Harm reduction: an approach that does not demand immediate abstinence

“I will tell you right now: I am not going to stop.” A man said this to me at a first appointment he had come to because his wife sent him. He said it with resistance, as though expecting me to send him out after that sentence. I told him it was not a condition for us talking, and something in his face loosened. He stayed. A year later he was drinking substantially less — not because anyone had given him an ultimatum, but because nobody had.

Harm reduction is an approach that in Slovenia still often meets discomfort. It sounds like approval. Like giving up. Like deciding on someone’s behalf that they deserve no better. None of that is true, and I think it is worth understanding why — whether or not you end up agreeing.

What harm reduction actually is

Harm reduction is a set of measures and attitudes whose first aim is not to end use but to reduce its consequences — infections, overdoses, injuries, loss of housing, loss of children. The starting point is simple: as long as a person is alive, there is a possibility that things improve. If they die, that possibility no longer exists.

It matters to say what this approach is not. It is not the opposite of abstinence and it does not discourage it. For many people abstinence is the goal they eventually reach, and harm reduction is the route by which they arrived there alive. Nor is it approval: nowhere does it say that use is good. It says only that we will not leave a person who uses without help until they stop.

In practice this is the difference between two questions. The first: are you ready to stop? The second: what would make your life a little less dangerous over the next month? For a great many people the first ends the conversation. The second opens it.

Where this approach came from

It did not arise in a lecture theatre but out of necessity. In the 1980s HIV infection was spreading across Europe, and mortality among people who injected drugs was high. In and around Liverpool, programmes began that gave people clean equipment and contact with health services without requiring them to stop. Not because anyone thought this was ideal, but because people were dying while waiting for motivation.

A similar shift happened in Portugal in 2001, where possession of a small amount for personal use was moved out of criminal law and money was redirected into treatment and social programmes. Estimates of the effects differ among researchers, and part of the difference is attributed to other simultaneous changes, but no serious analysis found what had been most feared — a large rise in use.

What matters for us is mainly the logic that emerged from it: if imposing conditions deters people from contact with the system, then the conditions are not a protection but a filter that lets the easiest cases through and screens out the hardest.

Why “are you ready to stop” is often the wrong first question

Because it assumes something that as a rule does not hold in addiction: that the decision is a single event and that it comes first. In reality readiness fluctuates and moves back and forth within the same week. Prochaska and DiClemente’s model described this back in the 1980s: a person passes through periods of not considering change at all, considering it with two minds, preparing, acting, and maintaining.

If you demand from someone in the first period a decision that belongs to the third, you do not get a decision. You get a lie or a disappearance. So in a conversation with someone who drinks or uses, I do not set a condition. The condition would be comfortable for me and fatal for them.

This is not permissiveness. Motivational interviewing, developed by William Miller, rests precisely on the finding that confrontation and pressure increase resistance, while open questions and respect for a person’s autonomy increase the likelihood of change. Meta-analyses credit it with small to moderate but stable effects — and, importantly, substantially lower drop-out from treatment.

What the evidence shows

Here one has to be honest about where the evidence is solid and where it is not. It is firmest for opioids. Opioid agonist treatment is one of the best-researched interventions in the whole of addiction medicine: a large meta-analysis in JAMA Psychiatry showed that mortality while receiving such treatment is substantially lower than during periods off it.

The evidence for needle and syringe programmes is also strong; in several countries they have reliably reduced transmission of HIV and hepatitis C without increasing use. Naloxone, the antidote to an overdose, is credited with many prevented deaths; Slovenia has widened access to it in recent years.

The evidence is weaker and more mixed for some other measures — supervised consumption or drug checking, for instance — chiefly because they are ethically and practically hard to study with random allocation. Weaker evidence does not mean the measure does not work. It means the certainty is lower, and that needs saying.

Alcohol: less is not nothing

With alcohol this debate touches a nerve in Slovenia, because drinking here is part of almost every social occasion. The World Health Organization and European guidance speak of levels of risk, not of two boxes. Moving from a very high level to a middle one means measurably lower risk of liver disease, injury and some cancers — even if a person does not stop.

This is clinically important, because it opens the door to people who are repelled by a demand for total abstinence. Research on reduction-oriented treatment shows that some people with milder to moderate harmful drinking successfully move to less and less risky drinking and stay there. Some do not — and that difference is the heart of the next section.

If you are wondering where to start at all, I have written about the routes to help in our system in the piece on referrals and waiting lists.

Where the limit is, and when stopping is dangerous

Now comes the part I must not write softly. In physical dependence on alcohol, and in long-term use of benzodiazepine tranquillisers, abrupt cessation can be life-threatening. Alcohol withdrawal can escalate to seizures and to delirium, a state with a genuine mortality rate.

So the rule holds without exception: if you drink every day, or if you have taken tranquillisers for a longer period, speak to a doctor first about reducing or stopping. Detoxification is a medical procedure, not a matter of willpower. Never stop overnight on your own, and never advise a relative to. I have written about when a doctor is the first rather than the last address in the piece on when to see a psychiatrist first.

Harm reduction does not dodge this truth. On the contrary: this is precisely the case where the approach itself sends a person to a doctor, because safety is part of the goal.

What is actually available in Slovenia

A network exists, even if many people do not know about it. Centres for the prevention and treatment of drug dependence operate across the country and also run opioid agonist treatment. Non-governmental organisations, among them DrogArt, Stigma and Šent, run outreach programmes, counselling and prevention in the night-time economy.

For alcohol there are outpatient dependence clinics, hospital programmes and self-help groups, including the clubs of treated alcoholics that have operated in Slovenia for decades. Separate groups exist for family members, which matters — a relative often needs their own care rather than only a supporting role.

All of this is publicly available and mostly free. Cost is rarely the obstacle. The obstacle is most often shame, which holds a person back from the first phone call — I have written about it in the piece on shame and the sense that something is wrong with me.

Where this piece does not hold

Now against myself, and seriously. For some people harm reduction is not the right route, and persisting with it means years lost. In severe alcohol dependence, total abstinence is for many the only form that holds — while repeated attempts at controlled drinking turn into a series of failures that convince a person something is wrong with them.

Critics of the approach also have a second point I would not want to dismiss too quickly: if reduction is always on offer, the decision can be postponed indefinitely. I know people for whom external, clear and unpleasant pressure — from an employer, a court, a partner — was exactly what moved things. The claim that pressure never works is not true.

And a third point: the evidence is uneven. For opioid agonist treatment it is solid; for some other measures it rests on observational data that is hard to separate from who enrols in a programme in the first place. Advocates do not always say so. I have written about why therapeutic approaches are hard to research at all in the piece on why therapy is harder to study.

What this means in my room

In practice it means three things. First: I do not set the goal. I ask what would be noticeably better for the person over the next month, and I work with that, even if it does not touch the drinking. Surprisingly often the drinking changes as a consequence, once sleep is repaired or one long-standing conflict is settled.

Second: a slip is not grounds for ending the work. If I excluded someone after a slip, I would be excluding them at exactly the moment they need me most. We treat a slip as information — what happened beforehand, what was missing, what could be different next time.

Third: shame is the opposite of safety. Someone who is afraid to say how much they drank will give me a number that is not true, and we will work with a fiction. So in the first hour I often say that I am not interested in judging but in accuracy. I have written about the difference between guilt that moves you and guilt that paralyses in the piece on healthy and toxic guilt.

What to remember

Harm reduction is not approval and it is not the opposite of abstinence. It is the position that help must not be conditional on a decision a person cannot yet make — and that every step which makes a life less dangerous counts for something in itself.

The evidence is firmest for opioid agonist treatment and for needle and syringe programmes. With alcohol, moving from a very high risk level to a lower one is a measurable benefit even without abstinence. For other measures the certainty is lower, and it is right to say so.

And most importantly, because it is a safety matter: with daily drinking and with long-term tranquilliser use, stopping abruptly is not brave, it is dangerous. There the route always goes through a doctor first. Everything else is a question of pace, not a question of whether you deserve help.