Harm reduction programmes in drug addiction have been, and continue to be, the spearhead of a realistic and compassionate approach to people with drug addiction.

By harm reduction we mean a set of practical strategies aimed at reducing the negative consequences of drug use, by incorporating methods ranging from low-risk use to controlled use or abstinence .

The role of Health Education

Let’s start by remembering that it is Health Education and its relationship with harm reduction in the area of substance addiction.

Health Education (HEP) is a planned and systematic process of communication and teaching-learning aimed at making the acquisition, choice and maintenance of healthy practices easy and making risk practices difficult. All the definitions of HPS establish a common objective, the search for the modification of the knowledge, attitudes and behaviors of the individuals that make up the community, in the sense of positive health

In 1975 the IV Working Group of the “National Conference on Preventive Medicine” in the United States, led by Anne Sommers, established that HPS should be

“a process that informs, motivates and helps people to adopt and maintain healthy practices and lifestyles, advocates the environmental changes needed to facilitate these goals, and directs vocational training and research towards these same goals”

Risk reduction strategies can be defined as a set of individual or collective socio-health measures that aim to reduce the negative effects (physical, psychological or social) associated with drug consumption.

These measures and strategies tend to diversify the healthcare offer, developing new therapeutic modalities or new devices of a psychosocial nature. In addition, these strategies recognize that the licit or illicit use of drugs is part of our world, and resolve to address the issue of minimizing the harmful effects, rather than simply condemning or ignoring them

With regard to drug users, the World Health Organization, MS has indicated that “effective public health interventions must have a tiered, hierarchical and pragmatic approach”.

Protection for the most vulnerable population groups

A public health intervention emphasizes the need for actions to focus on the reduction and prevention of risk factors, especially among the populations that are most “exposed” .

The spread of injecting drug use and of blood- and sexually-transmitted diseases has led many countries to abandon the maximalist goals of abstinence as a priority and to promote proposals with intermediate or prioritized objectives

What is Harm Reduction for Drug Problems?

The concept of “Harm Reduction” as an intervention strategy for drug abuse problems began in the late 1980s. It originated in the province of Merseyside, England, one of the areas in Britain suffering from a strong heroin epidemic and a high prevalence of HBV infection.

As a result of observing that the traditional repressive model adopted to fight this situation had served more to aggravate the situation than to minimise the problem, they decided to try a new approach to the phenomenon of drug dependence: harm reduction. The development of effective interventions on reality derived from this new working philosophy has promoted the international recognition of the “Mersey Model of Harm Reduction”.

The main reasons for the implementation of risk reduction programs in our environment are

  • The increase in infectious diseases transmissible via the intravenous or sexual route, the fact that marginality and behaviour associated with the consumption of illegal drugs is a risk factor for tuberculosis, the high incidence of AIDS cases in Injecting Drug Users (IDUs) and their partners, occupying the highest rates in Europe in recent years, twenty-two times higher than in the Netherlands.
  • The confirmation that those affected by deterioration do not go to the care or social centres because of their institutional rejection.
  • The existence of a large group that lacks effective resources and over the years goes from one centre to another in pursuit of the palliative benefit to their situation.

The objectives of these programmes

The general objectives of such a programme are summarised in the following five points:

  1. To increase the quality of life of drug users, that is, to improve the state of health and social situation of this group.
  2. Decrease transmission of HIV, HBV, and HCV infection from, among, and to
  3. the drug users.
  4. To increase the awareness of drug users of the risks and harms associated with their use.
  5. To reduce or eliminate the risks and harms associated with drug use, as well as sexual risk behavior among drug users.
  6. Encourage and promote the emergence of risk-free behaviours against HIV, HBV and HCV infection.

Buffering the negative effects of drugs

As Alan Marlatt, author of Relapse Prevention and a reference in the treatment of addictions, argued, these programs aim not so much at abstinence from drug consumption, but rather, admitting the difficulty of achieving this objective for some people, and given that there is a significant number of drug users, try to reduce the damages or consequences caused by this consumption .

The importance of minimizing the harms associated with intravenous drug use is recognized as a strategy in the prevention of HIV infection, and risk reduction is shown to be compatible with primary prevention of drug use. Harm reduction programmes constitute an effective alternative to prevent the infection and transmission of HIV , as well as of HBV and HCV apart from being in themselves a model of approach and treatment of problems caused by drug use.

Why is this perspective of health intervention useful?

The model accepts the evidence that people will continue to use drugs, that not all drug users are in a position to undergo detoxification treatment and that many of those who use drugs do not approach or contact existing health services.

Policies and programs cannot be based on utopian ideals about a “drug-free society” or a society in which all people always use drugs safely. In this line, drug use should be defined as a complex and multi-causal phenomenon, which involves a “continuum” from severe dependence to abstinence; this implies extending interventions to all moments of the process.

These programmes, obviously, cannot solve all the problems associated with drug consumption and should therefore be considered as integrated programmes within the framework of a global policy of broader action against drug consumption (which also includes treatments aimed at obtaining abstinence of users, care for families, etc.).

It should be borne in mind that the risk potential arising from drug use depends on the type of drug consumed, the frequency and quantity, how it is administered, and the physical and social circumstances of this consumption. It is important to note that in some cases policies to reduce drug use may increase the risk associated with drug use, such as when drug users are not informed about available health services or when abstinence-only services are offered.

The levels of intervention

Harm reduction interventions cover different levels: individual, community and socio-political . From this model, interventions are proposed that impact on each of the levels aimed at modifying social norms and perceptions, knowledge, attitudes and behaviour of people, identifying and overcoming existing obstacles.

Many of the risks associated with drugs can be eliminated without necessarily reducing drug use. An obvious example is intravenous use with sterile injecting equipment versus injecting with HIV-contaminated equipment.

The harms associated with drug use are multidimensional. The recipient of the harm can be the individual himself, his immediate social context (family, friends, neighbours) or society in general.

A model that seeks participation

These programs are characterized by an attitude of approach to the drug users by the workers of these interventions, that allows the involvement of the users in them .

Only in this way can these programmes be expected to make adequate contact with a significant part of the “hidden” user population, and to become “bridge” programmes to other socio-health services.

Harm reduction is compatible with the belief that everyone has the right to use drugs if he or she wants to. However, harm reduction does recognize the possibility that drug use can impair judgment, and that many drugs can produce physiological and psychological dependence.

Fighting Stigma

CDs must be treated with the respect that every human being deserves, and they should be integrated into society rather than excluded and marginalized. Many of the risks associated with drug use are the result of the social stigmatization of drug users rather than of the use itself.

Seeking Empowerment

It promotes the competence and responsibility of the drug users themselves, including, but not limited to, the use of these substances. To this end the opinion of the consumers themselves is requested in the design of policies and programmes created to respond to their needs and their active participation in them.

At the same time, it is recognized that situations of social precariousness, isolation, marginalization and poverty affect people’s autonomy and their ability to reduce harm and act in a healthy manner.

The Effects of Harm Reduction

According to the World Health Organization, this type of intervention seeks various effects.

Modify the person’s behavior

Firstly an individual’s change of behaviour , which often manifests itself in an interpersonal context and is affected by a series of elements that go beyond simple information; for example, the person’s beliefs about the risks of a certain habit for their health, the intentions and motivations to modify that behaviour, and the capacity they have to effect that change.

A collective change

On the other hand, significant change is also sought not at the individual level, but at the collective and group level, which recognizes that an individual’s attempts to change behavior are influenced by the opinions and actions of the social groups through which individuals tend to move, as well as by the social circles in which substance use and sexual behavior occur. This is called the “subjective or peer norm.

The rules of the peer group influence the way people conduct themselves. Peer norms are important because they determine whether a behavior is acceptable or normal for the individual and the group. For example, there is a widespread belief in some communities of injecting drug users (IDUs) that having the syringe before the drug brings them bad luck, so they always get the drug before the syringe, making it easier to share a syringe that is “on hand”.

Therefore, individual change is facilitated by changing the rules of equals. Working with peers evolves peer norms on sexual behaviour and drug use, and addresses both group and individual behaviour changes.

Types of programs

There are several types of Harm Reduction programs.

Programs with opiate substitutes

Programmes with opiate substitutes such as low and high threshold fixed and mobile Methadone Maintenance Programmes (MMP) or controlled heroin dispensing programmes.

Patients in methadone maintenance offer lower rates of seroconversion to HIV than those who are not in treatment or are in other treatment programs. Overdose episodes and risk behaviours (less use of the injectable route and less sharing of injection material) are also reduced, with much lower mortality rates than those who are not in treatment.

In these programmes, lower levels of heroin use have been recorded among those in MMP than among those in other types of abstinence-limited treatment 26, 29, 34 and better conditions of use.

Programmes with opiate substitutes have also had a significant impact on reducing crime with fewer criminal acts, fewer arrests and fewer prison stays. Currently, the use of methadone is guaranteed by its safety in opioid-tolerant people, no significant adverse effects or toxicity having been found in follow-up studies of 10 to 25 years.

Heroin programmes are one of the most important resources among risk reduction programmes. Their controlled distribution from the health and social care network has the immediate advantages of other programmes and also has medium- and long-term benefits by moving their consumption away from exclusion (reducing collective crime linked to illegal markets, stabilising or reducing the number of users by not needing to traffic drugs).

Programs against risk behavior

On a second level are programs aimed at reducing “collateral” risk behaviors, directly or indirectly associated with substance use.

In order to avoid high-risk practices against the transmission of HIV, HBV and HCV , several types of programs have been developed within a Harm Reduction strategy

Lower risk consumption programs

These include: syringe exchange and distribution programmes that can be carried out from various locations (pharmacies, mobile teams with educators and “health agents” on the street, primary care centres, hospital emergency services, specific centres, etc.).

Safer Sex Promotion Programs

An example is the “Safer Sex Workshops” (TSMS) that provide health education on sexuality and prevention, as well as programmes or campaigns that favour access to condoms. Although in most countries, Harm Reduction programmes have been developed basically around injecting drug use, their scope is much broader and their methodology is applicable to any type of drug user and to various types of harm.