The Dharma of Harm Reduction

Responding to Substance Use

with the Compassion of the Buddha

BY BRIAN DEAN WILLIAMS[divide]

Our prime purpose in this life is to help others. And if you can't help them, at least don't hurt them.—His Holiness the Dalai Lama

[divide]

Introducing Stan

Stan has dropped by my office, sweating profusely. His face is red, tone escalated, speech pressured, and movements animated. I breathe into the fear that I feel arising in me — the increased heart rate, and the flush through my body. I’m in my Vancouver office doing some paperwork, and wasn’t expecting him.Stan is part of a program that I work with as a counsellor, which provides people with a rental subsidy and an interdisciplinary support team to overcome homelessness. While we have good rapport, Stan is a big young guy with a history of violence, who has worked for many years as a drug enforcer in a rough part of town. Stan likes to do speedballs (a combination of heroin and cocaine), and appears to be stimulated currently.I know that underneath the influence of the substances, there lies Stan’s basic goodness – the substance use cannot erase his basic goodness. Pausing, hands open, I ask Stan if he is injecting his drugs and he says yes. I respond by offering him a clean syringe, cooker, cotton swab, and alcohol wipe, so that he can inject his drugs in a less harmful way. Appreciative, Stan accepts, and his face softens. I ask about his vein health and where he is injecting, recommending that he inject from the elbows and knees down.As a Buddhist and a therapist, how could I possibly justify such an intervention? Is this doing harm by “enabling” this young man to destroy his life? And is this not in sharp contrast with the fifth lay precept, to abstain from intoxicants? Within mainstream treatment programs and Buddhist programs and publications related to substance use, the dominant approach has been abstinence-based. But perhaps the time has come to broaden the conversation to include harm reduction as an alternative and skillful response to substance use.

The Wisdom of Harm Reduction

According to the United Nations’ World Drug Report in 2012, problematic substance use affects at least 27 million people worldwide, or 0.6% of the general population.7,000 tons of opium was produced in 2010, and substance use kills 200,000 people worldwide each year.Substance use has far-ranging effects that transcend lines of culture, gender, and class. How do we respond wisely to the vastness of this dilemma? The Buddha was clear in the fifth precept: the use of intoxicants inhibits our ability to awaken. In our current colonial and capitalist context, we can also see clearly that some people’s suffering is so intense, often due to experiences of trauma, that full abstinence is not viable at this moment.Harm reduction is a pragmatic, evidence-based, and compassionate response to active substance use, which prevents the spread of disease, and hopefully preserves a person’s life long enough so that s/he can move closer toward abstinence, if that is their preferred path. Harm reduction acknowledges and seeks to limit the suffering associated with substance misuse, without requiring abstinence. This intervention includes:

• providing people who are using with clean equipment (syringes, crack pipes and mouthpieces)
• providing safer places to use like Insite in Vancouver (North America’s first medically supervised injection site)
• offering methadone / Methadose as a substitute for heroin use
• and using less harmful substances like marijuana as an alternative to more harmful substances.

Harm reduction is certainly not the only intervention, and is inappropriate for abstinence-based recovery centers and groups, but it is key for those who are currently using and not able or willing to stop.So why is this practice so often left out of the discussion around Buddhist responses to the suffering of substance use?Perhaps because of the prevalent misunderstanding that full and immediate abstinence is the only viable option, and that by responding to substance use with harm reduction, one is “enabling” users’ suffering.In his book In the Realm of Hungry Ghosts: Close Encounters with Addiction (2008), Dr. Gabor Maté, a physician in Vancouver’s downtown eastside for many years, writes:

In practicing harm reduction we do not give up on abstinence – on the contrary, we may hope to encourage that possibility by helping people feel better, bringing them into therapeutic relationships with caregivers, offering them a sense of trust, removing judgment from our interactions with them, and giving them a sense of acceptance.

By turning our backs on people who are using because they will not currently practice abstinence, we risk harming the person’s safety and wellbeing through disease or overdose, and limit the possibility of recovery.

Responding Compassionatelyin Vancouver’s Downtown Eastside

Vancouver, British Columbia, known for its natural beauty and green politics, is also home to one of Canada’s poorest neighborhoods, the infamous downtown eastside. The perfect storm for problematic substance use gathers in this area:

• high potency substances flowing through the port;
• a legacy of genocide, colonization, and abuse of First Nations peoples;
• a large psychiatric facility closing its doors without sufficient replacement resources;
• experiences of early childhood trauma;
• prohibition and the criminalization of substance use;
• and a broadening economic gap between rich and poor.

These causes and conditions have fostered high rates of heroin, cocaine, crystal meth, and prescription substance use. Injection drug use is widespread in this neighborhood. Public injecting and crack cocaine smoking is common.Since opening in 2003, Insite has had over 2 million visits for medically supervised injection, without a single death. 30 peer-reviewed studies in respected publications, that include The Lancet and New England Journal of Medicine, have attested to Insite’s services reducing the sharing of needles, disease transmission, and public injecting; and an increase in people accessing detoxification and residential treatment.3 Few people realize that there is also a recovery centre upstairs, called Onsite, which Insite clients can access for residential treatment – also one of the first places where I taught meditation. Engaging with staff in the supervised injection facility can act as a gateway to the possibility of recovery. Besides Insite, harm reduction is an accepted practice in the local health authority and healthcare settings throughout Vancouver, including needle exchange, crack pipe distribution, and Methadose maintenance.

Harm Reduction as Skillful Means

The compassion of the Buddha that we practice need not be conditional. When we encounter the complex dilemma of problematic substance use, rather than judgment or conditional acceptance, we can work to preserve life. Harm reduction is a skillful means to that end, because it saves lives. A person cannot recover if they are dead due to overdose or disease. Once life is preserved, then recovery remains an option.Dharma teacher and author Sharon Salzberg speaks of one of the four sublime attitudes, compassion (known in Pali as karuna), as “a quivering of the heart in response to another’s pain.” The unwise use of substances is deeply painful, both to experience, and to witness. Our hearts move in response, and we are called to action. Twelve Step recovery and abstinence have clearly helped millions of people, but they are not the only solution. Harm reduction, where there is active and precontemplative substance use, stands as a skilful and compassionate response to substance use. On a personal level, I have been practicing abstinence for some time now as part of my Buddhist practice, seeing clearly the harms associated with using – however I can still assist others who are not ready or willing to quit, through harm reduction.

Stan’s Return

Stan shows up at our office again a few weeks later. His eyes are clear and he appears calm. Stan looks tired and thin.He tells me that he is sick of cocaine and heroin, and what they have taken from him. Stan wants to go to residential treatment and practice abstinence. But he needs my help: they won’t take him back unless he does some anger management counselling. Appreciative Joy arises spontaneously and washes over me. Stan laughs at my wide-eyed response to this news, and I join him in lightly teasing myself about it. Then we sit down and get to work on helping him move further toward abstinence.