HLTHAGE 2L03, Winter 2021, Instructor: Dr.

Savelli SAS Notes

January 29th, 2021: Lecture 3

Topics: Harm reduction; Alcoholics Anonymous; Four pillars of addiction; Coercive
treatment

w/ Melissa and Dr. Savelli 

Questions for Mel about harm reduction:
Could you explain the philosophy of harm reductions, its relation to the four pillars, and how it differs
from other ways of respond to addiction?
 Its definition is quite literal; reduce the harms related to drug use
 Harm reduction doesn't try to stop it; accepts that drug use is a fact of life and we
shouldn't exercise judgment on those who use; seeks to respond to harms that might arise
from using
o Ex. A needle exchange program - risk of abscesses, infections, diseases
associate with intravenous drug use; providing clean needles can help
reduce this harm
 Accepts that abstinence-based treatment/enforcement doesn't work for a lot of people
Humans have been using drugs forever - harm reduction is rooted in the fact that drug use is always
going to happen
 
Question to Mel: what is your personal experience with harm reduction?
 Worked in alcohol management program; it's a residence that provides structured alcohol
consumption for those with alcohol dependence
o If someone is diagnosed with alcohol use disorder they'd be admitted and
given certain amounts at set times each day
o Helps them to work towards more moderate use
 Consumption and treatment service (overdose prevention site/supervised injection
site/supervised consumption site)
o Staff are trained to react to overdoses
o Also provides new gear that will reduce harms associated with many types
of drug use (not just needles)
 
Could you talk about why you're so passionate about this approach?
 It saves lives; currently there are lot of dangers with the way that drug use happens in our
society
 Things like criminalization, prisons, and abstinence programs don't work for people
 A lot of people get treatment via AA or NA; she's never found stats on if they're successful;
highest success rate statistic she could find was 25%; partially because AA post their own
stats

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HLTHAGE 2L03, Winter 2021, Instructor: Dr. Savelli SAS Notes

 Harm reduction is one of the most viable ways to respond to how society interacts with
drugs
It can help people reduce/moderate their use
 She wants to be clear that harm reduction isn't the end goal of addressing substance use;
a lot of the harms that happen are a result of ongoing policy issues
o When drugs are criminalized and stigmatized, they may not want to use
harm reduction programs
Advocates for harm reduction might say a society that is better ready to tackle harm reduction in a
realistic way doesn't judge people - there's must be a reason people do it
 
It's not universally accepted, why is there so much opposition?
 Throughout history, drug use has been moralized, and that's the same today; society
thinks that people CHOOSE to use, and that harm reduction enables them...
 There's pushback to have those programs in neighbourhoods because they think it will
increase crime or addiction, which isn't statistically true
The opioid crisis... one idea was to provide prescription heroin to avoid overdose on fentanyl on the
streets
 Those programs do have their challenges, but safe supply doesn't necessarily enable;
these people are facing a lot of issues that harm reduction would help
 A lot of organizations benefit from the opposition; if you make it impossible to go to jail
for using, then that's a lot of profit gone
All these different groups see the issue differently, and might benefit or lose out; poses a real threat to
those who view it as a vice and enforcement as a way of responding
 If we stop thinking of these people as bad and a threat, then we begin to think about
addiction in a totally different way
 
Question for Dr. Savelli... could you talk about the idea that addiction is treatable?
 Some people go into abstinence programs and succeed, so it IS possible... But there's lots
of disagreements on how successful they are
 CBT happens, pharmacotherapy - implants/drugs that make people not want to use
o Disulfiram - the person becomes violently ill as soon as they consume
alcohol
 Most impactful (dominant treatment) is AA
 A lot of people swear by it and believe in it, but we also must acknowledge that it doesn't
work for everyone
 
Alcoholics Anonymous
 Early 20th c. Bill W begins to chat about the toll alcohol has taken on his life, and came to
believe that alcohol was controlling his life
 AA was formed as a peer support group
 They meet regularly, lots of portrayals of it in pop culture

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HLTHAGE 2L03, Winter 2021, Instructor: Dr. Savelli SAS Notes

 12 steps to surmount addiction - it recognizes addiction as a disease BUT it also suggests

that it has a moral dimension: disease of the spirit
 Religious under and over tones connected to AA and its branches
 Says that a person it fundamentally an addict (the susceptibility model); there's something
spiritually different about the addict; they will always be an addict
 Interesting tone of evangelism; people are charged to belong to the group and to spread
the message; carry their Big Book written by Bill; they must memorize phrases and trying
to go bring this message to other people
 AA has become the dominant form of treating addiction; even if you go to a physician
(who is biomedically trained) they will still refer people to AA; accepted by mainstream
medicine
 This is one of the groups that is challenged by harm reduction groups
 
B.C. example... Nurse who was using... She was ordered to enrol in NA or be fired; challenged the
supreme court to use a program OTHER than NA - alarming because it has religious implications
 The AA model has been applied to many different realms of addiction
 It's so dominant in the world of addiction
 Its primacy being challenged is quite recent
 Those who feel helped by AA might see it as an attack on the institution
 
Coercive treatment... Some people suggest that someone who has a problem with addiction is
enslaved to a substance or a behaviour - in those cases people should be treated against their will -
what do you think Mel?
 Categorically opposed... Understand that people might not feel in control of their
behaviour so you COULD make the case that forced treatment is helpful...
 But, since we don't know what causes it, how to treat it, or how to cure it, forcing
someone into a program that we don't know will work is questionable
It might prejudice them against dealing with it in the future; removes their autonomy
 People most often choose to use again after they're released from charge
 Some argue that forced treatment is more humane than imprisonment... But she feels
that decriminalizing is the true way to go
 Remind students that we don't necessarily agree on what addiction is... There's no test for
it
 Argument whether it's a concrete thing or a way to quickly say that someone has an issue
with a substance/behaviour
 Hard to mandate treatment because it might just be forcing behaviour on them
 Decriminalization and enforcement (4th pillar) - we need harsh laws against drugs and the
best way to prevent it is scare them from starting/limit their access... Enforcement gets
most of the money (like 90% or something) - for courts, police, prison, etc., SPOILER ALERT
it doesn't work!
 We are beginning to accept that enforcement might not be the only way

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HLTHAGE 2L03, Winter 2021, Instructor: Dr. Savelli SAS Notes

 The main way we see addiction is as a moral failing, but then contradict ourselves by
punishing them for an 'inability' to make good choices
 We have a hybrid approach where we see addiction as a disease, but then moralize it and
view it as a vice; bad people doing bad things
 Mel says that a lot of the people she's helped are kind and good people and the way we
treat them doesn't reflect that