3. Why is a harm reduction approach necessary?
In the previous section, we discussed Canadaâs changing love-hate relationship with harm reduction as part of our shifting national drug policy landscape. We, as authors of this book, are not conflicted. Harm reduction is a critically important public health response for people who use substances problematically. You will notice we have given away our position right in the question, by not asking if a harm reduction approach is necessary, but rather why it is necessary. Following from the section on drug use as a public health issue, you likely have a pretty keen sense of why we think it is important, but we would like you to begin this chapter by outlining the thoughts you have at this time.
Perhaps you feel that you know why harm reduction is necessary. If so, we encourage you to use the space below to write down your ideas. It is also possible that after reading the previous section you still have doubts about Canadaâs move towards implementing harm reduction strategies and legislation. That is okay too. If you are unsure, we invite you to write down any questions or arguments you might have against harm reduction in the space below. Be sure to return to them after reading the section, to see whether any of your views have changed.
Please also remember that this writing is for you to take stock of your knowledge and standpoint at the start of the section and you may write as much or as little as you would like.
How to complete this activity and save your work: Type your response to the question in the box below. When you are done answering the question navigate to the âExportâ page to download and save your response. If you prefer to work in a Word document offline you can skip right to the Export section and download a Word document with this question there.
The answer to why harm reduction is a necessary approach rests with the explanation of what harm reduction is. We begin our discussion here with a brief animated video from the Harm Reduction Action Centre entitled, âHarm Reduction 101.â
Harm reduction is both a philosophical orientation and set of practices that aim to reduce the harm people experience associated with risky behaviours. This harm may be to themselves, to their family, friends, or society as a whole. As shown in the video, we use harm reduction in many areas of our lives, including the use of seatbelts to reduce harms associated with driving and applying sunscreen to prevent risks from sun exposure. The idea of harm reduction makes practical sense, yet as Dr. Bernie Pauly explains in the next video, it is not always embraced in the context of drug use because of long-standing biases and misconceptions rooted in prohibition.
Dr. Bernie Pauly: Why is a harm reduction approach necessary?
In this video Dr. Bernadette [Bernie] Pauly discusses the broad scope of harm reduction interventions that have existed throughout history. She traces the early roots to the 1950s when physicians in the United Kingdom began prescribing their patients alternatives to the illicit drug market. In the 1980s harm reduction become more popular as a means of preventing HIV transmission, through the introduction of clean supplies, needle exchange, and supervised injection services. Currently, harm reduction efforts have been expanding through the distribution of Naloxone and calls for safer supply measures like decriminalization and regulation of the toxic drug supply. Dr. Pauly is clear to note that beyond the scope of interventions, it is important for people to understand harm reduction within the context of very criminalized use. This is because harm reduction provides a way of taking a non-judgmental, non-stigmatizing approach that acknowledges and accepts people where they are at. Through harm reduction, trusting relationships are formed that allow people to access services and get help without being judged for their substance use. Dr. Pauly cautions people who work in health care and/or harm reduction that there is a long-standing legacy of criminalization tied to prohibition that will have influenced them long before they entered the field. She calls for the decriminalization of drugs to help destigmatize drug use and enhance the potential for greater access to services. This video is 4:47 in length and has closed captions available in English.
Key Takeaways â Dr. Bernie Pauly: Why is a harm reduction approach necessary?
- Historically, harm reduction has been reflected in a broad scope of interventions.
- Harm reduction was introduced in the 1950s in the United Kingdom by physicians who wanted to mitigate harm for their patients by prescribing alternatives to the illicit drug market.
- n the 1980s harm reduction was popularized, particularly to prevent the risk of HIV transmission, through the introduction of clean supplies, needle exchange, and supervised injection services.
- Currently, harm reduction practices are expanding with the introduction of Naloxone distribution and calls for safer supply measures like decriminalization and regulation of the toxic drug supply.
- Harm reduction is particularly important in the context of very criminalized use because it provides a way of taking a non-judgmental, non-stigmatizing approach that acknowledges and accepts people where they are at.
- A foundational piece of harm reduction is the trust and relationships that help connect people with other services. This happens through interventions, such as needle exchange and supervised injection sites, where people can be helped without judgement.
- Harm reduction prevents a broad range of harms that include overdoses and HIV transmission, but also harms related to stigma and discrimination as well, by establishing safe and trusting relationships.
- People who work in health or harm reduction fields have to understand how criminalized drug use is, and that they will have already been influenced by prohibition throughout their lives.
- There is a historical and ongoing legacy of criminalization. Decriminalization is important, not as the solution, but to help destigmatize drug use and enhance the potential for greater access to services.
Harm reduction is necessary because it provides an empathetic person-centered approach that is lacking in alternative approaches like criminal enforcement and asking people to âjust say no.â Professor Stephen Gaetz has written, âWhile not all people who experience homelessness have substance use disorders, many respond to experiences of trauma and exclusion through the use of substances, and in many cases this leads to problematic use. In a context where people who are homeless regularly experience the control and regulation of their lives through emergency services, harm reduction approaches provide a welcomed alternative through humane, respectful, effective and client centred approaches to addressing substance use disordersâ (Gaetz, 2018, pg. S195).
We saw previously that addiction occurs for many complex and inter-related reasons like genetics, brain chemistry, social environment, mental health, and as a means of coping with stressors and trauma (CAMH, 2021). It is therefore unreasonable to expect that something that complicated could be resolved by telling people to stop using drugs or being addicted. That approach has been tried and has led to our current drug crisis situation. Rather than telling people to stop and then punishing them if they are unable to comply with an unreasonable demand, harm reduction approaches accept that substance use will occur and try to find ways to improve peopleâs quality of life without blame or judgement. Dr. Rebecca Schiff discusses these ideas further in the video that follows.
Dr. Rebecca Schiff: Why is a harm reduction approach necessary?
In this video, Dr. Rebecca Schiff explains that harm reduction is about human rights because housing is a human right and people should not be denied housing on the basis of using substances. She notes that harm reduction is necessary because the more traditional model of abstinence does not work for everyone. Dr. Schiff concludes that if we want to solve homelessness, we need to think in complex ways and address a range of interconnected challenges using different approaches for different people. This video is 2:37 in length and has closed captions available in English.
Key Takeaways â Dr. Rebecca Schiff: Why is a harm reduction approach necessary?
- Harm reduction is about human rights.
- Housing is a human right and people should not be denied housing because they use substances.
- Harm reduction is necessary because abstinence does not work for everyone.
- Harm reduction can result in better outcomes for many people, whether decreasing substance use or managing use in a way that is better for health and housing security.
- If we want to solve homelessness, we need to also solve its interconnected challenges using a range of different approaches.
- As demonstrated in the principles of Housing First, there are different solutions that work for different people. For some, abstinence will work and for others, harm reduction will work.
- There are different harm reduction approaches, so we need to think in a very complex way about what we mean and how we go about implementing it as a solution to achieving better health and housing stability.
Dr. Schiff reminds us that we have to think in very complex ways about how we implement harm reduction for different individuals. What works for one person might not work for another. For instance, researchers are actively investigating ways to adapt harm reduction to the needs of diverse populations, such as within Indigenous communities (Firestone et al., 2019; Victor et al., 2019; Young & Manion, 2017). Researchers have also considered the impact of harm reduction within the context of mental illness and/or Housing First programs (Maremmani et al., 2017; Urbanoski et al., 2018), and onthe experiences of women and gender-diverse individuals who use substances (Kitson & OâByrne, 2020; Meyer et al., 2019; Scheim, Bauer, & Shokoohi, 2017). As we continue to look at why harm reduction is necessary, it is important to keep in mind that harm reduction is not one single or unitary approach, but that different people will benefit from different measures, based on their own unique set of needs.
The application of harm reduction, as a practice, takes many different forms. Among the most common and effective approaches is substituting one substance for another, whether at the same frequency or varied. For instance, a person might be encouraged to reduce their use of injection drugs, even if it means they increase their use of non-injection drugs because it reduces risks such as infection. There is evidence that supports the substitution approach as an effective harm reduction approach. Youth, in particular, might choose to continue one type of drug while discontinuing another (Lake et al., 2018). For instance, in a study of 481 street involved youth in Vancouver, researchers found that those who reported daily cannabis use had lower rates of stimulant injection initiation, which challenges the notion of cannabis use as a gateway to harder and more addictive substances (Reddon et al., 2018). Likewise, use of the illicit drug MDMA (commonly referred to as ecstasy, E, or molly) has been linked to reductions in injection drug use amongst youth (Gaddis et al., 2018).
What do you think?
The substitution method encourages people to use less harmful substances, even if they use them at the same or higher rates. Does this logic make sense to you as a harm reduction strategy? Can you see the parallel if we suggested that a person with diabetes should eat two sugar-free chocolate bars rather than one regular bar, even if it means they consume more chocolate?
Substitution is one method of reducing the harms associated with problematic substance use. Another related approach involves replacing one substance with a medication that has similar pharmacological effects but without the same harms to the body. We see this approach taken with many different substances. Although we may not commonly think of tobacco as being amongst the most problematic drugs, it is frequently used and has harmful effects over time. In a study of 639 individuals who had a severe mental illness and were experiencing homelessness or housing instability, tobacco use was high among nearly three-quarters of respondents, including nearly half who smoked contraband cigarettes and a quarter who remade cigarettes from discarded butts (Pettey & Aubry, 2018). The same study found that smokers were more than 9 times more likely to have a co-occurring substance use disorder (Pettey & Aubry, 2018).
The PROMPT study (point-of-care for tobacco dependence) in Ottawa used community-based participatory action research to evaluate the effectiveness of recruiting 80 people who use drugs, providing them access to counselling, nicotine replacement therapy, and peer-support in a community setting (Pakhale et al., 2018). Results of this study indicated that over 6 months there were reported reductions in the use of cigarettes and illicit opioids such as heroin, fentanyl, and Oxycontin, as well as benefits like improved health, return to work, and greater community engagement (Pakhale et al., 2018). The success of this project demonstrates how replacing a substance with a medically supervised alternative can result in positive outcomes, particularly when combined with community supports.
Another pharmaceutical replacement method involves using synthetic opioid agonists, like methadone or suboxone, to replace heroin or painkiller use. These pharmaceuticals work to prevent the physical symptoms of heroin and other opiate withdrawal without producing the same mind-altering effects or mental high. Methadone maintenance treatment has had widespread uptake in many communities across Canada, being provided in clinics or pharmacies, as a way to reduce the harms associated with opioid addiction. Researchers examined the sociodemographic profiles of clients receiving methadone maintenance treatment in a clinic in western Canada and found that clients were 36 years old on average, had early exposure to drugs and alcohol, presented with complex health care needs, and had experiences of trauma that included poverty and homelessness (Maina, Crizzle, Maposa, & Fournier, 2019).
At this point, you might be thinking to yourself, âIf methadone replaces opioids, why donât we just give it everyone with an opioid addiction and solve the overdose crisis?â If this is indeed what you are thinking, you are on the right path to having a harm reduction mindset. At the same time, we come to the familiar book refrain that these seemingly simple kinds of questions often have rather complex answers. In short, methadone maintenance treatment is not a quick fix for the opioid crisis because not everyone wants to take it, and choice is a fundamental human right that is recognized as a core harm reduction principle.
There are many reasons people do not want to take methadone or that they discontinue its use after a period of time. In a Vancouver-based study researchers sought to identify factors associated with discontinuing methadone and found that discontinuation was more common among people who used heroin daily and those who were experiencing homelessness (Klimas et al., 2018). A study with a cohort of people who use drugs in Vancouver identified homelessness, daily heroin injection, daily prescription opioid use, recent incarceration, and not being on any form of income assistance as factors that were statistically linked to discontinuing methadone maintenance treatment (Lo et al., 2018). The authors of the study argue this demonstrates the need to reduce potential barriers by providing access to stable housing and preventing treatment interruptions during discharge from incarceration (Lo et al., 2018).
Research with participants from the Vancouver At Home / Chez Soi site investigated the effect of Housing First compared to Treatment as Usual, on methadone maintenance adherence but found no significant differences (Parpouchi et al., 2018), indicating that while housing is critical, it is not a direct pathway to methadone. It is promising to note that receiving other concurrent addiction treatment in addition to methadone maintenance has been found to help prevent discontinuation and promote adherence to the treatment (Klimas et al., 2018). Methadone is one harm reduction strategy that has gained a foothold within many communities, but it requires regular visits to get the medication and produces horrible withdrawal symptoms if not taken according to the schedule.
Harm reduction strategies apply to a range of substances. Some people who experience homelessness have severe alcohol dependence, including the consumption of non-beverage alcohol like mouthwash and hand sanitizer (Crabtree et al., 2018). In a commentary published in the International Journal of Drug Policy, Ivsins et al., (2019) argue that there is a gap in harm reduction for individuals experiencing structural vulnerabilities like poverty and homelessness and have severe alcohol use disorder. They explain that because these individuals are doubly impacted by structural oppression and severe alcohol use disorder, conventional abstinence-based programs are largely ineffective. Rather, they point to Managed Alcohol Programs (MAPs) as a way to address these intersecting harms that has great potential but is not receiving enough attention within the broader harm reduction landscape (Ivsins et al., 2019).
Managed Alcohol Programs are a harm reduction approach that have been shown to be effective with this population. Using case study analysis from five Canadian cities, Dr. Bernie Pauly and her team (2019) found that prior to entering a MAP, participants in the study were often stuck in a revolving institutional cycle between health, justice, housing, and shelter use where abstinence is often required to qualify for services. The MAPs case study found that prior to entering the programs, most people were using alcohol while engaged in risky street-based environments characterized by criminalization, unmet health needs, stigma, a lack of safety, and disconnection from family and social supports (Pauly et al., 2019).
In contrast, MAPs reduce harms by providing people with access to safe spaces and a managed supply of alcohol (Pauly et al., 2019). They are a better harm reduction alternative because people may still use alcohol at high rates, but their safety, health, and social connections are likely to improve. MAPs can be offered in different ways, such as through residential live-in programs or as drop-in day programs. In Pauly et al.âs (2018) study there were six key dimensions that researchers found differentiated these programs from one another, including program goals and eligibility, food and accommodation, alcohol dispensing and administration, funding and money management, primary care services and clinical monitoring, and social and cultural connections.
We encourage you to read some of the most recent work that combines research into cannabis substitution and managed alcohol programs, both harm reduction approaches we have discussed above. In this sectionâs featured reading Professor Bernie Pauly and her team examine these inter-related strategies.
Featured Reading:
Pauly, B., Brown, M., Chow, C., Wettlaufer, A., East Side Illicit Drinkers Group for Education, ⌠& Sutherland, C. (2021). âIf I knew I could get that every hour instead of alcohol, I would take the cannabisâ: Need and feasibility of cannabis substitution implementation in Canadian managed alcohol programs.Harm Reduction Journal, 18, 65.
Many of the harm reduction approaches we have considered, such as pharmaceutical replacements (like methadone) and supervised distributions (like managed alcohol programs) fall under the broader umbrella of âsafe supply.â Particularly as drug poisonings and overdose deaths have risen during the COVID-19 pandemic, there have been calls to expand these efforts to provide safe supplies as an alternative. For instance, Fleming et al., (2020) have written a commentary piece arguing that much like methadone replaces street opioids, there are pharmaceuticals that could be used as substitutes for stimulants, such as cocaine and methamphetamine, that could be regulated to reduce the number of stimulant-related deaths.
Safe supply is one harm reduction measure we can take to help reduce the number of drug overdoses that are occurring across our country. In this next video, Dr. Abe Oudshoorn explains this idea further.
In July 2021, British Columbia became the first Canadian province to introduce a safe supply alternative to a range of street drugs, including opioids and stimulants, as Fleming et al., (2020) advocated for. This approach, of providing a safe supply, is a public health measure that has the potential to reduce harm and save many lives. Consider this brief news clip from CBC Vancouver, in which advocates call for the safe supply strategy to go even further. We would like to caution you that this video shows images of injection drugs being prepared for use, and viewer discretion is advised.
At the Provincial level, British Columbia has implemented many progressive harm reduction approaches. Most notably Canadaâs first sanctioned supervised injection facility, InSite, opened in Vancouver in 2003 as a place where people can go to use drugs under the supervision of medical, nursing, and social work professionals, reducing the risk of overdose and improving access to non-judgmental support services. Research from Vancouver has shown that people most likely to use supervised injection facilities over time include those who experience homelessness, inject heroin daily, engage in binge injection and/or injection in public, have experienced a nonfatal overdose, have had difficulty accessing addiction treatment, and have a history of incarceration (Kennedy et al., 2019). This research suggests that supervised injection facilities have success in retaining clients who are among the most at risk of negative, and potentially fatal, outcomes from injection drug use.
At this point in the chapter, we would like to invite you to step inside InSite and take a virtual tour as an interactive experience. You can use the controls on the top left side to change the camera angle and experience the organization through a 365-degree viewpoint. Again, we would like to caution you that there is a description of drug injection in this video and that you should use your discretion in choosing whether to view this media.
InSite opened after much advocacy and, although there is a large body of evidence highlighting its effectiveness in reducing social and physical harms associated with injection drug use, calls to expand these types of services nationwide require support at the Federal legislation level (Kerr, Mitra, Kennedy, & McNeil, 2017). In a commentary piece, published in 2018, Young and Fairbairn agreed that while InSite is supported by evidence that shows reductions in overdose mortality, infectious-related complications, and public disorder, expansion of these types of services across the country is at risk because Canadaâs socio-demographic and political landscapes leave the application of supervised injection facilities a major uncertainty.
In the years since these pieces were written, and within the context of rising overdose deaths during the COVID-19 pandemic, Canada has made national strides towards expanding access to these types of services across the country. We now call these âSupervised Consumptions Sites and Services,â which are offered in communities alongside other types of programs to support people who use drugs.
What do you think?
As we have seen, Canadaâs national drug policies and strategies are re-integrating harm reduction as one of the central pillars. One practical application of this approach has been the development of Supervised Consumption Sites and Services in communities across the country. Have you noticed harm reduction services available where you live and, if so, are they effective? What other services do you think could be added to make your community safer for people who use drugs? To learn more, check out this Interactive map: Canadaââs response to the opioid crisis
In response to the escalating drug poisonings, some supervised injection facilities have begun offering drug checking as a service. The brief video below, created by the Drug Policy Alliance, provides an overview of what drug checking is and why it is important.
In a study conducted at InSite from July 2016 to June 2017 only 1% of clients opted to test their urine for the presence of fentanyl, but among those who did 80% came back positive (Karamouzian et al., 2018). This suggests that exposure to fentanyl is considerably higher than people consuming it may even realize. Further results of this study indicated that a positive fentanyl result did not make people intend to dispose of the drug, but it did mean they were likely to reduce the dose they took, which could decrease the chances of overdose (Karamouzian et al., 2018). Kennedy et al., (2018) conducted a study to better understand the willingness of supervised injection facility clients to access these services and found that just under half (43%) would be willing to frequently check their drugs if the service was available and that this willingness was more common among those who were female-identified, experiencing homelessness, and/or dealing drugs (Kennedy et al., 2018).
These studies suggest that while drug checking may not be accessed by all individuals who use drugs, this is a valuable harm reduction service that has the potential to save lives for those who do. In the video that follows Dr. Nick Kerman explains the importance of expanding harm reduction capacity at the community level, through partnership building and collaboration.
Dr. Nick Kerman: Supporting harm reduction in communities
In this video, Dr. Nick Kerman discusses the impact that the ongoing and worsening drug overdose and poisoning crisis in Canada is having on community programs, that often are the ones to intervene. Dr. Kerman argues we need to enhance capacity within the social service sector to address this issue, by strengthening relationships, partnerships, and collaboration between social service agencies that provide supports to people experiencing homelessness and harm reduction services, including those within the health care system. He concludes that with collaboration and integration we can position services to respond to overdoses more effectively and provide people with a safe place to use substances without feeling like they have to hide or do so in an unsafe way. This video is 1:30 in length and has closed captions available in English.
Key Takeaways â Dr. Nick Kerman: Supporting harm reduction in communities
- We are experiencing an ongoing and worsening overdose and drug poisoning crisis in Canada.
- Community programs are being impacted by this crisis, as they are often the ones who intervene on fatal and nonfatal overdoses.
- We need to strengthen capacity within the social service sector to address this issue.
- Increased capacity entails strengthening relationships, partnerships, and collaboration between social services that provide supports to people experiencing homelessness, and harm reduction services including those within the health care system.
- With collaboration and integration we can position services to respond to overdoses more effectively and provide people with a safe place to use substances without feeling like they have to hide or do so in an unsafe way.
At the start of the section, we asked you to consider why harm reduction is a necessary approach for people who use drugs problematically. We encouraged you to take stock of your own position and see whether you agreed that it is important, had questions, or had arguments against. If you wrote down a response, please return to it now and see whether any of your ideas have changed throughout this section.
We have argued unequivocally that harm reduction is an important and necessary approach in Canada. We began by learning about the early roots of harm reduction and considering the importance of individual choice about which services and supports are needed. There are many different types of responses that fall under the harm reduction umbrella, and which one is the ârightâ one will vary for each individual. For instance, a person may choose to substitute substances for less harmful ones or seek pharmaceutical replacements like methadone maintenance treatment. As an extension, we discussed managed alcohol programs and invited you to read contemporary research on the impact these programs can have for people with severe alcohol dependence, including the consumption of non-beverage alcohol.
Calls for safe supply have been made across the country and during the COVID-19 pandemic British Columbia became the first province to implement a generalized safe supply initiative. It was in 2003 that British Columbia also opened Canadaâs first supervised injection facility known as InSite. We invited you to take a virtual tour and to check out a map of how Canada has expanded Supervised Consumption Sites and Services across the country today. Finally, we discussed drug checking as an important, yet underutilized, service that is available in many of these locations. We ended with a consideration of how communities can, through collaboration and integration, support people who use drugs in safer and healthier ways.
Podcast: Why is a harm reduction approach necessary? (9:45)
Click the link below to listen to all of the researchers answer the question âWhy is a harm reduction approach necessary?â in audio format on our podcast!
Listen to âWhy is a harm reduction approach necessary?â on Spreaker
