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Non‑Abstinent Recovery: Harm Reduction as the Front Door to Healing · Talking FACS

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  Welcome to Talking FACS, what you need to know about family,
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  food, finance, and fitness.
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  This nationally recognized, award-winning podcast is hosted by the University
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  of Kentucky Family and Consumer Sciences Extension Program.
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  Our educators share research knowledge with individuals, families,
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  and communities to improve quality of life.
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  Welcome to Talking FACS, where we share research-based information to help
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  improve the quality of life for Kentuckians.
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  I'm your host, Dr. Alex Elswick, Associate Professor and Extension Specialist
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  for Substance Use Prevention and Recovery.
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  As a reminder, our disclaimer, we're speaking today from our personal areas
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  of expertise, and our views do not represent the official views of the University of Kentucky.
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  Having the housekeeping out of the way, I'm honored and grateful and excited
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  to introduce our guest for today, Alex Johansson.
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  Alex is a second-year psychology PhD student at University of Kentucky,
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  where her research focuses on developing treatments for substance use disorders,
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  specifically cocaine and methamphetamine.
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  And Alex was also recently featured in the UK Now periodical.
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  So she's a star and we're so grateful she could make time for us.
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  So Alex, thanks for being here. Oh, thank you for having me.
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  And in particular, what we're talking about today is something that I'm very
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  excited and passionate about, and that is harm reduction. And more specifically,
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  we're talking about non-abstinent recovery.
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  And so before we start getting into the meat and potatoes of non-abstinent recovery,
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  I thought we might start by just addressing a couple of myths,
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  because on its face, to some people, that just sounds like an oxymoron,
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  non-abstinent recovery.
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  So maybe I'll give you a couple of myths and you can tell me why they're mythology
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  and not quite true. Sound good? That's great.
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  Okay. So myth number one that I hear frequently in the general public and also
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  kind of in the recovery community is that non-abstinent recovery is really just
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  giving up and in particular giving up on abstinence. How would you respond to that?
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  So when people hear non-abstinence, they think they assume that that means like encouraging drug use.
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  In reality, non-absence really means recognizing that people can make meaningful
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  progress toward health and wellness goals without being perfect.
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  And we say this in just the broader healthcare space. So for diabetes or weight
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  loss, people have goals and it's kind of incremental changes over time that
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  they're encouraged to achieve to reach their ultimate goals.
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  It's such a good example that I think makes it all more readily accessible for
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  everybody to understand because weight loss is a struggle for so many people,
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  especially in Kentucky.
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  We know that like a third of the state is pre-diabetic or diabetic.
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  And this is something that lots of people struggle with. And we recognize, as you've said, that.
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  You know, maybe becoming a model on the front page of a fitness magazine isn't
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  your goal, but maybe losing 10 or 15 pounds helps reduce the burden on your health. Exactly.
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  Another myth that I hear frequently is that harm reduction and abstinence are opposites.
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  That kind of, it's similar to what we said before, but that because harm reduction
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  is sort of giving up on abstinence, that harm reduction and abstinence are opposites.
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  How would you respond to that?
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  I hear that a lot too. Harm reduction is not the opposite of recovery.
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  It's really a front door to recovery. It's one of the most robust pathways in recovery.
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  For example, people who use drugs who engage with strict service programs are
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  more likely to access treatment.
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  So recovery isn't one huge decision about drug use.
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  It's really a bunch of small incremental decisions that people make as they
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  navigate the resources that are available to them and try to build recovery capital.
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  And recovery capital is really just the sum of all the resources,
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  both internal and external, that people have access to to help start or continue
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  their recovery journey.
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  And that's really interesting when you say that harm reduction is not the opposite
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  of recovery, but it's a front door to recovery, a robust pathway of recovery.
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  What it brings to mind for me is that even people for whom their recovery is
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  characterized by abstinence, complete abstinence today, for the majority of even those folks,
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  they weren't completely abstinent the day that their recovery journey began.
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  And even for those folks, most people experience recovery as nonlinear.
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  So like fits and starts and three steps forward and two steps back.
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  And so I think that makes a lot of sense.
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  And then I guess relatedly, but the third myth that I hear a lot is that recovery
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  is abstinence, that abstinence is recovery, that recovery is abstinence,
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  and anything else isn't recovery.
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  I think that's probably the prevailing view in the general public too.
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  What would you say to that?
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  So abstinence is really focusing on what you aren't doing, right?
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  And recovery is really focusing on the things that you can do instead.
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  So instead of saying something like, stop using and life will get better,
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  we can say, try to improve recovery capital.
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  So try to improve the resources you have access to, focus on your own growth,
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  focus on building your social networks, finding supports, and life will get better as a result.
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  And recovery is enabled through that process.
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  So most people take, as you said, kind of a non-abstinence pathway.
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  It's a process that's not this one moment or this one decision.
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  And we also know that substance use disorders are chronic and they're relapsing.
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  So even those who want to ultimately take an abstinence pathway do have periods of non-abstinence.
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  So, again, recovery is really this process and making room for non-abstinence,
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  as we talk about recovery is really highlighting recovery as a process.
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  Yeah, I was honing in on the same word as you there, that word process,
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  that recovery is never an event for anyone.
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  That it is a process kind of by definition, even if it meant it's been characterized
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  by abstinence all along, for everyone, recovery is a process.
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  Okay. Okay. So that's helpful myth-busting, but we can also use a little bit
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  of a refresher on harm reduction.
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  And we have a couple of other Talking FACS episodes that we can link in the
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  description notes to give some background on harm reduction.
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  But for context, for listeners, What do we mean when we say harm reduction?
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  Yeah, so harm reduction, it's both a philosophy and a tool. And at its core,
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  it's really just accepting that drug use has always been a part of our world.
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  And instead of judging it, condemning it, assigning some moral value to it,
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  it accepts that it's a reality.
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  And the goal is to really meet people where they are and to try to reduce risks
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  associated with substance use.
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  Now, we usually talk about it in the context of substance use,
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  But it really is something that we see pretty frequently just in our healthcare
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  system and our public health guidance.
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  For example, wearing sunscreen when you go out to tan or you go to the beach
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  to help reduce the risk of skin cancer and things like that.
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  I always use the example that, again, these are not the express views of the
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  University of Kentucky, but Coke Zero has like the new formulation of Coke Zero is so good.
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  And there is no positive health benefit to me continuing to drink any kind of
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  soft drink. It only adds to the public health burden.
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  But dang it, I want to taste a Coke. And so instead of drinking full sugar Coke,
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  I drink a Coke Zero. Right.
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  And as much as it's like a silly example, I do think those examples help bring
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  to light that abstinence isn't always the answer to a potentially harmful health
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  behavior, that sometimes harm reduction is the answer that's best for us.
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  And so when we apply harm reduction to substance use disorder,
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  then what does that look like?
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  Right. So harm reduction acknowledges that substance use disorders,
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  they're chronic, they're relapsing, it's not acute.
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  And they are characterized by continuing to use drugs despite adverse consequences.
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  And the goal, as we said earlier, is to really reduce the severity of those
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  consequences or eradicate them altogether.
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  And so in that context, what does recovery then look like from substance use disorder?
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  Right. So recovery, as we've said many times during this conversation,
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  is a process that is not a standalone event.
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  There are several different, infinite different paths to recovery that people can choose to take.
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  And recovery can look different for different people. Some people want an abstinence-only
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  outcome for substance use, and then some people are looking to simply reduce.
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  And then some people are also really interested in just building up their access
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  to other resources available to them. In other words, building up their recovery
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  capital to improve quality of life.
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  Has research shown whether or not abstinence or non-abstinence is a safer approach?
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  So abstinence is the safest option. But there is some evidence to suggest that
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  reductions in use can still confer benefits and harm reduction accepts that both can be true.
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  So there's actually a growing body of research that highlighted the benefits
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  of reducing alcohol use specifically.
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  And the FDA now recognizes partial reductions in drinking as an endpoint for
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  clinical trials for alcohol.
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  And in other words, I'm just saying alcohol or drinking less is better for your
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  health overall. You don't need to quit completely to experience benefits.
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  Again, quitting completely is probably the best for your health.
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  It's the safest option. But there is a middle ground.
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  It's just really interesting, given the recent guidance from the Surgeon General
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  and just the broader academic community around alcohol, where we used to say
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  there was a safe amount of alcohol to drink or maybe that a glass of red wine
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  was good for cardiovascular health.
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  And now the more recent guidance seem to suggest that really any alcohol consumption,
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  is associated with with harm, certainly the potential for harms.
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  And so even though we're seeing people drink less and less, I think,
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  your average listener who might enjoy responsibly drinking alcohol likes to
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  hear the fact that maybe they don't have to entirely give up on alcohol and
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  that reductions come with health benefits as well.
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  And we're doing some of that work specifically at the University of Kentucky.
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  Is that right? Exploring some of those reductions in use rather than just abstinence alone?
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  Yes. And my mentor, Phil Stoops, has been doing a lot of this work in the cocaine space.
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  So we've done some recent research through a clinical trial showing that reductions
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  in cocaine use improved cardiovascular health, immune system function,
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  overall quality of life, and possibly cognition.
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  So that's really interesting work. It's fascinating work, and it's fascinating
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  in part because the opioid epidemic receives a lot of the media attention, but we know in Kentucky,
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  and we can link a Talking FACS episode to this as well below,
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  that there are twin epidemics in the state of Kentucky, and that what gets lesser
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  attention is the increase in stimulant use.
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  And so this, I think, is really timely and relevant as we explore some of the
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  benefits and reductions in stimulant use.
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  Before we close out, I want to make sure. So I think it's, I think it's probably
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  pretty much immediately obvious to most listeners,
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  why reductions in use are valuable on its face, that reducing,
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  that using less drugs or fewer drugs is, is better.
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  It's going to have fewer negative health, adverse outcomes, that sort of thing.
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  That makes sense. But still, I think sometimes making the connection between
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  reduced drug use and recovery is, is hard for people because it's not as easy
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  for them to connect in their minds as complete abstinence and recovery.
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  So I want to think just a little bit more about how non-abstinence helps in recovery.
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  And so you mentioned recovery capital. Can you talk a little bit more about
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  the relationship among those things?
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  Yes. So I kind of like to think about recovery capital as a little bit of a bridge here.
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  And it basically helps people connect where they are now with where they want
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  to be in their recovery journey.
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  And we kind of alluded to this earlier, but there's three domains to recovery
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  capital you can kind of think about. One is personal, so things like physical health coping skills.
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  A second is family or social relationships, supportive recovery efforts.
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  And then the third is community. So societal supports, whether that's stable
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  housing, access to transportation, access to treatment, things like that.
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  So by reducing use, that allows people to,
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  build recovery capital, to gain new skills, to help foster new connections,
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  find access to resources in their communities that are going to help them continue
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  to achieve their goal, whether that is an abstinence or a non-abstinence.
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  Recovery outcome. Thank you. Okay. That helps make the connection there.
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  Before we completely close out, I also want to make sure that the implications
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  of this are well understood because I think there are some really important
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  implications here. So from a research perspective, why does this work matter?
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  Yeah, this work is really important from a medications development standpoint.
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  And what I mean by that is that it helps inform what we choose as endpoints
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  or our main outcomes that we're measuring in our research studies.
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  So a medication that may not result in complete abstinence may still contribute
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  to substantial reductions in use, which again may be linked to overall well-being
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  or improvements in quality of life.
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  And as a field, we've overlooked these outcomes for a long time.
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  We've only focused on abstinence and arguably to the detriment of treatment
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  development for substance use disorders. So if we take a little bit more of
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  a harm reduction lens to this.
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  It may help facilitate new inroads, more treatment options. Right now,
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  I know you mentioned stimulants earlier. There are no FDA-approved medications
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  for stimulant use disorders, either for cocaine or for methamphetamine.
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  So that's an active area of research right now. I love that.
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  And I love the way you framed that applying this harm reduction lens may help
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  facilitate new inroads because it makes me think about,
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  how much broader the umbrella of well-being and recovery is when it isn't just
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  about abstinence, when it's really about trying to accomplish all these other
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  forms of improving quality of life.
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  And so then from a public health perspective, why does this work matter?
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  Yeah. So again, I kind of alluded to this earlier, but substance use disproportionately
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  impacts communities in Kentucky compared to other states.
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  And we talk a lot about the opioid crisis, but actually according to the 2025
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  Kentucky drug overdose fatality report, methamphetamine was the most frequently
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  identified drug in overdose death toxicology reports actually ahead of fentanyl.
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  So, to me, that says we urgently need treatments for standard use disorders
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  and advancing non-absent outcomes will help us achieve this goal while also
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  reducing stigma around substance use disorder treatment and recovery.
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  Fascinating. And I'll just underscore one more time what you've just said,
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  that in the latest Kentucky Drug Overdose Fatality Report, that methamphetamine
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  was the most frequently identified drug per toxicology results in overdose deaths ahead of fentanyl.
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  And that's really shocking, I think, given the disproportionate amount of attention
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  that fentanyl's received.
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  That's really fascinating. So Alex, thank you for your really important work.
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  Thank you for taking the time to be our guest today. And I hope you'll come
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  back and tell us more about some of your future work.
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  Thank you so much for having me. If you're just tuning in, you're listening
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