Harm reduction​

Why harm reduction?

Harm reduction challenges the traditional notion of abstinence as a universal treatment goal for problem substance use. It focuses on reducing the harm of drug use to the user and society rather than requiring abstinence as a condition of treatment.

Harm reduction at Sistering, a women's drop-in in downtown Toronto, has many faces and stories. What Is Harm Reduction? is a promotional video in which women explain harm reduction treatment at Sistering.

Definition

Harm reduction refers to policies, programs and practices that aim to reduce drug-related harm without requiring the person to stop using the substance. Harm reduction strategies aim to reduce drug-related harms not just for the user, but also for families, friends and communities. The approach is based on the belief that it is in both the user's and society's best interest to minimize the adverse consequences of drug use when the person is unable or unwilling to discontinue using.

Harm reduction orientations can suggest different choices for different people. Here are some examples:

• Methadone maintenance treatment programs are based on research evidence indicating that when the goals of treatment retention and abstinence appear to be in conflict, it is usually more beneficial to give priority to treatment retention and withdrawal management.
• Psychoeducational approaches focus on providing practical information to help people manage the risks associated with substance use. Topics include safer injection procedures and alternative routes of administration; needle distribution; and infections caused by HIV, hepatitis B and C, tuberculosis and sexually transmitted diseases.

Balancing risk

People often misunderstand the concept of harm reduction and do not realize that this approach to care balances the person's right to self-determination within the broader public health model of care.

Even in abstinence-oriented programs, there are three compelling reasons to introduce harm reduction strategies in the stabilization phase:

• Clients seldom achieve abstinence overnight.
• Relapse is a common event in treatment.
• Some harm reduction strategies have little to do with whether or not the client continues to use the substance.

For clients who are dependent on opioids or substances such as heroin, morphine and codeine, overdose is the immediate danger. Research suggests that educating clients about overdose is an appropriate intervention for harm reduction because it drives empowerment and self-determination.

Harm reduction is not synonymous with legalizing drugs; it is about balancing control and compassion within a framework of respect for individual rights.

Principles of harm reduction

Harm reduction helps care providers to adopt a less judgmental stance in working with clients who continue to use substances while seeking to reduce the stigma associated with the substance use. Harm reduction is built on various guiding principles:

• Pragmatism: Harm reduction accepts that some level of drug use in society is normal, although this assessment varies considerably across different groups of drugs and communities.
• Focus on harms: The focus of harm reduction policy and programs is on reducing harmful consequences of substance use without necessarily requiring any reduction in use because a change in the way a substance is used may also reduce harm.
• Prioritizing goals: Harm reduction prioritizes each person's goals to emphasize immediate, realistic reductions in drug-related harm rather than hoped-for, longer-term outcomes.
• Flexibility and maximization of intervention options: Initiatives are flexible and collaborative to account for the uniqueness of each person.
• Autonomy: The person's decision to use is acknowledged as a personal choice for which the person takes responsibility.
• Evaluation: Initiatives must reduce drug-related harm and priority must be given to policies and programs that demonstrate their effectiveness within the limits imposed by available resources.

Collaboration

• The success of harm reduction approaches is measured in terms of individual and community quality of health, not in consumption levels of the substance.
• A flexible system approach to harm reduction involves collaboration among provincial programs and policy-makers, family members, peers, community organizations, schools and spiritual or religious leaders.
• The opportunity to consider harm reduction initiatives does not always imply controversial dialogue. Many organizations and groups work together to integrate non-controversial harm reduction initiatives covering major topics such as alcohol and smoking.
• Many harm reduction frameworks span multiple levels of society, bringing together individuals, community groups and organizations with a provincial mandate to establish measures designed to identify and reduce harms from substance use.

Related approaches

• client-centred care
• trauma-informed care.

Evidence summary

Ballon, B. (2012). Substance use problems. In A. Khenti, J. Sapag, S. Mohamoud & A. Ravindran (Eds.), Collaborative Mental Health: An Advanced Manual for Primary Care Professionals (pp. 179–194). Toronto, ON: Centre for Addiction and Mental Health.

Brands, M.G. & Marsh, D. (2003). Phases of treatment: Stabilization. In G. Martin, B. Brands & D.C. Marsh (Eds.), Methadone Maintenance: A Counsellor's Guide to Treatment (pp. 99–119). Toronto, ON: Centre for Addiction and Mental Health.

Centre for Addiction and Mental Health. (2002). CAMH and Harm Reduction: A Background Paper on Its Meaning and Application for Substance Use Issues. Toronto, ON: Author.

O'Grady, C.P. & Skinner, W.J.W. (2007). A Family Guide to Concurrent Disorders. Toronto, ON: Centre for Addiction and Mental Health.

Resources

Online resources

• The Canadian Harm Reduction Network is the virtual meeting place for individuals and organizations dedicated to reducing the social, health and economic harms associated with drugs and drug policies.

• Harm Reduction International is a leading non-governmental organization working to promote and expand support for harm reduction and reduce the negative health, social and human rights impacts of drug use and drug policy.

• Ontario Harm Reduction Distribution Program provides harm reduction supplies, educational materials, knowledge translation and exchange opportunities to needle syringe programs across Ontario.

Recommended reading

• Nothing about Us without Us: Greater, Meaningful Involvement of People Who Use Illegal Drugs – A Public Health, Ethical, and Human Rights Imperative summarizes the main issues addressed in the Legal Network's paper on greater involvement of people who use illegal drugs, particularly in Canada's response to HIV/AIDS, hepatitis C and injection drug use. The document also includes a manifesto written by people who use drugs.

• Trauma and Recovery amongst People Who Have Injected Drugs within the Past Five Years was released in 2013 by the Scottish Drugs Forum. The report argues that drug services in Scotland need to be more trauma-minded, focusing less on drugs and more on underlying traumas and life difficulties.

For your clients and their families

• ConnexOntario provides information about treatment for substance use problems. For information about local assessment referral centres, people can call its 24-hour toll-free number at 1 800 565-8603.

• The video-based Life Recovery Program provides a trauma-informed psychoeducation program for addiction and mental health recovery. It offers tools for both people experiencing problems, as well as for their families and other supports.

• The Methadone Maintenance Treatment: Client Handbook, published by the Centre for Addiction and Mental Health, offers information about treatment duration, side-effects, other drugs, counselling, pregnancy, travel, withdrawal and ending treatment.

• The Methadone Registry, maintained by the College of Physicians and Surgeons of Ontario, keeps a list of doctors authorized to prescribe methadone in Ontario. People can call the registry to find a doctor offering treatment in their area. Call 416 967-2600 ext. 661 or email methadoneinfo@cpso.on.ca.

Training

• Harm Reduction is a self-directed tutorial offered by the Centre for Addiction and Mental Health that introduces harm reduction in a substance use and mental health context. The material is intended for people who work in non-clinical roles in these fields, or who have friends or family with substance use or mental health problems.

• York University offers the online Certificate in Harm Reduction consisting of 117 hours of instruction that introduce service providers, administrators and policy-makers to the principles, concepts and practices of harm reduction and critically examine examples of harm reduction work.

A story

From my perspective

My name is Walter Cavalieri. It is through social work that I came to harm reduction. I discovered as I was doing social work that I was actually "doing" harm reduction – at least as I came to understand it, especially through my reading about structural social work – without labelling it as such. Placing the client in a leadership position in the working relationship, seeing the client in a social context, taking seriously the injunction from drug and HIV/AIDS warriors and ethicists of "Nothing about us without us," and using a multi-system approach to problem solving informed and shaped my work.

Implementing harm reduction on the policy, agency and institutional levels, and at the personal and individual levels is simple in concept, but not necessarily so in practice. It is a major struggle to deal with the ignorance, fear and stigma that surround drugs and the people who use them. But it is a struggle that can and must be won if we aspire to attain equity in individual and public health, and in human rights. It requires addressing these barriers on all levels by combining personal, community and agency-based advocacy with the advocacy of people who use drugs.

Here are few thoughts about how to go about this:

Although the current Canadian government does not support harm reduction and removed it from its drug policy shortly after taking office, harm reduction support is often accessible through provincial and municipal governments, who may have built it into their drug strategies or framed it within public health. Organizations and individuals need to advocate policy change to address lapses in harm reduction support and the deadly stigma against people who use illicit drugs.

Harm reduction is a public health approach that supports both individual and community goals. It places the social determinants of health above the attainment of abstinence and is sensible, intuitive and evidence-based. In agencies that house harm reduction programs, all agency personnel should be educated about what harm reduction is (and what it isn't) and its myriad proven successes. Full buy-in is essential, and over time harm reduction can be integrated into other programming.

Harm reduction programs, which include elements such as street outreach, the provision of safer injection and crack-use supplies, methadone maintenance, overdose prevention and Narcan distribution, and drug user groups, should be components of all agencies that deal with marginalized people. Successful programs have a strong peer component, and some are peer-driven, which is ideal.

People working in harm reduction programs must be caring, non-judgmental, respectful, open-minded, and client- and person-centred. They must also be good advocates. They must be committed to social justice and to working from a harm reduction perspective.

At all levels of work, from planning through evaluation, the voice of people with drug use experience needs to be heard.