At first glance it may seem that a goal of harm elimination is far more desirable than a goal of harm reduction, and indeed these programs are a wonderful asset for the population of individuals for whom these programs work. However, harm elimination programs are successful with only a tiny fraction of all substance users. AA's Triennial Surveys report that only 5% of new members are still attending meetings at the end of one year. Ditman's study shows that drunk drivers coerced into AA attendance are as likely to be rearrested as drunk drivers receiving not treatment at all. Brandsma's study shows that drunk drivers coerced into AA participation are more likely to binge drink than those receiving no treatment at all. Harm elimination programs may be a great asset to those who choose them, however this is not the case with those who are in them against their own wills. Ultimately harm elimination programs are not very effective in reducing the harms caused to society by substance use.
The value of harm reduction programs lies in their attractiveness to substance users. No one wants to get AIDS from a dirty needle, and no one wants to go to prison for killing someone while driving drunk. Because harm reduction programs support goals chosen by participants rather than imposing goals upon participates they have a great success in helping participants achieve the goals which they have chosen and hence are highly effective at reducing harm to both the user and society at large. Harm reduction programs are often referred to as "low threshold" programs since they are very easy for at-risk populations to participate in.
Experience has taught us that harm reduction programs are successful only when they do not attempt to impose goals upon clients from above. They are only successful when they are supportive of goals which clients have chosen for themselves. Needle exchange programs which use the exchange as a platform from which to preach abstinence to clients soon lose their clients. Needle exchange programs which thank clients for helping to get dirty needle off the streets steadily gain clients.
Harm reduction programs are also hierarchical in that they are more concerned with reducing major and immediate harms than minor and long term harms. Most clients are also more concerned about reducing major and immediate harms. Avoiding arrest for drunk driving today is a higher priority than a possibility of liver damage 40 years from now.
People who are accustomed to abstinence-only models may be surprised to see Moderation Management (MM) classified as a harm elimination program since it still allows members to use alcohol. However, it is clear from MM's published literature that MM is firmly in the harm elimination camp and adheres quite strongly to the disease model and ultimately to AA ideology.
MM tells us that it is not for "alcoholics" and urges persons who score more than 20 points on the SADDQ test to pursue join an abstinence-only program rather than join MM. MM also urges persons who fail to complete a 30 day abstinence period to leave MM and join an abstinence-only program. Finally MM urges persons who fail to drink within MM's Moderate Drinking Limits to leave MM and join an abstinence-only program instead. (MM's Moderate Drinking Limits are: no more than 4 standard drinks per day and 14 per week for men and no more than 3 per day and 9 per week for women.)
Not every program which uses the words "harm reduction" in its description is actually a harm reduction program. "Harm reduction" has become a buzz word which attracts grant money. I have seen on program online with the words "harm reduction" in its title which has non-drinking college students lecture binge drinking college students on the "abnormality" of their behavior. This is not harm reduction. This is the same sort of preaching which has been with us since the days of the temperance movement. There is one thing which we know for sure about preaching: it is ineffective.
HAMS is the only support group around which fits the category of harm reduction, HAMS encourages any positive change and is open to anyone wishing to reduce the harm in their life cause by drinking. HAMS never tells members to leave because they drink too much--safer drinking is just as important at HAMS as is reduced drinking or abstinence. The choice of the goal is up to the individual.
Am J Psychiatry 124:160-163, August 1967
A Controlled Experiment on the Use of Court Probation for Drunk Arrests
KEITH S. DITMAN M.D., GEORGE G. CRAWFORD LL.B., EDWARD W. FORGY PH.D.3, HERBERT MOSKOWITZ PH.D. , and CRAIG MACANDREW PH.D.
Outpatient treatment of alcoholism : a review and comparative study
by Jeffery M Brandsma; Maxie C Maultsby; Richard J Welsh
Baltimore : University Park Press, © 1980
ISBN: 0839113935 9780839113935