and the building of the harm reduction-abstinence ... - ResearchGate

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S.H. Kellogg / Journal of Substance Abuse Treatment 25 (2003) 241–247
Table 1
Diagnosis and HR intervention
Extreme Dependence Dependence Abuse Use
Dance Drug/‘‘Ecstasy’’ testing—————————————— X
Substance Use Management—————————————————————————————————————–X
Moderation Interventions——————————————————————————X
Harm Reduction Psychotherapy————————————————— X
Buprenorphine-Naloxone Treatment—————— X
Safety Glassware in Bars——————————————————————————————————————–X
Designated Drivers————————————————————————————————————————— X
Server Training——————————————————————————————————————————– X
Earlier Liquor Store Hours to Prevent
Non-Beverage Alcohol Consumption——X
Needle/Syringe Exchange—————————————X
Safe Use/Injection Rooms—————————————X
Heroin Maintenance——————————————— X
Drop-in Centers—————————————————X
Low Threshold——————X Medium/High Threshold —X
Methadone Treatment
Methadone Treatment
Contingency Management Approaches Based on Use Reduction————————X
Naltrexone (Alcohol)————————————————————————————–X
Standard Methadone Treatment————————————————————— X
Naloxone Distribution—————————————————————————————————————X
Motivational Interviewing————————————————————————————————————————————X
Acupuncture and Herbal Treatments——————————————————————————————————————————————— X
Overdose and Safe Injection Information————————————————————————————————————————————— X
Drug and Alcohol Education—————————————————————————————————————————————————— X
(i.e., safety glassware to protect patrons during fights in bars
or pubs). The time perspective is, generally, somewhat
longer than those in the ‘‘staying alive’’ group.
The ‘‘getting better’’ group includes interventions that
look more to control and reduce use—if not necessarily
eliminate it. As can be seen from the list, most of these
interventions have some kind of therapist-patient or physician-patient
aspect to them, while the other two groups are
more focused on paraphernalia and education.
Some of the concerns about harm reduction interventions
can be clarified, if not necessarily resolved, through the use
of this goal typology. For example, there has been some
distress expressed over the therapeutic value of low threshold
methadone programs (Ball & Van de Wijngaart, 1994) in
that continued drug use may be a common occurrence
(Reuter, 1994). However, low threshold programs have been
found to reduce HIV infection because they lead to lower
levels of heroin abuse—even if they do not result in the
rehabilitation of most of the patients (Rezza, 1994). In this
respect, they meet the first two goals, if not the third. Wodak
(1994) argues that this is not necessarily without some
therapeutic potential as many drug- and alcohol-dependent
persons do eventually terminate their use, and that ‘‘simply
keeping alcohol- and drug-dependent people alive and well
for as long as possible is a very important component of
treatment’’ (p. 804).
The third harm reduction categorization seeks to look at
the relationship between intervention and motivational state.
For the most part, harm-reduction approaches and abstinence-only
approaches are fundamentally addressing themselves
to the needs of different groups. That is, the ideal
target group for reduced-use interventions would be individuals
who: (1) would quality for a DSM-IV diagnosis of
alcohol or substance abuse or perhaps meet the minimum
criteria for a DSM-IV dependence diagnosis; and (2) who
are seeking to reduce but not discontinue their involvement
with drugs and alcohol (Klaw & Humphreys, 2000; Larimer
& Marlatt, 1990; Marlatt, Larimer, Baer, & Quigley, 1993).
One of the positives of this option is that by giving these
individuals an opportunity to attempt moderation, a number
of them will then chose to cease using drugs or alcohol
(Marlatt, Larimer, et al., 1993; Marlatt, Somers, & Tapert,
1993; Tatarsky, 1998). In terms of men and women who
would qualify for a diagnosis of alcohol or substance
dependence, abstinence-oriented programs serve the needs
of those who wish to stop using, while harm reduction
interventions serve the needs of those who are not in
treatment, do not presently wish to be, and may not be
ready to discontinue their substance use. Again, some of the
abstinence-harm reduction conflicts (Szalavitz, 2000–2001)
are unnecessary since all of these approaches are catering to
the needs of different audiences.
The harm reduction literature does not seem to be
particularly bound by diagnostic categories; however, an
informal motivational typology of substance users does
emerge from the literature. This consists of: (a) those who
are rationally choosing to use substances; (b) those who are
unwilling to stop using at the present time (Westermeyer,
2003a, 2003c); and (c) those who are unable to stop at the
present time (Westermeyer, 2003a, 2003c).