What is the role of harm reduction when drug users say they want abstinence?
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This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

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What is the role of harm reduction when drug users say they want abstinence?

Neale J., Nettleton S., Pickering L.
International Journal of Drug Policy: 2011, 22, p. 189–193.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Neale at jneale@brookes.ac.uk.

A team including one of the researchers responsible for the original finding have queried the interpretation of the highly influential report from a national Scottish study that most drug users starting treatment wanted to become abstinent. On the basis of in-depth interviews, they caution that it is just not that simple.

Summary Starting from the axiom that all research involves questions of meaning, definition and value, and the understanding that knowledge is ultimately subjective, relative and socially constructed, the featured article reviews findings from a paper one of the authors co-authored, which was presumed to indicate that most problem drug users starting treatment in Scotland wanted to become abstinent rather than reduce the harm they experienced from their drug use.

The paper published in 2004 derived from the DORIS study of 1007 drug users starting treatment in Scotland during 2001/02 at community, residential or prison-based drug services offering substitute prescribing for opiate addiction, detoxification, rehabilitation, counselling and/or group work. One of the questions they were asked was: "What changes in your drug use do you hope to achieve by coming to this agency?" In reply they could tick one or more of:
• abstinence/drug free;
• reduced drug use;
• stabilisation;
• safer drug use;
• no goals;
• other goals.

In response to this question, 57% indicated that their sole objective was abstinence. Just 7% each endorsed stabilisation or reduced drug use and under 1% safer drug use as their sole goals. Of the 24% who endorsed several goals, most aspired to abstinence and harm reduction.

These results have been interpreted as meaning that drug users want to be drug free and that therefore services should be abstinence-oriented, ignoring the uncertainties and limitations expressed in the paper. As it made clear, though an aspiration, abstinence may not be realistic for some drug users. Participants may have ticked the responses they thought cast them in the best light. What they meant by "abstinence/drug free" was not explored, so it was impossible to tell whether they meant 'no illicit drugs at all', 'abstinence from my main problem drugs', or abstinence as a distant aspiration rather than a more immediate objective.

The paper did not make the more fundamental point that a different methodological approach might have enabled a better understanding of what drug users really want from treatment. Instead of the quantitative approach used in the DORIS paper – requiring both standardised questions and responses so they can be counted – authors of the featured report drew on in-depth interviews with 30 drug users also starting treatment, but in the south of England. Evenly divided between men and women, a third were starting opiate substitute prescribing treatment on methadone or buprenorphine, a third were detoxifying from illicit or prescribed opiate-type drugs, and a third had recently started residential rehabilitation. In this study conversational prompts and probes encouraged interviewees to expand on what they meant, particularly when the issue of abstinence arose – for example, asking whether this included alcohol or cannabis and how they rated their chances of achieving this goal.

Main findings

As in the Scottish study, many participants did convey a clear desire to stop taking drugs, but they were also frequently unsure they could achieve this. Also, what they meant by abstinence was varied and often not clear cut. Some explained that they never wanted to use heroin or crack again, but would probably always use cannabis, alcohol, ecstasy, or cocaine, especially in some cases if they had to do without their main problem drugs. Others were simply unsure whether they wanted to use drugs other than heroin or crack. Some later clarified that they wanted to be in control of their drug use rather than totally abstinent. Sometimes the aim was to stop using certain drugs now but address others later, and sometimes stopping use was not seen as necessarily forever. Though almost all smoked tobacco, stopping this was rarely mentioned as part of becoming 'drug free'.

Patients being prescribed opiate substitutes hoped to come off these eventually, but some said this would need to done slowly, and/or emphasised the current benefits of the treatment, including subdued cravings, controlled withdrawal symptoms, and less need to commit crime.

Though these were their drug-focused ambitions, their comments also revealed that changing drug use was often not their main priority and/or was intertwined with others. Asked what they wanted from treatment, frequently they began by talking about improving personal relationships, especially with their children – to be a 'good' parent and/or to have their children returned to them. Other similar aspirations included a meaningful relationship with a partner or spouse, developing good friendships, and repairing damaged relationships with family. In particular, they emphasised honest and trusting relationships built around reciprocity and respect. Also they wanted treatment to help them achieve general life goals Such as a 'normal' or 'better' life, 'new start', and a 'sense of purpose and direction'. and psychological wellbeing. Expressed for example as to 'be happy', 'gain confidence', 'develop self-esteem', or to 'find themselves'. Some also hoped treatment would enable them to engage in meaningful activities, Including employment, education, hobbies, and travel. obtain material possessions such as a car or house, markers of an accepted position in society such as a driving licence, address health problems, or to look and feel better.

The authors' conclusions

These findings from a qualitative study investigating abstinence ambitions in depth show how potentially misleading statements such as '57% of drug users approaching drug services want abstinence' can be. In this study (let alone in a more varied and larger sample) it was impossible to quantify the proportion who sought abstinence since this was not uniformly and often not clearly or consistently defined. Reflecting the messy reality of human experiences, behaviours, emotions and feelings, interviewees adopted fluid, contingent and context-specific interpretations of being drug free.

More specifically, when drug users say they want to be 'abstinent', we do not necessarily know what drugs they are talking about. If researchers do not probe for cannabis, alcohol or tobacco, interviewees will probably not think to mention them. Also, does abstinence really mean no drug use at all, or controlled use? And when are individuals talking about being abstinent: now and forever; now but not in the future; or not now but in the future? Those in treatment may want to be free from prescribed opiate substitutes, but may also recognise their benefits for the time being. Sometimes clients do not know what they want in relation to their drugtaking, or might know, but find it difficult to separate this from what they feel they can achieve. A standard survey question, such as that used in the DORIS study, cannot hope to unpick this complexity.

Additionally, drug use per se may not be their focus – changing it may simply be a means (if an important or essential one) to ultimate objectives such as improving relationships, regaining a normal life, or addressing health problems, suggesting that treatment and harm reduction discourses must similarly prioritise these diverse 'wellness' goals.

Findings logo commentary As the featured report points out, the desire for abstinence of most drug treatment starters in Scotland recorded by the DORIS study has been fundamental to critiques of what is seen as the harm reduction orientation of addiction treatment services across the UK. That finding was itself hedged about by the original researchers in ways reflected in the featured report, which establishes the reality of the concern that by abstinence the respondents need not have meant all drugs including legal substitutes, all illicit drugs, abstinence now rather than some time in the future, or an intention to actualise their desires in action. For some Scottish drug users, getting 'clean' means clean of 'dirty' street drugs, not pharmaceutical quality medications. It is also of course equally obscure what the patients in the DORIS study meant by the other options including reduced drug use (of which drugs when?), stabilisation (in what sense?), and safer drug use (of which drugs and in what ways?). It has also not been questioned that whatever they did mean, more preferred to define it as "abstinence/drug free" than in harm reductions terms.

Worth expanding on is a further consideration raised in the featured report – the context-specific nature of their (and any such) responses. Though many thought it "surprising" (as the DORIS report put it) that 57% endorsed only abstinence, given the question and their situations, it would perhaps have been surprising had they not. Instead of a mismatch between patient goals and treatment orientation, the findings can be interpreted as indicating that patients quite sensibly say they hope to get from a treatment service what that service offers rather than what it does not. Details below.

The question – "What changes in your drug use do you hope to achieve by coming to this agency?" – limited the focus of their aspirations to drug use. A question like, "What changes in your life do you hope to achieve by coming to this agency" might have exposed a greater priority for issues like relationships, health housing and welfare benefits. Also the question was specifically about "this agency". For 44%, this was a service Drug-free counselling or group work, detoxification or residential rehabilitation. offering drug-free and/or explicitly abstinence-oriented treatments, and the same proportion were in prison at the time, where abstinence at least most of the time would normally have been the only feasible objective. As commentators on the original article pointed out, in situations where abstinence from illegal drug use is enshrined not just in law but in social and cultural norms, it is to be expected that people seeking access to help reproduce those norms. The fragility of their allegiance to them – or their inability to conform – is indicated by the fact that over the next eight months, 41% sustained even two weeks' of limited abstinence (non-use of drugs other than alcohol or cannabis), and at the end of this period, just 15% to 17% met this criterion.

When the focus was sharpened to methadone programmes, most patients (57%) endorsed goals including reduced, stabilised or safer drug use as well as or instead of abstinence. That left 43% seemingly at odds with their treatment because their sole aim was abstinence. But nearly all these From an earlier paper from the study (Neale J. et al. "Comparing community and prison-based drug treatments." Drugs: Education, Prevention & Policy: 2004, 11(3), p. 213–228) it is known that 24% of the DORIS prison sample were starting methadone treatment. Extrapolated to the relevant DORIS report, these would constitute 39% of the methadone treatment sample. could have been starting methadone in prison, where reduction and abstinence would at that time normally have been Scottish Prison Service. Partnership and coordination. SPS action on drugs. Revised guidance on the management of drug misuse in Scotland's prisons. 2000. See page 43. the only objectives on offer.

Though important, these complications should not obscure the fact that, however the individual defines it, stopping use of some drugs (especially those so problematic that they have driven them to seek help – in the UK, normally heroin and/or cocaine) is a common goal, and that for substitute prescribing patients, it often extends to eventually being free of legal substitutes too. Surveyed in 2007 – but specifically about their long-term goals in respect of drug use – 81% of responding drug treatment clients in England who used heroin wanted to stop doing so; for cocaine, the figure was 73%. But only minorities wanted to cease using cannabis, alcohol or benzodiazepines and 51% methadone. Given the question, fewer would have wanted to stop their methadone right now or in the next weeks or months.

Ambivalence about taking medication in the form of a desire to be free from having to take the pills or concern over their side-effects and efficacy is commonly observed in long-term prescribing, not just for opiate addiction, but for chronic physical and psychiatric conditions. Such is the scale of this problem that it is a major concern for clinicians, leading patients to decide not to take or to prematurely cease or cut down medication, to the possible detriment of their health. That opiate users prescribed methadone or other substitutes share this ambivalence should not be a surprise, especially given the unusual burdens the treatment often entails, such as supervised consumption and daily attendance, the stigma attached to regularly consuming opiate-type drugs (even legally prescribed), and the fact that the treatment marks the patient as an 'addict'.

As formulated by the chair of the Recovery Orientated Drug Treatment Expert Group looking in to these and related issues in England, such findings mandate attention to moving patients towards abstinence, and this should include from legal substitutes, but only "after appropriate careful planning, when they are ready". While confirming the desires of many to be entirely free of the substances which have been dominating and restricting their lives, the featured report should help prevent a partial and unsophisticated understanding of the original DORIS research leading to premature or inappropriate insistence on total abstinence on the grounds that this is what patients want, when their wants are often not so easily encapsulated.

Thanks for their comments on this entry in draft to Joanne Neale of Oxford Brookes University in England, Neil McKeganey and David Liddell of the Scottish Drugs Forum. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 06 December 2011

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