Welcome to the Alberta Harm Reduction Conference – I hope that by the end of the workshop, you and your organization will be ready to embrace the principles and practice of harm reduction – I can promise it is not difficult nor painful.Although Harm Reduction as a public health strategy comes in many shapes and sizes for different behaviours, this workshop will focus on people who use drugs. Please note – I mean people who use drugs – not drug users or abusers. Lesson #1 - Recognises and acknowledge the person before the behaviour.The millions of people around the world who use drugs are immensely diverse and their relationship with drug-taking takes many forms
Drug use, particularly injection drug use, can be highly stigmatizing, and people affected by poverty and homelessness often carry the heaviest burden of stigma in society as a result of multiple intersecting factorsAccess to services is often impeded by factors including poor availability, accessibility and quality of services, restrictive inclusion criteria, lack of gender-responsiveness, high costs of services, compulsory or ineffective drug treatment approaches, stigmatization, and a lack of confidentiality and protection of personal information.There is growing awareness that vulnerability to the harms of drug use, particularly the risk of HIV infection, is increased within certain environments, including disadvantaged and impoverished neighbourhoods, lack of stable housing and incarceration
Despite the injuries, environmental impact, pollution and death toll associated with motoring, its elimination is not seen as realistic because people depend on their vehicles and, realistically, will not relinquish them. Speed limits, emission controls, seat belt and crash helmet laws can all be understood as harm reduction strategies to reduce the risks and harms of motoring.
Stephen Lewis has been a tireless champion of advocacy and social justice. He is the former United Nations Specialist Envoy for HIV/AIDS in Africa..
The view that harm reduction may encourage drug use seems to underestimate the complexity of the factors that shape people's decisions to use drugs . Far from “disempowering communities”, as critics claim, studies have also found needle exchanges highly successful in reducing the rate of unsafe disposal of injecting equipment in areas where they operate.Many critics argue that harm reduction has iatrogenic effects. Needle exchanges, for example, encourage users to inject more and result in greater numbers of new initiates to injecting. However, the DPMP review concluded: “Fears that harm reduction ‘sends the wrong message’ have no evidentiary basis.”In light of the overwhelming supportive evidence surely everyone’s interests are best served when people who use drugs are provided with high-quality, effective health and social services.
If there are people around, then there are drug users around. It is simple as that, people have been using drugs to get high since prehistoric times, and they aren't going to stop anytime soon. Chances are you might be addicted to a drug, like nicotine or caffeine.
Drugs affect the brain by binding to receptors on nerve cells. Opiateswork on our built-in receptors for endorphins—the body’s own, naturalopiate-like substances that participate in many functions, including regulationof pain and moodIn human beings endorphins are released in the infant’s brain when there are warm, non-stressed, calm interactions with the parenting figures. The fewerendorphin-enhancing experiences in infancy and early childhood, the greaterthe need for external sources. Hence, a greater vulnerability to addictions.
Most psycoative substances produce feeling of pleasure; particularly stimulants which give feeling of power, self-confidence and increase energy. In contrast, depressants tend to provide feelings of relaxation and satisfactionMany people who suffer from social anxiety and/or stress may use drugs to “take the edge off” and feel more comfortable. Some people who have experienced trauma (particularly when young) or who suffer from depression may use drugs to lessen intense feelings of distressThe increasing pressure to improve performance leads many people t use chemicals to “get going” or “keep going”.As social creatures we are strongly influenced by the behaviour of those around us, and substance use can be seen as a way to build connections with others. Additionally some people naturally have a higher need for novelty and a higher tolerance for risk which can promote substance use.
Society's reluctance to view drug use as a legitimate form of risk taking posesanother significant barrier to acceptance of Harm Reduction. While societiestolerate and even encourage some far more dangerous forms of risk-taking(such as car racing, mountain climbing, boxing and bungee jumping), drugtaking is singled out as something inherently and primordial evil. Harmreduction, because it accepts the possibility of drug-taking under certaincircumstances, is often viewed as promoting intolerable behavior.
In Canada, people are protected from discrimination based on “race, national or ethnic origin, colour, religion, age, sex, sexual orientation, marital status, family status, disability or conviction for an offence for which a pardon has been granted” under the Human Rights Act.
Positive change is relative to the individual and therefore needs to be determined by the individual. Harm Reduction Advocates work with individuals to determine what changes are desired. Advocates can help determine goals for change that are realistic given the myriad of circumstances that create unique situations for all individuals. Interaction should include all possible avenues for change and to assist individuals in obtaining their goals, in a non judgmental, respective interaction.They are informed that they can choose the avenues for change, when and if they want to. This form of self empowerment allows them to make the choice(s) in how they want to interact with the Harm Reduction effort. This often creates a trusting, respectful relationship which allows for a positive Harm Reduction interaction. Energy or effort once used by the client to fit into a program or service can now be directed to focusing on the real needs of the client and positive change can begin to happen. Once goals are established by the client, advocates work with the client to clarify what the client seeking and begin to discuss the avenue(s) for change educating the client so the client can make informed decisions on how to proceed. The advocate then can offer suggestions based upon their experience and their knowledge of what services are available to reach their goals.
.Collaborative evaluation allow the client participation and ownership in his/her change process.
Knowing urban myth from reality will help you understand why people make a conscious decision to start using drugs. Drug use has been long recorded throughout the history of humankind; there is no such thing as a stereotypical drug user. Famous 'users' include: Salvador Dali, Charles Dickens, Arthur Conan Doyle, Ben Franklin, Jimi Hendrix, Albert Hoffman, Pope Leo XIII - learn to accept that while drug use may not be healthy, it is a common feature of modern and ancient society
People who struggle with other health issues are given choices about the types of services they receive.They are often offered a wide range of services and supports.People who struggle with substance use deserve the same respect for choices, services and supports
Shame and fear of judgment limit use of mainstream services therefore for many PWUD, Urgent Care is the primary point of access to health & social care – often at late stage requiring hospital admission. Link clients to community based services including housing, needle exchange, etc to reduce “revolving door” The Dr. Peter Centre in Vancouver provides low-threshold access to care for people living with HIV/AIDS including a high proportion of IDU offers one example where harm reduction has been successfully integrated with a medical facility. Many conventional barriers have been removed at the Centre including the need to remain drug-free. MMT and the distribution of condoms and clean needles are also provided . An interdisciplinary team embraces harm reduction through the promotion of self-care and autonomy. Participants are able to build trusting relationships with healthcare staff; such a facility offers an important solution to increase acceptability of care while reducing stigma among IDU. Importantly, the continuity of care from both nurses and doctors has shown to be an effective means for reducing injection-related complications and the need for hospital admission
Access to appropriate housing is a basic fundamental need and a human right.Homelessness can compromise mental and physical health including addiction, family break-down and physical & sexual abuse & exploitation. Housing is a site through which relationships and social support as well as privacy is enacted The reduction of risks and harmful effect associated with substance use and addictive behaviours not only assist the affected person but have a positive impact on urban neighbourhoods where street level substance use problems are concentrated.
Zero-tolerance approaches are ineffectual among youth in particular, and may serve to further alienate youth from making use of drug services.There is growing evidence that traditional, non-harm reduction focused shelters and programs for youth drug users do little to reduce theincidence of drug use or associated health issues including HIV/AIDS and Hepatitis C. Introduce low threshold entry and intake processes that make services more accessible (e.g.. extended hours of operation, drop-in service etcThe intake process should include screening questions to assess immediate risk in the main life domains (e.g. mental health, safety, housing, food, etc) as well as safety planning to address substance use risksWith each contact, track and maintain focus on practical short –term actions that will help reduce immediate and harmful consequences of substance use and other high risk behaviours
The Public Health Agency of Canada describes positive mental health as “the capacity of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of equity, social justice, interconnections and personal dignity. A major challenge in applying a public health approach in addictions is the negative moral evaluation, or stigma, attached to those who appear to lack control over their drug use. This assessment is amplified when the behaviour is also illegal. Consequently clients will often forgo treatment or lie about their drug use.The therapeutic alliance is an agreement between a client and their clinician about the treatment approach to be taken based on the expressed needs and desires of the client.) Grounded in the knowledge that their very relationship has the power to facilitate positive change, the worker accepts that the client may make less than optimal choices for their health in the short term. Yet by respecting these choices and being available to deal with their consequences, the therapist intentionally strengthens the therapeutic alliance.Rather than seeing this as enabling the client to keep harming himself, the worker understands that she cannot realistically prevent a client from making particular choices at the given moment. But by keeping the door open and helping to address the adverse consequences when they occur, the worker can strengthen the motivation of the client to behave in a less harmful way, and facilitate their engagement in further treatment when the client is ready to move closer to a less harmful pattern of use or abstinence.
Community barriers will always exist. Service providers should take every opportunity possible to explain in clear culturally relevant terms the goals of their harm reduction strategies. Given the distrust that exists in various communities around drug related harm reduction initiatives, building community relations is an indispensible part of everyone’s role. Listen and learn from what the clients and the communities tell you.Building rapport and trust and within a community is time consuming but is critical to the success of harm reduction initiatives. Some of the barriers that may ariseNegative attitudes, prejudices, homophobia, racism & sexismBeing judgmental toward target populationsLack of respect for individual choices, fear of change
This was a human right campaign introduced by a NGO in UK.There is no medical diagnosis other than drug use to which the term “abuse” is applied as a diagnostic term. This language does not support people with substance use issues to improve their quality of life or to improve their self esteem. It also speaks to a totality of identity that is neither fair nor accurate.People are more than their substance use, they are people first, and they are also mothers and sons, musicians and artists, students and teachers, etc.So, when should you start introducing a harm reduction approach to your organization - you can start when you leave here today.
What does harm reduction have to with me anyway
WHAT DOES HARM REDCUTION HAVETO DO WITH ME ….OR MY ORGANIZATION?Barbara Ross RN HV BA MBAProvincial Harm Reduction Supervisor – Alberta Health Services
WHO NEEDS HARM REDUCTION?Inequities in access to services are prevalent for thosewho use drugs, and that these disparities are furtherexacerbated by the social determinants ofhealth, including inadequatehousing, poverty, unemployment and the lack of socialsupportHarm Reductionl 2013
HARM REDUCTION - FOR ALL“It works”“We’re here to make you feelbetter”“It does what it says on thelabel”“The taste of success”Harm Reductionl 2013
WHY HARM REDUCTION?Harm reduction provides skills in self-care (andcare for others), lowers personalrisk, encourages access to treatment, supportsreintegration, limits the spread ofdisease, improves environments and reducespublic expense.It also saves lives.Harm Reductionl 2013
WHAT DOES IT DO?• Recognizes that both legal and illegal substance use are enduringfeatures of human existence• Focuses on decreasing the adverse consequences of substanceuse while building non-judgmental, supportive relationships• Includes abstinence as an option if and when the person isready, while recognizing that abstinence is not always realisticHarm Reductionl 2013
WHAT ABOUT HUMAN RIGHTS ?Human rights apply to everyone.People who use drugs do not forfeittheir human rights, including the rightto the highest attainable standard ofhealth, to social services, to work, tohousing and to be part of acommunity.Harm Reductionl 2013
DOES THIS LOOK FAMILIAR ?• Provide safe, compassionate, competent and ethical services• Promote health and well-being• Promote and respect informed decision-making• Preserve dignity• Maintain privacy and confidentiality• Promote justice• Be accountable.Harm Reductionl 2013
CRITICISMS OF HARM REDUCTIONIt doesn‟t work International evidence strongly supports HR interventions as effectivemethods of preventing HIV transmission and improving the lives ofinjecting users.Keeps addicts stuck in their substance use Only part of a continuum of prevention and treatment strategy.Consistently performs better atretaining people in programs and reducing drug useFails to get people off drugs Drug treatment programs requiring abstinence for entry reach only20% of active users. HR programs designed to reach the other 80%Encourages Drug Use Studies and clinical trials have found the provision of needles doesnot cause a rise in drug use or injectionThere is no scientific evidence Endorsement by the United Nations General Assembly, UNAIDS, theUN Office of Drugs and Crime, the World Health Organization andmany others.Harm Reductionl 2013
UNDERSTANDING DRUG USENo one “contemplates”addiction and no one becomesor remains addicted because ofharm reduction interventions.(WHO 2012)Harm Reductionl 2013
UNDERSTANDING ADDICTION“It is impossible to understand addiction withoutasking what relief the addict finds, or hopes to find,in the drug or the addictive behaviour.”“Not why the addiction but why the pain.”“Why do we despise, ostracize and punish the drugaddict, when as a social collective, we share thesame blindness and engage in the samerationalizations?”• . -Harm Reductionl 2013
WHY PEOPLE USE DRUGSSubstance use, especially illicit druguse is often highly stigmatized andmisunderstood.People generally use drugs to:1. To feel good2. To feel better3. To do better4. Curiosity or social interactionHarm Reductionl 2013
STEPS TO A HARM REDUCTIONAPPROACH• Develop a Policy or Position Statement that includes: program specificdefinition of harm reduction, a statement that commits your service torespective treatment of people who use substances, define what specificmeasures will be taken to implement a harm reduction approach• Provide training and education on harm reduction to your team.Communicate your commitment to your staff and the clients you serve• Identify specific actions that support the principles and practice of harmreduction• Support the principles of GIPA/MIPA and encourage participation ofPWUD in developing harm reduction practices – “Nothing About UsWithout Us”Harm Reduction 2013
GOAL 1Harm reduction does not require at-risk practices be discontinued whilefocusing on promotingsafety, preventing death anddisability, and supporting safer usefor the health and safety of allindividuals, families andcommunities.Harm Reduction 2013
GOAL 2Provide non-judgmental care toindividuals and families affected bysubstance use, regardless of setting,social class, income, age, gender orethnicityLearn not to judge people based on theirlife decisionsHarm Reduction 2013
GOAL 3Recognize human rights and theimportance of treating all people withrespect, dignity and compassion,regardless of drug use.Harm Reduction 2013
GOAL 4Recognize the power of positivechange.Stigmatizing behaviour is not amotivator for positive change.Harm Reduction 2013
COLLABORATIVE ASSESSMENT orASKING THE RIGHT QUESTIONS• What would you like to change regardingyour drug use?• How important are these things to you?• Which change(s) would you like to workon first?• How would you like to make the changesyou desireHarm Reduction 2013
GOAL 5Fight ignorance – raise awarenessand share knowledge with yourclients, colleagues, teams andcommunitiesHarm Reduction 2013
WE’RE ON OUR WAY• Primary goal to engage and retain the client in theservice• Embrace the client “as is”• Lower the threshold for access to services• Incorporate user-centered practices• Negotiations are made possible when the source(s) ofdifficulty are better understood• Know what resources are available – tell your clients• Respect is a two way street• Listen and learnHarm Reductionl 2013
HEALTHCAREASSUMPTIONS• Clients are usually “drug seeking”• Healthcare should be dependenton abstinence or it will not besuccessfulRESPONSETreat all people with respect, dignity andcompassion to reduce the stigmaassociated with drug use.• Stigma and judgmental attitudesencourages clients to reject heathinterventions and/or lie about their druguse• Leaving AMA predisposes individualsnot only to poor health outcomes due toinadequate treatment but also to majordisruptions in the patient-providerrelationshipHarm Reductionl 2013
HOUSINGASSUMPTIONS• Abstinence is the only realisticmodel for successful communityintegration• Giving homeless peopleapartments before they were“housing ready„” is setting them upfor failure• Housing PWUD put the rest of thecommunity at risk• One size fits allRESPONSE• Supported housing is essential to goodhealth and recovery from addiction andmental illness.• Fostering a sense of self determination andsocial inclusion empowers clients to makeinformed decisions• Adapted to the needs of the client – notefficiencies or expertise in service delivery• Minimise attrition and “drop-out “rate• Positive impact on urban neighbourhoodHarm Reductionl 2013
SCHOOL/YOUTH HEALTHASSUMPTIONS• The “Just say no” abstinencemodel works• Allowing drug use will increasedrug use among homeless youthwho are not currently using drugsor create a drug-oriented cultureamong youth using generalshelter/program servicesRESPONSE• Provide staff with trainingopportunities that help build harmreduction practice skills• Provide strategies to prevent ordelay the start of substance useand promote awareness aboutsafer use• Display up to date, youth friendly,accurate information on harmreductionHarm Reductionl 2013
MENTAL HEALTHASSUMPTIONS• Many people think of harmreduction initiatives in relation tosafer injection rooms or legalizingcannabis• Supporting a harm reductionapproach enables clients tocontinue high risk behaviour• Continued relapse means theclient is not interested in changingtheir drug useRESPONSE• Commitment to a client-centred"therapeutic alliance• Discuss short terms goals to decreaseimmediate risks• Motivate client towards positive change• Review of treatment goals is on-goingbetween client and worker.• Strengths and weakness and resilience ofclient are appreciated built uponHarm Reductionl 2013
PROMOTE COMMUNITY INVOLVEMENT• Build rapport and a trusting relationship with the community• Raise awareness about prevention, care and social services forHIV/AIDS, STD‟s, drug use and homelessness• Educate the community about resources and current services withinthe community• Support communities and build self esteem among targetedcommunities• Respect the community and the people within itHarm Reductionl 2013
“NICE PEOPLE USE DRUGS”People who use drugs are human beings – not justclients or patients; not victims or service users.Like all of us, people who use drugs are uniqueindividuals with hopes, dreams and potential.“We could be your daughter, your sister, your brother, yournephew, your niece, your whatever. And what if we were yourbrother, or your sister or your mother? How would you feel?People have feelings, we have feelings?”.Harm Reductionl 2013