Harm Reduction: An Alternative Model to Abstinence

In this article, I will be writing about harm reduction, an approach to minimize the harmful risks involved in drug use, and the efficacy of different practices used with this approach, such as Needle Exchange Programs (NEP’s), Methadone Maintenance Treatment (MMT), and Safer Injection Sites.

Traditionally, there have been three main approaches to dealing with the drug problem: prevention, treatment, and control. The prevention approach believes that drugs are a threat to our society and all drug use eventually leads to abuse. This approach employs strategies such as scare tactics to discourage youth from experimenting with drugs, and drug testing and searches in school and work settings.  The treatment approach believes that all addicts want to stop using; therefore, the main objective should be to encourage addicts to abstain completely. The control or enforcement model focuses on supply reduction and criminalization of drugs, through the establishment of a strong partnership between the national government and law enforcement. The newest and most controversial approach is harm reduction, whose goal is to reduce health risk associated with drug use by providing users with safe drug use and safe methods of administration. However, this approach has been met with strong opposition from countries, like the United States, who have strongly adhered to the more traditional approaches.  The opposition to harm reduction comes primarily from the belief that it is thought to challenge or contradict the existing models, but advocates of harm reduction assert that it should not be regarded as in opposition of other approaches, but rather as an alternative.1

Philosophy of Harm Reduction                                                                                                                  

Although, the concept of harm reduction has been viewed as a controversial approach and is thought to condone drug use by many countries, including the United States, it has been accepted by countries, like Canada, who view it as a pragmatic and nonjudgmental approach to drug use. Harm reduction seeks to minimize the health risks associated with drug use without requiring complete cessation from the drug user. Its philosophy is grounded in the belief that drug use should primarily be a public health issue and the best drug policies are those that are not politically driven.1 Advocates of harm reduction acknowledge that some users may be unable or unwilling to abstain from drugs; therefore, measures need to be taken to ensure that their drug use is done in the safest way possible.2 Harm reduction, therefore, does not focus on the drug use itself as the problem, but rather focuses on the potential harmful consequences that addictive behavior can have on the lives of drug users. Harm reduction does not evaluate drug use on whether it’s morally right or wrong, but on whether the consequences of that drug use are positively or negatively impacting the life of a drug user.

Harm reduction is not anti-abstinence; however, it considers abstinence a somewhat unrealistic goal for many addicts when considering that relapse is common among recovering addicts. In addition, abstinence is such a high-threshold requirement that many addicts are discouraged from seeking receiving any addiction treatment, as abstinence is usually a prerequisite. Harm reduction provides an alternative, as a more low-threshold approach that is more easily accessible and acceptable to the majority of drug users. Harm reduction reduces the stigma surrounding drug use and is receptive to feedback from drug users themselves to develop new services and programs.3

Harm Reduction Practices

Needle Exchange Programs

Needle Exchange Programs (NEPs) continue to be an ideal example of what grassroots activism can do in the establishing harm reduction practices. Needle Exchange Programs were the result of a grassroots movement in the 1980’s, during the AIDS epidemic, concerned with preventing the spread of the disease by promoting safe drug use practices. In spite of the success of NEP’s the United States, Congress passed the Helms Amendment in the 1990’s that banned the allocation of federal funds to any harm reduction programs. In 2010, President Obama revoked the ban, but due to the financial crises at the time there was little expansion to such programs. Unfortunately, the ban was reinstated a year later in 2011 under the Omnibus Budget, reflective of the still enduring hostility against harm reduction practices, and demonstrating that once again politics triumphed over public health.4

Methadone Maintenance Treatment

The United States has long opposed the maintenance approach to treating addictions. Maintenance treatments often administer medications meant to manage and decrease withdrawal symptoms in drug users. The controversy lies in the fact that many medications, like Methadone (used to treat opiate addiction), is itself an opioid and produces similar effects to other opioids. However, unlike the euphoric high that most opiates (e.g., heroin, Hydrocodone, OxyContin) produce, Methadone affects individuals with opiate addiction very differently by alleviating withdrawal symptoms and craving following abstinence. 5 In 1914, the U.S. Harrison Act banned the use of medically prescribed opiates as a way of treating addictions after stories of doctors overprescribing drugs to their patients for profit were exposed. The maintenance approach was largely discredited and American medicine distanced itself from narcotic maintenance as a form of addiction treatment.6 Not until1964 did maintenance treatment become once again used after the pioneering work of Dr. Dole and Dr. Nyswander and their research on the efficacy of methadone maintenance treatment at the Rockefeller University.7 Although the United States pioneered the use of methadone to treat opiate addictions, implementation has largely failed as a result of moral ideology, as exemplified by Mayor Rudolph Guiliani. In 1998, Mayor Guiliani began a campaign calling for an end to the use of Methadone Maintenance Treatment (MMT) in New York City. He described MMT as “immoral” and “perpetuating enslavement to narcotics”. He sought to shut down all methadone clinics in NYC, issuing eviction notices to all clinics and programs that were occupying city owned properties, and replaced them with programs upholding the abstinence model of treatment. Unlike in Canada, where methadone treatment is under the jurisdiction of individual provinces, in the United States, dosages, admission, and termination criteria for treatment programs are almost under the complete control of the Drug Enforcement Administration, a federal agency primarily focused on law enforcement and supply reduction, rather than public health.5 Additionally, much of the continued opposition comes from individuals who believe that maintenance or medically-assisted treatments are simply substituting an existing substance use disorder for a new one.

Safer Injection Sites (SIF’s)

Safer Injection Sites (SIF’s) also referred to as “supervised injection sites” or “user rooms”, provide drug injection users with safe, controlled environments, in which they can inject drugs while being supervised by medical staff.8 Most SIF’s not only provide injection drug users with safe, sterile injection equipment, but also with emergency care in case of accidental overdose, referral to addiction treatment, and other health care services. SIF’s have been shown to attract high risk injection drug users— an important population to target among the drug using population as they significantly contribute to the rise in spread of diseases and high rates of overdose.8 By attracting this population, SIF’s have yielded great benefits among the injection drug users: SIF’s have been associated with reductions in overdose mortality, HIV risk behavior, and has improved access to addiction treatment.9 Although the efficacy (i.e. reducing risk of overdose, and HIV risk) of SIFs has been shown through several studies conducted in Canada and the establishment of these facilities has been implemented in Canada and internationally, there has yet to be a SIF opened in the United States, reflective of the still pervasive anti-harm reduction sentiment among the majority of Americans influenced by our past and current drug policy.

Conclusion

The United States continues to be largely opposed to the idea of harm reduction, yet we must look to the United States ideology on addiction and past drug policies to get a more comprehensive understanding of why this is. American views on drug addiction operate under conflicting models, the criminal and medical models of addiction, such polarized perspectives prevent progress in the area of drug policy and public health policy.  According to the criminal model, addictions are deemed a moral failing deserving of punishment, promoting the increase in power of law enforcement in implementing harsher penalties for drug users. Under this model, harm reduction is seen as a blatant disregard of the law, undermining efforts to reduce supply. Alternatively, the medical model claims that addictions can be explained as “mental and physical deficiencies beyond the control of the addict”, advocating for the use of medical treatment driven primarily by public health policy, rather than criminal punishment through the strengthening of law enforcement.11 Furthermore, the United States passed drug policies have been largely based on a moral ideology demonizing drugs and drug users and advocating complete abstinence, ultimately delaying implementation of harm reduction practices. This view was further perpetuated by President Nixon who coined the phrase “war on drugs”, a movement initiated during his administration that focused on supply reduction, harsher penalties for drug violations, and strengthened the role of law enforcement in dealing with the drug problem.1  

The ultimate goal of harm reduction is to reduce the stigma surrounding drug use and normalizing high-risk behavior associated with drug use, so people can start viewing addiction as the result of maladaptive responses rather than a moral failing, encouraging more drug users to seek addiction treatment.3 There is hope for the future of harm reduction in the United States given that individual states have more authority over public health issues than the federal government, making it possible for Needle Exchange Programs and Methadone Maintenance Treatment outpatient clinics to serve communities despite the complete lack of federal funding.12  However, the current lack of regulation and governmental sponsorship affects the universal quality of such practices. The goal is that as the quality of harm reduction programs improve and empirical research corroborates their efficacy, harm reduction programs will eventually be integrated into the States’ healthcare system.

 

1 Jourdan, M. (2009). Casting light on harm reduction: Introducing two instruments for analysing contradictions between harm reduction and ‘non-harm reduction’. International Journal of Drug Policy, 20(6), 514-520. 

2 Hobden, K. L., & Cunningham, J. A. (2006). Barriers to the dissemination of four harm reduction strategies: A survey of addiction treatment providers in ontario. Harm Reduction Journal, 3

3 Marlatt, G. A. (1996). Harm reduction: Come as you are. Addictive Behaviors, 21(6), 779-788. 

4 Drucker, Ernest. "Failed Drug Policies in the United States and the Future of AIDS: A Perfect Storm." Journal of public health policy 33.3 (2012): 309-16. ProQuest. Web. 9 Dec. 2013.

5 National Institute of Drug Abuse (2018). “Medications to Treat Opioid Use Disorder”. https://www.drugabuse.gov/publications/medications-to-treat-opioid-addiction/what-are-misconceptions-about-maintenance-treatment

6 Drucker, Ernest, and Allan Clear. "Harm Reduction in the Home of the War on Drugs: Methadone and Needle Exchange in the USA." Drug and Alcohol Review 18.1 (1999): 103. ProQuest. Web. 9 Dec. 2013.

7 Joseph, Herman, Sharon Stancliff, and John Langrod. “Methadone Maintenance Treatment (MMT): A Review of Historical and Clinical Issues.” The Mount Sinai Journal of Medicine (2000).

8 Wood, Evan, et al. "Do Supervised Injecting Facilities Attract Higher-Risk Injection Drug Users?" American Journal of Preventive Medicine 29.2 (2005): 126-30. Print.

9 Shoveller, Jeannie, Kora DeBeck, and Montaner, Julio. "Developing Canada's Research Base for Harm Reduction and Health Equity Approaches to HIV Prevention and Treatment." Canadian Journal of Public Health 101.6 (2010): 442-4. ProQuest. Web. 9 Dec. 2013.

10 Hettema, Jennifer E., and James L. Sorensen. "Access to Care for Methadone Maintenance Patients in the United States."International Journal of Mental Health and Addiction 7.3 (2009): 468-74. ProQuest. Web. 9 Dec. 2013.

11 Fischer, Benedikt. "Prescriptions, Power and Politics: The Turbulent History of Methadone Maintenance in Canada." Journal of public health policy 21.2 (2000): 187-210. ProQuest. Web. 9 Dec. 2013.

12 Des Jarlais, Don C., et al. "Doing Harm Reduction Better: Syringe Exchange in the United States." Addiction 104.9 (2009): 1441-6. ProQuest. 9 Dec. 2013