Harm Reduction in Action: Here is Ed’s Story
“How long are we just going to let people die?”
This is a quote from a colleague during a recent conversation about harm reduction. It is a common sentiment among proponents of the abstinence-only school of thought; allowing people to use marijuana while recovering from alcohol or cocaine addiction, or promoting safe injection education and providing the tools to do so, are practices tantamount to murder.
I don’t like arguing, but I love a good story – especially one that doesn’t end in death. What follows is a detailed look at a real harm reduction case study.
- Patient: Ed, gay white male, early 50s, living with AIDS for over 20 years. Multiple strokes and heart attacks in the 1990s. History of poly-substance abuse. He described symptoms of depression and anxiety since childhood.
- Substance use on intake: Six 12 oz. beers per day with two to four “binges” per week (>12). He no longer drank liquor. He smoked marijuana three to four times a day. Abstinent from cocaine for over a year, quitting after he was assaulted and robbed (diagnosed with PTSD). Prescribed Ritalin for ADHD. Approximately a half pack of cigarettes a day.
- Stated treatment goals: Initially, to address his depression and anxiety resulting from the assault. He had become increasingly isolated and his partner encouraged him to follow up on his doctor’s referral. By the end of the intake interview, he admitted that his drinking had become problematic and that he needed to cut down – maybe quit, eventually. He added addressing marijuana use to the list, but he quickly admitted it was a token gesture to appear more motivated; he really didn’t see himself ever giving up the weed. Detox and inpatient treatment were not an option, even if he was motivated to quit. His first experience was marred by discrimination and harassment, as was his attempt at AA. He knew he couldn’t make any positive change if he didn’t feel safe.
…he couldn’t make any positive change if he didn’t feel safe.-Keith McAdam
Ed’s case embodies the core components of the harm reduction philosophy, as laid out by the Harm Reduction Coalition’s “Principles.”
Briefly summarized: Non-judgmental provision of services where the client is primary agent of change. Recognition that psychosocial stressors including discrimination affect capacity for change. Acknowledging that quality of life, not abstinence from substances is the true measure of success.
Course of Treatment
- Year One
After learning that he would determine frequency and intensity of treatment, Ed agreed to weekly individual therapy. He was not ready for group work, and transportation was an issue. He was open about his lifestyle and substance use history. Due to his PTSD, a good amount of time was spent building rapport. The focus of the first three months was building a sense of self-efficacy and monitoring alcohol intake. He couldn’t track his intake on paper, but later expressed gratitude for not pressing him on it. He set lofty goals in an attempt to gain approval, but not for very long. While he could identify past instances of successful behavior change, he was unable to take credit for them. We put out some fires, built some stress management and communication skills, talked mind-body-spirit connection. Despite his experiences with AA he retained what he had learned and began integrating those concepts.
The focus of the first three months was building a sense of self-efficacy and monitoring alcohol intake.-Keith McAdam
He dealt with gastro-intestinal problems that he attributed to medications and AIDS, but his HIV was well controlled and his doctor could find no explanation. We did a lot of health education on the effects of alcohol on the body. Around this time he revisited the idea of inpatient treatment and psychiatric medications. He was also struggling with intimacy issues. His weekly goals had become more realistic, and he was achieving them. The binges were a little less frequent. His marijuana use remained at baseline.
At around six months he stopped minimizing his Ritalin use, admittedly because he acknowledged he was using it to compensate for the decrease in alcohol. He had partner ration pills and money as he had before with some success. Shortly thereafter, he slept with an old “coke buddy.” He considered stopping therapy; he was wasting my time. He asked for a meeting list but came back the next week. He decided to stop drinking first thing in the morning and achieved this for two weeks. He admitted with guilt that he was smoking more pot, so we assessed the ramifications of the tradeoff.
By month 10 he had two weeks abstinent; it was the longest he had ever gone without alcohol.-Keith McAdam
He later acknowledged this was a turning point. He met a treatment goal, felt good about it, and wasn’t made to feel shame about his marijuana use. He developed and adhered to a taper. His Ritalin prescription had run out and he considered not getting it refilled. He started rolling cigarettes to cut back. He began to attribute positive physical and emotional changes to behavior changes.
He reluctantly took credit for some successes: sticking with treatment, and his own commitment; feeling better physically and knowing why. His relationship survived infidelity. He didn’t refill the Ritalin. By month 10 he had two weeks abstinent; it was the longest he had ever gone without alcohol.
- Year Two
After two months Ed relapsed. The episode lasted four days, and by his report he could only drink one 16 oz. each day. He “tried to drink more but [his] body wouldn’t have it.” He realized what he was doing and it motivated him to listen to his body. We discussed the drinking dreams, the shame dreams, the just plain weird dreams. He decided not to “count time” and I told him to stop asking me for permission. Work on spiritual grounding.
After a death in the family and recognized improvement in his emotional processing, we worked on triggers, cravings and resentments.
He attended a wedding with an open bar and resisted triggers. Their dog passed away and he was grateful to have had clarity preparing for it…-Keith McAdam
By month five Ed sat on a discussion panel and told his story. He was grateful for charting his own path, for having a program that understood his specific life situations. The work turned to spirituality and meditation for stress management. People noticed changes; he no longer slouched, and rarely presented with depressed mood or affect.
Ed began using a vaporizer for nicotine and THC after looking into possible decrease in lung damage and ability to reduce nicotine.
He attended a wedding with an open bar and resisted triggers. Their dog passed away and he was grateful to have had clarity preparing for it, and strength to support his partner after. Preparing for stressful events and maintaining boundaries also paid off during a visit with his mother and stepfather. Ed considered this a milestone, after years of strained relationship.
- Year Three
The remainder of Ed’s treatment focused on processing his progress and adjusting to life without alcohol. His relationships improved. He continued to attribute his overall wellbeing to abstinence and we continued to discuss triggers, cravings, and acceptance – standard relapse prevention material.
But to my original point – he didn’t die. I didn’t ‘let’ him continue to use and watch him spiral out of control. We approached his treatment pragmatically, without judgment.-Keith McAdam
He let go of the nicotine. He only used marijuana two to three times a week, mostly to help with arthritis pain but sometimes just for fun. And he was okay with that because he could do it without relapsing. He had a feeling of control over his thoughts, feelings, and behaviors that he had never experienced. And he never stopped talking about how grateful he was for his recovery, and all of the wonderful things he was able to do and feel without alcohol. He lived with caution, not fear.
So it may just be one example of the harm reduction approach allowing one alcoholic to improve his quality of life. But to my original point – he didn’t die. I didn’t “let” him continue to use and watch him spiral out of control. We approached his treatment pragmatically, without judgment. We placed equal value on his psychosocial struggles and his drug and alcohol use. Quitting smoking was never in the treatment plan, nor was such a drastic reduction in marijuana use – these happened organically, as he continued to assess his progress and revise his treatment plan.
And perhaps most importantly, he stayed in treatment because he felt respected, understood and able to take control of his treatment – and ultimately his life. Maybe if we allow our patients a little more autonomy, and dignity, we might keep them around long enough to find their own wellness.