Harm Reduction Presented by Mike Nielsen

Introduction Brief History Brief History Definition Definition Relationship to Therapy Relationship to Therapy Controversies Controversies Areas of Effectiveness Areas of Effectiveness Example of Programs Example of Programs Therapy Continuum Therapy Continuum Research Research Conclusion Conclusion

Brief History Social Constructionism Social Constructionism Postmodern Knowledge Postmodern Knowledge Licit versus Illicit Licit versus Illicit Person = Problem Person = Problem Substance = Problem Substance = Problem Relationship = Problem Relationship = Problem Prevention Models Prevention Models Policy Models Policy Models Substitution Therapy Substitution Therapy Disease Prevention Disease Prevention Merseyside Model Merseyside Model

Brief History Social constructionism posits that there is no “objective” reality or truth, but multiple realities and truths that are socially ‘engineered,’ ‘created,’ or ‘constructed.’ - Mid 1960’s Social Constructionism

Brief History Knowledge does not develop from ‘proven’ or empirically- tested theory or hypothesis, it does not reflect an objective truth but is rather a product of social discourse; particular ‘knowledges’ are seen as social constructions, stories that have been shaped in contexts of relationships or power. Certain knowledges achieve dominance, become accepted as truth, re-creating, then, the contexts of power relationships in which they were crafted. - Early 1990’s Postmodern Knowledge

Brief History Most substances that are now illicit were legal at one time: Morphine Morphine Cocaine Cocaine Marijuana/Cannabis Marijuana/Cannabis LSD LSD Ecstasy Ecstasy Licit versus Illicit

Brief History Locating the problem in the person, not the substance. Solution : Demand reduction; Moral theory Person = Problem

Brief History Locating the problem in the substance, not the person. Solution : Prohibition; Criminal justice model: ‘War on drugs’; Supply reduction Substance = Problem

Brief History Locates the problem in the relationship between the person and the substance (drug, set, and setting), which may change over time. Solution : Harm Reduction ‘Safer’ Use Relationship = Problem

Brief History Nicotine Use Preventions 1964: Surgeon General’s report linked smoking to cancer and heart disease 1964: Surgeon General’s report linked smoking to cancer and heart disease Public health messages: “Don’t start; if you already smoke, quit.” Public health messages: “Don’t start; if you already smoke, quit.” Advertising Regulation Advertising Regulation Prevention Models

Brief History Minimum drinking age laws Minimum drinking age laws Drunk driving laws Drunk driving laws Alcohol server training and interventions Alcohol server training and interventions Restricted sales and taxation Restricted sales and taxation Designated driver initiatives Designated driver initiatives Bottle labeling: Alcohol content; warnings to pregnant women Bottle labeling: Alcohol content; warnings to pregnant women Environmental policies: second-hand smoke Environmental policies: second-hand smoke Policy Models

Brief History Methadone treatments Methadone treatments Opiate Dependency Opiate Dependency Used in detox: to alleviate withdrawal symptoms Used in detox: to alleviate withdrawal symptoms Substitution Therapy

Brief History To reduce transmission (primary or secondary prevention) of blood-borne pathogens such as HIV or Viral Hepatitis 1970’s: Drug user organizing in Netherlands to reduce spread of viral Hepatitis B (“Junkie Unions”) 1970’s: Drug user organizing in Netherlands to reduce spread of viral Hepatitis B (“Junkie Unions”) 80’s HIV/AIDS prevention from activists: Needle exchange 80’s HIV/AIDS prevention from activists: Needle exchange 1990: Birth of a “Movement” at the First International Conference on the Reduction of Drug Related Harm, Liverpool, UK 1990: Birth of a “Movement” at the First International Conference on the Reduction of Drug Related Harm, Liverpool, UK Disease Prevention

Brief History HIV is a greater threat than drug use HIV is a greater threat than drug use Abstinence therefore should not be the only goal, or necessarily the first goal Abstinence therefore should not be the only goal, or necessarily the first goal Reach out to users and engage them Reach out to users and engage them Provide innovative services Provide innovative services Use a multi-disciplinary approach Use a multi-disciplinary approach Merseyside Model

Harm Reduction Definition The term “harm reduction” refers to policies, programmes and projects which aim to reduce the health, social and economic harms associated with the use of psychoactive substances. It is an evidence-based and cost-effective approach – bringing benefits to the individual, community and society. Harm reduction is a targeted approach that focuses on specific harms. It requires that politicians, policymakers, communities, researchers and frontline workers ask two questions: 1.What specifically are the harms associated with different psychoactive drugs? 2.What can be done to reduce the risk of those harms occurring? International Harm Reduction Association

Relationship to Therapy Abstinence Model Abstinence Model 5 Stage Change Model 5 Stage Change Model

Relationship to Therapy What is Abstinence? Abstain from heroin, but continue on methadone? Abstain from heroin, but continue on methadone? Abstain from all drugs but allow occasional alcohol? (cannabis?) Abstain from all drugs but allow occasional alcohol? (cannabis?) Abstain from all illegal drugs and alcohol, but cigarettes and caffeine are OK? Abstain from all illegal drugs and alcohol, but cigarettes and caffeine are OK? Abstain from ALL mind affecting substances. Abstain from ALL mind affecting substances. Abstinence

Relationship to Therapy Contradictory or Complimentary Abstinence

Relationship to Therapy Precontemplation Precontemplation Contemplation Contemplation Preparation Preparation Action Action Maintenance Maintenance Relapse Relapse 5 Stages of Change

Controversies Safer vs Safe Safer vs Safe Short term gain vs all- or-nothing approach Short term gain vs all- or-nothing approach Politics, Morals & Religion Politics, Morals & Religion Recreational Drug Use vs. Medicinal Recreational Drug Use vs. Medicinal Corollary controversies not directly related to drug use Corollary controversies not directly related to drug use

Areas of High Effectiveness HIV/AIDS HIV/AIDS STD STD Alcohol Alcohol

Example of Program Types Needle Exchange Needle Exchange Alcohol Alcohol Information Sharing Information Sharing Drug Testing Drug Testing Housing Initiatives Housing Initiatives

Continuum of Therapy Styles Harm Elimination / Abstinence Harm Elimination / Abstinence Recovery Readiness Recovery Readiness Moderation Management & Controlled Use Moderation Management & Controlled Use Substitution Therapy Substitution Therapy Relapse Prevention Relapse Prevention Overdose Prevention Overdose Prevention Alternative approaches Alternative approaches

Research Risk Reduction Risk Reduction Current Limitations Current Limitations Measures Development Measures Development

Conclusion

Conclusion Harm Reduction Coalition International Harm Reduction Association Needle Exchange Best Practices Harm Reduction Journal Harm reduction organization promoting health and safety within the rave and nightclub community Alternative theories of addictive change behavior Considers issues surrounding care of body, mind and relationships. Not overtly labeled as ‘harm reduction’, but follows the tenets. Resources