The Common Goals of Abstinence Based Treatment and Role of Harm Reduction: The Integrative Possibilities of Recovery-oriented Systems of Care:The Philadelphia Experience

Marcella A. Maguire, Ph.D.Director for DBH Homeless ServicesCity of Philadelphia

Reviewing the two schools of thought regarding how we assist persons suffering

from Addiction Disorders

"Those who cannot remember the past are condemned to repeat it“.-George Santayana

(1905)

Reason in Common Sense, p. 284, volume 1 of The Life of Reason“

Two Schools of Thought: The Opposing Turf

Abstinence Based Addiction Treatment:

Goal of immediate and complete abstinence based lifestyle

Harm Reduction:

Minimizing injury to self, others and the community

The Extremes

Abstinence Based Harm Reduction

Addiction Treatment (HR)

(ABAT)

-No Interaction with -Encouraging

Supports till Completely Substance Use

Clean

Rebirth of Addiction Medicine (1935 - 1970)

» Re-medicalization of severe and persistent alcohol and other drug problems.

» Dramatic increase in Federal, State, and local investment in treatment

» Rebirth of physician-directed treatment institutions.

The Modern Practice of Addiction Medicine

» Professionalization of addiction medicine.» Growth in addiction treatment institutions

and physicians working in addiction medicine.» Defense of medical approaches to treatment

and reconceptualization of addiction as a chronic disease.

» Transfer of the core technology of addiction medicine into mainstream medical practice.

» Friday Nov 8th, 2013, Parity Rule Issued

Harm Reduction Approach

»Born in the HIV/AIDS crisis of the 1980s»Views Drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors.»Establishes quality of life as criteria for successful interventions and policies.»Calls for the non-judgmental, non-coercive provision of services and resources »Ensures that drug users have a real voice in the creation of programs and policies.

Harm Reduction Approach

»Seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.

»Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.

»Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

Can We Transcend the Debate: Philadelphia’s work on Integrating the Practices

• Assist persons with multiple, severe, complex, and chronic challenges

• Enhance Coping Mechanisms • Increase Social Supports• Reaching the same individuals at different stages of

their AOD use, addiction, and recovery careers• Resistance and ambivalence are a natural—not

pathological—response to internal and external pressure to change deeply engrained behaviors.

• Resistance and ambivalence are reduced when people have real choices and are empowered to choose.

PHILADELPHIA, PA»Whose in Philadelphia?

◦ 1.5 million people◦ Area Median Income =

$36,957◦ Percentage below the

poverty level = 25.6%◦ Average Monthly

enrollment in Medicaid in 2012 = 470,159

◦ Unique individuals enrolled in Philadelphia Medicaid in 2012 = 569,236

Lessons of Integration for a Recovery Oriented System of Care

»Both models of intervention must be publicly and professionally defended through the integration process. »Leadership and strategy at multiple levels are essential. »Ideas matter. ABAT/HR integration involves processes of conceptual stretching within both the AATR and HR communities. »Science helps, but stories and direct experience are essential. » Relationships matter. ABAT/HR integration involves relationship building and relationship maintenance across systems boundaries. » Money and public/professional recognition matter. ABAT/HR integration must address issues of personal/professional/institutional interests that inhibit collaboration.

Lessons of Integration for a Recovery Oriented System of Care

»HR and ABAT collaborations can be a win/win process. »HR and ABAT are not either/or options. »Drug users may be viewed as “incompetent and pathological” and thus only “objects of intervention” or as “allies and participants in their own individual and collective health.” »Recovery initiation is about a synergy of pain and hope. »ABAT and HR are the products of heterogeneous social movements made up of constituency groups with widely varying philosophies and service practices, all of whom cannot be expected to approve of or participate in processes of collaboration. »HR and ABAT integration must be bi-directional.

Safety, especially of Children in Families

»The role of the child welfare system in your community.»All services providers are “mandated reporters” and need training and policies that support this fact. »Liaisons and partnerships with your communities child welfare system and the agencies that work for them will be essential in any Housing First program for families. »These agencies have professional expertise in assessing safety issues.

Contact Information:

Marcella.Maguire@phila.gov

www.dbhids.org

Twitter: @Cella65 @PhillyRecovery

Paper Link: http://www.williamwhitepapers.com/pr/Recovery%20and%20Harm%20Reduction%20In%20Philadelphia.pdf