1. Harm Minimisation

2. Basic Principles of Harm Minimisation Do no harm! Focus on drug related harms, not the drug itself Maximise the range of options for intervention Choose appropriate treatment outcome goals – give priority to those that are practical and achievable Respect the rights of the person with drug related problems.

3. Harm Minimisation National Drug Strategy “To improve the health, social and economic outcomes by preventing the uptake of harmful drug use and reducing the harmful effects of licit and illicit drugs in Australian society” NDS Mission Statement 2004-2009

4. Harm Minimisation harm reduction supply reduction demand reduction The National Drug Strategy is built upon three pillars:

5. Harm Minimisation Education and Information Controls and Treatment and Enforcement Rehabilitation Research and Evaluation Supply Demand Harm Reduction Reduction Reduction

6. Harm Minimisation Harm Minimisation in Action 1. Supply Reduction Legislation Law Enforcement (incl. Customs, Criminal Justice System) Community Attitudes 2. Demand Reduction Information e.g. ‘Drinkwise’ Education Treatment Rehabilitation Drug Substitution Community Interventions e.g. promotion of low alcohol drinks 3. Harm Reduction Education Information e.g. cigarette packet labelling Needle & Syringe Programs Treatment e.g. controlled drinking substitution therapy (nicotine patches, MMT) Community Intervention e.g. RBT unleaded petrol.

7. Harm Minimisation Harm Minimisation (HM) “… refers to policies and programs aimed at reducing drug-related harm. It aims to improve health, social and economic outcomes for both the community and the individual and encompasses a wide range of approaches, including abstinence- oriented strategies.” National Drug Strategy 2004-2009

8. Harm Minimisation Applying HM Principles Consider: whose needs (clinician’s vs. patient’s) influence decisions rationale behind practice policies options, supports, resources available to patients and the practice risks to the patient by intervening (or not!) risks to others (e.g. drink driving, violence, safety & welfare of children/partner) that the type of intervention may vary (e.g. safety issues, readiness to change).

9. Harm Minimisation HM in General Practice When patients are not interested in ‘giving up’: identify the health, social, and behavioural impact of drug use develop awareness of links between AOD use and related harms (where evident) attempt to reduce harms associated with AOD use generally (or where they are related to specific drugs) encourage patients to return when they are contemplating a need to address specific AOD issues.

10. Harm Minimisation HM Examples in General Practice Eric, aged 54, presented with sleeping difficulties to his GP. The GP’s AOD assessment revealed: 6 stubbies of full strength beer most nights. Brief intervention offered: GP discussed and provided information about standard drinks and low-risk drinking acknowledged importance of alcohol in Eric’s life linked sleep issues and Eric’s current health problems to alcohol arranged a long appointment in a week to discuss further. To the GP’s surprise, Eric presented 10 days later stating he had one of the new low alcohol beers ‘which didn’t taste too bad’ and were ‘cheaper’. He had only had alcohol on three days of the week, and ‘felt better for it’.

11. Harm Minimisation Acquisition Administration Drug affected behaviour Recovering from drug use Withdrawal Cycle of AOD-related Harms

12. Harm Minimisation What is ‘Drug-Related Harm’? Drug-related harm: directly or indirectly affects the health, safety, security, social functioning and productivity of all Australians. Drug-related harms cause or contribute to: illness and disease accident and injury violence and crime family and social disruption economic costs and workplace concerns. Illicit drug-related harms include: prosecution and conviction involvement in production and distribution of illicit drugs.

13. Harm Minimisation Hierarchy of Drug Administration Risk Swallowing Snorting Smoking Injecting RISK MOST LEAST Hierarchy of Risk

14. Harm Minimisation Preventing Drug-related Harm Primary prevention: targets individuals at ‘no-use’ and ‘low-use’ end of continuum prevents harm occurring; prevents, delays or reduces uptake involves health promotion activities e.g. education, legislation, policy, enforcement, promoting alternatives to drug use. Secondary prevention: aims to moderate use patterns and  awareness of risk targets those already using, and ‘at risk’ e.g. early detection, referral, information (incl. media), developing skills for safer using. Tertiary prevention: aimed at individuals already experiencing problems includes provision, development and improvement of specialised services for those with established dependence e.g. withdrawal services, pharmacotherapies, counselling, diversion.

15. Harm Minimisation Harm Reduction Strategies Establish and maintain an empathic relationship Retain contact with patient Maximise physical and mental health Enhance motivation via education about dependence Involve patient + significant others in harm reduction Emphasise personal responsibility Other forms of support may include: –family or vocational counselling –establishing non-drug using relationships –time management –problem solving –skill and hobby building.

16. Harm Minimisation Harm Reduction Steps for GPs Be familiar with patterns of AOD use and related harms Routinely assess patients’ AOD use and related harms Provide information and feedback re drug use activity and related harms Assist patient to identify drug use goals Collaborate with patient to develop harm reduction strategies Monitor patient behaviour –reinforce positive changes –address patient difficulties.

17. Harm Minimisation GPs Can... Identify drug use and intervene early Provide information about safer or lower risk use strategies Advise about associated risks and harms (e.g. infections) Advise about treatment options Encourage less risky forms of administration e.g. give advice about: –safe injecting –high-risk drinking.

18. Harm Minimisation Harm Minimisation (HM) Doesn’t promote or condone drug use Involves a range of approaches to prevent / reduce harms including prevention, early intervention, specialist treatment, supply control, and safer (though not risk free) use Includes abstinence Encourages existing or intending drug users to use in less risky ways HM recognises that: –there is no completely drug free society –the spectrum of use ranges from acute  chronic –drug use is a risk factor for both physical and social harms –most drugs can be used in low risk ways –‘realistic’ approaches to reducing harms are necessary.

19. Harm Minimisation Benefits of HM Approach Builds rapport: shows that GP is interested and prepared to assist suggests that GP is not simply ‘telling the patient what to do’ (i.e. not telling the patient to ‘say NO to drugs’). Engages the patient: trust-building increases potential to influence behaviour and decrease AOD-related harms increases likelihood of return. Empowers the patient: responsibility for change is given to the patient.