The Case for Harm Reduction
Harm Reduction is currently known and understood by the general population as a public health approach to substance use disorder, but its roots in community solidarity and liberation movements are very much unknown and unappreciated. Due to public and political pushback, as well as stigmatized misinformation campaigns, harm reduction has had a tough go at getting the support and funding necessary to adequately meet need and scale up related programming. It is viewed by many as a band-aid solution, not able to do much more than keep people breathing yet living in untenable circumstances. This belief leads people to believe that harm reduction programming is simply ‘enabling’ substance use and further entrenching those with substance use disorder in pain and chaos. “Things are getting visibly worse! It’s right in front of our eyes! Who else’s fault would it be, but those bleeding hearts?” is the refrain from those who claim it’s just common sense to continue to criminalize substance users and force everyone to dry out, via involuntary institutionalization if necessary, and that achieving sobriety is the standard one must reach before they are afforded the basic necessities humans need to survive, such as safe and secure shelter. There is a lot of history and context missing in these ‘common sense’ proclamations, including a basic understanding of what substance use disorder and harm reduction actually are.
The National Harm Reduction Coalition, based in New York City, outlines the following eight principles central to the practice of harm reduction:
1. Accepts, for better or 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.
2. Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe use to total abstinence and acknowledges that some ways of using drugs are clearly safer than others.
3. 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.
4. 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.
5. Ensures that people who use drugs and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.
6. Affirms people who use drugs (PWUD) themselves as the primary agents of reducing the harms of their drug use and seeks to empower PWUD to share information and support each other in strategies which meet their actual conditions of use.
7. 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.
8. Does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use.
The most well known and widespread harm reduction service that has been implemented in Canada are supervised consumption sites, also known as safe injection sites and overdose prevention sites, but these sites alone do not represent the entire scope of harm reduction practices, as there are many other services included along the spectrum of active use through to recovery and sobriety. Many of these services are offered within the scope of SCS’s, however. These practices include, and are not limited to, education and information on safer drug use, needle and pipe exchange, drug checking, Narcan and overdose reversal, access to health professionals who can offer would care and prescribe medication assisted and opioid agonist therapies, connections to low barrier housing that does not require sobriety, and access to legal services. These services are all rooted in evidence and are pragmatic and direct solutions to limit death and illness for those who are using substances, and it offers these solutions without judgement or shame.
Harm reduction is not just about reducing the harms of illicit substance use, but about reducing the harms of the many comorbidities and related issues that go alongside substance use, such as the negative effects of living in poverty, compounding grief and trauma, social isolation, and lateral violence. Going deeper into the philosophy of harm reduction, particularly the core principles of a decolonial practice, includes themes of the following (from FNHA):
1. Addressing the root causes, in particular trauma, of the related harms of SUD.
2. Rejecting punitive approaches, including forced abstinence, surveillance, policing, and banishment.
3. Centering the lived experience of substance users and marginalized community members.
4. Holistic and cultural healing that encompasses not only physical and mental wellness, but also spiritual and emotional wellness.
5. The restoration of personal autonomy and cultural sovereignty.
6. Building and developing the infrastructure for community care and mutual aid.
Ultimately, harm reduction is about creating sustainable, long term, positive change in people’s lives, based on their own goals and priorities, and on their own terms and timeline.
Many people also hold the opinion that substance use is not a health condition or a disability at all. These people are not entirely wrong as substance use alone does not mean someone meets the threshold of symptoms and behaviours that would be considered problematic, but there is a threshold where substance use meets that criteria to be diagnosable as a disorder. While there are valid critiques of the DSM-5, it is still largely used as the guidebook for diagnosis within psychiatry. Due to the limitations of the DSM, there is the likelihood that SUD is over pathologized leading to an over-diagnosis of relatively mild substance use. On the other hand, because of the stigmatization of SUD and PWUD, shame leads people to keep problematic use hidden and those not meeting the stereotypical appearance of a user often mean certain groups may be underdiagnosed. Keeping in mind that both over and under-diagnosis is common for various reasons, two or more of the following 11 conditions within a 12-month period must be met to meet the criteria for SUD, and meeting six or more criteria indicates a severe substance disorder (aka “addiction”):
Using more of a substance than intended or using it for longer than you’re meant to.
Trying to cut down or stop using the substance but being unable to.
Experiencing intense cravings or urges to use the substance.
Needing more of the substance to get the desired effect — also called tolerance.
Developing withdrawal symptoms when not using the substance.
Spending more time getting and using drugs and recovering from substance use.
Neglecting responsibilities at home, work or school because of substance use.
Continuing to use even when it causes relationship problems.
Giving up important or desirable social and recreational activities due to substance use.
Using substances in risky settings that put you in danger.
Continuing to use despite the substance causing problems to your physical and mental health.
SUD is also understood to be a treatable disorder, with the first step often identified as withdrawal management or ongoing medication assisted treatment to reduce cravings and risk of overdose. These medications include methadone, buprenorphine (Suboxone and Sublocade), naltrexone (less common for OUD, more common in AUD), hydromorphone (Dilaudid), extended release morphine (Kadian), fentanyl patches, and, at one clinic in Vancouver and several across Europe, heroin assisted treatment. The success of these treatments relies on treatment retention and reduction in illicit drug use, and they are found to have lower relapse rates than abstinence only treatments, which have 90% relapse rates within the first year. Treatment that includes medication has been shown to reduce risk of death from overdose by 75%, and on top of higher retention and greater decrease of illicit drug use, major reductions in illegal activity is also found.
Residential treatment is generally seen as the one and only way to achieve sobriety, but there are many barriers to accessing residential treatment, especially when going from street entrenched homelessness into a structured and supportive environment, only to be released back to the street once the government funded three months is up. Long term recovery housing is unregulated, having no general standard of care, and it does not require any reporting on the long term successes and failures of specific treatments. As with any chronic and complex health condition, periods of relapse and remission are common, and risk of overdose and death upon relapse is well known due to the lowered tolerance of opioids, as well as the fact that the illicit street supply of fentanyl varies greatly in strength and composition. The addition of veterinary tranquilizers and designer benzodiazepines has added a whole other layer of risk, both of overdose and dependence on entirely new substances. A potential serious complication of both overdose and benzo withdrawals is brain injury, which only further complicates effective treatment for SUD.
The idea that we need to let people with SUD ‘hit rock bottom’ to recover is not evidence based and withholding basic needs because it is believed that people who use substances need treatment, whether they want it or not, is counterproductive. Treatment has better outcomes when it is accessed voluntarily and from a more stable baseline of living (i.e. being housed, on MAT or OAT) and with good connections to community support (i.e. low barrier programming and employment). The recent push towards involuntary treatment in BC has already been found to be unconstitutional by the BC Supreme Court. Not only does forcing treatment infringe on human rights as outlined in Canada’s Charter Rights, it has been known to generate trauma and distrust in the medical system, further delaying, or even halting, the desire to partake in traditional treatment methods in the future.
There is also the somewhat ironic belief that to receive treatment for SUD, you cannot be using any substances. How can it make sense that sobriety is held as the standard minimum to access effective treatment, when sobriety is the very thing that has been found so difficult to sustainably achieve? One of the major reasons it is difficult to retain a semblance of stability while actively using is the lack of a regulated and predictable drug supply, which is why offering medication or access to a regulated and legal supply of drugs is a major cornerstone to overcoming the epidemic of opioid use and opioid related deaths. People need to have options that lift them up out of chaos so they have the bandwidth to participate in their own lives again. The federal government discontinued its support for safer supply programs, despite the recommendations of their own Expert Advisory Group, which was assembled in 2019. This EAG completed its mandate in June 2023, and it’s final recommendations were not published to the public. CBC’s The Fifth Estate were able to receive this report via an FOI request, and reported that the group advocated for expanded access to pharmaceutical alternatives, to explore a non-medical safer supply pathways such as compassion clubs or buyer co-ops, and to partner all safer supply initiatives with comprehensive health, housing, and social supports.
If people are able to stabilize on less dangerous substances and no longer have to participate in criminal or “drug seeking” behaviour, a lot of mental and physical energy is freed up to exit any involvement in criminal or illegal situations and participate in more positive activities. These activities can include low barrier access to programming that is offered in the communities where people live and give them access to healing without banishment or incarceration. Some examples of this programming include grief and loss group therapy, contingency management, talking circles, educational programming, conflict resolution and non-violent communication, job training, employment that accommodates disability, and peer-to-peer outreach and support.
The evidence shows that the success of treatment for SUD increases when a combination of medications, therapies, peer support, and reduced societal stigma are included. A robust system of holistic and social care is also essential for providing a safe and stable environment where people can work on healing their trauma. By openly and honesty addressing housing stability, employment, co-occurring mental and physical health challenges, we can ensure that everyone is able to build a strong foundation for themselves that sustains meaningful and lasting recovery.
This is why it is essential that harm reduction services are expanded to create a continuum of care, support, and resources that run from the most basic of life saving services through robust community supports up to treatment and beyond into long term recovery support.