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Harm Reduction: An Alternative Approach to Managing Addiction
In September, 2013, at the age of 45, Marco* tried Crystal Meth (also known as “Tina”) for the first time. Someone smoking from a pipe blew it into his mouth. A month later, he smoked it directly from a pipe. By the start of 2014, he began smoking every weekend. By March, he was smoking almost every day.
By August of 2015, Marco had lost contact with all friends and family members, and had lost his career. He smoked more, which added to his depression. He stayed at home, arranging Party and Play (PnP) encounters with other users, where they would consume the drug in order to enhance sexual activity.
He states, simply: “I knew I wanted to die.”
What is “Harm Reduction”?
When we hear the words “addiction” and “recovery,” many of us think of the 12-step model, founded in 1935 as Alcoholics Anonymous. For decades, however, there have been alternative roads to recovery, and the “harm reduction” model is one such approach that has gained in popularity and effectiveness in recent years.
While Harm Reduction may be used for all substances, this article focuses on the outpatient group program of “Crystal Clear,” at Mt. Sinai Hospital’s Addiction Institute in New York City, which works to treat crystal meth addiction, primarily among the gay male population.
Harm reduction is defined by a focus on reducing the negative effects of substance use, rather than trying to prevent or stop the usage itself, incorporating a spectrum of strategies that includes safer use and managed use. Advocates of harm reduction support the goal of people working towards abstinence, but recognize that, for many, this process takes time and that setbacks do not amount to defeat.
Harm reduction isn’t a new idea. While the term can be dated back to 1987, the idea of minimizing the harm caused by substance use disorder can be traced to the 1920s. The International Harm Reduction Association (IHRA) was founded in 1996.
Principles of Harm Reduction
The IHRA lists eight principles of harm reduction. The first two of these principles embody the non-judgmental approach toward managing addiction:
1. Accepts for better or worse, that licit and illicit drug use is part of our world, and chooses to work to minimize its harmful effects rather than simply ignore or condemn them
2. Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe use to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others
A common misconception about Harm Reduction is that it condones or encourages drug use. The eighth and final principle combats this fallacy:
8. Does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use.
For a full list of the Association’s eight principles of Harm Reduction check out the National Harm Reduction Coalition’s website.
Joseph Ruggiero, phD, is a clinical psychologist who has worked in the field of addiction for twenty years. He is the co-founder and director of the Crystal Clear program, the only program of its type for crystal meth addiction in New York City.
With crystal meth use among the gay male population reaching epidemic proportions at the start of the 21st century, Dr. Ruggiero saw the need for a program that specifically addressed the needs of gay men and crystal meth addiction.
Dr. Ruggiero does not believe that the harm reduction and 12-step approaches are in conflict. In fact, many of the program’s clients take advantage of both models. But he does believe that the harm reduction approach is more integrated, in that it can include tools such as psychotherapy, skills building, pharmaceutical interventions, support groups that encourage “cross talk,” and a deeper understanding of the complex of drug use in people’s lives.
Ruggiero states that “harm reduction is about working on goals that the client wants to work on and not making assumptions, and meeting people ‘where they’re at.’” He describes an approach in which relapse, ambivalence, and struggle are often a part of that process.
Kaitlyn Murphy, M.A., MHC-LP, co-leads the Crystal Clear program, and runs many of its outpatient groups. She sees the program as one which helps people make choices by looking at their motivations, while also giving them tools to achieve their goals.
During the COVID-19 shutdown, Murphy’s groups have been meeting virtually. With consistency in membership, over time, comes trust in one another. Members talk of shame and trauma and shared experiences.
Murphy believes that success in the program is about someone reaching their goals and living a life that is happier or has meaning. It is about living a life within the person’s own values — which generally goes hand in hand with using less, and often leads to abstinence.
Both clinicians talk about the amazing transformations they see in their clients.
This is one of those transformations.
Marco was in a spiraling depression, with suicidal thoughts. He didn’t take his HIV medication for a year, and he weighed 90 pounds, down from his normal 145. That summer, his brother had made two attempts to check in on Marco at his apartment. During his third attempt, in October, he came with the police. The next morning, Marco admitted himself into the psych ward at Bellevue Hospital. No one close to him had ever suspected that drugs were involved with his deep depression; he had been adamantly “anti-drug” until the age of 45.
He was at Bellevue for 10 days, for suicidal ideation. Upon his release from Bellevue, Marco revealed his drug use to his brother.
But that didn’t stop him. As soon as he left the hospital, his drug use returned, and with a vengeance. In January 2016, Marco was out of a job and behind on his rent when a marshall came to evict him from his apartment.
In the summer of 2016, Marco’s use escalated further, from smoking to “slamming.”
“Slamming” is a term for injecting a substance into a vein, via a syringe and needle. Not all who smoke crystal meth slam. But those who do see it as the surest way to addiction, psychosis, and a precipitous decline in health, welfare, and social interaction.
In August 2017, Marco began attending Crystal Clear group therapy, along with occasional 12-step meetings. During his first year, he continued to relapse. But, slowly and surely, the tools he learned through the program began to take hold and, with an enormous amount of strength, courage, and commitment, Marco was able to turn his life around. In August 2020 he “graduated” from the harm reduction program after two full years of sobriety. He is now studying to become a drug addiction counselor.
Marco’s success story is remarkable, given his rapidly escalating drug addiction, many relapses, and descent into physical and emotional darkness.
Understanding relapse is, in fact, a vital part of getting sober, according to Marco. The key to his recovery has been in recognizing the triggers and using the tools he has learned.
When he first came to Crystal Clear, he didn’t believe he could do it. After months of sobriety, he began to believe, for the first time, that he could stop using totally. Through the Crystal Clear program, Marco was at first able to process his recovery in a more responsible way, in a non-judgmental atmosphere, until he finally reached his ultimate goal of complete abstinence.
Recovery Takes Commitment
Marco’s journey to recovery may be an extreme one, but it is not at all unique. Some in his support group continue to struggle with addiction, after many years of use. Many have periodic relapses. Others have left the group and continue to use. And still, others in the group have died from drug-related causes.
Despite the differences among the group members, there are striking commonalities: the progression from casual use to addiction; feelings of shame, trauma, and alienation that both fuel, and are the result of, addiction, as well as the sexual validation that comes from the drug’s euphoric and invincible powers.
The Harm Reduction model has helped group members make use of the tools they learn through the program. One member, Raphael,* states that, for him, the term “relapse” can be daunting, whereas a “slip” means that he needs to keep coming to group and committing, perhaps in a different way, to the tools he has learned.
Members are discovering the deeper meanings behind their use. And that helps them to use more responsibly, less frequently, or to achieve abstinence.
Through open, honest communication, often by revealing wounds that have been locked up in shame for their entire lives, members find that recovery is possible, in an atmosphere of non-judgmental support and encouragement.
*Clients interviewed for this article used pseudonyms in order to speak freely.