Harm Reduction: The Only Realistic Approach to Substance Use and Recovery
Psychoactive substance use — certainly including alcohol and psychiatric medications, on top of illicit drug use — is nearly universal in Western societies. It is becoming more, not less, so, and it’s beginning at younger ages. American public policy and treatment don’t recognize this reality.
I will be debating Scottish addiction researcher Neil McKeganey in Glasgow and Edinburgh in September. Professor McKeganey has announced the death knell for the policy of harm reduction in Great Britain. Harm reduction — which recognizes continuing use by addicts — is widely credited with forestalling in the U.K. the second wave of HIV infection among injecting drug users, which overcame the United States. But Professor McKeganey says it has outlived its usefulness there, both in terms of educating youths about the harms from drugs, and in treating addicts.
It is ironic that Professor McKeganey should be making such pronouncements at this point, given that, at least as far as needle exchange goes, President Obama has adopted some harm reduction policies, belatedly, from the rest of the world. Nonetheless, Professor McKeganey’s point of view would not seem out of place in the United States, where all drug education and virtually all treatment are entirely abstinence-oriented. This is not so true in the U.K. and elsewhere (keep in mind that the drinking age is 18 in the U.K., and 16 with parents in a restaurant).
What further puzzles me about his taking this position currently is that a number of developments should, I think, make us aware that returning to zero-tolerance is an Edenesque ideal not likely to be realized in my and Professor McKeganey’s lifetimes, nor those of our children or grandchildren.
The first of these was the mammoth U.S. government study, called NESARC, which I review here. This national survey of 43,000 Americans found that only a minority of both treated (35 percent) and untreated alcoholics (12 percent) in the U.S. have abstained during the last year, but that the majority of the remainder have either improved or achieved full remission. America’s entire treatment system, predicated as it is solely on abstinence, is very much out of kilter with the reality of Americans’ drinking, for better (the high percentage of those who remit, despite neither receiving treatment — fewer than 15 percent of alcoholics enter AA or rehab — nor abstaining) or for worse (treatment produced no better outcomes than were noted among untreated alcoholics — 28 percent of the treated and 24 percent of the untreated remained alcoholic).
Let me summarize NESARC’s results more succinctly. Even in a highly treated place like the U.S., the large majority of alcoholics go untreated (including exposure to Alcoholics Anonymous) and do not abstain, but they mainly get better with time. The number of untreated alcoholics who improve is two to three times the number that remains alcoholic. That most improvement occurs outside of treatment may be the natural result of the fact that treatment can only accept, encourage and deal with abstinence.
Let’s turn to the dream that young people will never drink or take drugs. It’s preposterous, really, given that by age 21 they can legally drink, and nearly all do. One hoary debate is whether restricting legal drinking until (relatively) later in life encourages or discourages moderate drinking. In the U.S., we are firmly in the camp that delay is beneficial (this is less the case in the U.K., and certainly not in Spain, Italy or Greece). I’ll leave that debate here, since individuals have such strong opinions about these matters, and I can’t change them.
And I won’t even get into the debate about whether we can permanently reduce the use of illicit drugs by American youth. These figures rise and fall, and lately we have seen some resurgence in teen drug use, but not to former peaks. In 2010, 21 percent of high school seniors reported having used marijuana in the past 30 days.According to the director of the National Institute on Drug Abuse, Nora Volkow, “We should examine the extent to which the debate over medical marijuana and marijuana legalization for adults is affecting teens’ perceptions of risk.”
In other words, Dr. Volkow is warning us, the very debate over changing our drug laws may be encouraging youthful drug experimentation. But that discussion cannot be put back into its box, as most recently revealed by the Global Commission on Drug Policy, and widespread commentary on the 40th anniversary of Nixon’s announcement of our war on drugs. Both the Global Commission Report and the anniversary commentaries (like this one by Jimmy Carter) emphasize the legalization of marijuana, and decriminalization and control of other illicit drug use. (Professor McKeganey strongly disagrees with the Commission’s recommendations.)
Moreover, Dr. Volkow feels, “We must also find better ways to communicate to teens that marijuana use can harm their short-term performance as well as their long-term potential.” But, we may wonder: How much more can we do in the schools to discourage drug experimentation than we have done for nearly half a century now?
What makes this latter issue most noteworthy is a) the massive pharmacologization of American youth, whose prescriptions for psychiatric medications have risen by several multiples over the last two decades, and b) the fact that the fastest-growing drugs of abuse are pharmaceuticals: “Six of the top 10 illicit drugs abused by 12th-graders in the year prior to the survey were prescribed or purchased over the counter.” The leading drugs used were the painkillers Vicodin and OxyContin, and also included stimulants prescribed for ADHD. Most experts don’t prefer a Vicodin or amphetamine-like habit over marijuana use.
In this picture, can we realistically hope to create a drug-free generation, or even to reduce overall psychoactive drug use? Nearly all signs, really, seem to point in the opposite direction, where children will be expected to learn some skills in managing psychoactive substances, and where there will be less time, effort and money that can be devoted to encouraging, with great difficulty, a small percentage of all alcoholics and addicts to quit their substance of choice entirely.
Returning that Pandora’s box to a 1950s “Just Say No” model is, now and forever after, beyond human grasp.