The harm reduction approach represents a paradigm shift in the treatment of substance use disorders. It emerged as an alternative to the moral and disease models of drug addiction. It calls for a non-judgmental, non-coercive provision of services and resources to people who use drugs. The philosophy of harm reduction has not just been applied to substance use, but also in other areas like HIV-AIDS prevention, preventing teenage pregnancy etc. It has been widely accepted by many organizations, including the WHO, and is adopted by clinicians, researchers and policy experts (Tatarsky, 2003).
Principles of Harm reduction
The approach sees drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe use to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others. Thus, abstinence is seen as the endpoint of a series of other objectives, such as lowered drug use, healthier usage habits, and the presence of activities that minimize secondary health hazards, such as safer sexual practices, maintaining secure housing, receiving adequate nutrition, and the establishment of support networks. As harm reduction sees abstinence as one of the possible goals for substance users, wishes of those individuals who don’t initially wish to abstain are respected.
Autonomy — While one of the responsibilities of health care and public health providers is to enhance the health awareness of patients by offering advice and education about the medical alternatives of patients, patients ended up making their own decisions to the best of their knowledge, values, finances, treatment preferences, and lifestyle factors.
Incrementalism — It refers to the principle that any improvement exhibited by the patient is a movement towards better wellbeing and that positive health transformations often can take months or years to attain. By allowing patients to be successful in small ways and reinforcing progress toward their own objectives, they stay engaged in treatment. It is crucial to recognize that at times, all people experience plateaus or negative trajectories. Celebrating small attainments also serve to strengthen the alliance between the care provider and patient.
Individualism — A case-by-case approach is taken and the strengths and motivation of the client are harnessed to bring about positive change at every step of the treatment. There is also an emphasis on cultivating a collaborative treatment alliance and clients can determine their own drinking goals.
Pragmatism — With regard to treatment implications, harm reduction takes a multi-pronged approach and offers an integrated range of treatment options that are adapted based on the unique needs of the client. Harm reduction does not seek to take away an individual’s primary coping mechanism until other more adaptive coping mechanisms are in place.
Finally, there is an emphasis on de-stigmatizing substance users and challenging the punitive and coercive way in which substance users are treated in society. These negative attitudes may be internalized by the client causing them to reject treatment.
Strategies used and examples of success
Harm reduction interventions take the stance that “one size does not fit all”, and promotes a stepped care model beginning with prevention based approaches and working up to inpatient treatment options, tying in with the Trans-theoretical model of behavior change. At the prevention stage for example, harm reduction could take the form of educating adolescents about substance use. Secondary intervention programs could take the form of promoting safe drinking behavior on college campuses. For example, drinking in moderation and using rideshare apps instead of driving while intoxicated. Tertiary interventions could take the form of moderation based self-help groups or pharmacological approaches like opioid substitution (Marlatt, 2002).
Harm Reduction approaches have been shown to be effective in cases of school children and college going youth. The School Health and Alcohol Harm Reduction Project SHAHRP is a classroom based programme aimed at reducing alcohol-related harm and risky consumption. For college students, The Alcohol Skills Training Program (ASTP) incorporates cognitive-behavioral skills, norms clarification, and techniques for motivational enhancement in a group setting.
Holistic programs can also help such as the one provided by Insite. Established in 2003, Insite is a legal supervised drug injection facility that offers a controlled and health-focused venue for the use of injection drugs and a free service that permits the consumers to examine their substances for carfentanil and fentanyl. Health personnel at Insite provide addiction care, mental health support and first aid in the case of an overdose or injury.
1. Hawk, M., Coulter, R.W.S., Egan, J.E. et al. Harm reduction principles for healthcare settings. Harm Reduct J 14, 70 (2017). https://doi.org/10.1186/s12954-017-0196-4
2. Marlatt, G. A., & Witkiewitz, K. (2002). Harm reduction approaches to alcohol use: Health promotion, prevention, and treatment. Addictive behaviors, 27(6), 867–886.
3. Tatarsky, A. (2003). Harm reduction psychotherapy: Extending the reach of traditional substance use treatment. Journal of substance abuse treatment, 25(4), 249–256.
4. Toumbourou, J. W., Stockwell, T., Neighbors, C., Marlatt, G. A., Sturge, J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use. The Lancet, 369(9570), 1391–1401.