Substance Use Management: A Harm Reduction-Principled Approach to Assisting the Relief of Drug-Related Problems

Dan Bigg, CRADC
Chicago Recovery Alliance


Disease has increased our motivation to reconsider how our help system deals with drug related problems.

A more concrete focus on disease prevention as an additional goal has, for many, lead to a re-evaluation of the goals of drug help work.

Such a critical examination shows how much there is to improve with the system even in the absence of blood borne disease.

Integrating the heart of harm reduction -- respecting work on any positive change as a person defines it for his/herself -- fashions a health sensitive alternative to the predominant practice of abstinence-only assistance for the relief of drug problems.

This new approach is called Substance Use Management (SUM) as it no longer requires abstinence but instead focuses on a range of options for improvements while still including abstinence among the possible self-selected outcomes.

SUM is suggested as a framework for change within the treatment system so as to maximize treatment's constructive impact, cost- effectiveness and maturation as a distinct discipline which can appropriately attract support and resources for making society healthier.

This paper describes a formalized system of application of some of the main principles of harm reduction within the treatment system. Viable options for SUM treatment focus are suggested herein as well as a critical process, based on respect and collaboration, for use with these options.

Definition of Substance Use Management (SUM)

SUM is the practice of setting a new perspective on what constitutes help with drug problems and respectfully and collaboratively assisting the positive changes selected by the person seeking help. The role of the helper is to refocus the outcome on an individual's own view of success -- offering as wide a variety of options for improvement as possible -- and allowing the person the freedom to select the option(s) they choose to work on with the intensity they desire.

Abstinence becomes a tool to achieve other ends versus being an end in and of itself. Most of all, SUM seeks to build a relationship with the respectful collaboration described here so as to have a basis with which to engage and continue SUM's work until the person is happier and healthier.

SUM makes no condemnation about a person's choices in consumption but rather seeks to assist people in fulfilling their own desires for life improvement and satisfaction even when these desires include ongoing drug use.

SUM recognizes that no matter how far into drug abuse a person is their basic humanity is never completely lost. Inherent in SUM's practice is the belief that the Human Spirit we all possess is more powerful than the Human Destructiveness we are all capable of demonstrating. Trust in this belief is necessary for SUM to be practiced in earnest.

Rationale for Substance Use Management

Our history of attempting to assist others in lessening negative consequences of drug use is relatively brief compared to other disciplines. The building trades have had thousands of years to improve and diversify their methods and the practice of medicine has had hundreds of years to mature.

Such disciplines have made changes regularly with the accumulation of evidence and other factors.

American society's initial reactions to people experiencing drug problems, especially moral condemnation and legal oppression, has obstructed us from taking an earlier focus on the development of the drug problems relief system which only appeared formally this century.

Additionally, society's fight against an individual's non-problematic drug use have warped our ability to prevent and treat drug problems because our resources are wasted on a 'drug-free' utopian end and not realistically focused on preventing and relieving harm from drugs.

We would be failing to learn from other disciplines if we believed major changes in the institution of drug treatment are not likely and, indeed, expected and normal.

I suggest that it is only the strong association between drug use, especially injection drug use, and AIDS that has now precipitated critical evaluation of the way we help with drug problems despite plenty of pre-existing reasons as noted in a large review of the drug treatment system:

The negative correlation between scientific evidence and application in standard practice remains striking, and could hardly be larger if one intentionally constructed treatment programs from those approaches with the least evidence of efficacy. (Hester, RK and Miller, WR, 1995, p. 33)

Yearnings to develop and practice what I describe here as Substance Use Management (SUM) have been present informally as long as one individual has sought to assist another person in a way she, herself, would like to be treated. Such urgings are present in many ancient religions and specifically regarding drugs in The Natural Mind where Andrew Weil writes almost thirty years ago:

I have consistently found that if one dwells on the negative side of the patient's personality, one is unable to change his behavior except for the worse. But if one looks for the positive side (which is always there), contact is established, and one can then motivate the patient to use his developing consciousness to solve his problems with the world (Weil, 1972, p. 66).

SUM's approach is also grounded in research as shown in one of the largest longitudinal studies of drug use:

Neither the efforts of dedicated clinicians nor the individual's own willpower appear to be able to cure an alcoholic's conditioned habit at a given time... Our task is to provide emergency medical care, shelter, detoxification, and understanding until self-healing takes place (Vaillant, 1995, 384 - 385).

Further, analyses aimed at improving the treatment system offer similar advice:

Reason for optimism in the treatment of alcohol problems lies in the range of promising alternatives that are available, each of which may be optimal for different types of individuals. (Institute of Medicine 1990, p 147).

It is the committee's hope that the creation of alternatives and the ability to match persons to the appropriate treatment will bring additional persons with severe and substantial problems who are not being seen into...treatment. (Institute of Medicine 1990, p 480).

More recently, books have been published which seek to define and elaborate on the practice of Harm Reduction in helping relieve drug problems. Most notably, the work of Alan Marlatt entitled Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors (1999) and Patt Denning entitled Practicing Harm Reduction Psychotherapy: An Alternative Approach to Addictions (2000).

As well, the developing movement of Moderation Management attests to the popularity and possibility of alternative definitions of success in dealing with drug problems. Within Moderation Management's text there is a clear and present description for abstinence and its utility in helping people come to deal with their drug problems even when the goal is not necessarily permanent abstinence from drugs.

Such diversity of approaches seems perfectly consistent with the diversity of human existence. SUM is simply one more perspective to add to this rich and diverse voice for change.

This article takes a critical look at predominantly abstinence-only approaches used in the drug help system today and offers an alternative in SUM which leads to the following three improvements:

1) Greater effectiveness at attracting and engaging individuals in sustained efforts at improving their lives;

2) Inspiration and assistance for drug counselors to broaden and deepen their expertise in assisting the relief of drug-related harm, including avoiding inappropriately taking on their client's burden or responsibility by presuming to have the answers for them; and

3) Offering a solid chance at developing the field of drug help to rise above oppressive ideologies against drug users and, because of its cost effectiveness and success, mature into a respected and autonomous discipline.

SUM brings about these improvements because it reflects what we really know about the ways people change their behavior.

Expanding the Options: Setting the Table

SUM, if viewed metaphorically, would look like well-laden buffet table with each food item representing an option for relieving drug-related problems. The greater a drug help worker's skills, the bigger and broader the buffet table they would set.

Such skills can come from personal experience, formal education or as a consequence of using respectful ears in listening to other people who are using drugs -- all of whom have something to teach about successful drug use.

I believe 'successful' drug use is use which meets a person's needs while not causing unnecessary harm. Even if seeking help for drug problems I believe everyone has had some measure of success in their drug use if they are allowed to elucidate such meaning from it.

SUM activities generally address three types of issues related to: Drug (issues around the drug(s) themselves), Set (the individual's mindset or expectations about the drug(s) using experience) and Setting (the environment in which drug(s) are consumed).

Such a trilogy of critical factors in one's drug use was presented by Norman Zinberg and each appear to have amazing power in initiating positive change in and of themselves (Zinberg 1984).

A drug counselor working according to SUM principles might, for example, address the utility of the following alternative actions with his/her client:


.    Abstinence from one or more drugs and for a limited or open period of time.

.    Switching routes of administration.

.    Decreasing frequency of use and potential impact of this on increased pleasure from use and other consequences.

.    Decreasing concentration of drugs consumed.

.    Switching drugs consumed both in formal drug substitution therapies such as methadone and through informal and private substitutions such as cannabis for alcohol.

.    Considering risks and benefits of combining drugs.

.    Learning drug purification and drug purity testing measures.


.    Considering the personal benefits/purposes of drug use.

.    Elucidating a person's hopes and expectations in using certain drugs and how this relates to successful accomplishment of personal objectives in using.

.    Considering alternative means of accomplishing the same ends desired through drug use.

.    Developing constructive personal rituals around a person's drug use.

.    Discussing the role of shame in a person's drug use. SETTING

.    Separating drug use and driving/working/other tasks.

.    Creating a safer drug use environment.
    - where, with whom, when, etc.
    - reducing outside responsibilities when using.
    - safer purchase/possession practices.

.    Working to address affordability of drugs consumed.

.    Considering mediation with significant others regarding drug-related problems.

.    Considering the utility of 12-Step meetings, Rational Recovery, Women for Sobriety, Moderation Management, etc.

.    Sleeping on stomach after using to avoid choking.

.    Learning about overdose and being prepared to assist with preventing it, and dealing with it including having and using naloxone for opiate overdose if appropriate.

.    Developing a relationship with a physician respectful of drug use to monitor physical condition, especially organs or conditions effected by the drugs used.

.    Learning about legal issues and risks caused by using illicit drugs OTHER

.    Share and discuss utility of, and alternatives to, the disease model of addiction, as well as a neurochemical perspective, and other conceptions of drug use patterns.

.    Share and discuss long- and short-term benefits and negative effects of drug use.

.    Share and discuss all forms and types of abstinence (for which drugs?, of what duration?)

.    Increasing intake of water to avoid dehydration.

.    Addressing nutritional health including possibility of nutritional supplements.

Eating well, especially protein, prior to drug use -- including increasing intake of vitamins/nutrients drugs deplete.

For example, taking thiamin to prevent deficiency with heavy alcohol use, etc.

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