Harm reduction
From Drug Rehab Wiki
Harm Reduction is a philosophy of addiction treatment and the basis for public health policies regarding drug use. Contrary to traditional views which strive for complete abstinence and prohibition of illicit drug marketing, this philosophy focuses on safer drug use if there is not abstinence.
Overview
Harm Reduction policies and approaches include education, prevention and treatment based upon the following beliefs:
• a drug-free society is not a realistic goal
• practical solutions can be implemented to decrease the degree of harm drug use causes
• an array of interventions may be needed to reduce the harm of drug use
• addiction interventions should respect the rights and dignity of those affected by drug use
• treatment not incarceration should be the primary societal intervention for drug use
• some drugs are less harmful than others
• prohibition causes drug-related problems
• drug use prevention should be based on research-based education
A Continuum of Drug Use and a Continuum of Care
Harm Reduction philosophy views abstinence as desirable, but considers drug use treatment along a continuum of goals that will improve the overall well-being of the drug user. Substance use is considered to lie along a continuum from responsible use to the other extreme of dangerous and destructive use. Reducing the risks of HIV or hepatitis infection is an example of a Harm Reduction approach to intervention with IV users who are not yet abstinent. Interventions such as providing sterile syringes and educating active drug users about infection control are common Harm Reduction strategies that significantly expand the traditional role of addiction treatment.
Treatment based upon complete abstinence as its primary and only goal is replaced in Harm Reduction philosophy with treatment that can include abstinence as a goal, but works with addicts at every stage of use in order to optimize health despite ongoing drug use.
Health goals for active drug users can include infection and disease prevention, psychiatric support and the acquisition of shelter, safety and nutrition. Healthcare and other service providers who work with a Harm Reduction philosophy typically attempt to establish a collaborative relationship with clients in which there is mutual participation in goal-setting. Awareness that achieving abstinence or greater safety may involve multiple attempts and the accomplishment of smaller goals in the interim leads to an open door policy in which clients are expected to return for varying degrees of health intervention. A collaborative, non-judgmental and supportive clinical environment in which care coordination among various resources occurs is considered optimal.
Different Drugs/Differing Risks for Harm
Harm Reduction philosophy believes that the harm potential of one drug is not necessarily that of another even if both are considered mood altering and/or addictive. Similarly, Harm Reduction philosophy views the harm of drugs apart from their legal classifications. Many Harm Reduction proponents have supported changes in law and public policy to reflect the pharmacological differences between substances. Public policy supporting Harm Reduction efforts in The Netherlands, for example, resulted in an amended Opium Act in 1976. The amended law distinguished between drugs according to each substance’s risk for harm. In that act, marijuana was considered a “soft drug” with less harmful effects than opiates. In previous legislation, marijuana and opiates were classified similarly.
Other related Harm Reduction views include distinctions between the amounts of a drug used, the frequency of use, the method of use, use in combination with other drugs and individual responses to use. All are considered when determining degrees of harm for individual and relevant treatment interventions. Daily use and IV use, for example, would generally be considered more harmful than occasional and non-injectible use as would the use of several addictive substances simultaneously rather than the use of only one. Additionally, substituting one drug for another, while traditionally viewed as continuing the disease of addiction, may be seen as positive progress in the Harm Reduction model. This would be true if the substituted drug use was less negatively impactful than that it replaced.
The co-occurrence of high risk behavior when using a particular substance, however, may be idiosyncratic for certain individuals such as those who are dually diagnosed. The individualized treatment plans of a Harm Reduction treatment model would target all such factors based upon each individual’s situation.
The Relationship to the Drug vs. the Disease of Addiction
Traditional drug treatment and public policy has focused upon the disease concept of addiction in which total abstinence is seen as the only viable means to remission of an incurable condition. Harm Reduction on the other hand, focuses upon the high risk behaviors involved in substance use and seeks to minimize their impact upon the drug user and society. The addict’s relationship to the drug becomes the target for change. The end result of a less harmful relationship (less harmful use) is significantly contrasted with the traditionally desired outcome of complete abstinence.
While often considered at odds philosophically, in practice the two approaches can work in concert to benefit addicts. Complete abstinence can remain the goal while treatment steps are taken to reduce harm until abstinence is achieved. The Harm Reduction philosophy is considered by many to offer a more realistic and compassionate view of the struggle toward recovery. Harm Reduction interventions allow all addicts access to care despite their level of commitment to abstinence. Consequently, participating in Harm Reduction efforts is considered by many to lead to increased hope for wellness and mobilization of the ability to seek abstinence later.
History of Harm Reduction
Harm Reduction efforts in the U.S. gained momentum in the 1990’s as a social justice movement. This movement was hallmarked by the formation of the Harm Reduction Coalition (HRC) which was founded in San Francisco in 1994. Initially, this coalition was generally regarded as associated with needle exchange programs designed to reduce disease among injecting drug users.
Prior to the founding of HRC, Harm Reduction efforts had been formulated in the U.S. as early as the 1960’s. Nicotine use was cited by the U.S. Surgeon General in 1964 to be linked with cancer and heart disease. Public education that advocated increased safety for smokers included prevention among non-smokers, cessation, reduced second-hand smoke in public places, ‘safer’ cigarettes (low-tar, filters) and the use of nicotine gum.
Another landmark of Harm Reduction occurred in the 1970’s in the Netherlands. There “junkie unions” were first organized to voice the needs of drug users. These activist organizations were collectives of drug users who advocated the end of discrimination and marginalization of addicts, the humane treatment of addicts and the creation of public policy to support more compassionate care. The first such union was created by Nico Adriaans In 1977. Known as the Rotterdamse Junkiebond (Junkie Union), this organization created initiatives for change in the provision of services to the addicted and the level of societal acceptance of the addict. For example, toleration zones, methadone maintenance and the “tippelzone”—an area of Rotterdam where addicted sex workers would be tolerated-- were the result of their efforts. In later years, the need for infection control among addicts resulted in the Union’s distribution of sterile syringes.
Increased concern about infectious disease occurred in the 1980’s and was first focused upon the prevention of hepatitis. It continued through the 1990’s with the worldwide HIV/AIDS epidemic. Harm Reduction attempts focused upon blood borne pathogen education, infection prevention and needle exchange programs for injecting drug users. Other Harm Reduction efforts have supported maintenance therapies such as methadone and in more recent years, buprenorphine; treatment vs. incarceration; the prevention of lethal overdose and access to humane treatment at all stages of addiction.
Needle Exchanges and Safer Injection Programs
Efforts to decrease the health risks of drug users have included needle exchange programs in which used syringes can be traded for new and sterile ones. Some programs have also provided other supplies and services that would lower the risk of infectious disease spread by unsanitary practices among addicts. Supplies have included bleach and sterile water, alcohol swabs, sharp bins for used needles and other sterile provisions for the preparation of injectible drugs. HIV and hepatitis testing, HIV/AIDS counseling and condoms for men and women have also been typically supplied by Harm Reduction services.
Popular opinion and fear that such programs would condone and escalate drug use resulted in needle exchange programs in the U.S. becoming banned in 1988. A covert or ‘underground’ movement has developed in some areas that continue to work toward providing sterile syringes for illicit drug users; however, the possession of syringes without a prescription in the U.S. is a crime. Harm Reduction proponents commonly advocate the decriminalization of syringe possession so that risk of infection is decreased. Generally, Harm Reduction philosophy views the risk of HIV/AIDS as more threatening than the risk of escalated drug use in a decriminalized society. Significant clinical trials have not found needle exchange programs to increase drug use.
Safe Injection Rooms
Several countries, including Canada, Switzerland and Spain, now have programs in which drug users may self-administer injectible substances under the supervision of medical staff. Known as safe injection rooms, these were designed to decrease the number of lethal overdoses among drug users. Typically these facilities are staffed by nurses that do not assist with injections but monitor the safety of participants who inject themselves. Medical assistance is provided in the event of overdose or other medical complication.
Advocates of safe injection rooms propose that such facilities be placed in public health clinics and other facilities that serve addicts such as homeless shelters and drug treatment centers. Freestanding facilities are also supported. While at odds with the legality of possessing and using injectible drugs and syringes, safe injection rooms do operate in countries with such existing laws. This practice exemplifies the pragmatic philosophy of Harm Reduction modalities and their emphasis upon compassionate care for addicts despite their illegal activity.
Alcohol and Harm Reduction
Harm Reduction philosophy considers safer drinking practices to greatly reduce the harmful effects of alcohol use for individuals and society. Such practices include reduced drinking, safe sex practices while intoxicated, use of designated drivers, education, prevention and the support of abstinence for those who choose it. Drinking more moderately and/or more safely is viewed as significantly decreasing the harmful effects of alcohol for both individuals and their communities.
Clinical support of more moderate and/or safer drinking practices offers a treatment orientation alternative to that advocated by more traditional treatment options. Harm Reduction practices also offer alternatives to the more traditional self-help approach to problematic alcohol use. 12 Step groups such as Alcoholics Anonymous view abstinence as the solution to problematic drinking and drug use. Harm Reduction strategies for alcohol use, however, are considered to meet the needs of problematic drinkers who do not desire complete abstinence or who are unwilling to seek abstinence. Treatment based upon Harm Reduction for alcohol use collaborates with drinkers to set treatment goals that move toward minimization of risk and harm. Non-abstinence based treatment goals are considered positive if any incremental progress toward abstinence and/or increased safety is achieved.
Marijuana and Harm Reduction Policies
Harm Reduction efforts emphasis not only harm to the individual user but to society at large. Given this, initiatives designed to decriminalize marijuana are considered to reduce the legal consequences for individuals who use marijuana. Decriminalization of marijuana is also viewed as reducing society’s burden in prosecuting and incarcerating users. Further, Harm Reduction philosophy emphasizes initiatives geared toward treatment efforts and the needs of users rather than prohibition, zero tolerance and the ‘war against drugs’.
Other Harm Reduction efforts involving marijuana concentrate on the health risks incurred by marijuana users. The development of alternative delivery systems that reduce exposure to the harmful effects of smoking are some of the Harm Reduction initiatives involving target marijuana use. Additionally, some proponents of Harm Reduction interventions for marijuana users advocate the provision of marijuana that is higher in THC levels so that users smoke less.
Harm Reduction, Incarceration and the Legal System
The incarceration of drug users has been a longstanding practice resulting from public policies designed to control drug use. The possession of specified substances for use or distribution and in many areas, the possession of drug paraphernalia for personal use, continue to be criminal offenses in the U.S. Harm Reduction policies focus public policy efforts upon the provision of treatment services to drug users rather than upon criminalization. For example, Harm Reduction philosophy targets drug users involved with the judicial system for jail diversion treatment programs designed to address drug use.
An example of Harm Reduction that decreased incarceration of drug users is the Merseyside project in England which began in the 1980’s. Police, clinics and pharmacists formed an alliance to target the heroin epidemic of the area. Syringe exchanges, prescribed injectible and smokable drugs, counseling, housing, employment services and delayed incarceration resulted in significant drops in the rates of HIV infection and crime.
Harm Reduction efforts also address the incarcerated population’s needs since many enter institutions with infectious disease or will contract Hepatitis C and HIV while incarcerated. Prisoners are exposed to high risk sexual behavior, voluntarily and by assault. Further, many who were addicted prior to incarceration continue to use injectible drugs while incarcerated. Non-acceptance of prisoner addiction in public policy is viewed in Harm Reduction philosophy as contributing to the infectious disease epidemic in society at large and to the disregard of the human rights of prisoners. Health initiatives that target the ongoing risks of illicit drug use and high risk sexual behavior in jails and prisons as well as the overall health of prisoners are also the focus of Harm Reduction public policy advocacy. Harm Reduction initiatives for prisoners have targeted limited access to sterile syringes, sharing of syringes, lack of prophylactics and limited access to replacement therapies such as methadone maintenance.
Harm Reduction and Replacement/Maintenance Therapies
The use of replacement and maintenance therapies such as methadone and buprenorphine treatment are now commonly used Harm Reduction modalities. Replacing illicitly used addictive substances with those prescribed and controlled by governmental entities reduces the risk of harm to both individual users and society at large. Programs such as methadone maintenance re-integrate drug users into the community and decrease their associations with ‘black market’ and criminal activities. Replacement and maintenance therapies decrease the criminal activity necessary in the distribution and procurement of illicit substances and the support of habitual illicit drug use. Additionally, such programs provide improved health-related safety for addicts.
Illicitly used substances dramatically increase the risk of lethal overdose and death by poisoning due to lack of dose standardization and lack of purity control. Contamination of illicit drugs is a widespread factor in the medical complications addicts experience. Controlled replacement drugs, however, are regulated for purity and prescribed dosage. Programs provide supervised dosing and ongoing medical monitoring. Additionally, replacement and maintenance therapies engage addicts in treatment services and serve as rehabilitation gatekeepers for many who would not access other drug treatment services.
Other replacement/maintenance therapies such as the Heroin Assisted Treatment (HAT) are gaining credibility. HAT is a maintenance therapy in which clinically controlled heroin is dispensed to addicts. These programs available in several countries including Denmark, Switzerland, The Netherlands, Spain, Britain and Canada, are said to reduce criminal activity and decrease the costs of governmental interventions for illicit use. Studies conducted in Canada and Europe have also found that the overall health of users improve in such programs and that participants are more steadily employed consequently more re-integrated back into society at large.
Harm Reduction and the Dually Diagnosed
Traditionally, treatment for mental health conditions has been separated from that for substance issues. Consequently, individuals with dual disorders often did not “fit” into either program model. A combined and comprehensive therapeutic effort in which both disorders are treated simultaneously by the same care providers has proven to be the most effective approach. Harm Reduction strategies are typically individualized and tailored to accommodate the circumstances and unique needs of individuals with dual disorders. Such individualized treatment leads to improvement of both conditions, greater stability in the community and better use of available services for care. Complete abstinence from substance use, typically required in traditional substance treatment settings, is not always the desired goal for individuals with dual disorders. Many with co-occurring disorders have come to rely on substances to manage symptoms. Consequently, treatment becomes complicated by the intertwining of substance use and mental health management. Additionally, the risk for harm related to mania, depression, psychosis and suicidality requires treatment when abstinence from substances has not been achieved. Harm Reduction strategies designed to minimize immediate harm and work over an extended period toward abstinence are more pragmatic for many who are dually diagnosed.
Harm Reduction, Prevention and Education
Harm Reduction strategies provide prevention and education opportunities for individuals at risk, care providers and the community at large. Collaborative efforts occur in which at risk individuals are engaged in planning positive change for enhanced personal safety and health. At risk individuals are encouraged to participate by identifying problems, needs and solutions. They are also encouraged to participate in creating Harm Reduction strategies and initiatives. Therapeutic approaches are designed to engage participants through open and non-judgmental dialogues in which they are treated with respect as valued members of the community. An emphasis is placed upon mobilizing motivation for whatever positive change the individual chooses.
A broad range of Harm Reduction services address a variety of health and safety issues related to substance use. Some of these include HIV/AIDS, Hepatitis, crime, sex work, gambling, violence, at risk youth and other vulnerable populations, prison life, legislation and public opinion. There are coalitions and organizations that provide education, advocacy, community outreach and program development in all of these areas.
Harm Reduction efforts are found in local, regional, national and international forums that develop, implement and use Harm Reduction strategies. Affiliations with international human rights organizations and health practices organizations are typical for Harm Reduction organizations around the world. Conferences, consortiums, web sites, publications, political initiatives and peer support activities are available and accessible by Internet.
