POCKET GUIDE MEDICATION-ASSISTED TREATMENT OF OPIOID USE DISORDER Nearly 80 percent of individuals with an opioid use disorder do not receive treatment. In the 2014 National Survey on Drug Use and Health (NSDUH), 435,000 respondents ages 12 or older reported current use of heroin. Nonmedical use of pain relievers continues to be more widespread than heroin use— 4.3 million NSDUH respondents reported nonmedical use of pain relievers in the past month. Medication-assisted treatment (MAT) is an effective response to opioid use disorder. It is the use of medications, in combination with behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders. Individuals receiving MAT often demonstrate dramatic improvement in addiction-related behaviors and psychosocial functioning. The first barrier to accessing treatment is failure to recognize substance use disorder. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an approach in which screening is followed up as appropriate with brief intervention to promote healthy behavior change and with referral to treatment for those needing more extensive care. (www.samhsa.gov/sbirt) Produced by the Substance Abuse and Mental Health Services Administration (SAMHSA). Checklist for Prescribing Medication for the Treatment of Opioid Use Disorder Assess the need for treatment � For persons diagnosed with an opioid use disorder, first determine the severity of patient’s substance use disorder. Then identify any underlying or co-occurring diseases or conditions, the effect of opioid use on the patient’s physical and psychological functioning, and the outcomes of past treatment episodes. Your assessment should include: A patient history • Ensure that the assessment includes a medical and psychiatric history, a substance use history, and an evaluation of family and psychosocial supports. • Access the patient’s prescription drug use history through the state’s prescription drug monitoring program (PDMP), where available, to detect unreported use of other medications, such as sedative-hypnotics or alcohol, that may interact adversely with the treatment medications. TREATMENT OF OPIOID USE DISORDER 3 TREATMENT OF OPIOID USE DISORDER • A physical examination that focuses on physical findings related to addiction and its complications. • Laboratory testing to assess recent opioid use and to screen for use of other drugs. Useful tests include a urine drug screen or other toxicology screen, urine test for alcohol (ethyl glucuronide), liver enzymes, serum bilirubin, serum creatinine, as well as tests for hepatitis B and C and HIV. Educate the patient about how the medication works and the associated risks and benefits; obtain informed consent; and educate on overdose prevention. There is a potential for relapse and overdose on discontinuation of the medication. Patients should be educated about the effects of using opioids and other drugs while taking the prescribed medication and the potential for overdose if opioid use is resumed after tolerance is lost. Evaluate the need for medically managed withdrawal from opioid Naltrexone patients must first be medically withdrawn from opioids. 4 Address co-occurring disorders Have an integrated treatment approach to meet the substance use, medical and mental health, and social needs of a patient. Integrate pharmacologic and nonpharmacologic therapies All medications for the treatment of the opioid use disorder should be prescribed as part of a comprehensive individualized treatment plan that includes counseling and other psychosocial therapies, as well as social support through participation in Narcotics Anonymous and other mutual-help programs. Refer patients for higher levels of care, if necessary Refer the patient for more intensive or specialized services if office-based treatment with buprenorphine or naltrexone is not effective or the clinician does not have the resources to meet a particular patient’s needs, Providers can find programs in their areas or throughout the United States by using SAMHSA’s Behavioral Health Treatment Services Locator at www.findtreatment.samhsa.gov. TREATMENT OF OPIOID USE DISORDER 5 TREATMENT OF OPIOID USE DISORDER Medications Approved in the Treatment of Opioid Use Disorder* Frequency of Administration Extended-Release Injectable Naltrexone Monthly† Methadone Daily Buprenorphine Daily (also alternative dosing regimens) Route of Administration � Extended-Release Injectable Naltrexone Intramuscular (IM) injection into the gluteal muscle by a physician or other health care professional.† Methadone Orally as liquid concentrate, tablet or oral solution of diskette or powder. Buprenorphine Oral tablet or film is dissolved under the tongue. 6 Who May Prescribe or Dispense � Extended-Release Injectable Naltrexone Any individual who is licensed to prescribe medicines (e.g., physician, physician assistant, nurse practitioner) may prescribe and/or order administration by qualified staff. Methadone Buprenorphine SAMHSA-certified Opioid Treatment Programs dispense methadone for daily administration either on site or, for stable patients, at home. Physicians must have board certification in addiction medicine or addiction psychiatry and/or complete special training to qualify for the federal waiver to prescribe buprenorphine, but any pharmacy can fill the prescription. There are no special requirements for staff members who dispense buprenorphine under the supervision of a waivered physician. *Table highlights some properties of each medication. It does not provide complete information and is not intended as a substitute for the package inserts or other drug reference sources used by clinicians (see www.dailymed.nlm.nih.gov for current package inserts). For patient information about these and other drugs, visit the National Library of Medicine’s MedlinePlus (www.medlineplus.gov). Whether a medication should be prescribed and in what amount are matters to be discussed between an individual and his or her health care provider. The prescribing information provided here is not a substitute for the clinician’s judgment, and the National Institutes of Health and SAMHSA accept no liability or responsibility for use of the information in the care of individual patients. † Naltrexone hydrochloride tablets (50 mg each) are also available for daily dosing. TREATMENT OF OPIOID USE DISORDER 7 TREATMENT OF OPIOID USE DISORDER Pharmacologic Category � Extended-Release Injectable Naltrexone Methadone Buprenorphine Opioid antagonist Opioid agonist Opioid partial agonist Naltrexone displaces opioids from receptors to which they have bound. This can precipitate severe, acute withdrawal symptoms if administered in persons who have not completely cleared opioid from their system. Patients who have been treated with extended-release injectable naltrex­ one will have reduced tolerance to opioids. Subsequent exposure to previously tolerated or even smaller amounts of opioids may result in overdose. Patients starting methadone should be educated about the risk of overdose during induction onto methadone, if relapse occurs, or substances such as benzodiazepines or alcohol are consumed. During induction, a dose that seems initially inadequate can be toxic a few days later because of accumulation in body tissues. For guidance on methadone dosing for all phases of MAT consult: TIP 43 (http://store. samhsa.gov/product/TIP-43­ Medication-Assisted-Treatment-forOpioid-Addiction-in-Opioid­ Treatment-Programs/SMA12-4214) Buprenorphine’s partial agonist effect relieves withdrawal symptoms resulting from cessation of opioids. This same property will induce a syndrome of acute withdrawal in the presence of long-acting opioids or sufficient amounts of receptor-bound full agonists. Naloxone, an opioid antagonist, is sometimes added to buprenorphine to make the product less likely to be abused by injection. 8 Clinical Uses/Ideal Candidates � Extended-Release Injectable Naltrexone Prevention of relapse to opioid use disorder following opioid detoxification; studies suggest benefits for patients who are experiencing increased stress or other relapse risks (e.g., visiting places of previous drug use, loss of spouse, loss of job). Appropriate for patients who have been detoxified from opioids and who are being treated for a co-occurring alcohol use disorder. Extended-release naltrexone should be part of a comprehensive management program that includes psychosocial support. Other good candidates include persons with a short or less severe addiction history or who must demonstrate to professional licensing boards or criminal justice officials that their risk of opioid use is low. Methadone Detoxification and maintenance treatment of opioid addiction. Patients who are motivated to adhere to the treatment plan and who have no contraindications to methadone therapy. Methadone should be part of a comprehensive management program that includes psychosocial support. Buprenorphine Treatment of opioid dependence. Patients who are motivated to adhere to the treatment plan and who have no contraindications to buprenorphine therapy. Buprenorphine should be part of a comprehensive management program that includes psychosocial support. TREATMENT OF OPIOID USE DISORDER 9 TREATMENT OF OPIOID USE DISORDER Contraindications � Extended-Release Injectable Naltrexone Contraindicated in patients receiving long-term opioid therapy. Contraindicated in patients who are engaged in current opioid use (as indi­ cated by self-report or a positive urine drug screen) or who are on buprenor­ phine or methadone maintenance therapy, as well as in those currently undergoing opioid withdrawal. Contraindicated in patients with a history of sensitivity to polylactide­ co-glycolide, carboxymethylcellulose, or any components of the diluent. Should not be given to patients whose body mass precludes IM injection with the 2-inch needle provided; inadvertent subcutaneous injection may cause a severe injection site reaction. Should not be given to anyone allergic to naltrexone. Methadone Contraindicated in patients who are hypersensitive to methadone hydrochloride or any other ingredient in methadone hydrochloride tablets, diskettes, powder or liquid concentrate. Contraindicated in patients with respiratory depression (in the absence of resuscitative equipment or in unmonitored settings) and in patients with acute bronchial asthma or hypercarbia. Contraindicated in any patient who has or is suspected of having a paralytic ileus. Buprenorphine Contraindicated in patients who are hypersensitive to buprenorphine or naloxone. 10 Warnings � Extended-Release Injectable Naltrexone Use with caution in patients with active liver disease, moderate to severe renal impairment, and women of childbearing age. Discontinue in the event of symptoms or signs of acute hepatitis. As with any IM injection, extendedrelease injectable naltrexone should be used with caution in patients with thrombocytopenia or any coagulation disorder (e.g., hemophilia, severe hepatic failure); such patients should be closely monitored for 24 hours after naltrexone is administered. Patients may become sensitive to lower doses of opioids after treatment with extended-release injectable naltrexone. This could result in potentially lifethreatening opioid intoxication and overdose if previously tolerated larger doses are administered. Clinicians should warn patients that overdose may result from trying to overcome the opioid blockade effects of naltrexone. Methadone Methadone should be used with caution in elderly and debilitated patients; patients with head injury or increased intracranial pressure; patients who are known to be sensitive to central nervous system depressants, such as those with cardiovascular, pulmonary, renal, or hepatic disease; and patients with comorbid conditions or concomitant medications that may predispose to dysrhythmia or reduced ventilatory drive. Methadone should be administered with caution to patients already at risk for development of prolonged QT interval or serious arrhythmia. The label includes a warning about somnolence that may preclude driving or operating equipment. Buprenorphine Caution is required in prescribing buprenorphine to patients with polysubstance use and those who have severe hepatic impairment, compromised respiratory function, or head injury. Significant respiratory depression and death have occurred in association with buprenorphine, particularly administered intravenously or in combination with benzodiazepines or other central nervous system depressants (including alcohol). Buprenorphine may precipitate withdrawal if initiated before patient is in opioid withdrawal, particularly in patients being transferred from methadone. The label includes a warning about somnolence that may preclude driving or operating equipment. TREATMENT OF OPIOID USE DISORDER 11 TREATMENT OF OPIOID USE DISORDER 12 Use in Pregnant and Postpartum Women � Extended-Release Injectable Naltrexone Pregnancy: FDA pregnancy category C‡ Nursing: Transfer of naltrexone and 6ß-naltrexol into human milk has been reported with oral naltrexone. Because animal studies have shown that naltrexone has a potential for tumorigenicity and other serious adverse reactions in nursing infants, an individualized treatment decision should be made whether a nursing mother will need to discontinue breastfeeding or discontinue naltrexone. Methadone Buprenorphine Pregnancy: FDA pregnancy category C‡ Methadone has been used during pregnancy to promote healthy pregnancy outcomes for more than 40 years. Neonatal abstinence syndrome may occur in newborn infants of mothers who received medication-assisted treatment with methadone during pregnancy. No lasting harm to the fetus has been recognized as a result of this therapy but individualized treatment decisions balancing the risk and benefits of therapy should be made with each pregnant patient. Pregnancy: FDA pregnancy category C‡ Neonatal abstinence syndrome may occur in newborn infants of mothers who received medication-assisted treatment with buprenorphine during pregnancy. No lasting harm to the fetus has been recognized as a result of this therapy but individualized treatment decisions balancing the risk and benefits of therapy should be made with each pregnant patient. Nursing: Mothers maintained on methadone can breastfeed if they are not HIV positive, are not abusing substances, and do not have a disease or infection in which breastfeeding is otherwise contraindicated. Nursing: Buprenorphine and its metabolite norbuprenorphine are present in low levels in human milk and infant urine. Available data are limited but have not shown adverse reactions in breastfed infants. Potential for Abuse and Diversion � Extended-Release Injectable Naltrexone No Methadone Yes Buprenorphine Yes Animal studies have shown an adverse effect on the fetus and there are no adequate, well-controlled studies in humans, but potential benefits may warrant use of the drug in some pregnant women despite potential risks. ‡ TREATMENT OF OPIOID USE DISORDER 13 TREATMENT OF OPIOID USE DISORDER Clinical Opiate Withdrawal Scale This tool can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. Resting Pulse Rate: beats/minute Measured after patient is sitting or lying for one minute. 0 1 2 4 pulse rate 80 or below pulse rate 81-100 pulse rate 101-120 pulse rate greater than 120 Sweating: Over past 1/2 hour not accounted for by room temperature or patient activity. 0 1 2 3 4 no report of chills or flushing subjective report of chills or flushing flushed or observable moistness on face beads of sweat on brow or face sweat streaming off face Restlessness: Observation during assessment. 0 1 3 5 able to sit still reports difficulty sitting still, but is able to do so frequent shifting or extraneous movements of legs/arms unable to sit still for more than a few seconds GI (Gastrointestinal) Upset: Over last 1/2 hour. 0 1 2 3 5 no GI symptoms stomach cramps nausea or loose stool vomiting or diarrhea multiple episodes of diarrhea or vomiting Tremor: Observation of outstretched hands. 0 1 2 4 no tremor tremor can be felt, but not observed slight tremor observable gross tremor or muscle twitching Yawning: Observation during assessment. 0 1 2 4 no yawning yawning once or twice during assessment yawning three or more times during assessment yawning several times/minute 14 Pupil Size: Anxiety or Irritability: 0 1 2 5 0 1 2 4 pupils pinned or normal size for room light pupils possibly larger than normal for room light pupils moderately dilated pupils so dilated that only the rim of the iris is visible Bone or Joint Aches: If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored. 0 1 2 4 not present mild diffuse discomfort patient reports severe diffuse aching of joints/muscles patient is rubbing joints or muscles and is unable to sit still because of discomfort Runny Nose or Tearing: Not accounted for by cold symptoms or allergies. 0 1 2 4 not present nasal stuffiness or unusually moist eyes nose running or tearing nose constantly running or tears streaming down cheeks none patient reports increasing irritability or anxiousness patient obviously irritable or anxious patient so irritable or anxious that participation in the assessment is difficult Gooseflesh Skin: 0 skin is smooth 3 piloerrection of skin can be felt or hairs standing upon arms 5 prominent piloerrection TOTAL SCORE: The total score is the sum of all 11 items. SCORE: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal Initials of person completing assessment: http://www.drugabuse.gov/sites/default/files/files/ClinicalOpiateWithdrawalScale.pdf Source: Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs, 35(2), 253–9. TREATMENT OF OPIOID USE DISORDER 15 Disclaimer Nothing in this document constitutes an indirect or direct endorsement by the Substance Abuse and Mental Health Services Administration (SAMHSA) or the U.S. Department of Health and Human Services (HHS) of any non-federal entity’s products, services, or policies and any reference to a non-federal entity’s products, services, or policies should not be construed as such. No official support of or endorsement by SAMHSA or HHS for the opinions, resources, and medications described is intended to be or should be inferred. The information presented in this document should not be considered medical advice and is not a substitute for individualized patient or client care and treatment decisions. Electronic Access and Printed Copies This publication may be downloaded or ordered at store.samhsa.gov. Or call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). Information contained in this guide is condensed from the SAMHSA publication Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide (SMA14-4892R), which is available at http://store.samhsa.gov. For more information visit: http://www.samhsa.gov SMA16-4892PG 12 HARM REDUCTION Meeting Clients Where They Are Regina R. Moro Jana Burson A s the name of the theory implies, the basic notion of harm reduction (HR) is reducing the harm associated with addiction. Although one specific definition of the theory is not available, two of the most widely accepted definitions of HR come from the Harm Reduction Coalition (HRC) and the International Harm Reduction Association (IHRA). The HRC (n.d.) defines HR as a composition of “practical strategies and ideas aimed at reducing negative consequences associated with drug use. HR is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs” (para.1). The IHRA (2015) defines the approach as “policies, programmes and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs” (para. 6). These two definitions offer a glimpse into the theory of HR, and we elaborate on each of the specific components throughout this chapter. Copyright © 2017. SAGE Publications. All rights reserved. BASIC TENETS OF THE THEORY To some people, HR is shorthand for controversial policies like needle exchange, the teaching of safe injection practices, distribution of naloxone kits to reverse opioid overdose in opioid addicts, and the prescribing of methadone and buprenorphine to treat opioid addiction. Antiharm reductionists often see these policies as contradictions to the classic definition of recovery, defined as abstinence from all drugs (White, 1998). Opponents believe such treatments enable addicted people to stay stuck in a lower quality of life than that achieved by complete abstinence. However, Denning (2001) describes HR as “a philosophy of inclusion, respect, collaboration, and choice” (p. 24). Not all individuals living with addiction or using substances are able or willing to stop using all substances completely. For some, it is impossible even to imagine living without all substances for one day, let alone forever. Because some individuals seeking help may wish to reduce the harms associated with use but not eliminate their use, complete abstinence from all substances may not be the ultimate goal of people entering addiction treatment. This creates a divergence in treatment goals, even before treatment begins. Participation in abstinence-based treatment may feel overbearing and even disrespectful for someone who wants to reduce the negative consequences of his or her addiction 235 Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 236 Theory and Practice of Addiction Counseling Copyright © 2017. SAGE Publications. All rights reserved. without completely abstaining. Feeling acutely uncomfortable, such clients may not fully engage throughout the process and may even leave treatment. The prospective client may feel like a person who tries to buy a gallon of milk only to be told by a salesperson that he should buy a herd of cows to get better, fresher, and more wholesome milk. Whereas it may be true, the person may see cow ownership as too onerous, difficult, and inconvenient. That person may feel as if he is trying to be sold something he does not want or need. In 1997, the city of San Francisco addressed the growing gap between traditional abstinence-based addiction treatment and rising support for HR practices by hosting the first of three Bridging the Gap conferences (Gleghorn, Rosenbaum, & Garcia, 2001). During the planning stage for this first conference, eight core principles for effective integration of HR into practice were developed and disseminated to conference attendees. The eight core principles as described by Gleghorn et al. (2001) are as follows: 1. Providers of services for those who misuse or abuse alcohol or other drugs shall deliver care in a culturally competent, nonjudgmental manner which demonstrates respect for individual dignity, personal strength, and self-determination. 2. Service providers are responsible to the wider community for delivering interventions that will reduce the economic, social and physical consequences of substance abuse and misuse. 3. Because those engaged in active substance use are often difficult to reach through traditional service venues, in order to reduce risk, the service continuum must seek creative opportunities and develop new strategies to engage, motivate, and intervene with potential clients. 4. The goal of substance abuse treatment services BOX 12.1 Reflective Exercise is to decrease the short and long-term adverse Consider the following quote illustrated in the consequences of substance abuse, even for those text: “The prospective client may feel like a perwho continue to use drugs. son who tries to buy a gallon of milk only to be 5. C  omprehensive treatments for those who misuse told by a salesperson that he should buy a herd of or abuse drugs and/or alcohol must include cows to get better, fresher, and more wholesome strategies that reduce harm for those clients who milk.” Now consider you are the person attempting to purchase milk: are unable or unwilling to stop using and for their loved ones. •• What feelings might you experience during 6. R  elapse or periods of return to use should not this exchange with the salesperson? be equated with or conceptualized as “failures of •• What thoughts might you have during this treatment.” experience? 7. Medical services are an important component of •• What actions might you take during this situation with the salesperson? comprehensive substance abuse treatment; patients prescribed medications for the treatment of medical A key learning in our role as addictions counand psychiatric conditions, including addiction, selors is that of empathy. Being able to consider must have full access to substance abuse treatment what your experience (i.e., feelings, thoughts, services. actions) might be can help give you insight into 8. Each program within a system of comprehensive what the other person’s experience is and what he or she may need from you during that time. services will be stronger by working collaboratively with other programs in the system. (p. 2) Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction Marlatt, Blume, and Parks (2001) summarized the themes of the core principles as embracing a compassionate and realistic approach, offering low-threshold access to services, and creating programs by partnering with the individuals who will be using the services. The elements of collaboration, respect, and inclusion described by Denning (2001) resonate throughout these core principles. Copyright © 2017. SAGE Publications. All rights reserved. PHILOSOPHICAL UNDERPINNINGS AND KEY CONCEPTS OF THE THEORY Harm reduction as a theoretical framework primarily began during the mid to late 20th century and gained popularity as a treatment option due to the emerging acquired immune deficiency syndrome (AIDS) epidemic of the time (Cook, Bridge, & Stimson, 2010). The medical test to screen for human immunodeficiency virus (HIV) antibodies was developed in the mid-1980s and led to the discovery of high rates of HIV and AIDS among intravenous (IV) drug users (Cook et al., 2010). Initial harm reduction efforts as we know them today developed to reduce the harm associated with the spread of HIV/AIDS via contaminated needles. The capital city of the Netherlands, Amsterdam, instituted comprehensive programs aimed at making contact with IV drug users and simultaneously slowing the spread of HIV/AIDS through the community (Buning, van Brussel, & van Santen, 1988). The program involved multifaceted approaches, including but not limited to public education and unique opioid substitution programs. According to Buning et al. (1988), the government refurbished city buses that drove to different locations throughout the city and provided opioid substitution medication to eligible patients. Eligibility was based on a variety of requirements such as doctor referral, receptivity to counseling, and urine screens. Although some critics of harm reduction approaches believe that such programs will reduce treatment admissions, findings of Buning et al. suggest that increasing the availability of these supportive programs actually increased treatment admissions by 200%. This increase in admissions may be attributed to the comprehensive approach offered by the city (meeting clients where they were) and is also likely due to a shift in attitudes resulting in a reduction of the stigma of addiction. Grassroots programs such as Amsterdam’s harm reduction efforts spread worldwide. Although HR is typically associated with substances of abuse, there have been many efforts to use a similar approach to reduce harms in other areas. For example, unwanted teenage pregnancies and transmission of sexually transmitted diseases have benefited from HR condom programs in schools, as opposed to the historical abstinence-only programs (MacCoun, 1998). Although there are many critiques against the HR movement, it appears as though it is increasingly being implemented worldwide. Key Concepts Like a beautifully cut gem, HR has many facets. One of the main concepts is that client care should be client focused and client driven. Respecting the autonomy of people to make their own choices is key to the approach. Care providers do not set goals for treatment; instead, they work collaboratively with clients and strongly consider them as the experts on their needs and associated goals. In the end, the client is the only person who can make life changes. When change is forced on a client, it is more likely that the client will drop out of treatment or be only superficially compliant in the short term. Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 237 Copyright © 2017. SAGE Publications. All rights reserved. 238 Theory and Practice of Addiction Counseling One of the biggest barriers to treatment for individuals living with addiction is the notion of denial. Many users do not want to discuss use patterns for fear of being judged and labeled as in denial. HR does not embrace such a notion, instead believing that an individual is in a state of ambivalence about his or her use (Denning, 2001). Clients are given a menu of options, with the focus on improving the person’s quality of life. Hopefully they get the message that “we care about you, even if you don’t want to stop using drugs completely. Here are the ways you can be safer now.” That kind of unconditional affirmation can be a powerful agent of change. Change often happens as a result of the therapeutic relationship (Assay & Lambert, 1999), and harm reduction messages can build trust and rapport between drug users and the treatment community. Denning (2001) suggests that the most important part of embracing a HR orientation is to develop an ongoing relationship with the client based on a foundation of respect. In building on the respectful partnership, the HR counselor embodies the role of an educator. Specifically, the client is informed about the effects of drugs on the body through psychoeducation. The client is given as much relevant information as possible in order for him or her to make the best decision. In addition to the counselor embracing an educator role, the client is also encouraged to educate the counselor. Once the counselor gains a clear picture of the client, the integrative treatment incorporates all aspects of the client’s life. This means that different forms of treatment can be mixed to provide the support the client desires, and this is not the same for all clients. It is important to be creative and openminded when individualizing a plan of treatment for each person. Additionally, families and friends are encouraged to be a part of the process (Denning, 2001). In other models, family members and friends may be seen as enabling the individual, and separation may be encouraged. This is not the case in HR in that community involvement is important. The complexity of change is embraced in this model. Few people are able to change a destructive habit in one day. Clients are supported as they make advances and have setbacks, keeping in mind that change is usually a process that takes place over days to months to years. The focus is on the short term, embracing more easily achievable goals, rather than commitment to lifelong change. This approach acknowledges change usually happens in small increments. HR looks at substance use, misuse, and addiction as a continuum. People with addiction are not the only ones harmed by drug use. At times, experimental users can experience severe consequences. For example, a young adult may have an opioid overdose the first time he experiments with heroin. If a bystander has a naloxone kit, the ultimate harm (i.e., death) can be prevented. If the user has not developed an addiction, the event may be enough to convince him heroin is not worth the risk of death. Without a naloxone kit, he would not be alive to make that choice. Harm reduction intends to help daily users and occasional users alike. As highlighted in this example, it is not necessary to have the disease of addiction to benefit from harm reduction treatment. Philosophical Underpinnings All theories have philosophical roots, and HR is no different. Utilitarian thought appears to be most consistent with HR. Utilitarianism suggests that the morally right action is the one that provides the most good (Driver, 2014). In order to understand this in relation to HR, we must examine the idea of morals. Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction Morals refer to dichotomous (e.g., right and wrong or good and bad) ways of being, acting, or thinking. In our daily life, moral judgments are unconscious characterizations of actions in a dichotomous way (Richardson, 2013). Many people do not know that what they are doing is making a moral judgment. For example, this can be seen in our criminal justice process. During a criminal trial the judge and/or jurors are charged with convicting an individual as displaying the right or wrong action under investigation (i.e., making a moral judgment about behavior). There are limited options in the decision-making process; most commonly a verdict of either guilty or not guilty is required (see Exhibit 12.1). Traditionally, drug use has been classified as either right or wrong. Users may classify it on the right side, due to the benefits they experience while using, whereas others may classify use as wrong. The HR approach expands moral judgments from being a dichotomy to a spectrum as seen in Exhibit 12.2. The middle section shows an overlap between the dichotomies, creating an area that may be both right and wrong, which in essence removes the right and wrong nature of what is being classified. As applied to addiction work, if we embrace the notion that some behaviors may be both good and bad, they just become behaviors, without the judgment. This expansion helps us consider more than one viewpoint and helps form a bridge between counselors and clients. For clients it is important to recognize that although there are benefits associated with use, there are also harms, and vice versa for counselors. Acknowledging that there is more to the spectrum reduces defenses that both parties may bring into the discussion. EXHIBIT 12.1 ■ Dichotomous Moral Judgement Beliefs Copyright © 2017. SAGE Publications. All rights reserved. RIGHT WRONG EXHIBIT 12.2 ■ Spectrum of Moral Judgement Beliefs RIGHT WRONG Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 239 240 Theory and Practice of Addiction Counseling The morally right action, as it relates to utilitarianism, results in reduction of harm to one individual or to society on a larger scale. Therefore, all HR practices are the morally right action, because harm is reduced. Copyright © 2017. SAGE Publications. All rights reserved. Comparison With Other Approaches In fields of medicine besides addiction treatment, HR concepts are the core of treatment. Medical doctors often embrace harm reduction when managing other chronic diseases. For example, when physicians work with patients living with type 2 diabetes, they often do a thorough assessment and make treatment recommendations according to the individual’s circumstances. Although the importance of people with type 2 diabetes limiting their carbohydrate consumption is well known, a physician often does not recommend a no-sugar diet but will be satisfied with the patient limiting his or her sugar content. Most chronic diseases, like addiction, have behavioral components, and patients often do not follow their physician’s advice precisely. Physicians continue to work with these patients, recognizing behavioral change takes time. Physicians know the amount of harm done by the disease can be reduced by smaller changes and accept those changes as better than no changes at all. Physicians usually do not dismiss such patients but rather continue to prescribe medication and attempt to motivate behavioral change. Continued treatment reduces the amount of harm done to patients, even when they are noncompliant. As discussed, dichotomous thinking in terms of right and wrong categories is easier for most people. Treatment providers may find it easier to condemn the use of any euphoriaproducing drug and view recovery solely as abstinence from all drugs. In reality, many shades of gray exist between the two extremes; however, the middle phase of the change process is often ignored, and a false dichotomy is set up between the two extremes. Prochaska and DiClemente (1983) recognized the need for an expansion of this idea and developed the transtheoretical model of change, also known as the stages of change model. This model was examined in detail in Chapter 10, and we encourage you to review it at this time. Motivational interviewing (MI; Miller & Rollnick, 2013) is the most well-known approach embracing the stages of change model. As discussed in Chapter 11, in this person-centered approach to counseling, a client is fully recognized as being ambivalent about change, not in denial. In this respect, MI is highly consistent with the HR approach. The shared philosophy of person-centered treatment found in both HR and MI is derived from Rogers’s (1957) core conditions of counseling. Rogers posited six core conditions for change, three specifically relating to the counselor. The counselor must embrace a stance of unconditional positive regard, strive for empathic connection, and be genuine in his or her interactions with clients. These elements are core to HR practice. Influences on Social Policy HR is more closely associated with social policy than any other addiction theory. Expansion and reconceptualization of social policy is crucial for an HR approach to be successful. One social policy of the last century that has needed to be drastically reconsidered for HR to be effective is the “war on drugs.” In 1971, President Richard M. Nixon coined this phrase, which has been responsible for countless policies (Drug Policy Alliance, 2015). In order to successfully implement HR approaches, the “war” would need to be lessened, or at least Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction reconceptualized. Legal regulation of substances, including minimum sentences for drug possession and distribution, has had a significant effect on offenders’ lives and society in general. The most common evolving social policy of the past decade is marijuana legislation. Historically, the possession, use, and distribution of marijuana was punishable by jail time, yet there has been a significant change to this policy, mainly in terms of medical marijuana legislation. So far 23 states, as well as the District of Columbia, have legalized medical marijuana (ProCon.org, 2015). In 2012, voters in Washington and Colorado approved recreational marijuana use (Smith, 2012), and many other states are considering similar legislation. Federal law still classifies marijuana as a Schedule I illegal drug, a classification reserved for the most dangerous and most addictive substances. Social policy, including laws, needs to allow for exceptions to the law for harm reduction purposes. The mayor of Gloucester, Massachusetts, made national headlines with a recent harm reduction approach challenging established social policy. The mayor declared an amnesty program, in which individuals could turn themselves in, with drugs in their possession, and immediately begin treatment (Becker, 2015). This shift in policy away from criminalization appears to be an evolution of the drug court process. A harm reduction approach was used by removing the criminal justice system entirely. Harm reduction approaches allow for individual circumstances to be considered for furthering the good of the individual and ultimately of society. Copyright © 2017. SAGE Publications. All rights reserved. Outcomes Associated With a Harm Reduction Approach Numerous studies have examined the outcomes of HR practices. Such studies often examine outcomes relating to the physical body of the client, psychological outcomes, and/ or sociological outcomes. Phillips, Stein, Anderson, and Corsi (2012) studied the outcomes of client education, a common HR approach associated with needle exchange programs. The authors enlisted current IV heroin users and randomized the sample to either an intervention group or an assessment-only group. Each group of participants was asked to demonstrate the skin cleaning procedures he or she would use prior to injecting heroin. In addition, they were asked to demonstrate the needle cleaning procedures they commonly used. Researchers rated each participant’s demonstration according to approved protocols. Following the baseline assessment, the intervention group participated in brief educational sessions aimed at teaching approved protocols for skin and needle cleaning practices. The findings of the Phillips et al. (2012) study suggest that education along with a 1-month booster session significantly improved participants’ skin and needle cleaning practices at a 6-month follow-up in comparison with the assessment-only group. In addition, the authors report that the intervention group participants reported a larger reduction in IV heroin use and a reduction in use days, although this was not significant between groups. This is encouraging because it highlights the role HR education practices can have on supporting client change, even when not the focus of the practice. The small sample size of the study (N = 48) limits the availability to make meaningful insights, but these findings do encourage future research concerning client education on safe use practices and the effects on consumption rates of substances. There has been large-scale support for methadone maintenance treatment in the scholarly literature. Fullerton et al. (2014) examined the literature base for methadone maintenance Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 2 41 242 Theory and Practice of Addiction Counseling Copyright © 2017. SAGE Publications. All rights reserved. programs and found numerous supportive studies for the HR practice. Many of the studies reviewed were meta-analyses, a type of research in which multiple studies are compiled and results are analyzed on a large scale. The authors report that methadone maintenance programs reduce clients’ use of illegal opioids, as well as increase client involvement in treatment. In addition, the programs have been shown to reduce mortality, illegal activity, nonopioid illegal drug use (e.g., cocaine, methamphetamine), and behaviors associated with HIV infection. With such positive outcomes associated with methadone maintenance it is no wonder the programs are widely supported as an HR practice. Grazioli, Hicks, Kaese, Lenert, and Collins (2015) completed a study with chronically homeless adults who met the diagnostic criteria for an alcohol use disorder. Study participants received counseling based in HR practices. They received personalized feedback about their alcohol use, were encouraged to discuss their own goals for counseling (not necessarily related to alcohol use), were introduced to common safer-drinking practices, and received medication (naltrexone). Study participants were followed over the course of 3 months to see which of the safe-drinking practices they embraced and whether there was change with this over time. The authors report no change over time in endorsement of the practices, but on average the participants endorsed using three safe-drinking practices. The most common practices included limiting the effects of alcohol on the body (e.g., including food when drinking) and changing the manner of drinking (e.g., drinking lower-proof alcohol). In examining the participants’ view of alcohol use and abstinence, Grazioli et al. (2015) state that the participants’ “abstinence was primarily viewed as a temporary reprieve from ongoing alcohol use instead of long-term lifestyle change” (p. 67). The embracing of safe-drinking practices makes sense given the reported participant attitudes toward abstinence. This study highlights that substance users do embrace and use HR practices when appropriately informed. The previously referenced studies comprise not even 1% of the available research on HR practices. However, these findings suggest the outcomes one can expect from implementing these strategies. More research examining specific practices and intervention levels would benefit not only clients but also practicing counselors. HOW THE THEORETICAL APPROACH IS USED BY PRACTITIONERS The theoretical approach of HR is not only used by individual counselors but also embraced on a larger scale by treatment programs. This section examines current practices of HR, including safe-needle exchanges, client education, and methadone maintenance programs. The section also provides an overview of how HR practices may be implemented by organizations. Needle Exchange and Injection Education Perhaps the practice most usually associated with HR is needle exchange programs (NEPs). These programs offer free or low-cost distribution of new, unused needles to intravenous drug users. NEPs have been shown to help prevent transmission of infectious diseases such as hepatitis and HIV and also reduce the risk of local soft-tissue infections such as cellulitis Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction and skin abscesses. Other serious health issues such as endocarditis (bacterial infection of a heart valve) are reduced when drug users use fresh needles and syringes. In addition to receiving clean needles, users are taught safe injection practices. For example, drug users are taught to try a small test dose of heroin as a way of assessing how strong the drug is, prior to injecting a full dose, because heroin purity can vary immensely. In addition, users are trained to use cotton filters in the syringes, which can prevent particles and debris from being injected along with their drug. They are taught not to reuse these filters, to reduce the risk of “cotton fever.” Cotton fever is a well-known illness among IV drug users and is marked by fever, abdominal pain, and nausea and vomiting, among other medical concerns (Xie, Pope, & Hunter, 2016). Other users are advised against using cigarette filters. It is common for some to use these filters thinking they are safe, but these filters contain glass particles that can be problematic if injected along with the drug. Users are also told not to use lemon juice to help dissolve their drug, as is common practice, because it can contain a type of harmful fungus. Education also includes discussing the importance of not using while alone. The idea is that by using in groups, someone would be available to call for help if an overdose occurs. In addition, injection times are encouraged to be staggered, to allow one person to be alert enough to call for help if needed or to use a naloxone kit to reverse the overdose. Copyright © 2017. SAGE Publications. All rights reserved. Naloxone Kits A growing HR practice is increasing the availability of naloxone kits. Naloxone, a prescription medication, reverses the signs of opioid overdose and can be administered in several ways: intravenous (into a vein), subcutaneous (under the skin), intramuscular (into a muscle), and intranasal (sprayed up the nose). Naloxone can be thought of as a kind of anti-opioid, causing the reversal of opioid effects in case of an overdose. Naloxone has been administered in emergency departments for years, but with the recent rise in opioid overdose deaths, many organizations have pushed to have naloxone kits become more available to opioidusing people, opioid addicts, and first responders such as police and emergency medical personnel. These kits are becoming increasingly user-friendly, with some containing automated messages describing the instructions for use. The quicker an opioid overdose is reversed, the less the chance of death or disability from oxygen deprivation, so time is of the essence when naloxone is needed. Many states now allow third-party prescribing of naloxone. This means doctors can prescribe kits to opioid users and opioid-addicted people and also to their families. At present, laws differ among states. In addition to the distribution of naloxone kits, opioid-addicted people, friends, and family members are educated on overdose management techniques. Participants are taught how to position the body of an addict who is unresponsive while waiting for help to arrive. They are also taught what not to do, such as not injecting ice water in the user’s veins and not putting the person into a cold shower. Medication-Assisted Treatment (MAT) Medications are available to assist with some of the related harms of addiction. Some of the most common medications used for addiction treatment are methadone and buprenorphine. Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 243 244 Theory and Practice of Addiction Counseling These are medications prescribed to individuals to help manage the withdrawal symptoms associated with discontinuing opioid use. Severe withdrawal is common in opioid addiction and is one major reason users continue to use despite negative consequences. These medications work by activating the same neurotransmitters activated in opioid use, but the feelings of euphoria are not produced. As a result of the medicine blocking the neurotransmitter receptor sites, the user is able to reduce use while not experiencing the physical withdrawal symptoms. Methadone-assisted treatment has been available since 1964 (Fullerton et al., 2014). The management of opioid addiction with methadone and buprenorphine has traditionally been considered harm reduction, though now many experts feel MAT is a stand-alone treatment in its own right. This position is supported given that addiction is a chronic illness, and as with many other chronic illnesses, the client may need to take medication for an indefinite period of time. Case Conceptualization Another major use of an HR approach by counselors is embracing the core principles outlined by Gleghorn et al. (2001) as a framework for case conceptualization. Embracing an HR lens demonstrates a commitment to clients, acknowledging that any reduction in harm is positive for the client and society as a whole. This shift is not an easy one to make, particularly because we are socialized with certain beliefs about addiction (e.g., addiction is a weakness, drug users are bad). It is important for counselors to examine their own biases and reflect on how their beliefs are helping or hindering the population they hope to work with. Whereas the previous is not a fully exhaustive list of all HR techniques, the measures and strategies have in common the goal of keeping drug users safe. All policies and techniques that have this goal in common can rightly be termed HR and ideally are delivered in a caring, compassionate, and nonjudgmental way by care providers. Indeed, all forms of addiction treatment and counseling should reduce harm to the patient. Even if the provider’s goal is abstinence and the client does not achieve abstinence, HR has been accomplished if the client uses less or uses a little more safely. Proponents of an HR approach would say that treatment has not failed because the client is better off than prior to receiving treatment. Copyright © 2017. SAGE Publications. All rights reserved. ASSESSMENT AND PREVENTION IMPLICATIONS Because HR honors the right of an individual to determine how much and what kind of treatment is desired, care providers need to assess the client’s willingness to change in the context of substance use. Ideally, practitioners can respectfully assess the client’s reason for seeking treatment and the desired outcomes. Often this would include determining the patient’s stage of change, using Prochaska and DiClemente’s (1983) model. In order to assess a client’s readiness to change, an addictions counselor may choose to use a standardized assessment tool. The Readiness for Change Questionnaire (Rollnick, Heather, Gold, & Hall, 1992) is a 12-item tool that assesses the following three stages: precontemplation, contemplation, and action. Each of the 12 items corresponds to one of the three stages and once compiled indicates a score from -8 to +8. The scale with the highest number indicates the current stage of change. The questionnaire was expanded to 15 items for use in treatment settings (i.e., Readiness for Change Questionnaire [Treatment Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Copyright © 2017. SAGE Publications. All rights reserved. Chapter 12 • Harm Reduction 245 Version]; RCQ-TV) by including items related to abstinence, as opposed to the sole focus on reducing BOX 12.2 Exploring alcohol consumption found in the original version SAMHSA’s TIP Series (Heather & Hönekopp, n.d.). The assessments mentioned in this chapter Another assessment tool for assessing a client’s can be found in the Substance Abuse and Menreadiness to change is the Stages of Change Readiness tal Health Services Administration, Treatment and Treatment Eagerness Scale (SOCRATES; Miller & Improvement Protocol (TIP) Series Number 35, Tonigan, 1996). There are 19 items on the questionnaire, publication titled Enhancing Motivation for and a participant’s score indicates one of three scales Change in Substance Abuse Treatment, which as corresponding to the client’s readiness for change: can be downloaded for free on the SAMHSA website. The website and further information recognition, ambivalence, and taking steps. Two forms about ordering printed material is found in the of SOCRATES are available, SOCRATES 8A, the Resources for Continued Learning section at the Personal Drinking Questionnaire, and SOCRATES end of this chapter. 8D, the Personal Drug Use Questionnaire. The two forms allow for separate assessment of change related to drinking and/or drug use, which is a strength over the RCQ questionnaires previously discussed. In addition to the standardized tools examined earlier, addiction counselors may also use subjective means to assess a client’s readiness to change. One counseling skill common to solution-focused brief therapy (De Jong & Berg, 2013) is scaling questions. Clients are asked to rate their readiness for change on a scale from zero to 10, zero meaning no readiness and 10 meaning full readiness. Once clients state a score, they are asked to consider what an incremental change would look like. For example, a counselor may say, “You mentioned that you scored a 6 out of 10 on your readiness to change. What might a 7 look like for you?” The smaller increment of change helps to not overwhelm the client. A counselor may also ask about motivation on a similar scale, remembering to follow up with what the increment of change would look like. If treatment professionals do not assess willingness to change, they risk assuming that the patient desires complete abstinence from all drugs. Motivational interviewing (MI) counseling techniques work well in drug addiction treatment, and as identified previously, both MI and HR have the same underlying principles: respect for the individual and recognition that long-lasting change comes only when and if the person decides to change. External pressures may force change in a client, but if there is no desire on the part of the patient to sustain that change, it may not be permanent. Some treatment programs force patients to be superficially compliant in order to make it through whatever treatment program they have entered. For example, a client in an inpatient residential setting may want to stop using cocaine but may be uninterested in quitting marijuana. The client may detect that voicing her desire and intention to keep using marijuana would lead to unwanted attention from treatment providers. Providers may single out this client in a group setting and pressure other group members to confront the client’s attitude toward marijuana. The client, feeling targeted and singled out, may begin to parrot what other clients say rather than being honest about her real plan to continue using marijuana. Treatment providers may mistakenly think they have been successful in changing their client’s mind, when in truth, she just decided to avoid conflict. Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 246 Theory and Practice of Addiction Counseling Throughout the assessment phase, it is crucial that counselors maintain focus on the client and embrace the client’s treatment goals according to an HR approach. The HR approach has the ability to reduce clients’ defenses if embraced fully by the counselor. Instead of dictating what the treatment goals will be, the client is encouraged to be creative and focus on what he or she would realistically achieve. If a client suggests he or she wants to make a change, the counselor inquires about how that change will benefit the client and helps build up his or her motivation for continuing with the change. This assessment is crucial because it is often the first line of interaction with clients. Copyright © 2017. SAGE Publications. All rights reserved. STRENGTHS AND WEAKNESSES OF THE THEORY Proponents of the HR approach identify numerous strengths with the model. The first is the expansion of treatment, both in reaching more clients and in expanding the definition of services considered treatment. More individuals may be encouraged to enter treatment when it is not solely focused on abstinence. In addition, treatment services such as the medication-assisted therapies discussed previously fall under the HR umbrella and therefore expand our definition of treatment. Another strength of the model is that HR reduces large societal costs of drug use and addiction. A client being prescribed methadone maintenance therapy is at a reduced risk for engaging in criminal behavior to acquire opioids illegally. The reduction in criminal behavior can have a direct result on the reduction of arrests for drug use and trafficking. Not only would the number of offenders in prisons be reduced overall, but there would also be a reduction of the number of offenders in prisons who would require additional costly medical attention for withdrawal symptoms as well as addiction treatment. Last, and perhaps the most embraced strength of the HR approach, is the reduction in moral judgment championed by the model. As stated by Denning (2001), the model seeks to include individuals, not exclude them because they are unable or unwilling to follow strict rules. Any sort of change, no matter how small, is embraced and championed. Clients are expected to be the experts on their lives and are encouraged to educate the counselor on what is best for them. People who object to HR practices usually do so with the best interests of drug users in mind. Many opponents of HR honestly feel that these strategies serve only to enable the person to keep using drugs and in the end cause more harm than if the client were allowed to suffer consequences of active drug use. Some 12-step groups maintain that users must “hit bottom” before being able to find true recovery. They may feel HR keeps users from experiencing a bottom necessary for a complete change of lifestyle. Opponents of an HR approach also define true recovery as being achieved only with complete abstinence from all euphoria-producing drugs. For example, recovery advocates who feel abstinence is the only recovery may deem clients who are prescribed methadone or buprenorphine as still in active addiction. Although these sentiments are coming from a desire for all to live a drug-free life, clients may hear the message that they will never be able to get clean if they are using supportive medications, which may cause them to lose all hope. The Great Debate The strengths and weaknesses of HR have been debated since the model was first conceptualized. The following is an imaginary debate between two addiction treatment Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction professionals. One professional endorses HR measures as worthy activities and feels such measures can keep drug users alive and healthy, even if they never completely stop using. This individual is identified as the advocate. The other professional feels HR does not allow a drug user the opportunity for full and happy recovery, which she believes is seen with complete abstinence from all drugs. This individual is identified as the opponent. They begin by sharing views about needle exchange programs. Advocate: I fully support needle exchange programs. They have been proven to reduce transmission of infectious diseases, including HIV and hepatitis. Why wouldn’t we want to help people avoid getting these potentially devastating diseases? Opponent: Because giving out needles sends the wrong message. It says we are OK with people injecting drugs and that we are willing to make it easier for them to do so. Appearing to condone drug use in any way sends the wrong message to young adults, who may be considering using drugs for the first time. Stigma toward drug users can be harmful, but maybe it is a good thing to have stigma surrounding dangerous activities like injection drug use. Advocate: Studies do not show needle exchange increases the likelihood that people will start using drugs intravenously. Do you really think easily available clean needles and syringes would convince a person to start injecting drugs? Besides, even if you have little compassion for the drug user, for every case of HIV we prevent with needle exchange, we save our society countless dollars in medical care. Besides being morally right, needle exchange makes financial sense. Opponent: No, it doesn’t. It sends a message to drug users that we’ve given up on them. It says we don’t think they will ever be able to live without injecting drugs. In a way, it infantilizes them. By making drug use easier, we may cheat them out of trying to become clean and sober. Copyright © 2017. SAGE Publications. All rights reserved. Advocate: I disagree. Needle exchange tells drug users that we care about their welfare, whether or not they choose to use drugs. They will feel our compassion for them, and these drug users are then more likely to come to us for help if they are ready to stop using drugs, because they trust us. The advocate and opponent move to the topic of medication-assisted treatment of opioid addiction with methadone and buprenorphine. Advocate: I fully support medication-assisted treatment. We have 50 years of studies that show people who are addicted to opioids are less likely to die if they enroll in methadone maintenance or buprenorphine maintenance. It is one of the most heavily evidence-based treatments in all of medicine, and it is endorsed by many professional agencies, such as the Institute for Medicine, the Substance Abuse and Mental Health Services Administration, the World Health Organization, and the American Society of Addiction Medicine. We have study after study showing how opioid-addicted people have a better quality of life when on medication-assisted treatment with methadone. We have more information about methadone because it has been used in the United States much longer than buprenorphine, which was approved by the Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 2 47 248 Theory and Practice of Addiction Counseling Food and Drug Administration in 2002, after the Drug Addiction Treatment Act of 2000 was passed. Opioid-addicted people enrolled in methadone treatment are more likely to become employed, much less likely to commit crime, and more likely to have improved mental and physical health. They do receive addiction counseling as part of the process of treatment. We think buprenorphine has the same benefits, though there have been fewer studies than with methadone. We do know the risk of opioid overdose death is much lower when an opioid-addicted person is also treated with buprenorphine. Because medication-assisted treatment is so effective, it should be considered a primary treatment of opioid addiction and not only a harm reduction strategy. Copyright © 2017. SAGE Publications. All rights reserved. Opponent: For that matter, all evidence-based treatments should reduce harm, because they treat the patient. But especially with methadone, opioid-addicted people may be harmed more than if they continue in active addiction. It is no different from giving an alcoholic whiskey. It is a heavy opioid that is very difficult to stop using. The opioid treatment programs that administer methadone don’t try to help these people to get off of methadone, because they make more money by keeping them in treatment. These patients are chained to methadone with liquid handcuffs forever. Advocate: Methadone and buprenorphine treatments are not like giving an alcoholic whiskey, because of the unique pharmacology of these medications. Even after an opioid-addicted person stops using opioids and endures the acute withdrawal, he will usually feel postacute withdrawal. This syndrome, often abbreviated PAWS, can cause fatigue, body aches, depression, anxiety, and insomnia. It is very unpleasant. Many people in this situation crave opioids intensely. We think this occurs because that person’s body no longer makes the body’s own opioids, called endorphins. Endorphins give us a sense of well-being, and without them, we don’t feel so good. When humans use opioids in any form, their bodies stop making endorphins. In some people, it takes a very long time for that function to return. In some cases, it may never return. We can’t yet measure endorphin levels in humans, so this is just a theory but one borne out by years of observation and experience. Methadone and buprenorphine are both very long-acting opioids. Instead of the cycle of euphoria and withdrawal seen with short-acting opioids, these medications occupy opioid receptors for more than 24 hours. It can be dosed once per day, and at the proper dose, it eliminates craving for opioids and eliminates the postacute withdrawal, which is so difficult to tolerate. We often compare opioid addiction to diabetes, because in both cases, we can prescribe medication to replace what the body should be making. And yes, methadone is difficult to stop using, but most of the time it is in the patient’s best interests to stay on this medication, rather than risk a potentially fatal relapse to active opioid addiction. Some patients are able to taper off of the drug, if they can do it slowly. Do you think of a diabetic who needs insulin as being “handcuffed” to it? Do you think the doctor who continues to prescribe insulin is just trying Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction to make money off of that patient? Why is it wrong to make money from treating addiction but not other chronic diseases? Opponent: What about all of the former opioid-addicted people, now in 12-step recovery, who are healthy and happy off all opioids? Why are these people doing so well, even though they had as severe an addiction to opioids as the patients in opioid treatment programs? Advocate:  I don’t know. One form of treatment, even medication-assisted treatment, will not be right for every patient. Maybe the support that a 12-step group can provide got these people through the postacute withdrawal. We don’t have much information about these recovering people due to the anonymous nature of that program. But not all opioid-addicted people want to go to 12-step meetings. If they feel well off of all opioids, that’s great. They don’t need medication. But don’t prevent other people who do benefit from medicationassisted treatment from being helped with methadone and buprenorphine. Copyright © 2017. SAGE Publications. All rights reserved. Opponent: These treatments cheat patients out of full abstinent recovery. Methadone and buprenorphine blunt human emotions and make it impossible to make the spiritual changes necessary for real recovery. Methadone and buprenorphine are intoxicants, and they prevent people from achieving the spiritual growth needed for full recovery. You keep these people from finding true recovery and condemn them to a life of cloudy thinking from these medications. Advocate: Various people say that patients on maintenance methadone and buprenorphine have blunted emotions and spirituality, but there’s little evidence to support that claim. How can you measure spirituality? If spirituality means becoming reconnected with friends and loved ones and being a working, productive member of society, then studies show that methadone and buprenorphine are more likely to assist patients to make those changes. Physically, studies show patients on maintenance methadone and buprenorphine have normal reflexes and judgment. They are able to think without problems, due to the tolerance that has built up to opioids. They can drive and operate machinery safely, without limits on their activities. Contrary to popular public opinion, clients on stable methadone doses are able to drive without impairment. However, if clients mix drugs like sedatives or alcohol with methadone, they certainly can be impaired. That’s why we warn patients not to take other sedating drugs with medication-assisted treatments. My bottom-line argument is this: Dead addicts can’t recover. Far too many opioid-addicted people have abstinence-only addiction treatments rammed down their throats. Most of these patients aren’t even told about the option of medication-assisted treatment, which is much more likely to keep an opioid drug user alive than other treatment modalities. Too often, people addicted to opioids cycle in and out of detoxification facilities over and over, even though we have 40 years of evidence that shows relapse rates of over 90% after several weeks in a detox facility. We’ve known this since the 1950s, and yet we keep recommending Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 2 49 250 Theory and Practice of Addiction Counseling this treatment that has a low chance of working. And then we blame the addict if he relapses, when in BOX 12.3 Reflective Exercise reality he was never given a treatment with a decent The text provides a debate between two addiction chance of working! Medical professionals, the wealthy, treatment professionals. One is the advocate and and famous people are treated with 3 to 6 months one is the opponent. Based on the conversation, of inpatient residential treatment, and they do have higher success rates, but who will pay for an average 1. What do you think are the advocate’s three main points? opioid user to get this kind of treatment? Many have no insurance or insurance that will pay for only a few 2. What are the opponent’s three main points? weeks of treatment. For those people, medication3. If you were to get into a discussion with a assisted treatment can be a life-saving godsend. It isn’t classmate or future coworker, what side would right for every opioid-addicted person, but we do you take? know these people are less likely to die when started in medication-assisted treatment. After these people make progress in counseling, there may come a time when it is reasonable to start a slow tapering off of either methadone or buprenorphine, but let us first worry about preventing their death. Opponent:  Given the time, money, expense, and stigma against methadone and buprenorphine, it should be saved as a last-resort treatment. If an opioid-addicted person fails to do well after an inpatient residential treatment episode, then medication-assisted treatment could be considered as a secondline treatment. Let’s save such burdensome treatments for the relapse-prone opioid-addicted people. Advocate: You mean if they live long enough. It seems disingenuous to claim stigma as a reason to avoid medication-assisted treatment when you are the one placing stigma on this treatment. Copyright © 2017. SAGE Publications. All rights reserved. CASE STUDY RESPONSES The case of Gabriel discusses numerous incidents of harm to himself, his family, and society. The immediate harm identified is his alcohol use. He is drinking in a dangerous pattern and is most likely to cause immediate and irreversible harm to himself. Harm reduction tends to focus on the most serious risks first, if the patient agrees. If Gabriel does not see his alcohol use as a problem, the harm reduction approach honors his decision and asks him what he sees as the most critical problem, encouraging discussion of reducing some harm. The aim of HR is to meet Gabriel where he is and encourage him in any change he might be open to as opposed to no change or treatment. The following are some of the identified harms organized in a biopsychosocial framework. Biological/Medical Concerns Gabriel’s substance use raises serious medical concerns. Gabriel reports alcohol consumption in patterns that result in blackouts, along with steady use of marijuana. These periods of time are a major concern because blackout drinking can cause significant changes to his brain’s structure and function, especially the prefrontal cortex. This part of the brain is Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction responsible for decision making and judgment and does not complete development until an average age of 24. Because Gabriel is 26, he is ingesting chemicals during a sensitive time of brain development. Even without drug use, the part of his brain responsible for decision making may not be finished forming. Another potential medical concern is Gabriel’s reported sexual activity—sex with two female patients during his last inpatient admission while in a committed relationship. It is unknown how many other partners these females had and whether they used protection with these other partners as well as with Gabriel. Such activity could put him at risk for sexually transmitted diseases (STDs) such as syphilis, gonorrhea, herpes virus, and HIV, among other ailments. At present, we don’t know if Gabriel sees his sexual activity as behavior worthy of change. Sexual activity does not have to carry risk, yet it is not known whether contraception was used. We may make an assumption that it was not, because sexual activity is typically in violation of the rules at treatment centers and therefore condoms would not be available for patient use. Psychological Concerns Copyright © 2017. SAGE Publications. All rights reserved. The case study mentions that there is mental health comorbidity, yet there is no mention if Gabriel is currently getting any care for these two treatable conditions, obsessive-compulsive disorder (OCD) and anxiety disorder. A counselor using this treatment approach would be concerned about the use of substances and the impact on mental health symptoms. There is also a chance that Gabriel is suffering from what he believes to be symptoms related to OCD and anxiety disorder, yet it may be directly linked to his substance use. A thorough assessment would help sort out the cause of his symptoms, but we can assume his drug use is not improving Gabriel’s ability to cope with negative mood states. In addition to the diagnosed mental health comorbidity, Gabriel is questioning his sexual orientation, which can be a confusing time that brings on additional stress. He reports a great deal of shame around an early sexual encounter, which could be fueling some of his drug use and perhaps worsening his mental health and anxiety issues. It would be important for any counselor or treatment provider working with Gabriel to adopt a nonjudgmental stance and be open to exploring issues related to sexuality. Sociological Concerns Gabriel has had interactions with the legal system due to his drug use. We need to learn Gabriel’s perceptions regarding his legal involvement and also his risk for future issues. Gabriel may be motivated to reduce his risk of being involved with the legal system again, and thus addiction treatment can be framed as a way to reduce the harm done to his personal freedom by drug use. Gabriel’s family dynamics could also be harmed by his drug use. He reports that he has always had a distant relationship with his father. In addition, although his mother and sister are great sources of strength and support currently, his mother is attending Al-Anon and has been setting more firm boundaries. Gabriel may realize further drug use is likely to harm his relationships. Gabriel could be offered the option to see a physician for a medication evaluation. For example, naltrexone, dosed daily in pill form or by monthly injections, has been shown to Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 251 252 Theory and Practice of Addiction Counseling help patients with alcohol addiction. It is particularly helpful with reducing the amount of alcohol consumed per occasion, because part of alcohol’s euphoric effect is mediated through the brain’s opioid receptors. With naltrexone, those receptors are blocked, leading to less euphoria and less enthusiasm for heavy drinking. Acamprosate is another medication approved for use in alcohol addiction. The mechanism of action for this medication is not completely understood, but it appears to modulate the balance of neurotransmitters in the brain. This interaction in the brain eases anxiety and cravings in early alcohol abstinence, thus reducing a client’s risk of relapse. Working With Gabriel In order to be effective, the counselor must really believe in the HR approach and accept that reducing harm possibly without reducing drug use is a helpful and worthy goal. After adopting this philosophical approach a counselor is well equipped to do the client-centered harm reduction work with clients. Initially it would be important to ask Gabriel about his perceptions of harm. In addition, it is important to assess Gabriel’s readiness for change. This may be done in a variety of ways, but most likely the SOCRATES screening tool (Miller & Tonigan, 1996), both A and D forms, would be used to examine his readiness for change with both his drinking and drug use. After that identification, we could provide Gabriel with a menu of options for this problem, including information about harmful effects of drugs such as alcohol, outpatient counseling, intensive outpatient programs, and possibly even inpatient treatment again. Motivational interviewing may also be a helpful approach to embrace in conjunction with HR to enhance Gabriel’s reported readiness and motivation for change. If working with Gabriel’s family, it would be important for each family member to discuss and possibly rank-order the harms they are experiencing due to Gabriel’s substance use. They can also consider how they also contribute to the harm and what they are willing to do to reduce harm to Gabriel, themselves, and their family. Although we just discussed how we may work with Gabriel’s family, by following a patient-centered approach, it is crucial to ask him how much he wishes to involve his family members. Copyright © 2017. SAGE Publications. All rights reserved. Key Techniques and Strategies Consistent with harm reduction principles, Gabriel would be given a menu of possible treatment choices, including medical screening, sexual education, addiction treatment, and any other idea that Gabriel has for himself, to see which appeal to him the most. Harm reduction tends to focus on short-term, immediate goals, so it is important to ask Gabriel what he sees as the most important issue to work on first. Because harm reduction is nonjudgmental, it is crucial that treatment providers deliver care in this manner. In addition, using open-ended questions, affirming Gabriel for his successes, and using reflective listening techniques are foundational skills of motivational interviewing that would greatly benefit our relationship with Gabriel (Miller & Rollnick, 2013). Medical Screening Earlier we discussed the importance of assessing for biological harms, which also would include a thorough medical evaluation, specifically screening for prescription medications. Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction If Gabriel has not been prescribed any medications for the management of his OCD and/ or anxiety disorder it would be important to provide psychoeducation, particularly because medications can be enormously helpful for both disorders with the addition of counseling. If Gabriel is open to one or both routes of treatment, this can reduce the psychological distress, or harm, he feels in daily life. The provider can offer to connect him with providers for one or both treatments. Sexual Education HR strategies such as female or male condom use, human papillomavirus vaccine, or a reduction in number of sexual partners would allow Gabriel to protect himself from STDs and may be an area of interest for Gabriel. Interestingly, some of the medications most effective at treating OCD and anxiety disorders also reduce libido. Usually this is seen as an unpleasant side effect, but in Gabriel’s case it may reduce compulsive elements of his sexuality. Treatment providers would have to be very sensitive when informing Gabriel about these medications and their side effects, because he may not believe his sexuality is a problem worth addressing, and his choice must be honored in an HR approach. Also, the case study points out that Gabriel has some shame around his sexuality, so great care must be taken not to add to that shame by suggesting a lowered libido is desirable. Whereas it’s possible a decreased libido could help him focus on getting help with his other issues, this must be Gabriel’s choice. Copyright © 2017. SAGE Publications. All rights reserved. Addiction Treatment Treatment options may be presented to Gabriel. An identified strength of Gabriel’s is that he does have familiarity with treatment because he has been in inpatient treatment twice. It is important to note that some treatment providers may see these as treatment failures, but when taking a longer and more optimistic view, Gabriel likely learned something from each of his encounters with addiction treatment professionals. As a result of these encounters he may have a broader base of knowledge on which to build. It would be important to discuss with Gabriel what worked, what did not work, and what may be different if he was open to pursuing that option. It would be important to educate Gabriel further about other treatment options, specifically intensive outpatient (IOP) and also less intensive forms of outpatient counseling. He may not be aware of these options and also may not be aware that different centers may have different philosophical approaches to addiction treatment. Educating Gabriel about his options is crucially important. Weaknesses or Challenges of the Theoretical Approach Harm reduction honors the client’s choice. Sometimes the client may not choose to work on the issues treatment providers feel are the most important. For example, if Gabriel were drinking heavily and driving drunk daily, but felt he only wanted to work on his anxiety issues, his treatment provider may be fearful about not addressing a behavior that could very well kill Gabriel. The treatment provider may believe that failure to address dangerous drinking is unethical. Such a situation creates tension between what the practitioner sees as most critical for his well-being and what Gabriel sees as a priority for his well-being. Another challenge of the harm reduction approach is that harm can be defined in many different ways. We chose to use a biopsychosocial framework to conceptualize harm, yet this Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 25 3 25 4 Theory and Practice of Addiction Counseling may also be limiting. It is important to be able to help clients conceptualize harm and even define it for themselves from this perspective. Strengths of the Theoretical Approach Copyright © 2017. SAGE Publications. All rights reserved. As many of us know, permanent change occurs only with the cooperation of the client, and this approach wholeheartedly honors individual client choice. Thus, the practitioner is working with the client’s own motivations, on areas the client wants to address. It is believed that this will enable each client to be more enthusiastic about instituting changes seen as most important to well-being. When care is delivered in a nonjudgmental and empathetic fashion and the client’s voice is valued and respected, the therapeutic relationship is more likely to be strong and an effective mode of change. Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 • Harm Reduction SUMMARY This chapter examined the HR approach to addictions counseling. This client-centered, compassionate, and optimistic approach has a long history of reducing personal and societal harms related to addiction. Foundational to the practice of HR is the assessment of client readiness and motivation for change, allowing for infusion of motivational interviewing strategies. Common practices of HR include client education, naltrexone kits, and methadone maintenance programs. Strengths and weaknesses of the approach were examined and a debate was presented to encourage further thought. RESOURCES FOR CONTINUED LEARNING Books Anderson, K. (2010). How to change your drinking: A harm reduction guide to alcohol. Scotts Valley, CA: CreateSpace. Denning, P., & Little, J. (2012). Practicing harm reduction psychotherapy: An alternative approach to addictions (2nd ed.). New York: Guilford Press. Marlatt, G. A. (2012). Harm reduction: Pragmatic strategies for managing high-risk behaviors (2nd ed.). New York: Guilford Press. Stout, D. (2009). Coming to harm reduction kicking and screaming: Looking for harm reduction in a 12-step world. Bloomington, IN: AuthorHouse. Scholarly Journals International Journal of Drug Policy: www.ijdp .org. Websites Harm Reduction Coalition: http://harmreduction .org. Harm Reduction International: www.ihra.net. Screening and Assessment Tools for Enhancing Motivation to Change in Substance Abuse Treatment, SAMHSA TIP Series #35: www .ncbi.nlm.nih.gov/books/NBK64976/# A62297. Substance Abuse and Mental Health Services Administration, Enhancing Motivation for Change in Substance Abuse Treatment: http:// store.samhsa.gov/shin/content/SMA13-4212/ SMA13-4212.pdf. Copyright © 2017. SAGE Publications. All rights reserved. Harm Reduction Journal: www.harmreductionjournal .com. REFERENCES Assay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 33–56). Washington, DC: American Psychological Association. Becker, D. (2015). Gloucester, Mass., police program provides treatment for drug users. Retrieved from www.npr.org/2015/06/04/412046914/ gloucester-mass-police-program-providestreatment-for-drug-users. Buning, E. C., van Brussel, G. H. A., & van Santen, G. (1988). Amsterdam’s drug policy and its implications for controlling needle sharing. In R. J. Battjes & R. W. Pickens (Eds.), Needle sharing among intravenous drug abusers: National and international perspectives (pp. 59–74). Rockville, MD: National Institute on Drug Abuse. Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 255 Copyright © 2017. SAGE Publications. All rights reserved. 256 Theory and Practice of Addiction Counseling Cook, C., Bridge, J., & Stimson, G. V. (2010). The diffusion of harm reduction in Europe and beyond. In T. Rhodes & D. Hedrich (Eds.), Harm reduction: Evidence, impacts, and challenges (pp. 37–56). Lisbon, Portugal: European Monitoring Centre for Drugs and Drug Addiction. De Jong, P., & Berg, I. K. (2013). Interviewing for solutions (4th ed.). Belmont, CA: Brooks/ Cole. Denning, P. (2001). Strategies for implementation of harm reduction in treatment settings. Journal of Psychoactive Drugs, 33(1), 23–26. Driver, J. (2014). The history of utilitarianism. Retrieved from http://plato.stanford.edu/ entries/utilitarianism-history. Drug Policy Alliance. (2015). A brief history of the drug war. 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A revised edition of the Readiness to Change Questionnaire (Treatment Version). Retrieved from http://nrl.northumbria .ac.uk/149/1/A%20revised%20edition%20 of%20the%20readiness%20to%20change%20 questionnaire.pdf. International Harm Reduction Association. (2015). What is harm reduction? Retrieved from www.ihra.net/what-is-harm-reduction. MacCoun, R. J. (1998). Toward a psychology of harm reduction. American Psychologist, 53(11), 1199–1208. Marlatt, G. A., Blume, A. W., & Parks, G. A. (2001). Integrating harm reduction therapy and traditional substance abuse treatment. Journal of Psychoactive Drugs, 33(1), 13–21. doi:10.1080/02791072.2001.10400463 Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York: Guilford Press. Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers’ motivation for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behaviors, 10, 81–89. Phillips, K. T., Stein, M. D., Anderson, B. J., & Corsi, K. F. (2012). Skin and needle hygiene intervention for injection drug users: Results from a randomized, controlled Stage I pilot trial. Journal of Substance Abuse Treatment, 43, 313–321. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390–395. ProCon.org. (2015). 23 legal medical marijuana states and DC. Retrieved from http:// medicalmarijuana.procon.org/view.resource .php?resourceID=000881. Richardson, H. S. (2013). Moral reasoning. Retrieved from http://plato.stanford.edu/ archives/win2014/entries/reasoning-moral. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality changes. Journal of Consulting Psychology, 21(2), 95–103. Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short “readiness to change” questionnaire for use in brief, Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. Chapter 12 Harm Reduction White, W. L. (1998). Slaying the dragon: The history of addiction treatment and recovery in America. Bloomington, IL: Chestnut Health Systems. Xie, Y., Pope, B. A., & Hunter, A. J. (2016). Cotton fever: Does the patient know best? Journal of General Internal Medicine, 31(4), 442–444. doi:10.1007/s11606-015-3424-1 Copyright © 2017. SAGE Publications. All rights reserved. opportunistic interventions among excessive drinkers. British Journal of Addiction, 87(5), 743–754. Smith, A. (2012). Marijuana legalization passes in Colorado, Washington. Retrieved from http://money.cnn.com/2012/11/07/news/ economy/marijuana-legalization-washingtoncolorado. • Theory and Practice of Addiction Counseling, edited by Pamela S. Lassiter, and John R. Culbreth, SAGE Publications, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/utarl/detail.action?docID=5945469. Created from utarl on 2021-11-17 17:42:27. 257
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