Keynote speaker at harm-reduction summit calls for not requiring abstinence for drug users to get access to 'recovery capital'

By Melissa Patrick
Kentucky Health News

Helping people in addiction recovery meet their basic needs should not focus on abstinence, but instead should be provided along the continuum of a person's drug use as a way to mitigate harm, with a focus on wellness and autonomy, says an expert who knows recovery from his own experience. 

Alex Elswick

Alex Elswick, an assistant extension professor for substance-use prevention and recovery at the University of Kentucky, was the keynote speaker for the virtual Kentucky Harm Reduction Summit Aug. 10 and 11.

"Harm reduction and capital building are the things that we should be doing all the time for everyone," Elswick said. "We shouldn't be waiting until someone becomes abstinent, or until they become involved in the criminal legal system, or until they reach out for treatment. We can go and engage people who are suffering in our communities and we can mitigate harms. And we can build capital right now, without any barriers to access." 

Elswick, who is in long-term recovery, often says that there is nothing special about his addiction to OxyContin and heroin, since it followed the same path as many others have experienced. What he says is special is his recovery, largely because of the abundance of resources that were available to support him, including housing, transportation, employment, education, access to medical and mental-health care, and relationships with family and community.

Elswick calls those resources "recovery capital" and described them as anything that promotes recovery, or anything that improves the odds that a person will be successful in their recovery. 

He stressed that everyone recovery needs such resources, and not just after they stop using drugs. And just like Maslow's Hierarchy of Needs, which describe motivation, he said a person who has an addiction to drugs must have their basic needs met first before they can even consider seeking treatment and recovery.

But the problem, he said, is that we often use abstinence as a precondition to providing these basic needs for people in the recovery process. 

"I want to suggest that we're flipping it upside down. We're expecting people to do the incredibly, in some cases impossible, work of becoming abstinent without providing them with all the resources that they need in order to do so." 

A key example of this upside-down thinking is housing, because there is little to no housing available for people who use drugs or who are in the early stages of the recovery process, Elswick  said. Nor is there housing for people who are abstinent but are on a medication for opioid-use disorder, like buprenorphine or methadone.

Instead, he said, we have sober housing for people who are already abstinent -- and if a person living in one of these houses experiences a recurrence, which is common, they are kicked out. 

He added that the same is true for drug users' access to social services, which often requires a drug test; that people are kicked out of treatment if they relapse, even if they sought treatment for exactly that problem; and that families are often told to deny support of a loved one if they are using drugs, regardless of circumstances.

In each of those circumstances, "You're going to be deprived of your recovery capital, despite the fact that research says that would improve your odds of recovery," he said. And the only way to change this, he added, is to prioritize recovery above abstinence. 

Elswick traced the concept of recovery capital to a study by University of Denver Professor William Cloud, who found that college students with addictions were recovering at a significantly higher rate, than the general population, sometimes with no formal interventions. 

Cloud determined that the students recovered better because most came from relatively privileged backgrounds and had access to most of the social supports that they needed to recover. 

"The value of recovery capital and harm reduction is that it allows us to have a relationship with someone, as opposed to saying, 'Come to me when you're sober'," said Elswick. "It allows us to have a relationship so that that relationship itself can be a therapeutic. That relationship itself can be a component of recovery capital." 

Elswick concluded with pushes to battle the stigma that still plagues drug users, even among health-care providers and treatment centers, and to make medication-assisted treatment for opioid-use disorder more accessible. He cited studies that prove this is the gold standard of care, but 90% of people who need treatment don't get it. 

"My main takeaway message is, I want us to shift the focus away from abstinence toward recovery capital and building recovery capital and mitigating harms, because it's the more effective approach and I think you might find it'll lead to more abstinence than you realize." 

Elswick is the co-founder of Voices of Hope, a recovery community organization.