Episode 12

  • What does abstinence mean in the context of addiction?

  • What is the difference between harm reduction model and abstinence?

  • Is the harm reduction model and abstinence mutually exclusive?

In the addiction treatment world, abstinence and harm reduction can often be seen as contrary to each other. We need both models available in order to truly help clients. Our goal is to meet clients where they are and help walk with them to building a life worth living sober. 

In this Podcast: 

  • Abstinence is based on the biological model of addiction that we discussed in Episode 7 (Brain Science and addiction)
  • Abstinence is based on the idea that the only way to arrest addiction is to remove the substance(s) that cause craving
  • Much of the literature and programs promoting abstinence are based in the 12 Steps and 12 Traditions of Alcoholics Anonymous. 
  • Some early treatment programs were strictly abstinence based and would turn people away or discharge them if they were found to be using. 
  • Harm reduction model  was created as a result of those clients needing services that were accepting of their stage of change. 
  • Harm reduction model aims to minimize the negative effects of drug use on the person who is using.
  • There are many harm reduction strategies. 
  • The three discussed in the podcast today are the availability of naloxone (the antidote to opiate overdose), needle exchange programs (providing clean needles free of charge to IV drug users), and medication assisted treatment programs using Suboxone (or methadone). 
  • We need to talk about the whole spectrum of treatment with all clients. Presenting harm reduction model and talking about progression’s impact. 

Helpful Links:

National Harm Reduction Coalition  https://harmreduction.org/about-us/principles-of-harm-reduction/

Harm reduction: An approach to reducing risky health behaviours in adolescents https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528824/

Harm Reduction Therapy: A Practice Friendly Review of Research https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928290/

The Big Book of Alcoholics Anonymous  https://www.verywellmind.com/the-big-book-of-aa-67255

Drug Policy Alliance-Harm Reduction https://drugpolicy.org/issues/harm-reduction

Subutex, Suboxone and Buprenorphine https://www.workithealth.com/blog/subutex-suboxone-buprenorphine/

How Naloxone Saves Lives in an Opiate Overdose  https://medlineplus.gov/medlineplus-videos/how-naloxone-saves-lives-in-opioid-overdose/

Needle Exchange Programs (Syringe Services Programs) https://www.cdc.gov/ssp/syringe-services-programs-faq.html

Free Treatment Planning Tool  www.betsybyler.com/treatmenttool


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler, and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and confidence needed to add substance use to their scope of practice. 

I  take topics that are typically aimed at substance abuse counselors and share them with mental health therapists in a way that is relevant and tailored to meet our needs. By adding substance abuse to your scope, you can expand your ability to treat the whole person and better meet your client’s needs. Bringing more hope, healing and freedom to the people you serve.

Doing therapy is hard work. Made harder when addiction is thrown into the mix. Many of us didn’t get the training we needed to deal with substance use and finding the knowledge that you need to fill that gap can be difficult. Each episode, I’ll bring you information on substance abuse, topics that impact our work, helping you gain knowledge and confidence. In a relatable and practical way. So join me each week as we talk about All Things Substance.

Welcome back.  Last week, we talked about progression in addiction. The idea that addiction always gets worse over time, unless something intervenes.  Most people I come across will agree that addiction is progressive.    They’re willing to look at people in their lives, their clients, whomever, and they see how somebody’s use went from not a problem to kind of concerning to, “wow,  that’s a really big problem”.

They agree that the person should quit drinking or quit using.  Where we tend to differ is does that mean that they have to quit forever?  This is where  the discussion tends to splinter. The idea that we have to give up something forever seems too strict, legalistic , unreasonable. After all, there are plenty of people who can use or drink and they don’t get addicted and they are able to moderate. So as long as the person can moderate, they should be able to use.

I agree that this would be a great thing  and in fact, the majority of addicts and alcoholics want that too. It is the dream that someday they can go back to when they used to be able to have a drink or use something and not have it take over their lives.   For those who are truly addicts and alcoholics, we know that that just isn’t possible. 

This is an unpopular opinion.   Those outside the addiction and recovery field might not even realize that it’s an unpopular opinion or that there’s a debate about this.  

I gave a presentation earlier this year and one of the comments in the feedback was that the field is moving in a harm reduction direction.  I thought about that for a while, because I don’t think it is. But wherever that person came from, that’s their experience. and so for them, it feels like the field is moving in that direction  

The argument I’m making is that you don’t have to be for abstinence or for harm reduction,  but rather both are needed in order to develop and sustain recovery. 

We need to talk about what exactly, I mean, by abstinence and by harm reduction. 

The word abstinence sometimes gets a bad rap.  For a lot of people we don’t think about the word abstinence, unless we’re talking about sex and sex education and abstinence only education being ineffective. And with that I absolutely agree.  There just, isn’t a better term for talking about quitting using, or staying away from drugs and alcohol than abstinence. So we’re going to have to use that one. 

The idea of abstinence is that an addict or an alcoholic is not going to be able to go back to regular using, and they’re going to have to stay away from all mood altering chemicals.  A lot of the wording that we use when we’re talking about abstinence in the field comes from Alcoholics Anonymous.  

Now there are people who have good opinions of AA and bad opinions of AA, and typically that has to do with the religious portions of it.  What I want to encourage you is not to throw out AA because it has a religious connotation. 

So, let me briefly explain what AA is about.  The first edition of the big book, which is the main text used in Alcoholics Anonymous, was printed in 1939.   The book has been updated several times since then and it still has some language that’s pretty outdated. Sometimes that can seem like a turnoff to some people. However, when you read it and you get past some of the more flowery language, there are some really important truths in the book. 

You don’t have to read the whole big book, but if you want to read some of it, there are a few chapters in the beginning that are really quite helpful.  There are a few problems when it comes to Alcoholics Anonymous and some of its members. Because humans are involved, it’s imperfect. 

Over the years, there have been people who have made it difficult for people to follow the path of recovery by requiring incredibly strict adherence to everything that the big book says as though it’s a holy scripture. That is a problem. Because recovery is deeply personal and the book is not perfect and is meant to be a story of how a couple of alcoholics and others like them were able to find freedom from alcohol.

Within the organization there are people who are really strictly 12 step and they think that there’s no other way to get sober. That’s not the majority though.   As things have moved forward, even in the last 20 years, that rhetoric has been changed quite a bit by some newer members who are saying “no other people have gotten sober using other means; it doesn’t have to be the 12 steps.” 

In chapter three of the big book, there is a section where Bill W., the founder, is talking about the things that they have tried. they being alcoholics, to get sober.  I’m just going to read you a few of the things:

“ drinking beer only, limiting the number of drinks, never drinking alone, never drinking in the morning, drinking only at home, never having it in the house,  never drinking during business hours, drinking only at parties, switching from scotch to brandy, drinking only natural wines, agreeing to resign if ever drunk on the job, taking a trip, not taking a trip, swearing off forever with and without a solemn oath, taking more physical exercise, reading inspirational books” and the list could continue. 

This should sound a little bit like when people try to go on diets and they want to cut out certain foods. The diet industry is based on moderation, even though a lot of people have difficulty moderating around certain foods. 

We’re actually going to be talking about food addiction in a few weeks when I interview a trainer and a kick ass woman , from the East coast, who I consider to be an expert on food addiction. 

People have talked about, I’m not going to eat in front of the TV. I’m only going to eat at the table. I’m going to use smaller plates. I’m not going to eat this food. I’m going to cut out that food, those different things. The diet industry itself is built on trying all sorts of new tricks to try to make it so people can moderate.

One of the big ones is “just have a bite”. Well, for some people that works really well, they can have a bite or two bites of something that they really love and they feel okay. For others though  that’s a recipe for disaster, pun, not intended.

It’s the same way for addicts and alcoholics. There’s a phrase in the big book that says one is too many and a thousand is never enough.  The idea of being that one is never going to be enough and that the upper limit just keeps growing. This is the progression thing that we’ve been talking about.

So we’ve talked about abstinence and where the concept comes from and now we need to talk about harm reduction.

As much as I try to present things from a neutral perspective, I’m talking to therapists and you can probably hear my bias. And so I figure might as well bring it out there. I am not neutral about this. In fact,  I am incredibly passionate about abstinence needing to be the end goal for addicts and alcohol.

That does not mean that I don’t think harm reduction has a place and is completely necessary because I believe it is. And for a long time, I didn’t even know that there was a problem with harm reduction and abstinence.  Because in running a program, we set up rules and guidelines for the program to include people who wanted to work towards abstinence and people who didn’t. We would never, ever turn someone away just because they didn’t want to give up drinking or using totally. Where they belong in the program does differ depending on the goal and I think that that’s the important distinction. 

I’ve been in the field 17 years. It feels long to me because in my lifespan that is long, but it’s not very long to others who’ve been sober 30, 40, 50 years. From what I’ve gathered, there were programs that were really legalistic about using and harm reduction and would turn people away or kick them out if they were found to be using.   That’s really unfortunate that that was happening. 

In modern day treatments, I don’t see that as being the norm. I’m certain that it probably exists because there are extremes on either side of any spectrum. It has not been my experience though, in working in treatment centers.

The harm reduction model came out of a need to provide a place for people who weren’t ready to do abstinence.  but wanted to try to reduce some of the damage they were doing to their lives. Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.  Harm reduction is  also a movement for social justice, built on belief in and respect for the rights of people who use drugs.

I’m going to share with you the tenants of harm reduction  that are put forth by the National Harm Reduction Coalition.  

Number  One :accept for better or worse that drug use is part of our world and we choose to work to minimize its harmful effects rather than simply ignore them or condemn them or people that use.

Number Two: understands that drug use is complex multifaceted phenomenon that encompasses a continuum of behaviors from severe use to total abstinence. And acknowledges that clearly some ways of using are safer than others.

Three: Establishes quality of individual and community life and wellbeing. Not necessarily cessation of all drug use as criteria for successful interventions and policies.

Four:  Calls for the nonjudgmental non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them and reducing attendant harm.

Five:  Ensures that people who use drugs and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them 

Six:  Affirms people who use drugs themselves as the primary agents of reducing the harms of their drug use and seeks to empower them to share information and support each other in strategies which meet the actual conditions of use.

Seven: Recognizes that the realities of poverty, class racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug related harm. 

Eight: Does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use. 

So basically harm reduction’s whole point is to engage people who are using drugs and alcohol  in strategies designed to help keep them safe while they’re using. 

One of the things you’ll hear, people say is that they want to meet people where they’re at. This is absolutely what we need to do with all people who are using substances. and it could be argued with all people that show up in our offices. But it’s specifically important,with substance use given the fact that some of the history of  involving people in substance use programs was that they didn’t feel like they were meeting people where they’re at, because they were requiring abstinence  as a condition of being involved in the program.

I want to share some things that are harm reduction strategies, so that we can put a little bit more of a face on what we’re talking about.  Some of these strategies are more controversial than others. When it comes to drug use it’s hard for the general public to get behind something that seems like it’s encouraging drug use or condoning it. 

It’s sort of the same argument with whether or not we provide birth control to people free of charge or under age, that kind of thing.  Because people feel like it’s permission for people to engage in sexual activity.  We know that the research is solid though, and that providing contraception does help reduce a lot of complications from sexual activity. Just like drug use we know that sexual activity is going to happen. 

Most of us in the therapy world are already going to be on board with this because we know that we have to just accept where people are at, regardless of what they’re doing.  We aren’t judging people based on the morality of what we’re talking about.  It’s more about how do we help this person in this moment and how do we help them move forward to a better quality of life.

There are a lot of different strategies for harm reduction. I’m only going to focus on a couple today, but in the future,  I’ll be doing podcasts on some of these strategies to help explain them better. 

The first strategy I want to talk about is Naloxone.   Naloxone  is an FDA approved  generic medication that reverses opioid overdose. It is frankly a miracle. It can take someone who is on the brink of death or dead and bring them back to life.

So it comes in two forms,  a nasal spray just like the ones you would see for cold or allergies,  or injection. For those of you, who’ve seen Pulp Fiction, this is not the same thing. You don’t stab someone in the heart with a needle.  You use the needle in a muscle and you inject the medication. 

Opiate overdose happens because of respiratory depression and the way people die from opiates is that they stop breathing. Once someone has stopped breathing, or if they are on their way to overdose, you can administer Naloxone and it will immediately reverse the effects of the opiates by blocking the opiate receptor.

Naloxone is so strong that it knocks the other opiates off of the opioid receptors and blocks them bringing the person around.  Now, it has to be administered very quickly within a few minutes of the person stopping breathing, because  any longer than that and we lose the ability to get them back.

This medication is available with, and without prescription. It depends on the state where you are and whether or not you need a prescription for it. It’s sold in pharmacies across the country.  There are programs that are designed to make this available for people free of charge so that they can have this.

Now it’s being used a lot of times by emergency personnel and they’re carrying it with them because it is something that they can use on the scene. It’s being offered to people who are using drugs  so that they can administer it to their friends and family members and loved ones can carry it as well.

There are stories and plenty of them, of people who were carrying it  and we’re able to use it on someone. A colleague of mine was carrying some in her purse and was in a bathroom and saw someone overdose and she used it and it brought the person back. 

There’s a lot more to say about Naloxone, but that’s just one of the strategies we’re going to talk about today.

Needle exchanges have been around for quite some time and I think that they’re somewhat controversial.  A needle exchange is just what it sounds like; that you can bring in dirty needles and exchange them for clean ones for free.  Programs vary widely on how many needles they’re going to give you.

Some might only give you 20.  Some might give you a hundred.  These programs are designed to distribute needles and they also have some other services onsite, typically, like testing for Hep C and HIV,  access to contraceptives, referrals to treatment if necessary and somebody who can talk with the person about their use.

There’s no judgment. There’s no name gathering  because they’re not patients. They’re just there. And it’s something that people do use and they do trust in the community. So what this does is it’s two things. It keeps needles from being discarded on the street and it helps people get fresh needles so that they’re not sharing them and increasing the risk of infectious diseases.

The last one I’ll cover today is something that I don’t totally consider harm reduction, but I do know that in the field and even outside the field, people see it as that. It’s controversial in a way that I don’t totally understand, but I think it has to do with this leftover opinion about drug use being evil, deviant, shameful, that kind of thing.  

For years, there’ve been methadone programs that were designed as an opiate replacement. So someone who was addicted to heroin could go to a methadone program and get methadone instead of heroin.  Then they could move on with their day. 

A lot of times this was a daily dose kind of situation .  You go to the methadone clinic, you get your dose and then you go to work or do whatever else you’re doing that day. Sometimes people had “take homes”, they call them where they get their dose and they bring them home. These programs still exist and some are run better than others. 

Methadone is a one for one replacement. It’s fully an opiate. It is addictive and what it’s accomplishing is getting the person out of the cycle of having to get drugs off the street and helping them move away from that lifestyle. There are some issues with it, but that’s something we’re going to cover in a different podcast because of its complexity.

In 2002, the FDA approved a medication that would give another option other than methadone. Suboxone is a medication called buprenorphine plus Naloxone.  I think Suboxone can be a great option.  I believe that it should be done in conjunction with treatment and I would love to see every community have an opportunity to have this available.   Suboxone, like methadone, has to have a prescription. You have to get it from a place that dispenses it.  So for Suboxone, that’s going to be a pharmacy. 

It is a partial agonist, meaning that it partially activates the opiate receptor. It is an opiate. It is addictive. The medication also has Naloxone in it, which we talked about is the antidote for opiate overdose.  So what it does is it keeps you from being able to overdose and it doesn’t allow you to get as high as you did before. You could of course use other drugs rather than just the Suboxone, and that’s part of the criticism of it.

It takes the use and puts it on a prescribed dose that is not going to get you high.  That is something that is going to take you away from getting drugs off the street. 

So a person who’s using opiates would come in, they would get inducted, meaning that they would get their first dose of Suboxone. There is going to be some withdrawal from that because it’s not going to be as powerful as the dose that they’ve been using. Then they have a daily dose In the form of sublingual strips.  You get these strips from the pharmacy, you take your dose, which is a certain part of the strip,  and then that’s your day. 

I have seen it be extremely effective and people return to normal life where they’re able to hold jobs, take care of children, build a life, go to school, get different jobs. It is quite frankly, I believe,  a miracle option for people. There is criticism that it keeps people addicted and yes, they are still dependent on opiates. And if they choose to go off Suboxone, then they’re going to have withdrawal.

The idea isn’t to necessarily stay on Suboxone for life, although someone could.  So technically yes, it’s a harm reduction strategy because it doesn’t involve abstinence from all mood altering chemicals per se. And my opinion though, that is abstinence. This person is not out using street drugs. They’re not doing any of the activities that are involved in it and they’re just taking a medication as prescribed. For me, this absolutely “counts” as abstinence.

So the last thing I want to cover today is just briefly how a harm reduction model would work in individual therapy. For that, I’ll tell you a story.  So I was working with a guy who was in high school ; about 17 at the time. He was smoking marijuana and super in love with marijuana,  really loved it; was telling me all about how amazing it is. He knew that I wasn’t a huge fan of how much he was smoking, but I never was judgmental about it.  We had talked really openly, which is always the way I choose to go with teenagers when I’m talking about drugs and alcohol.  

So we were talking about any potential effects from marijuana that weren’t so great.  I asked him, “All right, so are you good with where you’re smoking now? Do you think that you need to cut back at all? “And he’s like, “No I’m okay right now. I might want to not smoke say before I go to my grandma’s house or before school”. 

And I was like, “all right, so how much is too much then?” And so we spent some time talking about how much marijuana would be too much in his opinion. And I said, “so how will we know if your use is getting problematic?”. And we came up with some benchmarks.

One of them was going to school high, another was missing work and another was missing family functions or showing up to them high. These were his values, not mine.  We set that out as something we were going to watch. 

So when those things started happening, I was able to bring it back around and say, “All right, man.  So we talked about this a few months ago and here we are. What do you think?” We were able to have this discussion and talk about his  use from that perspective.  In no way, was I suggesting that he had to quit using drugs or alcohol altogether.  I was simply guiding him as he was evaluating his own use to see what he thought.  This is something that is super important, I think, in individual therapy, because we see someone typically on a weekly basis. And so we’re able to check in with them and watch progression. 

If you have a client that is using and you’re wondering about that, I created a free treatment tool and it’s on the website. You can go to betsybyler.com/resources, and there will be a link to the treatment tool. 

The document is designed to help you take one client and walk them through this process of evaluating their use. This isn’t something that you do with them typically, but something that you’re doing to help conceptualize what’s going on and help you plan where to intervene. This isn’t a goal of getting them to be sober.

This is designed to help you look at the different areas of their life and think about where you want to start talking with them to see if the substance use is a problem. Again,  like I said, the treatment planning tool is totally free. 

It comes with an email course. When you sign up for the treatment tool, you’ll be getting an email for 10 days in a row. You can open them or not up to you, but the emails are there to help give a little more context to the different steps in the process.  It’s yours to use. There’s no strings, there’s no money and if you want to opt out of emails, you are certainly welcome to. 

As I prepared for this podcast, I went back and forth in my mind about how to do it. I want to present abstinence and I want to present harm reduction in fair, informative, and useful ways. . And they’re fairly complex.

The subject of harm reduction and abstinence sometimes feels like walking a tightrope to me because I firmly believe that true addicts and alcoholics cannot and will not be able to moderate. And I think that it is dangerous to suggest otherwise. 

I truly support harm reduction strategies and want them to be a part of our national, state and local health policies and initiatives. Because I believe that it takes time for somebody to get to the place where they’re ready to quit and until that time we need to keep them alive and try to minimize the amount of damage they have to figure out on the other end.

If we can keep them from getting diseases,  if we can keep them from destroying other parts of their life. I want us to do that.  Picking a side of harm reduction only, or abstinence only something look black and white, that is actually really complex. I think picking one or the other is actually pretty dangerous.

I think being draconically abstinence-based is going to turn people away and potentially trigger people’s shame about their drug or alcohol use. I think being harm reduction only, isn’t being honest about the progression and the potential danger. 

I hope I’ve made the case for why we need to have both abstinence discussions and harm reduction discussions when working with people who are using substances. 

This podcast marks the end of a series, and we’re going to be shifting gears.  For the last seven or so podcasts we’ve been talking about addiction and the basic foundation of it. 

We’re going to talk about other types of use disorders  such as internet gaming disorder, gambling, food addiction, and sex addiction.  I hope you’ll join me next week for the first installment of that series. When we talk about internet gaming disorder, 

If you’re ready to take the next step in addressing your client’s substance use head on over to betsybyler.com/treatment tool. The treatment planning tool I created will help walk you through the process of evaluating your clients use and deciding how and when to intervene. The tool is completely free and will be delivered to your email so that you can use it right away.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist, friends, and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast and until then have a great week.

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal clinical or any other professional information.