Harm Reduction Approach to Addiction Treatment

Harm reduction is a pragmatic approach to dealing with substance use disorders. It acknowledges the difficulty of getting someone to quit substances and instead tries to reduce the harm associated with their drug use.

Drug use can be very harmful both to the user and to the people around them; harm reduction policies try to mitigate this harm.

Harm reduction became popular in the UK during the 1980s, during the HIV epidemic. Needle-sharing was a major spreader of HIV for people who injected drugs such as heroin.

So-called ‘shooting galleries’ – places where dozens of heroin users gathered to inject heroin, often using the same needle – could be found in the UK as well as the USA.

This gave rise to needle exchanges: places where drug injectors could bring used needles and replace them with sterile ones. The first needle exchange in the UK opened in 1986, in Peterborough. ^[1]

Needle exchanges were one of the first harm reduction programmes to be enacted in the UK.

Other harm reduction policies, such as drug testing, have become more common since the 1980s. However, harm reduction policies remain somewhat controversial.

Critics say that harm reduction legitimises the use of illegal drugs. Advocates say that people will always use illegal drugs – and harm reduction policies simply reduce the harm associated with this behaviour.

Harm Reduction: a Controversial Approach?

The Brookings Institution recently raised concerns about harm reduction approaches in this blog post. It argued that harm-reduction policies, such as needle exchange programmes and the provision of naloxone, (a drug that can save the life of someone having an opioid overdose), led to ‘unintended consequences’.

It cited studies that found that syringe service programmes (SSPs) reduce rates of HIV transmission but also lead to riskier opioid use. They do so by facilitating ‘easier, cheaper and safer’ heroin use. ^[2]

As for naloxone, one study found that the increased access to this medication led to a rise in opioid-related mortality of 14% in the American Midwest.

The explanation for this, it is argued, is that those who have access to naloxone are more likely to overdose because they believe they have a ‘safety net’ which will save them if they go too far. This is a good example of the ‘unintended consequences’ which can result from harm reduction policies.

There may well be some truth in these criticisms. However, the Brookings Institution does not write off these policies completely. It simply suggests that harm reduction methods ‘should be paired with broad access to substance abuse treatment and alternatives to pain management’.

Principles of Harm Reduction

Harm reduction is based on a set of core principles. These have been outlined in multiple places, including the BC Centre for Disease Control’s Harm Reduction Training Manual: A Manual for Frontline Staff Involved with Harm Reduction Strategies and Services. ^[3]

They are as follows:

• Pragmatism. Harm reduction takes into account the varied nature of substance use, which can range from total dependence to mild use and can cause varying degrees of harm. It also understands that the ‘non-medical’ use of substances is a ‘universal phenomenon’. It suggests that there may be some benefits to this phenomenon, both to the user and society
• Human rights. Harm reduction recognises the rights of people who use substances and suggests that these rights ought to be maintained. It neither condemns nor supports the use of drugs; instead, it emphasizes the right of the drug user to make their own decisions, using their own agency and responsibility
• Emphasis on harms. Harm reduction focuses on the harms caused by drug use, including social, psychological and health-related harms. It argues that these harms need to be addressed, and tries to find pragmatic solutions to achieve this goal. It suggests that a range of solutions may be necessary, depending on the level of dependence manifested by the substance user
• Access to as many intervention options as possible. Harm reduction recognises that every substance user has their own unique circumstances, history and relationship with substances. It argues that substance users benefit from having access to as broad a range of treatment options as possible. This helps people stay safe, and has a positive knock-on effect for the community
• Importance of immediate goals. Rather than stressing the need for every drug user to get clean immediately, harm reduction emphasizes the benefit of substance users having achievable goals. Harm reduction, therefore, begins with ‘where the person is’ in their drug use, and tries to encourage them to achieve a feasible goal for someone in their position. One step at a time is seen as a much better way of approaching addiction treatment since it can be demoralising for a substance user to contemplate the idea of total abstinence from a position of dependence.
• Role of drug users. Harm reduction understands that drug users are often best-placed to offer advice and information about drug use. It attempts to empower drug users to make changes that benefit other drug users, recognising their agency and expertise

Aims of Harm Reduction

Besides a set of principles, harm reduction also has several aims, as outlined by Harm Reduction International on their website.

Their aims are based on the idea that many people across the world simply cannot, or do not want to, stop using drugs.

They are as follows:

• Keep people safe and help them to improve their lives. The most important thing, on the individual level, is to reduce the death toll of drug use and improve the health of drug users. In harm reduction, the emphasis is on ‘facilitating’, or helping people to help themselves, rather than ‘coercing’, or forcing people to do things. This respects the agency of the individual. Furthermore, harm reduction understands that only a minority of drug users experience problematic drug use, and attempts to maximise the advantages that some gain from using substances
• Improve drug laws and policy. Some policies, according to harm reduction, actually exacerbate harms from drug use rather than minimising them. Harm reduction seeks to rectify this. Drug laws and policies which harm reduction deems to be damaging include: the criminalisation of drug users; corrupt policing; failure to provide medical care that could save lives; not allowing drug users access to sterile needles and other paraphernalia; locking people up and forcing them to have urine tests as part of ‘rehabilitation’, and discrimination based on drug use and other characteristics. Harm reduction seeks to improve policy-making at the national and international level with regards drug use and drug users
• Supply alternatives to abstinence-based treatment. For many users with substance use disorders, abstinence-based treatment programmes, including detox, therapy and aftercare, are very important. However, according to harm reduction, not all drug users need treatment, and those that do need treatment may not need abstinence-focused treatment. Some simply do not want to stop using drugs, or cannot stop using drugs. Harm reduction says we should respect people’s wishes and provide them with the support and treatment that is right for their needs. To do otherwise would be coercive and morally wrong. Abstinence from drugs should be treated as a choice, rather than a necessity

Harm Reduction Initiatives

There are several harm reduction initiatives, all of which aim to reduce the harm involved with drug use.

They include:

• Drinking and driving laws. This may not be the first thing to spring to mind when one thinks of harm reduction policies, but drinking and driving laws are actually a good example of a harm reduction policy that has been in place (in the UK) for years. Any amount of alcohol can make someone drive less safely, but it is legal to drive when you have drunk a small amount of alcohol. This is because policy-makers accept that many people drink before driving, and they want to target the worst offenders: people who regularly drink whilst very inebriated. These are the people who do the most damage, and pose the biggest risk to other citizens. By taking a pragmatic approach, it is hoped that more harm can be averted than by taking a more rigorous approach
• Needle exchanges. Needle exchanges provide clean needles for drug users for free. They aim to reduce the transmission of diseases such as HIV, thereby improving the health of drug users. As we have seen, there is some evidence that points towards exchanges leading to an increase in risky opioid use; however, there is also evidence to point towards some health benefits with needle and syringe exchange programmes (NSPs). ^[4] More evidence is needed to ascertain the benefits and drawbacks of these programmes
• Safe injection sites. Similar to needle exchanges, safe injection sites go a step further by allowing drug users to inject at the site, under the watchful eye of medical staff. As well as improving health outcomes by slowing down the spread of HIV, safe injection sites also allow staff to deal with overdoses. If a drug user overdoses at the site, they are much more likely to survive than if they do so in their own homes, where they are less accessible to medical staff. Another bonus of safe injection sites is that they provide a point of contact between drug users and treatment opportunities. If someone is struggling with their drug use, they can speak to people working at these safe injection sites, who will refer them to treatment. The downside of safe injection sites is that it does seem to legitimise drug use to an extent; it might also encourage more drug use, although this is difficult to prove and would require investigation
• Free sexual health supplies. Sexually-transmitted diseases (STDs) are another common problem among drug users. ^[5] By handing out free condoms at safe injection sites or at sexual health clinics, these services aim to reduce the amount of unprotected sex, and, through doing so, the numbers of unplanned pregnancies and STDs
• Drug testing in clubs and at festivals. Recently, several clubs and festivals in the UK have started offering drug testing services through an organisation called The Loop. This was prompted in part by a rise in purity of drugs like MDMA, which can be dangerous for users who are expecting a lower level of purity. Drug testing services like this allow users to ascertain what their drug is, and how pure it is. This helps people to stay safe when taking these substances

Some Tips for Harm Reduction

If you are a substance user who does not want to get treatment – perhaps someone who only uses substances occasionally – then you should still be aware of the dangers of substance use, and be careful when you take substances.

Here are some tips that will help you to stay safe if you do decide to use drugs:

• Always start with a small amount, then work up to a larger amount if needs be. The Loop recommend ‘Crush, Dab, Wait’ when using MDMA: in other words, crush up your pills, dab a little bit on your tongue, then wait for a few hours. This will help prevent an overdose or an adverse reaction to impure drugs
• Make sure to use clean needles, and never share your works
• Don’t mix drugs
• Put friends in the recovery position if they are asleep and have taken drugs.
• Make sure to stay hydrated when dancing – but don’t drink too much water. Drinking too much when you have taken MDMA can be dangerous
• Don’t drive if you have taken drugs
• Never take drugs alone. Tell your friend what you have taken so they can help if something goes wrong

Useful Resources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528824/

A page that looks at the evidence around harm reduction, especially in adolescents.

https://theacademy.sdsu.edu/wp-content/uploads/2019/02/Research-Summary_Harm-Reduction-in-Substance-Abuse-Treatment_April-2018_Final.pdf

A page that takes a detailed look at harm reduction in substance use treatment, including its benefits and disadvantages.

https://www.hri.global/what-is-harm-reduction

This is from the website of Harm Reduction International. It outlines harm reduction, some principles of the approach and its main goals.

References

[1] https://www.exchangesupplies.org/article_history_of_needle_and_syringe_sharing_and_the_development_of_needle_exchange.php

[2] https://www.brookings.edu/blog/up-front/2018/12/07/research-roundup-what-does-the-evidence-say-about-how-to-fight-the-opioid-epidemic/

[3] BC Harm Reduction Strategies and Services. (2011). Harm Reduction Training Manual: A Manual for Frontline Staff Involved with Harm Reduction Strategies and Services. BC Centre for Disease Control (BCCDC). http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/Epid/Other/CompleteHRTRAININGMANUALJanuary282011.pdf

[4] NICE, ‘A review of the effectiveness and cost-effectiveness of needle and syringe programmes for injecting drug users’, Lisa Jones et al., Centre for Public Health, Liverpool John Moores University, 2008.  https://www.nice.org.uk/guidance/ph18/documents/needle-and-syringe-programmes-review-of-effectiveness-and-cost-effectiveness-executive-summary2

[5] ‘Relationship between drug use and sexual behaviors and the occurrence of sexually transmitted diseases among high-risk male youth’, M. A. Shafer et al., 1993. https://pubmed.ncbi.nlm.nih.gov/8108752/

Related posts