The New Recovery Movement In Victoria; The Discussion
It seems that the recent post by guest writer Anonymous AOD Worker elicited a lot of interest, with a large number of page visits and some discussion in the social media multiverse. As I suggested in my introduction to the article, I thought that some might consider the article divisive, but I thought the article could also engender some frank and respectful discussion about both the differences and common ground shared between the concepts of recovery and harm reduction. It was with some gratitude then that I received a comment on Anonymous Drug Worker’s article contending some of the points made. As you will see Just as Anonymous covered a lot of ground in their comment and therefore my response in turn was quite lengthy. In the interests of readability I have copied Just As Anonymous’ comment and my reply as a new blog article. I welcome the (respectful) contribution of others to the discussion.
I would also like to again thank both Anonymous AOD worker and Just as Anonymous for their contribution to this important discussion.
Just as Anonymous’ comment
Dear Harm Reduction Henny Penny,
Just curious, are you aware that methadone maintenance, is NOT a harm reduction strategy. Ritter and Cameron in 2005, in ‘A Systematic Review of Harm Reduction’ (Drug Policy Modelling Project MONOGRAPH 06; Turning Point), removed activities such as methadone maintenance therapy from this modelling. They found under the definition of harm reduction strategies those such as as methadone replacement therapy would not be included, as it’s has as it’s primary aim, the reduction of ‘drug’ use. This narrows the strategies that can be truly termed harm reduction strategies. The specific harm reduction strategies are, needle and syringe exchange program NSP, supervised infecting facilities, non-injecting routes of administration, outreach, education and information, brief interventions, overdose prevention interventions and lastly legal and regulatory frameworks. In trying to push harm min (not harm reduction) people want to jump on the evidence of MM, the best you could do as I can see it, is try to put MM under a demand reduction strategy.
Henny Penny, I think you do get to the point after some brow beating, the aim is for our clients, and really these 2 approaches are far more similar than they are opposite. I do think the government is very clever in keeping this debate going, because as long as we bicker among ourselves, rather than trying to find ways to unite, they government is happily chopping away at services, and the only losers are those with the least to loose, those in need of recovery, for what we fail to see is that harm min does fail some, and whilst recovery is happy to care for all those wanting it, harm min is only just coming to be able to utter the words abstinence and for too long has neglected the needs of those wanting more than to just continue to use drugs ‘safely’.
Just as anonymous
Hi Just as Anonymous, thanks for your response to the article.
Apologies for the lengthy comment post but you covered a lot of ground in your comment and I wanted to respond to what I identified as the key points with the care and attention I believe they deserve.
In the introduction that I posted at the start of Anonymous AOD workers article I suggested that while some may consider the article divisive, I believed that it offered a an opportunity to address some of the confusion and concerns that I have heard many AOD workers express in the last few months. Without frank discussion about such issues (identifying both the common ground and the differences), confusion and resistance will remain, to the detriment of both the AOD sector and the communities that the sector seeks to serve. It is in this spirit that I wish to address some of the points that you have made.
Methadone Maintenance – Harm Reduction or Demand Reduction?
You are completely correct in asserting that Ritter and Cameron in 2005 in ‘A Systematic Review of Harm Reduction’ (Drug Policy Modelling Project MONOGRAPH 06; Turning Point), did not include activities such as methadone maintenance therapy from this modelling. This was due to the fact that they focussed upon those interventions that solely addressed drug related harms without having an impact upon demand. This is not to say that methadone (or other demand reduction activities for that matter) does not reduce drug related harms, but instead many such interventions can sit across both the demand and harm reduction categories.
Yes methadone reduces demand, but it has also been acknowledged as being a highly effective tool in reducing the overall harm that both individuals and communities experience in relation to illicit opiate use. According to a systematic review of the evidence supporting treatment ANCD research paper 3—Evidence supporting treatment (Gowing et. al 2001):
“The value of substitution treatment lies in the opportunity it provides for dependent drug users to reduce their exposure to risk behaviours and stabilise in health and social terms before addressing the physical adaptation dimension of dependence.”
Methadone maintenance reduces the risks of drug related harms in a variety of ways including:
- By providing an effective way to meet the physical demands of opioid dependence that does not necessitate injecting. The provision of non injecting routes of administration is a harm reduction intervention that is very clearly articulated by Ritter and Cameron (2005). For a number of heroin dependent people introducing non injecting routes of administration for heroin is not an achievable goal as they would require much larger amounts of heroin (hence more money) in order to stave of withdrawal. Methadone makes this goal far more achievable while also reducing the likelihood of blood borne virus transmission.
- By providing a regulated and legal dosage effectively reducing both the likelihood for overdose, as well as the potential for the legal harms associated with the acquisition of illicit drugs
In short it is a false dichotomy to suggest that if a particular intervention reduces demand it does not potentially act as a harm reduction strategy. That would be like suggesting that recovery does not reduce drug related harms or that harm reduction strategies do not offer an opportunity for people to enter into recovery. Regardless of this, I believe Anonymous Drug Worker’s point was that while a wealth of long standing evidence supports the notion that methadone significantly reduces drug related harms that some within the New Recovery movement have either ignored or not been aware of such evidence.
The Government is keeping this debate going.
You have stated in your response to the article:
“ I do think the government is very clever in keeping this debate going, because as long as we bicker among ourselves, rather than trying to find ways to unite, they government is happily chopping away at services, and the only losers are those with the least to loose, those in need of recovery,…”
First of all I would have to say that I have seen no evidence that the government has been keeping this debate going. In fact to my knowledge the government has been very quiet regarding recovery. If you have any evidence to the contrary I would be quiet interested in seeing it. I mean this in the most respectful of manner as I can in all sincerity say that I am interested in drug policy and the potential implications it has for the communities we serve.
In regards to keeping the debate going, I don’t know that it has really begun. Ending it now might be a little premature. While I agree with you that there is more common ground than not between harm reduction and recovery there are also a range of significant differences. With the public discourse in Victoria regarding the new(ish) concepts of recovery only being a matter of some months old, are we meant to take it as a given that we move to somebodies barely discussed notion of what AOD services should be doing in Victoria? Healthy, respectful debate is well …healthy. It ensures (hopefully) that all stakeholders get a fair say and that the end result is a considered and deliberate series of changes that respond to the needs of people who use drugs in a way that reflects a range of views. From a harm reduction point of view many of the interventions that are now generally accepted have undergone a lengthy process of debate, review and public discussion before they became reality.
“It could be argued that one of the consequences of a continuing resistance to harm reduction strategies and programmes is that such strategies have come under far greater scrutiny than other forms of alcohol and other drug intervention. Needle and syringe programs in Australia have undergone two major economic evaluations nationally in the past decade, testing their economic viability, methadone as an opiate substitution therapy is one of the most well researched and evidenced pharmacotherapies utilised in drug treatment and the medically supervised injecting centre in Sydney has operated under a trial status for over a decade. “
Recovery is happy to care for all those wanting it
You have also stated in your response that:
“…for what we fail to see is that harm min does fail some, and whilst recovery is happy to care for all those wanting it, harm min is only just coming to be able to utter the words abstinence and for too long has neglected the needs of those wanting more than to just continue to use drugs ‘safely’.”
It is unfortunate that this has been your experience as mine has been somewhat different. I first commenced work in the AOD sector in 1998. For a number of years my beliefs were probably more closely aligned with the concepts and values espoused by the New Recovery movement (this may come as a shock to some of my regular readers!) and believed that Recovery was open to all that wanted it. The longer I have worked in the AOD sector however the more I began to realise that not everyone who uses drugs and indeed not everyone who comes into contact with an AOD treatment service wants recovery (or the version of recovery on offer at that service). Many people who use drugs are not drug dependent and do not consider themselves to have ‘a problem’ and therefore have no desire to enter recovery. This does not mean that they are not at risk or that they do not experience drug related harms. People in these kinds of scenarios benefit equally from harm reduction interventions as do those who are drug dependent but who do not currently desire recovery. Whilst I am sure that recovery is happy to care for all, all are not necessarily seeking recovery. Some may want recovery at a later date, others will never see it as an option they require.
I am extremely happy for people when they begin a journey of recovery and I have supported people both personally and professionally in that journey but I will not apologise for supporting people who use drugs in reducing the harms associated with there drug use either. The New Recovery movement has produced a body of literature about reducing stigma experienced by drug users; not judging people about there choices about continued use is one way of reducing this stigma.
In response to your suggestion the harm minimisation “…is only just coming to be able to utter the words abstinence…” I can honestly say that as someone who has taught both the theory and practice of harm minimisation and harm reduction to hundreds of AOD workers in Victoria in three different institutions over the last seven years that this is patently untrue. Harm Minimisation acknowledges that the most effective form of harm reduction is abstinence, while at the same time acknowledging that despite the best efforts in the domains of supply and demand reduction there will be people within our communities who will continue to use drugs. In short Harm Reduction is a pragmatic response that many people now in recovery have benefited from in there time of active drug consumption.
I would like to take this opportunity to thank you again for your comments and hope that you take my response in the spirit that it is meant. I do believe that such discussions are important and that we require more of them to gain a better understanding of both recovery and harm reduction. I look forward to a time when we can reach a consensus within the Victorian AOD sector about not only what recovery means but also how recovery and harm reduction can be offered in a complimentary fashion (if it isn’t already).
Stonetree Harm Reduction