The concept of ‘harm reduction’ refers to a set of policies, programs, and practices that aim to reduce the health, social, and economic consequences of drug and alcohol abuse.1,2
Strategies might include providing a safe environment for heroin use that minimizes the risk of overdose or contraction of HIV. But the precise strategies deployed will vary depending on the specific drug being used, the harms caused by use of that drug, and the person who uses the drug.1
A majority of the world’s countries have harm reduction strategies to different degrees, including the United States, which offers needle and syringe programs and opioid substitution therapy.3
What Is Harm Reduction?
Essentially, harm reduction acknowledges that completely abstaining from drugs isn’t a realistic solution for everyone and that many people worldwide use drugs and alcohol in spite of the strong efforts of various organizations and governments to promote total abstinence.
Believing that no one should suffer or die from preventable causes, those running these programs attempt to mitigate the damage associated with drug abuse and addiction.2
According to the Harm Reduction Coalition, the principles of HR are:4
- Acknowledging that drug use is inevitable and choosing to reduce the harms of drug use instead of disregarding them.
- Understanding that drug use is a complicated phenomenon and that some methods of drug use are safer than others.
- Determining that quality of life is the criteria for successful approaches and rejecting the idea that total abstinence is the only way to address the issue of drug abuse.
- Using non-judgmental services and providing resources to people who use drugs and their communities, without forcing them to participate.
- Making sure that drug users have a say in the programs and policies of which they are a part.
- Seeing drug users as the ones who have control over preventing the harms of drug use and empowering them to share information and support each other.
- Accepting that factors such as poverty and racism can impact people’s ability to deal with the consequences of drug use.
- Facing the realities and risks of drug abuse.
Harm reduction can be very effective. Studies have found that:5,6,7
- Cities that have needle and syringe programs have an average annual decrease in HIV prevalence of 18.6%, compared with an annual average increase of 8.1% in cities without these programs. Between 2000 and 2009, these programs are estimated to have prevented more than 32,000 new HIV infections in Australia.
- Methadone maintenance programs are tied to decreases in death rates.
- Methadone maintenance is effective at reducing heroin use, crime, and risk behaviors for HIV.
The number of drug users sharing needles in Vancouver, Canada dropped from almost 40% in 1996 to 1.7% in 2011 after the city opened Insite, the country’s first supervised injection site for drug users in 2003.
The health of drug users improved, and the number of people on methadone treatment went from 12% in 1996 to 54.5% in 2008. There were also fewer new infections of HIV and hepatitis C from sharing needles.8
Harm reduction can encompass a number of different approaches. The main areas of focus are the reduction of harm associated with alcohol and opioid addiction, the prevention of overdose deaths, and the reduction of disease transmission.
Opioid Addiction Treatment
One of the most common forms of harm reduction is medication-assisted treatment (MAT) for people who are addicted to opioids such as heroin and prescription painkillers. The most common drugs used in MAT are methadone, buprenorphine, and naltrexone.
MAT combines medications with counseling and behavioral therapies to help people recover from addiction. Opioid agonist (e.g., methadone and buprenorphine) medications help to stabilize brain chemistry, normalize certain physical functions, and ease cravings without the treated individual experiencing the negative effects of the previously abused opioid drug. Other treatment drugs (e.g., naltrexone and naloxone—the latter a component of Suboxone) are opioid antagonists, and will block the effects of opioid misuse.9 MAT can make it easier for people who are dependent on these drugs to participate in treatment.6
Patients participating in MAT will attend therapy which teaches them techniques to resist drugs and lead healthier lives. For example, they learn how to recognize thought patterns that can lead to drug use, identify situations that can lead to relapse, and tap into their motivation for recovery.10
Other goals of MAT include:6,9
- Helping the person to stay healthy until they can achieve a drug-free life.
- Reducing the use of illicit opioids (heroin) and/or the non-medical use of prescription opioids.
- Reducing the dangers of drug use, such as contracting HIV and other infections.
- Minimizing the likelihood that the person will engage in criminal activity.
- Improving overall functioning.
- Improving the health of babies born to mothers who have been opioid-dependent.
Opioid Overdose Prevention
Overdoses from opioids have reached epidemic proportions in the U.S., and many harm reduction programs are seeking to reduce the deaths from these overdoses by disseminating naloxone and providing overdose training to their communities.
Naloxone is used to reverse an opioid overdose by blocking opioid receptor sites in the brain. It can be given as a metered nasal spray or an injection. Even though emergency response personnel usually administer naloxone, doctors and pharmacists can show drug users, their family members, and caregivers how to use it.11
The Clean Works Program in Grand Rapids, Michigan is an example of a harm reduction program that instructs participants in how to recognize an overdose and how to intervene and provides naloxone to use in case of an emergency.1
Managing Drinking Behaviors
When it comes to drinking, harm reduction can mean reducing alcohol intake or practicing healthier habits when drinking.
This method acknowledges that not all alcoholics are ready for recovery. Many problem drinkers simply won’t stop drinking altogether or may not be comfortable with the abstinence-only approach of Alcoholics Anonymous. Instead, this model seeks to reduce the likelihood of death or injury as a result of dangerous drinking behaviors or help the person slowly cut back on the amount they’re drinking.
The Harm Reduction Therapy Center in Oakland, California allows clients to continue drinking while they set small but achievable goals that may include reducing their intake of alcohol, not drinking and driving, or eventually quitting. Co-founder Patt Denning says, “We make the threshold [for entering treatment] as low as possible.”13
The National Institute on Alcohol Abuse and Alcoholism (NIAAA)—a department of the National Institutes of Health (NIH) and preeminent funder of worldwide alcohol research—believes that a singular approach to treatment does not work for everyone and encourages people to drink in healthier ways.13
Strategies for reducing alcohol harm might include:15
- Giving your car keys to someone before drinking.
- Taking public transportation so you can’t drive home drunk.
- Carrying condoms when you go out drinking.
- Planning one abstinence day if you drink daily.
- Scheduling days/times you drink so they don’t interfere with work or school.
- Reducing the number of drinks you have per day/week/month.
- Eating before drinking.
- Staying hydrated.
A 2013 study found that treatment that emphasized controlled drinking was likely as effective as abstinence treatment for at least some people with alcohol problems. Another study found that problem drinkers who drank less during treatment had significantly fewer alcohol-related effects and better mental health.14
Some alcohol harm reduction programs are aimed at teens and children. One successful program, the Alcohol Misuse and Prevention Study (AMPS), targeted children in grades 5 and 6 and educated them about the dangers of alcohol use and how to handle peer pressure. A follow-up study showed that participants had fewer alcohol problems than students who did not participate in the program. A study on a comparable program in Australia showed similar results.5
Reduction in Disease Transmission
These programs allow people who inject drugs to 1) obtain a sterile needle or syringe for each time they use drugs and 2) safely dispose of used needles. Other services might include prevention materials such as alcohol swabs, vials containing sterile water, condoms, and education on safer injection practices.16
These programs can be located at pharmacies, emergency departments, or primary care settings; be standalone programs; be attached to specialist drug services; be part of a community outreach program; or be a mobile service.6
Goals of these programs include:17
- Preventing contraction of HIV, viral hepatitis, and other bloodborne diseases.
- Increasing the likelihood that a drug user seeks treatment.
- Reducing deaths from overdose.
- Preventing needlestick injuries among first responders and the public.
- Minimizing healthcare spending related to disease transmission.
Proponents of this form of harm reduction say that the user’s presence at these centers gives them a gateway into recovery. According to the Centers for Disease Control and Prevention, people who inject drugs are 5 times more likely to enter addiction treatment when they use a syringe services program.17
A study found that areas that implemented needle exchange programs showed decreases in HIV seroprevalence (number of people who tested positive for HIV in blood tests) compared to areas that did not use these programs.5
Other services offered at harm reduction programs include:16
- Overdose prevention practices.
- Referral to substance abuse treatment programs.
- Referral to HIV care and treatment programs.
- Testing for HIV and hepatitis C.
- Referral to hepatitis C treatment and hepatitis A and B vaccinations.
- Screening for sexually transmitted diseases and tuberculosis.
- Prevention of mother-to-child HIV transmission.
- Services for medical, social, and mental health problems.
Criticisms of the Harm Reduction Model
Some of the criticisms of harm reduction are that it:6
- Doesn’t work. Critics don’t believe that someone can beat an addiction while they’re still using because their judgment is clouded and they are still seeking out substances.13
- Keeps users “stuck” in addiction. Opponents believe it will keep people in a pattern where they keep using instead of allowing them to hit rock bottom and find their way out of addiction.
- Promotes drug use. Some critics think that helping people do drugs more safely encourages them to start or keep using drugs.
- Is really a pathway to legalize drugs. Certain critics think that harm reduction advocates have an ulterior motive to reform drug laws and promote a legal, regulated market for drugs.
The Drug Free America Foundation, a nonprofit that advocates prevention and reduction in drug use, argues that harm reduction can lead to the belief that drugs are not dangerous, which can in turn support drug use. According to the foundation, the policies prolong addiction, promote acceptance of drug use by adults and youth, and lead to the perception that drugs can be used safely and responsibly. They espouse the belief that the only way to prevent harm from drug use is abstinence. Per the foundation, harm reduction only makes sense when it is combined with an approach that includes prevention, treatment, and law enforcement.19
The United States has historically taken more of an enforcement and abstinence-only approach to drug use. However, in 2009, the Obama administration lifted a 21-year ban on federal funding for needle exchange programs. Programs such as needle exchanges and medication-assisted treatment for opioid addiction are available in many parts of the country. Still, these programs are not available in certain regions and are affected by local laws.18
Leaving Addiction Behind
Harm reduction programs offer a number of potential benefits to drug users, their families, and the public. But those who eventually want to stop using drugs should seek out some form of treatment.
A number of options are available, including therapy, self-help groups, and drug rehab centers. Medical and mental health professionals can help you safely complete detox, develop strategies to resist drugs, and examine the reasons for your addiction.