The opioid crisis: A hard lesson learned in addiction treatment
Note: This article, written by Albert Park, originally appeared in a Hampshire Gazette column on April 23, 2018.
I began working in addiction treatment in 1990 in San Francisco. I remember the year well because a requirement for the job was two years in recovery. I met the minimum.
At that point, my only training was my own experience in Narcotics Anonymous, a program based on Alcoholics Anonymous, which has become the gold standard for peer-run recovery support. Based on that life-changing experience, I believed abstinence was the only path toward recovery, that anything less was a half measure that availed nothing, according to the literature of AA.
Later, I was hired for a residential program for people with HIV/AIDS and substance use disorder. This was before the medications that made HIV manageable, so people were still dying. It was common for people to progress to full blown AIDS within months of testing HIV positive. Back then, everyone thought AIDS was a death sentence and much scarier than addiction.
I cannot remember his name, although I will always remember the face of a person I’ll call Henry, a soft-spoken African American man who had been using crack and heroin for at least a decade. During Henry’s first week, the AIDS symptoms his drug use masked became pronounced. Decaying teeth caused constant pain that made it difficult for him to eat. He suffered severe neuropathy in his legs and feet. The most difficult symptom was uncontrolled diarrhea. His heroin use had masked that symptom because opiates are severely constipating. Stopping use meant he could not walk more than two blocks from the house without soiling himself. At this point, these were the gifts of his recovery.
One rainy day, Henry signed out to go to the store and did not return. It was protocol when a resident did not return as planned to lock the door because we assumed the person was using and that was a deal-breaker. As I heard the tumblers click, I remember thinking I was locking out a man in chronic pain with full blown AIDS and it was raining. Back then, I did not question locking the door. It was to keep the other residents safe, I told myself. But on some level, I knew it was wrong: I ended up leaving the field for years.
I think about my experience with Henry quite often when I hear this saying in professional treatment circles: “Abstinence might not include harm reduction, but harm reduction includes abstinence.” When I left that job, harm reduction was just starting to be discussed at that agency. If we had subscribed to its approach, I’m certain I would have handled that situation differently.
By the time I returned to the field, harm reduction had gained traction as a model in San Francisco. In simplest terms, its goals are prevention of overdose and stemming the spread of disease. Today, as a harm reduction treatment professional, I very much believe in abstinence. However, I do not believe it is the only choice for people seeking recovery.
Instead of aiming only for the holy grail of abstinence from all substances, harm reductionists see the value in any positive change. If I had harm reduction tools when I worked with Henry, I would not have closed the door on him, and I certainly would not have locked it.
Practicing harm reduction means meeting people wherever they are with their drug use, believing they are the experts in their own lives, not assuming what a suitable outcome should be and nurturing an individual’s power rather than imposing power on that person. The goal is to remove morality and judgment from interventions. After all, they have no place in any medical treatment, including treatment for substance use disorder.
Many people mistakenly believe harm reduction is enabling or condones drug use. There is often a sort of invisible division between those who support abstinence-only recovery and treatment and those who practice harm reduction. I have seen unpleasant exchanges from both sides on social media.
When I look at what I believed at the beginning my career, I find this understandable. However, this black-and-white thinking is not helpful. In order to address the current overdose crisis, all paths to all positive change are vital to maintain and create. It’s crucial that those of us in the treatment field work together.
I believe in the power of Twelve Step programs. However, I also know they do not work for everyone. As a treatment professional, I have learned that abstinence is always a possibility, but that abstinence is not always a person’s goal. That’s where harm reduction can save lives. Let me be clear here, I will always be happy for someone celebrating a sobriety birthday. At the same time, I also will be happy when someone who uses has not shared needles, has not contracted HIV or Hep. C or has not died from overdose.
Twenty years later, I still think about locking the door on Henry. There are nuances to harm reduction; it is often misinterpreted and implemented in less-than-optimal ways. To promote and educate about the concepts of it, HRH413, a nonprofit I started with co-founder Jess Tilley, is dedicated to elevating the quality of the approach in our region. We believe that foundational understanding of harm reduction is vital to saving lives and responding to the overdose crisis. I know now that I could have helped Henry regardless of his use. The third tradition of Narcotics Anonymous states, “The only requirement for membership is a desire to stop using.” As a harm reductionist, that tradition tells me the only requirement for recovery/treatment/change is to not die. I will never know what ultimately happened to Henry, but I do know this: He did not fail treatment, treatment failed him.
If you are interested in learning more about HRH413, reach out via the website www.hrh413.org
Albert Park and Jess Tilley are best-practices harm reduction trainers and consultants and members of the Hampshire HOPE opioid prevention coalition run out of the city of Northampton’s Health Department. Members of the coalition contribute to a monthly column in this space about local efforts underway to address the opioid epidemic.