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Harm Reduction and Abstinence Based Treatments

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This essay will be constructed into four parts, harm reduction, abstinence based reatments, substance misuse and recovery. There will be a discussion on the history of harm reduction and what harm reduction is in the substance misuse field, for example problematic or harmful behaviour that is caused to the individual or others either socially, psychologically, physically or legally brought on by substance misuse. Secondly an explanation on abstinence based treatments, what they are and what the relationship is between them and harm reduction. Thirdly referring to recovery and what it means in the substance misuse field and what the implications are for the service users. Last but not means least a discussion about the two different approaches and how it impacts on the service user. To conclude a summary of the main points will be made. (136

Harm reduction pilot schemes started back in the 1980's and were a response to reduce the risk associated with harm caused by alcohol problems and injecting drug use, in response to the HIV and AIDS prevention strategy. Harm reduction is a process and not a treatment and should be integrated with other forms of intervention, it reduces the negative consequences of drug use. It is about educating the individuals, carers, partners and family members about the risks involved with their drug use and helping them take responsibility and learn to accept it rather than to ignore it. Most harm reduction interventions are aimed at preventing diseases due to blood- borne viruses (BBV) as well as overdose and other drug related deaths (Tatarsky & Marlatt 2010). Harm reduction services include needle exchange services methadone and buprenorphine programmes. Needle exchange provides services where the users have the opportunity to dispose of their old needles, syringes and spoons for example. Moreover they will also receive advice and support on safer injecting, reducing injecting and prevention of overdose, they will receive a pack which contains clean injecting equipment to take away, reducing the risk of them sharing equipment with others (NTA 2006). Substitute prescribing such as methadone and buprenorphine programmes, buprenorphine and methadone are licensed for use in opioid dependence where methadone is dispensed in liquid form and buprenorphine is administered by tablet form sublingually (Connock, Juarez-Garcia & Jowett, et al 2007). (236)

Abstinence based treatment

Abstinence means refraining from an activity which is known to be harmful and addictive or reducing this activity with the ultimate goal of being abstinent (McKeganey et al 2006). Doing this involves not taking a particular substance, avoiding areas where this is likely to be on offer or adopting a healthier lifestyle. Abstaining can be difficult to do especially when the substance has been part of their life for so long, this is where the individual has to look at healthier ways to deal with their substance use. This can include a range of abstinence based treatments to help the individuals with alcohol or drug such as Non-drug interventions the twelve step programme (self help) and Psychosocial interventions such as motivational interviewing or CBT. The twelve step programme is a set of guiding principles outlining a course of action for recovery from addiction, compulsion, or other behavioural problems, it was originally proposed by Alcoholics Anonymous (AA) as a method of recovery from alcoholism. Motivational Interviewing is usually offered to achieve and maintain abstinence, it was originally used with problem drinkers but has also been applied to the treatment of illicit drug misuse (Raistrick et al 2006). There are several Pharmacological interventions available to treat alcohol dependence which are disulfiram, acamprosate and naltrexone. These all work in different ways Disulfiram is used for individuals who wish to abstain altogether, if taken with alcohol it can cause some very unpleasant effects; vomiting, headache, palpitations and breathlessness. Acamprosate and naltrexone are an anti-craving drugs used in the maintenance of abstinence (SIGN 2003). However there is an increased risk of overdose or death due to a relapse after a period of abstinence as tolerance levels will have changed to that particular substance (REF). (288)

Substance misuse

Substance misuse is defined as the use of a substance for a purpose not consistent with legal or medical guidelines (WHO, 2006).

It is a misuse of all psycho-active substances including illicit drugs, non-prescribed pharmaceutical preparations and alcohol misuse.

People use substances because it makes them feel good, feel different and makes them more sociable. Using substances only becomes misuse when a problem arises such as it having a negative impact on health or functioning and may take the form of drug dependence causing problematic or harmful behaviour to the individual or others either socially, psychologically, physically or legally. (99)

Recovery

The Recovery Model as it applies to mental health is an approach to mental disorder or substance dependence that emphasises and supports each individual's potential for recovery. Recovery is seen within the model as a personal journey, that may involve developing hope, a secure base and sense of self, supportive relationships, empowerment, social inclusion, coping skills, and meaning. For someone who misuses substances recovery may not be about being totally abstinent it may simply mean still using drugs but in a safe way, for instance having clean works for injecting or substitute prescribing for opioid misuse. Recovery principles bring about the change in the way a service user thinks and aims to produce a change in behaviour, however before these changes can only happen if the person is ready to change, ambivalence may be experienced by the service user and this can affect motivation on a daily basis. Motivational interviewing techniques go hand in hand with the harm reduction model as one of the key factors with motivational interviewing is dealing with ambivalence. Prochaska and DiClemente 1983 provide a framework to understand the change process it was originally created to help understand what individuals go through in changing their behavior. it uses 5 principles, precontemplation, contemplation, preparation, action and maintenance (Hansen et al 2008). Service users with little or no motivation and who are not engaging in any attempts to change are seen as being in the pre-contemplation stage as they do not see their behaviour as a problem and there is no need to change it, this could be due to an attempt to change in the past without success and may feel demoralised so may become resistant to change. It is important to engage service users at this stage and build a trusting rapport so that in the future they will be able to turn to the practitioner for help. The contemplation stage is when a person acknowledges that they may have a problem and work towards developing motivation to change but could become ambivalent, engaging with the service user in discussion about their ambivalence is the goal at this stage getting them to think about what their problem is and how it is affecting them. Individuals in the preparation stage may want to change and have a plan but need help to do so, the reason individuals may seek treatment could be that their problem is having negative effects on life for example, criminality or job loss. The action stage comes next this is where the service user is actively setting goals to change and will be developing skills to do so, supporting the service user in making these goals achievable are key here, goals need to be small and achievable to the service user. In the maintenance stage the service user sustains changes in behaviour and works towards preventing relapse by identifying the supports around them, at this stage the service user may decide to make long term goals and problem solve how to best accomplish them. Prochaska and DiClemente 1983 describe a sixth stage and it is the relapse stage the service user reverts to the behaviour they were trying to change, the practitioner should provide support for the individual in a non-judgemental way as they may be feeling ashamed and guilty for relapsing, re-evaluate the stage of change the individual is at explore the relapse episode trying to discover if the relapse was shorter or longer than previous relapses and were they able to reduce their use, this may be an opportunity for the service user and practitioner to work on other relapse prevention techniques. (Prochaska & Diclemente 1983). However service users may move back and forth between the stages. This does not represent failure, but rather the nonlinear nature of the model. Recovery is about making the best out of their life and having quality of life and as nurses we should provide support and advice to achieve their goals (Network 26 2009). (660)

Both the abstinence model and the harm reduction model have similar goals. The goal in this case is to create a better quality of life for the person receiving the service. Harm reduction approaches are often perceived to be the opposite of abstinence based approaches to drug use and sometimes even as condoning drug use. This is not the case, harm reduction complements abstinence based drug treatment approaches by providing Injecting drug users with the knowledge and tools to stay healthy and alive until they are able or willing to achieve abstinence. Abstinence remains the most effective way of reducing the negative consequences of drug use. For injecting drug users who are unable to remain abstinent, harm reduction measures such as methadone maintenance treatment and needle and syringe programs are ways to reduce negative consequences. For example the abstinence approach to caring for an individual who uses heroin and has HIV service users would find that they would be encouraged to stop using heroin completely and to abstain from sex. While with the harm reduction programme the individual may be taught how to use heroin more safely i.e. clean needles and spoons and other paraphernalia or to substitute methadone for heroin and to practice safer sex. It can be argued that because abstinence based services were not providing HIV education and preventive tools such as condoms and syringes, individuals using these services would remain unaware of the risks of HIV and how to protect themselves from it. (247)

Conclusion

In conclusion, the integration of harm reduction and abstinence based treatment is more powerful than either model separately. The abstinence goal provides more room for the more abstract harm reduction work to occur. The accepting atmosphere of harm reduction with the addition of the clarity of the goal of abstinence promote patient retention better than either separately. The implications of this integration is that harm reduction can be more accepted and powerful in the public sector. It is important to look at the wider context of why people use drugs. Taking away a coping mechanism from a drug user may do more harm than good unless the core issues that led to drug use are dealt with in the first, hence the reason the motivational interviewing approach is more empowering for the service user (134


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