There is some controversy within addiction recovery around the idea of abstinence vs. harm reduction. Some believe that a person with a substance use disorder must quit completely—that there is no safe middle ground. But a growing number of people in the treatment community are embracing the idea of harm reduction: That reducing the dangers associated with addiction, or the severity of a person’s addiction, is also a worthy goal.
So, what is the real difference between these two approaches? Here, Dr. Paul R. Linde (Medical Director, Psychiatry and Collaborative Care at Ria Health), offers his take on harm reduction vs. abstinence—and what matters most in supporting people with alcohol use disorder.
What Is the Difference Between Abstinence and Harm Reduction?
Dr. Paul R. Linde:
In my opinion, abstinence is a form of harm reduction. And it is part of a continuum and part of a spectrum.
So, in other words, if you say, “Harm reduction is not okay, people need to stop and that’s the only way to stop. Once an alcoholic, always an alcoholic. Any amount of drinking can set you off on a binge and back to daily, heavy drinking”—there’s definitely a subset of people for whom that is true. And some people learn it the hard way.
But, in my opinion, there’s also a subset of people who can become controlled drinkers. It’s hard to know on the front end, honestly. And I do think it’s worth giving people an opportunity to figure it out as they go.
The discussion I have on the front end always is: “Yeah, well, let’s definitely make a goal to reduce, because you’re going to improve your health, and that’s useful in and of itself. And then you may find, as you feel better over time with less alcohol, you at some point may be thinking, ‘Can I give this up completely?’ ”
And I do hear people say “Y’know, I’d like to be able to drink 3 or 4 times a year—like have a glass of champagne at a wedding.” That to me seems very doable. I think the tough one is, “I’d like to have 2 glasses of wine every Friday and Saturday night.” That’s a little bit harder. I think it’s a common wish, it’s like “I wish I could have one or two and be done, like my friend or my partner.”
So, to me, it shouldn’t be a battle, and sometimes it’s a battle because on the other side, the harm reduction advocates, they often come not so much from an alcohol background. They definitely come from an injection drug use background.
With people who have been injecting heroin, cocaine, methamphetamine—clearly injecting any of those substances is much more harmful than smoking it, snorting it, or taking a pill. So, to me, a lot of the really strong harm reduction advocates are coming at it from: “If I can get this person to stop shooting heroin, and [instead] smoking heroin, it’s unlikely they’re going to die from an overdose by smoking heroin.” Their odds of dying from an overdose if they’re injecting heroin are high.
So, there’s that, plus all the infections related to injecting—risks for hepatitis C, HIV, and then the risk for local infections if you’re continually jabbing yourself—you’re at risk for abscesses, etc. So I think the people who are most passionate about it come from working with those kinds of patients.
With alcohol it’s a little bit more nebulous. And I still feel like alcohol has this extra layer of stigma attached to it. I think in part because it’s so “everyday,” so ubiquitous, that I think people feel like, “you should be able to do that.”
I mean, I think people who drink too much, often they don’t put themselves in the same bucket as a heroin addict—there’s extra stigma associated with an injection drug user beyond alcohol. But alcohol has its own sort of pernicious stigma associated with it in that, “you should be able to do that, you’re a normal person, why can’t you just stop.”
But this thing I really hate [about the abstinence vs harm reduction debate] is that we’re really all on the same page of trying to help people with their goals. What I like about Ria Health is that we meet people where they’re at. I know it’s become kind of a buzzword right now in our generation. But the bottom line is it’s respectful: “Let me ask you what you’d like to do rather than me telling you what to do.”1 I think there needs to be a lot more of that in healthcare. Because it works better, y’know?
So, I like that. People come in, and I think people are very open. They’re just starting; they’ll go, “Well, that’s my goal. But I’m open to stopping completely, but I don’t know.” And I’m like, “Awesome, you’re going to have a physician and nurse practitioner and a coach, and you’re going to be reading and you’re going to be doing stuff, and you’re gonna figure it out for yourself. And we’re here to help you figure it out.”
To me, that’s a change that’s more likely to stick. Rather than you doing something because I told you to, or just to avoid a negative consequence—which is probably not going to be enough at the end of the day.
Ria Health offers support for alcohol use disorder via telehealth, tailored to each individual’s needs and goals. Learn more about how it works.