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Book Review   |    
Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors
David Greenleaf, Ph.D.
Psychiatric Services 1999; doi:
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edited by G. Alan Marlatt, M.D.; New York City, Guilford Press, 1998, 390 pages, $40

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While most mental health and health professionals are familiar with such interventions for the addictions as needle exchange programs, methadone maintenance, and controlled drinking strategies, many are probably not so familiar with the concept that underlies these apparently disparate measures. The concept is harm reduction, which essentially refers to any systematic effort—whether clinical, social, or public policy—designed to minimize the harmful consequences and reduce the risks of alcohol and other drug use as well as high-risk sexual behaviors.

Readers of Harm Reduction will certainly come away with an understanding of this important concept, its many compelling examples, and the often logic-defying controversies surrounding it. Quite simply, this is an extremely important and valuable work, for it firmly, but rather modestly, points the way to a needed paradigm shift in how we approach some of our greatest societal ills—particularly the AIDS epidemic and illicit drug use.

The sobering message of this comprehensive book is that all too often our best intentions as clinicians and policy makers actually make matters worse when it comes to drug treatment and HIV reduction. Marlatt and the numerous contributors to this volume show over and over again that rigid adherence to a paradigm—for example, abstinence-only models of substance abuse treatment—does a serious disservice to our efforts to solve serious problems.

Marlatt himself wrote all three chapters in part 1, which provide an excellent overview of harm reduction. Included is a review of some of the innovative drug treatment programs in Australia, Canada, and parts of Europe. Particularly convincing is the Dutch model of harm reduction, exemplified by Amsterdam's Jellinekcentre. It offers a range of services from low-threshold programs involving a mobile "methadone bus" to high-threshold, abstinence-based inpatient programs. Needle exchange is commonplace in the pragmatic Dutch model, and the overarching treatment philosophy is one of meeting the client where he or she is and working from there. Let the client set the treatment goal whether it be abstinence or continued, but safer, use.

The book is packed with empirical evidence that consistently demonstrates that needle exchange programs, wherever they are, reduce HIV infection rates and do not encourage drug use. In fact, the opposite is often found. Needle exchange programs can serve as an entry point for substance abuse treatment. The addict's first encounter with a health professional is likely to be one characterized by compassionate nonjudgment. The addict may begin to see the value not only of clean needles but of using less heroin.

The book is largely devoted to the themes of illicit drug use and HIV-AIDS prevention, but the controversy of controlled drinking is also intelligently presented, as are harm-reduction strategies for nicotine and smoking. Another major strength is the section on matching harm-reduction strategies to black and Native American communities.

But this work is more than the title suggests. It can be a reference text for a variety of drugs and treatment approaches and their histories. For this reason alone, Harm Reduction belongs on the bookshelf of health and mental health professionals.

However, the real impact of this seminal volume is that it makes the case for harm reduction as a powerful model for both treatment and public-policy innovations. The reader will likely wonder why harm reduction approaches are so controversial when they are so clearly cost-effective and clinically effective. An analogy is that most psychotherapists treating a non-substance-abuser would naturally start from where the patient is psychologically and would not tend to push for goals not shared by the patient. Yet rigid adherence to abstinence as a goal for alcohol abusers and drug addicts seems to do just that. The public-policy equivalent of this position is that of "zero tolerance," which is critiqued in the book as well.

Alan Marlatt apparently is not afraid to enter the fray of controversy, and in so doing he does us a great service. Harm Reduction is a needed eye-opener for clinicians, patient advocates, and policy makers alike.

Dr. Greenleaf is assistant professor in the department of psychiatry at the University of Massachusetts Medical School in Worcester.




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