Transforming the US Addiction Treatment Workforce, Part 2

By Tom Horvath, PhD, ABPP

image of narcan to symbolize transforming the US addiction treatment workforce by embracing harm reductionTransforming the US Addiction Treatment Workforce, Part 1, argued that the US needs to follow other nations, which have substantially lowered overdose rates and rates of addictive problems by adopting harm reduction. To offer this approach we need providers who work with the client not against the client’s disease, accept that there are as many pathways for change as there are individuals, work with the client to discover their individual pathway (and not assume that the provider knows what it is), empathize with the value experienced from the addictive behavior, and not confront the client about the desirability of change. Part 2 reviews specific examples of how the US addiction treatment workforce (the providers and systems) would operate having made this transformation, and the types of discussions that might be needed to launch this transformation out of the traditional US addiction treatment approach.

Transforming the US Addiction Treatment Workforce – Embracing Harm Reduction

The essence of harm reduction is to support progress, even if the desired progress would only improve the client’s problems and not resolve them. In this approach, providers start not from the perspective of what providers think clients need to do, but rather what clients are willing to do. Classic harm reduction efforts include providing clean needles (because the client is not willing to stop injecting, but is willing to use a clean needle, thereby protecting themselves and others from disease), providing monitored drug-using spaces (because the client is not willing to stop using but is willing to use in a monitored space where health care professionals and equipment are available in case of drug poisoning or overdose), providing fentanyl and other test strips (because the client is not willing to stop using the drug but is willing to test to confirm it is the drug they want), and providing water at a rave (because the client is unwilling not to be there, but would be willing to drink water if it were available).

The provider needs to get past the idea that these harm-reduction activities enable substance use. These clients or potential clients will be using their substances, regardless of whether these harm-reduction efforts are available. If these efforts are not available, fewer of these clients will be alive later to make further positive changes. If the clients remain alive, they may be more significantly disabled than they needed to be.

How could we educate providers to get past the idea that “harm reduction is enabling?” What discussions might we have with them? Should we just let clients suffer? Shouldn’t they be allowed to experience the consequences of their actions? Generally, “let them suffer” is our current course of action. However, substance users are one of only a few groups we take this approach with. If we took this “let them suffer” approach consistently, we might have no seat belts, guard rails, or medical interventions for individuals “who do not take care of themselves.”

A traditional provider might argue that drug users bring these problems on themselves and that guard rails and seat belts, for instance, protect drivers when they have been hit by someone else. What that argument leaves out is how many substance users have been “hit by someone else” in the form of traumatic experiences and had insufficient support for knowing how to cope with intense emotion. Not everyone with traumatic experiences develops substance problems. However, those who experience trauma without a foundation for dealing with it (such as trauma early in life, or without a sufficient interpersonal world), are much more likely to experience themselves as having been “hit by someone or something else” and much more likely to fall into substance use as self-medication.

Does the client have a disease? The provider would not insist on a specific answer to this question, but instead follow the client’s lead, and the implications of the client’s perspective. If I have a disease, then abstinence makes sense as part of the solution. If I do not have a disease either abstinence or moderation would appear to make sense. For many current providers, this shift out of the disease orientation could be very difficult. The client is an individual who has a perspective on their own substance problems and the causes of those problems. Working to reduce harm from their perspective is the provider’s role, not to convince the client of a specific perspective as a pre-condition for participating in treatment or support.

Providers would gather knowledge about the potential resources for clients in their communities. In addition to treatment facilities, sober homes, coaches and therapists, and medications, etc., providers would know about (or know about where to find) alternative activities that would engage their clients. The more satisfaction the client gets from playing sports, being in a club, enjoying the outdoors, etc., the less satisfaction they would be seeking from substance use. Providers can be informational supports as clients build their own pathways to change.

Providers might initiate their discussions with clients by exploring what the benefits of substance use have been. That course of action seems counterintuitive to many providers. Should I not be showing the client what is wrong with substance use? No. Many sitting in front of you will already know something is wrong. That knowledge is why they are there. Those who are there against their wishes will not likely listen to your traditional harangue. They might be willing to engage in an objective discussion of the benefits of substance use and appreciate that those benefits are being understood. That sense of being understood could open them to considering that the benefits they experience are typically short-term, that there are indeed long-term costs, and there might be other ways to accomplish the benefits of substance use (or at least to approximate them) without incurring the costs.

In the traditional approach, confrontation has been common, although acceptance of the finding that confrontation makes people worse appears to be increasing. Discussing the benefits of substance use will be more likely to engage the client in change, rather than confronting them about problems. Consistent with the notion of individual pathways, clients also do not need to be confronted about accepting the label “addict” or “alcoholic.” If they use these labels, that use can be supported.

When providers are particularly stubborn about re-considering their own beliefs, we can remind them that harm reduction is more effective. Even if providers are slow to change, with luck lawmakers and the public are increasingly appreciating this reality.

In the envisioned harm reduction US treatment system, clients would pursue their own goals at their own speed. Providers would support them. Providers would be prepared for the requests clients typically have, rather than the requests providers think the clients should have. A client would not be barred from attending a session if they arrived late. There would be no “programs” that clients had to comply with. Clients would attend the services they want to attend. Clients would not be required to believe or endorse any ideas they did not already have.

These kinds of practices are already followed in state-of-the-art treatment. In time I hope these practices will be much more widespread.

If you or a loved one are in need of cutting-edge addiction treatment, Practical Recovery can help. Please don’t hesitate to reach out – you don’t have to do this alone.

Missed Part 1? View it here: Transforming the US Addiction Treatment Workforce, Part 1