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... Effective implementation of a smoking RTI may therefore also require provision of such a space in addition to the standard counseling, foil, and matches. Precedent for such "tolerance areas" exists (Riley and O'Hare 2000). For example, they have taken the form of drug consumption rooms or supervised/safe injecting rooms in Europe, Australia, and Canada (Haemmig and van Beek 2005;Hedrich et al. 2010), as well as unmolested open-drug-scene parks in Frankfurt, Germany, in the 1980s that facilitated provision of services to heavy drug users (Riley and O'Hare 2000). ...
... Precedent for such "tolerance areas" exists (Riley and O'Hare 2000). For example, they have taken the form of drug consumption rooms or supervised/safe injecting rooms in Europe, Australia, and Canada (Haemmig and van Beek 2005;Hedrich et al. 2010), as well as unmolested open-drug-scene parks in Frankfurt, Germany, in the 1980s that facilitated provision of services to heavy drug users (Riley and O'Hare 2000). But not all tolerance areas have been a success. ...
... But not all tolerance areas have been a success. "Needle Park" in Zurich, Switzerland, for example, was closed twice in the early and mid 1990s because it became "unmanageable" (Riley and O'Hare 2000). Nevertheless, the successes demonstrate that the concept is viable. ...
An HIV epidemic threatens injecting drug users in Kabul, Afghanistan. Although opioid substitution therapy (OST) has been proven to reduce the spread of HIV and decrease injecting drug use in many parts of the world, including on a small scale in Afghanistan, political obstacles suggest that at this time it may not be a viable intervention there. In this thesis, therefore, I assess the feasibility of implementing an alternative to OST as an HIV-prevention strategy, namely, a non-OST route-transition intervention (RTI) designed to encourage and enable opiate users to switch from injecting to smoking (also called chasing). Based on semi-structured interviews and a focus-group discussion with drug-related institutional stakeholders in Kabul—including harm reduction professionals, treatment providers, public health officials, and police officers—I describe the perceived obstacles to, as well as facilitators and benefits of, harm reduction in general and RTI in particular. Most participants supported the RTI concept and believed that it would be feasible to implement such a program provided that doing so included educating communities and stakeholders about harm reduction and the harms of drug use, building cooperative alliances with them, and involving them in the planning process. Many also stressed the importance of incorporating a sanctioned place for opiate smoking into an RTI program. RTI appears to be a promising component of efforts to address the emerging concentrated HIV epidemic in Kabul and prevent its further spread, but it is not free of significant challenges. I discuss these and suggest potential ways of overcoming some of them.
... Indeed it had arrived, but to a relatively cool reception from U.S. policymakers. In previous federal administrations, proponents of harm reduction were marginalized, and harm reduction approaches were often criminalized (Moskalewicz et al., 2007;Riley & O'Hare, 2000). Fortunately, at the time we are writing this chapter, harm reduction is enjoying a warmer welcome. ...
... To demonstrate this multifactor approach, we will use injection drug use and HIV risk as an example. We may consider harm on (1) an individual level (e.g., HIV contraction from shared needles, necrotizing skin infections); (2) a community level (e.g., unsafe drug use environments posing risks to the affected individual and their community, overburdened local police); and (3) a societal level (economic loss due high emergent use of publicly funded health services, increasing infection rates) (Riley & O'Hare, 2000). Given the particular set of circumstances in a spe cific culture and setting, what constitutes "harm" may look very different. ...
... Definitions of what constitutes harm reduction have varied widely in the literature and have not been without controversy (Ball, 2007;Heather, 2006;Leshner, 2008;Riley & O'Hare, 2000;Single, 1995). Deciding what a harm reduction approach will entail in a given situation requires a thorough analysis of the targeted harm, the context (i.e., culture, feasible approaches, targeted level and areas), and additional harms that might be encountered in other areas as harm is reduced in one . ...
... Whilst there had been reference to minimising harm in the alcohol and drug literature from the mid 1970's (Erickson, 1995), it only emerged as a significant paradigm in Australia in 1985. The first needle exchange programs were established in the UK (at Merseyside) in 1986 and in Amsterdam in 1984 (Riley & O'Hare, 2000). In 1990 the first International Conference on the Reduction of Drug Related Harm was held in Liverpool. ...
... @BULLET that it is built on evidence-based analysis (strategies need to demonstrate, on balance of probabilities, a net reduction in harm); @BULLET that there is acceptance that drugs are a part of society and will never be eliminated; @BULLET that harm reduction should provide a comprehensive public health framework; @BULLET that priority is placed on immediate (and achievable) goals; and that @BULLET pragmatism and humanistic values underpin harm reduction (Hamilton & Rumbold, 2004; Heather, 1995; Hunt, 2003; Lenton & Single, 1998; Riley & O'Hare, 2000; Single, 1995). Other terms used include harm minimisation, risk reduction, and risk minimisation (Riley & O'Hare, 2000). ...
... @BULLET that it is built on evidence-based analysis (strategies need to demonstrate, on balance of probabilities, a net reduction in harm); @BULLET that there is acceptance that drugs are a part of society and will never be eliminated; @BULLET that harm reduction should provide a comprehensive public health framework; @BULLET that priority is placed on immediate (and achievable) goals; and that @BULLET pragmatism and humanistic values underpin harm reduction (Hamilton & Rumbold, 2004; Heather, 1995; Hunt, 2003; Lenton & Single, 1998; Riley & O'Hare, 2000; Single, 1995). Other terms used include harm minimisation, risk reduction, and risk minimisation (Riley & O'Hare, 2000). The preferred term in the DPMP is harm reduction, following the somewhat Australian convention of using harm minimisation to refer to the philosophical approach or general principles, and harm reduction to the specific interventions. ...
... The harm reduction model is an atheoretical approach (Brocato & Wagner, 2003) that is largely informed by the public health model that seeks to lessen the harm alcohol and drug users do to themselves and society (Denning, 2001;Erickson, 1995;Marlatt, 1996). Harm reduction approaches have predominantly been applied to substance use disorders, although they have also been used in the areas of HIV/AIDS, heart disease, and smoking prevention (Marlatt, 1996;Riley & O'Hare, 2000). In this article we use the term substances to include alcohol and other drugs and substance use disorders to include both alcohol and other drug use disorders. ...
... In this model, practitioners utilize assertive outreach and engagement and motivational strategies such as education, resource allocation, and client support to minimize the primary and secondary harmful effects of alcohol and drug use such as overdoses, spread of infectious diseases, victimization, criminal activity, homelessness, and violence (Marlatt, 1996;Riley & O'Hare, 2000). ...
... Although the most desirable outcome in harm reduction programs is the elimination of use (i.e., abstinence), programs that use harm reduction differ from traditional, abstinence-only programs in that these programs do not make abstinence or the desire to obtain abstinence the only treatment goal or a prerequisite to receive services. Rather, harm reduction programs focus on a continuum of outcomes that include helping clients switch to safer substance alternatives (i.e., methadone, nonintravenous drugs), educating clients about safer use practices to prevent overdose, prevention of victimization, reduction of health problems (i.e., using with trusted others, use of clean needles or bleaching kits, condom use), and motivating clients to reduce their alcohol or other drug use (Marlatt, 1996;Riley & O'Hare, 2000). The vast majority of research on the harm reduction approach has involved programs designed to reduce the harmful consequences of intravenous (IV) drug use. ...
The social work literature recently has supported greater use of the harm reduction approach in professional practice. Implementing this approach, however, presents its challenges. We explore how practitioners in a housing program for people with histories of psychiatric disabilities, substance use disorders, and homelessness perceived the harm reduction approach. Prior to the opening of this new program, agency staff completed a questionnaire and participated in focus groups designed to explore their perceptions and level of support of the harm reduction approach used in the program. The goal of this evaluation was to understand the challenges of implementing a harm reduction approach in programs serving people with dual diagnosis and the implications this has for program administrators, staff, and clients. We found that practitioners, overall, favored the approach's pragmatism and its focus on client engagement, but many were frustrated by its perceived ambiguity regarding long-term outcomes and client expectations. We conclude with recommendations for how program administrators can facilitate the effective implementation of the harm reduction approach.
... Harm reduction has traditionally focused on mitigating the risks of injection drug use (IDU) [7,[12][13][14][15] by providing access to sterile syringes via syringe service programs (SSPs) [16], and, more recently, supervised injection facilities [14,[17][18][19][20]. SSPs and the concept of risk reduction were adopted as public health strategies by several countries in the 1980s (e.g., Australia, Brazil, Denmark, Netherlands, some states in the U.S., United Kingdom) in the midst of the HIV/AIDS epidemic [7,21]. In 1986, the World Health Organization was the first major international body to accept and endorse harm reduction [21], marking an influential shift in historically punitive global drug policies [22]. ...
... Harm reduction has traditionally focused on mitigating the risks of injection drug use (IDU) [7,[12][13][14][15] by providing access to sterile syringes via syringe service programs (SSPs) [16], and, more recently, supervised injection facilities [14,[17][18][19][20]. SSPs and the concept of risk reduction were adopted as public health strategies by several countries in the 1980s (e.g., Australia, Brazil, Denmark, Netherlands, some states in the U.S., United Kingdom) in the midst of the HIV/AIDS epidemic [7,21]. ...
Background
Providing sterile drug smoking materials to people who use drugs can prevent the acquisition of infectious diseases and reduce overdose risk. However, there is a lack of understanding of how these practices are being implemented and received by people who use drugs globally.
Methods
A systematic review of safer smoking practices was conducted by searching PubMed, PsycInfo, Embase for relevant peer-reviewed, English-language publications from inception or the availability of online manuscripts through December 2022.
Results
Overall, 32 peer-reviewed papers from six countries were included. 30 studies exclusively included people who use drugs as participants ( n = 11 people who use drugs; generally, n = 17 people who smoke drugs, n = 2 people who inject drugs). One study included program staff serving people who use drugs, and one study included staff and people who use drugs. Sharing smoking equipment (e.g., pipes) was reported in 25 studies. People who use drugs in several studies reported that pipe sharing occurred for multiple reasons, including wanting to accumulate crack resin and protect themselves from social harms, such as police harassment. Across studies, smoking drugs, as opposed to injecting drugs, were described as a crucial method to reduce the risk of overdose, disease acquisition, and societal harms such as police violence. Ten studies found that when people who use drugs were provided with safer smoking materials, they engaged in fewer risky drug use behaviors (e.g., pipe sharing, using broken pipes) and showed improved health outcomes. However, participants across 11 studies reported barriers to accessing safer smoking services. Solutions to overcoming safer smoking access barriers were described in 17 studies and included utilizing peer workers and providing safer smoking materials to those who asked.
Conclusion
This global review found that safer smoking practices are essential forms of harm reduction. International policies must be amended to help increase access to these essential tools. Additional research is also needed to evaluate the efficacy of and access to safer smoking services, particularly in the U.S. and other similar countries, where such practices are being implemented but have not been empirically studied in the literature.
... "Harm reduction" is the name given to a social and health services approach that seeks to reduce the harmful effects of usually stigmatized behaviours. HR emerged in the mid-1980s in response to rampant HIV infection among injection drug users [46]. Prior to the rise of HR, the principal approach to injection drug use was prevalence reduction, whose primary goal was to get drug users to stop using. ...
... HR was developed on the ground by front-line workers and drug users seeking a practical solution to a burgeoning HIV crisis [46]. As a social and health services approach, HR has in general retained a narrow focus, and the literature reproduces that narrow focus. ...
In this paper, I offer a prolegomenon to the philosophy of harm reduction. I begin with an overview of the philosophical literature on both harm and harm reduction, and a brief summary of harm reduction scholarship outside of philosophy in order to make the case that philosophers have something to contribute to understanding harm reduction, and moreover that engagement with harm reduction would improve philosophical scholarship. I then proceed to survey and assess the nascent and still modest philosophy of harm reduction literature that has begun to emerge. I pay particular attention to two Canadian philosophers who have called for the expansion of harm reduction beyond the realm of so-called “vice” (that is, addiction, intoxicants and sex work). Finally, I sketch some of the most interesting and important philosophical issues that I think the philosophy of harm reduction must grapple with going forward.
... Prevalence of these diseases is significantly higher in IDU populations because they are efficiently transmitted through the sharing of drug injecting equipment [5,6]. To address this public health problem, many cities have sought to establish SEPs which strive to reduce the harm experienced by drug injecting behaviors [7]. Grounded in the concept of harm reduction, SEPs seek to minimize the negative consequences associated with drug use by providing education, support, or alternative behaviors, with the understanding that abstinence from drug use behaviors may not be realistic or desirable for everyone [7,8]. ...
... To address this public health problem, many cities have sought to establish SEPs which strive to reduce the harm experienced by drug injecting behaviors [7]. Grounded in the concept of harm reduction, SEPs seek to minimize the negative consequences associated with drug use by providing education, support, or alternative behaviors, with the understanding that abstinence from drug use behaviors may not be realistic or desirable for everyone [7,8]. First introduced in the United States in the 1980s, SEPs gained momentum and appreciation after the advent of HIV, when it was realized that HIV's rapid spread among drug injectors could be controlled if individuals used clean syringes instead of sharing potentially disease-infected ones [9,10]. ...
This study examines trends of injection drug users' (IDUs) use of a Philadelphia, Pennsylvania, syringe exchange program (SEP) from 1999 to 2014, including changes in demographics, drug use, substance abuse treatment, geographic indicators, and SEP use. Prevention Point Philadelphia's SEP registration data were analyzed using linear regression, Pearson's Chi square, and t-tests. Over time new SEP registrants have become younger, more racially diverse, and geographically more concentrated in specific areas of the city, corresponding to urban demographic shifts. The number of new registrants per year has decreased, however syringes exchanged have increased. Gentrification, cultural norms, and changes in risk perception are believed to have contributed to the changes in SEP registration. Demographic changes indicate outreach strategies for IDUs may need adjusting to address unique barriers for younger, more racially diverse users. Implications for SEPs are discussed, including policy and continued ability to address current public health threats.
... The term "harm reduction" has been used variously to describe a principle, concept, ideology, policy, strategy, set of interventions, target and movement (Ball, 2007). It is a term which is used interchangeably with "harm minimisation" and "risk reduction" (Riley & O'Hare, 2000;Hunt, 2003). Although harm reduction has been variously practiced in different forms and locations for some time, it received renewed impetus and became more formalised more recently as a direct result of the spread of viral Hepatitis and HIV/AIDS among intravenous drug users (Riley & O'Hare, 2000;Royal College of Psychiatrists, 2000;Ghodse, 2002). ...
... It is a term which is used interchangeably with "harm minimisation" and "risk reduction" (Riley & O'Hare, 2000;Hunt, 2003). Although harm reduction has been variously practiced in different forms and locations for some time, it received renewed impetus and became more formalised more recently as a direct result of the spread of viral Hepatitis and HIV/AIDS among intravenous drug users (Riley & O'Hare, 2000;Royal College of Psychiatrists, 2000;Ghodse, 2002). Harm reduction education is education about, rather than against substances and is non-judgemental and neither condones nor condemns drug use, but accepts that it does, and will continue to occur (Cohen, 1992). ...
Background: The study aimed to trial an adapted version of the School Health and Alcohol Harm Reduction Project (SHAHRP) in Northern Ireland. The intervention aims to enhance alcohol-related knowledge, create more healthy alcohol-related attitudes and reduce alcohol-related harms in 14–16-year-olds.
Method: A non-randomised control longitudinal design with intervention and control groups assessed students at baseline and 12, 24 and 32 months after baseline. Students were from post-primary schools (high schools) in the Eastern Health Board Area in Northern Ireland. Two thousand three hundred and forty nine participants were recruited at baseline (mean age 13.84) with an attrition rate of 12.8%% at 32-month follow-up. The intervention was an adapted, culturally competent version of SHAHRP, a curriculum programme delivered in two consecutive academic years, with an explicit harm reduction goal. Knowledge, attitudes, alcohol consumption, context of use, harm associated with own alcohol use and the alcohol use of other people were assessed at all time points.
Results: There were significant intervention effects on all measures (intervention vs. controls) with differential effects observed for teacher-delivered and outside facilitator-delivered SHAHRP.
Conclusion: The study provides evidence of the cultural applicability of a harm reduction intervention (SHAHRP) for risky drinking in adolescents in a UK context.
... Broadly defined, harm reduction is a pragmatic set of strategies that aim to reduce harms associated with drug use both in terms of immediate intervention as well as preventive support for continued or habitual use [42,56]. Over the years, definitions of harm reduction evolved and adapted to broad policy measures and intervention programs, ranging from harm reduction as public health strategy and alternative to criminalization [43], to recognizing pleasures of drug use, peer safety and care [53], to harm reduction as a liberatory practice and a political philosophy [35]. ...
Recent years have marked a shift in selling and buying illicit psychoactive drugs from darknet cryptomarkets to publicly accessible social media and messaging platforms. As more users turn to procuring drugs this way, the role of digital harm reduction has become particularly urgent. However, one of the main obstacles complicating the implementation of digital harm reduction is the increasingly automated content moderation by the social media platforms. While some platforms are less restrictive about harm reduction content (e.g., TikTok), others implement higher degrees of moderation, including the removal of individual content and banning of entire profile pages (e.g., Instagram). This article discusses community guidelines of five popular social media and messaging platforms and their content moderation tools. It aims to highlight how these guidelines may be inadvertently curbing the dissemination of harm reduction and health promotion materials, and erroneously interpreting it as a promotion of drug use and sales. The discussion concludes that digital harm reduction requires transdisciplinary collaboration of professional organizations, researchers, and social media platforms to ensure reliable implementation of digital harm reduction, and help build safer digital communities.
... However, these practices acknowledge that "high-risk" behaviors are deeply complex and influenced by the current societal climates. Overarchingly, the harm reduction lens provides guidance on intervention at the individual, community, and societal levels and views the health, social, and economic consequences of behaviors (Riley & O'Hare, 2000). Building from these roots, the harm reduction model can be taught in all disciplines of health care, as all providers should seek to reduce harm for clients. ...
... Though these elements tend to be overlooked in technical definitions of THR as product substitution, they have shaped harm reduction in the addiction field since its origins. 53 When we "elevate the value of users' experiential knowledge over biomedical authorities", we see a more complete and contextualized person and can build harm reduction strategies from the ground up. 48 Especially prominent in a person-centered approach to harm reduction is the incorporation of peers in harm reduction efforts. ...
Introduction:
Cigarette smoking is among the most harmful ways to consume nicotine and tends to be concentrated among socially marginalized groups of people, including sexual and gender minorities (SGM). Though some approaches to tobacco control in the U.S. are harm reduction strategies (e.g. smoke-free environments), often abstinence is an explicitly-stated goal and discussions of tobacco harm reduction (THR) are controversial, particularly for young people. Despite this controversy in the tobacco field, emerging research suggests that THR may be gaining momentum as a "community-led" rather than 'public health-led' health practice. To date, little is known about how SGM young adults negotiate their use of tobacco products, particularly in terms of minimizing the harms associated with smoking.
Methods:
We conducted 100 in-depth interviews with SGM young adults ages 18-25 living in the San Francisco Bay Area, to better understand participant perceptions and everyday practices related to THR.
Results:
A thematic analysis of interview narratives revealed the ways in which participants relied upon various THR strategies while balancing their wellbeing within the context of broader socio-structural harms. Participants' narratives also underscored beliefs about the importance of pragmatic, nonjudgmental, and person-centered approaches to preventing inequities in tobacco-related illnesses.
Conclusions:
Findings represent a significant departure from the mainstream discourse in the United States surrounding THR, by revealing how understanding the practice of THR among SGM young adults who use nicotine and tobacco can be instrumental in shaping approaches to tobacco control policy and prevention that may ultimately help to reduce inequities in tobacco-related illnesses.
Implications:
Findings from this study present the perspectives and practices of tobacco harm reduction among sexual and gender minority young adults and emphasize the importance of integrating this approach in tobacco control to better achieve tobacco-related equity. Results can be used to better design tobacco prevention, treatment, and policy strategies that are compassionate and responsive to the needs of these important priority populations.
... Public health and social interventions and policies that address the causes and consequences of structural vulnerability are a core component of a robust societal response to substance use. This includes supporting PWUD to be as safe and healthy as possible through a harm reduction approach to policymaking which does not enforce abstinence or make care contingent on reductions in substance use ( Riley & O'Hare, 2000 ). Harm reduction developed as informal and illegal grassroots practice (e.g., distribution of sterile syringes) led by PWUD, frontline workers, and allies, and aimed to promote and protect the human rights of PWUD and achieve broader structural changes such as access to adequate housing and income, and the legalization of drugs and sex work ( Roe, 2005 ;Smith, 2012 ). ...
Background
Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD.
Methods
The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings.
Results
The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors.
Conclusions
Structural vulnerability is salient within Canadian policy actors’ discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity.
... Harm Reduction was originally proposed as a strategy for engaging people who use illicit substances in a respectful nonjudgmental manner recognizing that abstinence from drug use may be unrealistic or undesirable (Riley & O'Hare, 1999). In nursing, harm reduction values are aligned with professional ethical values in nursing (Lightfoot et al., 2009;Pauly et al., 2007). ...
People who use illicit substances and experience socioeconomic disadvantage experience poor health as a result of structural vulnerabilities made worse by barriers to health care. In particular, stigma and discrimination often act as a barrier to health care for people who use illicit substances. Lack of respect for persons and judgements based on discrimination are in violation of core ethical principles of nursing practice. Harm reduction, as a guiding philosophy, is proposed as a way to promote respectful and non-judgmental care and minimize the harms associated with illicit substance use in alignment with principles of ethical nursing practice. Utilizing McLeroy’s Ecological Model of Health Promotion as the guiding framework, we conducted an integrated review of relevant literature to identify recommendations for implementing harm reduction in nursing practice at the intrapersonal, interpersonal, and institutional levels. The search yielded 20 primary research articles published from 2008 until 2020 to identify the actions necessary to implement harm reduction in nursing practice. This integrative review summarizes evidence-based actions necessary from the micro- to meso-level to support the implementation of harm reduction as a guiding philosophy to enhance ethical practice in nursing.
... For instance, some construe it as a strategy while others consider it a goal. Some take it to encompass measures that are aimed at eventually weaning off those addicted to scheduled drugs, while others consider the reform of laws that seek to decriminalise drug possession as an integral part of it (Michels, Stover, andGerlach, 2007 Bewley-Taylor, 2012;Riley and O'Hare, 2000;Roe, 2005;Reinarman and Levine, 1997). ...
This study will attempt to map a set of personality and psycho-social factors to the social media postings of two groups of individuals who were influenced by propaganda material about or from the Islamic State in Iraq and Syria (ISIS). The aim of this study is to see if – and how – the social media postings of the individual actor can be used to distinguish foreign fighters (i.e., individuals who travelled to join ISIS) from sympathisers (i.e., individuals who did not travel to join ISIS). 622 tweets posted by a sample of three foreign fighters and three sympathisers were mapped against 12 factors. Mean interrater reliability was .81, and ranged from good to excellent across all variables. One significant difference (i.e., readiness to use violence) was found between the two groups and the finding has opened new direction for further research, with the goal of providing empirical support for the online threat assessments of violent extremists.
... De manière générale, même si le concept de réduction des méfaits n'est pas précis (Kleinig, 2008), plusieurs auteurs s'entendent pour définir la réduction des méfaits comme un ensemble de mesure qui vise la prévention ou la diminution des conséquences néfastes sur la santé, le bien-être, le plan social et économique sans toutefois exiger l'abstinence de drogues (Riley et O'Hare, 2000 ;Kleinig, 2008). ...
La relation entre les intervenants en milieu de soins et leurs clients est souvent le lieu de profondes incomprehensions et de tensions entre les valeurs de liberte et de securite. Cela est particulierement perceptible dans la relation avec les personnes souffrant de problemes de sante mentale et d’abus de substances. Le but de cet article est de fournir des pistes de reflexion sur les enjeux ethiques qui se presentent a l’interieur du programme de suivi intensif dans la communaute autour de la coercition et des conduites abusives de consommation. Les principes de base qui organisent le suivi intensif dans la communaute sont fondes sur les concepts ethiques d’egalite, de respect et de recherche commune de la verite. Chaque personne est susceptible d’avoir la sagesse de sa propre vie et les habiletes pour gerer ses propres experiences. Il s’agit de creer un espace respectueux de reflexion, qui permet un dialogue entre les differentes perspectives, afin de concilier diverses preferences. Les interventions doivent etre discutees avec le client, car celui-ci est au coeur de la prise de decision. Le cadre souple du suivi intensif, en regard de la complexite de la clientele avec une double problematique, permet d’intervenir en respectant le rythme du client dans le processus de retablissement et dans le changement de ses habitudes de vie.
... Harm reduction as a concept is difficult to define because it represents both a philosophical approach as well as more specific practical strategies (Ritter and Cameron 2006), such as the provision of responsible gambling tools in online poker settings. Identifying risk and strategies to mitigate risk in gambling, of any type, is a relatively new research area in contrast to other potentially addictive behaviours such as alcohol and narcotic abuse where harm reduction strategies have been in wide application since the early 1980s (Riley and O'Hare 2000). However, harm reduction approaches to gambling, and indeed online poker, should aim to follow the approach taken to reducing harm in relation to substance abuse by (i) focusing on the harm caused rather than the suitability of the behaviour, (ii) placing priority on immediate goals, while (iii) ensuring that pragmatism rather than moral evaluation underlies the strategies selected to reduce harm (Hamilton and Rumbold 2004). ...
The present paper conducts a critical analysis of the potential for gambling-related harm in relation to online poker participation, and a theoretical evaluation of current responsible gambling strategies employed to mitigate harm in online gambling and applies the evaluation of these strategies specifically to online poker gambling. Theoretically, the primary risk for harm in online poker is the rapid and continuous nature of poker provisions online, and has been demonstrated to be associated with disordered gambling behaviour, including the chasing of monetary losses. The following responsible gambling features were deemed relevant for consideration: informed player choice, voluntary self-exclusion, employee intervention, pre-commitment, in-game feedback, behavioural tracking tools, and age restriction and verification. Although current responsible gambling features are evaluated as theoretically robust, there remains a fundamental need for experi- mental validation of their effectiveness. Furthermore, despite online poker gam- blers perceiving the responsible gambling features as valuable tools, in reality very few players regularly use available responsible gambling features. Ultimately, for the online poker gambling industry to retain market credibility and avoid substantial top-down regulation, it is imperative to demonstrate effectiveness of responsible gambling approaches, and increase customer utilisation of available harm-mitigation features.
... They also argued that currently society does not accept drug use as a 'legitimate form of risk taking', thus the moral stance is prevalent. These notions, in addition to laws already in place and to lack of knowledge in the general public regarding the true nature of substance abuse, leads to a political climate which is less than supportive of efforts to implement harm reduction measures (Riley & O'Hare, 2000), possibly including methadone. At the organizational level, Rosenberg and Phillips (2003) that the low rates of adoption of methadone, which were conceptualized as a form of harm reduction in their study, were attributed mostly to lack of consistency with agency philosophy, and to a lesser degree, to a lack of resources and funding. ...
Methadone and buprenorphine/naloxone are the two recommended pharmacotherapies for the treatment of opioid dependence, having been demonstrated to be effective in numerous clinical trials. While methadone has been an approved treatment for opioid dependence for that past 50 years, buprenorphine/naloxone is a newer substance that was only approved for use in 2002. This mixed-methods study utilizes a comprehensive conceptual framework of neoinstitutional theory and institutional logics to explore possible factors that might predict adoption of medication-assisted treatment.
First, in-depth qualitative interviews with managerial level staff at substance abuse treatment centers were conducted. The interviews were semi-structured and explored perceptions of treatment philosophy, the merging of substance abuse and mental health, managed care, services, funding, licensing and accreditation and personal and professional networks. Next, logistic regression models were used to explore possible predictors of medication-assisted treatment. The National Treatment Center Study (NTCS), a nationally representative survey of private substance abuse treatment facilities conducted between 2002-2004, was used in this study, allowing for the exploration of early adoption of buprenorphine/naloxone.
Findings from the qualitative interviews suggested that the two medications are viewed differently and should therefore be explored separately. Findings from the logistic analysis of the NTCS supported this distinction. The proportion of clients with a primary diagnosis of opiate dependence or abuse was the only factor positively associated with both the early adoption of buprenorphine/naloxone and methadone provision. The program's proportion of managed care funding was the only other significant predictor for early adoption of buprenorphine/naloxone. Accreditation by JACHO, proportion of clients who are women and past organizational participation in research, all positively predicted methadone provision, while the proportion of counselors with a master's degree or higher negatively predicted it.
The results indicate that coercive and normative institutional forces, as well as the institutional logics operating on organizations and the organizational networks they are embedded in, impact service provision and adoption of innovation. To promote adoption of pharmacotherapies into treatment, attention must be paid to the unique barriers and opportunities facing the adoption of each medication.
... There are few established programs for people experiencing both severe alcohol dependence and housing instability [14][15][16][17][18][19][20][21]. However, "Housing First" programs, which are a relatively recent innovation to address homelessness, seek to incorporate a harm reduction philosophy and practices to reduce the harms of substance use without necessarily eliminating or reducing use [16,[22][23][24][25]. Some programs seek to reduce harms for a particular population, primarily by providing stable housing, which can have intrinsic health and social benefits, and tolerating continued use of alcohol. ...
Background
Managed alcohol programs (MAPs) are a harm reduction strategy for people with severe alcohol dependence and unstable housing. MAPs provide controlled access to alcohol usually alongside accommodation, meals, and other supports. Patterns of alcohol consumption and related harms among MAP participants and controls from a homeless shelter in Thunder Bay, Ontario, were investigated in 2013.
Methods
Structured interviews were conducted with 18 MAP and 20 control participants assessed as alcohol dependent with most using non-beverage alcohol (NBA). Qualitative interviews were conducted with seven participants and four MAP staff concerning perceptions and experiences of the program. Program alcohol consumption records were obtained for MAP participants, and records of police contacts and use of health services were obtained for participants and controls. Some participants’ liver function test (LFT) results were available for before and after MAP entry.
Results
Compared with periods off the MAP, MAP participants had 41 % fewer police contacts, 33 % fewer police contacts leading to custody time (x2 = 43.84, P < 0.001), 87 % fewer detox admissions (t = −1.68, P = 0.06), and 32 % fewer hospital admissions (t = −2.08, P = 0.03). MAP and control participants shared similar characteristics, indicating the groups were broadly comparable. There were reductions in nearly all available LFT scores after MAP entry. Compared with controls, MAP participants had 43 % fewer police contacts, significantly fewer police contacts (−38 %) that resulted in custody time (x2 = 66.10, P < 0.001), 70 % fewer detox admissions (t = −2.19, P = 0.02), and 47 % fewer emergency room presentations. NBA use was significantly less frequent for MAP participants versus controls (t = −2.34, P < 0.05). Marked but non-significant reductions were observed in the number of participants self-reporting alcohol-related harms in the domains of home life, legal issues, and withdrawal seizures. Qualitative interviews with staff and MAP participants provided additional insight into reductions of non-beverage alcohol use and reductions of police and health-care contacts. It was unclear if overall volume of alcohol consumption was reduced as a result of MAP participation.
Conclusions
The quantitative and qualitative findings of this pilot study suggest that MAP participation was associated with a number of positive outcomes including fewer hospital admissions, detox episodes, and police contacts leading to custody, reduced NBA consumption, and decreases in some alcohol-related harms. These encouraging trends are being investigated in a larger national study.
... Par ailleurs, dans son application clinique, l'approche de réduction des méfaits a pour objectif de permettre à l'usager de réduire (tant en intensité qu'en fréquence) les conséquences négatives associées à sa consommation de SPA (Brisson, 1997 ;Marlatt, Larimer et Witkiewitz, 2012 ;Marlatt et Tapert, 1993 ;Massé et Mondou, 2013). Elle ne vise donc pas l'abstinence bien que cette cible puisse éventuellement être ou devenir l'objectif de la personne (Denning, 2000 ;Riley et O'Hare, 2000). À plus large échelle, elle vise à aider la personne à avoir recours à des moyens lui permettant de réduire les conséquences négatives qu'elle, son entourage et la société subissent en raison de sa consommation (Brisson, 1997 ;Denning, Little et Glickman, 2004). ...
... Par ailleurs, dans son application clinique, l'approche de réduction des méfaits a pour objectif de permettre à l'usager de réduire (tant en intensité qu'en fréquence) les conséquences négatives associées à sa consommation de SPA (Brisson, 1997 ;Marlatt, Larimer et Witkiewitz, 2012 ;Marlatt et Tapert, 1993 ;Massé et Mondou, 2013). Elle ne vise donc pas l'abstinence bien que cette cible puisse éventuellement être ou devenir l'objectif de la personne (Denning, 2000 ;Riley et O'Hare, 2000). À plus large échelle, elle vise à aider la personne à avoir recours à des moyens lui permettant de réduire les conséquences négatives qu'elle, son entourage et la société subissent en raison de sa consommation (Brisson, 1997 ;Denning, Little et Glickman, 2004). ...
La grande majorité des personnes judiciarisées adopte un style de vie dans lequel l’usage de drogues fait partie intégrante (Pernanen, Cousineau, Brochu et Sun, 2002). Toutefois, malgré l’ampleur de cette problématique et son lien étroit avec la récidive, encore très peu d’établissements de détention offrent une intervention intensive ciblant les problèmes d’abus et de dépendance aux SPA (substances psychoactives) (Ministère de la Sécurité publique, 2009, inédit). Le programme Toxico-Justice du CRDQ (Centre de réadaptation en dépendance de Québec) offert à l’ÉDQ (Établissement de détention de Québec) cible les personnes incarcérées qui présentent un problème d’abus et de dépendance aux SPA requérant un niveau de service spécialisé en dépendance. Ce programme d’une durée de six semaines utilise l’abstinence involontaire occasionnée par la période de détention comme levier pour amener la personne incarcérée à réfléchir à sa problématique de dépendance. Le programme est né d’une alliance tripartie entre l’ÉDQ, le CRDQ et le Centre d’éducation aux adultes Conrad-Boudreau et il a pour objectifs de favoriser leur réinsertion sociale, de diminuer leurs risques de récidive, de poursuivre leur scolarité et de changer leurs habitudes de consommation. Les participants sont repérés par les agents correctionnels et doivent répondre à certains critères de sélection avant de pouvoir être orientés vers l’Unité spécialisée en toxicomanie. Au total, douze personnes peuvent y séjourner simultanément pendant une période de six semaines. Lors de leur séjour les participants partagent leur temps entre le volet scolaire (assuré par le Centre d’éducation aux adultes Conrad-Boudreau) et le volet réadaptation (assuré par le CRDQ).
... A harm-reduction practice orientation carries the primary aim to alleviate harm (Riley & O'Hare, 2000). EMRPs work within a harm-reduction model in that they are not necessarily seeking to eliminate or completely resolve the risk of revictimization, depending on the client's construction of a successful outcome. ...
Community-based elder mistreatment response programs (EMRP), such as adult protective services, that are responsible for directly
addressing elder abuse and neglect are under increasing pressure with greater reporting/referrals nationwide. Our knowledge
and understanding of effective response interventions represents a major gap in the EM literature. At the center of this gap
is a lack of theory or conceptual models to help guide EMRP research and practice. This article develops a conceptual practice
model for community-based EMRPs that work directly with cognitively intact EM victims. Anchored by core EMRP values of voluntariness,
self-determination, and least restrictive path, the practice model is guided by an overarching postmodern, constructivist,
eco-systemic practice paradigm that accepts multiple, individually constructed mistreatment realities and solutions. Harm-reduction,
client-centered, and multidisciplinary practice models are described toward a common EMRP goal to reduce the risk of continued
mistreatment. Finally, the model focuses on client–practitioner relationship-oriented practice skills such as engagement and
therapeutic alliance to elicit individual mistreatment realities and client-centered solutions. The practice model helps fill
a conceptual gap in the EM intervention literature and carries implications for EMRP training, research, and practice.
... When applying the tenet humanistic value it is important to recognize that a problem exists and treat the individual who is engaging in the risky health behavior with respect (Brocato & Wagner, 2003;Riley & O'Hare, 2000). To be consistent with humanistic values when initiating cues to action, it is important to maintain nonjudgmental communication so that at-risk individuals begin to appraise their risk of a negative health outcome rather than react to how you are communicating with them about the at-risk behavior. ...
This article examines the ways in which integrating a metatheory to guide qualitative interviews supports health theory and the research methodology of interviewing. This study applied Harm Reduction Theory (HRT) as a metatheory to the Reconceptualized Health Belief Model (RHBM) in targeting motorcyclists to practice safety behaviors. After integrating the metatheory with a health behavior theory to develop research questions and frame the interview guide, we recruited and interviewed 37 at-risk motorcyclists. The process of interviewing participants and the results of the study support the integration of harm reduction metatheory to enhance interview methodology as a way to effectively engage participants by building rapport, encouraging participants to apply theory, and empowering them to be open and honest in their responses. This research process highlights ways in which incorporating a metatheory to guide theory diverges from the more traditional, theory-driven approach to interviewing.
... Grassroots harm-reduction movements began in Liverpool, Amsterdam and Rotterdam in response to pervasive drug-related public health problems resulting from injection drug use (Erickson et al., 1997;Heather, 1993). In Liverpool, for example, the Merseyside project coordinated needle-exchange clinics, pharmacists and even the police force to maintain a harm-reduction programme that actually prescribed drugs to people instead of taking a punitive approach to drug use (Hilton et al., 2001;Riley and O'Hare, 2000). ...
In this paper, we argue for the importance of unsettling dominant narratives in the current terrain of harm-reduction policy,
practice and research. To accomplish this, we trace the historical developments regarding the Human Immunodeficiency Virus
(HIV), the Hepatitis C Virus (HCV) and harm-reduction policies and practice. We argue that multiple historical junctures rather
than single causes of social exclusion engender the processes of marginalisation, propelled by social movements, institutional
interests, state legislation, community practices, neo-liberalism and governmentality techniques. We analyse interests (activist,
lay expert, institutional and state) in the harm-reduction field, and consider conceptualisations of risk, pleasure, stigma,
social control and exclusionary moral identities. Based on our review of the literature, this paper provides recommendations
for social workers and others delivering health and social care interested in the fields of substance use, HIV prevention
and harm reduction.
... There are few established programs for people experiencing both severe alcohol dependence and housing instability [14][15][16][17][18][19][20][21]. However, "Housing First" programs, which are a relatively recent innovation to address homelessness, seek to incorporate a harm reduction philosophy and practices to reduce the harms of substance use without necessarily eliminating or reducing use [16,[22][23][24][25]. Some programs seek to reduce harms for a particular population, primarily by providing stable housing, which can have intrinsic health and social benefits, and tolerating continued use of alcohol. ...
Managed Alcohol Programs (MAPs) are a harm reduction strategy for people with severe alcohol dependence and unstable housing. MAPs provide controlled access to alcohol usually alongside accommodation, meals and other social supports. We investigated patterns of alcohol consumption and related harms among MAP participants and controls from an emergency homeless shelter.
... Accepting that immediate and complete cessation of substance use is not possible for all clients, harm reduction strives to develop collaborative and unconditional partnerships to support clients in making healthier decisions (Marlatt & Tapert, 1993;Riley et al., 1999). Taking a pragmatic (what is most likely), empirical (what does research show works) stance, harm reduction avoids moralizing and value judgments on client behavior, and focuses rather on the presenting problem and minimizing associated consequences (Riley & O'Hare, 2000;Roche, Evans, & Stanton, 1997). ...
... This approach has reportedly saved tens of thousands of lives (Wodak, 2011;World Health Organization [WHO], 2005). Other applications of harm reduction include prescriptions for methadone and other drugs, education and outreach, law enforcement with a soft touch, tolerance zones, nicotine programs, and lenient marijuana policies (Riley & O'Hare, 2000). ...
This article examines the National Football League’s (NFL) policy on illicit psychoactive drugs from a harm reduction perspective. The NFL’s policy reinforces the punitive tradition in U.S. drug policy. The policy features drug testing and requires abstinence from illegal drugs. The NFL punishes players with suspensions from employment and loss of pay. The harm reduction tradition does not require abstinence and counts lost employment as a form of harm to workers. The article analyzes three cases of player suspensions from a harm reduction perspective. An introductory proposal to reform the NFL’s policy emphasizes intensive communication by the league with the community of stakeholders, including advertisers and the public. The article addresses both the league’s need for public approval and the goal of reducing harm to its workers.
... There have been several attempts to define the term harm reduction by those involved in the movement {see, e.g.. Newcombe 1992; Strang 1993; Erickson et al. 1997; Riley et al. 1999; Wodak 1999; Inciardi & Harrison 2000; Riley & O'Hare 2000). In the first "textbook" on harm reduction (based on the presentations at the first Intemational Conference on Harm Reduction in 1990, Liverpool, UK), Russell Newcombe (1992) defined the concept as follows: ...
Despite its relatively long hi.stoiy in the inlernational drug policy field, the meaning of the temi harm reduction is .^till di.sputed. From a description of the different actor-based footings of the international hann-reduction school of thought, the analysis concludes that the diverse conceptualizations of harm reduction are to be understood as interpretive frameworks that arc functionally different according to the different types of actors and iheir .social and professional positions. Three epistemic fractions of harm reduction are recognized: a professional new public health fraction: a mutual-help and identity movement fraction of the drug users; and a globally oriented fraction. It is argued that, rather than one, the international harm-reduction school of thought is a policy community of the three epistemic fractions that are in dialogue with each other and thus are constantly redefining the meaning of harm reduction.
With the ongoing opioid epidemic, evidence-based interventions are needed to prevent and respond to opioid-related overdoses. Overdose prevention sites (OPS) have been operating effectively internationally since the 1980s. In the United States, despite unprecedented numbers of overdose-related deaths, only two sites operate in New York City. California, generally a beacon of progressive policy, has been unable to implement a sanctioned facility. Using two waves of survey data (2017 and 2022), this paper seeks to answer the following research questions: (1) Do CA voters support overdose prevention sites? (2) How has support changed over time? And, (3) What factors contribute to the support and opposition of these programs? Results reveal that most respondents would support an OPS in California, despite the recent veto of such measures by California Governor Newsom. Further analyses examine factors that contribute to both support and opposition, as well as exploring potential avenues for reform.
North American police responses to the ‘drug issue’ have long been shaped by a crime control rather than a harm reduction imperative. Consequently, police officers’ responses to safe consumption sites (SCSs), where people who use illicit drugs can reduce personal health risks by administering previously obtained drugs in the presence of trained staff, were initially hostile. This paper draws on interview data from police officers in two western Canadian cities to highlight an apparent softening in attitudes, perhaps due to the current fentanyl-driven drug poisoning crisis. While some officers clearly recognized their public health benefits, others accepted SCSs, acknowledging the futility of a continued ‘war on drugs’. Some voiced reservations about SCSs, but not because of a generic ‘drugs are bad’ sentiment. Rather, they worried about specific downstream implications for communities and police work. These findings, reflecting apparent changes in police officers’ responses to SCSs, are discussed in the context of contemporary debates about police culture and the possibilities and desirability of pursuing police reform.
Background: Cigarette smoking is among the most harmful ways to consume nicotine and, troublingly, tends to be concentrated among socially marginalized groups of people, including those who identify their sexualities and genders in ways that classify them as sexual and gender minorities (SGM). Though some approaches to tobacco control in the United States may be considered harm reduction strategies (e.g. smoke-free environments), often abstinence is an explicitly-stated goal and discussions of reducing harm in the absence of cessation are controversial, particularly when it comes to young people. Despite the controversy of tobacco harm reduction (THR), emerging research suggests that interest in and reliance on THR strategies may be gaining momentum as a “community-led” rather than ‘public health-led’ health practice. To date, little is known about how SGM young adults negotiate their use of tobacco products, particularly in terms of minimizing the harms associated with smoking.
Methods: We conducted 100 in-depth interviews with SGM young adults ages 18-25 living in the San Francisco Bay Area, to better understand participant perceptions and everyday practices related to THR.
Results: A thematic analysis of interview narratives revealed the ways in which participants employed various individual-level, ad-hoc THR strategies while negotiating their wellbeing within the context of broader socio-structural harms. Analysis also underscored beliefs about the importance of pragmatic, nonjudgmental approaches to drug use that are guided by a person-centered ethos of respect and compassion.
Conclusions: Findings from this study represent a significant departure from the mainstream discourse surrounding tobacco harm reduction in the United States. Analysis of participants’ narratives highlights the ways in which understanding the practice of THR among SGM young adults who use nicotine and tobacco can be instrumental in shaping alternative approaches to tobacco control policy and prevention efforts, ultimately helping to reduce inequities in tobacco-related illnesses.
Objective:
The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.
Inclusion criteria:
To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts.
Methods:
An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives.
Results:
A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed.
Conclusions:
We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.
The COVID-19 pandemic is presenting significant challenges for health and social care systems globally. The implementation of unprecedented public health measures, alongside the augmentation of the treatment capacity for those severely affected by COVID-19, are compromising and limiting the delivery of essential care to people with severe substance use problems and, in some cases, widening extreme social inequities such as poverty and homelessness. This global pandemic is severely challenging current working practices. However, these challenges can provide a unique opportunity for a flexible and innovative learning approach, bringing certain interventions into the spotlight. Harm reduction responses are well-established evidenced approaches in the management of opioid dependence but not so well-known or implemented in relation to alcohol use disorders. In this position paper, we explore the potential for expanding harm reduction approaches during the COVID-19 crisis and beyond as part of substance use treatment services. We will examine alcohol use and related vulnerabilities during COVID-19, the impact of COVID-19 on substance use services, and the potential philosophical shift in orientation to harm reduction and outline a range of alcohol harm reduction approaches. We discuss relevant aspects of the Structured Preparation for Alcohol Detoxification (SPADe) treatment model, and Managed Alcohol Programs (MAPs), as part of a continuum of harm reduction and abstinence orientated treatment for alcohol use disorders. In conclusion, while COVID-19 has dramatically reduced and limited services, the pandemic has propelled the importance of alcohol harm reduction and created new opportunities for implementation of harm reduction philosophy and approaches, including programs that incorporate the provision of alcohol as medicine as part of the substance use treatment continuum.
Harm reduction approaches to heroin addiction treatment are safe and effective, particularly those using medication‐assisted therapy, yet they remain underutilized in the drug treatment field. This paper posits the need for a psychoanalytic formulation of harm reduction. It draws on object relations theory, to illustrate the ways in which harm reduction, as a philosophy and as a practice, maps onto the particular developmental and attachment themes of addiction. It explores heroin addiction and harm reduction at the intersection of the psyche and the social and calls upon psychoanalysis to challenge oppressive systems in the lives of heroin users.
This thesis is a comparative analysis of the reasons for the differences in success of the drug prohibition policies of Japan, and England and Wales. These countries are both large, highly developed island nations with histories of overseas colonial expansion, parliamentary liberal-democracies, constitutional monarchies and ministerial civil services. Their drug policies, while using very similar laws, are vastly different in outcome. I will attempt to explain the differences in the extent of drug use in terms of Situational Action Theory (temptation, deterrence, and law-relevant morality), adapted to a national scale. This is achieved through a historical institutionalist analysis, supported by a comprehensive survey of the available nationwide statistical indicators, creating a thick description of the policy environment affecting each variable.
Background:
The twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA).
Methods:
We examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of "messy", "ordered" and "social arenas" maps that provide insight into the social worlds of participants and the impact of MAPs.
Results:
Prior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing.
Conclusions:
In a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.
Drs. Jihane Tawilah and Ahmad Mohit described the HIV and injection drug use trends in the Eastern Mediterranean region. Although HIV transmission among IDUs accounts for approximately 4 percent of all AIDS cases reported annually, with the majority originating from heterosexual contact, almost all countries in this region have reported HIV cases among IDUs. Although injection drug use has existed for some time in this region, the number of IDUs remains relatively low and is estimated to account for 10 to 17 percent of all users of illicit drugs in the region. Many countries are experiencing outbreaks among subgroups of sexually transmitted disease (STD) patients and IDUs. Since 1996, Iran also has experienced major outbreaks of HIV among IDUs in prisons. Overall, this area is experiencing a low-level epidemic, although IDUs are clearly leading other subgroups in terms of high HIV rates and have the potential for explosive outbreaks. The countries in this region serve as either producers (for example, Afghanistan) or as transit routes and consumers for a wide variety of substances, including an increase in heroin use. Data of the United Nations International Drug Control Programme (UNDCP) indicate that injectable forms of drugs are becoming increasingly available in this region, and that many of the drug injectors are young.
My thesis is an ethnography of the harm reduction staff of the syringe exchange program (SEP) of Prevention Point Philadelphia (PPP) during a period of six months between 2011 and 2012. Using interviews, participant observation, and secondary research, the thesis examines how the political dimensions of a now institutionally recognized, albeit controversial public health strategy have adapted to new structural constraints by contextualizing the movement’s trajectory through the perspective of individuals involved in the organization. Profiling the current staff of the SEP facilitates an exploration of the radical political heritage of harm reduction internationally, nationally, and in Philadelphia. The incorporation of harm reduction into a neoliberal public health framework resulted in an uneasy and ongoing transition characterized by a tension between principles and practices that site workers embody. I draw on Foucault’s concept of biopower as a means of critiquing the disciplinary effects of institutionalized harm reduction practices, while using Mbembe’s concept of necropolitics to theorize the precarious state of PPP. I suggest that a return to the radical politics of its genesis provides an avenue of resistance to the more repressive consequences of a biopolitical and necropolitical public health system.
Approximately 1 out of 11 people in the USA suffer from a substance use disorder, and the economic costs associated with these disorders are extensive. This chapter examines the history and current state of national drug control policy. We argue that the allocation of funds to various policies and practices can be largely attributed to approaches that have dominated the field of substance abuse in the USA for many decades. While moral approaches assume that substance abuse is morally wrong and that the use and distribution of certain substances is a crime and therefore deserving of punishment, medical approaches view addiction as a biological or genetic (acute) disease that should be cured or prevented and emphasize treatment and rehabilitation. Despite their difference, both approaches are based on the premise that the only acceptable goal should be abstinence, and they tend to focus on the individual drug user. Since the 1980s, with the emergence of HIV/AIDS and other infectious diseases, many countries worldwide have recognized the need for more pragmatic and public health focused approaches to substance abuse, and a third approach, harm reduction, entered the field. We introduce these approaches and argue that harm reduction approaches are more consistent with the values of the social work profession and thus have profound implications for both policy and practice in our field.
Harm reduction, a concept that challenges the mainstream notion of abstinence as a universal treatment goal for problem substance use, has emerged as a promising approach for women struggling with alcohol use problems. Harm reduction moves beyond the dominant deficit-based, abstinence-focused, disease-oriented interpretations of substance use problems and addiction, and emphasizes empowerment and self-determination. Thus, strategies based on harm reduction are harmonious with women-centered approaches to health care delivery (Bepko, r99U Dennin g, zooo; Pasick &White, r99r). In this chapter we discuss several issues related to harm reduction approaches to alcohol use, review the research findings on controlled drinking and present our own research on the topic of influences and considerations that affect women's success in reaching harm reduction goals. Our research reveals that many women in alcohol-use treatment have deeply internalized the dominant social ideology on sub$tance use and treatment (i.e., that abstinence is the only treatment goal). Currently, harm reduction approaches do not recognize the impact of this widespread internalization of mainstream addiction discourse. For controlled drinking to be a real option for women who have problems with alcohol use, it is not enough for programs to simply offer the choice of abstinence or controlled use as outcome goals. Instead, they must offer education and training in skills for controlled drinking that would make harm reduction goals a real choice for problem drinkers. 431
Cigarette smoking remains a leading preventable cause of disease and death in the United States, and the impairment of smokers and those in their social environments is a concern for social workers. Despite primary prevention and cessation-based policies and interventions, quit rates are low and nicotine replacement therapies are underused and of limited efficacy. Tobacco harm reduction has garnered attention due to tobacco policy shifts and the increasing use and marketing of such products as electronic cigarettes. Social work has been criticized as ignoring this topic, and existing literature is limited. This article considers questions and concerns surrounding tobacco harm reduction, and offers guidance in formulating a social work position regarding this important issue.
Versión revisada de Nureña et al., Culture, Health & Sexuality; 13(10):1207-21 (2011). < https://goo.gl/la6wop > ABSTRACT: In Peru, commercial sex involving men and male-born travestis, transgenders and transsexuals (CSMT) is usually represented as a dangerous practice carried out on the streets by people experiencing economic hardship and social exclusion. However, in reality little is known about the complexities of this practice in Peru. This paper presents findings from an ethnographic study of the characteristics, patterns and sociocultural aspects of CSMT in three Peruvian cities. The study included participant observation in sex work venues and interviews with 42 sex workers and 25 key informants. We found that CSMT in Peru takes many forms (some not previously described in the country) and is practised in different places by people from various socioeconomic levels. In many cases, the practice appears linked to ideals of social mobility, migratory experiences and other economic activities. In addition, the increasing use of the Internet and mobile phones has changed patterns of sex work in Peru. We review the implications of these findings for future research and public health interventions.
Illicit drug use in the US remains concerning, with injection drug use linked to transmission of blood-borne diseases as HIV/AIDS; persons of color, including Black Americans, experience disproportionately higher transmission rates. Harm reduction programs such as methadone and needle- and syringe-exchange (NEP/SEP) are empirically demonstrated to reduce HIV transmission, yet are believed largely opposed by Black communities. Using interview data from 21 service providers of substance abuse and related service organizations located in and/or serving predominantly populations of color, this study explored perceptions of harm reduction programming for illicit drugs and race in the US. Criticizing each program for unique reasons, respondents deemed them largely inadequate and inappropriate responses to community drug problems. While some believed these programs worsen Black communities, others believed they are becoming more accepted there. Views were informed by racial dynamics surrounding drugs in society, burdens borne by program host communities, and racialized stereotypes of drug use.
U.S. federal drug policy has long emphasized criminalization and incarceration, and many negative policy outcomes have disproportionately impacted communities of color and Blacks in particular. The framework of harm reduction informs a range of alternative policy strategies from decriminalization to legalization, treating drugs more as a public health than a criminal justice issue. While Black communities are seen as opposing harm reduction with illicit drugs, Black leadership has recently supported ending the war on drugs. Using in-depth interviews with 21 substance abuse service providers in a Northeastern U.S. urban hub, this study explores views toward the potential impact of, and support for, harm reduction illicit drug policies in Black U.S. communities. Cognizant of the racially skewed impact of drug policies, respondents endorsed policy changes but were generally mixed on harm reduction, opposing liberalization of ?hard? drugs, yet supporting it for marijuana given its link to race-based policing. Respondents indicate many Black communities need more than drug policy change, at best seeing harm reduction as only part of larger scale reinvestment. Findings inform considerations of reforming drug policy strategies and priorities for these communities, given views toward illicit drugs and racially skewed outcomes of current drug policy.
Harm reduction is a general term for pragmatic interventions aimed at reducing problematic behaviors. Emerging from addiction treatments, it is based on the understanding that people will continue to behave in ways that pose a risk to them and their communities, and that an important goal of any treatment program is to minimize the harm associated with these behaviors. Despite its evidence based background, harm reduction is not readily applied in general psychiatry. This is mainly due to the complex ethical dilemmas arising within harm reduction practices, as well as a lack of scientific knowledge and theoretical frameworks essential for dealing with such ethical dilemmas. In this paper we introduce the fundamental theoretical and scientific base of harm reduction strategies, and present three clinical examples of the complex ethical dilemmas arising when working within a harm reduction practice. We finally present a theoretical framework for dealing with the ethical dilemmas and argue this may make harm reduction strategies more accessible in general psychiatry.
Kenneth Burke's dramatistic perspective is applied to accounts told by staff members working in methadone maintenance treatment centers in Copenhagen, Denmark. As a harm reduction strategy, methadone maintenance is designed to reduce the costs and dangers of chronic long-term drug use by providing substitution (methadone) treatment to users. Burke's dramatistic perspective calls attention to the recurring relationships among rhetorical elements within accounts of social reality. The elements form a pentad: scene, purpose, agent, agency and acts. Our analysis examines how the ideal of governmentality is constructed by staff members to justify and criticize the operations of the Copenhagen methadone maintenance program. For Burke, social criticism involves rearranging pentadic elements to produce new meanings and justify alternative actions. We discuss how Burke's perspective might be developed by sociologists as a critical dramatism of social policies and programs.
In the 1990s methamphetamine (meth) emerged as a significant drug problem in the United States. Along with more widespread meth use was a growing pattern of localized production of the drug in small-scale clandestine laboratories, creating public health issues beyond the drug’s direct harms to the health of users. Early efforts in analyzing aggregate patterns of meth lab production across communities suggest this phenomenon is different from other types of crime and drug problems, showing distinctive geographic patterns and different causal/etiological dynamics. This paper assesses the viability of public health outcomes as predictors of methamphetamine laboratory problems and compares them with traditional criminological predictors as explanations for aggregate patterns in meth lab problems across U.S. counties. It documents how local variations in meth production are different from other types of crime patterns and identifies whether geographic variations in local meth labs might be more effectively predicted and explained in public health terms.
This article examines selected social work literature that has been published in mainstream social work journals in the United States from 1950 to 1959 in order to deconstruct how alcoholism and alcoholics have been historically constructed within the social work profession. The theoretical framework employed is that of social constructionism and deconstruction. The methodology is qualitative research, specifically historical analysis. The findings of this article are discussed for their relevance to social work practice and social work education.
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