Introduction
Substance abuse is a major social problem in the world today. Research indicates that over 35 million people globally suffer from substance use disorders (SUDs), while only one in every seven receive treatment (United Nations, 2019). In addition, over 20 million people in the United States have a drug use disorder, with approximately 10% under treatment (National Institute on Drug Abuse, 2021a). The growing number of substance-related deaths in the country has also skyrocketed, with over 100,000 drug overdose fatalities being reported in 2021 alone (Centers for Disease Control and Prevention, 2022). Despite the increasing prevalence of substance abuse globally, the traditional abstinence-oriented treatment for drug and alcohol abusers continues to register poor outcomes with high relapse cases (Tatarsky, 2007). As a result, several governments across the globe have shown increased efforts in adopting harm reduction programs to fight against the adverse effects of alcohol and drug use. Harm reduction involves practices, policies, and programs that reduce the negative health, economic and social impacts of drug abuse (Rhodes & Hedrich, 2010). The harm reduction model has effectively treated substance use disorders and decreased blood-borne infections among drug users.
History
The harm reduction practice has greatly evolved throughout history to become one of the most successful interventions in averting the harmful effects associated with alcohol and drug use. The model was initiated by activists, healthcare professionals, and policy-makers who contested the legal suppression of substance use and the mistreatment of drug abusers in the late 1900s (Tatarsky, 2007). Nevertheless, the first government-supported harm reduction framework originated in Europe, particularly in the Netherlands, in the 1970s (Marlatt, 1996). This adoption of a more humane and pragmatic approach to drug use was inspired by substance abusers and addicts, leading to a change in drug use policies. In this case, by 1984, the needle exchange program had been initiated in Amsterdam (Marlatt, 1996). The harm minimization practice later spread to the United Kingdom, which pioneered the medication strategy where substance abusers were given medically prescribed drugs, such as heroin and cocaine, for maintenance (Marlatt, 1996). Although the adoption of these alternative interventions was gradual, they later spread to other countries.
The growth of the harm reduction model was fueled by its efficiency in curbing the spread of the human immunodeficiency virus (HIV). By the mid-1980s, these alternatives to managing drug use became widely known as risk-reduction or harm-reduction solutions to the issue of HIV among people who inject drugs (PWID) (Roe, 2005). In the 1990s, Canada enforced legal and social policy reforms to embrace harm reduction interventions, which proved effective in curbing the spread of HIV, particularly among intravenous drug users (Roe, 2005). Thus, the efficacy of this intervention encouraged different nations to incorporate it into their health policies, resulting in positive health outcomes for substance users.
The harm reduction practice was introduced in the United States through pilot syringe exchange programs (SEPs). However, these initiatives faced much opposition from the political class in the 1980s due to the dominant ideology of the moral model, which stressed the war on drugs (Showalter, 2018). The critics of the syringe exchange programs triggered the inclusion of a provision prohibiting the use of federal funds to finance the programs unless research proved they were safe and effective. The breakthrough for SEPs in the United States began in 2015 following the opioid epidemic, which also triggered the outbreak of HIV (Showalter, 2018). This led to the legalization of SEPs in several states resulting in the lifting of the ban on using federal funds for the programs (Showalter, 2018). Nevertheless, the national finances could not be used to buy syringes and needles but only to pay staff, rent, and other services or expenses required to operate the programs effectively (Showalter, 2018). Therefore, since its inception, the harm reduction approach has gained popularity as a prevention measure against HIV and a treatment for drug use disorders.
Principles of Harm Reduction
The harm reduction approach is guided by principles that ensure substance users receive the necessary support unconditionally. All harm reduction programs and policies are grounded on robust evidence guaranteeing that the interventions are feasible, effective, practical, cost-effective, and safe across diverse social, economic, and cultural settings (Harm Reduction International, 2022). For instance, most harm reduction strategies, such as SEPs, have proven to be economical, easy to implement, and positively impact individual drug users and the larger communities (Harm Reduction International, 2022). In addition, the harm minimization practice is also guided by the precept of pragmatism (Kimmel et al., 2021). This principle acknowledges that alcohol and substance abuse is a multi-faceted and complex issue that involves a continuum of behaviors from acute drug use to abstinence. Therefore, abstinence from risky behaviors should not be assumed or prioritized as the patient’s goal; instead, a range of supportive services should be provided to substance users.
The commitment to protecting human rights is a critical value guiding harm minimization initiatives. This principle is referred to as humanism, which necessitates healthcare providers to treat alcohol and drug users, their families, and communities with dignity, respect, and kindness (Kimmel et al., 2021). Individuals with alcohol or drug addictions are still entitled to the right to life, high-quality healthcare services, and freedom from inhuman and degrading treatment. Similarly, the harm minimization techniques adopt a non-judgmental approach that accepts individuals where they are in life (Logan & Marlatt, 2010). These programs and policies are grounded on the notion that substance abuse forms part of society and drug users should be supported without judgment or condemnation. Equally, the harm reduction programs are informed by the value of empowerment of substance abusers as the primary agents for lessening the harms linked to their drug use (MacCoun, 1998). Supporting substance abusers through education and access to vital supplies such as sterile syringes and medically prescribed opiates places them in a better position to prevent harm.
The harm reduction practice is directed by the principle of inclusion of drug users and those in recovery in the creation of substance use-related policies and programs. The involvement of these substance users in treatment programs may significantly boost adherence to various treatment plans hence lessening incidences of drug overdose (Harm Reduction International, 2022). Additionally, this approach focuses on quality improvement of life over abstinence. It emphasizes enhancing the well-being of substance abusers and their communities without compelling the affected populations to cease using drugs. Furthermore, these interventions are informed by a precept that opposes the stigmatization of alcohol or drug use disorders (Harm Reduction International, 2022). This principle directs a non-judgmental and non-coercive delivery of resources and services to substance users and first responders in their communities to lessen drug-related injuries. Moreover, incrementalism is another key tenet of the harm reduction practice (Kimmel et al., 2021). It acknowledges any positive change made by the substance abusers, no matter how small. Allowing alcohol and drug users to succeed in small steps reinforces progress in their treatment plans.
Evidence-based Harm Reduction Methods
Harm reduction incorporates several social services and practices that apply to substance use. Some of these strategies include the SEPs, also known as syringe services programs (SSPs). These community-based initiatives provide PWID with access to sterile needles and syringes. The programs aim to decrease the spread of blood-borne infections, including HIV and hepatitis C virus (HCV), among drug users by discouraging needle-sharing. Research indicates that SSPs have caused a 58% decrease in the incidences of HIV among PWID (Lambdin, 2020). In addition, the SSPs offer evidence-based education on opioid overdose and serve as avenues for naloxone distribution (Lambdin, 2020). Similarly, the programs offer referral to drug use disorder treatment or detoxification services while providing screening, care, and treatment for HIV, HCV, and tuberculosis, among other viral infections. The programs also offer information and education on drug use reduction, safer injection practices, and prevention of HIV and other sexually transmitted infections (STIs). Moreover, SSPs provide referrals to mental health, social, legal, and other medical services. They also facilitate the safe disposal of used syringes, further preventing the transmission of infections among PWID.
Providing a safer injection facility is another approach to harm reduction among drug users. These are legal, medically-supervised sites for intravenous drug use. These facilities offer a hygienic and safe environment where drug users can inject themselves intravenously with drugs (Krawczyk et al., 2022). However, the premises do not sell illegal substances, nor do the medical staff administer the drugs. The benefit of the safe injection sites is that by providing a secure and sterile environment for PWID, they lessen the risk of public injection, which may result in the transmission of infections, including HIV and HCV (McClure, 2022). In addition, the presence of medical staff is critical in preventing overdose and offering the first response in case of overdose. This personnel is trained to use naloxone, the overdose-reversing medicine (Krawczyk et al., 2022). Similarly, safer injection sites also provide other services such as referrals for drug use disorder detoxification or treatment programs and access or recommendations to psychological, social, legal, or other medical services (McClure, 2022). Thus, safer injection centers provide a sterile and secure setting that prevents transmission of infections through needle-sharing and cases of drug overdoses.
The overdose prevention program is another vital harm reduction technique that has benefitted many drug users. This initiative educates drug users on the risks and symptoms of drug overdose to prevent the loss of lives (Krawczyk et al., 2022). It also increases the access of drug abusers to naloxone, a medicine that counters the impacts of opioid overdose (Krawczyk et al., 2022). Through this program, drug users and other first responders, such as social workers and law enforcement officers, receive training on resuscitating overdose victims and administering naloxone to lessen overdose-related deaths. For instance, a naloxone distribution project in Massachusetts decreased fatalities linked to opioid overdose by about 11% in nineteen communities involved in the program without accelerating opioid use (National Institute on Drug Abuse, 2021b). Research also indicates that opioid-related overdose deaths declined by 14% across the states following the enactment of naloxone access laws (National Institute on Drug Abuse, 2021b). Hence, the overdose prevention initiatives provide access to naloxone, which is critical for reversing the effects of opioid overdose.
Opioid substitution treatment (OST) decreases illicit opioid usage and overdose-related deaths. Substitution therapy, also known as agonist pharmacotherapy, is an evidence-based intervention for individuals with opiate dependence that replaces illegal substances with orally administered opiates that are medically prescribed (O’Connor et al., 2020). OST is mainly used for individuals dependent on heroin or opioids such as morphine, fentanyl, or oxycodone. The illicit drugs are replaced with medically prescribed opiates, including methadone and buprenorphine (Krawczyk et al., 2022). These opioid agonists occupy the same receptor cells in the brain as heroin and other illicit opiates, alleviating withdrawal symptoms and blocking cravings for hard drugs. Thus, OST has significantly helped treat opioid use disorders (OUD), which has led to a decline in opioid overdose-related fatalities (O’Connor et al., 2020). In addition, this approach has been linked to a reduction in HIV risk tendencies, criminal activities, and harms associated with the injection of drugs (O’Connor et al., 2020). This can be attributed to the counseling and education about safer injection practices and the need for adherence to HIV and other treatments offered by these programs.
Legislative Efforts in Promoting Harm Reduction Programs
Over the years, there has been growing research indicating the efficacy of the harm reduction approach in treating drug use disorders and decreasing the transmission of HIV and HCV. As a result, governments across the globe are slowly integrating these programs into their health policies. For instance, in April 2022, the White House included the harm reduction approach as a fundamental pillar in the National Drug Control Strategy for the first time (McClure, 2022). This initiative aims to provide critical services to drug users to avert incidences of drug overdose and transmission of infectious illnesses, as well as enhance the social, mental, and physical well-being of these communities. Additionally, the Centers for Disease Control and Prevention (CDC) and Substance Abuse and Mental Health Services Administration (SAMHSA) agencies have permitted local governments to use federal finance to purchase fentanyl test strips (McClure, 2022). Similarly, since 2021, SAMHSA has offered over $30 million worth of harm reduction-related grants to around 25 counties, cities, and community groups to foster education, counseling, and overdose reversal drugs (McClure, 2022). This indicates the attempts by different agencies to support harm minimization interventions.
Several states and territories across the United States have shown increased efforts in embracing some harm reduction interventions. About 43 states have legalized and expanded the SSPs, allowing for needle exchange, education, and testing for HIV and HCV, as well as referrals for drug use disorder and mental health treatment (McClure, 2022). Additionally, by July 2022, all 50 states had permitted the use of naloxone without a prescription (McClure, 2022). Furthermore, other states, such as New York, have introduced overdose prevention centers to connect substance users to treatment options.
Generally, the growing adoption of harm minimization interventions is being witnessed globally. Research indicates that approximately 92 countries have enacted needle and syringe programs (Harm Reduction International, 2022). In addition, about 87 nations offer opioid agonist therapy, while around 16 countries have functional drug consumption rooms (Harm Reduction International, 2022). Not to mention, approximately 104 nations have included harm reduction in their national policies (Harm Reduction International, 2022). This proves the increased acceptance and adoption of harm reduction interventions in different parts of the world.
Challenges of Harm Reduction
Despite the efficacy of harm reduction programs and policies in treating drug use disorders and reducing the spread of infectious diseases, the success of these approaches has continuously been limited by several problems. One of the significant challenges facing harm reduction strategies is increased political opposition to implementing and expanding harm minimization programs (McClure, 2022). For example, overdose prevention centers (OPC) or supervised consumption sites have been cited as safe spaces for drug users and have been shown to save lives and connect substance users to treatment. In addition, OPCs have been identified as cost-effective and have not been linked to increased crime or drug use. Nevertheless, in the United States, only New York has authorized the operations of OPCs (McClure, 2022). In 2022, Vermont and California legislatures approved bills authorizing OPCs to be considered in the states; however, in both cases, the legislation was vetoed by the governors (McClure, 2022). Gavin Newsom, the California Governor, cited concerns that OPCs may promote illegal drug usage, while Phil Scott, the Vermont Governor, claimed a lack of data supporting the efficacy of OPCs.
Another challenge affecting the efficacy of harm reduction programs in managing SUDs is the limited expansion to suburban and rural areas. Most harm reduction services are prevalent in urban regions, making it difficult for individuals who use drugs in rural areas to access them (Ibragimov et al., 2020). This has resulted in high overdose cases and high transmission rates of infectious diseases in these remote regions. There are also economic and transportation challenges in delivering the harm reduction services to drug users in isolated territories (Ibragimov et al., 2020). Not to mention, another pressing problem for harm reduction programs is limited funding. For example, states that have authorized SEPs are severely underfunded (Wenger et al., 2021). As a result, most of these states lack active syringe exchange initiatives, with a few having them in one or two towns in the entire state. The chronic underfunding for harm minimization programs challenges their efficiency in treating SUDs.
Conclusion
In conclusion, the harm reduction model has become integral in managing the adverse effects associated with substance abuse. The traditional abstinence approach to drug use has become ineffective amidst the growing substance misuse epidemic worldwide. This has necessitated a mild, humane and pragmatic intervention that focuses on reducing the harmful effects of substance abuse rather than total elimination. The principles of pragmatism, humanism, incrementalism, evidence-based research, and empowerment of substance users guide the harm reduction model. The main harm reduction programs include SEPs, safe injection sites, overdose prevention programs, and OSTs. SEPs provide access to sterile needles and syringes to discourage needle sharing, which lessens the transmission of HIV and HCV. Alternatively, the safe injection facilities offer a safe environment and sterile equipment to intravenous drug users, which have proven effective in decreasing overdose cases and transmission of blood-borne infections. The overdose prevention programs and OST offer access to overdose-reversal medication, reducing drug-related fatalities. However, despite the growing acceptance of the harm reduction model, limited funding and political opposition remain a great hindrance deterring its efforts to assist all substance users who need physical, emotional, and mental health services.
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