Harm Reduction, Treatment, and Recovery in Scotland

Scotland may be on the verge of a very bold and exciting overhaul of their treatment system.

They have depended almost exclusively upon methadone maintenance. The majority of their clients have been expressed a preference for abstinence oriented treatment and they are poised to move toward a recovery oriented treatment system.

I had been thinking of this as an example of the failure of harm reduction as treatment. Not to say that there is not a place for harm reduction, rather to say that it is a poor substitute for treatment.

I had also been thinking about it as an example of the limitations of responding to addiction as a public health problem. A lot of treatment advocates argue that addiction should be treated as a public health problem instead of as a criminal problem, but I often feel I alone shudder at the idea. I tend to think of public health as advocating community (or, public) welfare even if it means that some individuals will suffer. I fear that addicts will too often end up on the losing side of this accounting exercise.

Interestingly, I was listening this morning to a lecture by Neil McKeganey. His observations suggest that some of the failures could be laid at the feet of harm reduction and public health, but his emphasis was on this as a failure of treatment-oriented treatment. He argues that the focus of services in Scotland has been to get people in treatment and keep people in treatment to the exclusion of helping people get well. The treatment system's belief was that the system was succeeding as long as people were continuing to take their methadone. The result was that people entered the system and never exited. The patient never achieved their goals, but the system gave itself a pat on the back for achieving its goals.

This raises one of the biggest dangers of framing addiction as a chronic disease. I suspect that this tension between recovery and addiction as a chronic illness is something that can't be resolved. The result is that we'll have to find a way to live on the slippery slope and be vigilant that we don't allow ourselves to slide in one direction or the other.

UPDATE: About my cringing at calls for a "public health" approach. I just fear approaches that put community welfare ahead of individual welfare. Here's a description of public health:

Most definitions share the premise that the subject of public health is the health of populations—rather than the health of individuals—and that this goal is reached by a generally high level of health throughout society, rather than the best possible health for a few. The field of public health is concerned with health promotion and disease prevention throughout society. Consequently, public health is less interested in clinical interactions between health care professionals and patients, and more interested in devising broad strategies to prevent, or ameliorate, injury, and disease.

I'm not sure what term I'd rather see people use instead. I'm reluctant to say we should call it a "medical problem" because I support addiction treatment as a specialty or categorically separate field. I'm not crazy about "behavioral health", but maybe that's the least bad option.

We should stop treating addiction as a criminal problem and start treating it as a behavioral health problem!

I'm not feeling it.