Harm Reduction Programs

Harm reduction programs utilize a public health approach to alcohol and substance use that relies on principles and practices designed to reduce the personal, familial, and societal harms of substance use without requiring abstinence. Unlike treatment programs that require abstinence from alcohol and other drugs (AOD), harm reduction practitioners and programs conceptualize abstinence at the end of a larger range of positive outcomes. These outcomes include reduced substance use; safer use of substances (e.g., avoiding sharing needles, using clean needles); the use of safer substance alternatives (e.g., methadone or buprenorphine instead of heroin); the provision of housing and other medical, social, or psychiatric services that are not contingent upon abstinence; and the use of education to help people manage symptoms and develop healthier lifestyles and habits.

The most widely recognized harm reduction programs include needle exchanges in which intravenous drug users exchange used (dirty) needles for clean needles. Another common harm reduction program includes opioid replacement therapy, whereby addicted persons substitute the opioid heroin for supervised use of the synthetic opioids methadone or buprenorphine (e.g., Subox-one). These substances are longer acting, do not require intravenous administration, and produce fewer euphoric effects than heroin, making them less dangerous. Another form of harm reduction treatment is the use of the opioid antagonist nal-trexone. This substance blocks the euphoric effects of opioids and alcohol and can assist addicted individuals in managing the cravings associated with addiction. Harm reduction practices in community mental health settings can include providing low-threshold access to desired services and other practical supports without requiring abstinence as well the provision of unconditional support, motivational strategies, and education and practical guidance to reduce the harmful effects of AOD use.

Harm reduction practice requires human service practitioners to respect consumers’ decisions to use substances and to be tolerant of substance use behaviors while encouraging open dialogue around substance use in order to develop collaborative partnerships with consumers designed to support them in seeking out healthier and safer alternatives. Harm reduction started in the Netherlands in the early 1980s as a response to the rising prevalence of hepatitis and human immunodeficiency virus (HIV) among intravenous drug users. Street workers would engage in assertive outreach efforts to identify drug users and provide them with access to clean needles, safe housing, and places supervised by medical personnel so that they could use drugs more safely. Other strategies included the provision of educational pamphlets that contain information regarding safe sexual and drug use practices and opportunities to enter into treatment programs. These interventions led to a reduction in the spread of infectious diseases, including hepatitis and HIV. Harm reduction programs soon spread to other parts of northern and western Europe and Australia.

Harm reduction remains a controversial approach in the United States, although less so Recently, because it contradicts a U.S. drug policy that has focused mainly on controlling supply through interdiction and punishment of drug users at the expense of reducing demand or providing treatment. In the United States, AOD treatment has also remained focused mainly on abstinence. Critiques of harm reduction have included claims that the approach condones drug use and thereby increases the use of drugs and riskier forms of drug use such as intravenous. Another critique is that harm reduction programs shield drug users from the natural consequences of their actions, thereby enabling drug users to continue their problematic behaviors. These claims have largely gone unsupported. Needle exchange and methadone maintenance programs have been shown to significantly reduce the rates of overdoses and infectious disease transmission without increasing the incidence of drug use. Likewise, the provision of on-demand independent housing and other community-based physical and mental health services have led to higher rates of engagement and retention in services, an increase in stable housing, and higher consumer satisfaction without a corresponding increase in drug and alcohol use. However, practitioners often struggle to practice harm reduction due to the high tolerance of drug-using behaviors the approach requires. Adequate [Page 610]ongoing supervision and training are necessary for the effective implementation of the approach.

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