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

S.H. Kellogg / Journal of Substance Abuse Treatment 25 (2003) 241–247 243
Table 2
Typology of HR interventions
Staying
alive
X
X
Designated Drivers
Earlier Liquor Store Hours to
Prevent Non-beverage
Alcohol Consumption*
Naloxone Distribution
X
Overdose and Safe Injection Information X
Low Threshold Methadone Treatment X X
Dance Drug/‘‘Ecstasy’’ Testing X X
Safe Use/Injection Rooms X X
Low Beverage Acohol* X X
Maintaining
health
Getting
better
Safety Glassware in Bars*
X
Server Training*
X
Needle/Syringe Exchange
X
(Prevention Model)**
Needle/Syringe Exchange
X
(X)
(Risk Model)**
Heroin Maintenance
X
Motivational Interviewing X X
Harm Reduction Psychotherapy X X
Medium/High Threshold
X
X
Methadone Treatment
Motivational Interviewing X X
Acupuncture and Herbal Treatments X X
Substance Use Management X X
Moderation Interventions X X
Acupuncture and Herbal Treatments X X
Drop-in Centers X X
Harm Reduction Psychotherapy
X
Buprenorphine-Naloxone Treatment
X
Naltrexone (Alcohol)
X
Standard Methadone Treatment
X
Contingency Management Approaches
X
Based on Gradual Use Reduction
Drug and Alcohol Education X X X
* Single (1997).
** Strike, Myers, & Millson (2002).
Harm reduction interventions for the first group would
primarilybeeducational(i.e.,DanceSafe,2003),butcouldalso
include substance-use management interventions (Denning
& Little, 2001; Marlatt, Larimer, et al., 1993; Moderation
Management, 2003). The second group includes those who
are not ready to change their use pattern because they feel
that their alcohol and drug use serves a purpose (Director,
2002; Tatarsky, 1998, 2003). As Tatarsky (1998) noted,
‘‘people use substances because they address some psychological,
social, or biological needs.... [and] substances may
come to serve important psychological functions that help
the user cope more effectively’’ (p. 11). In addition to coping
and self-medication functions (Khantzian, 1985; Kohut,
1977), the use of substances may be intimately connected
with identities or relationships that appear to be central to the
person’s sense of self (Biernacki, 1986; Kellogg, 1993;
Moore, 1990), and the discontinuation of use may result in
the disruption of various social networks. Lastly, the prospect
of treatment itself may appear to be unattractive (Denning,
2001; Marlatt et al., 2001; Roche, Evans, & Stanton,
1997; Springer, 2003; Westermeyer, 2003b).
In terms of intervention, patients in this group could be,
and frequently are, understood within a stages of change
model (Denning & Little, 2001; Prochaska et al., 1992;
Springer, 2002), and Motivational Interviewing is a recommended
technique (Denning, 2001; Denning & Little, 2001;
Miller et al., 1995; Springer, 2003; Westermeyer, 2003a).
The purpose of the encounter would be to help them move
along the continuum toward taking some kind of action. A
psychotherapeutic intervention might be focused on discerning
the personal meaning and symbolism of the drug use,
evaluating the cost-benefit analysis involved in the decision
to keep using (Tatarsky, 1998), understanding the relationship
between trauma and substance use (Springer, 2002,
2003), clarifying their drug-related identities and social networks
(Biernacki, 1986; Kellogg, 1993), and understanding
their conception of their personal life alternatives.
In contrast, the third group consists of those who are
‘‘unable’’ to stop. To see people as being unable to stop leads
to what might be called the harm reduction of despair. In one
approach, which humanistically emphasizes the needs of
these terribly addicted users, harm reduction interventions
may serve as a kind psychosocial hospice (see also Gelormino,
2002); a way of ‘‘being with’’ people who are
incurably ill, a way of walking with them on a journey
toward death. Another approach, which takes more of a
societal view, is to see these highly addicted patients as a
disease vector, be it for hepatitis C, HIV, or crime; here, the
emphasis becomes one of reducing the harm to the surrounding
community. The covert (or not so covert) message,
however, may be that they no longer matter as individuals
(Ibrahim, 1996).
3. Harm reduction as a pathway to abstinence
Gradualism, which has a great deal in common with the
work of Marlatt (Marlatt, 1996, 1998a, 1998b; Marlatt &
Kilmer, 1998; Marlatt, Larimer, et al., 1993; Marlatt, Somers,
& Tapert, 1993; Marlett et al., 2001), seeks to create a
continuum between the world of harm reduction interventions
and the abstinence-oriented treatment field. Again, this
approach differs from other calls for integration (Denning,
2001; Marlatt et al., 2001) because there is a much greater
emphasis on making abstinence the eventual endpoint of
most harm-reduction enterprises. This paradigm would
combine the harm reduction emphases on outreach to the
addicted, incremental change, and gradual healing with the
abstinence-oriented therapeutic perspective that the use of
substances in an addictive or abusive manner is antithetical
to the growth and wellbeing of humans. As will be discussed
below, this also means using the full compendium of
recovery oriented interventions. Instead of being an abstinence-only
model, this combined approach could best be
understood as an ‘‘abstinence-eventually’’ model.