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.