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

My Response

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. “

Source: https://stonetreeaus.wordpress.com/2011/06/24/a-case-against-the-argument-that-harm-reduction-strategies-are-costly-and-encourage-people-to-use-drugs/

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).

Regards

Matt Gleeson

Stonetree Harm Reduction

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Comments
5 Responses to “The New Recovery Movement In Victoria; The Discussion”
  1. I’m glad that the long-standing recognition of abstinence by harm reduction is addressed here.
    I believe it is essential to also recognize the concept of ‘co-option’ and what this typically means in a context where blatant injustice continues to be executed by supposedly legitimate authority bodies. It is all too easy to point out the problems of internal “bickering”, but history has clearly shown us that a highly effective strategy employed by those responsible for human rights breaches is to actually participate in, and subsequently hijack, movements (usually with funding, as money is an incredibly powerful tool to both divide and dilute).

    Most inspiring for me at the moment are commentators such as Monica Barrett, and activism such as Vixen (Victoria, Australia) and Students for Sensible Drug Policy Victoria University (Victoria, Australia), whose activity I have so far interpreted as sincere and borne of authentic passion for the rights of people who use drugs illicitly. Careerism, dollars and ego seem to have not only taken a back seat, so to speak, but have actually been relegated to the boot!.

    Also, without getting distracted by the concept of ‘identity politics’, I would be most interested to learn more about what you have gained from personal experience:

    “I am extremely happy for people when they begin a journey of recovery and I have supported people both personally…”

  2. stonetreeaus says:

    Hey thanks for your comments Limitless Shunt. I would be interested in knowing more about what you mean by co-option and what you see as the blatant injustices that you have identified. (I ask this not as a challenge to your position but in the spirit of seeking to understand how you see this is related to the current discussions about the emerging discourse regarding new recovery). I’m not familiar with Vixen but have spent time rteading materials from both Monica Barratt and SSDP and have had the particular privelege of swapping thoughts and ideas with Monica both face to face and in social media environments.

    You have mentioned identity politics and also asked about my personal experience. My belief is that there are normally a range of factors that motivate people to do the things that that also shape their positions.

    Yes it is true that I get paid to work in the AOD sector and in fact that has been my career since 1998. Easy to understand why it -it pays the bills. However the story does not begin or end there. Prior to 1998 I worked as volunteer in an AOD agency for a couple of years, and the last year and a half I have voluntarily spent my time (and a small amount of money) to write about the alcohol and other drug issues that I feel passionately about. For me the motivation is not just money or career (admitedly I need a job to pay the bills and I just happen to be lucky enough to find one that allows me to work in an area that I am passionate about), but also about the impact that some profound personal experiences in my past have had on me. I do not want to spend this time going into what those experiences were as I think the details are in many ways irrelevant here, but I will say that they have left me with the strong conviction that regardless of what drugs you use, how much of them you consume and what your intention is into the future regarding drug use, people are just people, able to make their own decisions about their life and sometimes requiring some assitance to reach the place that THEY aspire to reach.

    Hope that makes sense. Anyway thanks again for the comments.

    Regards

    Matt Gleeson, Stonetree Harm Reduction

    P.S.To anybody else reading this I happen to know that Limitless Shunt writes a blog regarding among other things the often biased media reporting of AOD issues which is well worth a read http://sundaybottle.blogspot.com.au/

  3. I appreciate the candidness Matt, as I know these are difficult matters to articulate – even in print. Whilst it may seem like I am going off topic, or merely being confrontational, the reason that I am introducing the aforementioned concepts and sentiment is because, first and foremost, I perceive this issue as a grave and global social injustice – I think you would agree that any matter involving a war (especially one that has no substantial rationale) is, by default, a matter of “blatant injustice”, as you have asked about. Also, I refer to authority bodies worldwide, so we can thus create a list that includes state-sanctioned murder etc etc.

    The reason why I introduce such ideas into a discussion about the ‘new recovery’ is because, for me, intent and motivation is essential in this particular issue (as it is for so many of life’s issues). Call me a curmudgeon or misanthropic, but I am someone who doesn’t celebrate the growth of ‘the sector’, whichever country it is in. Why? Because this growth is not only fostered by the continuation of the aforementioned war and the countless people who bear its brunt, but it is also in direct contradiction to the core aims of harm reduction. Meeting a previously unmet need is one thing, but to then feed off the drug war, because an increase in harms means more business, is another matter entirely. Ludicrous, I hear you say? Well, unfortunately, (and this is where intent also comes in) I have observed an influential current in ‘the sector’ which is not genuinely interested in meeting the ultimate aspiration of harm reduction (ie. to maximize the amount of harm reduced), but, in fact, approaches the sector in a rudimentary business-like fashion. That is, there is a demand that needs to be met and money/careers/perks can be made from meeting this demand, so let us work out ways to ensure longevity, regardless of what or who loses out. And it is no coincidence that many of these people have no personal connection to the issues (which is why I bring that matter up).

    My raising of ‘co-option’ is not just an axe I’m trying to grind. It is because anyone who looks at the bigger picture can see that the fundamental injustice that is the drug war – that is, the core component of this issue that must be tackled front-on if we are to make any real progress as a society – will be continually perpetuated unless the tacit approval of harm reduction, amongst other things, comes to a screeching halt. That is, we need to stop riding the ‘gravy train’ that has been constructed on the backs of people who use drugs illicitly, as it ‘benefits’ all sides of the issue – not just the dealers etc. The best way to ‘co-opt’ an authentic movement is to introduce money, as people become easier to control and everything is diluted, as “we are just here to do a job – nothing more, nothing less”. Additionally, participants end up focusing more on climbing the career ladder than advocating for meaningful change – a notion that wouldn’t be so unethical if, essentially, it wasn’t built on the aforementioned “blatant injustice”.

    So, when discussion about the ‘new recovery’ emerges in the perceived context I have just described, I can’t help but cry ‘foul’, as I am not convinced that the responses that have emerged are borne of genuine concern for drug users. Instead, I believe that it is yet another connection in the web that has become the drug war, whereby people are motivated by their own financial and/or power stake in the sector, rather than a genuine concern for drug users (again, it is no surprise that many of these people have no personal connection). Also, whilst I may not support the ‘new recovery’ agenda, I would be interested to understand what their motivations are.

    My opinions are not just based on academic analysis, but are primarily based on my direct experiences. For example, an organization that has come out against the ‘new recovery’ was involved in the closing of an after-hours NSP that did not involve consultation with the service users in any way. We need transparency if we want to actually get anywhere Matt, and I am leaning more and more towards people/orgs that do not have ‘bill paying’ as their primary concern. When people deal solely deal with illicit drug use between 9 and 5 on a weekday, it is easy for them to not really care.

    • stonetreeaus says:

      Thanks Limitless Shunt

      I guess I am somewhat pragmatic regarding the issues that you have outlined. I guess my position on the war on drugs and the institutionalisation of stigmatic responses to people who use drugs is best represented by some of the articles I have written in the past:

      No drug decriminalisation but we can still change drug laws to improve health outcomes https://stonetreeaus.wordpress.com/2012/04/25/no-drug-decriminalisation-but-we-can-still-change-drug-laws-to-improve-health-outcomes/

      What’s the deal with harm reduction & drug law reform https://stonetreeaus.wordpress.com/2011/11/08/whats-the-deal-with-harm-reduction-drug-law-reform/

      The Bad, The Sad & The Redeemed http://injectingadvice.com/articles/guestwrite/260-mattgleeson2

      The ‘j’ word & journalism http://injectingadvice.com/articles/guestwrite/228-stonetree1

      I don’t believe that drug laws are like to change any time soon and therefore for the the benefit of people who may potentially experience drug related harms,services must continue to provide services that reduce said harms even in a structural context that continues to contribute to potential harms. How we do this without colluding with the forces that reinforce harmful drug laws and stigma is often tricky. At the heart of the matter for me is a pragmatic consideration of my actions asking myself :

      – whether my actions will potentially reinforce stigma,
      – What is the immediate benefit in terms of risk reduction vs the cons

      A good example of this might well be prison based programs. At a structural level I find locking up increasing numbers of people for drug offences well…offensive, however as I know that such environments contribute to drug related harms (e.g. greater potential for BBV transmission while incarcerated & greater potential for overdose post incarceration) I will continue to advocate for prison based health programs that can potentially alleviate these health issues.

      It’s a tricy balancing act and brings me to a belief that we need advocates working both with and without of the treatment/HR systems to bring about both incremental and revolutionary change. this why I appreciate the work of peer organisations such as HRV, NUAA and AIVL that rattle the cage for human rights.

      As to profiting of the war on drugs I can see the thrust of your argument, however I would much rather see well funded treatment/HR services than underfunded ones (which I assert is the case at the moment). I can see how this may be viewed with some scepticism as I, in my day job are one of the people who profits from a better funded service system, however I come from the belief that without adequate funding services for people who use drugs will be diminished.

      I agree that motivation is an important component in this regard however it can become a circular argument as it is difficult to evidence. One of the criticisms apparently (I say apparently because nobody has stated this directly to me at this point) asserted to people from within the AOD sector who have questioned the validity of recovery in Victoria is that they are resistant due to a motivation to protect their ‘professional patch’. I think that as this can’t be clearly evidenced and is an easy catch all argument to level whenever there is opposition to recovery it is less useful, stymieing further debate. I would add that a similar debate killer is the representation of recovery advocates as having vested interests in getting rid of harm reduction.

      Please don’t get me wrong, I do believe that there are vested interests in both sides of the debate, I just don’t believe that attributing motivation get’s us anywhere. It is difficult to prove and therefore can be easily cast aside. If we want to challenge an injustice I think it is more beneficial to seek out the evidence that no or little consideration has been given to how actions undertaken by an individual or an organisation contribute to increased harm or stigma.

      Thanks again for your comments. I would love the opportunity to collaborate with you at some time to discuss some of these issues further – maybe a joint Limitless Shunt/Stonetree blog article?

      Regards

      Matt Gleeson
      Stonetree Harm Reduction

  4. stonetreeaus says:

    I should add in reference to the statement:

    “Please don’t get me wrong, I do believe that there are vested interests in both sides of the debate, I just don’t believe that attributing motivation get’s us anywhere.’

    I should have also mentioned that I also believe that there are many (the majority) in both the Harm Reduction and Recovery camps who are motivated by a sincere and passionate desire to improve the circumstances of people who use drugs. This is one of the key areas of common ground for many involved in the discourse. for many motivation is not the issue, it is process that raises concerns

    Cheers

    Matt

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