Harm reduction and specific treatments for heroin addiction. Different approaches or levels of intervention ? An illness-centred perspective

ENGLISH :
So far, harm-reduction campaigns have focused on the personal and social needs of heroin addicts, with the aim of preventing the consequences of addictive behaviours. An unduly sharp dichotomy usually seems to come to mind when harm-reduction interventions are compared with specific treatments for heroin addiction. In reality, some of the specific targets in the treatment of heroin addiction, as well as features of mentally ill subpopulations, may be reasonable targets for harm reduction, too. Convergence on overlapping targets may be hypothesized as long as harm reduction and specific treatment come to share the same therapeutic instruments. Opioid agonists, the primary option for the specific treatment of heroin addiction, are also valuable as harm reduction instruments, as long as harm reduction is conceived of as a means for acting on that disease, but only at a low-threshold level. The personal and social impact of possible agonist-mediated harm-reduction seems to carry special weight in higher-risk populations, such as mentally ill heroin users, who have turned out to be sensitive to therapeutic opioid agonism. Harm reduction can best be regarded as a low-level approach to more severely disabled subjects, bridging the gap between the street and clinical settings by a sub-therapeutic but specific pharmacotherapy. Stepping up from harm reduction to a higher level of intervention should, in fact, be the ultimate goal of harm reduction. Transition to specific treatment is particularly important for dually diagnosed addicts, who can be expected to receive a relatively greater benefit ; without that transition, they are likely to quickly lose the opportunity to attain a positive outcome. (Author' s abstract)