Harm Reduction and Substance Abuse: Theory to Practice

Introduction and Context

Substance abuse represents a significant global public health challenge. Approximately 200 million people, or 5% of the global population, are estimated to have used drugs at least once in 2006. Around 2.7% of the global population use drugs at least once a month, and approximately 0.6% are recognized as drug addicted or problem drug users. It is estimated that currently around 13 million persons worldwide inject drugs, with an increasing trend in the numbers of persons abusing cannabis and amphetamine-type stimulants (United Nations Office on Drugs and Crime, 2006). These figures demonstrate that substance abuse is a critical issue requiring comprehensive intervention strategies.

Beyond the immediate concern of drug use prevalence, substance abuse creates numerous problems for both individuals and wider communities. One of the most serious consequences is disease transmission, most notably HIV/AIDS. The connection between drug use and HIV transmission often occurs directly through the sharing of unsterilized injecting equipment among injection drug users. It can also occur indirectly when injecting drug users transmit the disease through sexual intercourse to non-users (Schumacher, Fischer, and Qian, 2007). It is estimated that injecting drug users have contributed to more than 10% of HIV infections worldwide (UNODC, 2006). The mechanisms by which infections spread from drug users indirectly to non-users signify one of the many dangers arising in a community as a result of drug use. Therefore, prevention of such public health consequences is arguably equally important as, if not more important than, addressing the absolute numbers of people who currently use illegal drugs.

Harm reduction is a theoretical model that has been proposed to address the harm caused by individual behavior, not only to the person engaging in the behavior but also to the wider community. This model has been developed into many practical applications, ranging from tobacco and alcohol addiction to weight loss. The model has also provided a potential framework for dealing with substance abuse and has been adopted in practice in many countries around the world. This paper examines the principles underlying the theoretical model and how these can be applied to successfully treat substance abusers. Specific applications of the model will be examined to determine how successful certain strategies have been in reducing harm, and how any limitations could be overcome to improve future implementations.

There is some disagreement in the literature regarding the actual components of harm reduction theory. Disagreement exists as to the definition of harm reduction, as many other terms such as risk minimization and risk reduction are used interchangeably with it. Additionally, advocates of harm reduction disagree as to whether imprisonment of drug users for possession constitutes harm reduction, or even whether laws prohibiting drug possession contribute to harm reduction.

Theoretical Foundations of Harm Reduction

However, certain principles of harm reduction theory are generally agreed upon. Harm reduction is an approach or strategy rather than an actual goal, the aim of which is to reduce or eliminate the negative consequences of drug use rather than eliminate the actual drug use itself. There is an emphasis on reducing adverse consequences among individuals who cannot be expected to cease their drug use at the present time for various reasons (Riley et al., 1999). The underlying philosophy is that the practitioner approaches the client in a nonjudgmental manner and works to help the client meet goals established personally by the client (Bradley-Springer, 1996). In the harm reduction model, the rights of the individual are of prime importance, including the client's rights to dignity and the right to make personal decisions.

Harm reduction includes a holistic, incremental, and multidimensional approach to decreasing risks for individuals and communities (Bradley-Springer, 1996). Although the model contradicts the traditional abstinence model, it may be compatible with the eventual goal of abstinence. The model proposes that social support, health assistance, education, and disease prevention measures should be maximized for all, while repressive and punitive measures should be minimized (Bradley-Springer, 1996).

Harm reduction contrasts sharply with the prohibition philosophy, also known as the abstinence model. This model concentrates on increasing interdiction, treatment, and prevention efforts combined with keeping mind-altering drugs illegal (DuPont and Voth, 1995). Advocates of prohibition theory often refer to the dramatic decrease in dangerous drug use in the early 20th century, which coincided with a substantial tightening of drug laws. Prohibitionists point to the drop in illegal drug use in the United States in recent years as evidence that prohibition may help reduce drug use and therefore drug harm (DuPont and Voth, 1995).

The basic process of harm reduction consists of providing the client with a continuum of options for their consideration, ranging from the riskiest behavior to the least risky behavior. This continuum serves a dual purpose. First, it allows the client to assess their current behaviors in comparison to both more and less risky behaviors, which may help them see where they need to make changes. This is particularly true when a client may perceive their behaviors as not very high risk when they actually rank very highly on the continuum. The continuum may also help clients assess where their behaviors have improved or deteriorated over time, giving them a means of measuring behavioral change. Second, the continuum provides the client with a range of behaviors so that they can choose the most suitable changes based on their personal circumstances (Bradley-Springer, 1996). For a continuum to be utilized effectively, health and social care professionals must adopt pragmatic tactics rather than absolute solutions.

The theory of harm reduction acknowledges that various external factors impact an individual and may affect their behaviors in ways that they cannot control or find difficult to control. For this reason, one of the underpinning criteria of the harm reduction model is that the individual is allowed to choose their own targets based on what they feel is achievable under their current circumstances. These environmental factors may take various forms. Family-related or peer-related issues could impact any change an individual tried to make. A wide array of socio-economic factors, such as the client's background or occupational history, must also be considered. However, since the emphasis of the harm reduction model is based on changing behaviors, the process used assists the individual in identifying areas of their life causing potential conflicts of interest and forming strategies to enable changes that would facilitate behavioral transformation. For instance, if a client's behaviors were negatively influenced by their work environment, the client might choose to implement strategies to reduce this influence or end it altogether. The emphasis, however, remains on the client to choose these changes rather than on the professional to insist that changes be made.

With regard to substance abuse specifically, advocates of harm reduction acknowledge that many environmental factors influence the behavior of substance abusers. Des Jarlais (1995) claims that the use of non-medical, mind-altering drugs is unavoidable in societies with access to these drugs and that it is inevitable that drugs will cause harm at both individual and societal levels. Des Jarlais further claims that drug users form an integral part of the larger community and therefore must be included in measures to protect public health. This view of the substance abuser as an integral part of the community forms the basis for harm reduction applications. Harm reduction emphasizes that all humans have intrinsic value and dignity (Bradley-Springer, 1996).

Environmental Factors and Individual Agency

Harm reduction strategies aim to protect substance abusers along with all other community members. This contrasts with prohibition models, in which the substance abuser is viewed as an individual who must be punished rather than protected. These prohibition models have been described as "a simplistic moral solution to complex human problems" (Griffin, 1998). Harm reduction accepts that some harm is inevitable but recognizes that the ideal of zero tolerance excludes compromise and sets goals that are not achievable (Riley, 1998).

The time orientation of the harm reduction model is not concentrated in one particular period but instead utilizes the concept of a continuum. This continuum allows the client to view their behaviors in comparison to a whole spectrum of behaviors, both more and less risky than those currently performed. The client can place their level of behavior on the continuum and assess the levels of risk associated with their actions. The continuum also allows clients to assess how their behaviors have changed over time by examining how their current behaviors differ from past patterns. This may allow clients to recognize that they have already made progress toward less harmful behaviors or to identify specific events that led to developing more risky behaviors. The harm reduction model allows clients to assess their current situation and plan actions they wish to take to change their future behaviors.

Although harm reduction has been applied predominantly to drug misuse issues, it is also appropriate for a wide range of social and health behavior changes. The model has been successfully used in many areas, including weight loss, tobacco addiction, and alcohol addiction. From the principles of harm reduction, it is possible to develop appropriate, situation-specific continua for almost any client who wishes to change behavior and decrease potential harms.

Harm reduction has proven effective in treating alcohol addiction due to the accessibility of the model. It has succeeded by addressing problems related to alcohol abuse without requiring complete abstinence from individuals. Many who have failed on traditional abstinence programs, such as those promoted by Alcoholics Anonymous, have made progress using harm reduction techniques. These techniques succeed because they establish a series of stepping stones decided by the clients themselves. This may lead to full abstinence at some future time, although that decision is left to the individual and not imposed upon them (Witkiewitz and Marlatt, 2006).

Applications Across Health Behaviors

Harm reduction theories were first applied to substance abuse in the 1920s when a group of English doctors concluded that it might be necessary occasionally to maintain a person on drugs to help them lead a more productive life (Riley, 1998). The province of British Columbia in Canada became the first North American jurisdiction to adopt methadone maintenance as a form of harm reduction, with much of North America following in the 1960s (Griffin, 1998). When HIV infection became a serious threat for injecting drug users, harm reduction strategies became more comprehensive and holistically based.

Harm reduction is increasingly taking hold as an alternative to the moral model, exemplified by the ongoing "war on drugs," and the medical model, in which addiction is defined as disease. These two models have long dominated U.S. drug policy and addiction treatment philosophy. Harm reduction is seen by advocates as a middle path between the two polarized opposites of the medical and moral models. It promises to provide practical and humane assistance to drug users, their families, and communities. Active drug users have provided much of the impetus for the development of harm reduction, including their advocacy for needle exchange programs in the Netherlands, which are designed to reduce the risk of HIV infection among drug users who would otherwise share potentially infected syringes. Critics of harm reduction reject it as being overly permissive in its rejection of strict "zero-tolerance" policies and its promotion of alternatives to abstinence, with some labeling it a "front" for drug legalization (Marlatt, 1998).

Harm Reduction and Substance Abuse: Core Principles

Five basic principles have been identified for harm reduction. First, it offers a practical alternative to other models available, focusing on the consequences of harmful behaviors rather than their moral implications. Second, harm reduction accepts alternatives to complete abstinence, such as needle exchange programs and methadone maintenance. Third, harm reduction is based on consumer input and demand rather than a "top-down" model, which makes drug users more receptive to it. Fourth, harm reduction supports low threshold access to treatment and a user-friendly approach, reducing barriers and widening access. Lastly, harm reduction is based on compassionate pragmatism rather than moral idealism (Marlatt, 1999).

One major difference between harm reduction and other approaches is that drug users are accepted as individuals capable of rational, informed choices. The harm reduction theory accepts that drug users will choose to reduce harm to both themselves and to society when given the knowledge and opportunity to do so (Des Jarlais et al., 1993). The model does not attempt to either condone or condemn drug use but does respect it as a choice (Hilton et al., 2001).

The model of harm reduction aligns with the Transtheoretical Model of Change, which reflects behavioral change in an individual. According to this model, the first stage in change is the precontemplative stage. At this stage, harm reduction strategies should provide comprehensive assessment of behaviors in a nonjudgmental and supportive atmosphere. The professional should begin to build a relationship of mutual trust and respect with the client to ensure they remain approachable to the subject of change despite not yet having decided to change. Assessment of the client's behaviors should be used at this stage to point out problems, raise doubts about behaviors, and discuss positive aspects of change.

The second stage is the contemplative stage, in which the client intends to change their behavior within the next six months. At this stage, the continuum of behaviors should be introduced to identify with the client their current risk of harm. This provides an opportunity to discuss a spectrum of options for change, allowing the client to decide which areas of the continuum they feel capable of achieving under their current personal circumstances. It is important to emphasize the client's right to change their mind. There should be a thorough analysis of the risks and rewards of current behaviors, and information should be provided to aid the client in achieving their goals.

The preparation stage follows, in which the client is seriously planning change within the next month. The most important factor of harm reduction at this stage is education and skills training specific to the behaviors the client has identified as acceptable.