Running head: RESEARCH PAPER Harm Reduction and Substance Abuse Liberty University Abstract This paper examines how harm reduction is a theoretical model which has been proposed to address the harm which is caused by the behavior of an individual, not only to themselves, but also to the wider community. In particular, it looks at how the model has also provided a potential framework for dealing with substance abuse, and has been adopted in practice in many countries around the world. This paper examines the principals behind the theoretical model, and how these can be applied to successfully treat substance abusers.
Specific applications of the model are also examined to determine how successful certain strategies have been in reducing harm, and how any limitations could be overcome to improve future implementations. Harm Reduction and Substance Abuse Introduction About 200 million people or 5% of the global population are estimated to have used drugs at least once in 2006. Around 2. 7% of the global population use drugs at least once a month, and around 0. 6% are recognized as drug addicted or problem drug users.
It is estimated that currently around 13 million persons worldwide inject drugs and that there is an increasing trend in the numbers of persons abusing cannabis and amphetamine-type stimulants (United Nations Office on Drugs and Crime, 2006). It can be seen from these figures substance abuse is an important issue which needs addressing. However alongside the concerns relating to the number of illegal drug users around the world are a barrage of other concerns. There are many problems which drug addiction causes to both individuals and societies. This includes disease transmission, most notably HIV/AIDS.
The connection between the two is often a direct result of sharing unsterilized injecting equipment among injection drug users. It can also be indirectly a result of drug use, where injecting drug users transmit the disease through sexual intercourse to non users (Schumacher, Fischer and Qian, 2007). It is estimated that injecting drug users have contributed to more than 10% of HIV infections worldwide (UNODC, 2006). The nature by which these types of infections can be spread from drug users indirectly to non-users signify one of the many dangers which can arise in a community as a result of those choosing to use illegal drugs.
Therefore it could be argued that the prevention of such problems is equally, if not more important than addressing the number of people who currently use illegal drugs. Harm reduction is a theoretical model which has been proposed to address the harm which is caused by the behavior of an individual, not only to themselves, but also to the wider community. This model has been developed into many practical applications, ranging from tobacco and alcohol addiction to weight loss. The model has also provided a potential framework for dealing with substance abuse, and has been adopted in practice in many countries around the world.
This paper will examine the principals behind the theoretical model, and how these can be applied to successfully treat substance abusers. Specific applications of the model will be examined to determine how successful certain strategies have been in reducing harm, and how any limitations could be overcome to improve future implementations. Theoretical model There is some disagreement in the literature with regards to the actual components of harm reduction theory. There is no agreement as to the definition of harm reduction as many other terms such as risk minimization and risk reduction are used interchangeably with harm reduction.
There is also disagreement between advocates of harm reduction as to whether imprisonment of drug users for possession is harm reduction, or even whether laws prohibiting drug possession contribute to harm reduction. However there are certain principles to the theory of harm reduction which are generally agreed. Harm reduction is an approach or strategy rather than an actual goal, the aim of which is to reduce or eliminate the negative consequences of drug use rather than eliminate the actual drug use itself.
There is an emphasis on the aim of reducing the adverse consequences among individuals who cannot be expected to cease their drug use at the present time for various reasons (Riley et al. , 1999). The underlying philosophy to harm reduction is that the practitioner approaches the client in a nonjudgmental manner and works to help the client meet goals which have been established personally by the client (Bradley-Springer, 1996). In the harm reduction model, the rights of the individual are of prime importance, which include the client’s rights to dignity and the right to make personal decisions.
Harm reduction includes a holistic, incremental and multidimensional approach to decreasing risks for individuals and communities (Bradley-Springer, 1996). Although the model of harm reduction is contradictory to the traditional abstinence model, it may however be compatible with the eventual goal of abstinence. The model proposes that social support, health assistance, education and disease prevention measures should be maximized for all. It also emphasizes that repressive and punitive measures should be minimized (Bradley-Springer, 1996).
Harm reduction contrasts to the prohibition philosophy, also known as the abstinence model. This model concentrates on increasing interdiction, treatment and prevention efforts, combined with keeping mind altering drugs illegal (DuPont and Voth, 1995). Advocates of this theory often refer to the dramatic decrease in the use of dangerous drugs in the early 20th century which coincided with a substantial tightening of drug laws. Prohibitionists see the drop in the use of illegal drugs in the US over recent years as evidence that prohibition may help reduce drug use and therefore drug harm (DuPont and Voth, 1995).
The basic process of harm reduction consists of providing the client with a continuum of options for their consideration, ranging from the riskiest behavior to the least risky behavior. Presenting the client with this continuum is dual-purpose. Firstly, it allows the client to assess their current behaviors in comparison to both more and less risky behaviors, which may help the client to see where they need to make changes. This is particularly true where a client may perceive their behaviors not to be very high risk, when in reality they rank very highly on the continuum.
It may also help clients to assess where their behaviors have improved or degenerated over time, giving them a means of measuring the changes in their behavior. The continuum also provides the client with a range of behaviors so that they can choose for themselves the most suitable changes based on their personal circumstances (Bradley-Springer, 1996). In order for a continuum to be utilized effectively it is essential that health and social care professionals are able to adopt pragmatic tactics rather than absolute solutions. Environmental effects on the individual
The theory of harm reduction acknowledges that there are various external factors which impact upon an individual and may affect their behaviors in ways which they cannot control, or are difficult for them to control. It is for this reason that one of the underpinning criteria of the harm reduction model is that the individual is allowed to choose their own targets based upon what they feel is achievable under their current circumstances. These environmental factors may take a variety of forms, for instance there could be family related issues or peer related issues which would impact upon any change that the individual tried to make.
There could also be a wide array of socio-economic factors, such as the background or occupational history of the client which must be considered. However as the emphasis of the harm reduction model is based on changing behaviors, the process used will assist the individual in identifying areas of their life which are causing a potential conflict of interest. Use of the harm reduction model would also assist them in forming strategies to enable them to make changes which would facilitate changes to their behavior.
For instance, if it were identified that the client’s behaviors were influenced negatively by their work environment, the client may choose to implement strategies which would reduce this influence, or even end it altogether. However the emphasis would be on the client to choose these changes rather than the professional to insist that these changes are made. With regards to the particular case of substance abuse, advocates of using the harm reduction model acknowledge that there are many environmental factors which influence the behavior of a substance abuser.
Des Jarlais (1995) claims that the use of non-medical, mind-altering drugs is unavoidable in societies which have access to these drugs. He also states that it is inevitable that drugs will cause harm at both individual and societal levels. Des Jarlais claims that drug users form an integral part of the larger community and therefore must be included in measures to protect public health. This cvx mgview of the substance abuser themselves as an integral part of the community is the basis for harm reduction applications. Harm reduction emphasizes that all humans have intrinsic value and dignity (Bradley-Springer, 1996).
Harm reduction strategies aim to protect substance abusers along with all other members of a community. This is in contrast to prohibition models in which the substance abuser is viewed as an individual who must be punished rather than protected. These prohibition models have been described as ‘a simplistic moral solution to complex human problems’ (Griffin, 1998). Harm reduction accepts that some harm is inevitable but that the ideal of zero tolerance excludes compromise and sets goals which are not achievable (Riley, 1998). Time orientation of model
The time orientation of the model is not concentrated in one particular area of time, but instead utilizes the concept of a continuum. This continuum allows the client to view their behaviors in comparison to a whole spectrum of behaviors, both more and less risky than those currently performed by the individual. This allows the client to place their level of behavior on the continuum and assess the levels of risk associated with their behaviors. The continuum also allows the client to assess the ways in which their behaviors over time, by examining the ways in which their behaviors are now different to past behaviors.
This may allow clients to recognize that they have already made some progress toward less harmful behaviors, or may allow them to identify specific events which led to developing more risky behaviors. The harm reduction model allows the client to assess their current situation and plan the actions which they wish to take to change their future behaviors. Applications of the model The harm reduction model has been applied predominantly to drug misuse issues, however it is also appropriate to apply the model for a wide range of social and health behavior changes.
The model has been successfully used in many areas including weight loss, tobacco addiction and alcohol addiction. From the principals it is possible to develop appropriate, situation-specific continua for almost any client who wishes to change behavior and decrease potential harms. Harm reduction has been found to be an effective tool in the treatment of alcohol addiction, due to the accessibility of the model. The model has been successfully used due to the methods by which it addresses problems related to alcohol abuse without requiring complete abstinence from an individual.
Many of those who have failed on traditional abstinence programs such as those promoted by Alcoholics Anonymous have made some progress using harm reduction techniques. The techniques have been successful as they set a series of stepping stones which have been decided by the client themselves. This may lead to full abstinence at some future time, although that decision is left to the individual themselves and not imposed upon them (Witkiewitz and Marlatt, 2006). Strengths and limitations The main strength of the harm reduction model is in the way which the model can be applied in a non-discriminatory way to any area of the population.
The underlying principles are based upon approaching the client in a nonjudgmental way, which should remove many of the prejudices which may be associated with other models. For example some of the groups who are most at risk of harm from substance abuse are those of ethnic minorities and low socio-economic status. There main limitation to the model is that in order for the nonjudgmental principles of the approach to be achieved it is necessary for health professionals to remove any personal stigma or prejudice.
There is no room in the harm reduction model for the personal opinions of the health care or social care professional to allow their personal feelings to become involved in the decisions made regarding treatment. This may be difficult for some professionals, particularly those who have worked for many years in an environment which has promoted other models. For example nurses who have worked in an environment in which they have been encouraged to urge patients to quit smoking may struggle to adapt to a framework in which it is not acceptable to enforce abstinence.
Harm reduction model and substance abuse Harm reduction theories were first applied to substance abuse in the 1920s when a group of English doctors concluded that it may be necessary occasionally to maintain a person on drugs in order to help them lead a more productive life (Riley, 1998). The province of British Colombia in Canada became the first North American jurisdiction to adopt methadone maintenance as a form of harm reduction, with much of North America following in the 1960s (Griffin, 1998).
When HIV infection became a serious threat for injecting drug users, harm reduction strategies became more comprehensive and more holistically based. Harm reduction is quickly taking hold as an alternative to the moral model (exemplified by the ongoing “war on drugs”) and the medical model (addiction defined as disease). These two models have long dominated US drug policy and addiction treatment philosophy. Harm reduction is seen by advocates to be a middle path between the two polarized opposites of the medical and moral models.
It promises to provide practical and humane assistance to drug users, their families and communities. Active drug users have provided much of the impetus for the development of harm reduction including their advocacy in the Netherlands ‘needle exchange’ programs which are designed to reduce the risk of HIV infection among drug users who would otherwise share potentially infected syringes. Critics of harm reduction reject it as being overly permissive in its rejection of strict ‘zero-tolerance’ policies and its promotion of alternatives to abstinence. Some have labeled it a ‘front’ for drug legalization (Marlatt, 1998: 2-3).
Basic principles of harm reduction in substance abuse There are five basic principles which have been identified for harm reduction. It offers a practical alternative to the other models available which focuses on the consequences of harmful behaviors rather than the moral implications. Secondly, harm reduction accepts alternatives to complete abstinence such as needle exchange programs and methadone maintenance. Thirdly, harm reduction is based on consumer input and demand rather than a ‘top-down’ model, which makes drug users more receptive to the model.
Harm reduction also supports low threshold access to treatment and a user-friendly approach. This reduces barriers to treatment and widens access. Lastly, harm reduction is based on compassionate pragmatism rather than on moral idealism (Marlatt, 1999). One of the major differences between harm reduction and other approaches toward substance abusers is that through the harm reduction model they are accepted as individuals who are capable of rational, informed choices. The harm reduction theory accepts hat drug users will choose to reduce harm to both themselves and to society when given the knowledge and the opportunity to do so (Des Jarlais et al. , 1993). The model does not attempt to neither condone nor condemn drug use, but does respect it as a choice (Hilton et al. , 2001). Major guidelines and tools for assessment The model of harm reduction fits with the Transtheoretical Model of Change, which has been proposed as model which reflects behavioral change in an individual. According to this model, the first stage in change is the precontemplative stage.
At this stage, harm reduction strategies should provide a comprehensive assessment of behaviors in a nonjudgmental and supportive atmosphere. This is the stage at which the professional should begin to build a relationship of mutual trust and respect with the client to ensure that they remain approachable to the subject of change despite not having reached the decision to change at this stage. Assessment of the client’s behaviors should be used at this stage to point out problems, raise doubts about behaviors and discuss positive aspects of change.
The second stage of change in the transtheoretical model is the contemplative stage, at which the client intends to change their behavior within the next six months. It is at this stage that the continuum of behaviors should be introduced to identify with the client their current risk of harm. This stage provides an opportunity to discuss the concept of a spectrum of options for change, allowing the client to make decisions about which areas of the continuum they feel capable of achieving under their current personal circumstances. At this point it is important that there is an emphasis on the client’s rights to change their mind.
There should be a thorough analysis of the risks and rewards of the current behaviors, and information should be provided to aid the client in achieving their goals. The next stage in the transtheoretical model is the preparation stage, in which the client is seriously planning change in the next month. The most important factor of harm reduction at this stage is education and skills training specific to the behaviors that the client has identified as acceptable. The fourth stage of the transtheoretical model is the action stage, during which the changes are implemented.
Harm reduction plays an important role at this stage in supporting the change efforts and assisting the client with self evaluation of the changes and progress which is being made towards the chosen goals. At this stage it may be necessary to alter the goals and strategies at the client’s indication. The penultimate stage of change is the maintenance stage, where the changed behavior has continued for at least six months. Harm reduction strategies continue to play an important role in supporting the changes which have occurred.
As the client reaches goals and behaviors change, there should be a reintroduction of the continuum for the client to decide whether they wish to revise the plan and make further changes. The final stage of the transtheoretical model is relapse, in which the client returns to their previous behaviors. This stage is not met by all, only those in which the process has broken down at some stage resulting in return to harmful behaviors. At this stage harm reduction has an important role in supporting the client and ensuring that they begin again rather than accepting their behaviors as inevitable.
Reassessment of the goals and strategies is important to try and identify why they were not reached initially. Syringe exchange program One major example of the application of harm reduction to substance abuse is the creation of needle and syringe exchange programs (NSPs) which can prevent HIV/AIDS infections from spreading by providing users with new, sterile syringes in exchange for used syringes, which reduces transmission through needle sharing. NSPs also provide an opportunity to pass out educational materials and facilitate engagement in formal addiction treatment and other social services.
NSPs provide an opportunity for this through frequent contact with the users and the building of a personal rapport between the support workers at the NSP and the users of the service. Many studies have found that NSPs are effective in reducing injection related risk behaviors as well as reducing incidence of HIV and other blood-borne diseases such as Hepatitis B and Hepatitis C (Hilton et al. , 2001; Bluthenthal et al. , 1998). The first step in application of harm reduction through this process would be the advertisement of the service in the appropriate channels in a bid to encourage a majority of the area’s substance abusers to attend.
The higher the attendance, and the more accessible the service, the more likely that others will choose to attend. The attendance at this service is an indication that those attending are already aware that they are participating in high risk behaviors. It is also an indication that they wish to take action to reduce the risks related with substance abuse without necessarily abstaining from drugs. This highlights those attending such services as particularly suitable for treatment through harm reduction techniques. The second step is therefore to engage these individuals in such a way as to encourage them to proceed further with treatment.
However it must always be acknowledged that the choice to pursue treatment should be the individual’s decision and should not be something which they are told they must do. Once the service user has decided to pursue treatment, the process should proceed as outlined in the previous section. If at any point the service user makes the decision that they wish to leave the treatment program, they should be encouraged to maintain their visits to the syringe exchange program, as this still represents some level of harm reduction.
Syringe exchange is not the only method of harm reduction which has been applied to substance misuse. Provision of opioid substitution has been used safely and effectively for the last 40 years (Johnson et al. , 2000). It has been found that longer-acting oral methadone substitution can effectively suppress use of short-acting opioid drugs such as heroin and can reduce drug injecting and needle sharing practices (Amato et al. , 2005). Greater retention in treatment results in greater decreases in drug use, criminal activity, unemployment and death (Esteban et al. , 2003).
It has been found that psychological counseling and behavioral interventions lead to improvement in more areas when combined with substitution programs and it has been found that combining pharmacotherapy with behavioral therapies has an additive effect on outcomes (Hamers and Downs, 2004). Strengths and limitations of model Harm reduction is an extension of accepted approaches. It improves public health strategies that have limited effect and is frequently operationalized within a health promotion framework. This makes it compatible with evolving public health, epidemiological and population health strategies.
It is compatible with health promotion, which increases peoples’ control both individually and collectively over their health. This is achieved by increasing the participation of individuals and communities in both identifying and modifying risk behaviors present in their environment (Hilton et al. , 2001). This enables people to gain control over their own health environment, which is in keeping with the harm reduction model. One particular benefit of the continuum approach is that individuals who relapse do not necessarily revert all the way back to high risks and unhealthy behaviors.
It is important that if this happens that the client is shown that their failure is not absolute, as this will offer encouragement for the client to set new goals and begin the process again. There is however some limitations in the harm reduction model which remain to be addressed. There are large numbers of health care professionals who characterize drug users in a negative way. Drug users are often seen to be irremediable and receive unequal access to services (Hilton et al. , 2001).
As harm reduction focuses on the needs of marginalized groups, such as inmates and injecting drug users, its adherents can get caught up in other issues. These include poverty, racism and human rights. This can lead to the involvement of politics in decisions regarding funding and can jeopardize community and stakeholder support. Harm reduction programs are often insufficiently coordinated with each other, often overlapping and underfunded. This can lead to a competitive nature between the different harm reduction programs rather than the cooperation which is needed to increase their success (Hilton et al. 2001). Conclusions The advantages of harm reduction include its community driven grassroots-level methodology and its practical commonsense principles which can be interwoven with public health models subscribing to the notion that behavior changes occur in gradual, measurable steps. Harm reduction is designed to minimize the harmful consequences of personal drug use and associated high-risk behaviors. By treating the drug user as a member of the wider community which requires protection from the potential harm caused by drug abuse it ensures that it remains a more user-friendly model for treatment.
This in turn makes the treatment more accessible and increases the likelihood of success. Many countries and organizations have now adopted harm reduction. The World Health Organization (WHO) endorsed harm reduction as a strategy to prevent the spread of HIV as it they considered drug use to be less of a threat to individuals and communities than drug use itself (Riley, 1998). Despite current legislation in many countries which prevents the full adoption of the model as the framework for drug misuse treatment, there are still ways in which the principles can be promoted through treatment.
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