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What’s the point of harm reduction?

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Use-Both-Lanes-590What’s the point of harm reduction? To reduce harm; that much is obvious. Is that enough? Arguably it is, or it isn’t depending on where you stand. The Matrix Bites series in the carefully researched Drug & Alcohol Findings takes on this question and others in a reflective presentation on the evidence.

The narrative here points out that services need to be clear on what they do, whose harm they are trying to reduce (the individual’s, the community’s or society’s) and how far they want to go in this regard. Tensions can grow as people take polarising stands on the point of the service. The spectrum of intervention might go from passive supply of clean needles through wider works, (water, citric acid, foil) to detailed advice, Take Home Naloxone, engagement in treatment, connections to recovery communities, to abstinence oriented treatment.

The commentary lays out a perspective on what changed with the UK government’s strategy:

In 2012 the UK government’s “roadmap” to a recovery-oriented treatment system subjugated “All our work on combating blood borne viruses” to the national strategy’s “strategic recovery objective”, arguing that, “It is self-evident that the best protection against blood borne viruses is full recovery”. What ‘full recovery’ entailed was never spelt out, but what it did not entail was clear; out of the mix was continuing drug use of the kind which might prompt needle exchange attendance and remaining in opioid maintenance prescribing programmes.

Which provoked resistance from some quarters:

For the UK Harm Reduction Alliance and partners including the UK Recovery Federation, all this was not all self-evident. Their response transformed the government’s Putting full recovery first title in to Putting public health first, challenging the “ideologically-driven hierarchy” which places full recovery at the top, with “any other achievement marked as inferior”. That theme was trenchantly taken up by the Australian Injecting & Illicit Drug Users League. Concerned that the nation’s harm reduction orientation was under threat from UK-style “new recovery”, they attacked the UK government’s roadmap, insisting “Harm Reduction is the goal – not a step along the ‘road to recovery’ or the path to ‘freedom from dependence’.”

question markI’d be more sympathetic to this position if it considered what those attending services actually want rather than solely focusing on what they think politicians want. There is, of course, evidence that a significant number of people want to achieve recovery and not only that, but evidence that significant numbers can and do. The question for me then comes down to how we help those that do want abstinent recovery get there as safely as possible.

There is another question which is around aspiration. One problem with working pretty exclusively in a harm reduction setting (and I have been in that setting) is that you don’t get much positive reinforcement of recovery because you are seeing people at an early stage in their journey. If I don’t see recovery, I might begin to believe that it is an unachievable goal for most. The clients who do recover move out of my service and I don’t get to see them moving on. This leads to a belief in me that recovery is harder than it actually is.

There’s a worry that is well articulated in the Drug and Alcohol Findings commentary:

When trying for ‘full recovery’ (entailing planned treatment exit and no illegal drug use or prescribed substitutes) risks reversing harm reduction gains, on what basis can the decision be made about which takes priority? Should needle exchange staff actively pursue treatment entry and recovery objectives for their clients, even if it risks some being deterred from using the exchange?

For me, the concerns about losing the gains from harm reduction need to be taken back to what the client wants. Inform them, Get their consent. They are not passive recipients of ‘professional knows best’. The staff that are doing the informing will be better at it if they are fluent in recovery themselves. I think harm reduction service clients will benefit if staff know recovering people and work alongside them as peer supporters (and as fellow professionals). They will be better at their jobs if they have been to mutual aid meetings as part of their induction and go for ‘top-ups’ from time to time.

I know we have recovering people working in harm reduction services here in Scotland. There is no evidence to my knowledge that it deters clients. A local evaluation found high satisfaction from clients when such an intervention was piloted, so fears may not be realised. It would be a shame if we set the bar low because we thought that by having higher aspirations for clients we would lower their chances overall. There’s a self-defeating irony in that perspective that really does need to be named.

I like the Addiction and Recovery News byline which gets to the nub of the matter for me:

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    4 Responses to "What’s the point of harm reduction?"
    1. Michael Linnell says:

      Most clients of Needle Exchanges are now steroid users – abstinence based services and mutual self help groups for heroin ‘addicts’ are completely unsuitable – that is according to them – unless of course ‘non professional’ knows best. The purpose of needle exchange was to prevent the epidemic of HIV that has occurred in countries that did not adopt this policy, however, they always did far more than that and always attempted to refer people on to rehab or whatever services were available at the time. Your crude stereotyping of harm reduction workers as somehow being less aspiration than those in the recovery movement is based on what exactly? I remember needle exchanges as being full of volunteers, many of them ex- users or as we call them now, people “in recovery” and some very inspirational and aspiration professionals, I.e those good enough to be paid to do a job ( why do you use this as a negative term).
      Lastly the point about losing the gains in harm reduction. Everybody gives up at some point, the average career of a heroin user was something like 12 years, the point is that regardless if it is 5 or 50 percent, heroin users who manage to become abstinent while in services lose their tolerance and are much more likely to overdose and die if they relapse. Recovery services should have this at the top of their agenda – “first do no harm”. Harm reduction has never been about being negative about quitting, It has always been about being honest and about putting emphasise on avoiding and surviving overdose.

      • djmac says:

        Thanks for taking time to comment. My views on this are more nuanced than you acknowledge and I’m a harm reductionist at heart. I’ve argued strongly in the past for recovery services to adopt harm reduction at their core. I’m aware of the changing demographics of needle exchange clients, but locally we still have many opiate users using services. In addition greater numbers of clients dependent on NPS are presenting, some of whom would benefit from begin connected up to recovery community resources.

        Low aspiration is not universal, but there is evidence from the UK that at least some professionals have low goals for their clients. See here and here.

        Not everyone gives up. Research suggests a small majority will get to sustained remission. The question is: are there ways to shorten the journey and to bridge people out of services safely to sustained recovery? If that’s what a client wants then it makes sense to find out the best ways to do it.

    2. Deborah says:

      Often considered the ‘forgotten substance’, solvent abuse which has evolved from solvent based products to abusing aerosols and gas, particularly butane leaves leaves little room for harm minimisation as despite clients thinking otherwise, there really is no ‘safe’ way to do it.

      Anyone deliberately inhaling these volatile chemicals will always be at risk of Sudden Sniffing Death Syndrome (SSDS). However, it is possible to reduce the risk of other fatal accidents associated with solvent abuse, eg:

      • Don’t misuse volatile substances alone or in dangerous or out-of-the-way places.
      • Don’t put plastic bags over the head or impede breathing in any way.
      • Don’t misuse volatile substances near a naked flame or lit cigarette as they are highly flammable
      • Don’t drink alcohol or take other drugs.

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