Harm Reduction vs the Disease Model

Dear Dr. Bob,
I recently attended a lecture on alcohol treatment, and for the first time I heard of something called "harm reduction theory". This is way different than anything I've heard of. How can drinking not be a relapse?
Alfredo, Watsonville


Dear Alfredo,
To understand "harm reduction theory", it helps to understand the "disease model' of alcoholism. The American Medical Association pioneered the concept of alcoholism being a disease, because it fit the profile of other diseases: identifiable symptoms that were chronic, progressive, and treatable. Left untreated, this disease was fatal. Once someone develops this disease, like heart disease and diabetes, it can not be cured. But symptoms can be managed or controlled. For heart disease and diabetes, they are controlled through diet, exercise and medication. Alcoholism is managed through abstinence. Although there are several medications available that will adversely affect alcohol in the stomach or decrease cravings in the brain, these are not usually considered life long solutions. Abstinence is where the medical disease model and Alcoholics Anonymous overlap.


There are harm reduction theories used in this country, the "designated driver program" being one of the more popularly know. It does not advocate abstinence, it just  works toward reducing harm. But harm reduction treatment of alcoholism and addiction is not as common in the United States as it is in the rest of the world, including Canada. It theorizes some alcoholics and addicts can not be "helped" through abstinence. Therefore, allowing them to use alcohol or drugs in a managed setting to reduce the harm to themselves and society is advocated. The financial costs to society are extremely high for the almost daily arrests, jailing and hospital emergency room admissions for chronic late stage chemically dependent individuals. In a controlled harm reduction setting, medical, nutritional and psychological issues are all addressed, something that would not happen on the streets. The financial costs to society are considerably less. Individuals also get sober, although that is not the goal. Letting alcoholics drink is controversial, to say the least.


In many communities where "hard" drug addiction is rampant, particularly opiate and crack cocaine addiction, the damage to individuals, families and communities is staggering. Harm reduction theory does not advocate for  abstinence of all substances as the goal. The goal is getting off the heavy drugs and relapse would be using opiates or cocaine again. But alcohol and marijuana use would not be considered a slip. In essence, the goal is to accept "soft" drug use and reduce the harm to an individual and society of the medical, psychological, legal, and violent issues associated with "hard" drug use.


Each theory, the disease model and harm reduction, has its success with certain individuals, certain communities, and certain chemicals of use. And there are other theories of how to treat addiction besides these two also. It takes an open mind to look at all addiction treatment approaches and their underlying theories of causation, reason for their interventions, and their definitions of success.
Dr. Bob