The Concept of Harm Reduction and its Application to Alcohol: The 6th Dorothy Black Lecture

Harm reduction has proved to be effective, and has gained increasing official. acceptance in many countries. However, the concept is poorly defined, as virtually any drug policy or programme, even abstinence-oriented programmes, attempts to reduce drug-related harm. The principle feature of harm reduction is the acceptance of the fact that some drug users cannot be expected to cease their drug use at the present time. Harm reduction accords a high priority to short-term realizable goals, but is consistent with a long-term goal of abstention. The trend toward harm reduction in illicit drugs is closely paralleled by a similar trend in alcohol prevention toward measures aimed at reducing the consequences of hea y drinking occasions. Examples of harm-reduction approaches to alcohol are discussed, including measures to reduce non-beverage alcohol consumption by 'Skidrow' inebriates, measures to reduce intake of alcohol by drinkers (e.g. promotion of low-alcohol beverages, server training programmes) and measures to reduce the consequences of intoxication. Increased attention is likely to be given to suck prevention measures, which focus on preventing problems associated with drinking rather than restricting access to alcohol. Public support for controls over the availability of alcohol will continue to decline, as evidence regarding the potential benefits of moderate consumption becomes more widely publicized. Further, the trend to harm-reduction approaches for alcohol is supported by new empirical evidence, including results from a recent Canadian national survey indicating that it may be more efiective to target prevention programming toward reducing kea y drinking occasions rather than the individual's level of drinking.     

What is the role of harm reduction when drug users say they want abstinence?

Quantitative survey data indicate that most drug users starting treatment want abstinence rather than harm reduction (McKeganey et al., 2004). This finding has been seized upon by those seeking ‘evidence’ that abstinence is the bedrock of recovery and harm reduction is a negative and oppositional philosophy. However, all research involves questions of meaning, definition and value and an alternative research paradigm and different study design can provide important additional insights into treatment aspirations, including the desire for abstinence. Qualitative interviews conducted with 30 recovering heroin users (15 males and 15 females) in Southern England in 2009 confirm that those starting treatment often report a desire for abstinence. Nonetheless, drug users are frequently uncertain about their ability to achieve this and can have very different and inconsistent understandings of what being abstinent means. We suggest that the work of the critical theorist [Habermas, 1970] and [Habermas, 1991] could improve our understanding of abstinence and is consistent with recent efforts to achieve a working definition of recovery. Importantly, our qualitative data also reveal that drug users have treatment aspirations that extend far beyond their drug consumption. They additionally want to improve relationships, engage in meaningful activities, acquire material possessions, and achieve better mental and physical health. Moreover, these broader life goals are often inextricably linked to their drug taking. From this, we conclude that both abstinence and harm reduction discourses should more routinely prioritise the many diverse ‘wellness’ goals that so clearly motivate treatment clients. The harm reduction field will then likely find that it has more in common with abstinence-oriented services and the broader recovery agenda than it might otherwise have imagined.     

Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder

BackgroundPeople experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, harm reduction treatment for alcohol (HaRT-A) was developed together with people with lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. A three-month, two-arm randomized controlled trial was conducted to test the initial efficacy of HaRT-A compared to a services-as-usual control condition.MethodsPeople experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Self-reported alcohol use, alcohol-related harm, motivation, and QoL as well as urinary ethyl glucuronide were assessed over a 3-month follow-up. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: a) collaborative tracking of participant-preferred alcohol metrics, b) elicitation of harm-reduction and QoL goals, and c) discussion of safer-drinking strategies.ResultsCompared to control participants, HaRT-A participants reported significantly greater increases in confidence to engage in harm reduction and decreases in peak alcohol use, alcohol-related harm, AUD symptoms, and positive urinary ethyl glucuronide tests (ps < .05). Findings were inconclusive regarding group differences on QoL (ps > .12).ConclusionA low-barrier, low-intensity, patient-driven, harm-reduction approach has at least short-term efficacy in improving AUD outcomes in this population. Future studies are needed to establish its longer-term efficacy.     

Drug prohibition and the treatment system: perfect together

The "War on Drugs" in the U.S. is consistent with the predominance of the abstinence model for treatment and helps legitimate compulsory treatment. Alternative public health approaches such as harm reduction are suspect and devalued. The mission of treatment risks becoming trivialized, primarily focusing on separating individuals from "illicit" psychoactive substances, in perfect accord with current drug policy. The current policy breeds disrespect for law and imposes enormous social and economic costs on society, without demonstrable effects on the availability or costs of "illicit" drugs. Maintaining the policy has become an end in itself, as shown in the disproportionate campaign against marijuana use, but there are signs that the policy is becoming vulnerable. Similarities to the situation at the time of the repeal of alcohol prohibition in 1933 are discussed.     

Drug Prohibition and the Treatment System: Perfect Together

The “War on Drugs” in the U.S. is consistent with the predominance of the abstinence model for treatment and helps legitimate compulsory treatment. Alternative public health approaches such as harm reduction are suspect and devalued. The mission of treatment risks becoming trivialized, primarily focusing on separating individuals from “illicit” psychoactive substances, in perfect accord with current drug policy. The current policy breeds disrespect for law and imposes enormous social and economic costs on society, without demonstrable effects on the availability or costs of “illicit” drugs. Maintaining the policy has become an end in itself, as shown in the disproportionate campaign against marijuana use, but there are signs that the policy is becoming vulnerable. Similarities to the situation at the time of the repeal of alcohol prohibition in 1933 are discussed.     

More-than-harm reduction: Engaging with alternative ontologies of ‘movement’ in UK drug services

Over the last ten years, UK drug policy has moved towards making abstinence-based recovery rather than harm reduction its primary focus. Drawing on ethnographic fieldwork involving participant observations and interviews at two London drug services, we explore how this shift towards recovery materialises through the practices of drug service delivery as an ‘evidence-making intervention’. We understand recovery's making in terms of ‘movement’. Where previous policies performed harm reduction through ‘getting people into treatment’ and ‘keeping them safe in treatment’, new policies were said to be about ‘moving people through treatment’. Approaching movement as a sociomaterial process, we observe how movement is enacted in both narrow ways, towards abstinence from drugs, and more open ways, in what we call ‘more-than-harm reduction’. We think of the latter as a speculative practice of doing or ‘tinkering with’ recovery to afford a care for clients not bound to abstinence-based outcomes. This is important given the limits associated with a recovery-orientated policy impetus. By engaging with these alternative ontologies of movement, we highlight an approach to intervening that both subverts and adheres to perceptions of recovery, embracing its movement, while remaining critical to its vision of abstinence.     

Harm-reduction and zero-tolerance maternal messages about college alcohol use

Past cross-sectional research suggests that zero-tolerance messaging by parents of college students may be more effective than harm-reduction communication at reducing student alcohol risk. The current study employs longitudinal data to examine whether communication type interacts with student alcohol use to predict subsequent drinking outcomes. U.S. college students reported on their own exposure to zero-tolerance and harm-reduction maternal communication. Approximately seven months later, students completed measures of maternal alcohol approval and their own alcohol behaviors. The relationship between communication and subsequent alcohol behaviors depended on students' baseline drinking. For heavy drinkers, harm-reduction communication was associated with less alcohol use and consequences. For those who drank less than two drinks a week, zero-tolerance communication was associated with fewer negative consequences. Zero-tolerance communication was associated with perceiving mothers as less approving, while harm reduction communication was associated with perceiving mothers as more approving. There were indirect effects of communication on drinking through perceived maternal approval. While overall harm-reduction communication may lead students to perceive mothers as more approving of alcohol use, there may be contexts in which this type of communication is beneficial.     

What are drug users looking for when they contact drug services: abstinence or harm reduction?

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying 'abstinence' as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited 'reduced drug use', and 7.4% cited 'stabilization' only. Less than 1% of respondents identified 'safer drug use' or 'another goal', whilst just over 4% reported having 'no goals'. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.     

Will modifying inhalants reduce volatile substance misuse? A review

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying ‘abstinence’ as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited ‘reduced drug use’, and 7.4% cited ‘stabilization’ only. Less than 1% of respondents identified ‘safer drug use’ or ‘another goal’, whilst just over 4% reported having ‘no goals’. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.     

Harm reduction and cannabis social clubs: Exploring their true potential

AimCannabis Social Clubs (CSCs) seek to offer a community-based drug-policy strategy to efficiently reduce the risks associated with cannabis usage. But the actual mechanisms in place to achieve harm reduction have not yet been studied in depth. The goal of our ongoing research is to better understand what kinds of harm reduction practices exist in CSCs and how widespread they are.MethodFor our study we selected 15 CSCs, all members of the Catalonian Federation of Cannabis Associations (CatFac). An on-line survey was designed to collect data on the organizational aspects of each CSC and to focus on the presence or the absence of harm-reduction practices.ResultsThe studied sample had some significant gaps in providing information on risk and harm reduction, in offering health support services for general members and also in applying lab-tests on the actual cannabis being used at the CSC.DiscussionIn order to accomplish their role as harm prevention agents, CSCs need to address these specific gaps. Receiving support from innovative drug policies could be a key factor to actualize their harm-reduction potentialities.ConclusionFurther research on the relationship between organizational and structural factors defining the Clubs and their harm reduction practices must be conducted to encourage brand new strategies that support risk reduction within the CSCs.     

Integrating harm reduction therapy and traditional substance abuse treatment

One-size-fits-all therapy has not worked well for a majority of substance users seeking help. New approaches to substance abuse treatment are desperately needed. Traditional models of service delivery offer little, if any, help to people who may not choose abstinence as a goal. To address this concern, the Bridging the Gap Conference was sponsored by the San Francisco Department of Public Health. The overall goals of the conference were to improve standards of care, develop best practice principles for integrating harm reduction approaches into traditional substance abuse services, and increase the accessibility of quality services to people in need of alcohol and drug treatment. G. Alan Marlatt gave a keynote address on the integration of harm reduction therapy into traditional treatment services, an expanded version of which is presented in this article. Such integration would broaden the scope of services available to a larger group of consumers of substance abuse treatment. Furthermore, harm reduction therapy would infuse traditional treatment practices with scientifically-based pragmatism that pays close attention to individual and community public health needs. Because of its tolerance of treatment goals other than abstinence, harm reduction therapy offers the greatest hope to expand the availability of substance abuse services to people who have not benefited from traditional abstinence-based treatment models.     

Substance use management: a harm reduction-principled approach to assisting the relief of drug-related problems

Disease (particularly HIV) has increased our motivation to reconsider how the current help system deals with drug-related problems. A more concrete focus on disease prevention as an additional goal has, for many, lead to a reevaluation of the goals of drug help work. Such a critical examination shows how much there is to improve within the system even in the absence of blood borne disease. Integrating the heart of harm reduction--respecting work on any positive change as a person defines it for his/herself--into treatment fashions a health sensitive alternative to the predominant practice of abstinence-only assistance for the relief of drug problems. This new approach is called substance use management (SUM), as it no longer requires abstinence but instead focuses on a range of options for improvements while still including abstinence among the possible self-selected outcomes. SUM is suggested as a framework for change within the treatment system that would maximize treatment's constructive impact, cost-effectiveness and maturation as a distinct discipline that can appropriately attract support and gain stature for making society healthier. This article describes a formalized system for applying some of the main principles of harm reduction within the treatment system. Viable options for a SUM treatment focus are suggested herein as well as a critical process, based on respect and collaboration, for use with these options.     

Researching harm reduction--care and contradictions

This paper sets out to identify why research is important in realizing the potential a harm-reduction framework has for informing policy and practice in relation to all psychoactive drugs. In doing so it includes examples of research about alcohol and tobacco, since legitimizing the harm-reduction approach requires strengthening the research foundation across both licit and illicit drugs. There are some practical as well as ethical and theoretical complexities in conducting research in this area, some of which are novel or exaggerated using harm-reduction principles. Potential impediments to research are identified. Articulation of these complexities might help to facilitate research which can help to determine the validity of harm reduction. The notion of the researchers "duty of care" might offer a way of deciding among competing accountabilities, but needs further articulation to be useful. [Translations are provided in the International Abstracts Section of this issue.]     

Cocaine Dependence:

In this study, a cocaine abstinence syndrome is confirmed. Moreoever, the cocaine withdrawal syndrome was found to be medically and psychiatrically benign and required no medication for detoxification in this impatient setting. The 150 patients who underwent cocaine withdrawal did not show the three distince phases of the abstinence symptomatology previously described. No patients required pharmacological intervention for cocaine withdrawal, and the dropout rate was 8% of the 150 cocaine dependents. The common symptoms of acute cessation of cocaine were transient craving, hyperactivity, slight tremor, insomnia, and apprehension. The diagnosis of cocaine dependence alone without an additional drug or alcohol diagnosis was unusual in this study at 5%, as is the solitary use of cocaine also uncommon according to other studies. Studies clearly document the the concurrent and simultaneous use and dependence on multiple drugs and alcohol is present in the majority of treatment populations and common in the general population. As many as 54% of cocaine dependents qualified for alcohol prior to their cocaine dependence. Cocaine dependence appears to be yet another diagnosis in the spectrum of the multiple drug and alcohol dependent.     

The nonmedical use of ketamine, part two: A review of problem use and dependence

This is the second part of a review of the nonmedical use of ketamine. Part one discussed the history of ketamine, the sought-after effects for which it is taken in a nonmedical context, how these are produced, common adverse effects, the ketamine schizophrenia model and the neurotoxicity issue. Part two reviews what is currently known about problem use of ketamine, ketamine dependence, treatment options and harm minimization issues. Some ketamine users become dependent on the drug in a manner resembling cocaine dependence, with craving and a high tolerance but no evidence of a physiological withdrawal syndrome. The likely mechanisms of this dependence are discussed in terms of what is known about the neurochemistry of ketamine, its psychological effects, and published case histories in both the formal and informal literature. The conclusions are that ketamine dependence is linked with effects that this complex drug has in common with not only cocaine and amphetamine but also with opiates, alcohol and cannabis, as well as the psychological attractions of its distinctive psychedelic properties.     

Previous participation in outpatient methadone program and residential treatment outcome: a research note from Hong Kong

Methadone maintenance programs are good examples of harm-reduction efforts because heroin addicts stabilized on methadone have been found to be able to reduce illicit drug use and criminality and improve their life condition, even though they have not achieved abstinence. While excluding the criterion of abstinence allows the harm-reduction approach to distinguish itself from traditional treatment, little research attention has been paid to the relationship between methadone programs and abstinence-oriented treatment programs. This research note reports some of the findings of a study of 77 former male clients of SARDA, a voluntary residential treatment agency in Hong Kong, pertaining to such a relationship. Findings suggest that a client's previous participation in the Outpatient Methadone Program of the Department of Health could facilitate successful outcome in his subsequent participation in SARDA's treatment program and help him to continue his drug-free status in the post-SARDA treatment period. Conceptual and policy implications of the findings are discussed. [Translations are provided in the International Abstracts Section of this issue.]     

Exchange, deceit, risk and harm: The consequences for women of receiving injections from other drug users

Aims: To explore the consequences for women of being injected with illicit drugs.

Methods: In-depth interviews with 45 women injecting drug users who have been injected by other people.

Findings: Women's reliance on others to administer injections meant they had less control over their drug use. Exchanging drugs as currency for being injected was common and women had little choice but to provide the injector with drugs. Being injected by others often caused the recipient physical harm. Previous experience of deception and harm meant women became more knowledgeable about their injector's intentions and subsequently tried to reduce future damage when being injected. Women appeared to be confused about the risks associated with being injected and the perceived risks were often complex and polarized. Understanding the context and nature of being injected is important for services when working with injection recipients.

Conclusions: This work uncovered ideas about a complex area and highlights the importance for those working with drug users to pay attention to this. Increased training and awareness for drug-service staff about factors influencing being injected and the potential associated risks is recommended. Reinforcing current harm-reduction messages and providing related advice to injection recipients is also important. In improving the knowledge and awareness about being injected, women recipients may gain increased choice and agency in the injection process.     

Harm reduction: Come as you are

The purpose of this paper is to describe what harm reduction is, how it developed, how it works, and why it is becoming a major approach in the addictive behaviors field. Based on principles of public health, harm reduction offers a pragmatic yet compassionate set of strategies designed to reduce the harmful consequences of addictive behavior for both drug consumers and the communities in which they live. To illustrate how harm reduction has been applied to both the prevention and treatment of addiction problems, highlights of a national conference on harm reduction are presented. The historical roots of harm reduction programs in Europe (Netherlands and the United Kingdom) are described. The paper concludes with a discussion of four basic assumptions central to harm reduction: (a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addiction; (b) it recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm; (c) it has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “topdown” policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches.     

Gradualism, identity, reinforcements, and change

This paper reflects the ongoing development of gradualism, a drug treatment perspective that seeks to make use of the full array of effective, creative, and innovative harm reduction and abstinence-oriented treatments available to help addicted individuals move along a continuum from active/chaotic use to abstinence or moderation, as appropriate. The essence of gradualism is an emphasis on positive change and transformation as therapeutic goals. The paper first looks at manifestations of gradualism in harm reduction treatment facilities. Following this is a discussion of the role of identity transformation in the change process. The final section explores how contingency management or motivational incentive interventions could be used in harm reduction settings to facilitate this kind of therapeutic movement.     

Living with addiction: The perspectives of drug using and non-using individuals about sharing space in a hospital setting

Hospitals seem to be places where harm reduction approaches could have great benefit but few have responded to the needs of people who use drugs. Drawing on recent theoretical contributions to harm reduction from health geography, we examine how the implementation of harm reduction is shaped by space and contested understandings of place and health. We examine how drug use and harm reduction approaches pose challenges and offer opportunities in hospital-based care using interview data from people living with HIV and who were or had recently been admitted to a hospital with an innovative harm reduction policy. Our data reveal the contested spatial arrangements (and the related practices and corporeal relations) that occur due to the discordance between harm reduction and hospital regulatory policy. Rather than de-stigmatising drug use at Casey House Hospital, the adoption of the harm reduction policy sparked inter-client conflict, reproduced dominant discourses about health and drug users, and highlights the challenges of sharing space when drug use is involved. The hospital setting produces particular ways of being for people who use and those who do not use drugs and the demarcation of space in a drug using context. Moving forward, harm reduction practice and research needs to consider more than just interactions between drug users and healthcare providers, or the role of administrative policies; it needs to position ethics at the forefront of understanding the collisions between people, drug use, place, and space. We raise questions about the relationship between subjectivity and spatial arrangements in mediating the success of harm reduction.