Following the death of Glee star Cory Monteith from a heroin overdose after being discharged from rehab, questions have been raised about the ‘safety’ of abstinence-based programmes. The debate stems from a difference of opinion between advocates of ‘harm reduction’ policies adopted by many governments around the world and the 12 Step style treatment offered at many rehabs in the US, as well as at The Cabin – although ours has been secularised to be culturally sensitive.
Criticism of abstinence based clinical practice centres around the fact that addicts like Monteith are reduced too quickly from opiates (heroin and any other substitute medications), that the treatment duration is too short, and that consequently they are vulnerable to overdose when they re-enter the community because their tolerance is lowered during the period of sobriety.
Twelve Step programmes typically promote abstinence as the only ‘cure’. Now that medical bodies such as The American Society of Addiction Medicine (ASAM) – and The National Institute of Drug Abuse (NIDA) have defined addiction as a primary and chronic illness, which disturbs the normal balance of the brain’s reasoning and impulse control mechanisms, it is certainly the case that addicts will never be able to control any drug which is narcotic in its effect, in the way a ‘normal’ person would. What’s more they will never gain normal control because it’s a chronic illness which means it never goes away; it has to be treated.
Because addiction is a chronically relapsing condition in which many addicts will eventually return to harmful behaviors, harm reductionists argue that it is unsafe to take an addicted person completely off drugs such as heroin due to the risk of overdose, due to lower tolerance. Practioners instead provide substitute and ‘safe’ medications like methadone or subutex (for heroin addicts). Often the advice from harm minimization groups is to retain or maintain rather than reduce, in other words…keep the patient on that drug…..permanently, because this is safer than the risk of death.
The problem with this approach, as many 12 step groups would point out, is that it doesn’t take into account another ethical issue. Namely the rights of an individual (who is so impaired they can’t make up their own mind) to be free of chemical addiction and have their full emotional, physical, mental and spiritual functioning back. According to The Substance Abuse and Mental Health Services (SAMHSA) recovery from addiction is defined in the following way.
“Recovery from Mental Disorders and Substance Use Disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential”.
This, abstinence practioners would argue, is hard to achieve whilst still ‘high’, even on a legal medication. Experienced recovering addict counselors also point out that agonist or partial agonist medications like methadone and subutex, mimic the effect of the drug. Not only do they get you high enough to relieve cravings but they also stimulate the addicted brain’s reward system, causing cravings, and impaired reasoning around consequences. –including being seemingly unable to follow direction and continuing to abuse a wide variety of other drugs, sell their methadone for money for heroin, fake their urine tests and countless other methods of non-compliance.
However, abstinence is recommended as the predominant goal for complete and holistic treatment of and recovery from this disease by all the aforementioned medical bodies as well as The American Psychiatric Association (APA) who state:
“For most patients, the primary goal of treatment is attainment and maintenance of abstinence (with the exception of methadone-maintained patients), but this may take numerous attempts and failures at “controlled” use before sufficient motivation is mobilized…… Total abstinence is strongly associated with a positive long-term prognosis”.
Here at The Cabin we believe that a holistic approach is needed, and follow the guidelines of NIDA, SAMHSA and others, by assessing chronic heroin addicts with a goal to long term reduction and eventual abstinence. As NIDA point out – a long enough time frame for treating such addicts is essential. Harm reduction has its place but abstinence is always the ideal goal to be strived for if it can be safely achieved.