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Key points
- There is more than one successful, evidence-based way to help people struggling with addiction.
- Addiction experts have become increasingly siloed in their methods, fighting over which approach is “best.”
- Conflict is counterproductive to our shared goals but there are compromise solutions.
In my corner of the world—addiction treatment and recovery—we have a big problem.
I’m not talking about fentanyl or the opioid epidemic. Or alcohol, cocaine, or methamphetamines. Yes, these are big problems. But we’ve got a bigger one.
It's dogmatism.
It’s the steadfast belief by many outspoken professionals in my field that there is only one right way (their way) to solve America’s addiction and overdose crises, and all other methods are naïve (at best) and dangerous (at worst).
I’ve begun to see a false dichotomy emerge more and more frequently on social media, in op-eds, and even investigative journalism: the battle between traditional "abstinence-based" recovery (discontinuing the use of all addictive substances) and the newer paradigm of "harm reduction," in which goals are focused on limiting harms of use and restoration of health and functioning without the expectation of stopping use entirely.
For those unfamiliar with these terms, examples of traditional abstinence-based models include most professional addiction rehab programs, drug courts, and Alcoholics Anonymous, where complete discontinuation of substance use is a foundational goal. Alternatively, harm reduction providers often serve a different population: people who do not want to discontinue their substance use entirely, but do want to live a healthier and more stable life. Examples of harm reduction efforts include reducing the quantity and frequency of use, preventing the spread of infectious disease, and preventing accidental overdose deaths.
Step back for a second and think about these two perspectives: do they seem mutually exclusive to you? Sure, they have different philosophies and approaches, but could you imagine a world in which both strategies complement each other and work together? I certainly can—but my perspective is, sadly, in the vocal minority.
Tragically, the assumption reinforced by those with the loudest voices who dogmatically align with one perspective over another is that you can’t have it both ways. For example, the vast majority of treatment environments (e.g., rehabs) are designed only for patients who want to pursue complete abstinence. If you’re struggling with alcohol, and it’s threatening your health, but you’re not interested in complete sobriety, sorry—most of these facilities aren’t designed to help you.
This paradigm is imperfect, certainly, and sustains rightful criticism. But some take it a step further with overly broad or misleading claims like “abstinence-based SUD treatment is deadlier than no treatment at all.” On the flip side, those who defend abstinence-based programs fire back, with their own incomplete and alarmist claims that “harm reduction is killing [people].” And around and around we go.
These are just a couple of the ways that abstinence-based and harm reduction camps have been tearing at each other for years, calling each other misguided and delusional, and pitting dueling non-profits and lobbyists against each other to influence public perception and policy. "Abstinence versus harm reduction." That’s the language you see used over and over—but this issue is not one-sided. And, ironically, all parties who take this approach are actually contributing to the problem in the name of solving the problem.
Why is this framed as a zero-sum game? Can’t everyone have something valuable to contribute? We have myriad problems related to addiction—shouldn’t we have a myriad of tools to address them?
What might happen if we leaned toward open-mindedness? Collaboration? Inclusion?
What might happen if instead of one or the other, we said "and" instead? One and the other.
Over the last decade of working in policy, treatment, hospital administration, private practice, and education, I've discovered that there are many paradigms that do have something valuable to offer:
Harm reduction programs have something valuable to offer, and so do abstinence-based treatment programs.
Addiction medicine and psychiatry have something valuable to offer and so does addiction psychology, counseling, and social work.
Drug courts and the justice system have something valuable to offer and so does criminal justice reform.
Alcoholics Anonymous and other 12-Step fellowships have something valuable to offer, and so do SMART Recovery, Refuge Recovery, Lifering Recovery, Women for Sobriety, and other peer-support communities.
Youth prevention has something valuable to offer.
And
Stigma reduction efforts have something valuable to offer.
And
Vocational rehabilitation and housing programs have something valuable to offer.
And
Mobile apps, digital therapeutics, and AI-based tools have something valuable to offer.
And
Government regulation, taxes, and public policy changes to promote healthy behavioral change have something valuable to offer.
Why aren’t we supporting each other in all of these worthy efforts? Doesn’t limiting opportunities and access to care hurt the very population we are trying to help? Maybe there was a time when one set of ideals worked categorially better than the others, but we understand addiction so much better now than before. We understand that the problems we face in this field are more complicated and nuanced than any one solution can solve. Instead of turning against each other, shouldn’t we be banding together against these problems?
The true paradigm shift we need right now isn’t one, golden philosophy. It’s adapting from siloed, competitive, dogmatic fiefdoms to collaboration, cooperation, and synthesis of evidence-supported ideas. Here are some examples of what that can look like:
- Government bodies diversifying (and better yet, increasing) funding related to addiction to actively and equitably support all evidence-based interventions across prevention, treatment, and harm-reduction according to local levels of need;
- Community-based harm-reduction programs actively integrating and liaising with local treatment providers for on-site, warm handoffs if their clients decide they would like to break out of their addictive cycle;
- 12-step communities broadly calling for acceptance of people who are prescribed medications like buprenorphine and methadone to manage symptoms of opioid addiction, rather than perceiving them as not being “sober” or “trading one addiction for another”;
- Increasing the prescription rate of medications for alcoholism (e.g., naltrexone) to be more than the current 2.2% rate, and actively incentivizing primary-care physicians to receive training for how and when to prescribe them;
- Providing overdose-prevention education and supplies to incarcerated individuals with drug histories prior to their release to help prevent the current trend of post-release overdoses.
Ultimately we are all on the same team, even if we don’t see eye-to-eye about everything. We need to start acting like it. We don’t really have any other choice: we’re living in an era of interconnection and digital expression where we can't simply silence or bury the voices or opinions that we don't agree with. If we continue to fight instead of collaborate we’re just going to hurt each other, as well as those suffering with addiction who desperately need our help.
It’s time for a collective intervention: we must stop promoting divisiveness, conflict, and false dichotomies like “harm reduction vs. abstinence-based treatment” in the world of addiction policy, treatment, and recovery.
Over half a million people in the US lose their lives each year to addiction. Millions more are suffering.
Their lives depend upon us changing our mentality. This is the central problem we need to be working together to solve.
Can we drop the dogma for their sake?
