendment (prohibition), we still were convinced that criminalization of addiction was the solution.
Harm reduction emerged as a response to the failed application of punitive policies to effectively address addiction. Instead, the harm reduction movement focused on mitigating risks by providing safer alternatives or reducing exposure to harm. Examples of harm reduction initiatives include needle exchange programs for drug users, “wet houses” for chronic alcoholics, and e-cigarettes as alternatives to traditional smoking.
At its core, harm reduction purports to “meet people where they are.” Harm reduction philosophy believes that individuals may not be willing or able to stop certain destructive behaviors. Harm reduction practitioners enact practices and policies that minimize risks to the individual and others. This philosophy prioritizes health and safety over the cessation of the problematic behavior.
The Harm of Harm Reduction
Normalization of Risky Behaviors
Imagine going into your doctor and hearing them say, “You have lung cancer. You should cut down on your smoking.” Or, “You have cirrhosis of the liver due to a lifetime of drinking. You should cut back on your use of alcohol.” Or, “There’s lead in your water, you should only drink 6-8 glasses a day.” No, any good, self-respecting, AMA certified doctor would say to their patient, “You need to cease and desist with this behavior immediately, or it will kill you.”
A problem with harm reduction is it normalizes life threatening or risky behaviors. By providing alternatives that are perceived as safer, individuals feel less urgency to cease harmful practices. For those who are addicted, the harm reduction practitioner is unwittingly sugar coating the truth about the seriousness of the disease. The harm reduction specialist unintentionally communicates that the behavior is OK or nonproblematic.
While harm reduction aims to decrease immediate risks, it can sometimes lead to secondary consequences. For example, safety measures in cars, such as seat belts, have been associated with riskier driving behaviors, a phenomenon known as risk compensation. In other words, since the person has a perceived backstop or safety valve, they engage in the problematic behavior more frequently and with increased intensity.
People in the harm reduction community argue that they are only meeting the person “where they are at – without judgement.” This may be true, but if they are not sharing important medical information with the person as to the extent and severity of their disease, the harm reduction specialist is walking into a serious ethical conundrum.
What About the Real Alcoholic?
On page 21, of the book Alcoholics Anonymous, the author talks about the “real alcoholic.” He writes, “… the real alcoholic? He may start off as a moderate drinker; he may or may not become a continuous hard drinker; but at some stage of his drinking career he begins to lose all control of his liquor consumption, once he starts to drink.” What would the harm reduction model offer this person?
There is an old adage in the rooms of AA that says, “Once an alcoholic, always an alcoholic.” Oldtimers will often quip, “Once a pickle, never a cucumber.” This philosophy is reflected on AA’s website (aa.org) where we find, (3) “So far as can be determined, no one who has become an alcoholic has ever ceased to be an alcoholic. The mere fact of abstaining from alcohol for months or even years has never qualified an alcoholic to drink “normally” or socially.”
The website goes on to say, “Once the individual has crossed the borderline from heavy drinking to irresponsible alcoholic drinking, there seems to be no retreat. Few alcoholics deliberately try to drink themselves into trouble, but trouble seems to be the inevitable consequence of an alcoholic’s drinking. After quitting for a period, the alcoholic may feel it is safe to try a few beers or a few glasses of wine. This can mislead the person into drinking only with meals. But it is not too long before the alcoholic is back in the old pattern of too-heavy drinking — in spite of all efforts to set limits for only moderate, social drinking. The answer, based on A.A. experience, is that if you are an alcoholic, you will never be able to control your drinking for any length of time.”
Early in AA’s history they developed a test for harm reduction to determine if someone was a real alcoholic. The test can be found on pages 31-32 of the book “Alcoholics Anonymous.” There we find, “We do not like to pronounce any individual as alcoholic, but you can quickly diagnose yourself. Step over to the nearest barroom and try some controlled drinking. Try to drink and stop abruptly. Try it more than once. It will not take long for you to decide, if you are honest with yourself about it. It may be worth a bad case of jitters if you get a full knowledge of your condition.”
Given AA’s 90 year history of helping alcoholics recover from a “seemingly hopeless state of mind and body”, it would seem professionally irresponsible to say to a “real alcoholic”, “Let’s try the harm reduction model with your drinking problem.” It would be the biological equivalent of trying to turn the pickle back into a cucumber. Don’t we owe it to our patients, clients, and peers to be honest with them about their condition?
Conclusion
While harm reduction offers a valuable model for working with problem drinkers, it is not a panacea for alcoholism or the “real alcoholic”. In fact, its application for those who are living with alcoholism may be irresponsible and unethical.
(1) Mann, Brian (June 17, 2021). "After 50 Years Of The War On Drugs, 'What Good Is It Doing For Us?'". NPR.
(2) "Richard Nixon: Special Message to the Congress on Drug Abuse Prevention and Control". Archived from the original on December 12, 2013.
(3) Website: aa.org (https://www.aa.org/faq/can-alcoholic-ever-drink-normally-again)
