Balancing Harm Reduction and Structured Abstinence
Vanessa Greer
University of Victoria: School of Social Work
SOCW 471: Social Work and Substance Use
Instructor: Tyson Singh Kelsall
June 8, 2026
The contemporary debate in British Columbia surrounding substance use intervention is divided between the rigid prohibitionist abstinence model and the humanistic and flexible harm reduction model. While the abstinence model focuses on the often morally driven objective of completely eliminating all drug consumption from someone's life, the harm reduction approach is more flexible while prioritising immediate dangers such as disease and overdose protection. While harm reduction has proven to be a necessary tool in keeping people alive (Irvine et al., 2026), it raises the question of whether people can function within the relaxed structure of harm reduction or if they require the accountability and responsibility that the abstinence model provides. In her book, The Harm Reduction Gap, policy researcher Dr Sheila Vakharia (2024) highlights that an important gap persists in our care structure because low-barrier harm reduction services were fundamentally meant to alleviate the immediate consequences of drug use, not as standalone mechanisms for behavioural modification. This paper argues that while harm reduction approaches are proven to prevent overdoses, injuries, and disease transmission, they are rarely effective at helping those experiencing severe addiction who require a more structured abstinence model to decrease their consumption for long-term recovery.
Positionality
To ensure relational accountability, this paper adopts a decolonial framework that rejects the myth of the detached, objective observer. To align with decolonised social work practice, I approach this subject as a white, European-born settler who resides with deep gratitude on the unceded territories of the Lekwungen-speaking peoples, including the Songhees and Xʷsepsəm (Esquimalt) Nations. While I experience marginalisation as a disabled, transgender, and queer member of the 2SLGBTQSIA+ community, I am aware that my past substance experimentation during my youth was deeply insulated by my racial and socioeconomic privilege. My identity as a white settler ensured I never faced the unfair criminalisation or harassment that disproportionately affects BIPOC populations. Punitive abstinence models have historically functioned as tools of colonial violence, whereas harm reduction frameworks emerge as essential mechanisms of human rights and survival. This positionality allows me to critique the functional boundaries of low-barrier frameworks without unintentionally reproducing colonial, moralistic, or punitive arguments against the individuals we support.
Harm Reduction
The undeniable strength of the harm reduction framework is found in its immediate and compassionate utility as a life-preserving intervention during the crisis of a volatile, toxic drug supply. In her TEDx talk, Lyndsay Hartman (2019) stresses the importance of viewing harm reduction as “an act of compassion” (02:15). It is vitally important to lower the stigma around addiction and illicit drug use to allow those who use drugs to seek the help they need (Hartman, 2019). It is a matter of life and death. We know that unfair harassment and targeting of drug users does not lead to a reduction in drug use. As Hartman (2019) clearly says, it simply leads to people who use drugs going further into isolation for fear of being arrested.
Harm reduction is what Vakharia (2024) calls a reality-based approach, based on the understanding that people will engage in risky behaviours and that, while abstinence may be safer, it is not always realistic. To me, harm reduction is an approach which acknowledges that attempting to control what people do or do not do is unrealistic and could ultimately cause more harm. My mother took a harm reduction approach with my siblings and me when she acknowledged that we were going to drink alcohol anyway and that it was safer for her to allow us to have parties at home with some alcohol than to ban it and possibly have us drink in the woods away from safety. A major part of harm reduction is removing the stigma from any substance use (Hartman, 2019).
The pragmatic approach of harm reduction is apparent in how users negotiate the modern realities of the volatile, fentanyl-dominated supply. As Paredes et al. (2025) document in their review of harm reduction strategies, active drug users are not just passive participants in their substance use. Instead, they actively deploy safety strategies to minimise immediate mortality. These peer-led interventions include the co-use of stimulants, dose reduction, carrying naloxone, and deliberately shifting routes of administration to lessen overdose risks (Paredes et al., 2025). This demonstrates that harm reduction functions as a dynamic, responsive framework of survival, delivering immediate, life-preserving utility that rigid, all-or-nothing models cannot accommodate.
Limits of Moderation
During my seven-month practicum with Island Health’s withdrawal management services, I completed assessments where clients stated their recovery goals. While some wanted an immediate transition to long-term stabilisation care, some would opt for a moderation approach, such as reducing consumption to a few drinks per week. I observed that clients attempting to decrease their consumption were usually readmitted to the detox unit after slipping back into old habits in their daily lives. This reality of real-world practice raises vital questions for me regarding the limitations of harm reduction frameworks. It suggests that human behaviour, under the burden of severe dependence, can require the explicit structure of accountability to successfully disrupt the cycle of active addiction and help someone establish their new normal.
This loss of control is rooted in neurobiology. As Koob and Volkow state, “drug addiction can be defined as a chronically relapsing disorder” (2016, p. 760). Chronic substance use alters the executive control networks in the prefrontal cortex while hyper-activating stress systems in the brain (Koob & Volkow, 2016). This neurological alteration makes unassisted moderation biologically exhausting to sustain. This point is also reflected in statistical data. In a comprehensive U.S. national sample, Eddie et al. (2021) determined that while moderation pathways are attainable for some, people navigating severe dependencies show significantly higher metrics of long-term self-esteem and mental health when choosing a structured abstinence pathway. Additionally, for marginalised populations facing compounding disadvantages, a systematic review by O'Leary et al. (2024) finds that low-barrier care alone rarely leads to a sustained reduction in consumption volumes.
Abstinence Critique
While structure and accountability are clinically essential for successful long-term recovery, conventional treatment models frequently undermine their own efficacy by implementing abstinence through a perspective that is more rigid than necessary. For many people facing active addiction, the demand for immediate and total compliance can create an adversarial environment between the care team and the client. For example, under many abstinence-based models, clients are not allowed to use any mind-altering substances, including nicotine. This often causes clients to leave detox services purely because they are unable to smoke cigarettes while going through a stressful detox process. According to the meta-analysis by Prochaska et al. (2004), forcing strict, rigid behavioural restrictions during substance-use treatment can trigger immense psychological stress and even increase the risk of relapse on their primary substances.
Conclusion
Ultimately, harm reduction and structured abstinence should not be viewed as adversarial philosophies, but as complementary components within a unified continuum of addiction care. While low-barrier harm reduction services provide essential, life-saving interventions necessary to preserve human dignity and prevent unnecessary harm during a crisis, they are not designed to serve as standalone frameworks for long-term behavioural transformation. For people navigating severe dependence, sustainable recovery also requires structure and accountability. Meeting the realities of the toxic drug crisis effectively requires the integration of immediate, compassionate survival tools and structured stabilisation pathways to truly facilitate holistic long-term healing. It is encouraging to see that many public health agencies are starting to combine these two approaches to provide effective, compassionate care that meets clients where they are.
References
Eddie, D., Bergman, B. G., Hoffman, L. A., & Kelly, J. F. (2021). Abstinence versus moderation recovery pathways following resolution of a substance use problem: Prevalence, predictors, and relationship to psychosocial well‐being in a U.S. national sample. Alcoholism Clinical and Experimental Research, 46(2), 312–325. https://doi.org/10.1111/acer.14765
Hartman, L. (2019, October 30). Harm Reduction as an Act of Compassion | TEDX Talks [Video]. YouTube. Retrieved June 6, 2026, from https://www.youtube.com/watch?v=sUgxnYEA8F0
Irvine, M. A., Ge, W., Liu, L., Williams, S., Lock, K., Palis, H., & Kinniburgh, B. (2026). Widespread Take-Home naloxone use averted the majority of potential opioid poisoning deaths in British Columbia, 2019–2024: a Bayesian modelling study. Medical Decision Making, 46(5), 649–660. https://doi.org/10.1177/0272989x261436841
Koob, G. F., & Volkow, N. D. (2016). Neurobiology of addiction: a neurocircuitry analysis. The Lancet Psychiatry, 3(8), 760–773. https://doi.org/10.1016/s2215-0366(16)00104-8
O’Leary, C., Ralphs, R., Stevenson, J., Smith, A., Harrison, J., Kiss, Z., & Armitage, H. (2024). The effectiveness of abstinence‐based and harm reduction‐based interventions in reducing problematic substance use in adults who are experiencing homelessness in high income countries: A systematic review and meta‐analysis: A systematic review. Campbell Systematic Reviews, 20(2), e1396. https://doi.org/10.1002/cl2.1396
Paredes, J., Sandhu, A., Huo, S., & Timberlake, D. S. (2025). Mini-review: Harm reduction strategies among people who intentionally use fentanyl. Addictive Behaviors Reports, 21, 100615. https://doi.org/10.1016/j.abrep.2025.100615
Prochaska, J. J., Delucchi, K., & Hall, S. M. (2004). A Meta-Analysis of Smoking Cessation Interventions with individuals in Substance Abuse treatment or Recovery. Journal of Consulting and Clinical Psychology, 72(6), 1144–1156. https://doi.org/10.1037/0022-006x.72.6.1144