Harm Reduction in Addiction

For many years, abstinence-based recovery has been the go-to method for helping those struggling with a Substance Use Disorder achieve sobriety and maintain peace of mind. But for the last several decades, in North American and European countries, the idea of harm reduction has gained some steam.  Many in the recovery world are hesitant to embrace the ideas behind harm reduction techniques. Some of them, initially, are not based in complete abstinence. Rather, harm reduction strategies make the process of using drugs safer, in order to extend a drug user’s life and therefore give them additional chances to seek treatment. In this article we are going to cover:

  • What is harm reduction?
  • Harm Reduction Strategies
  • Harm Reduction Principles
  • Timeline of Harm Reduction in the U.S.
  • Controversy Surrounding Harm Reduction
  • Get help for addiction

What is Harm Reduction?

The Harm Reduction Coalition defines harm reduction as a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. This includes anything from Medication-Assisted Treatment like Methadone or Suboxone, clean needle exchange programs, safe injections facilities, Naloxone (Narcan) training, and decreased mandatory minimum sentences for non-violent drug offenders.  Harm Reduction International adds that harm reduction, “focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support.”

Harm Reduction Strategies

Safe Injection Sites

Safe injection sites–also known as supervised injection sites, overdose prevention centers, or drug consumption rooms–are a still uncommon form of harm reduction where drug users have access to clean needles and tourniquets, drug testing supplies and support from clinicians in order to immediately respond if someone overdoses.  Safe injection facilities also offer primary care for those using drugs, provide HIV and AIDS tests, pregnancy tests, immunizations and care for wounds. In addition to preventing overdoses, staff may build rapport with the clientele and eventually convince them to seek treatment for their addiction. Safe injection sites do not provide substances for clientele.  According to the Department of Nursing at University of Southern California, as of September 2018, news outlets have reported zero deaths occurring at safe injection facilities. As many as 70% of the people who register at safe injection sites have no previous connection with healthcare services.  

Needle Exchange Programs

Syringe Services Programs, also known as syringe exchange programs and needle exchange programs, offer services similar to safe injection sites, only without supervision. Many SSPs operate out of vans, or in centers that do not allow for a person to use in the facility.  In SSPs, sterile syringes are provided for those who need them. Used syringes are properly discarded, decreasing the risk for HIV and Hepatitis C infections, among others. According to the Centers for Disease Control and Prevention (CDC) people who take part in SSPs are more likely to seek treatment for their Substance Use Disorder than those who do not.

Medication-Assisted Treatment

Medication-Assisted Treatment is the use of medication in conjunction with therapy to overcome a Substance Use Disorder. Although most MATs are used to combat opioid dependency or overdose, there are also medications to combat Alcohol Use Disorder. MATs include:

Methadone

Methadone reduces opioid cravings, and blocks the effects of opioids such as heroin, prescription painkillers, codeine and morphine. Methadone is an example of an agonist, which blocks opioids by attaching to the brain’s opioid receptors while not activating them. 

Buprenorphine

Buprenorphine (Suboxone) is an example of a partial opioid agonist. When taken at low doses, Buprenorphine decreases euphoric feelings of opioid use and physical dependence. It is usually only prescribed as part of a treatment program including counseling, therapy and support groups. 

Naltrexone 

Naltrexone (ReVia, Vivitrol) is an antagonist, meaning it completely blocks the effects of opioids, including euphoria and pain relief. It is prescribed for both opioid use and Alcohol Use Disorder and is known to decrease cravings. 

Naloxone

Naloxone (Narcan) is an opioid antagonist that is used to reverse opioid overdoses. The drug only works if opioids are present in one’s system. There is no potential for abuse. Doses of Naloxone restore normal breathing to people experiencing slowed or arrested breathing as a result of an overdose. 

Acamprosate

Acamprosate (Campral) is a calcium medication used in conjunction with counseling in order to help people with Alcohol Use Disorder stop drinking. The medication restores balance of neurotransmitters in the brain, therefore reducing cravings for alcohol. Like all MATs, Acamprosate is not a cure for alcoholism. 

Disulfiram

Disulfiram (Antabuse) is an oral medication used to treat chronic alcoholism. The medication is meant to be a deterrent from consuming alcohol or binge drinking. If one drinks alcohol while on Disulfiram, side effects include nausea, vomiting, weakness, anxiety and other unpleasant symptoms.   Opioid Dependence Medications: Methadone, Buprenorphine, Naltrexone Opioid Overdose Prevention: Naloxone Alcohol Use Disorder: Naltrexone, Acamprosate, Disulfiram

Reducing Mandatory Minimum Sentences

After Congress passed the Anti-Drug Abuse Act in 1986, mandatory minimum sentences of five to 10 years in prison for drug possession became commonplace. Although the bill and the use of mandatory minimum sentences were meant to target high level drug traffickers, the amounts of drugs that need to be possessed, in many cases, are much less than what a major drug dealer would have. For example, five grams of crack cocaine results in a mandatory minimum sentence of five years in prison.  There is a large racial discrepancy in mandatory minimum sentencing that disproportionately negatively impacts poor, Black communities around the country.Harm reduction advocates recommend that mandatory minimum sentences either become shorter or abolished in favor of more compassionate, treatment-based addiction care options. 

Harm Reduction Principles

On its website, Harm Reduction Coalition lists the following principles as central to harm reduction practice:

  • Accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.
  • Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.
  • Establishes quality of individual and community life and well-being–not necessarily cessation of all drug use–as the criteria for successful interventions and policies.
  • Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.
  • Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
  • Affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use.
  • Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.
  • Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

Harm Reduction International features its own four principles, including respect for the rights of people who use drugs, a commitment to evidence, a commitment to social justice and collaboration with networks of people who use drugs, and the avoidance of stigma. 

History of Harm Reduction

A timeline produced by the Department of Nursing at University of Southern California states that the first “drug consumption room” opened in 1986 in Bern, Switzerland. Between the 1990s and early 2000s, safe consumption sites opened in the Netherlands, Germany and Australia. In 2003, the first North American safe consumption site, called Insite, opened in Vancouver, British Columbia, Canada.  In 2011, the Supreme Court of Canada ruled that safe consumption sites are exempt from federal prosecution. Although no safe consumption sites currently exist in the United States, major cities such as San Francisco, Denver, Seattle and Philadelphia have considered opening sites.

Controversy Surrounding Harm Reduction

Harm reduction is a controversial topic because the “meet people where they’re at,” philosophy strays from traditional interventions and abstinence-based recovery model that many addiction prevention programs advise. There is similar controversy regarding harm reduction for sexually transmitted diseases, which also traditionally believes that abstinence from sexual activity is the only 100% effective way to stop unwanted pregnancies and spread of diseases. Much of this comes down to the stigma surrounding drug use, as drugs such as heroin, crack and cocaine, though prominently used, are still illegal in the United States.  Others believe that the prevalence of strategies such as safe injection sites, syringe exchange programs and Naloxone training are enabling people to continue using drugs with fewer consequences rather than getting them to stop.  Advocates for harm reduction would point to the fact that these programs and facilities frequently save the lives of people with Substance Use Disorders, providing more opportunities for them to connect to resources and seek treatment.

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