Substance Use and the Dignity of Risk
I've taken a pause on weekly posting to preserve time for revising my book manuscript. Thank you for sticking around in the meantime!
When I gave my presentation on navigating substance use services, one of the concepts that provoked the most thought was the dignity of risk. The dignity of risk is pivotal to rights-based approaches in addiction treatment, warranting a post of its own.
The dignity of risk comes from disability justice discourse as a way to understand the meaning of autonomy in situations considered vulnerable or dangerous. For example, someone with mobility limitations might be advised not to walk around their city alone because they might fall or because they cannot move quickly when crossing the street. Dignity of risk does not mean that this person has solutions for all of these concerns. Indeed, none of us ever has access to perfect safety or certainty. Instead, it means they retain autonomy to assess and take risks for themselves, even if others may not agree with their judgments. The freedom to move through space independently is worth certain risks to the disabled person, and recognizing their dignity of risk means respecting their choice and supporting their safety– not insisting that it's simply too risky for them to walk around alone.
Substance use carries risks, and a lot of efforts in both prevention and treatment focus on convincing people that the risks aren't worth it. This includes scare tactics often used on young people, and interventions that ignore the many rewards of drugs to pretend quitting forever is a no-brainer. Obviously, substance-related risks can be minimized by abstaining, or avoided by never using substances in the first place. These are both popular options! But for some people, risks associated with using substances, or certain ones, are worth it, including risks in:
- Trying a new drug or increasing its use
- Using a drug by a faster/more potent delivery method (like snorting instead of taking orally, or injecting instead of snorting)
- Using Drugs B and C while trying to quit Drug A, because only Drug A ever got out of control
- Resuming use of Drug A itself, with intent to control it this time
Whether you're in recovery or not, this list may be stressful to read. I deliberately ordered the items to get progressively more uncomfortable for an outside assessor of risk. This is where the dignity of risk comes in, and it holds no matter how obvious it might appear to someone else that a particular idea is a bad one. In the best case scenario, people learn from both the good and bad outcomes of risks they choose, refining their choices accordingly as they go– like anyone taking any kind of risk.
Addiction treatment protocols tend not to respect patients' dignity of risk. Here are the two most common violations I see:
1) Prioritizing risk management over care. So many rules and policies that govern how we treat people are designed not to provide them the best care, but to protect providers and health organizations from legal liability. Even when the risk cited is technically a risk to the patient, like overdose or death, let's be real: these things happen all the time, and the system chugs on with barely an acknowledgment. The real threat is being held legally liable for such an incident.
Rosalie Genova
This is how we get protocols like discharging people for continued drug use, or refusing to prescribe opioid maintenance to patients who are combining their medications with alcohol or benzodiazepines (a risky drug interaction). Are such patients out of danger when providers stop supporting them? Certainly not, and in fact they may be worse off– but whatever happens next, the provider (and their employer) can't be held responsible because the treatment relationship has been terminated.
2) Withholding information that would allow people to weigh their own relative risks. A lot of treatment is labeled "psychoeducation," but the industry purposefully avoids educating patients when it might lead to choices that providers don't like. Harm reduction education is one major example: programs could educate on safer practices of substance use, from drinking alcohol to injecting street drugs, but generally do not because a) it might "send a message" that they approve, and b) their goal is for patients to be equally afraid of all kinds of substance use, and avoid it all– not to assess the relative risks of various substances or methods of use. Again, because drug use is worth risks for many people, this approach backfires when use continues and people have little or no information about how to protect their own safety.
Another example of withheld information undermining the dignity of risk: cutting corners on informed consent when prescribing opioid maintenance medications like Suboxone. These meds are recommended to be taken without interruption for the rest of the patient's life. Getting off is notoriously difficult and is associated with negative outcomes no matter how one does it. In my experience, prescribers do not spell this out (and I have been in the room to hear for myself). They might vaguely say, at induction, "This is a long-term plan," or "We don't recommend going off any time soon," but patients only find out later that they're actually meant to stay on indefinitely. In such cases, the prescriber simply assessed Suboxone's risks for the patient (i.e. that it is safer than illicit opioids– see #1 above) and didn't want their own judgment contested by way of complete information. Keep in mind as well that inductions are often done when the patient is in active opioid withdrawal: another reason both parties may rush through the process and avoid any critical discussion.
What complicates the dignity of risk? Situations where a person seems to be taking risks for others without their consent. Listen to the partners or families of people with addictions, and they'll tell you: "I'm not 'judging.' This is my business, because these risks always turn into problems I have to solve." Think crashed cars, ruined credit, or worse. Similar dynamics apply in community relationships and when sharing space.
In this case, the goal becomes pinpointing exactly what risk is unacceptable to us or to the group. It's almost never about substance use in and if itself, but rather risks that are more likely to occur in relation to use. Anyone with the potential to be affected can state the impact on them, set boundaries within their control, and inform the risk-taker of what they are or are not prepared to do in context of this risk. For example, "If you get fired, I am not going to cover your living expenses." But it is crucial that these are simple statements of fact, not threats or ultimatums. This means that the person stating them is solely accountable for follow-through! If that feels unrealistic, then the reality is– at least for now– that we are fully on the hook for risks we never chose. Again, ultimately this is true for everyone and for all kinds of risk. Addiction just has a way of highlighting the messy, shaky aspects of human experience, including human connection.
Up Next: Body brokering comes to Maine.
