Condoms, Suboxone, and Harm Reduction

And the woman conceived, and she sent and told David, “I am pregnant.” 2 Samuel 11:5

Part of the culture war waged during my teenage years involved fighting over teenager’s access to birth control. Conservatives argued that to give out birth control was to endorse premarital sex. Basically, if the government gave out condoms, they believed it would cause more teens to have sex. This turned out not to be the case. Studies have repeatedly shown that increased access to birth control – like condoms – doesn’t result in an increased number of kids having sex, but it does result in decreased teen pregnancy and transmission of STDs. This is the harm reduction model of approaching teen pregnancy. The harm reduction model doesn’t endorse premarital sex among teens, but it does acknowledge that it’s going to happen. Accepting that some teens will be sexually active, the harm reduction model tries to decrease the negative impact of that reality, by decreasing teen pregnancy and STDs.

So now, as a physician, it’s a no-brainer. Teens should have access to birth control. Still, I understand why my church isn’t handing out condoms. That’s simply not my church’s job. I don’t find it hypocritical for me to believe in easy access to birth control for teens, while belonging to a church that promotes abstinence until marriage. In fact, I don’t think that two messages must be mutually exclusive. I can educate my teen patients that it is healthiest to wait until marriage for sex. At the same time, I can accept that not all my patients are going to wait, and I can participate in efforts to decrease the negative impact of teen sex.

We’ve all made bad decisions, and we’ve all compounded our misery by allowing the consequences of our bad decisions to snowball, becoming bigger and bigger. This is what happened to King David in today’s passage. In the story, David took a married woman, Bathsheba, into his bed and then sent her on her way. Soon though, Bathsheba sent the king a scandalous message – I’m pregnant. Perhaps, at this point, if King David had some pregnancy crisis counseling, he could have avoided what came next. On his own though, trying desperately to cover up his sin, David panicked and orchestrated the death of Uriah, Bathsheba’s husband. It was bad enough that David committed adultery. Now, sin begat sin, as the consequences multiplied, and David became a murderer.

Strict application of the abstinence only model of sex would have simply told David that he shouldn’t have done what he did in the first place. Whereas the harm reduction model of sex would have accepted that it happened, while trying to not make things worse. I do believe there are limits to the methods that harm reduction should employ of course. For instance, I don’t believe David should have turned to abortion as a means of birth control. Rather, he should have confessed what he did and accepted the consequences, not making things worse.

Why am I writing about teen sex and birth control? I’m writing about this because it parallels my approach to treatment for drug addiction – specifically opioid addiction. There was a time that I was opposed to the use of suboxone – a long-acting opioid prescribed by a medical provider as a “replacement opioid”. I once believed that suboxone was simply replacing one addiction with another, preventing the patient from experiencing abstinence. I’m abstinent and I want my patients to experience the joy of abstinence as well.

Over the last several years though, I’ve recognized that there are some patients who simply aren’t going to be abstinent. Maybe they will be someday, but right now, they simply can’t stay off opioids. At a high risk for overdose and death, suboxone provides a far safer replacement that can keep the opioid user off fentanyl. No one overdoses and dies off suboxone and so, if I can use suboxone to get them to stay off of fentanyl, thereby keeping them out of jail, out of the hospital, and if I’m able to help them to find a home and get a job, then it would be wrong for me to deny them suboxone.

Still, I get why some programs or facilities don’t endorse it. Just like my church didn’t (and shouldn’t) hand out condoms, I get why some programs want to remain abstinence programs.

For my part though, as a physician in recovery, I’ve come to accept that some people are always going to use drugs, and some patients cannot maintain abstinence right now. I can work towards that goal with them, but if they live in a home where fentanyl is readily available, then I’d rather they go home on suboxone than without it. Again, there are limits to our harm reduction methods. For instance, the company I work for doesn’t distribute needles. Like my church and condoms, there are just some things that it’s not our job to do.

My view on harm reduction, condoms, and suboxone has evolved much over time and I suspect it will continue to do so. I’m not the authority on the subject and you will undoubtedly have your opinions. The facts though, say that we live in a broken world and that there will always be teen sex and opioid use. It is possible, as Christians, to teach that it is healthiest not to engage in those behaviors, while simultaneously participating in efforts to decrease the negative impact of them.