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PubMed1996

The prospects of a harm reduction approach among indigenous people in Canada.

A harm reduction approach to alcohol and substance abuse is becoming increasingly popular as an alternative to prohibitionist and abstentionist policies. It is seen as particularly valuable for some high-risk populations, such as injection drug users and street youth. A strong argument can be made that Aboriginal communities in Ontario, Canada, and probably across the country, are appropriate environments for a harm reduction approach. Aboriginal people are at extremely elevated risk for accident, illness and death. At the same time, alcohol use is a predominant factor in many of these outcomes, and elevates many of the risks associated with Aboriginal life. Isolated, remote reserve communities in northern Ontario present additional risks of extremely poor living conditions and extreme weather conditions. Prohibition and abstinence are currently the main approaches to alcohol and substance abuse in many of these communities, while the role of alcohol in morbidity, mortality and other social problems remains high. There are positive indications that the feasibility of harm reduction strategies could be broached in some communities. It is concluded that the obstacles are significant but a community-by-community approach is a strong feature of harm reduction, and may increase its prospects for piloting strategies in individual communities.

Journal Article↗

PubMed2002

From harm reduction to human rights: bringing liberalism back into drug reform debates.

This Harm Reduction Digest marks a return to theoretical discussions about harm reduction. Andrew Hathaway notes that harm reduction seldom articulates or acknowledges the moral foundation on which it might build to affect meaningful changes in policy. He argues that despite the rhetorical strengths of empiricism, an openly liberal, human rights orientation imbues rational argument with the principles needed to sustain pragmatic drug reform solutions. Liberalism, with its norms of social tolerance and respect for civil liberties, is presented here as key to the future development of harm reduction discourse as a way of advancing human rights themes in contemporary drug policy debates.

Harm Reduction↗

PubMed2003

Harm reduction psychotherapy: extending the reach of traditional substance use treatment.

Harm reduction is a paradigm-shifting idea that has the potential to significantly improve the treatment of problem substance users. The essence of harm reduction is the recognition that treatment must start from the client's needs and personal goals and that all change that reduces the harms associated with substance use can be regarded as valuable. The paper presents harm reduction's rationale, principles, treatment implications, and application to psychotherapy. The author describes his model of Integrative Harm Reduction Psychotherapy, an approach that integrates a strategic skills-building focus with an exploration of the multiple meanings of substance use and the importance of the therapeutic alliance.

Harm Reduction↗

PubMed2004

How do drug users define their progress in harm reduction programs? Qualitative research to develop user-generated outcomes.

BACKGROUND: Harm reduction is a relatively new and controversial model for treating drug users, with little formal research on its operation and effectiveness. In order to advance the study of harm reduction programs and our understanding of how drug users define their progress, qualitative research was conducted to develop outcomes of harm reduction programming that are culturally relevant, incremental, (i.e., capable of measuring change), and hierarchical (i.e., capable of showing how clients improve over time). METHODS: The study used nominal group technique (NGT) to develop the outcomes (phase 1) and focus group interviews to help validate the findings (phase 2). Study participants were recruited from a large harm-reduction program in New York City and involved approximately 120 clients in 10 groups in phase 1 and 120 clients in 10 focus groups in phase 2. RESULTS: Outcomes of 10 life areas important to drug users were developed that included between 10 to 15 incremental measures per outcome. The outcomes included ways of 1) making money; 2) getting something good to eat; 3) being housed/homeless; 4) relating to families; 5) getting needed programs/benefits/services; 6) handling health problems; 7) handling negative emotions; 8) handling legal problems; 9) improving oneself; and 10) handling drug-use problems. Findings also provided insights into drug users' lives and values, as well as a window into understanding how this population envisions a better quality of life. Results challenged traditional ways of measuring drug users based solely on quantity used and frequency of use. They suggest that more appropriate measures are based on the extent to which drug users organize their lives around drug use and how much drug use is integrated into their lives and negatively impacts other aspects of their lives. CONCLUSIONS: Harm reduction and other programs serving active drug users and other marginalized people should not rely on institutionalized, provider-defined solutions to problems in living faced by their clients.

Journal Article↗

PubMed1996

Harm reduction and social policy: should addicts be paid?

Harm reduction principles have not been applied to social policy programs that affect drug users. This paper considers whether income supports for the drug-dependent poor might be harm reducing, given that a principal harm related to drug dependence is crime committed to finance drug use. We examine the political fate of the principal income support program in the United States that targeted the drug dependent. Revelations that the money was being used in part for the purchase of drugs has led to a scaling back and tightening of the program. We suggest that the program might have been more effectively defended if attention had been paid to community harms rather than only to drug consumption by recipients. European and Australian governments provide income support which is no doubt also used for drug consumption, but in the context of universalist income support programs they do not require a harm reduction defense. We conclude that great potential for reducing drug-related harm may fall well outside the domain of targeted drug policy, whether of the supply reduction, demand reduction or harm reduction variety.

Journal Article↗

PubMed2000

"That original tension". Negotiating abstinence in clinicians' accounts of harm reduction in nonresidential treatment of heroin withdrawal.

The aim of this article is to examine how drug and alcohol clinicians, guided by a policy of harm reduction, approach their withdrawal work in their encounter with injecting heroin users seeking nonmethadone withdrawal treatment. The study, qualitative in design, involved detailed interviews with all seven clinicians who worked in the nonmethadone withdrawal program of a nonresidential drug and alcohol center in Melbourne, Australia. I draw attention to the difficulties that these clinicians have in their withdrawal work, especially concerning the place of abstinence in withdrawal and in harm reduction. Abstinence is a legitimate goal of harm reduction. Yet, how harm-reduction knowledge is practiced and reproduced in the clinical encounter is underpinned by dominant and taken-for-granted assumptions about abstinence as 'other' to harm reduction. The ideal of abstinence in drug and alcohol treatment and its decentering within the concept of harm reduction, make introducing harm-reduction strategies in the clinical encounter precarious. The work of withdrawal is compromised with an unresolved tension brought about through the paradox of legitimating illicit drug use in one context (the medical) when it is not legitimate in another context (the sociopolitical).

Adult↗

PubMed2003

Early unsupervised drinking--reducing the risks. The School Health and Alcohol Harm Reduction Project.

The School Health and Alcohol Harm Reduction Project (SHAHRP) aimed to reduce alcohol-related harm by enhancing students' abilities to identify and deal with high-risk drinking situations and issues. The SHAHRP study involved a quasi-experimental research design, incorporating intervention and control groups and measuring change over a 32-month period. The study occurred in metropolitan, government secondary schools (13 - 17-year-olds) in Perth, Western Australia. The 14 intervention and control schools involved in the SHAHRP study represent approximately 23% of government secondary schools in the Perth metropolitan area. The sample was selected using cluster sampling, with stratification by socio-economic area, and involved over 2,300 intervention and control students from junior secondary schools. The retention rate of the study was 75.9% over 32 months. The intervention incorporated evidence-based approaches to enhance potential for behaviour change in the target population. The intervention was a classroom-based programme, with an explicit harm minimization goal, and was conducted in two phases over a 2-year period. The results were analysed by baseline context of alcohol use to assess the impact of the programme on students with varying experience with alcohol. Knowledge and attitudes were modified simultaneously after the first phase of the intervention in all baseline context of use groups. The programme had little behavioural impact on baseline supervised drinkers; however, baseline non-drinkers and unsupervised drinkers were less likely to consume alcohol in a risky manner, compared to their corresponding control groups. In line with programme goals, early unsupervised drinkers from the intervention group were also significantly less likely to experience harm associated with their own use of alcohol compared to the corresponding control group. Unsupervised drinkers experienced 18.4% less alcohol-related harm after participating in both phases of the programme and this difference was maintained (19.4% difference) 17 months after the completion of the programme. This study indicates that a school drug education programme needs to be offered in several phases, that programme components may need to be included to cater for the differing baseline context of use groups, and that early unsupervised drinkers experience less alcohol-related harm after participating in a harm reduction programme.

Adolescent↗

PubMed2006

Tobacco harm reduction strategies: the case for physical activity.

Since the effects of tobacco smoke are so detrimental to health, growing consideration has been given to the development of harm reduction strategies for those smokers who are unable or unwilling to stop using tobacco. The term harm reduction refers to a policy, strategy, or particular intervention that assumes continued use of an undesired behavior and aspires to lower the risk of adverse consequences associated with the continuation of this addictive behavior. Up to this point, tobacco harm reduction interventions have focused on reducing tobacco-related harm through the utilization of innovative tobacco products, reduced tobacco consumption, and pharmaceutical medications. With the possible exception of medicinal nicotine products, these strategies remain unproven and thus far no scientific or medical literature exists to suggest these harm reduction strategies reduce tobacco-related exposure, morbidity, or mortality. Consequently, a need exists for broadening the range of potentially effective harm reduction strategies. This preliminary review suggests that physical activity has the potential to become one such strategy. Of the eight principles that characterize a harm reduction strategy, all are at least partially satisfied by physical activity. Further, emerging evidence indicates that physical activity may delay the occurrence of disease and premature death initiated by tobacco consumption. Significant concerns remain regarding the practicality of physical activity as a harm reduction strategy and the extent to which participation in physical activity may be used to justify continued smoking.

Attitude to Health↗

PubMed2004

Harm reduction and women in the Canadian national prison system: policy or practice?

Applying the principles of harm reduction within the context of incarcerated populations raises a number of challenges. Although some access to harm reduction strategies has been promoted in general society, a divide between what is available and what is advocated continues to exist within the prison system. This paper explores the perceptions and lived experiences of a sample of nationally incarcerated women in Canada regarding their perceptions and experiences in accessing HIV and Hepatitis C prevention, care, treatment and support. In-depth interviews were conducted with 156 women in Canadian national prisons. Q.S.R. Nudist was used to assist with data management. A constant comparison method was used to derive categories, patterns, and themes. Emergent themes highlighted a gap between access to harm reduction in policy and in practice. Despite the implementation of some harm reduction techniques, women in Canadian prisons reported variable access to both education and methods of reducing HIV/HCV transmission. Concerns were also raised about pre-and post-test counseling for HIV/HCV testing. Best practices are suggested for implementing harm reduction strategies within prisons for women in Canada.

Adolescent↗

PubMed1994

Harm reduction: an emerging new paradigm for drug education.

Harm reduction is a new paradigm now emerging in the field of drug education. This strategy recognizes that people always have and always will use drugs and, therefore, attempts to minimize the potential hazards associated with drug use rather than the use itself. The rationale for a harm reduction strategy is presented, followed by an example of the kind of needs assessment which may be needed for planning a harm reduction strategy.

Adolescent↗

PubMed2005

Sex-work harm reduction.

Sex work is an extremely dangerous profession. The use of harm-reduction principles can help to safeguard sex workers' lives in the same way that drug users have benefited from drug-use harm reduction. Sex workers are exposed to serious harms: drug use, disease, violence, discrimination, debt, criminalisation, and exploitation (child prostitution, trafficking for sex work, and exploitation of migrants). Successful and promising harm-reduction strategies are available: education, empowerment, prevention, care, occupational health and safety, decriminalisation of sex workers, and human-rights-based approaches. Successful interventions include peer education, training in condom-negotiating skills, safety tips for street-based sex workers, male and female condoms, the prevention-care synergy, occupational health and safety guidelines for brothels, self-help organisations, and community-based child protection networks. Straightforward and achievable steps are available to improve the day-to-day lives of sex workers while they continue to work. Conceptualising and debating sex-work harm reduction as a new paradigm can hasten this process.

Delivery of Health Care↗

PubMed2004

Harm reduction: a new perspective on substance abuse services.

This article provides information on harm reduction, a recent development in substance abuse services in response to the HIV/AIDS epidemic. The author outlines abstinence and harm reduction perspectives and the stages of change model and discusses how these perspectives can be integrated in social work practice. He proposes using harm reduction strategies for individuals for whom the abstinence perspective may not be appropriate. Together, the traditional abstinence and harm reduction perspectives provide a basis for a more comprehensive continuum of care for individuals experiencing problems related to their substance use.

Harm Reduction↗

PubMed2006

Barriers to the dissemination of four harm reduction strategies: a survey of addiction treatment providers in Ontario.

A sample of service providers at addictions agencies' in Ontario were interviewed by telephone to assess attitudes toward, anticipated internal and external barriers to implementing, and expected benefits of four harm reduction strategies: needle exchange, moderate drinking goals, methadone treatment, and provision of free condoms to clients. Respondents were also asked to define harm reduction, list its most important elements, and describe what they find most troubling and most appealing about harm reduction. Attitudes toward harm reduction in general and the services provided at each agency were also assessed. Results indicated that the service providers surveyed had positive attitudes toward each of the four harm reduction strategies and harm reduction in general, and the majority of respondents were aware of the benefits associated with each strategy. Almost all of the agencies surveyed allowed for moderate drinking outcomes in the treatment of alcohol problems, and most agencies provided free condoms to clients. In terms of barriers, anticipated negative community reaction to needle exchange, methadone treatment, and free condoms was a major concern for the majority of respondents. Lack of staff, of funding, or anticipated staff resistance were also cited as potential barriers to introducing these strategies. In the case of methadone maintenance, the unavailability of a qualified physician was listed as the primary constraint. Implications for future efforts directed at encouraging the adoption of these strategies and suggestions for future research are discussed.

Journal Article↗

PubMed1997

Harm reduction: roads less travelled to the holy grail.

In recent years, a number of countries have embraced harm reduction as their principal philosophical stance and policy platform on alcohol and other drug-related problems. Harm reduction, while argued by some as not being a new concept, has dramatically changed the overall orientation of many health and human service approaches. We argue that as a result many important considerations have been overlooked. This paper explores the merits of harm reduction and examines the limitations and potential pitfalls that may exist in its application in the real world. For instance, where do we position non-drug-use? Such questions are raised in light of the impression perpetuated by some leading practitioners in this field that harm reduction is a global panacea for alcohol and drug problems. Without exploring all possible paths, progress toward our holy grail of minimising the harms and maximising the potential benefits of drug use will be hampered. An integrated model is discussed, which we believe provides an opportunity for wider acceptance and ownership by alcohol and drug stakeholders, politicians and the community.

Alcoholism↗

PubMed2004

Does harm reduction programming make a difference in the lives of highly marginalized, at-risk drug users?

Harm reduction is a controversial model for treating drug users, with little formal research available on its operation and effectiveness. In order to advance the field, we first conducted participatory research of harm reduction with 120 clients using nominal-group technique to develop culturally relevant outcomes to measure progress. Second, we conducted focus group interviews with a different group of clients to help validate the outcomes. Third, we used the outcomes in an evaluation of the largest harm reduction program in New York City, which involved a representative sample of 261 and entailed baseline, post, and six follow-up assessments. The participatory research resulted in outcomes of 10 life areas important to drug users. Evaluation results showed that program participants made positive improvements across most outcomes, with the most substantial progress made in how clients dealt with drug-use problems. Along with their participation in the program, progress in some outcomes was also associated with clients' type of drug use (i.e., stable vs. chaotic), where more stable drug use was associated with better ways of making an income and types of housing. Surprisingly, progress was not associated with the kinds or numbers of services received or the length of time in the program. This was attributed to the service delivery model of harm reduction, in which clients are less inclined to associate their success with a single staff person or with a single service or intervention received than with the program as a whole.

Journal Article↗

PubMed2002

Tobacco harm reduction: promise and perils.

With the tobacco industry developing and test marketing a wide array of modified cigarettes and novel nicotine-delivery products, the era of tobacco harm reduction is upon us. Like today's new technologies, two previous generations of cigarette innovation-filtered cigarettes in the 1950s and low tar and nicotine cigarettes in the late 1960s and early 1970s were introduced to offer smokers an ostensibly less hazardous means of smoking, and therefore an alternative to quitting. Both innovations maintained cigarette sales and consequently may well have increased the morbidity and mortality toll of smoking. Will a new generation of harm reduction products improve the public's health, or will the experience of the past half-century be repeated? This paper examines the concept of tobacco harm reduction and describes the variety of methods employed in pursuit of it. Through an examination of the experience with filters and low tar and nicotine cigarettes, and an explicit consideration of today's issues and challenges, the paper focuses attention on the essential dimensions of the contemporary harm reduction debate: how science can establish whether novel products or methods will reduce risks to health for individual smokers, or at least exposures likely to influence risks; how a determination can be made as to the likely population impacts of the introduction and marketing of novel products; how health professionals and consumers can learn the potential and limits of harm reduction; and what role for governmental regulation is possible and desirable.

Behavior, Addictive↗

PubMed2001

Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature.

AIM: To provide a comprehensive review of the literature on harm reduction theories and strategies related primarily to licit and illicit drug use. BACKGROUND: Although human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) disease transmission is well understood, it continues to spread, particularly among injection drug users (IDUs). Despite early indications that HIV would be contained within the IDU community, it is spreading to non-IDU sexual partners and to children of IDUs, threatening a more widespread epidemic. METHODS: An examination of research studies and theoretical writings including reviews and policy papers published in English between 1990 and 2000. RESULTS: Harm reduction does not seek to eliminate drug use; it focuses on minimizing the personal and social harms and costs associated with drug use and spread of HIV. It seeks to ameliorate conditions surrounding drug use responsible for the spread of HIV in the IDU community: unequal access to health services; sharing of infected needles; racial and social discrimination; poverty; exposure to street violence; inadequate housing; lack of employment; poor general or mental health and other demographic and social determinants. Some controversial harm reduction strategies are described: methadone maintenance programmes, illegal drugs dispensing under controlled conditions, needle exchanges, HIV testing, vein maintenance, safe-sex and would-care programmes. CONCLUSION: The main challenge is to get IDUs to protect themselves against HIV when suffering physical and social privations and addiction needs. Diverse perspectives on harm reduction are problematic with consequences for success of drug use initiatives. Practical, ethical and theoretical complexities exist but further research is needed to build support for a harm-reduction orientation in practice and policy formulation.

Community-Institutional Relations↗

PubMed2006

Impact of joined-up HIV harm reduction and multidrug resistant tuberculosis control programmes in Estonia: System dynamics simulation model.

In Eastern Europe and Central Asia (ECA) the control of tuberculosis, multidrug resistant tuberculosis (MDRTB) and human immunodeficiency virus (HIV) poses important public health challenges. We used system dynamics simulation to determine impact on cumulative HIV/AIDS, tuberculosis and HIV-associated-tuberculosis deaths, over 20 years, of harm-reduction programmes to reduce needle-sharing and injection-frequency amongst injecting drug users (IDUs) and multidrug resistant tuberculosis (MDRTB) control in a population with an explosive HIV epidemic in IDUs and high MDRTB prevalence. We estimate that the number of HIV-associated-deaths will decline by 30% with effective harm-reduction programmes but double if these are ineffective. In our model, effective MDRTB and HIV control reduces cumulative tuberculosis deaths by 54%, cumulative MDRTB deaths 15-fold and cumulative HIV-associated-tuberculosis-deaths 2-fold. Effective MDRTB control, without effective harm-reduction programmes, only reduce tuberculosis deaths by 22%. However, effective harm-reduction programme with a poor MDRTB control reduce cumulative tuberculosis deaths by 34%, MDRTB by 14% and HIV-associated-tuberculosis by 56%. Even with good control programmes for drug sensitive TB, neglecting harm reduction and MDRTB control will result in 50% more tuberculosis-related deaths than if both are effectively addressed. Effective harm-reduction programmes reduces cumulative deaths from tuberculosis more substantively than effective MDRTB control. Our finding have important policy implications for communicable disease policies in post-Soviet countries, which need to substantially change if they are to effectively address the emerging HIV and MDRTB epidemics.

Antitubercular Agents↗