Recovery and harm reduction: time for a shared, development oriented,
programmatic approach? By Neil Hunt
In, Harm Reduction in substance use and high-risk behaviour, (Eds.) Richard
Pates and Diane Riley, Chichester: Wiley-Blackwell, 2012
In recent years, the UK has seen a marked shift in its discourse on drug policy, in
which a developing critique of its long-standing harm reduction based strategy has led to one that puts recovery at its core (Ashton, 2008, Scottish Government, 2008b, H M Government, 2010). Official versions of recovery have been conflated with an expected goal of becoming abstinent, which is explicit in the coalition government’s drug strategy “Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life” (2010). This has generated a degree of debate about real or perceived tensions between these two approaches, in which one is frequently characterised as being in opposition to the other. Proponents of the shift to recovery have been critical of the UK’s harm reduction based treatment system for its failure to produce people who are drug free. This has been attributed to an over-reliance on methadone within services that are driven by government targets and portrayed as doing little to develop people’s hope, optimism and ambitions for a life beyond treatment. Treatment services have been criticised for failing to meet people’s wider needs for psycho-social interventions within programmes that properly enable (re)integration. Simultaneously, they are portrayed as protective of professional power and reluctant to recognise the contribution that the wider recovery community does or could make (McKeganey, 2006, McKeganey, 2007, Best et al., 2008, Best et al., 2009a, Best et al., 2009b, Best, 2010).
From a harm reduction perspective, a prominent concern has been that evidence-based interventions, which reliably achieve important public health impacts, health gains and benefits for community safety (chiefly needle and syringe programmes [NSPs] and opioid substitution treatment [OST]) may be undermined if spending is shifted towards programmes where the evidence is perceived to be weaker and a treatment goal is imposed rather than negotiated.
Alongside a process that continues to have undeniable strands of conflict, there has also been a discernable move towards consensus. Dialogue has generally increased between people who are primarily associated with a harm reduction perspective and those with a greater recovery-orientation. This has been evident at a number of levels including: the diverse UK discussion lists and online forums; numerous meetings and conferences with recovery-related themes; and, various print and online publications, for example see Bamber (2010). Polemical voices can still be heard, but any observer of this process would find it difficult to miss the more widespread and quietly developing respect among people whose views reflect different traditions, needs and experiences, and the corresponding exploration of ways they can best work together.
This article evaluates the considerable common ground that exists between harm reduction and the particular ‘new recovery’ that is developing in the UK. In doing so, 2 areas that remain potentially divisive are examined as are opportunities for greater collaboration around shared values and goals.
Within a chapter that addresses readers from both harm reduction and recovery
perspectives, it is necessary to clarify some of the terminology that will be used.
Although many people readily describe themselves using terms such as ‘alcoholic’ or ‘addict’ and value the concept of ‘addiction’ as a way of making sense of their experiences, this language can also be experienced as offensive, subjugating and alienating by some of the people to whom it is applied. In particular, it can imply a disease model that is both contested and a focus for political struggle regarding drug using identities (Davies, 1997, Albert, 2010). Within this chapter, it is nevertheless taken as uncontroversial that for some people who use alcohol or other drugs, loss of control over the frequency and pattern of use is sometimes experienced as a profound problem. The term preferred throughout this chapter is ‘person experiencing an alcohol or other drug problem’, because it places use within a continuum of life experience, rather than turning the person into the thing.
Working across these two perspectives often requires looking past words that can
seem toxic and working hard to keep people’s underlying intentions and
understanding clearly in view. It requires openness to the possibility that our world view and the cherished concepts we use to describe it may need to become subtler, more fine-grained, amended or even discarded; and, that approaches which don’t work for one person can, equally, be life-saving for others, when all the time our own beliefs, experiences, perhaps even our entire biography, shouts out that this can’t be so.
‘Harm reduction’ and ‘recovery’ are concepts that are both contested and evolving. The comparative approach used in the chapter draws primarily on formal accounts that describe the principals on which each is based. The following two sections provide a brief historical context and the justification for selecting the versions that are compared.
Harm reduction is commonly traced back to 1926 when the Rolleston report urged a medical approach of prescribing people’s drug of dependence rather than the punitive, criminal justice approach that then (and still) prevailed in the USA; however, the term was first used by Russell Newcombe in 1987 (1987). It then entered widespread use as a term applied to the pragmatic responses to HIV/AIDS among people who inject drugs and has since been broadened to signify a philosophy that can potentially be applied to any harm that arises from the use of alcohol and other drugs.
Harm reduction’s definition builds on Newcombe’s early framework based a matrix of types and levels of harms (Newcombe, 1992). It is typically seen as operating across a hierarchy of types and levels of harm, focusing on those immediate threats to safety and well-being that are most amenable to change, yet recognising the importance of abstinence, where this can be achieved Advisory Council on the Misuse of Drugs, (ACMD, 1988).
1 A convention for which I am grateful to William White.
The detailed practice and policies of harm reduction tend to vary in a way that is
context dependent and according to factors including: a country’s specific drug
problems/harms; its economic situation; the stage of development of its services; and, broad socio-cultural factors (IHRA, 2010). See Rhodes and Hedrich (2010) and elsewhere in this volume for some illustrations of these variations
Since the inception of harm reduction, a variety of definitions have been proposed (Newcombe, 1992, Lenton and Single, 1998, Riley et al., 1999). In recent years, there has been a noticeable development in the way that human rights have featured within harm reduction advocacy; a process that has received strong support from Harm Reduction International (HRI), the global body through which the different regional and national harm reduction networks are affiliated (formerly the International Harm Reduction Association). It seems likely that the meaning of harm reduction will continue to evolve; however, the IHRA position statement “What is harm reduction?” (2010) is, in effect, an official definition and has therefore been used substantially as the basis for comparison within this chapter.
The origins of the recovery and temperance movements are intertwined, with both emerging in the USA and UK during the first half of the nineteenth century amidst concern with the drinking patterns of an increasingly urbanized migrant labour force (Yates and Malloch, 2010). Alcoholics Anonymous (AA), the archetypal recovery fellowship, was founded in 1935, followed later by Narcotics Anonymous (NA), and a wide array of other peer-based groups that includes diverse religious, spiritual and secular addiction recovery mutual aid societies (White, 1998).
Until recently, the UK the recovery movement has seemed largely synonymous with the 12-step fellowships: notably Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and, increasingly, Cocaine Anonymous (CA). Consequently, in terms of people’s general understanding of recovery within the UK, the 12-step approach has sometimes seemed like the only available model. For many harm reductionists, this has almost certainly engendered a degree of resistance to recovery due to a perceived clash between some of the central tenets of the 12-step movement and harm reductionists’ values and world-view. For example, harm reduction’s principle of promoting any positive change and focusing on immediate, urgent, achievable goals is in tension with the near-exclusive emphasis on abstinence as a control strategy that is embedded within the 12-step approach. Likewise, acknowledging being ‘powerless’ is inconsistent with a view which routinely incorporates behavioural change and selfcontrol strategies to achieve moderation and risk reduction across populations that include experimental and occasional consumers and for whom a notion of powerlessness contradicts the daily reality of people’s lives. Furthermore, the concept of a ‘higher power’ and the quasi-religious tenor of the 12-step approach evokes
caution among some harm reductionists; many of whom tend to hold a rationalist, secular outlook. Reliance on an external higher power may also be seen to conflict with a view that harm is reduced when people are supported to achieve greater autonomy and self-empowerment i.e. mobilising resources from within themselves. These are, of course, generalisations with all the caveats that generalisations require. Many 12-step advocates would immediately and rightly respond that their beliefs are considerably more nuanced than this somewhat superficial and stereotyped interpretation of the 12-step perspective. Nevertheless, this reading of recovery seems common among harm reductionists and worth noting as a potential source of some of the differences and misunderstandings within the unfolding debates about the interplay and respective roles of harm reduction and recovery within UK drug policy.
Despite the continued importance of the 12-step fellowships, in recent years there has also been a growth in the number of mutual aid groups operating outside of the 12- step tradition, which reflect a wider range of preferences and needs. Almost certainly, this expansion has been stimulated by the shift to a recovery focus within the UK’s various drug strategies. It is difficult to fully catalogue this new diversity but, within it, a great variety of local groups have developed out of programmes linked to treatment services. Additionally, more formalised systems such as SMART Recovery® UK, which offer a secular approach and draw explicitly on psychological theory have become far more visible. These developments are one reason for any harm reductionist who simply equates recovery with the 12-step fellowships to reappraise their understanding of the broader concept and principles that recovery now comprises. These changes are evident within several attempts by prominent interest groups to formalise a modern vision of recovery for the UK.
A key contribution to the attempt to define this distinctive UK recovery is provided by a ‘recovery consensus panel’ convened by the UK Drug Policy Commission (UKDPC). This included both people in recovery (i.e. experts through experience) and other professional experts (2008). The group took the work of The Betty Ford Institute Consensus Panel (2007) in the USA as a starting point and eventually developed a ‘vision statement’ as follows:
“The process of recovery from problematic substance use is characterised by
voluntarily-sustained control over substance use which maximises health and
wellbeing and participation in the rights, roles and responsibilities of society.”
It is instructive to read the full report on this process, which explains some of the
reasons for the ways in which this version differs from that of the Betty Ford Institute Consensus Panel (BFICP). For example, the BFICP (2007) uses the terms ‘sobriety’ and ‘citizenship’, whereas the UK statement talks of ‘voluntarily sustained control’ and ‘participation in the rights, roles and responsibilities of society’; changes that reflect concerns about a simple equation between recovery and abstinence and caution about ‘citizenship’ as a term that might be interpreted to require active engagement in employment, which then becomes an absolute requirement for recovery (2008).
Another influential point of reference for any contemporary UK understanding of
recovery is the set of 12 principles produced by the USA’s Center for Substance
Abuse Treatment (CSAT), within the Substance Abuse and Mental Health Services
Administration (SAMHSA). Although American, this work is often referred to by UK recovery advocates; possibly because it has been developed through a careful
consensus-building process and is therefore well-suited to bringing together different perspectives in a way that people feel to be needed here. Clearly, its recency and provenance as a government-promoted initiative in the country that is a global centre for the recovery movement also means that it carries considerable authority (Sheedy and Whitter, 2009). The CSAT group agreed the following ‘working definition’ – a term that suggests a degree of tentativeness:
“Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of
It is, however, their 12 ‘guiding principles’ that are most widely referred to in Britain. These provide a more elaborated understanding of recovery that is inclusive of diverse approaches and unhindered by some of the problems that some harm reductionists have found inherent within the 12-step philosophy. The principles state that:
1. There are many pathways to recovery
2. Recovery is self-directed and empowering
3. Recovery involves a personal recognition of the need for change and
4. Recovery is holistic
5. Recovery has cultural dimensions
6. Recovery exists on a continuum of improved health and wellbeing
7. Recovery emerges from hope and gratitude
8. Recovery involves a process of healing and self-redefinition
9. Recovery involves addressing discrimination and transcending shame and
10. Recovery is supported by peers and allies
11. Recovery involves (re)joining and (re)building a life in the community
12. Recovery is a reality
(Sheedy and Whitter, 2009)
It could be said – unfairly perhaps – that some of these are illustrative of the sort of woolly, meaningless statements that result from consensus building between parties with very different world-views; nevertheless, it will later be argued that some of these have considerable relevance to any discussion about an accommodation between harm reduction and recovery. One further reason for focusing on these principles is that they have recently been adapted by the UK Recovery Federation (UKRF) – also within a consensus-building process – albeit one that was not as well-resourced and extensive as that in the USA. Any claim to represent the true voice of recovery in the UK might be premature and would probably still be contested but, still, the views of any initiative that is attempting to build consensus across a federated alliance of interested parties is relevant to the discussion here. The amended principles published by the UKRF still reflect the core of the CSAT principles, but among other things they have more explicit reference to: the role of families; the structural factors that contribute to people’s experience of drug and alcohol problems.
In the interests of transparency, please note that I am an advisory board member of the UKRF representing the UK Harm Reduction Alliance (UKHRA). The UKRF’s initiative of extending an invitation to UKHRA to provide representation was an early signal to me that an inclusive, broad-based recovery was developing and that there were opportunities for a collaborative approach between parties who do not have a strong history of dialogue, which
might yield benefits that were not then fully appreciated. ‘recovery capital’, which is emerging as a key concept within the new recovery; and, the relationship between recovery, abstinence and harm reduction (UK Recovery Federation, 2011). For more on recovery capital see Best and Laudet (2010) .
The concept of recovery is not, however, restricted to the realm of problems people experience with alcohol and other drugs. In the UK, a mental health recovery movement has developed strongly since a vision for it was articulated in the early 1990s. Anthony (1993) characterises recovery as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” Mental health recovery also incorporates a notion of a hierarchy of needs and the mental health charity Rethink (2008) has argued that recovery requires the fulfilment of three basic conditions:
The person has a place to live that is safe and free from threat
The person has to be free from acute physical and psychological distress
The person has to have basic human rights that mean they are able to make
Recovery has been an explicit, government principle for mental health services since 2001 and well before it ever featured in the UK’s drug strategies (Department of Health, 2001). Consequently, alongside definitions of recovery embedded in the drugs field, an understanding of recovery in the UK is also, to some extent, informed by a concept of mental health recovery that is not directly connected with alcohol or other drugs; not least because many people experience overlapping mental health and drug and alcohol problems.
Recovery and harm reduction compared
The two previous sections have identified key, contemporary, formal accounts of
harm reduction and recovery that contain consensus statements about the core beliefs, values and principles of these two perspectives and provide a basis for comparison. To what extent do harm reduction and recovery have common ground? Where are there differences of emphasis? And in what ways do tensions arise? This section offers a commentary on these questions with reference to several of the more obvious and important themes.
Abstinence: more agreement than disagreement
Much of the debate about the compatibility of harm reduction and recovery seems to revolve around the question of abstinence; however, in terms of the identified texts there seems to be a large measure of overlap. In its position statement IHRA (2010) explicitly acknowledges that abstinence is a desirable option: “The objective of harm reduction in a specific context can often be arranged in a hierarchy with the more feasible options at one end (e.g. measures to keep people healthy) and less feasible but desirable options at the other end. Abstinence can be considered a difficult to achieve but desirable option for harm reduction in such a hierarchy. “
This is tempered with the recognition that attaining abstinence is often difficult and will not always be feasible; nevertheless, it reflects an underlying logic that, for any given substance, not consuming the substance at all is, ultimately, the most effective way of avoiding its harms. Most harm reductionists would be quick to add a caveat that if the pursuit of abstinence results in a succession of lapses, the net result can be an overall increase in risk and harm. The reduced tolerance and heightened risk of fatal overdose after elective detoxification or enforced withdrawal through imprisonment are widely recognised hazards that need to be weighed against the benefits of any interim period of abstinence. There is also a need to understand the consequences of abstinence from a drug or drugs in the round. A programme that achieves abstinence from illicit and prescribed opiates, yet sees this replaced by increased reliance on alcohol in a person with a liver compromised by hepatitis C infection may lead to a net increase in harm. It is also arguable that in cases where a person is using a drug to self-medicate an underlying trauma or disturbance, abstinence will result in net harm unless the more fundamental problems can also be effectively addressed. Each of these caveats has implications for the design and operation of abstinence-oriented programmes, the way they are integrated with other services and the calculus between the likely risks and benefits of attempting to achieve abstinence. They do not, however, detract from the principle that abstinence is a desirable option, which can confer a net reduction in harms and is achieved and sustained by some people. Conversely, the emerging UK model of recovery cannot reasonably be characterised as synonymous with or requiring abstinence. This is not to deny that abstinence from one or more substances is a widespread goal of people who define themselves as recovering or in recovery – it is. Recovery has, nevertheless, been reformulated as a broader concept that is not so exclusively predicated on the question of whether someone’s life is drug and/or alcohol free. This is evident in several ways.
The Recovery Consensus Group convened by the UK Drug Policy Commission
(2008) characterised recovery as “voluntarily-sustained control over substance use”. This is distinct from the definition agreed by the Betty Ford Institute Consensus Panel (2007) of “a voluntarily maintained lifestyle characterised by sobriety”. ‘Control’ is privileged over ‘sobriety’ with the latter’s implication of abstinence and the UK group further qualify their definition by saying recovery ”may mean abstinence supported by prescribed medication or consistently moderate use of some substances (for example, the occasional alcoholic drink).”
In the CSAT/SAMHSA “Guiding principles and elements of recovery-oriented
systems of care” (Sheedy and Whitter, 2009) the participants agreed a working
definition of recovery as “…a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life.”
Abstinence here is construed as an ultimate goal but not the ultimate goal and is regarded as integral to attaining goals of health, well-being and quality of life. The corresponding 12 principles also suggest a pragmatism that values a range of interim steps and diverse ways of approaching recovery that resonate strongly with a harm reduction approach. Three in particular warrant mention. The principle, “There are many pathways to recovery” embodies a non-prescriptive ethos that appears to allow the incorporation of any programme or intervention that confers benefit and enables the harm reduction maxim of ‘any positive change’. It also seems consistent with Lenton and Single’s
characterisation of harm reduction as an approach that ‘maximises the intervention options’ (Lenton and Single, 1998). Secondly, the view of recovery as “self-directed and empowering” seems very much in sympathy with the user-centred ethos of harm reduction encapsulated in the statement that “In particular, people who use drugs and other affected communities should be involved in decisions that affect them.” (International Harm Reduction Association, 2010) or, the pithier “Nothing about us, without us” (Canadian HIV/AIDS Legal Network, 2008). Empowerment here may refer largely to the degree of agency a person has to negotiate their available ‘recovery-orientated system of care’ within a given structural context. Nevertheless, it seems worth noting that a more comprehensive interpretation of empowerment could
accommodate the notion of a recovering person as someone who also engages with the broader, social, structural factors that may thwart their health, well-being and quality of life. Viewed this way, empowerment may be aligned with harm reduction and its engagement with the “Many policies and practices (that) intentionally or unintentionally create and exacerbate risks and harms for drug users. These include: the criminalisation of drug use, discrimination, abusive and corrupt policing practices, restrictive and punitive laws and policies, the denial of life-saving medical care and harm reduction services, and social inequities” (IHRA, 2010). The third principle to highlight is that “Recovery exists on a continuum of improved health and wellbeing.” This seems strongly reminiscent of the concept of a hierarchy of goals that is intrinsic to harm reduction for which
“The objective of harm reduction in a specific context can often be arranged in a
hierarchy with the more feasible options at one end (e.g. measures to keep people
healthy) and less feasible but desirable options at the other end.”
Just as the CSAT/SAMHSA definition of recovery sees abstinence as something
towards which people travel, the phrasing of IHRA’s position statement seems to
imply that although abstinence is not necessary and may well not be feasible, it is
generally desirable, insofar as this is the condition under which drug-related harms are entirely eliminated.
The UK Recovery Federation has elected not to define recovery, but has adopted the CSAT/SAMHSA principles with some variations. The three principles discussed above are retained, albeit with changes of emphasis for two:
There are many pathways to Recovery and no individual, community or organisation has the right to claim ownership of the ‘right pathway.’
Recovery lies within individuals, families and communities and is self directed and empowering.
There is an emerging critique of harm reduction theory arising from its focus on harms and an implied neglect of the enjoyment and other benefits that can arise from drug-taking. From this point of view, abstinence would not necessarily be a desirable general goal; however, at present this perspective has not been adopted within mainstream accounts of harm reduction.
For example see: HOLT, M. & TRELOAR, C. 2008. Pleasure and drugs. International Journal of Drug Policy, 19, 349-352, MOORE, D. 2008. Erasing pleasure from public discourse on illicit drugs: On the creation and reproduction of an absence. International Journal of Drug Policy, 19, 353-358.
Another principle is expanded specifically to refer to a structural dimension of
recovery, change and ‘recovery capital’. This suggests a model of recovery with a
clearer emphasis on social change, which is interesting to note in relation to the
discussion of empowerment above: Recovery involves the personal, cultural and structural recognition of the need for participative change, transformation and the building of recovery capital. Finally, an entirely new principle includes an important statement that addresses the dual role of abstinence and harm reduction within recovery, validating both: Recovery transcends, whilst embracing, harm reduction and abstinence based approaches and does not seek to be prescriptive.
Together, these contemporary accounts seem to suggest far more agreement than
disagreement between harm reduction and the developing understanding of recovery within the UK. Although the attainment of abstinence is recognised as a valuable goal that people may aim for and from which they may benefit, the emerging UK recovery model is not prescriptive but largely flexible, pragmatic, inclusive and personalised.
Formal accounts concerning recovery are not, however, the only influence on
people’s understanding of the concept and one factor has particular potential to
generate misunderstanding and distrust between approaches that otherwise appear to be converging. Notwithstanding the more nuanced way that the recovery movement itself addresses abstinence, the government’s adoption of recovery has been conflated with an imposed expectation that abstinence is the goal of treatment. In particular, the UK Drug Strategy (H M Government, 2008a) stated that “The goal of all treatment is for drug users to achieve abstinence from their drug – or drugs – of dependency. For some, this can be achieved immediately, but many others will need a period of drugassisted treatment with prescribed medication first.” This conflicts with a view that people should determine their own goals, which may or may not include abstinence. The shift that it also signifies regarding the role of opioid substitution treatment is addressed later.
As people attempt to make sense of the new recovery, this government narrative
prioritising abstinence is a critical point of reference, even though it might reasonably be argued that this has a lesser claim to authenticity than accounts of recovery developed within and by the recovery community. Although recovery comprises more than the sum of those services receiving government funding, it seems naïve to ignore the influence these have, as places through which many people pass and where recovery is implicitly defined by the government targets that are selected to measure how well providers perform within a recovery-oriented treatment system. If these focus too narrowly on indicators such as ‘completing treatment drug free’ and underattend to other measures of health, well-being, quality of life, or participation in society, they are likely to muddy people’s understanding of recovery and quite possibly construct recovery as something to be resisted rather than embraced by harm reductionists and recovery advocates alike.
Methadone and other medication: optimising their role, not whether they have one As has been noted, a critique of the expanded UK treatment system developed as part of the New Labour government’s shift to a focus on crime reduction has included the claim that there has been an over-reliance on methadone maintenance treatment (MMT).
Ashton (2008) attributes aspects of this critique to the ‘new abstentionists’. In turn, this has been a prominent part of the argument with which the emergence of the new recovery is associated. For harm reductionists, this produced two main perceived threats: the replacement of MMT with residential rehabilitation; and, the imposition of time limits and constraints on MMT in a way that contradicts its evidence-base.
In 2007, the ‘Addictions’ report of the Conservative think-tank, the Centre for Social Justice (Centre for Social Justice, 2007) concluded that “maintenance methadone prescribing which perpetuates addiction and dependency has been promoted under current policy while rehabilitation treatment has been marginalised”. This programme of policy analysis was overseen by the former Conservative leader the Rt. Hon. Ian Duncan Smith and was initially anticipated to be influential over the drug strategy of a future Conservative government, which polls at the time suggested was increasingly likely. The report raised the prospect of a policy that would see MMT abandoned in favour of a wholesale switch to residential rehabilitation programmes: an approach with a less compelling evidence-base, which would greatly disrupt the lives of the many people whose treatment was being managed in the community. In practice, this
threat has not materialised. Debate about the accessibility and role of residential
treatment is ongoing, but it seems clear that, currently, there is no realistic plan for a major shift of resources towards residential services as part of the UK recovery agenda.
Earlier, it was noted that the UK drug strategy (H M Government, 2008a) seemed to signal a change in the expectations surrounding OST. A prevailing maintenance
model began to look under threat from a view that prioritised abstinence – defined to include abstinence from prescribed medication – and an implication that medicines such as methadone should have only an intermediate, time-limited role. For some, the journey towards abstinence was portrayed as something that could be achieved immediately, whereas “many others will need a period of drug-assisted treatment with prescribed medication first.” Again, this change coincided with the emerging recovery agenda, meaning that a link with more restrictive prescribing policies could readily be perceived. With the duration of any ‘period of drug-assisted treatment’ unspecified, and services simultaneously under escalating cost pressures and with performance targets for treatment episodes that are ‘completed drug-free’, shorter treatment episodes have an evident appeal, even if this risks abbreviating care that is protective and conferring benefit. From a harm reduction standpoint, this means that,
rightly or wrongly, recovery can be construed as a threat.
What then is the role of OST within the new recovery? Three sources particularly help develop an answer to this question. The UKDPC Recovery Consensus Group (2008) conclude that “Recovery may be achieved in a variety of ways including through medically-maintained abstinence.” They clearly regard ‘maintenance’ as a valid form of recovery.
The second point of reference is a recent monograph on ‘recovery-oriented
methadone maintenance’ which is by far the most comprehensive treatment of the issue to date (White and Mojer-Torres, 2010). Their conclusions deserve attention because they can lay some claim to being the most definitive statements available.
Regarding the status of the person on methadone maintenance their conclusions,
contradict the view that abstinence requires someone to be free of medication;
“Denying “abstinence” or “drug free” status to stabilized MM patients (who do not
use alcohol or illicit drugs and who take methadone and other prescribed drugs only as indicated by competent medical practitioners) based solely on their status as methadone patients inhibits rather than supports their long-term recoveries.”
The authors also conclude that from a recovery perspective the question of how
continuation or cessation of methadone should be regardedis entirely a matter of
personal choice and does not signify a demarcation between addiction and recovery. This suggests that any external requirement that people move beyond methadone maintenance when this is not wholly their own goal cannot be justified in terms of any recovery imperative.
“For stabilized MM patients, continued methadone maintenance or completed
tapering and sustained recovery without medication support represent varieties/styles of recovery experience and matters of personal choice, not the boundary between and point of passage from the status of addiction to the status of recovery.” In some ways the most important of White and Mojer-Torres’ contributions is their review of the way that OST programmes in the USA during the 1970s and 1980s drifted and deviated from the early good practice established by Vincent Dole and Marie Nyswander (White and Mojer-Torres, 2010) Resemblances to the UK’s experience are considerable; however, in essence, they argue that the original, comprehensive methadone maintenance treatment model became undermined and diluted through a poorly-led process of rapid expansion for which a correspondingly knowledgeable and skilled workforce did not exist. Pressure to provide it on the cheap, with inadequate dosing and over-zealous tapering off of methadone – all driven by a relegation of a primary person-centred, rehabilitative ethos to an emphasis on the reduction of social harms all contributed to a corrosion of its reputation. People may argue about how to reconcile some of the tensions this analysis presents, but it is
difficult to conclude anything other than that the question is one of how best to
provide methadone – among newer approaches to medication-assisted recovery such as buprenorphine and heroin-assisted treatment, rather than whether it should be provided at all.
The third point of reference is the most recent UK drug strategy (2010) which has
some differences from the previous strategy that merit noting. In a section entitled ’Recovery is an individual, person-centred journey’ there is an acknowledgement that the government’s aspiration is for people to be drug-free:
“Our ultimate goal is to enable individuals to become free from their dependence;
something we know is the aim of the vast majority of people entering drug treatment.
Supporting people to live a drug-free life is at the heart of our recovery ambition.”
Prescribing approaches, nevertheless, seem to receive a clearer endorsement than previously. The term ‘maintenance’ is not used directly, but the language seems to recognise the value of long-term prescribing and there is nothing to suggest that medication has to be time-limited or constrained, if that is what is needed. Diamorphine prescribing receives a qualified endorsement, which is notable as this is a treatment that remains controversial in some countries and is sometimes perceived to be at a more radical end of harm reduction.
“Substitute prescribing continues to have a role to play in the treatment of heroin
dependence, both in stabilising drug use and supporting detoxification. Medicallyassisted recovery can, and does, happen. There are many thousands of people in receipt of such prescriptions in our communities today who have jobs, positive family lives and are no longer taking illegal drugs or committing crime. We will continue to examine the potential role of diamorphine prescribing for the small number who may benefit, and in the light of this consider what further steps could be taken, particularly to help reduce their re-offending.”
There is, nevertheless, a clear view that:
“…for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there. This must change. We will ensure that all those on a substitute prescription engage in recovery activities and build upon the 15,000 heroin and crack cocaine users who successfully leave treatment every year free of their drug(s) of dependence.”
Whatever White and Mojer-Torres (2010) might conclude about the continuing or tapering off of methadone as a personal choice between two varieties of recovery with equivalent merit, it is clear that the UK government wants more of the latter. If this is accomplished as a result of increased support, which enables more people to attempt and ultimately succeed in leading a life without OST in line with their own preferences, there is not necessarily any conflict with good practice. Indeed, depending on the cost of any increased support, there might even be a secondary societal benefit through a reduction in costs to the public purse. However, at a time of widespread public sector spending cuts in which there is an active objective of reducing the number of people receiving incapacity benefit, an evident concern must be that a clamour to produce people who are drug-free – in keeping with the government’s goal – may lead to poor practice within systems and services that lack the resources to provide the required ‘recovery activities’, which then detrimentally affects people who are prescribed or in need of OST.
Reducing stigma and discrimination: time for a shared, programmatic approach?
The next theme to be developed here concerns stigma and discrimination, which can operate both to intensify problems and to prevent or delay help-seeking (Lloyd, 2010).
Recognition of the need to engage effectively with stigma and discrimination has
come increasingly to the fore and has been endorsed by recovery and harm reduction advocates alike. As has been seen, the 12 principles of recovery developed by CSAT identify discrimination and stigma as problems to be addressed and transcended and the UKRF (2011) adopt this principle with the slightly stronger language of ‘challenging’ discrimination rather than ‘addressing’ it. In the CSAT report, the discussion of stigma and discrimination in relation to recovery highlights its
detrimental effects on people prior to receiving treatment ( i.e. people who are still among the active drug users with whom harm reduction works), as well as its impact on people later in the recovery process who may well be drug free, yet are still subject to prejudice in areas such as employment practises arising from their history of drug use. The authors also discuss stigma reduction initiatives in a way that makes it evident that an active approach to reducing stigma and discrimination is required within recovery-oriented systems of care (Sheedy and Whitter, 2009).
IHRA’s (2010) position statement also refers explicitly to stigma, the language that perpetuates it and its effects:
“Harm reduction practitioners oppose the deliberate stigmatisation of people who use drugs. Describing people using language such as ‘drug abusers’, ‘a scourge’, ‘bingers’, ‘junkies’, ‘misusers’, or a ‘social evil’ perpetuates stereotypes,
marginalises and creates barriers to helping people who use drugs.”
Discrimination is similarly identified as one of a range of related ways that people
who use drugs are oppressed: “Many policies and practices intentionally or unintentionally create and exacerbate risks and harms for drug users. These include: the criminalisation of drug use,
discrimination, abusive and corrupt policing practices, restrictive and punitive laws and policies, the denial of life-saving medical care and harm reduction services, and social inequities.”
It is uncertain how completely these understandings of stigma and discrimination
overlap and point towards a fully shared programme of action across the recovery and harm reduction movements. The recovery account focuses on access to treatment and employment, whereas the harm reduction version is situated more broadly alongside a range of concerns that receive less consideration within formal accounts of recovery.
Regardless, what these highlight is that there is a powerful case for people who are
committed to both perspectives to explore ways that they can pursue a collaborative approach which would maximise their impact on the pervasive effects of stigma and discrimination. Indeed, combating stigma and discrimination may be one of the critical issues that unite these two social movements programmatically and in a
A hierarchically-based development-orientation
Finally, recovery and harm reduction have overlapping concerns but do not deal with the same thing. Recovery is generally concerned with people who are experiencing serious problems with their drug or alcohol use. Becoming drug-free – whether permanently or temporarily – is a common goal for people aiming to achieve recovery and often favours particular control strategies and supports. Harm reduction’s focus is wider, in the sense that it addresses the needs of people irrespective of whether their use is currently experienced as problematic. Its main emphasis is on continuing or active users, but these may be experimental, occasional or recreational users. As such, many people within the scope of a harm reduction approach have nothing – in any sense whatsoever – from which they need to recover. Comparisons that assume they do commit what is sometimes called a ‘category error’. In other words, they contain a logical flaw that invalidates the comparison. Any debate about recovery and harm
reduction needs to recognise and acknowledge this difference in their general focus.
Harm reduction programmes work routinely with people whose use has become
profoundly problematic and who may benefit from a recovery approach. For this
reason, if harm reduction programmes fail to take all reasonable and available
opportunities to connect the population with whom they work with recovery-oriented services from which those same people are likely to benefit, they are squandering opportunities to reduce harm. Conversely, recovery-oriented services with a focus on supporting people who are endeavouring to become drug-free jeopardise the health and well-being of people who lapse and leave, if they do not take all corresponding measures to ensure that they then have access to services that can protect against immediate harms, most obviously NSPs and Take-Home Naloxone programmes.
The preceding discussion illustrates a major difference of emphasis. Being
substantially rooted in the public health challenge of HIV/AIDS prevention, harm
reduction prioritises: “Keeping people who use drugs alive and preventing irreparable damage.” (IHRA, 2010)
As its name suggests, harm reduction:
“…refers to policies, programmes and practices that aim to reduce the harms
associated with the use of psychoactive drugs in people unable or unwilling to stop. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs.” (IHRA, 2010)
As the CSAT/SAMHSA principles show, the focus of recovery is towards change and transformation within a process of healing and self redefinition (Sheedy and Whitter, 2009) which, in the UKDPC Consensus Group’s terms “maximises health and wellbeing and participation in the rights, roles and responsibilities of society” (2008).
There seems to be nothing within these positions that creates any intrinsic conflict between recovery and harm reduction. Their emphasis is different and often this means that programmes traditionally associated with one approach or the other tend to work with people who are at different points of a process. This idea of a process is, nevertheless, a unifying feature embraced by both harm reduction and recovery. Without for a moment saying people must move along it, harm reduction incorporates the notion of movement along a hierarchy of risks and harms that are progressively harder to achieve, but which are generally associated with a reduction in harm at each step (IHRA, 2010). Likewise, recovery is discussed as ‘a process of change, along a ‘continuum of health and well-being’ (Sheedy and Whitter, 2009). As has already been noted, Rethink’s (2008) account of mental health recovery also incorporates a notion of hierarchy in which the fulfilment of basic needs is a prerequisite for recovery. Viewed this way, there appears to be considerable consensus about an organising principle of development, which suggests that the task of recovery advocates and harm reductionists alike is to do all that is within their power to enable people to do exactly that – develop – as far as their goals, potential and circumstances allow.
The principle of development may well be one that deserves to be more central to the debate and has already becoming an organising principle for drug policy in some German speaking regions. For example, in the municipal treatment system that incorporates the world’s first drug consumption room in Berne, which opened in 1986 (Hedrich, 2004), a debate about how to reform and integrate abstinence-oriented services and those based on what is known in German-speaking countries as an ‘acceptance’ model (i.e. working within a harm reduction framework that accepts people irrespective of their lifestyle choices) has also taken place. This also reflected a perception that acceptance-based services were insufficiently ambitious on behalf of the people using them and failed to exploit opportunities which would enable people to develop. After much debate, the outcome was the adoption of an organising principle of entwicklungsorientiert (development-orientation), which was placed at the centre of the entire system4. Everyone working within services has a common goal of enabling people to develop to the fullest extent possible. As a result, acceptancebased services now have a greater emphasis on supporting people to make progress.
Conversely, development was elevated as a goal within abstinence-oriented services.
One possible benefit of bringing the language and principal of developmentorientation to the centre is that, whereas the term recovery seems likely always to have connotations of a disease model that is problematic for some people, the idea that services should strive to enable personal development seems uncontroversial.
Doubtless, many readers will also have been struck by the resonance between within this discussion and Maslow’s hierarchy of needs, with its ultimate goal of selfactualization (Maslow, 1943).
This chapter has very briefly traced the histories of the harm reduction movement and the ‘new recovery’ – a particular version of recovery that is developing in the UK. These have then been compared with reference to texts that appear to best represent formal, current, consensus accounts of their aims and principles. On this basis, it is apparent that recovery and harm reduction have far fewer differences than has sometimes been supposed. Although accounts of recovery vary in a way that suggest some differences, these are not pronounced and they diminish further when particular attention is paid to UK interpretations of recovery. Given the immense amount of discussion of the new recovery that has played out at conferences, within on-line forums and in papers, editorials and letters addressing drug and alcohol policy, it is inevitable that this chapter does not reflect every position that has been expressed. The focus here on consensus statements rather than some of the more polemical perspectives is intentional, as these marginal views often seem to generate more heat than light. In the UK, harm reduction and recovery can be characterised as having entered a phase of dialogue and rapprochement, an implication of which is that these more marginal perspectives, which are often also divisive and undermine dialogue should not be over-valued. This is not a prescription for censorship. On the contrary, debate is vital, but care is needed to ensure that this is undertaken in a way that helps build consensus, rather than undermining it.
Personal communication – Jakob Huber, Director, Contact Netz
Concerning abstinence, it is evident that harm reduction and recovery both value this without viewing it as an isolated, exclusive or over-riding goal. Where harm reduction programmes can identify and support people who will derive a net benefit from abstinence, the implication is that they should do so. Conversely, although many recovery advocates have extremely good personal reasons to regard abstinence as an effective self-control strategy, a contemporary understanding of recovery implies that it is also necessary to recognise the other choices that people sometimes make. To adapt a common expression, striving for the ‘perfection’ of an unattainable abstinence should never be an enemy of the ‘good’, where this good is ‘any positive change’ and achievable.
The role of methadone has been emblematic within debates surrounding the new
recovery. The analysis here has shown that although there are vocal critics of the use
of methadone and other prescribed treatments, the more consensual accounts of
recovery fully recognise that these have a legitimate and valuable contribution to
make. It seems certain, however, that this will remain an area where best practice will remain disputed and that this will, in part, reflect differences in the emphasis attached to individual, rehabilitative goals as opposed to social goals such as crime prevention.
Furthermore, this debate will be played out against a wider backdrop within the UK of cuts to public services driven by the economic crisis and an allied objective of reducing the number of people receiving incapacity benefit, with which changes occurring as part of a genuine commitment to recovery should not be conflated. The concern to reduce stigma and discrimination that recovery and harm reduction share stands out as an area where both movements have common goals. There has been little attention to this within the discourse concerning the supposed polarisation between these two perspectives, yet this is an evident area where people’s aims are closely aligned, which may well benefit from a closer, programmatic approach.
Exploring how this might be done more effectively seems like a strategic priority for harm reduction and recovery advocates alike.
Finally, the underlying model for both harm reduction and recovery has much in
common because of the way that it is grounded on ideas of progress along a series of hierarchical steps. The wider scope of harm reduction to encompass a concern with the whole population at risk of harm and not just those who are experiencing
problems has to be borne in mind to avoid seeing disagreement where none exists. For harm reductionists, it is important to recognise that the term recovery does not necessarily connote a disease model and that care is needed to look past any visceral response to the term. Likewise, recovery advocates also need to be mindful that there are multiple understandings of recovery, some of which can undermine a constructive, collaborative approach between people from different perspectives. To this end, it may be that emphasising the German principle of entwicklungsorientiert (i.e. development-orientation) is a way that recovery and harm reduction can best work together to maximise the health and well-being of the populations they aim to serve.
I wish to express my appreciation to:
Peter Hawley, Michael Cronin, Anton Derkacz, Chris and his colleagues from NA in
Kent, Andria Efthimiou-Mordaunt, Stephen Bamber, Annemarie Ward, Alistair
Sinclair, Michaela Jones and David Clark, David Best for his contribution to an initial
draft of this chapter, Bill White – for comments on an earlier version of this chapter,
Danny Morris, Chris Ford, Matthew Southwell, Peter McDermott, Pat O’Hare, Lisa
Mallen, Tim Bingham, Claire Robbins and Nigel Brunsdon; all of whom are among
the many people who have shaped my thinking in this chapter in one way or another,
irrespective of whether they agree with the final result.
Lastly, I’d particularly like to acknowledge Johnny Ruttledge who stands out among
those people whose lives exemplify how harm reduction and recovery should be
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