The foundational aspects of harm reduction are:
- to enforce policies that help people, instead of punishing them for using drugs
- to fight for people who use drugs to be treated fairly, with basic human rights
- understand the benefits that people get from taking drugs and why they do it
- to focus on the biggest issues first (harm to society and self rather than abstinence)
For most addiction treatment programs the goal is abstinence, while harm reduction therapy celebrates “any positive change.” The hierarchy of positive change starts with goals that are realistic but not as desirable and works toward goals that are desirable but not always realistic.
Abstinence can be difficult to obtain and maintain. Pushing someone to abstinence when they are not ready or offering abstinence programs when they are not interested may keep them from seeking help in limiting their substance use and making healthier choices.
It may also cause them to hide their drug use, which increases the chance of unsafe practices. Sharing needles and engaging in unprotected sex (a practice that may be increased by drug use) can lead to the spread of disease. Obtaining drugs from disreputable sources and uncontrolled use can lead to overdose.
Harm reduction programs seek to lower these risks by focusing on the harm caused by drug and alcohol use rather than the substance use itself. These programs empower the individual to live a healthier life and encourage safer drug use through various resources and services.
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Syringe Exchange Programs (SEPs)
A major concern addressed by harm reduction programs is the spread of diseases like human immunodeficiency virus (HIV) and Hepatitis C. These diseases are often transmitted through shared needles for injection drug use. Bacterial infections that eat away skin tissue can also result from injecting drugs with unsanitary needles.
Syringe exchange programs, also called syringe services programs (SSPs) or needle exchange programs (NSPs), provide clean needles for injection drug users and safely dispose of used ones. If someone uses a clean needle every time they inject a drug, they do not risk contracting a transmittable disease and their risk for bacterial infection is reduced.
Some of these programs only do a syringe-for-syringe exchange, requiring a person to turn in a used syringe in order to receive a new one. This ensures that all unsanitary needles are properly disposed of, but makes it more difficult for the individual, potentially causing them to reuse the needle several times before returning it. Other programs provide multiple syringes at a time.
Having a place to dispose of syringes in a sanitary way not only reduces disease risk, but also protects law enforcement agents and first responders who may accidentally be stuck with a contaminated needle at the scene of a crime or accident.
Syringe exchange programs may be in a brick-and-mortar facility, or they may be mobile, which allows them to move to where they are most needed. This provides convenient access for people who inject drugs and increases the chance that these people will use their services.
Community outreach is a component in many syringe exchange programs that gets face-to-face with injection drug users to address issues resulting from substance use. Outreach programs may distribute naloxone, a drug used to reverse opioid overdose.
Other services and resources outreach programs may offer could include:
- risk assessment
- disease screening
- information on drugs and disease
- tips for safer injection practices
- cotton and alcohol pads
- bleach (to clean needles)
Harm reduction programs are not against treating the substance use disorder itself. Some of them provide addiction treatment services or referrals to drug rehab facilities. It is important, however, to meet a person where they are, whether they are ready to stop using drugs or not.
Needle exchange programs began in Europe in the 1980s in the hopes of reducing the spread of bloodborne diseases like HIV, Hepatitis B, and Hepatitis C. It has since spread to some larger cities in the United States and is beginning to be used in more rural areas as well.
A 2015 outbreak of HIV and Hepatitis C in Indiana prompted the state to legalize needle exchanges, but several counties have since banned these programs for moral reasons. This public health emergency prompted an examination of disease prevalence in surrounding states and has supported the initiation of syringe services in some of them.
Virginia and Tennessee just passed legislation in early 2018 to allow needle exchange programs. Other states, like Pennsylvania, are still fighting for these programs to become legalized.
The National Institute on Drug Abuse (NIDA) supports syringe exchange programs as a means to connect with people suffering from addiction and encourage them to seek treatment. Studies have shown these programs to be effective in reducing disease transmission and healthcare costs, as it is more expensive to treat HIV than prevent it.
Other Types Of Harm Reduction Programs
The spread of disease and bacterial infection are not the only issues related to substance use. Because of the great amount of damage a person can cause by abusing drugs and alcohol, many programs are in place to address all aspects of harm to the individual and society.
Supervised Injecting Facilities (SIFs)
Supervised injecting facilities offer a safe environment where drug users have access to clean needles and medical monitoring as they take drugs. These facilities are also called safe injection sites, safe consumption spaces, and drug consumption rooms (DCRs). Some allow smoking and other forms of drug use.
These spaces ensure that drugs are administered in a sanitary environment and not taken in excess, which helps to reduce the rate of overdose and provides support if overdose occurs. Sanitary disposal of needles at these sites keeps used drug paraphernalia off the streets where it has the potential to spread disease.
Drug consumption rooms also keep the actual drug use out of the public eye, which decreases the chance of it negatively impacting others. This reduces the risk of spreading infection through shared paraphernalia and does not encourage drug use in people who have not tried it before.
These facilities carry a stigma, as many people believe they support drug use and perpetuate a problem rather than fighting for a solution.
Also, called “drug checking,” this process examines drugs to check for impurities and adulterants. It is popular in many European countries, and is also used in some areas of the United States. Frequently, pill testing occurs at clubs or festivals where ecstasy (MDMA) is present.
Pill testing at an Australian music festival in April 2018 revealed that half of the pills allegedly containing ecstasy were made purely of adulterants like toothpaste, glue, and milk powder. Two of them contained lethal substances. Without pill testing, people would be inclined to hide their drugs and may accidentally overdose or put unknown poisonous substances into their bodies.
When contaminated pills are found, harm reduction programs issue alerts to warn people in the area. These warnings make people aware that the illicit substances they are buying may not be what they think. It also reduces the risk of overdose by prompting individuals to be more careful about where they get their drugs.
Decriminalization Of Drugs
When a person receives criminal consequences resulting from drug possession or consumption, it goes on their record. This can make it difficult for them to find employment later in life when drugs may no longer be an issue. Knowing that they will continue to struggle even if they are successful in a recovery program may prevent people from seeking help or cause them to relapse.
Studies have shown that treating drug possession as a crime does not reduce drug use. Social or civil consequences may be equally effective, while still allowing a person the opportunity to live a normal life without a criminal record.
Civil penalties may include eviction from public housing, discontinuation of welfare benefits, and ineligibility for financial aid. These affect a person’s immediate life and may prompt them to recognize and improve negative behaviors associated with substance use.
Education And Communication
Education and communication use various types of media, such as leaflets, video, and online content to share information related to drug use and safe practices. It may examine side effects, disease symptoms, long-term health consequences, or results of unsanitary injection.
Informational resources may also teach people how to care for their veins, use a tourniquet, and prepare drugs for injection. While these practices are controversial, they are consistent with the idea of gradual improvement.
Sharing information about risks associated with substance use and how to reduce them makes people more aware of how dangerous illicit drug use can be. It also prepares them to deal with and avoid negative consequences such as overdose.
Maintenance treatment, also called replacement therapy, uses a less potent or dangerous substance to help people stop taking an illicit drug. This may be used as part of an addiction treatment program alongside counseling and therapy.
For opioid addiction, methadone or buprenorphine may be administered regularly until a person is ready to live substance-free. These drugs both target opioid receptors in the brain to reduce cravings associated with opioid withdrawal. Both have the potential to be used, but they have been found to be effective in helping people overcome opioid dependence.
People who support abstinence-only treatment programs may view maintenance treatment as trading one drug for another. However, strong cravings lead many people to relapse if they abruptly stop taking opioid drugs and try to remain abstinent.
Slowly weaning off of a powerful opioid by transitioning to methadone or buprenorphine can reduce cravings gradually enough to decrease the chance of relapse. Some people remain on maintenance drugs for years, but the harm reduction philosophy supports this as a safer practice than uncontrolled heroin use.
Prescribed heroin may be drastically different from heroin sold on the street. Illicit heroin is increasingly found to be laced with potent substances such as fentanyl, causing an unprecedented amount of overdose deaths.
The purity of prescription heroin reduces the chance of overdose. If a person does not have to guess how much the drug has been adulterated, they will be better able to regulate doses and only take a safe amount. Prescribed heroin may come with medical support that promotes healthier injection practices.
Along with the philosophy of any positive change, fewer overdoses and injection-related issues means lower health costs, which not only benefits the individual, but society as a whole.
The availability of prescription heroin reduces the demand in the illicit market, lessening the amount of the drug that is trafficked. This has been linked to fewer drug-related crimes, as people can safely get heroin and are less likely to be exploited.
Some people believe that prescribing heroin will bring more people to treatment who are not willing or ready to transition to methadone. They may gradually step-down to methadone treatments and eventually be able to live substance free. Without the incentive of prescribed heroin, some people may not seek help at all.
Motivational interviewing is used in many addiction treatment programs in combination with other therapies. Its goal is to motivate the individual to recognize the need for change and commit to living differently.
Though often used as part of an abstinence-based treatment plan, motivational interviewing supports the idea of “any positive change.” It may encourage people to use drugs less frequently if they admit that substances are interfering with their life. It could also lead to safer injection or consumption practices with the goal of improving health and preventing long-term issues.
Substance Use Management
Substance use management (SUM) is a treatment model that allows a person to be in different stages of recovery without being abstinent. It views healing on a spectrum, and praises any progress, with abstinence as the hopeful (but not necessary) eventual outcome.
This helps people feel less pressure and less like they are failing or ineligible for treatment if they cannot remain abstinent. Substance use management emphasizes that each individual has a human spirit and basic human rights, despite the harm they cause to themselves and others through substance use.
In valuing the individual, substance use management programs hope to build people up gradually, at their own pace. In line with harm reduction beliefs, these programs aim for positive progress. They respect the individual’s timeline and decision to enroll in or leave treatment at any time.
Arguments Against Harm Reduction Programs
Many people disagree with harm reduction initiatives. Some believe that these programs encourage drug use and remove a person’s motivation to seek treatment for addiction.
With safe drug practices, a person is less likely to “hit rock bottom,” the point at which many people enroll in treatment. Instead, they are allowed to remain addicted at a high-functioning level, which may not allow them the quality of life or health they could have without substance use. It may also negatively affect their loved ones and their ability to be productive members of society.
The idea of safe drug practices may also encourage drug use among people who use substances and those who are new to them. Harm reduction programs do not require people to eventually stop using drugs and believe that many people do not need treatment for drug use. This is contrary to the belief of addiction treatment programs that promote complete sobriety.
Some people believe that harm reduction programs have an underlying goal of legalizing drugs. This is an issue of both morality and public health. Some believe that legalizing drugs is wrong because they see drug use and addiction as weakness, while others are against it because of the health dangers it poses for the individual and society.
Others believe that harm reduction does not work and may be concerned about the cost of providing services that allow drug use. Prescribed heroin, for example, is more expensive than methadone. Easier access to heroin may prevent people from transitioning to methadone; they may take advantage of the safer heroin and continue abusing it.
While the cost of harm reduction is a valid concern, the cost of healthcare associated with unsafe drug use should also be considered in this argument, as well as the social and emotional costs of addiction in people who are unwilling to abstain from substance use.
Is Harm Reduction Effective?
Some harm reduction programs have been proven effective. Others are still being researched and tested. It is somewhat difficult to assess the effectiveness of these programs as they may not have a clear end goal, but they can be judged by their ability to produce noticeable positive change.
Syringe exchange programs are considered effective because they reduce the spread of disease from injection drug use. Methadone and buprenorphine have been found to help people gradually recover from opioid addiction and maintain sobriety. These programs are the most widely available harm reduction strategies.
Prescribed heroin, drug decriminalization, pill testing, and drug consumption rooms all have the potential to make a positive change, but do not yet have enough background or support to be widely accepted.
Information, education, and communication are long-standing harm reduction initiatives. They are integrated into many programs for harm reduction and addiction treatment. Awareness of the risks associated with uncontrolled substance use is the first step to reducing disease transmission and overdose as well as improving health and well-being.
Though the goal of harm reduction is not to get a person off of drugs or alcohol, these programs have led some individuals to seek treatment for addiction. The non-judgemental approach can make a person feel less guilty and safe enough to ask for help. Respecting the individual’s right to choose may lead them to make better choices, and one of those choices could be to live a substance-free life.