Harm Seduction
Addiction, abstinence and the misery we enable
Below is another submission from Anonymed. I’ve written about this issue previously.
Reading Anonymed’s essay brought to mind a few thoughts worth sharing.
When I was a med student in the 90’s, I never came across the term “harm reduction”. I did learn about the basics of “drug rehab”. Methadone programs were thought of as temporary. Methadone was used to mitigate withdrawal, and tapered over an agreed-upon timeframe: 3, 6, 12 months, sometimes longer. The program wasn’t just there to give methadone though. The “active ingredients” (I love this terminology - thanks Julian Somers) were things like finding housing, employment, counselling for mental health issues, helping reconnect with estranged family and friends. It was these things, and not the drug, that was "The Solution” to addiction. Johann Hari has said “The opposite of addiction is not sobriety. It is human connection.”. Patients in a program were regularly tested to make sure they weren’t taking other drugs, and kicked out if they tested positive. Eventual abstinence was almost always the goal, and there were consequences for breaking the rules.
Sometime in the early 2010’s I attended Nova Scotia’s biggest yearly physician education event. Over several days talks covered multiple topics from kidney stones to brain tumours to addiction. I recall being shocked (as were the docs I was sitting next to) when the addiction Expert™ explained in response to an audience question that they no longer kicked anyone out of a rehabilitation program for a positive drug test. The questioner was puzzled. So there are no consequences? The Expert™ explained that the positive test was a signal that the drug doses being given to the patient were too low. Rather than looking at a positive test as a sign of non-compliance and lack of commitment to moving beyond addiction, he saw it as a sign that the program was failing the patient. What more should we be doing for them? How much higher a dose do they need in order to “stay clean”? The answer was to give “enough” drugs. (The new slogan of drug rehab seemed to have become “Ask not what you can do for your own benefit, ask what the program can do for you”)
Over my time in medicine, drug rehabilitation programs have devolved into “Opiate Replacement Programs”, or “ORP”. The other parts of the program - help finding meaningful work, re-connecting with family, finding suitable housing, counselling for co-morbid mental health issues - have largely melted away and left the skeleton of a program which consists of getting your drug (previously methadone, now mostly Suboxone - safer, but also more expensive, under patent, and thus more lucrative for Big Pharma) every day.
Someone in Nova Scotia who wants to get OFF drugs has to pay privately if they want intensive (e.g. residential) treatment. Their only government-funded option is ORP. The same Big Pharma that helped to bring you The Opioid Epidemic™ has now brought us The Solution to the Opioid Epidemic™. And - surprise surprise - it’s a drug!
Anonymed is a Canadian physician, who for reasons that should be obvious in 2023’s political climate, prefers to keep his identity private. Here is his essay:
Harm Seduction
Addiction, abstinence and the misery we enable
Picture a room, small and intimate. A man slowly ascends a set of steps to a makeshift stage. He clears his throat before addressing his audience: “M-my name is Jake, and my drug of choice is crack cocaine.”
What setting comes to mind when you hear that statement? I think one would be forgiven for picturing a broken man, exhausted from shame, introducing himself at, say, his first Narcotics Anonymous meeting. Having watched his world crumble mercilessly around him - his job gone, his loved ones hardened, his dignity dismantled brick by brick - he stands, head hung and heart bared, before a group of strangers who simultaneously know nothing and everything about him. This Jake is a product of experience, of loss; his face a grayed and sunken tribute to the perils of addiction.
In this case, however, you would be wrong. The real Jake (not actually Jake) was an invited speaker at a course entitled Harm Reduction 101. He was there to tell his story, but not in the way one might think. He was not a cautionary tale. He was not the voice of regret or tortured experience. He was himself an addictions counsellor, and he was there to teach us about the hottest term in the progressive lexicon: harm reduction.
This was Toronto in the early 2010s. I was pre-medicine and surrounded by the kind of aloof academics and policy wonks that give such people a bad name. I felt detached from “real” people. Addiction and its accoutrements had long been of interest to me, and as a young man, the gritty, altogether human aspect of “the street” was intriguing. It was raw and genuine and tragic. It was a place where real good could be done.
I was naive about a lot of things back then, but when I signed up for the workshop, I expected to be inspired. I had some experience with the rough and tumble world of what is now referred to as “urban health”, and was fascinated. But in that course, in that room, there was something much more radical on offer.
It was clear early on that the workshop wasn’t especially focused on the harm caused by drugs, and certainly wasn’t fussing about reduction. Years ago, before images of open drug use painted social media and decriminalization (even of marijuana) was a political non-starter, I imagine those Canadians who had heard of harm reduction associated it with “clean needles” and disease prevention for society’s most downtrodden. It was permissive in the sense that addicts weren’t being rounded up and forced into treatment, but it wasn’t exactly endorsing drug use. It was a public health measure. It was sane. I imagine they pictured selfless social workers and intrepid doctors and nurses advocating for housing and rehabilitation programs, and treating the many by-products of lives that revolve around the procurement and administration of hard drugs. The assumption would always have been that the goal, no matter how difficult or circuitous to reach, was to help people stop using drugs.
Some of this was true then, and remnants of such an approach still exist today. But even ten years ago, abstinence was increasingly viewed not only as unachievable, but undesirable - a relic of a religio-paternalistic era where addiction was seen as a disease (if not a sin) rather than a response to the socio-cultural forces of the day. The notion of sobriety was thus dismissed as antiquated, and while addiction, like everything, was said to be “on a continuum”, abstinence was increasingly absent from that spectrum.
Jake spoke proudly of his “functional” drug use, describing how he maintained a work-life balance by only smoking crack cocaine during the evening and on weekends. Other speakers recounted the joys of working as harm reduction “peer support” workers, which is to say as active drug users employed to counsel and guide others with a similar affliction. Still others described the way in which clean needles, “crack kits” (which contain a fresh pipe and associated paraphernalia) and proper instruction in “administration” had helped them stay safe. All touted the benefits of “reducing harm” in such ways. All spoke of the benefits of preventing disease, reducing injury, and mitigating overdose. Much of this is positive and true. But even then, when abstinence was mentioned, it was always in the context of criticizing outdated and conservative approaches to “using.”
I can’t any longer remember how it was phrased, but at some point the moderator put a question to the audience: “Is there a downside to harm reduction?” I remember he almost laughed as he said it. To him it was rhetorical. Everyone in the room ought to have known the answer was “no.” It was a glimpse of now familiar DEI struggle sessions, wherein participants are asked whether they think they are racist, with the only acceptable answer being “yes, super duperly so.” Still, frustrated as I was by the hive-like mentality in the room, I raised my hand and gave it a go: “Ought we to consider the impact on the moral fabric of society that might come from normalizing drug use?” Not my most precise moment, but mine host didn’t even consider the question worthy of a response. He curled his upper lip in the way one does when a foul stench percolates in the air, waved his hand dismissively in my direction, and polled the audience: “What do we think?” he asked, again rhetorically. The audience laughed, collectively braying their disapproval: “nooo!”
Harm Reduction was woke before woke was cool. The term is intentionally impregnable. In the same way people were too terrified to oppose Black Lives Matter lest they be accused of suggesting the opposite, so too were many reluctant to criticize the tenets of harm reduction - who wouldn’t want to reduce harm? It is a seductive term. It plays on the desire of most of us to do good, to relieve suffering, and to be seen as compassionate. Even after my minor pillorying at Harm Reduction 101, I still believed the approach, broadly speaking, was sound. It seemed intuitive that if addiction to hard drugs was nearly impossible to fix (as much evidence seems to suggest) then the socially responsible thing to do was to mitigate its worst consequences, both for the individual addict and society in general. Unfortunately, harm reduction is like Black Lives Matter in another way: it is a societal-scale bait and switch. Its allure as an intuitive and righteous-sounding movement masks a radical agenda.
In 2008, physician Gabor Mate published In the Realm of Hungry Ghosts, an account of his many “close encounters with addiction” practicing medicine in Vancouver’s notorious Downtown Eastside. The book was a huge success, and exposed the reading public, perhaps for the first time, to the suffering and revolving-door misery of society’s most traumatized and, per the title, haunted individuals. The impact was far-reaching. For those like myself who longed for a selfless, hard-knocks kind of meaning, it was a clarion call. But more than that, it provided immeasurable publicity for Mate’s place of work, the InSite Supervised Injection Site, where addicts were provided with a safe place to administer their drug of choice.
As promotional materials go, it’s hard to imagine a greater boon to the harm reduction movement than Mate’s passionate tome. Safe injection sites, once an obscure concept advocated for by a small contingent of activists and front line workers, became the tip of the harm reduction spear. Despite initial pushback from a few pesky conservative types, sites were eventually approved in Toronto, Montreal and other smaller cities across the country. The ethical outlook that saw drug use as a societal cancer, and its enablement as morally scandalous, was slowly eroded.
Mate toured the country, sharing his view of addiction and promoting his preferred solutions. Reception in the medical community was mixed (for good reason, it turned out) but Mate’s core message - that drug use is a functional, even rational, response to deep-seated trauma - gained traction in the increasingly progressive health policy world. Not only was it no longer taboo to propose state-facilitated intravenous drug use, the harm reduction movement also drew closer to its ultimate goal - state-provisioned drugs.
It wasn’t that long ago that decriminalization of drugs, let alone legalization, seemed highly unlikely. For all their faults, the “Just Say No” generation and the American War on Drugs cast a long shadow. Growing up as a Millennial, marijuana was still widely viewed as a gateway drug, and use of anything beyond pot and mushrooms was taboo, even among the cool kids. But times change, and while no single figure or book can be credited with such a monumental shift in the public mood, a monumental shift it was. If the ultimate goal of the “right to die” crowd is unfettered access to the physician’s syringe by anyone who desires it (don’t kid yourself, this is and has always been the goal), the reductio ad absurdum of the harm reduction movement is the provision of legally available drugs to end users paid for by the Canadian taxpayer.
When I say this was always the goal I mean that it was always the goal. As my early experience suggests, harm reduction was never intended to be a progressive and compassionate partner on the bumpy road to abstinence. For abstinence to form part of the addiction continuum, there must at some level exist the assumption that being addicted to hard drugs is a suboptimal way to exist in the world. This is the classic approach advocated by the likes of Alcoholics Anonymous, Narcotics Anonymous, and (historically at least) most rehabilitation centres. But if addiction is instead viewed as a rational response to life circumstances brought about by the social determinants of health, then the problem is not so much the drugs, but the society that stigmatizes their users.
Addiction, particularly the life destroying kind of addiction that harm reduction policies are designed to address, is a complex phenomenon. Mate, for his part, was right to notice that his patients, to a man, had suffered greatly in their lives. I also agree that mandating treatment isn’t a one size fits all solution and has the potential to become too coercive and conflict with important civil liberties. However, when drug policy becomes so radical that we remove barriers to drug access while simultaneously diminishing the importance of treatment, we are in effect giving up on some of our most troubled and vulnerable fellow citizens. I know what the Downtown Eastside used to look like, and I know what it looks like now. The proof is in the empirical pudding. Have our efforts to destigmatize, decriminalize, and deinstitutionalize made the lives of addicts better or worse? I think the answer is plain to see. Far from reducing the harm of addiction, we have opted, in our quest for progress, to harm the ultimate goal of reducing individual misery.
Abstinence represents a mortal danger to those who "earn a living" working in the marketplace of treatment protocols and pathways.
We get what we tolerate.