Harm reduction (HR) is an important tool for the behavioral health professional’s use when considering how best to address the issue of substance use. It is a fact, however, disturbing it may be, that we human beings have used, continue to use, and will likely always use licit and illicit substances. Although most users do so without experiencing a substance use disorder (SUD), their use, as well as the use of those who do develop a SUD too often, involves health-related risks and problems, some of which result in death.
HR. is essentially a collection of principles[1] that acknowledge that although substance use is and will likely continue to remain a fact of life, it is imperative for society in general and healthcare professionals specifically to champion adherence to these principles and strive to reduce the likelihood of untoward consequences resulting from the use of any psychoactive substances, licit or illicit.
Substance use, licit or illicit, is neither a moral nor legal issue, it is a healthcare issue. As such, efforts to interceded in the use of such substances should seek to minimize the likelihood of harm for those who use and advocate for the treatment of those whose use has resulting in a SUD. Unfortunately, the use of illicit substances in general and “addiction” specifically carry the stigma of problems realized by those morally weak and/or criminally disposed members of society.
Addiction is, in many ways a social construction - A social construct is something that exists not in objective reality, but as a result of human interaction. It exists because humans agree that it exists[2]. In other words, addiction is a collection of behaviors that society has deemed outside the bounds of its vie of normal and therefore aberrant. Because those with addictions do not behave in accordance with what society deems acceptable and appropriate behavior, these individuals must, therefore, suffer from some degree of moral turpitude or be criminally inclined. This “moral model” view of addiction explains our societal reaction to those who use illicit substances or display the symptoms of what we call a substance use disorder. It also justifies our proclivity as a society to arrest and punish rather than diagnose and treat those who use illicit substances.
To pursue the specifics of the moral model and its impact on the history of the treatment of SUDs is
beyond the scope of this essay. It is the prevention of harm to those who use substances, licit or illicit, irrespective of their reasons for use…physical dependence or hedonistic reward…that is the reason for this piece.
The pursuit of harm reduction can lead a healthcare professional in one or two general directions. The first, regarding treatment, results in the practitioner’s efforts to engage individuals in a way that increases the likelihood of motivating users to reconsider their use, thereby increasing the likelihood of reducing the frequency and/or quantity of that use. The second regards simply reducing the risk of untoward consequences resulting from use. Treatment is not the primary objective, just the reduction of harm associated with the use, both to the user and to the society in which that user resides.
Interestingly, HR. efforts in pursuit of the second objective can and often do result in the opportunity to pursue the first, treatment. An example of this is the evidence that comes from harm reduction efforts like “user room.” In the Netherlands, Amsterdam specifically, user rooms are places where individuals can go to consume their substances…drugs…safely. Trained staff supervise these locations, often with EMT experience and access to Naloxone. At such facilities, users can shower, wash their clothes, get something to eat, and have their basic human needs addressed. While visiting a “user room,” individuals would often establish a rapport with staff and over a period of visits, begin to talk about their use with staff. The staff, often trained in Motivational Interviewing techniques, then engage users in a discussion about the benefits and costs of their use, helping users to take a critical look at the “return on investment” related to their substance use, a more than occasional result being the user’s entering treatment.
Harm reduction efforts related to substance use are more concerned with the user and those with whom the user has contact than with the legality of use or the socially constructed barriers that distinguish between the “appropriate use of licit substance,” like alcohol, or its “inappropriate use” or the use of any illicit substance. It is an approach rooted in the belief that the prevention of harm is rooted in the promotion of health and therefore a quintessential exemplar of health care.
And before rejecting this argument by citing concerns about needle exchange programs, the encouragement of use by user rooms, or state-supported addiction in methadone maintenance programs, notice how dependent we all are on harm reduction in our lives already: seat belts, airbags, antilock brakes, fire retardant clothing, smoke detectors, CO2 detectors, hand railings, antiskid strips on steps, sunscreen, etcetera, etcetera, etcetera.
What do you think?
Dr. Robert
[1] See Principles of Harm Reduction at https://harmreduction.org/about-us/principles-of-harm-reduction/ for a summary of these principles.
[2] Bainbridge, Carol (2020). CF - https://www.verywellmind.com/definition-of-social-construct-1448922
