In Washington state, where I live and work, the only kind of substance-use treatment currently allowed by state law is abstinence-based treatment, or treatment that demands sobriety. So as a substance-use treatment professional, that’s what I’ve been providing.
But I started realizing that this approach wasn’t reaching many of those struggling with substance use disorders. In fact, the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health showed that 19 million American adults had a substance use disorder in 2016, but only 11 percent of those who needed treatment received it. Of the other 89 percent, nearly 96 percent said they “didn’t need treatment.” For whatever reason, our abstinence-based treatments are not reaching the vast majority of people with substance use disorders.
As counselors and researchers, my colleagues and I at the University of Washington’s Harm Reduction Research and Treatment Center decided to go back to the drawing board. We asked the people we were working alongside — people with lived experiences of alcohol-use disorder and homelessness — how they would redesign alcohol treatment. Ninety-four percent of them favored harm reduction approaches.
Harm reduction refers to a set of compassionate and pragmatic approaches that aim to reduce substance-related problems and improve quality of life without emphasizing sobriety or a reduction in use. On the policy level, harm reduction can include decriminalization, legalization, and regulation of controlled substances. On the population level, it can be public service announcements, like the Ad Council’s famous “Friends don’t let friends drive drunk.” Evidence-based practices such as safer-consumption sites, needle and syringe exchanges, and low-barrier housing are all community-level manifestations of harm reduction.
On the individual level, which is where many counselors work on a daily basis, harm reduction can be supported by medications like extended-release naltrexone for alcohol use disorder or Suboxone and methadone for opioid-use disorder, but it must also be reflected in how we talk to people.
With that in mind, we co-designed a harm reduction treatment program with a community advisory board made up of staff, management, and clients at the Downtown Emergency Service Center in Seattle, an agency serving people who experience homelessness.
In the resulting harm-reduction treatment, counselors met with participants once a week for three consecutive weeks and again after one month. At each session, participants were asked, “What do you want to see happen for yourself?” Some generated their own substance-related goals, like reducing their drinking or not mixing drugs and alcohol. But about half chose to focus instead on other important quality-of-life goals, like getting housing, reconnecting with their children, or engaging in meaningful activities such as creating art or going to the library.
Participants also worked with research staff to brainstorm scientifically informed ways they could stay safer when drinking, such as eating before drinking or taking B-complex vitamins to support their brain health and function.
They also created their own metrics for success. Some defined success as experiencing fewer overall problems due to alcohol use. For others, the metrics were more specific, like having fewer blackouts or seizures. Researchers then helped participants track these outcomes over time so they could see incremental improvements in what they felt mattered most in their lives.
In a randomized controlled trial involving 168 participants, we compared the effectiveness of this harm-reduction treatment with usual care at three clinical and social services agencies in Seattle.
As we reported in the International Journal of Drug Policy, participants receiving harm-reduction treatment showed significantly greater improvements in alcohol outcomes than participants receiving usual care. Compared with their levels at the start of the program, alcohol use among harm-reduction treatment participants decreased by 66%, alcohol-related problems decreased 71%, and the number of alcohol use disorder symptoms declined by 63%. And even though the harm-reduction approach didn’t push sobriety, positive urine tests for alcohol decreased by 20%.
My colleagues and I have also seen promising initial findings that talking to people about harm reduction works for smoking. We believe it could also work for opioid-use disorder to support the use of medication-assisted treatment, though we are just beginning to test this hypothesis.
The bottom line: Even if people are not ready, willing, or able to stop using an addictive substance, they can start getting help and making positive changes in their lives. And a harm-reduction approach to treatment can help them do that.
This finding is important to me as a scientist and counselor, but also as a regular person. My family has an intergenerational experience of addictive behaviors and their sometimes tragic and deadly fallout. I started attending 12-step meetings when I was 16. Years later, I felt the rush of shame and anger that my clients must also feel when my doctor called me an “alcoholic” and dismissed any questions I had about his proposed diagnosis and treatment plan.
I eventually stopped drinking alcohol because of its effects on my health. I also stopped because I wanted to be fully present for my young daughter. So as a mother, a daughter, a granddaughter, a wife, a friend, and an “alcoholic,” I believe in the power of sobriety and the 12 steps.
But that’s not everyone’s pathway, and it doesn’t have to be. When it isn’t, I believe we need to support individuals’ autonomy to make safer and healthier choices for themselves and their families, even when they continue using substances.
Increasingly, that belief is backed up by the science.
Susan E. Collins, Ph.D., is a licensed clinical psychologist, co-director of the Harm Reduction Research and Treatment Center, and associate professor in the department of psychiatry and behavioral sciences at the University of Washington School of Medicine.