Harm Reduction (Harm Minimisation)

Describes the rationale behind the harm reduction approach, as well as the different harm reduction interventions, e.g. needle and syringe exchanges and methadone maintenance. (922 words)

Some people may not want to, or feel unable to, give up using drugs completely. They might just want to reduce the harm that drugs can cause, e.g. they might change from injecting heroin to smoking it. Harm reduction, or harm minimisation, is a model of working that has been associated with drug use treatment since the mid-1980s. It was initially a response to the need to try to minimise the harm caused by injecting drug use at the beginning of the HIV epidemic. 

The harm reduction model recognises that people will continue to use drugs despite the risks and prohibition, and works on the principle that some of the risks of drug use can be reduced and minimised. Prevention measures and education are important, but if they are unsuccessful, we must work with the consequences of drug use. Drugs can be harmful because of the effects of the drugs itself, contaminants mixed with the drug, the methods of delivery (e.g. injecting), and their effects on other people, in particular family members.

Harm reduction is about educating drug users about the risks of drug-taking and helping them to take responsibility for themselves. With this information, people are able to make choices about the level of risk to which they will expose themselves. Harm reduction is a process and not a treatment. It needs to be integrated with other forms of intervention.

One important harm reduction intervention is the development of needle and syringe exchanges. These exchanges provide drug users with free sterile needles, syringes, in some cases sterile water and other paraphernalia, and condoms. Exchanges also provide a means of safer disposal of used equipment. Needle exchange users are far less likely to share other people’s equipment. Attendance at a needle exchange also gives the person an opportunity to ask for advice on injecting and health issues, and to obtain referral to abstinence-based treatment services if requested. 

The provision of substitute prescribing is another important harm reduction intervention. An option for helping people who feel unable, or unwilling, to undergo abstinence-orientated treatment and abstain from drugs, is to prescribe a substitute drug in either reducing or non-reducing doses. This substitute may be the actual drug to which dependence has been developed, although it is more common for a drug to be used that is considered to be a better and safer alternative.

Maintenance treatment with a substitute drug eliminates withdrawal symptoms and allows the individual to address a variety of concurrent issues in their lives, e.g., the chaotic lifestyle often associated with the procuring of money to purchase the drug, and the drug itself. Moreover, it helps them avoid the contaminants that are present in street drugs, thereby providing a way by which the person’s health may improve or not further deteriorate. 

Methadone is a synthetic opiate which has been used as a substitute treatment for over fifty years. It has several properties that make it an excellent substitute for heroin and other opiates, including a long duration of action, being available in liquid form, which deters injecting, and having little euphoriant effect, thus eliminating withdrawal symptoms without reinforcing continued use. 

Methadone is often prescribed either on a maintenance programme—where a stable dose is used, sometimes for prolonged periods of time, even many years—or on a reduction programme, where the aim is abstinence following gradual reductions in dose. However, the best form of prescribing regime is one in which practitioner and client work together to decide changes (or no changes) in dose level and this may vary over time. This approach does not fit easily into a rigid maintenance vs. reduction distinction.

Most methadone programmes require the client to attend a pharmacy (or less public place) to consume their methadone. There is a great deal of variation across treatment services in the rehabilitation and psychosocial services that are offered in addition to methadone, and also in the dosage levels employed. The most successful methadone programmes have been characterised by high methadone doses (60 mg and above), more intensive counselling, and the availability of other supportive services. 

Research has revealed the benefits of methadone treatment are reduced levels of heroin use, reduced crime and imprisonment, reduced HIV risk behaviours, improved quality of life, improved physical and psychological health, reduced non-opiate use, and reduced death rate. Methadone is also considered important because it helps attract and retain heroin users in a treatment environment, increasing the chances that they may decide to try and stop using opiates altogether.

However, methadone is not an innocuous treatment. Methadone prescribing can lead to an increase in a person’s total drug consumption, as they may continue to use street-drugs on top of the methadone, and even result in overdose, although the incidence of the latter is far less than with heroin. Some people consider methadone to have a higher addictive liability than heroin, and to produce more severe and long-lasting withdrawal. 

An alternative substitute drug to methadone is Subutex (buprenorphine), which is a partial agonist at a subpopulation of opiate receptors in the brain. Subutex has been proposed to be more effective than methadone, whilst causing less adverse effects to the user. It is suitable for both detoxification and maintenance programmes. Subutex exerts sufficient effects to prevent or alleviate opioid withdrawal symptoms, but produces a milder, less euphoric, and less sedating effect than high doses of heroin.

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