Doing it wrong?

August 28, 2022
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(Wrong Way” by Jack Zalium is licensed under CC BY-NC 2.0.)

More and more frequently I’m hearing self-identified and publicly recognized recovery advocates state that providing harm reduction services with the goal of moving people toward recovery or treatment constitutes “doing it wrong.”

This perspective isn’t limited to a few outliers, I heard it voiced at a SAMHSA recovery summit and have seen it endorsed by public officials and influential leaders in and around the field.

I recently explored the limitations of framing harm reduction as liberation, particularly where people with the illness of addiction are involved.

When responding to an illness with high mortality rates, high rates of functional impairment, and high rates of negative externalities (negative effects on families, communities, public safety, and public health), it seems neglectful for public health or individual interventions to adopt a neutral attitude toward recovery and treatments that can prevent overdose and improve quality of life.

In cases that don’t involve the disease of addiction, I’d generally agree that recovery and treatment may be the wrong goals. However, the context of the overdose crisis makes it hard to be neutral about nonmedical opioid use.

I recognize the importance of things like respect, self-determination, the primacy of the relationship, and solidarity. Other relevant values might include healing, patient welfare, family welfare, community welfare, flourishing (maximizing global health and quality of life), hope, and restoration.

These values don’t line up neatly behind one intervention or another. One value could be aligned with multiple interventions but, in many cases, different values will more clearly align with different interventions and our challenge is to manage that tension. We may manage that tension by creating space for multiple approaches, or seeking ways to mitigate the trade-offs inherent in an approach so that we’re not choosing one group over another. Recovery-oriented harm reduction is an attempt to do this — recognizing that most people using AOD are not addicted, that lower-risk use is an appropriate goal for them, that full sustained recovery is the ideal outcome for people with addiction, that these interventions shouldn’t engage in coercion, that all change should be supported and affirmed, and that the participant’s worth does not — in any way — depend on their goals or current substance use.

This approach, however, requires choosing to tolerate dissonance, managing bias, and looking for both/and responses, which is unlikely to generate lots of cheers and clicks.

In that spirit, I’d wholly support a statement like, “If you’re providing harm reduction services, and treatment or recovery are the only goals that really matter to you, you’re doing it wrong.”

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