So much harm…

A LOT of you replied to my brief ramblings on Harm Reduction. Some of you see it as almost poisonous — a kind of quicksand making it more difficult to quit using. Others see it as a valuable perspective for helping people “where they are,” without imposing conditions or restrictions. Some of you see it as an expression of kindness, others as short-sighted or even lazy, and some note that it does more good for the society at large than for addicts trying to recover. It’s good for all of us to be aware of this diversity of opinions.

I don’t think I can help provide unity, but here are a few more impressions I got from that conference.

I mentioned in one reply, last post, how struck I was by a speaker who looked like he was about to collapse right there on the podium. A slender young man who spoke in a halting voice, sometimes unable to find his words. He asiantalked of being a young gay man from a traditional Chinese family. He was rejected by his family and peers with such vehemence that he ended up wandering around Toronto like a stray puppy, looking for anyone he could follow home. Not surprisingly, sex was part of that equation, and, apparently not uncommonly, so was crystal meth. Clean needles and condoms were the furthest thing from his mind. Until he got sick. Now, HIV-positive and who knows what else, he stood there, quavering, clearing his throat, telling this group of strangers all about his shameful deeds. And everybody’s heart went out to him. There wasn’t one person in the room who didn’t wish they’d gotten to him first, not to put a halt to his experimentation but to help him survive it. When he told us he’d been clean for almost four years, the room erupted in waves of applause. But it didn’t seem he’d be a poster-child for HR or anything else for very much longer.

needleteeth copyFrom that moment it was clear to me that harm reduction and abstinence were not opposing goals. And I was sold. I don’t think you can fully buy into harm reduction until you stare straight into the totality of harm.

Karen, a syringe program coordinator talked with me for awhile. Big heart, yes. Weird ideas? Maybe not.

“All I want to do is house them,” she said, “give them somewhere they want to go back to. You want to make it cozy for them, help them furnish it, make it their safe place.”

You’d think that might make it more comfortable for addicts to keep on using. But that wasn’t her view.

“When that happens,” she said,  ”their using levels out and the risk-taking all but disappears. They stop sharing any equipment, they stick to one dealer, they tend not to use in groups, and the quantity goes down: crystal meth, Dilaudid, old-style oxycontin, you name it.”

Okay, you might wonder, but don’t you try to get them to stop? Apparently it’s hard to do both at the same time.

“If clients fail to stop using something they said they’d stop using, then I never bring it up again,” Karen said.  “You never shame people, because shame is the hardest emotion, in my opinion. Kindness — that’s what you give them. You thank them for coming in.”

Others felt that way too. One heavily tattooed man who looked like he could bench-press his Harley told me, in the mildest voice: “The client is the boss. I’ll plan whatever you want…and at any point you want to change it, we’ll change it. Because it’s their life, not my expectations, that matter.”

sadman copyI never stopped wondering whether this was precisely the right approach. But I became convinced it was a lot better than nothing for seriously down-and-out users. If you met them with restrictions, rules, shame or disapproval, they would simply disappear. Disappearing was one thing they were particularly good at. That and destroying themselves.

My talk was well received. Almost everyone there wanted to understand how addiction works, and the neurobiology was a lot of what they were missing. But policy is not my thing. And all the biology I could offer seemed a pale wand to wave at the pain that surfaced in that room.

I left feeling that harm reduction was a desperate response to a desperate situation, bound to help those who needed it most.

 

P.S. Check out this recent discussion forum in the New York Times. See if you can tell the good guys from the bad guys.

55 thoughts on “So much harm…

  1. Shaun Shelly February 12, 2014 at 6:46 am #

    Great post Marc – I, as you know, am a great proponent of HR and non-abstinence based treatment approaches.

    • cheryl February 12, 2014 at 11:28 am #

      I am too. Let people get to a choice one way or another on their own without shame. Having a nice place to live as one of the women Marc talked to wishes to provide is a wonderful step in making that choice. I managed 2 sober houses for over 4 years. The houses were beautiful, felt secure due to the boundaries outlined for the houses. This was a big plus for the women living there in their forward movement. In there forward movement they dealt with battles that came before their abuse of substance so even though many went back to using they do it in a way that respects themselves more and harms less.

  2. Jan February 12, 2014 at 7:39 am #

    You seem to have captured the essence of the argument here Marc – a recent 60 minutes program about housing demonstrated that giving homeless individuals a roof over their head was cheaper than any other approach and some two years later, 97% were still in their homes. Maslow’s hierarchy of needs and the realities of social policy/government funding dictates that this same solution for substance use appeals to advocates and funders alike. Providing the conditions for harm reduction benefits everyone and abstinence is a choice. My experience working for 30 years in SA crisis intervention is that a choice for change is precipitated by an emotionally significant experience of one kind or another. That can occur in a variety of settings, for a variety of reasons, as you and others here have described.

    • cheryl February 12, 2014 at 11:36 am #

      I could not agree with this statement more.

      “People never change because they are under threat or under duress. Never. They change because they see something that makes their life seem valuable enough to start moving toward a life worth living.” Robert Downey Jr.

      There are many ways to get people to see at least a glimmer of value and hope. Prison is not one of them. The “life worth living” may or may not come and if it does it may take years. So be it.

      • Janet February 12, 2014 at 6:34 pm #

        Perfect. Thank you for writing this.

  3. William Abbott February 12, 2014 at 8:26 am #

    Sure harm reduction works for some people and so does prison. More people ” recover” without help than with ( natural).

    Im quite skeptical that optimal outcome from substance misuse will rarely be achieved witout at least a period of abstinence

    I think youre headed down the wrong path here Mark as a ” science” guy– just my opinion

    • Marc February 12, 2014 at 8:47 am #

      But who would deny the benefits of a period of abstinence?! That’s just the point of my post and a lot of comments from the last one. “HR vs abstinence” seems to be a false dichotomy. Rather, as Shaun states so clearly, in his comment on the previous post, these can be seen as two phases on a continuum of care.

      • Jennifer February 12, 2014 at 9:38 am #

        I agree, Marc. I see this in a color shift. To get from the black of using in its darkest moments, to the bright white of abstinence, the grey area of HR is a natural place to move to. Maybe the grey area is where you’re stuck forever, but it’s better than black. I see nothing but good in this.

        • cheryl February 12, 2014 at 11:44 am #

          Well said!

        • Marc February 13, 2014 at 3:42 am #

          Lovely metaphor.

      • cheryl February 12, 2014 at 11:39 am #

        There are many ways to improve life. If harm reduction does it…GREAT, if AA does it (would never be my choice) Great. Who said it has to be one size fits all.

        • Marc February 13, 2014 at 3:43 am #

          I think we finally dispensed with that some time last year….

  4. Lovinglife52 February 12, 2014 at 8:46 am #

    I think harm reduction can be an important tool for people who are not ready for abstinence. People can use different recovery techniques at different stages of their own journey. Many who aim at abstinence feel they have failed when things don’t go to plan and then go on a dangerous binge. They don’t see a slight blip as successful moderation, for most of the time and feel demoralised.
    I feel that harm reduction could be an important method for some people, especially those who are put off 12 step solutions by the religious nature. I choose abstinence, but it took me a while before I could achieve that year after year. I feel people could move onto abstinence after a period of Harm reduction,if they feel things are on the right track.

    • cheryl February 12, 2014 at 11:42 am #

      I saw this so much in the sober houses I worked at. “Relapse” was the biggest fear looming over all the girls and they really believed there life would be over if it happened. Not a healthy thought process at all. If you have a drink or what ever…move on.

  5. Elizabeth Guy February 12, 2014 at 10:19 am #

    Great Post. As much as we would like to convince those struggling with addiction that leaving those drugs behind will make life better, the choice is ultimately theirs. If they cannot find that spark within themselves, we should offer them some dignity. Who knows, that little bit of kindness and sense of respect may slowly change their perspective?

    • Marc February 12, 2014 at 4:40 pm #

      That’s what I think too. In my view, shame is the most painful of all emotions (with the possible exception of grief). Being treated kindly is truly an antidote for shame. Hence it reduces the pain that addiction is intended to buffer. That’s got to be a good thing.

  6. nodev ray February 12, 2014 at 11:05 am #

    As a medical professional who has dealt with addiction as a client, patient, and treatment provider, I have seen the value of harm reduction practices, meeting the addict where he is ……not where he (should ) be….namely abstinent.

    • cheryl February 12, 2014 at 11:43 am #

      Agreed

  7. JLK February 12, 2014 at 1:45 pm #

    Hi Marc

    I noticed on the first comment in the (yecchh) NYT the concept of intervention.

    I don’t like it much although I have seen it from time to time. Might be interesting as an item of discussion on its own.

    This woman also said that addicts will quit when “ready”. AA has been using that concept since the founding in 1935. Except we call it “hitting bottom”. All addicts have their own version. Fortunately I was a “high bottom” drunk. Didn’t lose my family, money, house…only my pride when I became disgustingly drunk on so many occasions. Plus as mentioned yesterday I was becoming a liar. I was on the cusp of losing everything but I saved MYSELF by quitting.

    I started my end of this conversation with the pandemic of Political Correctness which has stricken (my choice of words) our society. My fierce opposition to PC is based on one thing: taking responsibility for your own action. Same goes for addiction. I made the decision to quit but I also made the decision to do whatever it takes to quit. A Dr in the field talked me into AA (my attitude towards AA was similar to many on this blog). I found it was nothing like I assumed so I stayed.

    Now I am sure this young Asian kid has a sad story to tell. But the PC community has him convinced that it’s not really his fault and taking free needles “until he is ready to quit” is okay..

    BS. Being told that and being given the “tools of the trade” for free sends one message: well I am not a bad guy so I can keep going until I am ready. This stretches the time period it takes to be “ready” Like all of a sudden a lightning bolt from God will tell him when it’s time. The key sense of urgency is diluted by this message.

    Besides Aids usually comes from gay sex not dirty needles. How you going to stop the “bathhouse behavior”?

    Anyway my ramblings are (with difficulty this A.M.) sending only one message. Kids must be taught that the most important things in life are honesty, integrity and most of all taking responsibility for one’s own actions. That and that only is the message that will help the addict. Moral issues aside, everyone makes mistakes. And those unlucky enough to have a predilection towards addiction have to treat it like any other handicap….and that is doing your best to live a normal life AND taking personal responsibility to make that happen

    BTW That is one of AA’s primary messages.
    JLK

    • Marc February 12, 2014 at 4:37 pm #

      John, Who on earth is this PC community that you talk about? Do you really think there is some segment of society out there that wants to relieve addicts of any sense of responsibility? I just don’t see your point. This kid has spent his entire life feeling like he’s a “bad guy”. How much more do you want to pound that in?

      The feeling of “being ready” is really the core of this dialogue. But I don’t think you can propose a formula for that one.

      • JLK February 14, 2014 at 12:03 pm #

        Marc

        Sorry you completely misunderstood my message. Maybe my fault.

        As far as “bath house behavior” is concerned: my first wife’s best friend was a gay man. Great guy…singlehandedly changed me from a homophobic to homophile. Unfortunately, after lying to us about bath house use he ended up being the 4th terminal casualty in Oregon precisely because of his visits to bath houses from Seattle to San Francisco. Some of the devotees can have 200 sexual encounters per weekend. Extreme I know but true according to this same late gay friend who was actually THERE!
        Disbelief like yours is just another form of denial because you don’t WANT to believe it.

        Since the advent of HIV drugs gay men have resumed this behavior (on a lesser scale)But if you do the math and believe the figures you hear on hard drug, (mainly heroin) addiction (roughly 500,000 and rising).and use a rough estimate of 5% of the population being gay that would be 7- 8 million gay men alone. Of course not all are promiscuous but many are and they have the same raging testosterone problem that any young heterosexual man has but without the braking power of women who look at sex more seriously. So you tell me where the danger lies
        JLK
        JLK.

      • JLK March 16, 2014 at 9:45 am #

        Marc

        Please Note. Thanks…don’t have to publish but this is obviously a sore subject with me.

        Please reread what I am trying to say here. It is only that AA has used that “bottom” concept since 1935. And I personally find intervention distasteful except under extreme circumstances. Then you have ti ID “extreme circumstances” and so it goes.

        And if you don’t think there is a “PC Community” you must not have acquainted yourself with almost with almost any American college lately where free speech (especially conservative speech) is given the “1984″ treatment.
        Or these “Star Chambers” attaching them selves like leeches to the Canadian govt. attempting to prosecute anyone in the public eye saying or writing anything they don’t like especially against Muslims. Cases are usually brought by hate-spewing Mullahs. If you don’t believe me look up the Marc Stein (Canadian journalist with large following down here) case defending himself against the “Committee against Hate Crime” of a few years back.

        Or, on a more personal note try a dinner party where I live in the Greenest City” in America. (Even though a large river that runs through the city is on par with the Cuyahoga in Cleveland) My 1st wife was a Liberal Jewish woman who would kick me under the table if I took exception to statements like “Bush is a Nazi” or “all Republicans are morons” I am not a Republican or Democrat, neither fish nor fowl, but these kinds of statements are 1) idiotic and 2) considered “polite conversation” at a Portland dinner party. I have the permanent ankle bruises to prove it.

        JLK

        • Marc March 16, 2014 at 10:40 am #

          HI John. Once you click the “button” you are publishing your own reply. I don’t review or approve them, and Only extremely rarely do I take something down — if it’s truly nasty — and usually only if someone complains about it.

          Anyway, no one will likely read this since it’s already an old debate. Things age quickly online. But I get notification of everything that’s posted, so I often take a look.

          This isn’t my battle or my debate. I know there’s a lot of polemical bullshit under the PC banner. I don’t care for it personally, but it doesn’t particularly get under my skin. I guess the one exception is when people use expressions like “anti-racism” — as if racism is something you can crush like an invasion of fruit flies. My sense is that we are all racist and most of us men are homo”phobic” to a degree and we generally have opinions about women that we woudlnt’ necessarily want printed on our CV — the brain is designed to make judgements based on associations, not rationality – and to generalize…That’s just the way it works. You can’t “combat” that. All you can do is be aware of it and try to superimposed another perspective, based on objectivity — and to use it to dilute our own stupidity and slow down our impulsive reactions…at least a little.

          Ca va?

          Back to the current (most recent) post, I for one would be very curious as to how you resolve the “immediate future” problem given that depressing prognosis from one of your docs. The best thing of course would be to get a more optimistic prognosis!

    • Al February 13, 2014 at 8:38 am #

      JLK- The hitting bottom is only the beginning for this addict (ME) perhaps others can relate to this. I had hit bottom long before I was able to stop.Stopping using for me was only the beginning of severe suffering. Withdrawals and then PAWs the inability to function for weeks at a time. The ultimate running back to drug because you start to feel that so what even death is better than this crap. If this addict did not get the harm reduction there would most likely be 3 more damaged people in the world (my kids) and one dead mother. Addiction stole everything from me. and when you stop you see that and feeling the shame and guiilt along side of feeling the brain’s inability to cope with the shock of having no more feel good chemicals, whether natural or ingested can prove to be too much for some people. Cunning and baffling are not words put in the text for literary color.

    • Donnie Mac February 13, 2014 at 7:04 pm #

      “Besides Aids usually comes from gay sex not dirty needles. How you going to stop the “bathhouse behavior”?”

      Condoms ?
      ( I literally slapped my forehead with the palm of my hand )

      You are highly misinformed .

  8. Shaun Shelly February 12, 2014 at 4:29 pm #

    Marc, one of the greatest applications of the harm reduction principle is the Housing First initiative of Sam Tsemberis. Check out this video – there is plenty of data on the success of this approach where zero expectation is placed on the individual regarding substance use or treatment:

    http://content.time.com/time/video/player/0,32068,1011477093001_2085601,00.html

  9. Maia Szalavitz February 12, 2014 at 6:13 pm #

    Hi Marc! I am surprised that you have any ambivalence at all about harm reduction, as a scientist, given the overwhelming data. I actually happened to sum up some of it today here..

    http://healthland.time.com/2014/02/12/when-the-road-to-recovery-is-paved-with-a-dash-of-addiction/

    But there’s really no question that if saving lives is what you value— and really, how can you do anything else if you don’t do that?— harm reduction needs to be available. Dead addicts don’t recover, as I first said back in 1988 when writing about why, from an addict’s perspective, needle exchange is essential.

    • Jenny Hong February 13, 2014 at 7:49 am #

      Hi Maia! Very glad to see you here.

    • Marc February 16, 2014 at 3:59 pm #

      Hi Maia, I see your point — how could anyone really doubt its value? It wasn’t an intellectual ambivalence. I could see how it made sense objectively in a number of ways. There was something about the culture, though, that I found hard to accept. That could be a pretty complicated reaction on my part…

      But some of my other readers also feel ambivalence….and we’ve almost all been through it one way or another. So…I think there are sentiments here worth listening too.

      I will go to your link soon, and get back to you.

    • Marc February 21, 2014 at 11:08 am #

      Maia, I finally read your Time article. It’s fabulous! I’m sorry I didn’t get to it earlier. But I’ve now linked to it very prominently in today’s (guest) post.

      I don’t know how I got into this HR stuff, but it’s like Pandora’s Box….stuff just keeps coming out. Thanks very much for your contribution. And….good to meet you!

  10. Jaliya February 12, 2014 at 6:23 pm #

    There is so much richness in this one post and the conversation that I don’t know where to begin :-) ~ What stands out … Shame; staring “into the totality of harm”; “All I want to do is house them” … and kindness … kindness as the opposite of harm.

    It is often an agony simply to feel … simply to exist. It seems that we are wired (as so many creatures are) to modify our basic state of consciousness (I recall stories of bears, deer, and other animals who gorge on certain berries, plants, fermented fruits, etc. … and my own cats, who love to get high on catnip) … It may be that a facet of addiction is how stable our base consciousness is … How much equanimity have we at the root of our self?

    How proficient and willing are we to “treat” our own shame — for we all carry it to some degree — How much consciousness can we bear; how much can we stand to simply be ourselves?

    I still believe that the epitome of what we call harm reduction is to relinquish the use of whatever we are harming ourselves with … and I wonder if any moderation in use is possible — or if moderation, in addiction, ultimately means *no* use.

    Perhaps we need to learn how to moderate other aspects of behaviour before we can begin to moderate — and stop — the use of an addictive substance. Perhaps that is a way in to the edge of addiction — somehow to establish enough safety, stability, and sustenance that we can begin to witness what we are doing to ourselves, with even one iota less of shame.

    Two healers and their books come to mind: Peter A. Levine and *In An Unspoken Voice* (his masterwork of 40+ years in trauma studies), and Richard Mollica’s *Healing Invisible Wounds* (Mollica is the founder/director of the Harvard Program in Refugee Trauma). Both men write extensively of shame — its depth, impact, and healing (as does Gabor Mate). All write of trauma as a pivotal experience — Mollica calls it the existential injury.

    So many folks here point to this wound — and the primary medicine that we need to apply to it: essential sustenance — enough safety, stability, and sanity to open the eyes, mind, and heart to what is — Enough dignity, hope, and sense of worth to begin to separate the self from shame.

    “One step at a time” comes to mind. One step, even if retracted, *is* one step.

  11. Al February 13, 2014 at 8:22 am #

    Hi Marc,
    I have been trying to stop opiates for a few years. First usage was from an MD for chronic pain and then I was dropped when they sold their clinic, No one was willing to do chronic pain. That was my first time to stop. It did not last and I ended up finding Oxycontin on the outsides of the clinic. that progressed very fast. Onto Dilaudid and finally heroin, mainly because of finances. I knew I needed to stop but I could not get through the withdrawals. I developed serious malaise, as one counselor called it, I would say a form of catatonia, I could not function, even after a month, I was not getting anywhere in AA meetings, never felt accepted.I was becoming suicidal, on the verge of losing my kids, I felt I could not be a mother anymore. Then I met a PsyD from a new Suboxone clinic. She fast tracked me into treatment. I am now almost 6 months without any type of street drug, Just suboxone. I admit I do worry about the day I have to stop them but in the meantime I am becoming more involved with my addiction, I started to go to one meeting a week at NA. I go to meetings on line and I read what I can..Suboxone saved my life and I believe saved my children from more pain, perhaps me overdosing or killing myself in a moment of unbearable malaise. I do not know what the future will bring but for me, harm reduction did what it promised, it reduced the harm, I am still struggling but I do not “use” I have many more moments of productivity, And no more thoughts of suicide. That is my take on it,. I will have to update you when I start my weaning process. Bottom line is I am alive and I know i am still addicted but I feel that the suboxone is giving me the time to work on myself from many different angles to hopefully one day be free from the active addiction. I had not had hope for 5 years and now I do. And if I do not have a large amount of hope, I have appreciation for not using and no major depression. Its not all peaches and cream but it is buying me time. Thank you for listening.

    • Janet February 14, 2014 at 9:40 am #

      Hello Al, This took courage to write and it really gets to the heart. I like to call it “Compassionate Healing”. So glad you are getting your life back and your children, too. There is no finish line to cross… you are already there. Healing.
      And this path is full of angels. ! Janet

    • Marc February 15, 2014 at 5:29 pm #

      Thanks for sharing this. I’m glad you found something to see you through, give you time, and as Janet said there is not necessarily a line to cross.,,, Sometimes there can be a lot of little lines.

      To think of the medical community withdrawing their support when you needed it so intensely and so obviously….really blows me away. The phrase “harm reduction” should cover roughly half of what doctors are committed to doing day to day regardless. And your story just exemplifies the value of HR in its particular definition for addiction treatment. The state you were in sounds just awful. Very few people could move from that to full abstinence. So you got a lot of what you needed from suboxone, and that’s just terrific. I hope the rest of the journey is a lot less bumpy. Sounds like it will be.

      By the way, I just finished reading “Drunk Mom” by Jowita Bydlowska. I loved it. A real-time addiction memoir, with the overwhelming complication of having a baby to attend to, written in a style that floods you with honesty without any hint of sentimentality. My book of the week for parents with addictions.

      Do let us know how you’re doing, please, but it seems you’ve done a fair bit of “weaning” already.

      • Al February 15, 2014 at 10:16 pm #

        Janet & Marc, Both of your comments touched me deeply. I have always considered being clean as something for the future. And Yes there are at least a few angels. :) And yes, the Medical Comm. here in New Hampshire was very uncaring and to put it frankly, cruel. One MD in the very beginning of my attempts to stop told me to take clonodine and told my father (who is 80 and needs care from me) to cover my head with a cool cloth for two weeks and I would be “good as new”. Well I was worse than before after two weeks, went back to using (mainly inhaling crushed pills) and it divided my father and me because he believed that the doctor was right about being good as new. That was his proof that i was just doing everything because I am a piece of ______/ he stopped helping me when I need a check cashed in advance, money flow got screwed up and I switched over to heroin, and it really was terrifying to me. The people at AA took actual bets, or had a pool or something or other that was based on whether or not I would live or die by the end of 2013. If it were just dealing with people I could have done it on my own. it was just the withdrawals and horrendous depression and anxiety that seemed to be completely packed in my entire being, physical, metaphysical, existential and psychological. My self was just gone. Sometimes I fear that feeling or lack thereof will come back. I cannot express how horrified I was. There are no words for it. I was wondering from your perspective, Marc, Is there some effect from continuous attempts at cold-turkey? I mean, intuitively I sensed that each time I stopped it like trauma to my body and mind. And each time was many times worse. Ahhh the ability to think too much. its quite nice :) I actually wrote to you a few years ago about the catatonia like feelings I was experiencing. Anyways, I will look for that book. I still not have been able to read yours, which I have been waiting for for a long time. But, I promise I will. Once I get a little more caught up. I will get it, Thank you both again for your lovely comments and the encouragement to keep reaching toward the light.

        • Chris February 16, 2014 at 9:59 am #

          ” I was wondering from your perspective, Marc, Is there some effect from continuous attempts at cold-turkey? I mean, intuitively I sensed that each time I stopped it like trauma to my body and mind. And each time was many times worse.

          I think what you are talking about can be attributed to the neurological process of kindling. In another venue, Dr Lewis proposed it as a mechanism to explain how and why we (addicts) continue to obtain and use our substance of choice long after all fun and pleasure derived from using has ceased … A “Kindling” Model of the Development of Addiction.

          For what it’s worth, I have come to believe kindling pertains as much to my recovery as it did to my addiction. Addiction was a habit I learned, albeit a form of learning accelerated by the way drugs affected and altered the dopamine system in my brain. Recovery is a habit or skill I have learned (am learning) to employ in its place. Like any other habit or skill, the more I practice the easier it becomes; I am able to employ it more proficiently. It develops over time … and with time replaces the default that developed during my addiction. The struggle not to use, which was so intense and all consuming early on, has quieted, randomly triggered by events, thoughts, or emotions that quickly disappear into the stream of other events, thoughts, and emotions that arise to take its place.

          You seem to have discovered this already. Best wishes, as your path forward develops.

          • Al February 16, 2014 at 11:03 am #

            Chris, I have heard of the term kindling before. It was in relation to a time prior to my stepping out of the prescribed medications, when I was in a state of disassociative anxiety. My psyiatric nurse practioner told me that my high level of anxiety was because of kindling. That most people start from an “empty campfire” I already had kindling and fire at my base level (if 0 was a bare piece of ground and 10 was a ranging fire) my base level was close to an 8 or 9 which meant my anxiety sensations did not have far to go to become prominent and that the best way to get over it was to get my baseline down to 0 or 1. It helped to understand the process that way. Is Kindling in regards to addiction the same idea?

          • Al February 16, 2014 at 11:13 am #

            Ahhh, I just jumped to that link you posted with Marc’s writing on Kindling and it has answered my question. It appears tat my amygdala has been a bad girl for a long time. :) she seems to have been wreaking all sorts of havoc with me, psychologically. I want to know more about this model. Because once I understood the model pertaining to anxiety, I was able to find ways to help myself with the anxiety. Also I have PTSD, moderate to severe and am disabled from it. (Sexual abuse in my early life and war situation in my older years) It always seemed to me that there was a connection between my trying to quit and the PTSD. I felt every time the PTSD symptoms were getting worse or flaring up. Something to think about.

          • Marc February 17, 2014 at 6:03 am #

            Chris, this is very important. I never thought of recovery as a kindling process, but it’s a great analogy and good enough for jazz. The reason for seeing it a bit differently is because of brain mechanics. Kindling (classically) takes place in the amygdala, at least in regards to mental health issues. The learning to control impulses comes from very different places — regions of the (lateral) prefrontal cortex and the famous ACC (anterior cingulate). Learning to live by and with self-control is INDEED a developmental process and it builds on itself, becoming easier with time. I rediscover this nearly every day in parenting 7-year-old twins.

            But the limbic system (amygdala) learns unconsciously, whereas we learn self-control mainly consciously. What’s so important is your recognition of a developmental process. The fine-tuning is that the kind of learning we do in withdrawal is more complex, conscious, multi-faceted, and probably involves whole new ways of perceiving who we are and what our lives are about.

            So I love Figure 2 of this article. Never mind that it looks so technical. All you need to know is that that grey matter volume (GM volume) means more synaptic connections, and the line that represents GM volume in the cingulate (ACC) and other cognitive self-control regions rises well beyond the baseline — the average for never-addicted people — after less than a year of abstinence.

            In other words, IT’S A DEVELOPMENTAL PROCESS.

        • Marc February 17, 2014 at 5:52 am #

          Al, I’m really glad you got what we were sending!

          • Al February 17, 2014 at 9:31 am #

            Marc, I can totally see the connection with parenting and self-control. If my two youngest sons 6 and 8 had ever been adults in my home acting in the ways they do I would have probably committed murder a long time ago. It has not escaped me that what I have read about processes relating to the amygdala are entirely subconscious there must have been something I was doing differently the few times I came out from those states of disassociation and terrifying sensations. I have had 3 pronounced times ranging more than a year the first time I was a kid and when I hit my 20′s I just noticed one day that it had been gone for a long time (I was going to college and raising my first son alone) the second time was some years ago when I was in a very bad state of mind stressed and just dependent on prescription meds. I remember reading that you have to just face the anxiety and sensations and say in a sense bring it on. But there is a component that I am so unaware of, a missing link of how it all calmed down. that must be the subconscious workings. I guess the trick is how to manage something that is unseen. But, again, I have idea how it stopped. I do sense it was developmental and some rerouting or rewiring took place beyond my will. .

  12. NN February 13, 2014 at 9:31 am #

    This NY Times story of the mother of Alysa Hale, a young woman who died of a heroin overdose, is compelling. I believe the mother’s presents views and actions
    are a version of harm reduction.

    http://www.nytimes.com/2014/02/11/us/heroins-small-town-toll-and-a-mothers-pain.html?_r=1

  13. Jeffrey Skinner February 13, 2014 at 4:08 pm #

    The value of kindness: How can this be controversial?

    Yes if you offer non-judgemental support to junkies, some will never be able to leave their addiction behind, and will die addicts.This is why it’s called harm-reduction, not harm elimination. I’ll take a real world half loaf over a theoretical whole one.

    • Janet February 15, 2014 at 9:46 am #

      I think it is controversial because we fear. Fear because addiction by its very nature deconstructs so heavily and those administering the kindness often get caught up in the damage. The disappointment. The despair. And the broken cycle expands.
      But I like so much what Jeffrey wrote. It’s a healing that comes from deep within. We have to keep the light on. Kindness, Compassionate Healing, Harm Reduction need to be part of this process.

  14. Donnie Mac February 13, 2014 at 7:11 pm #

    Maybe if we can agree on this , maybe , just maybe we can agree on Harm Reduction .

    ” The idea that you’ll have more intrinsic worth sober than drunk is a bigoted, fascist view that holds that members of certain groups are intrinsically less or more deserving than others — a view that has caused more human suffering than any [other] single idea.
    Jack Trimpey

    http://en.wikipedia.org/wiki/Rational_Recovery

  15. marcus February 14, 2014 at 12:24 pm #

    I’m definitely for harm reduction. HAT (heroin assisted treatment) substituting Rx diacetylmorphine, suboxone, needle exchange to condoms to seatbelts, I am for all of it if it lessens destruction. However, I’m not so sure there’s such a neat line between being clean, harm reduction & using. Moreover, certain parts of the brain, specifically limbic, really don’t know and could care less if the addictor came from a street corner or a pharmacy. I think its called cortico-limbic dissociation. Also, the use of ideas, such as God, are in my view, at least in part an attempt to make the harshness of life more palatable, which is harm reduction, no? So I do not know what exactly is or isn’t harm reduction. The brain disease that causes the symptom of addiction (in some people) still has to be dealt with whether using, clean or somewhere in between.
    For me, this is the post of the day (written by Marc above):
    ” This kid has spent his entire life feeling like he’s a “bad guy”. How much more do you want to pound that in?”

    • Marc February 17, 2014 at 5:36 am #

      I agree, Marcus. What Donnie quoted above (from Jack Trimpey) about “intrinsic worth” is to me a red herring. I would never dispute Trimpey on that one, and most of those who engage in this debate intelligently I think know better than to denigrate addicts in terms of their “worth”. But addiction is still shit, and it is intrinsically happier and healthier to not be addicted than to be addicted.

      Hence the grey zone you describe. And what you say about God as “harm reduction” — it makes me smile but I have to agree with you. I imagine that God would not insist on abstinence but rather on “improvement”.

      And by the way, it’s true, your limbic system really isn’t involved in these choices, though it is involved in the consequences. It is very familiar with fear and shame.

      • Donnie Mac February 21, 2014 at 1:07 pm #

        I never read Trimpey’s quote as a denigration of an addicts “Worth” . In my little dyslexic mind it speaks more to the “Hubris” of the sober .

        PS : The 70s called , they want their idiom back .

  16. Julia February 16, 2014 at 8:58 am #

    Judging simply by the volume and intensity of the discussion around HR, both here and in so many other venues, it seems to be a gold mine for identifying many of the core issues driving policy, medical research and personal experience in regards to addiction (still a term I think has not been properly unpacked). Thanks Marc for providing this venue for a very respectful, inclusive, productive and moving discussion!

    I just have a few things to add to the rich wisdom already shared above:

    “Absitnence” – the word itself carries so much baggage! It repels me personally, to tell you the truth. For me it connotes ascetic monks trying to rise above earthly existence by denying themselves that which makes life worth living for most of us humans,creature comforts of any kind (hair shirts, sleeping on boards, bread and water, etc.), you get the point. In order to deal with any damaging behavior one needs to have a goal to move TOWARDS, not simply a focus on excising something “bad” (dare I even say “evil”?). I think using the word abstinence skews the conversation towards the latter. Good maybe for hardliners in society who care little about what the person’s life is like as a whole, just simply that they “stop using.”

    And stopping using in this context only applies to selected substances, mostly illegal or at least illegal usage. What about the fact that so many who “stop” using identifiable addictive substances end up substituting or relying on (dare I say addicted to?) other substances or behaviors which simply fly under the radar of those making the distinctions? The joke about AA meetings being a feeding frenzy of donuts and coffee, for instance. I am not saying that addiction cannot be overcome or that one thing is always replaced by another or that any of the above is bad. I am just saying that I think with few exceptions, recovery is ALWAYS a continuum, shifting dependence from the target “bad” thing to other less harmful things (or even fully positive things but with some of the same desperation that addiction carries). Be it socially approved addictions, coffee, sugar, TV, running, etc. Or even “dependence” on therapeutic treatment. Some people I know are stuck in the 12 step community. Their whole lives revolve around meetings, the literature and the people they know in that community. I’m not saying that’s a bad thing. I’m just saying that it should be recognized as a form of HR, as is ANY path to recovery.

    So why the brouhaha around HR in the policy sphere? (And I count the medical aspect so far as it attempts to support or oppose policies). Once again, as I mentioned in a comment to a previous post, naming often points towards politics. The question is not so much whether HR is good or bad. It’s going to exist no matter what others say. The question is whether the powers that be provide funding and political support for organized HR such as that described by Karen, the syringe program coordinator you, Marc, mention in your post.

    I’m also hearing a distinction in opinions of HR depending on which perspective the speaker is coming from. Society sees addiction as a drain on its resources (unproductive individuals sucking up services) and a source of harm to others (crime, disease, embarrassment, etc.). So the push from society’s side is simply stop all the above negative stuff. But from the addicts’ side (and those who are able to step into their shoes whether family or treatment providers) it’s a LOT messier. Even if you quit the “addiction,” there is still a mountain of other issues that need to be addressed, i.e. how to recover from trauma, how to create/repair a life, a family, a community. Where are the services, the support for that?

    Like the experience Al shares above, being expected to have a cool cloth applied and then be good as new, it takes a LOT more. And much of that can be classified (in my book) as HR. How far towards “complete” recovery one goes is as varied as there are humans. I forget who said it but isn’t the only real “cure” for what ails one death? I don’t say that out of pessimism, just to say to those absolutists to realize that life is by its nature imperfect and definitions have fuzzy boundaries. Show me what is NOT HR and I’ll give you my vote. Otherwise, we’re just arguing about who pays for what and what strategies the authorities endorse.

    From my understanding very few, if any, addicts (to anything, cigarettes, food, etc.) simply stop once and that’s it, go on with their lives without any change except the absence of the addiction.

    Picking up on what marcus (February 14, 2014 at 12:24 pm) said above, what exactly is HR? Where do ideas/beliefs fit into the continuum and definition. Society may be happier if the individual becomes a religious fanatic but, personally, I don’t count that as anything other than HR. Having been bulimic for over 15 years earlier in my life. And I do believe it would have killed me if I had continued, I am still unraveling the complexity of the internal and external forces that led me to the behavior.

    Julia

    • Marc February 17, 2014 at 5:49 am #

      Thanks for this, Julia. But it should really be a post, not a comment. You’ve covered the issue in real depth, intelligently and sensitively. The concept of a continuum is very important. Please see previous comments by Shaun Shelly.

      I assume “in my book” was figurative. If you have a book out there, we should certainly know about it and it should be linked in your (hoped for) post.

      The reason I suggest a new post is because a thousand or more people read the posts, while only a few dozen make it to the end of a comments thread. I would change very little in the revision. Probably just edit out or else clarify references to reader’s comments. Please email me to let me know your thoughts. Remember, brevity is a virtue in these things…

  17. Maia Szalavitz February 16, 2014 at 6:03 pm #

    Wow, I guess not many people here were shooting up in New York during the 80s and 90s when HIV rates were 50% among IVDUs. If you lived through that time— there was no cure, not even any good treatments for AIDS— it was 100% obvious that harm reduction was not only necessary, but a mitzvah. It saved my life: if someone hadn’t taught me to how to use clean needles (needle exchange wasn’t available, only bleach training), the odds were overwhelming that I would have been dead long ago.

    Moreover, for some addictions, moderation is the only way to deal: you can’t quit eating and it’s really quite unrealistic to quit sex and stopping shopping entirely or quitting the internet is extremely impractical. Are those people “not really in recovery” since they can’t stop entirely? Are you condemning all of them? So, why is it any different with alcohol or other drugs? Some can moderate, some can’t. It’s up to you to figure out what works for you and not impose your one true way on everyone else because that could harm them.

    And, for those who go on about “enabling” the data simply doesn’t support you: what it shows is that where you do harm reduction, *MORE* people go into treatment and when you use compassion rather than confrontation, MORE people stay in recovery. (One study famously found that the more counselor confronts, the MORE the client drinks) In fact, the idea that being kind to addicts is harmful in itself has done more harm than any kindness could possibly do because it has led to literally thousands of cases of PTSD, depression and many suicides in people subjected to it in treatment. (My book, Help At Any Cost details the twisted history of coercion in addiction treatment, focusing on how the worst abuse happens to teens).

    Finally, for the person on Suboxone: why do you *ever* have to come off if it works for you? Especially if you have chronic pain. I’m never stopping my antidepressants because I know that when I do, I am miserable, I make life miserable for those around me and I’m at incredible risk of relapse. So, why stop Suboxone? What’s the difference in the fact that an opioid works for you while an SSRI works for me? I would argue nothing but stigma. And there are some idiots who will argue that I’m “not really clean” because of my Prozac use. I have no time for them and someday, we’ll realize that it’s a stupid, backwards view.

    • marc February 21, 2014 at 10:26 am #

      Maia, Sorry I didn’t reply sooner. I think your points are just excellent. I have also often wondered “what’s so bad about feeling good?” whether it’s with opiates or SSRIs. In fact, the idea that pharma research is spending zillions looking for an opiate replacement that feels the least bit like being high seems to me truly ludicrous. As you say, our society acknowledges that our neuromodulator systems often need some help for us to feel on top of things, so the difference between serotonin-enhancing drugs and opioid-enhancing drugs pretty much eludes me. Unless, of course, you get strung out….but you can get strung out on a lot of things. Coffee and cigarettes come to mind.

      And thanks for your other stats-based correction to the assumption that HR decreases the likelihood of getting in or remaining in treatment. This is a helpful antidote to some pretty whacky rumors.

      Indeed….a mitzvah. I’m really not ambivalent about it. See the post that just went up.

  18. Margot Tesch February 17, 2014 at 2:14 am #

    I couldn’t get the image of the Chinese man out of my mind. it wasn’t so much his addiction pathway to harm, though that was extremely tragic. It was the thought of the unbending ideology that caused his family to reject him in such a devastating manner. Talk about harm reduction … that’s harm compulsion. I was rejected by my brother once, told to leave his house immediately when I had just arrived. My God that was the most excruciating agony.Poor Chinese man.

    • Marc February 17, 2014 at 6:09 am #

      I can’t get him out of my head either. Especially reading the paper the last week or so about horrendous anti-gay legislation and street violence toward gays in Nigeria and other parts of Africa.

      What is most tragic is the link between the two currents here. The isolation and rejection, leading irrevocably to drug use, lowered self-regard, inability to recognize one’s own value and therefore to take care of oneself, and then the diseases and the slow early death that is very likely next. It is truly a tragedy on the deepest level. Like those tragic heroes in Greek dramas, this guy never had a chance.

  19. JLK March 16, 2014 at 8:06 pm #

    Hi Marc
    Wonderful reply on previous subject except I find PC another ideology to find disgusting, mindless and backward and is an easy way to convince yourself you have the moral high ground without giving it deeper thought.

    Now the subject you have more interest in. How the hell do you fill the vacuum when you have little or no future in terms of time on earth

    Firstly I have had any number of Drs tell me I am going to die. It has happened maybe 4 times in the last 2 years. Since I am a victim (hate that word), among all that other shit it hits me more as one more thing to worry about along with paying the garbage bill or buy/building another rental house. As a matter of fact I had a misdiagnose from an idiot Vascular surgeon that came very close to killing, blinding of paralyzing me. I actually used a print from your book for a show-and-tell which he roundly ignored and even made fun of in his notes (which I read).
    Fortunately my architect was good friends with the dept head at the Med school and he sent me for a Ct Scan which saved my life. (Blockage in the carotid and blood was swirling.

    The point of all this is it can come any time from any direction and Drs are not Gods. So as Jack Reacher says…”think for the best prepare for the worst”. The process of preparation and its completion can be soothing on its own.,

    Gotta go and take my nephew (by a previous) out to an expensive place that he and his new wife could never afford. He is getting married and I thought it might be fun for them.
    JLK

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