Chapter 9.0: Opioids
Harm reduction first appeared in the literature during the late 1980s and early 1990s. The term was used to describe attempts to reduce adverse consequences associated with substance misuse, without necessarily eliminating substance use (Single, 1995). Two general levels of harm reduction effort emerged in the literature: clinical practice and policy interventions. Underlying harm reduction is recognition of the potential harms associated with engaging in substance misuse, as well as knowing that some individuals will continue to engage in these behaviors, at least for an unknown length of time, despite the potential for harms to self and others. “The essence of the concept is to ameliorate adverse consequences of drug use while, at least in the short term, drug use continues” (Single, 1995, p. 287). The harm reduction approach, derived from public health rather than criminalization motivations, aims to improve quality of life for individuals, families, and communities associated with the risky behaviors (Collins et al., 2012). Harm reduction strategies can reduce the risk of infectious disease transmission and drug overdose, among other potential harms (Drucker et al., 2016).
Harm reduction strategies can occur at the program, policy, or clinical level. Some examples of harm reductions strategies include:
- clean needle and syringe exchange programs to reduce risk of exposure to blood-borne communicable diseases like HIV/AIDS and hepatitis,
- medically supervised injecting facilities (more common in other countries than the U.S.),
- distribution of fentanyl testing strips to help prevent unexpected opioid overdose,
- wide public distribution of opioid overdose reversal kits (Narcan) available to first responders to save the lives of individuals who might otherwise die before professional treatment is accessible.
- access to pregnancy prevention resources such as birth control and education about safer sex practices
- nicotine replacement therapy to reduce harms associated with smoking tobacco products, and
- medication-assisted treatment (MAT) involving opioid substitution drugs (e.g., methadone, buprenorphine) to reduce harms associated with use of unregulated “street” drugs.
- teaching people who use intravenous drugs safer injection practices such as cleaning skin and not licking needles to reduce infection related hospitalizations
- rapid HIV testing
While harm reduction as a public health and social work strategy makes intuitive sense on the surface, controversy revolves around philosophy and implementation, led to some degree by a misunderstanding of harm reduction (Drucker et al., 2016).
One argument against harm reduction strategies is that it may be mis-perceived as sanctioning the problematic behavior. Some argue that harm reduction is too “soft” on individuals who break the law through substance misuse and abstinence-only policies are necessary to stop the harms caused by substance misuse, and risk-reduction approaches do not do enough to stop substance misuse.
On the other hand, harm reduction is viewed as being practical and humane. Harm reduction programs may serve as pathways to enter treatment and reduce substance misuse. Harm reduction approaches reduce the spread of HIV and Hepatitis, do not increase drug use, and can help keep a person alive long enough for treatment to work (https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/). An argument that harm reduction interferes with motivation to seek treatment and/or quit engaging in the problematic behavior is countered with the argument that, as a result of engaging in harm reduction programming, individuals may then become encouraged to engage in treatment to reduce or cease substance misuse (Drucker et al., 2016). An argument against nicotine or opioid replacement therapies is that the person continues to experience substance dependence. However, use of these therapies may allow the individual to gradually become weaned from dependence in a controlled manner, supported by behavioral therapies. While this is argument is offered in support of e-cigarettes/vaping as a harm reduction tool, evidence is mounting that significant risks of harm are associated with these devices (including injury from malfunctions/battery problems, chemical exposure not being reduced as much as advertised, worsening of the nicotine dependence, and poisoning of children and pets from the liquid nicotine).
A recovery orientation refers to a host of values, beliefs, and behaviors related to how individuals engage in and experience the process of recovery from a SUD (Bersamira, in press). The recovery orientation is fundamentally informed by the individuals’ own definitions of the problems, solutions, and subjective experiences, rather than those being imposed by others. Built into this orientation are issues such as having individuals define for themselves what constitutes “recovery”—this may or may not include abstinence as a goal, for instance. Another aspect has to do with adopting a holistic view where individuals’ recovery is embedded in a context of all life structures, functions, and wellness, including their future growth and development as a person, not just changes in past substance use/misuse behavior (Kaskutas et al., 2014). Thus, recovery does not simply mean achieving the absence of disease, it means promoting wellness across all life domains.
Many individuals and professionals actively engage in advocacy related to a general recovery-oriented movement, promoting recovery-oriented services and policy (Bersamira, in press). This orientation includes engaging indigenous and professional services and relationships in supporting individuals’ long-term recovery (and their families), as well as shaping the culture of communities and policy (White, 2008). For example, peer support systems are often an integral aspect honored and incorporated in a recovery orientation: peers being others who have lived the experience and found their own pathways to recovery. In other words, recovery-oriented systems of care differ quite markedly from traditional treatment systems: their services are more person-centered, self-directed, and strengths-based (Bersamira, in press).