At the recent SECAD ’06 conference for addiction professionals, an entire day on the agenda was devoted to the promise of medications for enhancing outcomes in the treatment of chemical dependence. Whereas most medications are intended to enhance abstinence (e.g., naltrexone, acamprosate), others can be used for detoxification and also prolonged treatment (e.g., buprenorphine), and at least one is now used by some patients for maintenance of a stable opioid state (methadone). These medications have been discussed extensively in previous issues of Addiction Professional and will be covered in more detail throughout 2007.
A growing acceptance of “multiple pathways to recovery” has emerged in our field, as exemplified by the wonderful mix of people who make up the membership of the group Faces and Voices of Recovery. Members of this up-and-coming advocacy organization decided during the group's inception to set aside philosophical differences concerning “the best” way to recover, in order to form a powerful voice to publicize that treatments and programs of all types work. As a result, those who have found better lives through abstinence now work together with people whose lives have been improved through methadone.
Methadone maintenance is a form of “harm reduction,” a poorly understood and still maligned term encompassing efforts to reduce the negative effects of drug use on individuals and society. For those devoted to abstinence, harm reduction represents a scary thought. Some groups in the past even have lobbied to suppress methods of harm reduction, or to prevent harm reduction experts from speaking at professional conferences. Interestingly, though, 12-Step groups and methadone maintenance have a commonality in that both promote long-term recovery from the chronic illness of addiction—a rare instance of unity in our field.
One size doesn’t fit all
Many people who have achieved abstinence from drug use through 12-Step programs oppose harm reduction, since the strategy is seen as antithetical (even a threat) to abstinence-based programs. But people helped by harm reduction methods are often drug abusers who may not require abstinence in order to achieve a better quality of life, or they are chemically dependent people for whom 12-Step programs are not attractive or effective. Our profession long ago should have given up the idea of “one treatment for all,” for such thinking creates further stigma and misunderstanding in the minds of the public and policy makers. Yet old emotions hang on, and what worked for many people is erroneously assumed to work for all.
While it is understandable that people who recover from drug problems should fervently embrace the method that gave them sobriety, our field is finally beginning to understand that there are many ways to overcome drug abuse and dependence. Medications are one of these, and controlled drug use (e.g., methadone) is another. In some cases, particularly in those who have an abuse problem rather than dependence, quality of life can be significantly improved by a simple reduction in frequency or quantity of drug use.
For those who are against harm reduction, it is important to remember that two examples of harm reduction strategies are public education about the dangers of drunk driving and needle exchange programs to reduce viral transmission among drug injectors. Can anyone be against trying to reduce drunk driving?
With regard to “recovery,” we now understand that this entails more than simply stopping or reducing drug use. For some people who are abstinent, recovery remains elusive and an enhanced quality of life is still to be achieved. Others who have struggled with drug problems have a greatly increased quality of life through a reduction of primary drug use or maintenance of drug use with counseling.
The best situations are either remission of all symptoms of chemical dependence or a higher quality of life through controlled drug use or reduced signs of disease. Just as with diabetes, total remission of symptoms is not necessary or always possible for a person to live a better life.