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Reprinted with permission from the Harm Reduction Coalition (www.harmreduction.org)
In the manual’s introduction, medical sociologist and consultant Richard Elovich and Daniel Wolfe, director if the International Harm Reduction Association, describe the common misperceptions about substance users that lead clinicians and researchers away from thinking about harm reduction:
Common Misperceptions About Drug Users
“Planet Heroin”
Common representations of substance users, particularly addicted users, seem to suggest there is something about the gravitational pull of the substance that draws people in so completely that their individuality or agency disappears. For someone on the drug, it’s as though he or she is on another planet—unreachable, alien, remote.
“An addict stays the same or gets worse.”
When someone demonstrates evidence of chaotic behavior related to drug use, it is assumed that both intensity of use and the user’s relationship to the substance(s) in question are constant or become progressively more debilitating.
“Drug use is the root of their problems.”
This view attributes a range of patients’ problems (e.g., from depression, failure to meet appointments, inadequate adherence, unstable housing) to drug use.
“It’s their choice, and their fault.”
This most common view holds that substance use is volitional, and that users cannot be helped until they choose to stop. If a patient really wanted to be healthy, he or she wouldn’t use drugs.
Beyond Stereotypes: Realities of Crack/Cocaine and Heroin Use
Some realities about substance users are that:
Crack/cocaine and heroin users fall along a continuum of use
Users of illicit drugs—like users of alcohol—fall along a continuum of use and abuse that includes people who are experimenters, situational users, periodic users, bingeing users, and addicted users. Analysis of large epidemiological surveys indicates that more than ten times as many people have used heroin, for example, as have developed dependence. Functionality of users—including those who are addicted—also falls along a continuum. Some addicts are able to maintain work or parenting duties, personal appearances, and engagements with medical care.
Substance use may be an expression of a problem rather than its cause.
Rather than the cause of erratic or unhealthy behavior, substance use may be an adaptive mechanism or best solution to a range of problems including depression, abusive partner, homelessness, sexual abuse, poverty, or other difficulties. A survey of crack-using women in New York, for example, found that nearly 1/3 had a past history of abuse and prior hospitalization for mental illness. In another, women who were HIV positive, were homeless in the last year, and had experienced combined physical and sexual abuse were also those most likely to report exchanging sex for drugs and money, using injection drugs in the past year, and having sex in crack houses. Instability or incapacity may also result from social sanctions against the drug user rather than the drug use itself. Incarceration or release from incarceration, for example—a common experience for substance users, who make up the majority of prisoners in New York jails—may result in disruption of care or other support systems.
Addiction is cyclic and variable in intensity.
While some addicts may follow the pattern, made familiar by alcoholism, of chronic, progressive illness, others may have periods of intense drug use and dysfunction followed by long periods of being drug free (or vice versa). Cocaine use, for example, is frequently characterized by periods of abstinence and bingeing, while a heroin user may maintain a constant daily dose for years.
Ongoing substance use is rarely a simple question of choice.
Much as with people in abusive relationships or those with compulsive disorders, “choice” for substance users is shaped by perceptions of self-efficacy, mental health status, and social conditions. Additionally, chemical dependency—like hypertension, asthma, or diabetes—is a chronic, relapsing condition whose etiology frequently includes a combination of behavioral, genetic, and environmental factors. As with substance users, only a minority of diabetics or hypertensives successfully abstain from behaviors contributive to these conditions, yet these patients are not stigmatized, blamed for their condition, or denied health services.
Substance use frequently involves more than one drug and more than one person.
While users may have a “primary” drug of choice, polysubstance use that includes some combination of alcohol, marijuana, crack and/or heroin is the norm rather than the exception. One study, for example, found that all those hospitalized for drug-related conditions also had alcohol dependency. Use, however, is rarely indiscriminate: just as cigarette smokers are brand loyal, users frequently have combinations of drugs they use regularly, and others they do not. Patterns and intensity of drug use are often shaped by particular relationships or social networks, rather than by individual character. Repeated studies of women and crack or heroin use have found that women frequently begin using with a spouse or sexual partner, and that relationships strongly impact on decisions to continue using. Users who inject crack—a practice emerging in New York and other North American cities—are more likely to do so with injection partners, and in communal settings. Several studies of injectors suggest that environment and characteristics of social networks may affect both needle-sharing patterns and related risks for HIV and hepatitis C.
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Elovich and Wolfe go on to describe how to improve communication between substance users and health providers, an essential step in the harm reduction approach. Although the following sections on improving communication with substance users are keyed to physicians, who are frequently the first to come into contact with them, the principles apply to therapists’ initial meetings with substance users as well.
Improved Communication Between Substance Users and Health Providers
“Sometimes you ask someone a question about their drug use, and you hit a brick wall. They answer, but you can see they don’t trust you…. If you can demonstrate to them that you mean them no harm and are there to give them the best care you can, sometimes…they relax a little; you can see it in their face. Their body relaxes.”
—Emergency room physician
Given the prevalence of substance use, its variability in terms of practices and risk, and its potential impact on health, effective communication between providers and substance users is essential. Specifically, providers should neither avoid questions of substance use nor limit discussion to the benefits of abstinence.
Techniques for Effective Communication with Substance Users
Substance users are not easy patients: [they can be experienced] as argumentative, noncompliant, and manipulative. Additionally, physicians frequently feel pessimistic about their ability to change the patient’s drug-using behavior, and so prefer not to engage the subject. Rather than repeating unsatisfactory patterns, physicians may find it useful to “reframe” their idea of a successful outcome, and to recognize that their interaction with substance users, while crucial, is likely one of many incremental steps in the complex process that users undergo in moving toward behavior change.
Techniques for enhanced communication include:
Emphasizing process over content
It is often not realistic…to expect patients to give up coping strategies, including substance use, before other coping mechanisms or supports are in place. Rather than attempting to secure an agreement about behavior change from a substance-using patient, [it may be useful] to focus on the process of the interaction and the patient’s experience of it. Specifically, physicians might ask if their encounter with the patient met three objectives:
Avoiding conflict and defusing institutional transference
Drug users often enter an exam room bringing a history of negative experiences with institutions and authorities, from health providers to law enforcement to child welfare. An encounter with a substance user could be termed a success if the physician manages to deliver needed care and defuse the patient’s expectation of disappointment, disrespect, or conflict. Even more than other patients, substance users appreciate physicians and staff who:
Helping patients to discuss past and present behavior, including drug use, without feeling judged
Users frequently perceive a negative change in the attitudes of health care professionals once their substance use or associated history (incarceration, prostitution) is revealed. Often, they are scanning your questions and behavior for evidence that they are being judged. A lowkey, respectful, and curious tone is helpful.
Allowing patients to experience their own ambivalence
People who are heavy users of drugs often feel…ambivalent about their behavior. This may be why many react strongly against being told that they should be concerned or stop using. Frequently, when you articulate the negatives associated with their drug use, patients focus on defending themselves or winning the argument rather than on their own mixed feelings. It is often more useful to keep your opinions to yourself and draw the patient out.
Patient-Physician Scenarios
These scenarios offer a chance to walk through and analyze different patient-physician interactions.
Patient
Sheila, 25, presents in the emergency room with a burn on her hand. In response to your questions, she tells you the drugs she likes to use. She tells you: crack (to get high), barbiturates (to help her sleep), Valium (to calm her nerves), alcohol (when she is with friends), marijuana (to help her come down from crack). She says that she is not an addict. She knows what addicts are, but she “uses drugs occasionally and can stop when she wants.”
Analysis
This is a relatively successful encounter: Sheila has provided some descriptive information about her substance use and expressed clear feelings about being categorized as an addict. The treating physician who moves to label, diagnose, or resolve her substance use issues will likely produce resistance, rather than greater willingness to volunteer information or seek care.
Patient
Teddy, a 48-year-old insulin-dependent diabetic, presents with multiple medical problems, including track marks. He does not mention current drug use, but explains that he has been in recovery from heroin use for ten years.
Analysis
Teddy is likely highly ambivalent about his current heroin use. A physician who disputes his account of recovery, even through matter-of-fact acknowledgment of physical evidence or toxicology results, may provoke denials or failure to appear for follow-up. Alternatively, you might begin by acknowledging that relapse is not incompatible with recovery, saying: “I know that bouts of drug use are common for people in recovery, especially in stressful periods.” Once the patient sees that you are not challenging his claim to recovery, he may allow you to seek further elaboration: “I’ve had other patients who have used drugs even while in recovery, and what I focus on is keeping them healthy. I wonder if you could tell me about an episode you’ve had: how long did it last; did you eat; were you able to take your insulin?” The physician can then focus on helping to maintain health and adherence to medication, leaving the discussion and definition of relapse to the patient and his AA sponsor or substance abuse counselor.
Patient
Robert is a 38-year-old Hispanic gay male who is HIV positive and also uses cocaine. His viral load is high, and evidence suggests that he is inconsistent in taking his HIV medications. Furthermore, Robert has heart problems apparently exacerbated by cocaine use. He reports feeling disillusioned and hopeless about his drug use and expresses desire to go into treatment.
Analysis
Expression of concern about substance use—recognition of the problem or intention to change—may indicate an important shift in thinking. Much as you would probe a patient’s off-hand mention of suicide to ascertain the degree to which the thought was developed, it can be useful to explore how strong a substance-using patient’s interest is in change.
….When people in recovery are later asked what made the difference, they often give the names of people who saw something in them that they didn’t quite see in themselves.