Advanced Harm Reduction: Managing Intoxicated Clients

• The Goal of Abstinence
• A Self-Labeled Alcoholic
• Drug Use by the Formerly Addicted
• Rethinking Non-Problematic Substance Use
• Empowering People to Find Purpose

First there was abstinence, then it was abstinence versus harm reduction. Now, it appears that intoxication management is becoming a necessary skill for therapists. With the ubiquity of alcohol use and its presence as an increasingly high-end activity, the growing legalization of marijuana, mini-dosing, psychedelic therapy and the ever-growing use of psychiatric drugs at younger ages … what’s a therapist to do?

The Goal of Abstinence

Abstinence has traditionally been the goal of treatment for substance use disorders. And while many therapists, particularly those with 12-step backgrounds, continue to tout abstinence, several factors have challenged its once hallowed position at the top of the treatment goal hierarchy.

Abstinence supporters and opponents alternately argue on the following grounds (supporters in plain type, opponents in italics):

• Abstinence provides a clear and unambiguous target
• People will refuse treatment altogether if they must quit entirely
• In order to participate constructively in therapy, the mind and body must be clear of intoxicants
• While living in a monastery or being in rehab encourages abstaining, living in the real world requires some substance exposure and use
• Some drugs create such an intense rush that users must dissociate themselves in order to recalibrate their pleasure responses
• Those on antidepressants, as well as medications for bipolar and other prescribed medications who encounter problems with using the drug, on the other hand, court lethargy and possibly intolerable dysphoria by quitting
• While avoiding one substance may be called for, there may be little cross tolerance or susceptibility to problems with use of another
• Giving in to the urge to use one drug reduces overall willpower strength, according to Roy Baumeister and John Tierney’s best seller on the topic

A Self-Labeled Alcoholic

Joyce drank heavily as a teenager, quitting in her early 20s. She attended AA, remade herself, and moved far away from her home state. Over the years, she smoked pot, and took medication as indicated for pain or sleep or anxiety, but with a wary eye on her penchant for addiction. She succeeded in not using anything excessively or addictively.

Along the way, Joyce developed severe depression, which antidepressants relieved. Eventually, she worried that she had become dependent on the medication, which caused her to stop. But, when Joyce renewed use of the drug, she had a frightening suicide-ideation reaction. She has been terrified of that medical category of drug since then. Joyce is prescribed and occasionally takes anti-anxiety medication, which she uses sparingly due to her fear of addiction. She has found opiates very helpful for her moods but understands that they should not be used that way and mindfully avoids traveling too far down that road when prescribed opioids for pain. She continues to consider reintroducing a depression medication into her life if she can get past her fear of them.

Although some cannabis advocates would say that she is using marijuana therapeutically, Joyce views her use of that drug as strictly recreational and restricts her use to evenings. Using the drug in this way doesn’t interfere with her work or other life functions, and she feels she can take the drug or leave it on any given night depending on her mood and what she’s doing. Keep in mind that Joyce remains completely “sober” with regards to alcohol, per her AA experience, though she occasionally uses Nyquil or cooks with alcohol. Many people in her current social group drink moderately, so that Joyce understands such drinking is readily possible.

Drug Use by the Formerly Addicted

An acknowledged “recovering” alcoholic, Joyce is far from being sober by strict 12-step standards. According to her former AA cohort, Joyce is living in dangerous territory. She uses mood-altering substances for fun, and she continues to take a variety of psychoactive medications. She also no longer attends meetings. Yet she is solid in her conviction that she is now a sober individual, and proud of it.

Joyce is in many ways a prototype of the modern American polydrug user. Her life calls into question the meaning of the terms abstinence, sobriety, and recovery. Of course, even the most hard-core abstinence proponents often don’t include cigarettes and coffee in their sobriety calculus, although both are addictive and can have serious negative health consequences. There is still heated debate among 12-step adherents about taking medications—their allegiance to abstinence precepts ranges from scorning all medication including not even taking an aspirin under any circumstances, to accepting prescribed medications, to believing use of anything that isn’t your drug of choice is okay (like Joyce’s easy use of cannabis). And this is before even considering the modern harm-reduction movement’s scope, including moderate use of a formerly abused substance, substituting a safer version of an addictive drug like taking suboxone or methadone in place of heroin and even continuing addictive or binge use under safe conditions (e.g., using heroin with clean needles or in a supervised consumption site).

Here are what we believe to be the underlying, fundamental guidelines for discussing continued substance use with people who have been diagnosed with or who themselves believe, as Joyce does regarding alcohol, that they have a substance use disorder:

• Be open minded and willing to consider all substance use options: abstinence, substitution or replacement with other substances, moderation, safer use, occasional or regulated addictive or intense use.
• Remain mindful of—and review—experienced outcomes with clients (this opposes the idea of “denial,” taken to mean that clients cannot accurately report their substance-use experiences).
• Measure the success of treatments against actual life functions—work, family and friends, and especially subjective client feelings.
• Avoid labeling the client or his or her substance use pejoratively as addictive, bad, or equally as harmful in all forms or methods of use.
• Consider first and foremost client values and preferences by using motivational techniques in use decision-making.
• Change is part of the process—the person, their situation, and the interchange between them are always in flux. There is no permanent solution.

We are in a sense in the new frontier of almost infinitely available substance use, considering that illicit opiates and other drugs can be ordered over the “Dark Web.” It does no good to regret or bemoan this reality. In a sense, we are at the final societal stage of what therapists should regard as the goal in all therapy—realizing the clients’ agency and freedom of choice in devising their best selves.

Rethinking Non-Problematic Substance Use

The 12 steps can be seen as one expression of American temperance attitudes that consider all forms of intoxicant use and intoxication to be bad or wrong—or, in modern terms, problematic, disordered, or addictive.

Consider Mary, who LOVES to smoke pot. She smokes it all day long, whenever she can, and she always strives to have a supply available. She also drinks, not heavily, but she likes to go out and get a little fuzzy and sparkly with alcohol once or twice a week. Do you think Mary has a substance problem? On the face of it, she uses substances regularly, heavily, and possibly dependently or addictively in the case of marijuana.

Mary owns and manages a local restaurant where she is beloved by workers and customers alike. She is responsible for its financial success as much as the hands-on and the public-facing part of the business. Mary also organizes large rallies and fundraisers for community causes. She is a good citizen. She is strong-willed and plain-spoken. She has a positive marriage. And she is happy with her lifestyle as it is, thank you very much.

Mary knows something about addiction. She used to do cocaine heavily, with terrible consequences for her and her husband’s lives. But that was many years in the past. Today, she seems dependent on pot, while her drinking is generally moderate and she doesn’t overdo her use of any other substance, including occasionally prescribed medications. Yet she rejects and is alarmed by destructive substance use, as occurred in her own life with cocaine.

Mary, like Joyce, expresses several contemporary trends in substance use attitudes and practices. She doesn’t accept standard substance use disorder definitions and recommended usage levels. She accepts, even welcomes, mood modification—a.k.a. intoxication when substances aren’t prescribed for therapeutic purposes. And she doesn’t feel limited by her intensely negative, i.e. addictive, former use of cocaine.

Consider Greg. He was a heroin addict in the late ‘60s, long before so much awareness and availability of opioids use had developed. He shot up, lived on the streets, the whole nine yards of addiction. He was lucky because he had a strong family (parents and siblings), and after many years of addiction, he went to a TC (therapeutic community) and finally quit heroin.

Those communities, at that time, allowed clients to reintroduce moderate drinking after a period of abstinence. That idea worked for many TC adherents, although Greg’s idea of moderation seriously exceeded recommended amounts for safe use. Greg drank to intoxication, specifically, two nights a week, although he never touched any other drug. He was positive that if he ever smoked a joint that he would go right back to heroin, and cocaine was just not his thing. But Greg put alcohol in a completely different category.

As he aged, Greg continued to drink two nights a week, but much less heavily. In many ways he followed a typical pathway of natural recovery with alcohol, even as he was a fully recovered heroin addict. And, we should also note, Greg identified personal emotional issues, made substantial changes to his life and created a life he could better live with than when he had been addicted to heroin.

Regarding Greg’s dual pathways to sobriety—one with opioids, one with alcohol—do we really think that someone who has, for instance, kicked a 10-year heroin habit has relapsed if they have a beer on a hot summer day? Greg didn’t fit this mold. He was a heavy and, for a time, potentially harmful drinker. But what if a formerly addicted person gets drunk at a class reunion every year? Should we perform an intervention? Or are these simply life events, rather than cases requiring a clinical consult?

We as Americans think use of some substances is more acceptable than others: antidepressants are consumed in enormous amounts, along with Adderall, sedatives, and anti-anxiety drugs (benzodiazepines) and other psychiatric medications. What about coffee, colas, and energy drinks? Now marijuana, depending on your residence, is used both recreationally and as medicine.

As for painkillers, we love them and we hate them. Americans have a strong urge to eradicate pain. It is normal to seek relief from pain. Yet we now have become overwhelmed by our quest for pain relief, including, seemingly, relief from the mental and emotional distress of daily life. We need to look seriously at what this need for escape says about society, particularly in areas characterized by little education, high unemployment, and so-called crises of despair.

Empowering People to Find Purpose

Allowing people to feel safe in openly discussing their lives with their counselors and providers, to convey what it is they think they are doing rather than what their counselor thinks they are or should be doing, increases trust and allows for a collaborative therapeutic relationship. This open process must include acknowledgment of and handling intoxicant use.

Such a therapeutic alliance encourages the client’s sense of agency. A path of empowerment by clients’ self-identification of their individual values and goals is the ultimate objective in this conception of therapy and helping. It is not a therapist’s job to identify how someone should live, but rather to explore and to help illuminate what is their best way in life, their unique purpose, with and without regard to their substance use profile.

Perhaps we should celebrate the availability of a modern cornucopia of substances for driving this point home.  

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