What is Harm Reduction?
Posted on: 02-Nov-2016
Posted by EKASS | on
This article examines the Philosophy of Harm Reduction and was written by East Kootenay Addiction Services' Executive Director, Dean Nicholson. The article below does not necessarily reflect the views and opinions of East Kootenay Addiction Services.
With all the talk about the Fentanyl
crisis, the term Harm Reduction is often raised as an approach to deal with the
problem. Many people are unclear what
Harm Reduction means and this article hopes to provide some clarification. Harm Reduction refers to an approach to
dealing with substance abuse, where the primary focus is to reduce
the harms associated with using substances, rather than the focus being on stopping
the use of substances. This doesn’t mean
that stopping or reducing use is not a goal, just that it is not the first
goal. Often Harm Reduction is associated with programs like needle exchanges or
safe-injection sites; programs in which people continue to use substances but
are encouraged to do so in safer ways. These are definitely Harm Reduction approaches
but Harm Reduction casts a much wider net.
Too often in the past Harm Reduction approaches were contrasted with
Abstinence approaches, with the two approaches being seen as polar opposites
and opposed in principle. From the
Abstinence side, Harm Reduction was often characterized as supporting or
encouraging substance use. For some
people on the Abstinence side, people on an Opioid Replacement Program like
Suboxone or Methadone (which is one of the best ways to support people to get
off Fentanyl) could be criticized for still being addicts because they were
still using a drug. In fact, Abstinence is also a Harm Reduction
approach, as is responsible social drinking, as are needle exchanges.
A problem with the debate around Harm
Reduction is that historically society’s focus on drug and alcohol use as been
on the behavior itself – on the using.
If using is the problem, then not using is the solution. This is further entrenched by then making using
illegal and with the consequence that users become criminals. A Law and Order approach, or a War on Drugs
approach, is the natural outcome. In
Canada, about 70% of all Federal dollars that go towards substance use problems,
goes to the law enforcement side, including the RCMP, the courts and
correctional services. Only 30% goes to
prevention, education, treatment and research. Law and Order and Abstinence-only approaches
limit the ways we can respond as a society.
Perhaps a good analogy is driving. We all know that one of the major causes of
death in Canada is motor vehicle accidents.
If we took a similar approach to driving deaths as we do to substance
use, we would make all driving illegal, ban automobiles and motorbikes, and
arrest and charge people caught using motor vehicles or involved in the
production or sale of motor vehicles.
Clearly this is not an approach that anyone would support, even though
we could all agree we would like to reduce motor vehicle deaths. So what do we do? We create a wide range of Harm Reduction
programs to try and reduce the likelihood of motor vehicle accidents while
allowing people to continue driving.
Programs like seat belt laws, graduated licensing systems for new drivers,
standardized traffic rules, maximum speeds, improved car design etc. etc. We don’t view driving as a criminal matter
but as a public health concern and we create policies and programs
accordingly. At the same time, we take a
Law and Order approach to certain behaviours associated with risky driving,
such as speeding or driving while impaired, but we accept that people are going
to drive. Harm Reduction in the area of
substance use is just the same. If we
accept that people are going to use substances (and in any given year over 80%
of Canadians 15 or over will use a substance) then it makes more sense to
develop programs and approaches that discourage unhealthy use, encourage
responsible use, and provide means for people who have more serious problems to
reduce negative consequences so that they can hopefully be in a place to make
healthier choices. At the same time,
there is a role for a Law and Order approach in areas such as trafficking, unregulated
drug production and inappropriate public use.
At East Kootenay Addiction Services, we
view substance use, abuse and addiction as both a personal and a public health
problem, rather than as a criminal problem.
Our aim is to provide services that reduce the harms that use can cause,
whether that is by supporting someone to quit using altogether, to use in a
more responsible and less harmful way, or to help them improve other areas of
their life that their use may be impacting.
If we consider substance use as a personal and public health issue, then
the goals for intervention can change, as can the types of interventions that
are used. This is what Harm Reduction
means and research shows that programs coming from this approach are more
effective in creating overall healthy change for people using and for
communities as a whole.
Addictions Treatment - Different options
Posted on: 13-Oct-2016
Posted by EKASS | on
This is the second of two articles regarding information about treatment -- what it is and what it isn't' and the different formats that describe treatment. The series is written by East Kootenay Addiction Services' Executive Director, Dean Nicholson. The article below does not necessarily reflect the views and opinions of East Kootenay Addiction Services.
As a new story seems to come out daily about the fentanyl problem and what’s being done to address it, it would be understandable if many people were confused about what services and programs are available to assist people with substance use problems. This article will outline some of the major components and approaches to substance use treatment and how they relate to the current fentanyl problem.
Firstly, it must be said that not everyone who is experiencing a problem with substances such as alcohol, marijuana, cocaine or fentanyl is necessarily ‘addicted’ in the strict clinical term. Substance use falls along a continuum from ‘no-use’ through ‘social use’ through ‘problematic use’, and finally ‘dependent or addicted use’. The type of services that could help will depend on where a person’s use falls on the continuum and what changes they want to make.
Secondly, substance use problems are no longer viewed as a ‘stand-alone’ issue. It is generally recognized that most people who struggle with substance use problems also have other concerns, such as depression or anxiety, housing and financial problems, relationship problems etc. It is not enough to deal with the substance use; to make lasting change people often need support in a number of areas of their lives.
With this being said, what are the different components of substance use treatment? At East Kootenay Addictions Services (EKASS) we believe that treatment starts as soon as someone contacts us. Reaching out for help means treatment has begun. After that there are various services that a person could become involved with depending on their situation.
Withdrawal Management: Often referred to as ‘detox’ or a ‘dry out center’. Withdrawal management assists people in the initial physical withdrawal that they may experience as they stop using substances. This could take place at home with outside support, in a withdrawal management center such as Ponderosa House in Cranbrook, or at a local hospital when other medical complications might be present. People are usually only in a withdrawal program for 5-10 days, depending on the substance, although some substances may take longer to taper off of. There is no cost for approved withdrawal management services.
Outpatient Counselling: Outpatient counselling is often the first type of treatment that people access. People are seen by a trained substance use counsellor who assists them in identifying the problems they are having, developing goals, implementing strategies and connecting them with other services that may be helpful. At EKASS we see people at our offices, but can also meet people at other locations if that is easier. There are no costs for people to access outpatient counselling at provincially funded mental health and substance use offices.
Residential Treatment Programs: This is what most people think of as ‘treatment’ although in reality it is just one type of service. Residential Programs can run from 6 weeks up to 3 months or more. The programs offer group counselling in a secure live-in environment. In B.C. some programs have been accredited and some have not. Being accredited means that the program has been thoroughly reviewed by an outside evaluator and that the treatment program, the facilities, the staff and the policies all meet an accepted level. All residential treatment programs have a cost for the user. If a residential program is run by an accredited not-for-profit society and has an agreement with the Ministry of Health, then a number of beds will be subsidized as $40.00 per day beds. People usually access these beds through a referral from an substance use counsellor. For people on Income Assistance the program costs are usually covered. Non-subsidized beds in not-for-profit programs typically run around $120.00 per day. People can access these beds without a referral from a substance use counsellor. Private for-profit residential programs can cost upwards of $15,000 per month. The philosophy of treatment at residential programs generally falls into one of two approaches: 12 Step Programs and Holistic Programs. The main difference between these approaches is the emphasis on the 12 Step or Minnesota Model of recovery. Both types of programs use group counselling as a primary counselling strategy. Aboriginal residential programs will usually include aboriginal healing practices as well. Helping people find the program that is the best match for them is part of what an substance use counsellor does when working with a client. Residential programs have waitlists, but these can vary from a few days to a number of months, depending on the program.
Harm Reduction Programming: In one sense all substance use programming aims to reduce the harms associated with using. In a more specific sense though, in relation to the fentanyl crisis this can refer to two types of programming: Opioid Replacement Programs and the Take Home Naloxone Program.
Opioid Replacement Programs: are programs that help someone get off of opioids like heroin, morphine, fentanyl etc, by replacing them with another opioid, such as Methadone or Suboxone. The purpose of going on Methadone or Suboxone is to prevent the person from going into withdrawal. Avoiding the pain and sickness associated with withdrawal from opioids is usually the primary reason people keep using. By having a regular dose of Methadone or Suboxone a person does not go into withdrawal and does not have to engage in the kinds of behaviours that will allow them to keep using. People are able to stabilize their lives and begin to work on changing other problem areas. When they are on the proper dose, people do not experience a ‘high’ from Methadone or Suboxone. There is a lot of monitoring that goes with the program. In the early stages people often have to get their medication each morning at a pharmacy. They will have meetings with the prescribing physician every two to four weeks, and they will be required to provide urine samples to show that they are not misusing other opioids. Despite some of the restrictions these requirements place on a person, research shows that people on an Opioid Replacement Program are less likely to relapse and go back to using. This means they are at less risk of overdose than people who try to quit opioids on their own. Furthermore, when people are maintained on an Opioid Replacement Program they are able to create stability in their lives and began working on other concerns to further improve their well-being. Although any doctor can prescribe Suboxone after a short on-line course, one of the biggest barriers for people getting on to an Opioid Replacement Program is the lack of prescribing doctors. At EKASS we operate a weekly Telehealth Clinic in which our clients have access to a prescribing doctor in Kamloops.
Take Home Naloxone Program: The Take Home Naloxone Program was developed in large part in response to the fentanyl crisis. Naloxone or Narcan is a drug that when taken helps to reverse an opioid overdose. Naloxone has been around for decades and has been used by paramedics and hospital emergency departments. In B.C. the Take Home Naloxone Program has sought to get Naloxone kits into the hands of people at risk for opioid overdose. Kits are available at a wide range of locations and eligible people can receive a free kit after taking part in a short training program. At EKASS we have been dispensing kits for nearly two years, and there are many other locations in the East Kootenay where people can receive free kits.
This article has described some of the common components of addictions treatment in British Columbia. For more information about services offered through EKASS please visit our website at www.ekass.com or call us at 1-800-489-4344.
Addictions Treatment – What it is, and what it isn’t
Posted on: 13-Oct-2016
Posted by EKASS | on
This is the first of two articles regarding information about treatment -- what it is and what it isn't' and the different formats that describe treatment. The series is written by East Kootenay Addiction Services' Executive Director, Dean Nicholson. The article below does not necessarily reflect the views and opinions of East Kootenay Addiction Services.
Over the past number of months there has been a lot of media
focus on the fentanyl crisis in B.C.
Many of the stories have talked about the lack of treatment, or the wait
for treatment, often with the subtext that if people could have gotten
treatment than the problem would have been solved. But what exactly is ‘addictions treatment’
and how does it work?
We typically think of ‘treatment’ as some kind of
intervention that brings about a ‘cure’ or an end to the problems we’ve been
having. Antibiotics are a good
example. We are sick with an infection,
we do a treatment of antibiotics which kills the bacteria, and in a few weeks
we are back to our normal health. Dealing
with addiction problems is very different.
Addictions treatment does not provide a ‘cure’, nor does the problem go
away. ‘Treatment Centers’ are programs
where individuals typically stay for 2-3 months. These programs provide structure, opportunity
for group and individual counselling and support, education, safety, regular
food and social connection. But despite
what certain programs might say, they cannot provide a ‘cure’ to addiction. Any program that promises to cure someone of
their addiction is selling a bill of goods.
Why isn’t there a cure for addiction or substance
abuse? Addiction and substance abuse are
basically brain disorders. People use
substances for a variety of reasons, but one of the main reasons is because
they like the way substances make them feel, at least in the beginning. Our brain is designed to turn behaviours that
we do repeatedly into habits. The
thinking part of our brain doesn’t have to be involved as much, and a deeper
part of our brain controls the behaviour.
Think of driving a car – when we first learned we had to pay attention
to every single thing we had to do – braking, accelerating, signaling etc. After a few months we could do most of that
without actually thinking about it. Much
of driving had become habitual. The same
thing happens when we use substances. If
we use a substance enough times our brain develops a habit for using, or for
using to feel a certain way. We don’t
have to think about how to use, a deeper part of the brain makes it
happen. If we use certain substances long enough, the brain
actually goes through physical changes, so that the substance use is regarded
as essential to feel a certain way.
As a person progresses from social use to habitual use to addicted use,
the amount of choice and control that the person has over using decreases. When a person has developed an addiction,
there is a part of their brain that will control their behaviour and compel them
use the substance even when they know it is harming them or that it
could kill them.
The good news is that the brain is remarkably able to rewire
itself. New habits can be learned to
replace old harmful habits. But just as
it takes time to develop a habit or an addiction, so too does it take to
develop new ways of behaving. The
reality of addiction is that there is no simple way to change a brain. Even when people want to stop using recovery
is a long-term process, often with many setbacks, that requires a lot of effort. Factor in that many people are ambivalent
about changing or stopping their use, and the process becomes even more
difficult. Difficult doesn’t mean
impossible, but it does mean that there is no simple ‘cure’, no ‘treatment’
that can be imposed on someone that will make their brain automatically
As a culture we have come to believe that there should be
quick fixes. We don’t like to be
uncomfortable or to suffer. We have a
society built around instant gratification.
This expectation is part of what fuels people getting in to trouble with
substances, and then it becomes part of what fuels people having unrealistic
expectations about recovery. Does this
mean there is no hope? Absolutely
not. Every day at East Kootenay
Addiction Services we see people who are learning to reorganize their lives,
develop new skills and move away from addiction towards happy and fulfilling
lives. And what makes those people
successful? They have come to recognize
that there isn’t a quick fix. Life
requires ongoing effort and focus, whether that is recovering from an
addiction, having a family, or building a career. Accepting that recovery is a process and not
a cure has allowed those people to work realistically and productively towards