Harm Reduction: Its Meaning and Application for Substance Use Issues Position Statement

Background

Despite the growth in the use of the term, the meaning, practice and implications of harm reduction are matters of some dispute. CAMH, with its involvement in a broad range of harm reduction initiatives and programs, sought to find internal consensus on this concept. CAMH believes that harm reduction can help circumvent the stigma associated with substance use and that it represents a pragmatic approach to managing addiction. It believes that directing resources at empirically proven successful interventions will result in better individual outcomes and greater systemic accountability. In its unbiased commitment to client-centred care and partnership in treatment, harm reduction is one approach that is offered within a broader spectrum that includes programs with an abstinence-based philosophy.

A CAMH ad hoc committee was formed to seek consensus for a working definition of harm reduction. This broad-based group examined the meaning of the term and its practical application to their diverse areas of work at CAMH, including treatment, prevention and issues of enforcement. Consensus was reached on the definition and principles outlined below, although no claim is made that it represents a universally acceptable perspective for what remains a broadly applied concept.

Definition

Harm reduction is any program or policy designed to reduce drug-related harm without requiring the cessation of drug use. Interventions may be targeted at the individual, the family, community or society.

Not all interventions intended to minimize the adverse consequences of substance use are harm reduction. Harm reduction programs and policies must demonstrate that they have the desired impact without producing unacceptable unintended consequences. If its evaluation reveals no support for the reduction of specified adverse consequences, or shows the unintended consequences are too serious, the program should not be considered part of a harm reduction approach and other alternatives should be developed.

The primary focus of harm reduction is on people who are already experiencing some harm due to their substance use. Interventions are geared to movement from more to less harm. Examples of proven harm reduction programs are: server intervention programs which decrease public drunkenness; needle and syringe exchange programs which prevent the transmission of HIV among injection drug users; and, environmental controls on tobacco smoking which limit the exposure to second hand smoke.

Guiding Principles

CAMH proposes the following guiding principles be used to guide the development and assessment of harm reduction programs and policies.

Pragmatism
Harm reduction accepts that some level of drug use in society is inevitable and normal, though this view varies widely according to culture and cultural values. Harm reduction seeks to reduce the more immediate and tangible harms rather than embrace a vague, abstract goal related to some future ideal like a drug free society.

Focus on Harms
The focus of harm reduction policy and programs is the reduction of harmful consequences of substance use without necessarily requiring any reduction in use. These harms may be related to health, social, or economic factors that affect the individual, community and society as a whole.

Prioritization of goals
Harm reduction strategies prioritize each user's goals with an emphasis on immediate and realizable goals. The eventual goal may be abstinence but the user does not have to begin this way. Where community and individual goals appear to conflict, there is an attempt to reconcile them.

Flexibility and maximization of intervention options
Harm reduction initiatives are flexible in design, in recognition of individual differences and the reevaluation of individual set goals. They provide a maximum range of options for intervention, such as diverting users to alternative community-based measures and a variety of treatment options such as drug substitution, drug maintenance and interventions that adopt safer methods of use.

Autonomy
The drug user's decision to use drugs is acknowledged as a personal choice, for which they take responsibility. Drug users are not stigmatized as deviants. The user is an active rather than a passive entity in managing their addictions. Reintegration is emphasized over social exclusion. According to the Aboriginal Community: "The philosophy of harm reduction encourages us to reach those outside of the circle and welcome them back in… [we] recognize that everyone in the circle is affected and thus has a responsibility to make this circle whole."

Evaluation
Responsiveness and innovation are to be encouraged in program and policy design but there is a strong need for evaluations of their effectiveness. Programs and policies should have clear mission statements and goals and also identify what "harms" are being addressed. Both the health and functioning of the individual and the net impact on harm indicators in the community are important indicators of the success of harm reduction.

Conclusion

Harm reduction is thriving in its second decade of diffusion and widespread application, and is integral to numerous programs at the Centre for Addiction and Mental Health. In the field, greater consensus is emerging on the boundaries of the concept and the behaviours to which it may legitimately be applied. Nevertheless, we recognize the limitations of harm reduction and do not expect it to be all things to all people. In our commitment to client-centred care, harm reduction remains but one approach in a broader spectrum that also embraces programs with an abstinence-based philosophy.

While our primary task is to inform the CAMH audience, provoke discussion, and build consensus on how we use the term within our own organization, we also hope that the community at large will be prompted to engage us in further dialogue.

Although there is a growing body of empirical evidence endorsing various harm reduction approaches, more research is required on both some of the established, as well as the newer and more controversial interventions whose aim is to reduce the harm associated with alcohol and drug use.

There is evidence that programs that reduce the short and long term harm to substance users benefit the entire community through reduced crime and public disorder, in addition to the benefits that accrue from the inclusion into mainstream life of previously marginalized members of society. The improved health and functioning of individuals and the net impact on harm in the community are notable indicators of the early success of harm reduction. CAMH believes that public policy should be guided by the principles outlined in this paper to support innovative strategies that most effectively respond to the needs of substance users and their communities. CAMH therefore calls on government and other relevant agencies to fund the development, trial, evaluation and implementation of a full range of harm reduction programs to be included among other proven successful interventions for those with substance use problems.