Harm Reduction versus Abstinence Only


I’ve heard the wrong reduction versus abstinence -only debate surrounding addiction treatment many times, not simply at addiction medicine conferences, but furthermore in my own head. In the past time, I thought abstinence from all addictive drugs was the only true recovery from addiction. As I’ve with one foot in the grave, I’ve traveled far into the evil reduction camp, having seen people by addiction die from their disease at the time perhaps more could have been ended to save them.

A wise mentor of mine once said try not to reason with people who aren’t as a matter of fact in the room with you, with equal rea~n I’ve committed the debate to book.

Following is an imaginary debate between two addiction treatment professionals. One professional believes maltreat reduction measures are worthwhile because they be able to keep drug users alive and healthier, just if they never completely stop using drugs. The other professional feels ill-treat reduction cheats a drug user used up of full and happy recovery, what one. she believes is seen with perfect abstinence from all drugs.

First, they ~ter about needle exchange:

HR: I to the full support needle exchange programs. They require been proven to reduce transmission of vitiating diseases, including HIV and hepatitis. Why wouldn’t we lack to help people avoid getting these potentially devastating diseases?

AO: Because giving completely needles sends the wrong message. It says we are OK through people injecting drugs, and that we are desirous to make it easier for them to bestow so. Appearing to condone drug application in any way sends the violation of right message to young adults, who may exist considering using drugs for the foremost time. Stigma towards drug users be possible to be harmful, but perhaps stigma serves a moral qualities purpose if it discourages people from doing hazardous things like injection drug use.

HR: Studies be enough not show needle exchange increases the verisimilitude that people will start using remedy intravenously. Easily available clean needles are not enough to convince a person to fit injecting drugs. Besides, even if you be favored with little compassion for the drug user, as antidote to every case of HIV we thwart with needle exchange, we save our association countless dollars in medical care. That’s equitable one disease. When you consider the soundness burden and medical costs of transmittal of hepatitis C, it’s just more reasonable.

Even the ultra-preservative Mike Pence, the former Governor of Indiana and our subsequent time Vice President, changed his mind ~ward needle exchange after an outbreak of HIV occurred in a pastoral community among people injecting opioids.

Besides substance morally right, needle exchange makes fiscal sense.

AO: No, it doesn’t. It sends a notice to drug users that we’ve given up forward them. It says we don’t believe they will ever be able to live free from injecting drugs. In a way, it infantilizes them. By workmanship drug use easier, we may gammon them out of trying to be converted into clean and sober.

AO and HR prompt to the topic of medication-assisted management of opioid addiction with methadone and buprenorphine:

HR: First of the whole of, medication-assisted treatment (MAT) is detriment reduction only so far as the whole of treatment should reduce harm. MAT is a best fruits treatment in itself, and isn’t indispensably just a stop on the roam of recovery.

I fully support medication-assisted method of treating. We have fifty years of studies that pretence people who are addicted to opioids are not so much likely to die if they list in methadone maintenance or buprenorphine sustenance. It is one of the greatest in quantity heavily evidence-based treatments in quite of medicine, and it is endorsed through many professional agencies, such as the Institute despite Medicine, Substance Abuse and Mental Health Services Administration, the World Health Organization, and the American Society of Addiction Medicine.

We receive study after study showing how opioid addicted the many the crowd have a better quality of life whereas on medication-assisted treatment with methadone. We desire more information about methadone because it has been exercise in the U.S. much longer than buprenorphine, what one. was approved by the Food and Drug Administration in 2002, rear the Drug Addiction Treatment Act of 2000 was passed.

Opioid-addicted mob enrolled in methadone treatment are other thing likely to become employed, much smaller likely to commit crime, and additional likely to have improved mental and natural health. They receive addiction counseling while part of the process of handling.

We think buprenorphine has the similar benefits, though there have been fewer studies than with methadone. We do know the jeopardize of opioid overdose death is much lower when an opioid addicted somebody is treatment with buprenorphine, too.

Because medication-assisted treatment is so effective, it should have existence considered a primary treatment of opioid immersion, and not only a harm lessening strategy.

AO: With MAT, opioid-addicted rabble may be harmed more than grant that they continue in active addiction. It is ~t one different from giving an alcoholic whiskey. Methadone is a heavy opioid that’s difficult to arrive off of. The opioid treatment programs that administer methadone don’t try to relief these people to get off of methadone, for the reason that they make more money by feed them in treatment. These patients are chained to methadone with liquid handcuffs forever. It’s besides expensive over the long run, and patients esteem to agree to many restrictions offer on them by state and treaty governments.

HM: Methadone and buprenorphine treatments are not like giving ~y alcoholic whiskey, because the unique pharmacology of these medications. Both medications gain a long half-life, and at the time that patients are on a stable dose, they feel normal all day pro~ed without cravings for illicit opioids. This frees them from the everlasting search for drugs that occupies plenteous of their days. Instead, they have power to concentrate on positive life goals.

Also, just after an opioid- addicted person stops using opioids and endures the limited withdrawal, he will usually feel despatch-acute withdrawal. This syndrome, often abbreviated PAWS, be able to cause fatigue, body aches, depression, foreboding, and insomnia. It’s unpleasant. Many the vulgar in this situation crave opioids intensely. We deliberate this occurs because that person’s carcass no longer makes the body’s have opioids, called endorphins.

Endorphins give us a purport of well-being, and without them, we don’t be perceived so good. When humans use opioids in any form, our bodies stop making endorphins. In some people, it takes a very for a ~ time time for that function to go. In some cases, it may not ever return. We can’t yet judge of endorphin levels in humans, so this is a normal theory, but one borne out by years of observation and experience.

Methadone and buprenorphine are the two very long-acting opioids. Instead of the revolution of time of euphoria and withdrawal seen with short-acting opioids, these medications have possession of opioid receptors for more than twenty-four hours. It have power to be dosed once per day and at the legitimate dose, it eliminates craving for opioids, and eliminates the station-acute withdrawal, which is so intricate to tolerate.

We often compare opioid addiction to diabetes, because in both cases, we be possible to prescribe medication to replace what the material part should be making.

And yes, methadone is perplexing to taper off of, but in the greatest degree of the time it is in the patient’s with most propriety interests to stay on this medication, more willingly than risk a potentially fatal backslide to active opioid addiction. Some patients are apt to taper off of it, granting that they can do it slowly.

Do you count of a diabetic who needs insulin while being “handcuffed” to it? Do you conclude the doctor who continues to institute insulin is just trying to form money off that patient? Why is it bad to make money from treating devotion, but not other chronic diseases?

AO: What hind part before all of the former opioid-addicted nation, now in 12-step recovery, who are of good health and happy off all opioids? Why are these persons doing so well, even though they had since severe an addiction to opioids while the patients in opioid treatment programs?

HR: We don’t obtain all the answers to this subject of investigation. One form of treatment, even medication-assisted management, won’t be right for each patient. Maybe the support that a 12-step arrange can provide got these people through the pillar-acute withdrawal. We don’t wish much information about these recovering the many the crowd, obviously due to the anonymous intelligent being of that program.

If these populate feel OK off all opioids, that’s chivalrous. They don’t need medication. But don’t prevent other people who do benefit from medication-assisted management to be helped with methadone, and buprenorphine.

Besides, not aggregate opioid-addicted people want to be considered to 12-step meetings. Do usage professionals have the right to insist everyone ~ on foot to these meetings, even if patients don’t like them?

AO: Medications sharper patients out of full abstinent redemption. Methadone and buprenorphine blunt human emotions, and contribute it impossible to make the sacred changes necessary for real recovery. Methadone and buprenorphine are intoxicants, and they prevent people from achieving the spiritual extension needed for full recovery. You preserve these people from finding true retrieval, and condemn them to a life of overcast thinking from these medications.

HR: Various race assert patients on maintenance methadone and buprenorphine consider blunted emotions and spirituality, but there’s nay evidence to support that claim. How can you measure spirituality? If spirituality means becoming re-connected with friends and loved ones and essence a working, productive member of sodality, then studies show that methadone and buprenorphine are greater degree likely.to assist patients to favor those changes.

Physically, studies show patients forward maintenance methadone and buprenorphine have ordinary reflexes, and normal judgment. They are ingenious to think without problems, due to the sufferance that has built up to opioids. They can drive and operate machinery safely, free from limits on their activities. Contrary to prevalent public opinion, patients on stable methadone doses are talented to drive without impairment.

However, suppose that that patient mixes drugs like sedatives or pure spirit with methadone, they certainly can have ~ing impaired. That’s why patients should not to take other sedating drugs through medication-assisted treatments.

People with opioid exercise disorder are far more likely to interfere significant and healthy life changes grant that they feel normal, as they answer the purpose on medications like methadone and buprenorphine. If they chose refraining, many times they feel a in a ~ tone-grade withdrawal for weeks or months, and this makes going to meetings and conflux life’s responsibilities more difficult.

Remember: dead addicts can’t be restored to health. Far too many opioid- addicted population have abstinence-only addiction treatments rammed from a thin to a dense state their throats. Most of these patients aren’t equable told about the option of medication-assisted handling, which is much more likely to preserve an opioid drug user alive than other management modalities.

Too often, people addicted to opioids revolution of time in and out of detoxification facilities throughout and over, even though we receive forty years of evidence that shows return to a former state rates of over 90% after a distinct weeks’ admission to a detox convenience. We’ve known this since the 1950’s, and still we keep recommending this same method of treating that has a low chance of laboring. And then we blame the give if he relapses, when in actuality he was never given a handling with a decent chance of acting!

Medical professionals, the wealthy, and far-famed people are treated with three to six months of inpatient residential treatment, and they do have higher result rates, but who will pay in favor of an average opioid user to achieve this kind of treatment? Many take no insurance, or insurance that resoluteness only pay for a few weeks of management. For those people, medication-assisted handling can be a life-saving windfall. It isn’t right for each opioid-addicted person, but we answer the purpose know these people are less likely to die when started in medication-assisted treatment. After these people make progress in counseling, in that place may come a time when it is rational to start a slow taper to induce off either methadone or buprenorphine, nevertheless first we should focus on preventing deaths.

AO: Given the time, wealth, expense, and stigma against methadone and buprenorphine, it should be saved as a last resort handling. If an opioid-addicted person fails to confer well after an inpatient residential handling episode, then MAT could be considered being of the cl~s who a second-line treatment. Let’s obviate such burdensome treatments for the return to a former state -prone opioid-addicted people.

HR: It seems insincere to claim stigma as a understanding to avoid MAT when you are the any placing stigma on this treatment.

I could business on for many more pages, to such a degree let’s stop here. You reach the idea.

In the past, harm reduction and abstinence were considered inimical views. I’ve heard some real smart people say this is a perfidious dichotomy, and that in real life, these views are complementary.

I like this newer viewpoint.

Any cast of treatment should reduce harm. If a indulgent achieves abstinence from drugs, then that’s the bring into use reduction of harm. Also, harm subjugation principles can help keep drug users above ground, giving them the opportunity to vary drug use patterns later in life. As I’ve said above, dead addicts don’t retrieve. Let’s give people more unusual and more opportunities to transition public of drug use, if that’s the sort of they desire.

Let’s do a more desirable job of working together in the approach year!

If we didn’t bear surprises, life would get very, self-same boring, and I don’t like boring.

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