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Definition
While there has been debate in the harm reduction literature about the
limits to which this term is applied (Strang, 1993), most sources would
agree with the core aspect of this definition: "Harm reduction is
any program or policy designed to reduce drug-related harm without requiring
the cessation of drug use." This separates harm reduction clearly
from zero tolerance approaches to drug use. Further, while urgency may
have directed many programs thus far at drug users who are currently experiencing
harm, harm reduction is applied at all levels and all stages of use: "Interventions
may be targeted at the individual, the family, community or society."
While other refinements of the definition emphasize the pragmatic and
proven requirements of effective harm reduction (Single, 1999), we consider
that these ingredients constitute the guiding principles of harm reduction
outlined below. Those who have been instrumental in developing the theory
and practice of harm reduction generally adhere to this basic definition
and underlying themes (Heather et al., 1993), but as in any dynamic movement,
there are ongoing debates about priorities, terms and different program
and policy options.
Empirical assessments have always been central to public health, and
to harm reduction (Ogbourne & Birchmore-Timmey, 1999), though core
values also play a crucial role. In an organization like CAMH, committed
to evidence-based best practice, it is reasonable to require that harm
reduction programs and policies must demonstrate that they have the desired
impact without producing unacceptable unintended consequences. If its
evaluation reveals no support for the reduction of specified adverse consequences,
or shows the unintended consequences are too serious, the program should
not be considered part of a harm reduction approach and other alternatives
should be developed. This may seem like stating the obvious, but in fact
most criminal justice based interventions against illicit drug use are
costly, have no supporting evidence of effectiveness and can be shown
to augment harm to health and social functioning (Inciardi & Harrison,
2000; Single, 1998). The evidence available in support of various strategies
differs widely depending on the status of research funding and the current
priorities of funding agencies. Depending on the intervention under consideration
the approach to evaluation may range from randomized clinical trials to
other methods of social impact analysis (Fischer et al., in press; Heather
et al., 1995; Krausz et al., 1999).
A central tenet of harm reduction that is compatible with CAMH's mission
and client-centered philosophy is the respect for individual decision-making
and responsibility (Cheung, 2000; Marlatt et al., 2001). This is also
a key aspect that distinguishes harm reduction from criminal justice interventions,
which augment stigma and impose punishment as an undifferentiated response
to any level of use (Killias & Rabasa, 1997).
II. Harm Reduction
in Relation to Treatment, Prevention and Enforcement
Harm reduction is incorporated into a wide range of programs for early
and late stage problem users of various substances. At the individual
level, harm reduction policies and programs are offered to those not willing
or able to cease their drug use in the short-run; however, this philosophy
remains compatible with an eventual goal of abstention. Programs requiring
abstinence as an immediate goal cannot be considered harm reduction. Though
not all clinicians agree with this approach, particularly when the client
may be ready to accept abstinence, the clinicians who do practice harm
reduction take a neutral, non-judgmental stance when treating a user "not
ready to quit." These clinicians may still, however, hold views on
the benefits of non-use and view it as a desirable long-term goal.
It is useful to think of a continuum of prevention efforts, geared to
level of use, personal and social characteristics of drug consumers, and
potential for harm. The most basic form of prevention, stopping the problem
before it happens, may be better thought of as total risk reduction rather
than harm reduction. Much of what is considered prevention in harm reduction
involves reducing harms to high-risk users by providing greater access
to services and safer ways to use drugs. Basically, harm reduction education
as a form of prevention emphasizes informed consumers and wiser personal
habits - persuasion over coercion -- rather akin to health promotion.
Prevention may also target the communities in which the drug users congregate,
through initiatives to reduce disorder on the streets and fear of victimization
among the public. When evidence of serious negative outcomes, as has been
well illustrated by the health impacts of smoking, points to non-use as
the most desirable way to reduce harm, some prevention efforts may be
targeted differently at smokers and non-smokers. However, in some settings
such as raves, it is not possible to know who is using drugs and who isn't,
so harm reduction initiatives may target all those attending. Universal
education messages are a general feature of a public health approach to
alcohol and tobacco use and other possibly detrimental "lifestyle"
choices.
Harm reduction is not synonymous with legalization, and in adopting a
harm reduction philosophy CAMH is not expressing support for legalization
(CAMH, 2000). Harm reduction recognizes a balance between control and
compassion within a framework of respect for individual rights. However,
drug policy reform that is compatible with harm reduction initiatives
has already been determined as worthy of support by CAMH (e.g. its official
endorsement of the development of an evidence based cannabis policy, to
replace the present reliance on criminalization of possession).
Enforcement of criminal or regulatory laws may also be directed at reducing
harm (Erickson, 2001; Hellawell, 1995). Although cannabis, cocaine and
opiates are governed by Canadian criminal law while the provinces regulate
alcohol and tobacco, some overlap can occur when drug consumption
is combined with a risky activity (e.g. impaired driving). Public health
perspectives have a greater affinity for regulatory laws over criminal
sanctions. In public health, laws are not moral absolutes, but are instruments
that are used to set standards and achieve health objectives for individuals,
communities and society. In deciding between criminal and regulatory law,
a harm reduction stance asks for proof of what policy components are most
effective for reducing specific drug-related harms. Punitive sanctions
would then be reserved for those drug use behaviours that pose a threat
to the safety or well being of others, such as smoking in offices, selling
to minors or providing a contaminated product. Public health regulation
generally provides more flexibility than criminal law in fitting the solution
to the problem.
Confusion over similar
terms
The lack of an accepted standard definition of harm reduction partly
stems from the multiple terms that are used somewhat interchangeably with
harm reduction: "risk reduction", "harm minimization",
and "risk minimization". The confusion over definitions also
leads some individuals to propose that any drug policy or program designed
to have an impact on harm is therefore harm reduction. This is not the
case; the definition stated above clearly distinguished harm reduction
from other drug use-related interventions imposing abstinence or imprisonment.
We prefer to adhere to the term "harm reduction" and avoid the
others noted above.
What is unique about harm reduction, in contrast to abstinence-based
and criminal justice models, is that it is more use-tolerant and seeks
to reduce the stigma associated with substance use. Some consensus has
been reached on the following guiding principles, articulated by many
writing about the theory and practice of harm reduction. These general
principles may be applied to a number of other areas in public health,
including gambling. It is their application to substance use that identify
them as harm reduction from our perspective.
Guiding Principles
or Underlying Themes of Harm Reduction
Pragmatism
Harm reduction accepts that some use of mind-altering substances is inevitable,
and that some level of drug use in society is normal, though this assessment
varies considerably by country and cultural values. It also recognizes
the considerable research evidence that experimental and controlled use
is the norm for most of those who try any substance with abuse potential.
Harm reduction seeks to reduce the more immediate and tangible harms of
substance use rather than embrace a vague, abstract goal related to some
future ideal like a drug free society. Just as the ongoing debate on cannabis
control policy is at odds with the evidence that cannabis use has become
endemic and unlikely to decline significantly, so harm reduction emphasizes
reducing the harms of criminalization and living with a certain level
of use in society.
Focus on Harms
The focus of harm reduction policy and programs is the reduction of harmful
consequences without necessarily requiring any reduction in use, since
a change in mode of administration or pattern of use may also reduce harm.
Although a lower prevalence of drug use is not the goal of harm reduction,
it may be an outcome that helps reduce harms. These harms may be related
to health, social, or economic factors that affect the individual, community
and society as a whole. The building of community social capital may also
help to reduce the vulnerability of certain populations to the most destructive
forms of substance use.
Prioritization of goals
Harm reduction strategies prioritize each individual's goals with an
emphasis on an immediate and realizable reduction in drug-related harm
rather than hoped for long-term outcomes. Some users' eventual goal may
be abstinence, but they are not required to be drug-free from the outset.
Although the goals of community and individual improvement may sometimes
appear to conflict, the attempt to reconcile them is very different from
victim blaming and punishment of individual users. Harm reduction also
recognizes the central role of the consumer in determining the extent
and nature of health care services.
Flexibility and maximization of intervention options
Harm reduction initiatives are flexible in design that allow for human
variation and the re-evaluation of individual set goals. The reduction
of drug-related harm involves a holistic approach, creativity and innovation.
Harm reduction initiatives should provide a maximum range of options for
users, front line workers, law enforcement officers and others dealing
with drug-related problems. For example, police can have the option of
diverting users to alternative community-based measures; physicians can
offer a variety of treatment options such as drug substitution, drug maintenance
and interventions that adopt safer methods of use.
Autonomy
Given some level of drug use in society is accepted as normal, the drug
user's decision to use is also acknowledged as a personal choice, for
which they take responsibility. Since the use of drugs is not intrinsically
immoral, sick, or criminal, drug users are not stigmatized as deviants,
since "drug users are people too." The user is as an active
rather than passive entity, illustrated by the fact that many harm reduction
programs have originated with drug users themselves. Reintegration is
emphasized over social exclusion. This has been expressed eloquently by
the Aboriginal Community: "The philosophy of harm reduction encourages
us to reach those outside of the circle and welcome them back in...[we]
recognize that everyone in the circle is affected and thus has a responsibility
to make this circle whole." (Aboriginal Peer Project, 2000).
Evaluation
In practice harm reduction initiatives must reduce drug-related harm
and priority must be given to those policies and programs that demonstrate
their effectiveness within the limits imposed by available resources.
Innovation and creativity must be encouraged within a harm reduction philosophy
but it is also imperative that evaluation of existing programs be conducted.
Current and future programs and policies should have clearly stated mission
statements, goals and an identification of what "harms" are
being addressed so that thorough evaluations of their effectiveness can
be conducted. Both the health and functioning of the individual and the
net impact on harm indicators in the community are important indicators
of the success of harm reduction.
IV Evidence, Needs
and Future Directions
This section provides some illustrations of how harm reduction has been
utilized, and with what results, in several areas of CAMH's work. As well,
we will indicate some areas in which we believe more research is needed,
plus some new topics that could be pursued within a harm reduction mandate.
An extensive bibliography covering general and major topic areas follows.
While many people think of harm reduction initiatives in relation to
controversial proposals such as that for safe injection rooms, many well
established programs in the alcohol area take harm reduction for granted.
ARF, and now CAMH, have undertaken a number of individual, community and
broader policy programs directed at "identifying those circumstances
in which harm occurs and acting to reduce those harms." Underlying
them is the respect for individual choice that recognizes that most persons
consume alcohol responsibly and derive benefits from doing so. Some initiatives,
including impaired driving laws and their enforcement, alcohol control
policies which focus on availability and cost, server intervention and
graduated licensing programs, have been extensively evaluated over some
years (Bondy et al., 1999; Mann et al., 2001; Narbonne-Fortin et al.,
1997). Other newer ones, such as "Safer Bars," are being examined
as a way to reduce violence in public drinking establishments. Others
like "First Contact" try to reduce consumption, targeting youth
as new drinkers who may experience increased risk even at lower levels
of consumption. While many people working in the alcohol field may not
have identified their activities as harm reduction a decade or two ago,
now there is a considerable literature around alcohol and harm reduction
(Single, 1997).
Like other drugs, tobacco does not lend itself to "absolutely safe"
levels of use or circumstances. The reality of its legal availability
means that reducing some of the risks of use both for those smokers who
will not or cannot quit, and for those in their vicinity, is a quest for
harm reduction. Much of past ARF and OTRU research has monitored changes
in consumption, especially among the younger cohorts, and led to policy
recommendations for higher prices and less attractive advertising. Some
initiatives like nicotine gum and patches could lead to significant harm
reduction, but have not as yet been shown to appeal to substantial numbers
of smokers. The reasons for this and ways to improve their utilization
could be important new research directions in harm reduction for tobacco
(IOM, 2001).
Many initiatives in the community, by CAMH staff and stakeholders, have
covered the whole gamut of substances and diverse target populations.
Certainly the increased availability of methadone, particularly at the
low threshold level, has been a long-standing and successful harm reduction
program in which CAMH has been a major player (Fischer, 2000; Brands et
al., 2000). The real possibility now of other forms of opiate substitution
trials in Canada builds on its successes (Kuo, 2000). The research on
HIV transmission among injection drug users in Toronto and the province
tends to have fallen more to the Public Health Sciences Department at
U of T, though often with collaborators at CAMH. Ongoing evaluation of
needle and syringe exchange, at both the client and agency levels, is
crucial in order to improve the system and also to understand the users'
reasons for compliance and non-compliance. The support given to groups
aimed at creating safer rave venues is also noteworthy, but in need of
more evaluation (Weber, 1999). Although a substantial body of research
on cocaine and crack use has been done by CAMH researchers (Erickson et
al., 1994), little progress towards harm reduction for this substance
has been accomplished to date. Community based initiatives like the "crack
kit" is one recent proposal that shows promise but has not yet been
evaluated. One point emphasized in our group is that CAMH staff often
have the opportunity to partner with community contacts to develop harm
reduction tools, but finding the resources to also provide evidence of
effectiveness can be difficult. Hence, many possible strategies go unevaluated
and "lost" to the larger community of harm reduction.
The treatment of substance use disorders is a vast area that encompasses
many established and new approaches (Skinner & Drake, 1997). The distinctive
contribution harm reduction makes is in it's commitment to a client-centred
"therapeutic alliance." The therapeutic alliance is an agreement
between a client and their clinician about the treatment approach to be
taken based on the expressed needs and desires of the client.) Grounded
in the knowledge that their very relationship has the power to facilitate
positive change, the health care professional accepts that the client
may make less than optimal choices for their health in the short term.
Yet by respecting these choices and being available to deal with their
consequences, the therapist intentionally strengthens the therapeutic
alliance. Rather than seeing this as enabling the client to keep harming
himself, the therapist understands that he or she cannot realistically
prevent a client from making particular choices at the given moment. But
by keeping the door open and helping to ameliorate adverse consequences
when they occur, the clinician can strengthen the motivation of the client
to behave in a less harmful way, and facilitate their engagement in further
treatment when the client is ready to move closer to a less harmful pattern
of use or abstinence.
From a more general addiction treatment perspective, harm reduction oriented
programs have for some time offered the client goal choice, from abstinence,
to the reduction in use of their primary drug, to abstinence from their
primary drug but continued use of other drugs. The relapse policy has
been that a single lapse, several occasions of use, or a return to more
regular use is not regarded as a reason to exclude or discharge a client
from treatment. The review of treatment goals is therefore ongoing between
client and therapist.
Although harm reduction is implicit in much of the practice in mental
health, it is not a generally used term in the field. However, it does
have some direct applicability in the area of concurrent disorders. Clearly
a significant proportion of mentally ill individuals consume alcohol and
other drugs for a variety of reasons, but this is an area in need of further
elaboration and research. Since many in this co-morbid population are
poor, homeless, under-housed and otherwise marginalized, this is an area
that touches on the broader potential of harm reduction as a response
to the inequities of health and social policy.
A considerable amount of past ARF and current CAMH research has focused
on illicit drugs and the role and impact of the criminal justice system.
Given that one of the serious harms of cannabis use is the potential acquisition
of a life-long criminal record, evaluating its impact on cannabis offenders
has been an important component in supporting the case for the modification
of penalties and the elimination of the offence for possession (Erickson,
1980). The scope of research gaps and opportunities remains large. Any
new legal measures introduced by the federal government could continue
the CAMH tradition of socio-legal evaluation of drug policy. Recommending
harm reduction strategies for cannabis that might be accepted by users
would require research on its long-term health impacts. Drug treatment
court as an initiative to keep seriously dependent users out of prison,
provide treatment, and help to integrate them back into the community
needs to be further evaluated (LaPrairie et al., in press). The implementation
and evaluation of harm reduction strategies for drug use in prison is
another area of concern to be pursued. The issue of inmates who are denied
methadone treatment, regularly use contaminated injection equipment and
expose themselves and others to diseases is too serious to be ignored.
Conclusion
Harm reduction is thriving in its second decade of diffusion and widespread
application, and is integral to numerous programs at the Centre for Addiction
and Mental Health. In the field, greater consensus is emerging on the
boundaries of the concept and the behaviours to which it may legitimately
be applied. Nevertheless, we recognize the limitations of harm reduction
and do not expect it to be all things to all people. In our commitment
to client-centred care, harm reduction remains but one approach in a broader
spectrum that also embraces programs with an abstinence-based philosophy.
While our primary task is to inform the CAMH audience, provoke discussion,
and build consensus on how we use the term within our own organization,
we also hope that the community at large will be prompted to engage us
in further dialogue.
Although there is a growing body of empirical evidence endorsing various
harm reduction approaches, more research is required on both some of the
established, as well as the newer and more controversial interventions
whose aim is to reduce the harm associated with alcohol and drug use.
There is evidence that programs that reduce the short and long term harm
to substance users benefit the entire community through reduced crime
and public disorder, in addition to the benefits that accrue from the
inclusion into mainstream life of previously marginalized members of society.
The improved health and functioning of individuals and the net impact
on harm in the community are notable indicators of the early success of
harm reduction. CAMH believes that public policy should be guided by the
principles outlined in this paper to support innovative strategies that
most effectively respond to the needs of substance users and their communities.
CAMH therefore calls on government and other relevant agencies to fund
the development, trial, evaluation and implementation of a full range
of harm reduction programs to be included among other proven successful
interventions for those with substance use problems.
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