Harm Reduction – What It Is and What It Is Not

This essay is part of a series on harm reduction responses to drug use in the MENA and Asian regions—the actors and networks engaged in such activities, the contributions they have made, and the roadblocks they have met. Read more ...
 

The often-misunderstood term “harm reduction” means simply that the paramount policy or clinical objective is reducing the harms from psychoactive drug use. In the conventional drug policy that has prevailed globally for decades, the reduction or elimination of drug consumption was considered the principal policy aim, while the harms caused by drug use or drug policies were usually an afterthought.

Harm reduction is not a new approach. A primary focus on reducing the harms from alcohol has existed for a long time. Accepting that some degree of alcohol intoxication and chronic excess was always going to be with us, policymakers and researchers decided decades ago that “making the world safe for drunks” was a quite legitimate objective and complemented other efforts to reduce high-risk drinking. Reducing the consumption of alcohol by increasing its price or decreasing its availability are different but also effective ways of reducing alcohol-related harm alongside harm reduction approaches such as the promotion of car safety belts. Contemporary interest in harm reduction and the application of this framework to illicit drugs was stimulated in the early 1980s when the epidemic spread of HIV among and from people who inject drugs was first acknowledged.

Approaches resembling harm reduction are very common not only in public health but also in many other policy areas. “Never let the best be the enemy of the good” could be a slogan for contemporary harm reduction; it is much more effective to aim for and achieve sub-optimal goals than to strive for but fail to reach utopian and unattainable objectives.

What is Harm Reduction?

Harm Reduction International (HRI), the main organization in the world advocating for and supporting harm reduction, uses this term to refer to “policies, programs, and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop.”[1]

This organization also defines “harm reduction” as “policies, programs, and practices that aim primarily to reduce the adverse health, social, and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families, and the community.”[2]

This definition means that harm reduction is more than just a clinical service delivery approach, as it also refers to government policies. The objective goes beyond aiming to only reduce health costs, as a reduction of social and economic costs is given equal weight. Importantly, harm reduction does not distinguish between reducing the harm from legal or illegal drugs. Both are considered important. In this definition, as emphasized by the reference to reducing adverse consequences “without necessarily reducing drug consumption,” decreasing the consumption of drugs is considered potentially just one way of reducing the harm from drugs. Reducing consumption should not be regarded as an end in itself but can be a legitimate way to reduce harm. The paramount aim must be to reduce net harm, and if that involves reducing consumption, so be it. All too often in recent decades, reducing the consumption of illegal drugs has been the only objective of conventional drug policy regardless of the nature or extent of unintended negative consequences. Negative health, social, and economic effects of drug use were often inadvertently exacerbated, but this collateral damage has all too often been ignored. It is important to note that the HRI definition also emphasizes that harm should be reduced not only for people who use drugs, but also for their families and indeed for their communities.

Harm Reduction in an International Context

Approaches that we would today call “harm reduction” have existed for a long time. In ancient China, authorities found that the most effective way of reducing the number of intoxicated citizens dying from hypothermia after falling into frozen canals in winter was to simply build barriers around the canals. Of course, these harm reduction measures complemented and did not replace other efforts to discourage high risk drinking.  

Within a few years of the identification of HIV in the early 1980s, it became apparent that in many countries HIV was a serious threat to the health and well-being of people who injected drugs, their families, and their communities. For many decades,  reducing or even eliminating drug consumption had been the only policy objective pursued. Now the notion of harm reduction was, somewhat controversially, revived. In many countries authorities with a deeply entrenched commitment to drug prohibition delayed or obstructed valiant and pragmatic attempts to slow the spread of HIV among and from people who inject drugs. They did this even though generalized epidemics of HIV in up to a dozen countries had started from epidemics among people who inject drugs. Effective harm reduction approaches to control HIV among people who inject drugs include needle syringe programs, opioid substitution treatment (with methadone or buprenorphine) for heroin dependent persons, explicit and peer-based education, and building organizations for people who use drugs. The United Nations has agreed on a package of nine measures constituting harm reduction efforts to control HIV among people who inject drugs.    

Harm reduction complements approaches that try to prevent the initiation of drug use or reduce the continuing use of drugs. It recognizes that many people throughout the world continue to use psychoactive drugs despite the very vigorous efforts to prevent the initiation or continued use of drugs. Harm reduction accepts that there will always be some people who use drugs and are unable or unwilling to stop. Access to effective and attractive drug treatment is important for people struggling with drug problems, but many such people are unable or unwilling to enter or remain in treatment. Also, many people with drug problems, even some with severe problems, manage to regain control of their lives or stop their drug use by their own efforts without the need to enroll in drug treatment.

People who use drugs should be provided with options to help them to minimize the risks associated with continuing drug use, including the risk of harming themselves or others. Keeping drug users alive and healthy is the highest priority in harm reduction. Therefore improving access for people who use drugs to primary health care and social services is always very important. Basic needs include providing non-judgmental education about drugs and drug-related risks.

Values and Principles

Harm reduction is strongly based on critical values and principles with a major commitment to protecting public health and respecting human rights.

1. Pragmatism: Harm reduction always seeks practical approaches. Policy and interventions have to be acceptable to all stakeholders and must be effective. When the Chinese leader Deng Xiaoping said “it doesn’t matter whether the cat is black or white as long at it catches the mouse,” he could have been commenting on the pragmatism of harm reduction. Harm reduction deals with the world as it is rather than the world that some would like it to be. Approaches are practical, feasible, effective, safe, cost-effective, and easy to implement while having a substantial impact on individual and community health. 
2. Evidence-based Policies: Harm reduction has a commitment to basing policy and practice on the strongest evidence available. In contrast, conventional drug policy aiming only to reduce use is often indifferent to evidence and is either intuitive or based on international treaties.
3. Cost-effectiveness: In a world where demand for resources is always strong yet their supply is always limited, benefit is maximized by preferring low-cost/high-impact interventions to high-cost/low-impact interventions. Many health and social interventions are low-cost and high-impact while many supply control interventions are high-cost and low-impact. Harm reduction looks for inexpensive ways to improve a difficult situation, while conventional drug policy often involves expensive ways of making a bad situation worse.
4. The Value of Incremental Gains: Harm reduction practitioners acknowledge the importance of positive changes that individuals make in their lives. But most people recover from their drug problem slowly, with incremental progress over time. Harm reduction interventions are facilitative and voluntary and are based on the needs of each individual. As such, harm reduction services are designed to meet people’s current needs. Small gains for many people have more benefit for a community than heroic gains achieved for a select few. Harm reduction advocates are conscious that it is better to have 20 percent of something than 100 percent of nothing. The objective of harm reduction in a specific context can often be arranged in a hierarchy with the more feasible options at one end (e.g., measures to keep people healthy) and less feasible but more desirable options at the other end. Abstinence should be considered a difficult to achieve but desirable option for harm reduction in such a hierarchy. For some, abstinence is also a dangerous option, as relapse, always a risk, can be fatal. Keeping people who use drugs alive and preventing irreparable damage is regarded as the most urgent priority, while it is acknowledged that there may be many other important priorities. Some opponents regard harm reduction and abstinence as mutually exclusive options. For harm reduction practitioners, this is a false dichotomy. Enduring abstinence is perhaps the ultimate way of eliminating risk. But not all can achieve or want to achieve abstinence, and abstinence, often unstable, can result in a fatal relapse. Voluntary efforts to achieve abstinence should be encouraged and supported with advice always offered about the risk of relapse. 
5. Dignity and Compassion: Harm reduction practitioners accept people as they are. Judgmental attitudes and behaviors should be avoided. People who use drugs are always someone’s son or daughter, sister or brother, or father or mother. This compassion extends to the families of people with drug problems and their communities. Harm reduction practitioners oppose the stigmatization of people who use drugs. Describing people using language such as “drug abusers,” “junkies,” or “drug misusers” perpetuates stereotypes and only further marginalizes people who use drugs. Terminology should convey respect and tolerance and recognize the inherent dignity of people who use drugs and people who don’t use drugs. Helping people who use drugs to get a job and reintegrate with their community are important parts of harm reduction, just as improving educational and employment prospects for young people probably help to reduce the demand for drugs.
6. Respect for Human rights: Human rights apply to everyone. People who use drugs do not forfeit their human rights, including the right to the highest attainable standard of health, to social services, to work, to benefit from scientific progress, to freedom from arbitrary detention, to free association, and to freedom from cruel, inhuman, and degrading treatment. Harm reduction opposes the deliberate hurts and harms inflicted on people who use drugs in the name of drug control and drug prevention, and promotes responses to drug use that respect and protect fundamental human rights. People who use drugs remain citizens of their countries with the same rights and responsibilities as other citizens.
7. Challenging Policies and Practices that Maximize Harm: Many factors contribute to drug-related risks and harms, including the behavior and choices of individuals, the environment in which they use drugs, and the laws and policies designed to control drug use. Many policies and practices intentionally or unintentionally create and exacerbate risks and harms for drug users. These include: the criminalization of drug use, discrimination, abusive and corrupt policing practices, restrictive and punitive laws and policies, the denial of life-saving medical care and harm reduction services, and social inequities. Harm reduction policies and practices must support individuals in changing their behavior. But it is also essential to challenge the international and national laws and policies that create risky drug- using environments and contribute to drug-related harms. Harm reduction not only attempts to reduce the harms caused by drugs, but also the harms resulting from drug policy. 
8. Transparency, Accountability, and Participation: Practitioners and decision makers are accountable for their interventions and decisions, and for their successes and failures. Harm reduction principles encourage open dialogue, consultation, and debate. A wide range of stakeholders must be meaningfully involved in policy development, program implementation, delivery, and evaluation. In particular, people who use drugs and other affected communities should be involved in decisions that affect them. Harm reduction emphasizes bottom-up developments, while use reduction is usually a top-down process. Harm reduction often grows out of local needs and developments, while use reduction usually flows from meetings behind closed doors in faraway cities.

What Harm Reduction Is Not

Despite frequent claims to the contrary, harm reduction is not pro-drug. Nor is harm reduction anti-drug. If anything, harm reduction is neutral about drug use. Harm reduction is only concerned with reducing harms from drug use and drug policy.

The relationship between harm reduction and drug law reform differs according to the circumstances. In a situation in which HIV spread among and from people who inject drugs is already epidemic or is considered a serious threat, the need to respond urgently to this threat overrides the longer-term need to support drug law reform. Thus harm reduction and drug law reform are always strategically connected but may sometimes be tactically separated. A major HIV epidemic among and from people who inject drugs has been raging in Russia for more than two decades. Getting this HIV epidemic under control as soon as possible with harm reduction measures is more important at present than advocating for drug law reform. But priorities could change if the authorities bring the HIV epidemic under control.

Harm reduction is not about sloppy, careless, or indifferent approaches. It is a pragmatic, evidence-based, and cost-effective approach that protects human rights and public health.

Conclusion

A quarter of a century ago harm reduction was marginalized and ostracized, but no longer. Harm reduction is now very much part of the international mainstream. Around 80 countries describe their drug policy as harm reduction, and a similar number provide needle syringe programs and opioid substitution treatment. The major UN organizations responsible for drugs and drug policy now support harm reduction, some very consistently while others somewhat less so. The highest levels of the United Nations have explicitly approved harm reduction. Harm reduction continues to gain support, while use reduction has seen declining support and is increasingly questioned. There has been a steady growth in organizations, conferences, meetings, and journals committed to harm reduction. The coverage of harm reduction programs is often poor and funding is often limited, but at least the trends are in the right direction. 

[1] Harm Reduction International (HRI), “What is Harm Reduction?” http://www.ihra.net/what-is-harm-reduction.

[2] Harm Reduction International (HRI), “What is Harm Reduction?”