Expand Harm Reduction Practices

Introductory Paragraph

Harm reduction supports interventions which are aimed at reducing negative effects without necessarily completely extinguishing potentially harmful behaviors. In a substance use disorder setting, harm reduction seeks to keep individuals alive while minimizing negative health impacts that can result from active substance use. It is not the primary goal of harm reduction strategies to get someone into treatment and recovery. Harm reduction is rooted in the view that we need to meet people where they are - and many are not ready to accept or able to access treatment or recovery. That being said, those involved in harm reduction work are nearly always ready to assist someone in getting connected to services if they express a desire to get additional support. As many in the harm reduction community will say, a dead person cannot recover.

The term harm reduction involves addressing all types of harm, including:

• Preventing death through reversing overdose
• Preventing overdose through the use of testing strips
• Preventing infection and disease transmission through needle exchange programs
• Supporting public awareness campaigns

An additional category of harm reduction is MAT (medically-assisted treatment). This a complex topic which warrants a detailed focus under the treatment domain. See the SAFE Solution article titled "Expand Access to Medicated Assisted Treatment/Recovery (MAT/MAR)."

Key Information

The Harm Reduction Journal defines harm reduction as "policies and programs which aim to reduce the health, social, and economic costs of legal and illegal psychoactive drug use without necessarily reducing drug consumption." The Harm Reduction Coalition defines harm reduction as "a range of widely accepted public health policies, practices, and programs that seek to reduce morbidity and mortality associated with drug use and sexual activity, while respecting the autonomy, rights, and dignity of people who use drugs or engage in sex work.” The Coalition has developed the following eight principles to guide to communities and agencies in effective harm reduction policies and programs.

• Accept, for better or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.

• Do not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use.

• Affirm people who use drugs themselves as the primary agents of reducing the harms of their drug use and seeks to empower them to share information and support each other in strategies that meet their actual conditions of use.

• Establish quality of individual and community life and well-being — not necessarily cessation of all drug use — as the criteria for successful interventions and policies.

• Understand drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe use to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others.

• Ensure that people who use drugs and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them.

• Call for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.

• Recognize that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination, and other social inequalities affect both people’s vulnerability to and capacity for effectively dealing with drug-related harm.

The cluster of SAFE wiki articles on harm reduction explore, in greater detail, many strategies used in communities across the country to achieve the outcomes sought by harm reduction advocates and practitioners. While the list below is not a complete inventory of research-based strategies, it includes approaches that challenge the stigma that is targeted at people who use drugs. Four of the most widely adopted strategies include:

• Naloxone Training and Distribution. Naloxone HCl is a life-saving medication specifically useful in the reversal of an opioid overdose. Also known by its name brand, Narcan, this medication is used via a syringe or a nasal spray by a bystander who intervenes in a suspected overdose. Naloxone does not have the potential for misuse. Naloxone is available to most Americans without a prescription from pharmacies. Saving a life provides the opportunity to find recovery. A wide variety of stakeholders are engaged in this strategy because there is no such thing as too many opportunities to get a use overdose reversal medication. Efforts are often accompanied with public awareness campaigns that inform the public about where to get Naloxone and encourage active users not to use alone.

• Increase Distribution of Fentanyl Testing Strips. This provides a way for users to detect the presence of Fentanyl and to prevent the risk of overdose. Likewise, access to testing strips opens additional options for users to reduce harm or learn about treatment opportunities.

• Expansion of Needle Exchange Programs. The use of non-sanitized needles or the re-use and sharing of syringes can lead to infection, the spread of disease, and create a tremendous increase in healthcare-related costs. The investment of a few cents in a single clean needle that can be accessed by users can save thousands of dollars. Having people participate in needle exchange programs provides another opportunity to connect with others and to services. As with most harm reduction strategies, there is an element of stigma which needs to be overcome, both with the user and the public. Many people in the public see these programs as enabling harmful or immoral behaviors.

• Harm Reduction in Special Settings. The focus here is on how to help those in specific situations, including those in the criminal justice system and women who are pregnant or who have recently given birth. In both cases, numerous strategies have been developed to improve harm reduction for all affected.

Relevant Research

• International Journal of Drug Policy. This study examined evidence from 44 US states and found that Naloxone expansion is not associated with increases in adolescent heroin use and injection drug use. “Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages.”

• Stanford University, School of Medicine. This article documents research that has been done on the implementation of the Safety First curriculum developed at Stanford for school-based harm reduction with adolescents.

• The Harm Reduction Journal is an open access, peer-reviewed journal that publishes research and commentary on approaches diminishing the harm of stigmatization, marginalization and criminalization of public health, human rights and social justice issues.

• Science/Research-Based Education. The role of developmentally appropriate substance use education is similar to the movement away from abstinence-only sex education. This maturation of the field is critical to preventing the harms associated with risky substance use behaviors. Many of the unwanted or undesirable outcomes of substance use can be prevented by appropriate sharing of available knowledge regarding substance use. In terms of harm reduction, this allows people who use drugs to more accurately anticipate and manage their own risk. Equipping individuals with an understanding of how substances interact with one another, how the route of administration impacts risk and effects of use, and how to indicate an overdose is an important tenet of harm reduction.

Impactful Federal, State, and Local Policies

Progress is being made in harm reduction policy in the following areas:

• Bystander interventions

• Naloxone standing orders and bulk funds

• Safe injection site and syringe access

• Paraphernalia laws

• Lift on the purchase of Fentanyl testing strips

To date, 47 states and the District of Columbia have enacted both Good Samaritan and Naloxone Access laws as part of an effort to reduce overdose deaths, while encouraging individuals to respond to opioid overdoses. These laws protect people from certain criminal penalties if they call 911 to save an overdose victim. The Government Accountability Office (GAO) reviewed 17 studies on Samaritan and Naloxone laws and found a pattern of lower rates of opioid-related overdose deaths among states that have enacted Good Samaritan laws, as well as an increased likelihood of individuals calling 911 if they are aware of the laws

Available Tools and Resources

• SAMHSA: Harm Reduction Framework This is the first document to comprehensively outline harm reduction and its role within the Department of Health and Human Services (HHS). The Framework was developed and written in partnership with the Harm Reduction Steering Committee, composed of harm reduction leaders from around the country. This group represents a broad array of backgrounds and experience, with most having lived experience of drug use. This document includes a definition of harm reduction, pillars and principles supporting that definition, and core practices that SAMHSA can support.
• SAFE Project:
  • "Opioid Overdose on Campus: Key Steps to Expand Harm Reduction Efforts" is a SAFE Project written article that equips students, staff, and faculty with the knowledge and tools to intervene effectively in an opioid emergency.
  • "Lessons Learned: The Truth About Harm Reduction" is a SAFE Project written article that explores the concept of harm reduction and offers resources on how to better implement harm reduction practices into substance use treatment programs.
  • "SAFE Community Playbook" is a downloadable resource that provides a blueprint on how communities can convene a local coalition, conduct an assessment, and prioritize actions to address the addiction epidemic.

• The National Harm Reduction Coalition works to create spaces for dialogue and action focused on harm reduction strategies. It hosts an annual conference and an online resource center. One example of the type of information available through the resource center is on Fentanyl test strips and safer use supplies.
• Harm Reduction International uses data and advocacy to promote harm reduction and drug policy reform. It promotes rights-based and evidence-informed responses to drug use in order to contribute to healthier and safer societies.
• SAFER-U: Strategies, Awareness, and Fentanyl Education Resources for Universities. This is an online training which models a Fentanyl eduction approach. The content of this training is available for reproduction and localized implementation.
• Never Use Alone (NUA) is a peer-led nonprofit. Their staff and volunteers have lived experience with substance use and have been impacted by the drug overdose crisis. They provide compassionate phone support regarding personal use or use by a loved one.
• Next Distro is an online and mail-based harm reduction service designed to reduce opioid overdose death, prevent injection-related disease transmission, and improve the lives of people who use drugs.
• TIME: What Harm Reduction Taught Me About My Ex's Addiction—And Myself. This article provides an account of the experience of folks whose loved ones struggle with substance use, recovery, and who utilize harm reduction services. The level of vulnerability is rare, making this a valuable resource, especially in on-campus work.
• The Network for Public Health Law "Policies in Schools to Reduce Overdose and Other Drug-related Harm" Webinar explores substance abuse policy issues in schools.

Promising Practices

• Syringe Services Programs (SSPs), also known as needle exchanges, are proven to have incredible impacts on preventing large-scale outbreaks of diseases such as HIV and hepatitis.

• Overdose Prevention Sites. These go by different names, but are basically supervised injection sites.

• Technology-Assisted Awareness and Safety. Hotlines are emerging that advocate to "never use alone." There is also a growing use of technological tools to generate “hot batch” alerts in areas where drugs are identified to be excessively potent. Likewise, there is a growing database generated from overdose response reporting.