Defining harm reduction

Harm reduction attempts to reduce the adverse consequences of drug use among persons who continue to use drugs. It developed in response to the excesses of a “zero tolerance approach”. Harm reduction emphasizes practical rather than idealized goals. It has been expanded from illicit drugs to legal drugs and is grounded in the evolving public health and advocacy movements. Harm reduction has proved to be effective and it has gained increasing official acceptance; for example, it is now the basis of Canada's Drug Strategy. However, the concept is still poorly defined, as virtually any drug policy or programme, even abstinence-oriented programmes, attempt 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 is neutral about the long term goals of intervention while according a high priority to short-term realizable goals. Harm reduction should be neutral about legalization. The essence of the concept is to ameliorate adverse consequences of drug use while, at least in the short term, drug use continues.     

Alcohol policy and harm reduction in Australia

With consultations having been held across Australia this year as part of the process of developing a new National Alcohol Strategy, it seemed timely to invite my colleagues from the National Drug Research Institute who are experts in the alcohol field to write this Harm Reduction Digest. The authors have canvassed a range of alcohol policy options and discussed their effectiveness in reducing harm for what is arguably Australia's number one drug problem. Australia's response to alcohol and other drug problems has, historically, been based on ‘harm minimization‐incorporating supply reduction, demand reduction and harm reduction’. At this time where the policy options for alcohol are being set for the next 5 years in a climate of ‘small government’, removing restrictions of ‘fair competition’ in business and a belief in the free market, what does the research have to say about recommended policies and strategies to reduce alcohol‐related harm?     

An evaluation of a harm reduction Summer School for undergraduate health professional students

Aims: The role of health professionals in the provision of harm reduction services is well established in some countries, but not all. We describe a two week course in harm reduction for undergraduate health professionals from a range of countries run in 2014, and provide an account of its evaluation. Methods: Before and after design, with Revised Interprofessional Education Perception Scale (RIEPS) and Harm Reduction Attitude Measurement Scale (HRAS) administered at the start and end of the course, and focus groups at the end of the course to explore perceptions of harm reduction. Findings: Student perceptions of interprofessional learning were generally positive at the start of the course. The only significant change at the end of the course was an improvement in “Perception of Actual Co-operation”. Attitudes towards harm reduction were positive, but there was a significant positive shift in total attitude score at the end of the course. Qualitative analyses indicated that students experienced a shift towards less stigmatising attitudes, and attributed some of this to the experiential visits they attended. Conclusions: An interprofessional harm reduction course can have a positive impact on students’ attitudes towards harm reduction.     

Revisioning women and drug use: gender sensitivity, embodiment and reducing harm

The purpose of this paper is ‘to revision’ our approach to women's use of drugs – which means to let go of how we have seen in order to construct new perceptions. Women use a variety of substances for a range of reasons, including pleasure. Yet, women who experience problems are left feeling stigmatised, marginalised and demoralised. The paper includes three inter-related discussions. First, two co-existing approaches to drug use, the classical and the postmodern, are explained. Second, after demonstrating how the postmodern approach is more valuable for the development of a gender-sensitive perspective, I will, with special reference to drug use, explain the complexities of two contemporary concepts, gender and embodiment. Here, I attempt to generate a deeper appreciation of these concepts in the postmodern approach. Third, I ask, ‘How can we develop a gender-sensitive, harm reduction approach’? The contention is that while harm reduction philosophies are admirable, these need to be gender-sensitive in order to be effective. A multi-levelled, ‘gender-sensitive’ view of harm reduction is put forward, as harm reduction is examined at the subjective, treatment, relationship, occupational and leisure levels.     

The politics of harm reduction in federal prisons

BackgroundWe need to understand better the political barriers to prison-based harm reduction programs. In this paper, I examine the situation in the Correctional Service of Canada (CSC), a federal prison agency with a zero-tolerance drug policy and general opposition to prison needle and syringe programs (PNSPs) and safer tattooing initiatives.MethodsThis study draws on 16 interviews with former CSC senior officials, former frontline staff, and external stakeholders; CSC policy and practice documents; and testimony from a House of Commons Standing Committee public study. Thematic coding and comparison of texts were used to examine emergent themes of interest.ResultsFour interrelated issues were central for understanding the political barriers: a narrower definition of harm reduction used in corrections, both in principle and practice; the Conservative government's tough-on-crime agenda; strong union opposition; and stakeholder perceptions that political constraints will likely persist, including the view that litigation may offer the only way to introduce PNSPs.ConclusionThe system is at an impasse and key questions remain about the importability of harm reduction services into federal prisons. Despite a highly challenging policy environment, moving forward will demand asking new, critical questions and devising more strategic ways of entering the political-operational dialogue that opposes evidence-based programs.     

Assessing community support for harm reduction services: Comparing two measures

Introduction and Aims . Previous attitudinal research has found that the way survey questions are asked can influence respondents’ answers regarding their support for sensitive issues. This study aimed to explore whether findings regarding community support for harm reduction services could be manipulated through priming of language and information contained within survey items. Design and Method. A convenience sample of 260 university students from Sydney Australia were surveyed during late 2008 about their attitudes towards harm reduction services. Participants were randomly allocated to two groups: one received a questionnaire that provided factual information about harm reduction services (Survey 1), while a second group received a questionnaire that contained no information about harm reduction services and framed heroin use as problematic (Survey 2). Results. Participants who completed Survey 1 expressed significantly higher levels of support for harm reduction services overall than participants who completed Survey 2 (t₍₂₄₉₎ = ?5.8, P < 0.001). Regression analysis indicated that overall support for harm reduction services was associated with the survey version that participants received and participants’ political affiliations. These two factors accounted for 17.5% of the variance in the data. Discussion and Conclusions. Research findings regarding community support for harm reduction services are influenced by questionnaire design. This has implications for the development and expansion of harm reduction services and policy.[Hopwood M, Brener L, Frankland A, Treloar C. Assessing community support for harm reduction services: Comparing two measures. Drug Alcohol Rev 2010]     

The definition of harm reduction

Welcome to the Harm Reduction Digest, where in each regular edition of Thug and Alcohol Review invited co-authors will contribute to pieces on the theory and practice of harm reduction. While the focus of subsequent HR Digests will be accounts of the practice of harm reduction interventions, programmes and policies from around the world, it was decided that the first Digest ought to address the definition of Harm Reduction. Consequently the style of this digest is probably more formal than most that will follow it. Many of you will have read DAR's special issue on harm reduction (1995, 14(3)) where Alex Wodak, Bill Saunders, Patricia Erickson, Eric Single and Nick Heather all addressed the issue of definition in their respective contributions. Since this there have been a handful of papers and reports which have also grappled with the issue of definition. Co-author of this piece is Professor Eric Single, from the Department of Public Health Sciences at the University of Toronto. Eric addressed issues around the definition of harm reduction in the 1996 Dorothy Black lecture in London and, with Professor Timothy Rohl, as independent evaluators of Australia's National Drug Strategy, wrote on the topic in their report ‘Mapping the Future’.     

Contested space in the pharmacy: Public attitudes to pharmacy harm reduction services in the West of Scotland

BackgroundInternationally, community pharmacies have become increasingly involved in providing harm reduction services and health advice to people who use illicit drugs.ObjectiveThis paper considers public opinion of community pharmacy services. It discusses attitudes to harm reduction services in the context of stigmatization of addiction and people who use drugs.MethodsThis exploratory study involved twenty-six purposively sampled members of the public, from the West of Scotland, participating in one of 5 focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, none of whom were problem drug users.ResultsThree thematic categories were identified: methadone service users in community pharmacies; attitudes to harm reduction policies; contested space. Harm reduction service expansion has resulted in a high volume of drug users in and around some Scottish pharmacies. Even if harm reduction services are provided discretely users' behavior can differentiate them from other pharmacy users. Drug users' behavior in this setting is commonly perceived to be unacceptable and can deter other consumers from using pharmacy services. The results of this study infer that negative public opinion is highly suggestive of stereotyping and stigmatization of people who use drugs. Participants considered that (1) community pharmacies were unsuitable environments for harm reduction service provision, as they are used by older people and those with children; (2) current drug policy is perceived as ineffective, as abstinence is seldom achieved and methadone was reported to be re-sold; (3) people who use drugs were avoided where possible in community pharmacies.ConclusionsCommunity pharmacy harm reduction services increasingly bring together the public and drug users. Study participants were reluctant to share pharmacy facilities with drug users. This paper concludes by suggesting mechanisms to minimize stigmatization.     

Widening the harm reduction agenda: From drug use to sex work

Harm reduction emerged in the 1980s as a public health response to HIV and injecting drug use. This paper reviews the literature to structure the harms associated with sex work and expand the domains of harm reduction. Sex work-related harms are often rooted in debates where moral arguments and health and criminal justice policies compete for priority. Like drug users, sex workers have a social history in which they have been stigmatised, criminalised, pathologised, and on occasion, celebrated. Yet, by focusing on drug-related harm specifically, the ‘harm reduction movement’ is missing opportunities to better promote health among sex workers. Harms associated with sex work include: the vulnerabilities that may lead to sex work; harms that are introduced by sex work; and mutually reinforcing harms such as problematic drug use. These harms are overwhelmingly concentrated in street sex markets and where sex workers’ pre-existing vulnerabilities can be most exploited. They include predation and victimisation, violence and child abuse, trafficking and slavery, stigma, sanctions and penalties, STIs, exposure to mutually reinforcing harms and public nuisance. Existing interventions and policy developments to reduce these harms are discussed.     

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, hepatitis C and opioid pharmacotherapy: an opportunity for integrated hepatitis C virus-specific harm reduction

While harm reduction advocates, policy makers and practitioners have a right to be proud of the impact of interventions such as needle and syringe programmes on HIV risk, we can be less sanguine about the ongoing high levels of HCV transmission among injecting drug users (IDUs) and the expanding burden of hepatitis C virus (HCV)-related liver disease. In this Harm Reduction Digest Drs Byrne and Hallinan from the Redfern Clinic and Dr Dore from the National Centre in HIV Epidemiology and Clinical Research offer a model of integrated HCV prevention and treatment services within the setting of opioid pharmacotherapy. In their experience, this common-sense approach provides an opportunity to reduce the burden of HCV and improve overall patient management. They believe that the key elements of a HCV-specific harm reduction model include: regular HCV testing; clinical assessment and determination of need for HCV treatment referral; use of broader HCV treatment inclusion criteria; and flexibility in opioid pharmacotherapy dosing. In an environment when our macro harm reduction interventions seem to have, at best, modest impact on HCV transmission, good clinical practice may be our most effective strategy against the HCV epidemic. This paper provides some practical suggestions as to how this can be done.     

Exploring social work student education: The effect of a harm reduction curriculum on student knowledge and attitudes regarding opioid use disorders

Background: This study evaluates the degree to which a harm reduction intervention course module impacted Master of Social Work (MSW) students’ knowledge and attitudes towards addressing opioid use disorder issues and clients. Methods: Using a mixed-methods approach, data from 124 MSW students were collected between 2011 and 2015. Students completed a 3-hour course module that focused on harm reduction philosophy and interventions specifically for opioid use disorders. Students completed pre- and posttest of the Harm Reduction Attitude Scale. Students were also engaged in focus groups to gain a better understanding of how and if their knowledge and attitudes changed. Results: Overall, attitudes towards harm reduction approaches for opioid use disorder shifted favorably following the course module. Paired t-test results show a statistically significant difference in the mean scores for pretest attitudes (M = 2.64, SD = 0.16) and posttest attitudes (M = 2.86, SD = 0.12) among social work students. This trend remained consistent despite treatment orientation and having a family history of substance use. Conclusion: Given the increased capacity for social work students to encounter clients with opioid use disorders, it is important to ensure that students are provided with relevant and accurate information related to client-centered approaches such as the harm reduction model to address opioid use disorders. Moreover, given the dearth of social work programs that have and required substance use disorder courses, it is imperative for schools of social work to ensure that students are provided with more than practical information, which is often gained during field placement.     

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions. [Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2006;25:611 - 624]     

The development of peer educator-based harm reduction programmes in Northern Vietnam

Introduction. Injecting drug use remains an important risk factor for transmission in Vietnam, with an estimated 50% of the 290 000 people living with HIV/AIDS reporting injecting drug use as a risk factor. Despite this, effective harm reduction interventions are generally lacking. This paper describes the implementation of peer-based harm reduction programmes in two rural provinces of Vietnam. Design and Methods. Peer educators were trained in basic HIV prevention, including harm reduction. After significant preparation work with the Provincial AIDS Committees of Bac Giang and Thanh Hoa and other relevant national, provincial and local authorities, the interventions were commenced. Harm reduction interventions were delivered through outreach as well as on-site. This included needle and syringe distribution and collection. Results. Community advocacy occurred throughout the life of the project. Local authorities and peers believed that while there was a general reduction in stigma and discrimination, legal barriers associated particularly with the carrying of injecting equipment remained. This impacted upon the ability of peer educators to work with their clients. Conclusion. Peer-based delivery of harm reduction intervention is acceptable. Harm reduction interventions, including needle and syringe programmes, are feasible and acceptable in these two rural Vietnamese provinces. Community acceptance and uptake of these interventions is key to successful expansion across the region. Active participation by families of drug users seems crucial. This initiative demonstrates that despite a difficult policy environment, peer-delivered needle and syringe programmes are feasible within a rural Asian environment as long as there is adequate local political and community support. [Walsh N, Gibbie TM, Higgs P. The development of peer educator-based harm reduction programmes in northern Vietnam. Drug Alcohol Rev 2008;27:200-203]     

Assembling the dominant accounts of youth drug use in Australian harm reduction drug education

Education programs are a central element of Australian harm reduction drug policy. Considered less judgmental and more effective than the punitive policies of Australia's past, harm reduction drug education is premised on the goal of reducing ‘risks’ and harms associated with illicit drug use rather than an elimination of use per se. In this article I analyse two sets of key texts designed to reduce drug related harm in Australia: harm reduction teaching resources designed for classroom use and social marketing campaigns that are targeted to a more general audience. I identify two significant accounts of young people's drug use present in Australian harm reduction drug education: ‘damaged mental health’ and ‘distress’. I then draw on some of Deleuze and Guattari's key concepts to consider the harm reducing potential these accounts may have for young people's drug using experiences. To demonstrate the potential limitations of current drug education, I refer to an established body of work examining young people's experiences of chroming. From here, I argue that the accounts of ‘damaged mental health’ and ‘distress’ may work to limit the capacity of young drug users to practice safer drug use. In sum, current Australian harm reduction drug education and social marketing may be producing rather than reducing drug related harm.     

Strengthening drug policy and practice through ethics engagement: an old challenge for a new harm reduction

Harm reduction proponents aim to identify and support policies and programmes that moderate or decrease the deleterious consequences of illicit drug use. While harm reduction is clearly a value-based response to drugs, for many, 'ethics' merely represent institutional research and professional practice regulations to be satisfied, subjective moral claims, or philosophy that is too abstract to offer tangible benefits in keeping with the pragmatism of harm reduction. In this paper we revisit the relationship between harm reduction and ethics, reframe ethics as a pragmatic concern for all of harm reduction, and argue that greater attention to the actual values and beliefs underpinning harm reduction can help to enhance policy, practice and research outcomes. Examples are given of early progress in this area to illustrate possible features of ethics engagement in harm reduction, and existing ethics materials are highlighted as suitable supporting resources for applied ethical decision-making in this field.     

From responsible users to recalcitrant dope fiends: Mapping modes of engagement with harm reduction

This article considers individuals' diverse modes of engagement with an increasingly medicalised strain of harm reduction that emphasises individual accountability for personal health and welfare. Drawing upon 1 year of ethnographic research at a New York City-based syringe exchange (“NYC Harm Reduction”, a pseudonym), I describe how drug users themselves made sense of harm reduction, negotiated its discourses of risk and responsibility, and incorporated its behavioural directives into their own body projects – or did not. While suggesting some participants' apparent absorption of risk reduction into a dominant, and enabling identity, I focus mainly upon individuals' “on-stage” performances and apparent depth of service use and acceptance while at NYC Harm Reduction. Building upon recent critiques of contemporary harm reduction's de-contextualised neoliberal subject, I discuss the crucial roles of public housing assistance and peer worker employment in incentivising participants' uptake of pro-risk reduction attitudes, and (presumably) practices. Ultimately, participants' multiplicity of approaches to harm reduction hinged upon differences in not only personality or stage of drug use, but also current living circumstances; moreover, individuals' differential engagement with NYC Harm Reduction reflected the ways in which the organisation and its government funders prioritised the material investment of certain “risky” bodies – namely, HIV-positive drug users.