Organisations that provide treatment for people with substance use disorders fall into one of two camps. The first aims for abstinence, where the therapeutic end point is clear to everyone. The second aims for harm reduction, which can mean different things to different people.

Harm reduction interventions

These interventions focus on the harm caused by substances, rather than the substance use itself. These therapies work to reduce the harm caused to the user, their immediate environment, and society at large. Harm reduction strategies view substance use as a maladaptive behaviour that is a function of circumstance. The belief is that by improving the circumstances of an addict’s life, substance use will morph into a non-hazardous behaviour. In other words, drug related harm comes from uncontrolled substance use. Therefore, using substances in a controlled fashion reduces the risk of harm. 

Harm reduction strategies try to understand the life circumstances of the addict or alcoholic and make their lives more bearable. This has led to a whole army of well-intentioned organisations trying to help psychotherapists, EMDR practitioners, social workers, silent weekend retreats, governmental agencies, NPO’s and street charities in their work.

Most importantly, harm reduction practitioners often provide less toxic drugs to addicts. They do this in the hope that the weaker drug will contain the addiction and limit the associated collateral damage. This is the principle that lies behind methadone maintenance programmes. The logic behind harm reduction interventions makes absolute sense except that it ignores one vital fact.

Loss of control

Addiction is fundamentally about an impaired ability to control the consumption of drugs or alcohol. Even while understanding the adverse consequences and in spite of various supportive inputs over the passage of time. Addicts only seek treatment for their substance use disorders after all attempts at self-controlled use and harm reduction have failed. Those that can successfully control their using with or without help get on with their lives and have no need for addiction treatment. The system filters out the addicts. Simply put, those that can control their using, do control it. Those that can’t, end up in addiction treatment. “Rehab” is always the last option, never a first choice.

Harm reduction or relapse

It is only after all other reduction strategies have failed, that addicts consider rehab. This is the principle that sits behind abstinence based programmes. Trying to teach an addict to use in a controlled fashion is like trying to teach someone to defy gravity – irrespective of the input, every time you jump, you fall.

At any point in time, up to 40% of our clients in treatment have returned because they have relapsed. Even for those who have previously suffered the nightmare of addiction, and then experienced some of the rewards of sobriety, maintaining that sobriety can be very difficult. Even with the benefit of a treatment programme, we have found that when person decides to use again – for whatever reason – it is rare that they use in a controlled and restrained fashion.

Regretfully, most addicts discover they are still addicts and inevitably, the impaired control returns. Relapse is generally driven by the mistaken belief that after a period of abstinence, the addiction is cured and controlled use with minimal harm is possible again.

Addicts and alcoholics are generally a pretty smart and intuitive bunch of people. The empirical fact is that controlled substance use seems to be out of reach of addicts. This suggests that the condition is a primary disorder that exists independent of circumstance and that abstinence therefore, is the most sensible way out of addiction.

Dr Rodger Meyer
CEO Good Hope Verslavingszorg and Rustenburg Clinic

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