Harm Reduction vs. Abstinence: Comparing Approaches to Treating Substance Use Disorder

When it comes to treating substance use disorder (SUD), providers usually take one of two approaches: harm reduction or abstinence. Harm reduction focuses on minimizing the negative effects of substance use and promoting safer practices, while abstinence aims for complete cessation of substance use.

Each method has its own philosophy and strategies for helping people manage their drug use and improve their quality of life. Understanding these approaches can help individuals and families make informed decisions about the best path to recovery. Below, we’ll explore the principles behind each approach, compare their benefits and challenges, and discuss how they contribute to the broader conversation about effective SUD treatment.

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History of the harm reduction framework

The harm reduction movement emerged from grassroots advocacy and organizing by public health advocates — especially women, people of color, poor people, and the LGBTQIA+ community  — throughout the 1960s, 70s, and 80s. These groups championed harm reduction,  a pragmatic approach that aims to reduce the adverse health effects of risky behaviors while respecting individual autonomy, as a practical and compassionate response to a range of public health crises, including the fight for reproductive health, the AIDS crisis, and the rising challenges of substance use. 

As the U.S. escalated its racially-motivated “Warn on Drugs” in the 80s and 90s, the harm reduction movement aimed to address mental and public health issues behind substance use. In response to rising overdoses, drug use, and drug-related incarceration, marginalized communities developed harm reduction strategies as community-driven solutions rather than viewing substance use as a top-down problem. These harm reduction strategies focused on meeting the immediate needs of people using drugs and reducing harm rather than relying on abstinence and incarceration. 

Today, thanks to the work of these advocates, the federal government recognizes the need to increase harm reduction efforts across the country, especially in the fight to end the opioid epidemic. Programs such as needle exchange initiatives and medication-assisted treatment (MAT) for opioid use disorder have become central to this approach. These evidence-based practices are now integral components of the national strategy to mitigate the impact of SUDs.

How harm reduction treatment works

Harm reduction encompasses a range of approaches and services that engage with substance use behaviors by meeting substance users where they are; all are based on the principle of respecting the dignity and rights of people who use drugs. Also, all harm reduction treatment approaches are designed to improve the physical, mental, and behavioral health of substance users, in addition to reducing the risk of overdose and increasing infection disease control. 

Harm reduction services are provided nonjudgmentally, with input from those with lived experience, and they consider social inequalities that impact drug use and management. The approach addresses the real harms of drug use while striving to reduce them. Common harm reduction methods are as follows:

• Needle exchange programs that provide clean needles and syringes to reduce the spread of infectious diseases like HIV and hepatitis C
• Medication-assisted treatment programs that use medications (such as methadone, buprenorphine, and naltrexone) to manage opioid addiction and reduce cravings
• Supervised consumption sites where people can safely use drugs under medical supervision, reducing the risk of overdose
• Distributing Narcan (naloxone), a medication that can reverse opioid overdoses, especially to people at risk of overdose, such as those in homeless shelters or people leaving prison
• Distributing fentanyl test strips, which allow people to test their drugs for fentanyl, an opioid with significantly more potency and lethality than standard forms such as heroin and Oxycodone
• Safe disposal programs that offer safe ways to dispose of unused or expired medications to prevent misuse and environmental contamination
• Programs that help homeless drug users find supportive housing that isn’t contingent on sobriety
• Educational workshops to teach people about safer drug use practices, overdose prevention, and health resources
• Public health campaigns that reduce the stigma associated with substance use and co-occurring disorders
• Employing people with lived recovery experience in the harm reduction field
• Integrating counseling and therapy into substance use treatment to address the psychological aspects of substance use

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Despite gaining mainstream acceptance, harm reduction remains misunderstood, largely due to persistent stigma around drug use. Critics argue harm reduction promotes drug use or increases criminal activity, but research shows it doesn’t. In one study, people who recently started using a syringe service program were five times more likely to enter treatment than those who didn’t use the program. And, according to the Brookings Institute, harm reduction efforts do not increase criminal activity. As discussed, harm reduction focuses on minimizing harm and offering support to those who may not yet be ready for abstinence. It is not against abstinence but sees it as one part of a broader continuum of care.

History of the drug abstinence movement

The abstinence movement traces its roots back to another movement — the 19th-century, church-based temperance movement, which emerged in response to the perceived moral and social ills associated with alcohol consumption. During this time, religious advocates argued that abstinence was essential for personal and societal well-being, and this movement laid the groundwork for later anti-drug campaigns, including Prohibition. 

Following the repeal of Prohibition, abstinence-based treatment approaches emerged, most notably including Alcoholics Anonymous — a 12-step program that’s provided the foundational model for many subsequent abstinence-only drug addiction programs (while the program is non-sectarian, it too draws upon principles influenced by Christian values). 

The 1980s and 1990s marked the escalation of the “War on Drugs,” a period characterized by aggressive law enforcement and punitive drug policies, which reinforced a focus on criminalizing drug use and enforcing strict drug laws. This era saw significant increases in incarceration rates (particularly among people of color) and heightened stigma around substance use disorders. More recent approaches to drug abuse have moved beyond strict abstinence. While abstinence remains a key strategy taken by some, there is now greater recognition of the need for comprehensive treatment options, including harm reduction.

How drug abstinence treatment works

Drug abstinence treatment focuses on helping people stop using substances entirely and maintain that abstinence over time. The process often involves detoxification, therapy, and support systems. Here’s an overview of these components of drug abstinence treatment. 

Detoxification 

After an initial assessment, the treatment process might begin with a medical detox, a process that involves safely managing withdrawal symptoms under medical supervision. A detox may include medications to ease withdrawal symptoms and support from healthcare professionals and is typically a treatment for people with severe addiction. 

Therapy

Individual therapy (such as cognitive-behavioral therapy or CBT) and group therapy are common components. These therapies help individuals understand their addiction, develop coping skills, and address underlying issues. Treatment often includes strategies to change harmful behaviors and establish healthy routines. This may involve developing new skills for managing stress, relationships, and triggers.

Support systems

Participation in support groups, such as Alcoholics Anonymous or Narcotics Anonymous, is often encouraged as part of drug abstinence treatment. These abstinence-based groups provide peer support and a sense of community. For some people, engaging family members in the treatment process can be beneficial, as it helps repair relationships and build a supportive home environment. 

Aabstinence-based addiction treatment can lead to significant improvements in overall health and quality of life for some. However, these approaches can punish people who don’t achieve full drug cessation and overlook the many adults with SUDs who recognize the need for help but aren’t ready to stop using substances, data shows. Also, according to research, a sole focus on abstinence can undermine the long-term effectiveness of SUD treatment by raising the risk and severity of relapse and potentially discouraging ongoing efforts toward recovery. These are some of the reasons why non-abstinence approaches to treating SUDs have become more popular in recent years. 

How Charlie Health can help 

If you or a young person in your life is dealing with a substance use disorder (SUD), Charlie Health is here to help. Charlie Health’s virtual Intensive Outpatient Program (IOP) provides more than once-weekly mental health treatment for young people and families dealing with serious mental health conditions, including anxiety, depression, substance abuse, and more. Our expert clinicians incorporate evidence-based therapies into individual counseling, family therapy, and group sessions. We also offer medication-assisted treatment in select states. With this kind of holistic treatment, managing your mental health is possible. Fill out the form below or give us a call to start healing today.