1. + Getting Ready for Harm Reduction 2010 Street Outreach Workers Conference Austin, TX Kevin Irwin June 21, 2010

2. + Objectives Convey a personal and agency definition of harm reduction Describe the evidence base for harm reduction Dialogue with people with varied understandings and beliefs about harm reduction Describe the current status of Texas laws relevant for harm reduction practices (e.g. paraphernalia law). Identify possible community-level barriers to implementing harm reduction measures and develop strategies for building community support to overcome these barriers.

3. + Policy Pathways The lifting of the Federal Ban on the funding of needle exchange programs on December 19, 2009 – what does it mean? In 2009 Senate Bill 308 passed by a 3/1 margin and cleared the House Public Health committee by better than 2/1. It seemed likely that the bill would have passed the full House had the legislative term not ended before it could come to the floor.

4. + Objectives Convey a personal and agency definition of harm reduction Describe the evidence base for harm reduction Dialogue with people with varied understandings and beliefs about harm reduction Describe the current status of Texas laws relevant for harm reduction practices (e.g. paraphernalia law). Identify possible community-level barriers to implementing harm reduction measures and develop strategies for building community support to overcome these barriers.

5. + Principles of Harm Reduction Being clear about Harm Reduction Harm reduction is a set of practical strategies that reduce the negative consequences of drug use experienced by individuals and communities. Harm reduction approaches incorporate a spectrum of strategies from safer use, to managed use, to abstinence. Harm reduction strategies engage drug users, identify their needs, and work towards goals that are attainable.

6. + Harm Reduction in 1842 “Is it just to assail, condemn, or despise them? Men ought not in justice to be denounced for yielding to it in any case, or giving it up slowly, especially when they are backed by interest, fixed habits, or burning appetites.”

7. + Abraham Lincoln, 22 February 1842 Address before the Springfield Washington Temperance Society

8. + “If tobacco suddenly were unavailable and was as expensive as heroin and cocaine, I think you would find that the behavior of some tobacco addicts would be very much like the behavior of some addicts of heroin and cocaine.”

9. + C. Everett Koop Surgeon General 1982-1989

10. + Harm Reduction Definitions Harm reduction is NOT “whatever happens, happens.” Harm reduction is NOT “anything goes” Harm reduction is NOT simply “meeting the client where the client is at” (it’s helping them to change behavior) Harm reduction is NOT “Helping a person who has gotten off drugs to start using again.” Harm reduction is NOT condoning, endorsing, or encouraging drug use. Harm reduction is NOT Legalization

11. + Compassionate Pragmatism Harm Reduction is a philosophy, integrated into a variety of practices There is no one right way Most life changes are gradual All chronic conditions are challenging Reducing harm is the fundamental objective of responses to all chronic conditions Abstinence is a state Any Positive Change

12. + The A-word Are abstinence and harm reduction compatible? HOW are abstinence and harm reduction compatible? Harm reduction and abstinence are highly congruent goals. Harm reduction expands the therapeutic conversation, allowing providers to intervene with active users who are not yet contemplating abstinence. Harm reduction strategies can be used at any phase in the change process.

13. + Harm Reduction and Behavior Safer Driving – speed limits, seat belts, intoxication limits, air bags, defensive driving, alternatives to driving…… Safer Sex – condom use, avoidance of risky sexual practices, abstinence…… Safer Drug Use – reduced use, avoidance of risky routes of administration, drug substitution, safe using partners (designated driver), abstinence…..

15. + Principles Accepts, for better and for worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them. Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others. Establishes quality of individual and community life and well- being - not necessarily cessation of all drug use - as the criteria for successful interventions and policies. Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.

16. + Principles, cont’d Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them. Affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use. Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people's vulnerability to and capacity for effectively dealing with drug-related harm. Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

17. + Objectives Convey a personal and agency definition of harm reduction Describe the evidence base for harm reduction Dialogue with people with varied understandings and beliefs about harm reduction Describe the current status of Texas laws relevant for harm reduction practices (e.g. paraphernalia law). Identify possible community-level barriers to implementing harm reduction measures and develop strategies for building community support to overcome these barriers.

18. + 20+ Years of Research… SEPs are associated with reductions in HIV/AIDS transmission SEPs do not encourage or increase rates of drug use in their communities (and may lead to decreases) SEPs do not increase crime in their communities SEPs do need increase needlestick injuries in their communities SEPs are associated with significant financial savings The Highest risk IDUs can be reached by SEPS SEPs are associated with increased access to, and utilization of health and social services, including drug treatment, primary care and housing SEPs are facilitating lower mortality due to overdose SEPs do not support drug use, they support people who use drugs

19. + Major Endorsements National Institutes of Health (1997) American Public Health Association (1997) US Surgeon General (2000) Department of Health and Human Services (2000) Institute of Medicine (2000) Centers for Disease Control (2002) National Institute on Drug Abuse (2002)

20. + SEP Best Practices into Policy Characteristics of Effective Programs Ensuring low threshold access to services Maximize access by number of locations and available hours Ensure anonymity of participants Minimize the administrative burden of participation Promotion of Secondary Syringe Distribution Training and support of peer educators Do not impose limits on number of syringes Maximizing responsiveness to characteristics of the local IDU population Planning activities and service modalities adapted to subgroup needs Provide or coordinate the provision of essential health and social services Include diverse community stakeholders in creating a social and legal (e.g. paraphernalia laws) environment supportive of SEP

21. + SEP Best Practices into Policy Practices to Avoid Supplying single-use syringes Limiting frequency and number of syringes Requiring one-for-one exchange Imposing geographic limits Unnecessary caps on syringe volume Requiring identifying documents Requiring unnecessary data collection

22. + Objectives Convey a personal and agency definition of harm reduction Describe the evidence base for harm reduction Dialogue with people with varied understandings and beliefs about harm reduction Describe the current status of Texas laws relevant for harm reduction practices (e.g. paraphernalia law). Identify possible community-level barriers to implementing harm reduction measures and develop strategies for building community support to overcome these barriers.

23. + Group Work

24. + Objectives Convey a personal and agency definition of harm reduction Describe the evidence base for harm reduction Dialogue with people with varied understandings and beliefs about harm reduction Describe the current status of Texas laws relevant for harm reduction practices (e.g. paraphernalia law). Identify possible community-level barriers to implementing harm reduction measures and develop strategies for building community support to overcome these barriers.

25. + Texas Law

26. + Objectives Convey a personal and agency definition of harm reduction Describe the evidence base for harm reduction Dialogue with people with varied understandings and beliefs about harm reduction Describe the current status of Texas laws relevant for harm reduction practices (e.g. paraphernalia law). Identify possible community-level barriers to implementing harm reduction measures and develop strategies for building community support to overcome these barriers.

27. + Advocacy - when you want to: Promote public health objectives. Overcome barriers that restrict public health opportunities. Promote the importance and relevance of prevention including increases in funding. Protect human rights. Ensure a better quality of life. Be responsive to needs, but be balanced with providing innovative proactive strategies. Be oriented towards outcomes for public health. Aim for empowerment of disadvantaged individuals and groups. Challenge stereotypes and stigma.

28. + Advocacy Check your facts Plan and promote for small wins Have an advocacy path Get the timing right Be open to windows of opportunity Make issues local and relevant Create and maintain partnerships Accentuate the positive! Framing your message Be passionate and persistent Be prepared to compromise Know your adversaries Keep your eyes on the prize Have some tricks up your sleeve Commitment to Continual Assessment Be Inclusive Create champions Enjoy yourself!

29. + Conditions that Facilitate or Deter Adoption of Harm Reduction Coalition building and community consultation are key to the acceptance and sustainability of new interventions. Leadership from politicians, public health officials, and program directors provide necessary authority, legitimacy, and access to resources. Grassroots activists took initiative and risks in the face of opposition, but often lacked the resources to sustain their efforts. Researchers played an important role in initiating interventions and legitimizing them by providing access to the scientific information supporting their safety and effectiveness. Successful implementers worked with or avoided the opposition rather than creating polarized positions. Lack of leadership in the political and public health sectors, and, indeed, fear of adopting or even discussing needle exchange because of perceived political opposition, were the biggest barriers to implementation of syringe exchange programs.

30. + Building Community Acceptance Coalition Building Community Dialogue (Create Opportunities) Rapid Assessment Techniques (Inclusive) Mapping Resources and Assets Local Policy and Practices Environment Local Sources of Capital Develop an Overall Strategy Media Strategy Law Enforcement

31. + Develop an Overall Strategy Master Plan (Gantt Chart) SMART Goals Specific: State clearly what the program is trying to achieve Measurable: Can be measured without massive resources devoted to research and evaluation Achievable: Challenging, yet not overly ambitious given the available human, financial and other resources Relevant: Useful to the overall process of working towards the goal Time-constrained: Identify a time limit within which it is to be achieved; otherwise the objective will be impossible to measure

32. + Media Strategy Assign a Coordinator of Public Relations Develop a Media Strategy Map Potential Outlets Media Releases, Press Conferences, Talk Shows, Articles Develop a Communications Toolkit Clear and Concise Tailored for Audience and Locale Build Relationships with Media Educate Staff on Dealing with Media

33. + Media Musts… Do your homework, know your stuff, and be prepared. Anticipate all possible questions, both “good” and “bad,” easy and tough. Practice in the “Hot Seat” Know what message you want to get across in an interview: Prepare your key points and the specific details, examples and illustrations that will support them and make memorable. Boil your message down into brief, clear, positive sentences that are free of jargon or insider knowledge. Collect or prepare supporting material (media releases, brochures, fact sheets, backgrounders and so on) that you can give to the reporter.

34. + Use Varied Strategies Media release Action alerts Letters to politicians Meeting with a politician Interviews Letter to the Editor Radio grab Television interview

35. + Working with Law Enforcement Police Advocates Have provided disposal of syringes found in the community; programs respond to any calls to clean up/dispose infected syringes Program staff will come to precincts to provide roll call presentations, sharps containers, needlestick, and syringe disposal information Syringe exchange programs teach IDUs how to inform officers they are in possession of syringes prior to being searched. Programs request that participants respect officers and document badge number and precinct if syringes are confiscated. Police can refer drug users to our services for medical care and drug treatment.

36. + Develop Dexterity The Moral Paradigm The Safety Paradigm The Legal Paradigm The Medical Paradigm The Public Health Paradigm The Social Good Paradigm

37. Prochaska & DiClemente’s Stages of Change PRE-CONTEMPLATION Not yet considering possibility of change. DETERMINATION OR PRE-ACTION “I’ve got to do something about this problem.” “This is serious. Something has to change.” ACTION MAINTENANCE Identify Strategies and support to prevent relapse RELAPSE Help renew contemplation, pre-action, action without giving up. CONTEMPLATION Considers change and rejects it. Reasons for concern vs. justifications for concern. Cost – Benefit Calculation

38. + Review Convey a personal and agency definition of harm reduction Describe the evidence base for harm reduction Dialogue with people with varied understandings and beliefs about harm reduction Describe the current status of Texas laws relevant for harm reduction practices (e.g. paraphernalia law). Identify possible community-level barriers to implementing harm reduction measures and develop strategies for building community support to overcome these barriers.

39. + This year in the US… 8,000 people will acquire HIV from a contaminated syringe 15,000 people will acquire Hepatitis C from a contaminated syringe 20,000 people will die from an accidental overdose 6-8 million people who need drug treatment will not get it

40. + Thank You! Kevin.Irwin@Tufts.Edu