Harm reduction approaches in healthcare settings

This briefing note was first drafted in July 2022

Background

Harm reduction refers to interventions aimed at reducing the negative effects of health behaviours without necessarily extinguishing the problematic health behaviours completely (Hawk et al., 2017).

Harm reduction approaches have been shown to be efficacious in sexual health, alcohol and substance use services (James et al., 2017). It has also been showing promising results in eating disorders, tobacco use and self-harm (James et al., 2017). It is prudent that this harm reduction philosophy and approach be extended to include “other health risk behaviours and a broader healthcare audience” (Hawk et al. 2017).

Alberta Health Services fully endorses harm reduction policies and programs. They acknowledge that “abstinence is not always a realistic goal for some people. It is about meeting people where they are and identifying the goals they wish to achieve based on their individual needs and circumstances” and they have a policy of supporting people impacted by substance use across the continuum of care (Alberta Health Services, 2022). Harm reduction philosophy and practice should underpin other services as well, including respite care centres. No one should be denied treatment for existing substance use engagement.

Harm reduction model arose in the 1970s and 1980s principally as a response infectious disease such as hepatitis B and HIV. It rose in prominence as an alternative pathway to medical models of addiction which viewed any illicit substance use as abuse and believed that the only effective treatment required abstinence from that substance.

Harm reduction in relation to substance use came into practice as a method of behavioural counselling that accepts people ‘where they’re at’ while helping them “make informed decisions to reduce their substance-related harm and improve their quality of life” (Collins et al., 2017, p.4).

Examples of everyday harm reduction practices

• Needle exchange opportunities
• Safe injection sites
• Condom distribution to prevent unwanted pregnancy and spread of STI’s
• Seat belts for motorists, helmet requirements for bicyclists and motorcyclists
• Nicotine patches for smokers

(CMHA Ontario, n.d.; Alberta Health Services, 2022).

Harm reduction and efficacy

There are many who oppose harm reduction including critics who advocate for abstinence-only programs. They may feel that harm reduction efforts enable and encourage continued drug use and produce greater harm to the community (Hawk et al., 2017). But evidence for the benefits of harm reduction programs is clear. In the context of substance use and housing, Housing First programs, in which services are provided to individuals without requiring that they abstain from substance use, reduce not only costs of medical and social care but also alcohol use (Hawk et al., 2017).

Housing organizations with harm reduction policies

The Homeless Hub advocates a harm reduction policy modelled on the Housing First philosophy. In Canada, Housing First was adopted as the solution to the housing crisis in Calgary. “’Housing First’ is a recovery-oriented approach to ending homelessness that centers on quickly moving people experiencing homelessness into independent and permanent housing and then providing additional supports and services as needed.”

Respite centres with a harm reduction policy

Barrett Centre for Crisis Support (Hamilton, ON)

• Clients do not require abstinence from substances on site but are encouraged to use safe substance storage
• People who use substances while at facility are not discharged but staff will have a conversation with them about the risk
• They employ a full-time harm reduction worker who engages with clients on substance use issues

Gerstein Crisis Centre (Toronto, ON)

Substance use is not exclusionary

• People are discouraged to use on-site but can go out and use. Don’t want people to use alone
• Gerstein views substance use as a symptom and asks, What is going on for you that makes you need to use substances? How are you managing? Are you able to keep yourself safe and work with us towards your safety? Are you a danger to yourself or anyone else? If the individual is managing, they can be admitted into the Centre

Harm reduction supports

Substance Abuse and Mental Health Administration (SAMHSA) – Harm Reduction

This is a helpful page of harm reduction resources put out by (SAMHSA) in the United States.

Alberta Health Services (AHS) – Harm Reduction Services

This is a page on harm reduction services and resources published by AHS.

Holding Hope Canada – Resources

A directory of harm reduction resources across Canada.

Harm Reduction Works

“Harm Reduction Works (HRW) in response to the need for a harm reduction- based alternative to abstinence only self-help/mutual aid groups.”

Moderation Management

“Moderation Management™ is a lay-led non-profit dedicated to reducing the harm caused by the misuse of alcohol.”

Harm reduction education

CMHA Recovery College offers a class on harm reduction, Navigating harm reduction. It is a 2-session course (online and in-person) that aims to understand harm reduction not just as a substance use issue but as part of one’s life.

Harm reduction principles for a healthcare setting

In 2017, Hawk and colleagues developed harm reduction principles for the healthcare setting. These are:

• Humanism: Providers value, care for, respect, and dignify patients as individuals.
• Pragmatism: Health behaviours and the ability to change them are influenced by social and community norms; behaviours do not occur within a vacuum. A range of supportive approaches is provided.
• Individualism: Every person presents with their own needs and strengths.
• Autonomy: Individuals ultimately make their own choices about medications, treatment, and health behaviours to the best of their abilities, beliefs, and priorities.
• Incrementalism: Any positive change is a step toward improved health.
• Accountability without termination: Patients are responsible for their choices and health behaviours but patients are not “fired” for not achieving goals (Hawk et al., 2017).

References

Alberta Health Services. (2022). Harm reduction.

https://www.albertahealthservices.ca/info/Page15432.aspx

Canadian Centre on Substance Abuse. (2008). Harm reduction: What’s in a name?

https://www.ccsa.ca/sites/default/files/2019-05/ccsa0115302008e.pdf

Canadian Mental Health Association Ontario. (n.d.). Harm reduction. https://ontario.cmha.ca/harm- reduction/

Collins, S. E., Clifasefi, S. L., Nelson, L. A., Stanton, J., Goldstein, S. C., Taylor, E. M., Hoffmann, G., King, V. L., Hatsukami, A. S., Cunningham, Z. L., Taylor, E., Mayberry, N., Malone, D. K., & Jackson, T. R. (2019). Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder. International Journal on Drug Policy, 67, 24–33. https://doi.org/10.1016/j.drugpo.2019.01.002

Hawk, M., Coulter, R. W. S., Egan, J. E., Fisk, S., Reuel Friedman, M., Tula, M., & Kinsky, S. (2017). Harm reduction principles for healthcare settings. Harm reduction journal, 14(1), 70. https://doi.org/10.1186/s12954-017-0196-4

James, K., Samuels, I., Moran, P. & Stewart, D. (2017). Harm reduction as a strategy for supporting people who self-harm on mental health wards: The views and experiences of practitioners. Journal of Affective Disorders, 214, 67-73. http://dx.doi.org/10.1016/j.jad.2017.03.002