How do we best address treatment for addiction?
We are all too familiar with Hollywood’s depiction of treating substance use. We have watched more than our fair share of movies where the protagonist struggles with an addiction: alcohol, cocaine, heroin, etc. We watch, with a gripping fascination, as our favorite actors and actresses “hit rock bottom” and emergency room their way into a detox program or stumble into the nearest AA/NA meeting in their pajamas and bed hair. The camaraderie in the group builds, we are alerted to the presence of that “one guy” who seems unable to control his cravings, who eventually succumbs to the evil call of (insert drug of choice here), and is kicked out of treatment for displaying such wretched weakness.
As represented by its frequent appearance in the media, we are well-accustomed to abstinence-based approaches to addictions treatment. These abstinence models – which primarily grew out of the 12-step movement – are the most traditional and prevalent treatment approaches to substance use. Studies show that over 90% of treatment programs across America base their approaches on 12-step models of abstinence.
If we look back at the history of abstinence models of treatment, we find that they are not rooted in medical discipline, but rather developed out of the self-help group movement – primarily Alcoholics Anonymous (AA), which began in the early 1930s.
One of the most traditional models of addictions treatment is the Minnesota Model, typically considered the pillar of abstinence programs. During the 1960s, the developers of the Minnesota Model implemented the first 5 steps of the AA program along with the consideration of medical and psychological factors. Through the evolution, modification, and various adaptations of the Minnesota Model, one critical component has remained unchanged: the goal of treatment is absolute abstinence. A zero-tolerance policy is commonly employed, wherein only individuals who are completely drug-free are accepted into the program.
Are abstinence models, however, necessarily the best course of treatment for everyone?
As our understanding of the brain chemistry involved in addiction has progressed over the years, pharmacological interventions have been introduced into the culture of addictions treatment.
Whereas people are commonly indoctrinated to view overcoming the use of substances as a matter of mastering control and the confrontation of denial, the development of pharmacotherapeutic interventions is a more medically-based and modern approach to address typical obstacles to recovery such as cravings, motivation, sleep difficulties, anxiety, and depression.
As an alternative to abstinence-based approaches, the harm reduction model focuses first on decreasing the negative consequences associated with substance use as opposed to eliminating the behavior completely. While proponents of the harm reduction model also perceive the ideal goal of treatment as being abstinence, they recognize that many individuals are unable or are unwilling to stop using absolutely. Knowing this, supporters still find a significant benefit in interventions targeted toward reducing harm, even at miniscule levels.
Methadone programs, which are often considered a part of a harm reduction protocol, have been in existence since the 1960s. As a bridge to abstinence, methadone is administered to individuals with opiate addictions. Such programs have shown efficacy in the stabilization and normalization of many drug users’ lives.
In the U.S., the harm-reduction movement began in the mid-1980s with syringe exchange programs and HIV/AIDS activism in reaction to the outbreak of HIV in impoverished communities related to sharing needles. These activists were working in defiance of the abstinence movement by providing clean needles to drug-users, identifying their primary focus as saving lives through preventing the transmission of HIV as opposed to bringing a halt to drug use.
Eventually, other groups who saw the benefit of harm reduction shifted the focus beyond HIV prevention and centered on substance use itself. Proponents of the harm reduction model highlight the individualized basis of addiction. Every person’s struggle is unique and is experienced along a continuum. Recovery is viewed on a continuum as well as opposed to an all-or-nothing mentality. Harm reductionists believe that productive change happens in steps, with abstinence as the ultimate goal. A popular tenet of belief in this model is that sobriety does not work for everyone. Substance use is commonly, and maladaptively, used as a coping mechanism. Relapse is viewed as part of the recovery process. Until more constructive coping skills are in place, imposing judgment on individuals and their lifestyle can be counterproductive to facilitating change.
Depending on the camp to which you belong, each of these models – abstinence and harm-reduction – can be controversial and is accompanied by its advantages and disadvantages.
Making a definitive decision as to which is the most appropriate method of substance use treatment is left up to debate.
What we know for sure is that relapse rates for addiction are high. They range between 40% to 60% and are comparable to other chronic medical conditions such as diabetes, hypertension, and asthma. The need for interventions, regardless of their theoretical foundations, is obvious. Any help is better than no help at all.
The ultimate goal of all treatment remains the same: enhancing the quality of life for individuals who are struggling with addiction.