Tough Love? Actually, a Harm Reduction Approach Works Better

The following thoughts from GLIDE’s Director of Harm Reduction Services Paul Harkin come in response to a frequent assertion by people addressing the crisis of drug use on our streets: that offering support to those who use drugs only encourages them to keep on using, thereby only adding to the problem, and that only abstinence-based, tough love measures and punitive approaches are sufficient to move people in the direction of recovery and health. While the evidence points in the opposite direction, the myth persists. Below, Paul offers a perspective from his years of work in the field of harm reduction.

As a long-term harm reduction service provider, I am committed to meeting people where they are at, and not leaving them there. There are multiple ways to help individuals deal with the manner in which they are using substances. Harm Reduction uses evidence-based, respectful, dignified and supportive responses to help individuals.

It is all too common for me to hear people who have experienced recent success in their struggle with substance use, get up on a podium and demand that everyone just does what they did and “cures” their problematic drug use. Everyone else is wrong, harm reduction is a failure, because it “makes it easy for people to use drugs.” This person has all the answers, if only we would follow his or her lead.

While it’s great that such a person is choosing at least for now not to use drugs, the indignation and borderline loathing towards harm reduction principles and practices that can accompany this position—an attitude well-known to providers of harm reduction programs—is not helpful in the effort to mitigate harms in general.

When someone puts him or herself forward as a born again “drug free” human being, we certainly wish them health and happiness in their life. My concern comes when he or she thinks their experience must be both relevant and the model for everyone; we must all pay attention to and heed their particular conclusions: “Look at me, I used to be a degenerate drug user and now I am an awesome drug-free person—you, too, can do like I did and be like me.”

The problem is, of course, that such an individual has no idea what another person is actually experiencing or why they are choosing to use drugs. He or she does not know if a person has had horrible adverse childhood experiences, for example, or if another person has a history of trauma, or another person has reasons for seeking refuge of sorts, self-medication, in substance use to mask other horrors that they are struggling to cope with.

Yet despite having no insight into other people’s lives, he or she is encouraged and lauded for telling us what every person needs. I do not believe that a born-again, “tough love” approach is actually geared to other human beings in any meaningful, compassionate or just way. If you don’t really bother to see and understand where a given individual is coming from, you’re not really seeing them at all, and certainly not caring about them. Only when you truly do not see a person are you capable of saying things like, “we make it too easy to use drugs.” What does that mean? Behind the accusing finger is nothing but the moralizing paternalism of Prohibition or the War on Drugs, each of them a scourge and failure of historic proportions.

Another thing we see a lot of are the ill effects on the evangelical non-user who decides to use again: then all the shame, guilt and stigma and self-loathing that they have learned gets directed inward towards themselves. This is not only common, it’s tragically unnecessary and counterproductive.

There will always be those who respond to their own substance use disorder by prescribing for others their particular treatment, based as is it on their own unique experience. They do this at the expense of denying others their own uniqueness.

We hear a wide variety of such proclamations. One person says, “It took jail to get me off drugs,” another says, “I needed my family to kidnap me and lock me in a room for weeks,” while still another says, “I almost died of an overdose and then I knew I had to change.” The reality is that, however extreme, these random successes are just that, purely random.

As healthcare providers, we need evidence-based solutions for treating substance use disorders. We need to be asking better questions. Not moralizing. We should ask a person who has come out of a serious substance use disorder while living on the streets: Did they get HIV or Hep C while out there using? If yes, did they get connected to treatment? Did they overdose and get saved by another user with Naloxone? Where they offered and connected to Medically Assisted Treatment? These are crucial evidence-based services that most people with substance use disorders may require.

Harm Reduction programs say, “support, don’t punish” drug users. Decades of dehumanizing and racist drug war propaganda has entrenched so many myths and false ideas that perpetuate stigma and oppression. The popular idea that people have to “bottom out” to “kick” drugs is proven to be false.

In the end, it does not matter if one person finds a lasting solution to his disorder or if he chooses to use again. As providers, we are here for him and everyone else. If someone tries abstinence and then chooses to use again (there is a  90-95% failure rate for 12-step programs), harm reduction programs will be right there, supporting them without judgement, ensuring that we offer them protection from HIV and Hep C and give them the tools to prevent/survive overdosing on opioids.

That is what harm reduction is: a non-judgmental, evidence-based response to support drug users. We oppose punitive responses to drug use because we know they only cause further harm to the user. We demand scientific, supportive, compassionate solutions to help individuals deal with substance use disorders in ways that work for them.

Paul Harkin has over 20 years of experience as a harm reduction professional and is the director of GLIDE’s Harm Reduction Services. The above opinions were shared in conversation with Robert Avila, Director of Communications, in December 2019.