Ending False Divides in Addiction Treatment Perspectives

Helping a person to change their substance use behavior if it is harmful or likely harmful is one of the major tasks for those practicing addiction medicine. Practice involves knowing when to encourage change, back off, or intervene urgently. The practitioner needs to work to know the person well and gauge their receptivity to dialogue about their substance use, which requires patience1 and considers the high likelihood of perceived mistrust and power differentials being present.2,3 Often, potential harm from a person’s substance use appears obvious to the practitioner and/or those around the person, despite the person not necessarily seeing it the same way, setting up a potential mismatch in expectations and goals. One of the hardest parts of addiction medicine practice is working with a person who is ambivalent or not ready to change, but also the most important. It requires intentionality and careful crafting of the words we use, while checking our own expectations and acknowledging our frustrations in not being able to make a person change, we see as suffering.4 Often it is this mismatch and our own frustrations, that unfortunately seems to lead to stigma and the creation of false dichotomies such as recovery versus harm reduction, psychosocial versus biomedical, psychiatry versus medicine, or even involuntary versus voluntary treatment. Despite knowing intuitively that treatment approaches need to meet the person where they are and that the needs of each person fall along a continuum between the polarized margins, it is easy to fall into the trap of false dichotomies. It only ends up dividing us needlessly, wasting time and resources that should be going towards those who are suffering. As a group of practitioners, we need to avoid being caught up in those things that divide us and, instead, work to challenge our perspectives, learn from others’ experiences, and keep a longer-term perspective that aims to help people make incremental change in their lives consistent with chronic illness management, and help them stick to healthier changes when they may be at risk for falling back into prior ways.5,6 This issue has several articles along the theme of looking at aspects of addiction care that can inadvertently lead to false divides. In the commentary by George et al,7 they thoughtfully discuss the important role that addiction psychiatry can play in the care of people who suffer from addiction, especially those with comorbid psychiatric disorders. They discuss how enhancing the training of psychiatrists can further benefit the overall care of people with addiction and the means to achieve this. It does not suggest that psychiatric approaches are better than medical ones, but that together services can be enhanced. The article by Oulette et al8 discusses findings from a survey of Northern Ontario first responders and emergency room staff on stigma and addiction. It speaks to the high prevalence of stigma toward those with addiction, but also the interest and amenability to tailored training programs to help combat stigma. It demonstrates how identifying potential sources of division can lead to meaningful change. And finally, the article by Forchuk et al9 involves a qualitative study of people with lived experience of methamphetamine use who had received hospital-based services, asking them about their experiences with abstinence-based versus harm reduction-based care. It identifies barriers to care if only abstinence-based approaches are emphasized, suggesting that harm reduction models also need to be incorporated into current hospital care. Again, the article speaks to how a continuum of care options is more optimal than focusing on one model to the exception of another. As practitioners of addiction medicine, we share more similarities than differences in our approaches to people suffering from addiction. Treatment options need to support a continuum of evidence-based approaches that more flexibly match the stage of change and current goals of each person we see with problematic substance use or other addictive behaviors.5,6 We should do our best to resist gravitating to false divides as a profession, as we are stronger together, rather than apart.

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