Despite the growth in the use of the term, the meaning, practice and implications
of harm reduction are matters of some dispute. CAMH, with its involvement
in a broad range of harm reduction initiatives and programs, sought to
find internal consensus on this concept. CAMH believes that harm reduction
can help circumvent the stigma associated with substance use and that
it represents a pragmatic approach to managing addiction. It believes
that directing resources at empirically proven successful interventions
will result in better individual outcomes and greater systemic accountability.
In its unbiased commitment to client-centred care and partnership in treatment,
harm reduction is one approach that is offered within a broader spectrum
that includes programs with an abstinence-based philosophy.
A CAMH ad hoc committee was formed to seek consensus for a working definition
of harm reduction. This broad-based group examined the meaning of the
term and its practical application to their diverse areas of work at CAMH,
including treatment, prevention and issues of enforcement. Consensus was
reached on the definition and principles outlined below, although no claim
is made that it represents a universally acceptable perspective for what
remains a broadly applied concept.
Definition
Harm reduction is any program or policy designed to reduce drug-related
harm without requiring the cessation of drug use. Interventions may be
targeted at the individual, the family, community or society.
Not all interventions intended to minimize the adverse consequences of
substance use are harm reduction. 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.
The primary focus of harm reduction is on people who are already experiencing
some harm due to their substance use. Interventions are geared to movement
from more to less harm. Examples of proven harm reduction programs are:
server intervention programs which decrease public drunkenness; needle
and syringe exchange programs which prevent the transmission of HIV among
injection drug users; and, environmental controls on tobacco smoking which
limit the exposure to second hand smoke.
Guiding Principles
CAMH proposes the following guiding principles be used to guide the development
and assessment of harm reduction programs and policies.
Pragmatism
Harm reduction accepts that some level of drug use in society is inevitable
and normal, though this view varies widely according to culture and cultural
values. Harm reduction seeks to reduce the more immediate and tangible
harms rather than embrace a vague, abstract goal related to some future
ideal like a drug free society.
Focus on Harms
The focus of harm reduction policy and programs is the reduction of harmful
consequences of substance use without necessarily requiring any reduction
in use. These harms may be related to health, social, or economic factors
that affect the individual, community and society as a whole.
Prioritization of goals
Harm reduction strategies prioritize each user's goals with an emphasis
on immediate and realizable goals. The eventual goal may be abstinence
but the user does not have to begin this way. Where community and individual
goals appear to conflict, there is an attempt to reconcile them.
Flexibility and maximization of intervention options
Harm reduction initiatives are flexible in design, in recognition of individual
differences and the reevaluation of individual set goals. They provide
a maximum range of options for intervention, such as diverting users to
alternative community-based measures and a variety of treatment options
such as drug substitution, drug maintenance and interventions that adopt
safer methods of use.
Autonomy
The drug user's decision to use drugs is acknowledged as a personal choice,
for which they take responsibility. Drug users are not stigmatized as
deviants. The user is an active rather than a passive entity in managing
their addictions. Reintegration is emphasized over social exclusion. According
to 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."
Evaluation
Responsiveness and innovation are to be encouraged in program and policy
design but there is a strong need for evaluations of their effectiveness.
Programs and policies should have clear mission statements and goals and
also identify what "harms" are being addressed. 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.
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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