*For seminar* Think about this: type II diabetes is a chronic medical condition that threatens those who are obese and have a sedentary lifestyle. Few people object to providing them with medication. Medication does not cure the condition, but the primary goal of treatment is to reduce the likelihood of secondary diseases (CV disease, retinopathy, neuropathy, etc). Losing weight and exercise is recommended but not everyone is successful in doing so. Compare that to your view of distributing condoms to prevent unwanted pregnancy and the spread of HIV. What’s the difference? What about seatbelts, bike helmets? Again, the goal is to reduce injury or harm.
There are several ways to define HR. It’s main goal is to reduce or minimize adverse health and social consequences associated with (in this case) drug use. Important to know that it doesn’t mean the discontinuation of drug use.
Translation: treating people as they are, providing education and options to reduce the harm associated with behavior (without changing behavior itself) I believe in the platinum rule. The golden rule states that we should treat other people how we want to be treated. The platinum rule treats other people how they want to be treated. And this is important when working with diverse population groups.
Our culture doesn’t look at the larger picture when it comes to substance abuse. We tend to focus on the individual and their problem instead of looking further. (victim blaming) Drug users are seen as “bad” and “it is their fault they are in that situation” In all drug users, we need to understand WHY, especially in FN peoples because of their past (abuse, residential schools, etc).
Humanistic Values – no moral judgements are made about the drug user. Acknowledgement of the respect of the dignity and the rights of the individual (CCSA, 2008). Focus on Harms – reduce the harms resulting from drug use rather than focusing on the extent of the drug use. The objective is to reduce the harmful consequences of drug use to the individual and others. Priority of Immediate goals – the most pressing, achievable and realistic goals are focused on first and are the first steps to a risk-free drug use. Starts with “where the person is”. Pragmatism – the improve the drug related harms short term rather than attempting to get the user to abstain completely. SRNA (in their 2008 pos’n statement) also includes autonomy, flexibility and maximization of intervention options, responsibility, education, dignity and advocacy.
- Insite reported 500 overdoses with no fatalities. On the street, these people would have most likely died.
Y do I believe in Harm Reduction is not the question. The real/riehl question is why don't I believe in abstinence. Treatment. Detox. List a bunch. B/c of the plat Rule. We r all different. Some of us R similar.
Concurrent Remanded HEP C 22 times higher and HIV 11times higher than general population Safer tattooing pilot program – 29,000 for HIV inmate and 26 000 hep c inmate treatment per year. Cost of pilot program 100 000 per year/per site project would have saved money if it prevented as few as four infections a year. Youth Ethical implications if under legal age, pragmatic for those over legal age. 3 areas that distinguish harm reduction policy as applied to you: Autonomy and ability to make informed choices (developmental processes) Specific harms and risks associated with youth (ie. laws re: access to alcohol) Unique opportunities for drug policies and programs targeting Youth (school based programming) These populations are underserved
Safe injection site? What about safe consumption sites, with regulations, and limits, and drugs that are monitored, measured, and dispensed by professionals.? http://www.health.gov.on.ca/english/providers/pub/aids/reports/ontario_needle_exchange_programs_best_practices_report.pdf
As Prime Minister Harper has said, our government is very concerned about the damage and pain drugs cause families and we take this issue very seriously. And that is why our new National Anti-Drug Strategy will place particular emphasis on educating Canadians, especially young people and their parents, about the negative effects – health and otherwise – of illicit drugs. My favorite Tony Clement quote “the party’s over” One size does not fit all Modelled after the failed War on Drugs. Nixon 1971
http://dpnoc.ca/about/a-letter-from-our-president/ “ Similarly, we do not agree with those involved in the Harm Reduction Movement wanting to legalize many of the currently illicit drugs. “ this is a myth or misconception
I have substituted HR for ethics……. Ethics is not a black & white subject Ethics is not something you either know or don’t know Ethics involves thinking and feeling, study and practice, knowledge and intuition
Substitute HR for The Code it of ethics is not a panacea Impossible to provide rules for every circumstance Does not tell you which value takes precedence over the other Provides guidance only- RNs must use critical thinking & problem solving skills to examine the values and how to weigh them in each situation E.g. Values and statements regarding ;promotion of health vs. patient Making informed smoke. Code can be overridden by other, stronger ethical or legal obligations: confidentiality vs. obligation to report child abuse cannot legally assist patient in committing suicide
We each have our own personal values, values about nursing, our institution has its values as well. At times these can collide. This is part of our culture as health care professionals A value is a belief or attitude about a goal, an object, a principle or a behavior. Our personal values affect our beliefs about health and illness and our sense of the “right” thing to do Values are reflected in the choices we make, in our actions and behaviors. But what about the choices of our clients In the process of making an ethical decision, our values can conflict. We may not be aware of it until we encounter conflict or something unexpected - Example: Individual-value life, value of freedom choice and control over one’s life pt with HIV and who becomes pregnant an informed choice to continue using injection drugs…the nursing values of choice and health and well-being come into direct conflict. situations in which one individual nurse’s values conflict with another individual’s personal or profession’s values or the institutions values.
It does not enable drug use. It can help prevent HIV and HCV for those that do not want to quit or can’t quit. It can be a gateway to addiction treatment. There is no evidence showing that that introduction of HR (ie. Needle exchange) increases drug use. This is only an assumption and isn’t looking at why people start to use drugs which is the main consideration that must be made. HR strategies are relatively inexpensive and cost effective (ie. By preventing the transmission of infection diseases or detecting the disease earlier before they have progressed into advanced states) Evidence has shown that HR doesn’t compromise the public’s safety in fact it does the opposite b/c it has been shown that more needles are recovered than are distributed therefore decreasing the public’s risk of contacting HIV or HCV
HR is not a moralistic concept that takes a stand on drug use. It’s a pragmatic solution in that some levels of drug use in society is expected and attempting to ameliorate drug related harms is more feasible in the short term rather than trying to eliminate the drug use all together. (in this case, we’ll focus on the spread of HIV in the Aboriginal population) It makes no assumptions about drug use and those that use drugs.
http://www2.cna-aiic.ca/CNA/documents/pdf/publications/JPS_Harm_Reduction_2012_e.pdf Why are position statements important
Used in Vancouver and Toronto
The primary objectives of these strategies is the reduction of adverse consequences associated with IDU. Needle exchange: provision of clean needles and syringes for IDU. Purpose is to prevent the spread of blood borne diseases and reduce the risk of infection. Injection sites: provide IDUs with a clean and safe environment where sterile equipment is provided and health care and social professionals are available to provide counselling and deal with health issues. Overdose intervention is available. (In Site) Individuals bring in their own drugs. The average amount of daily visits per day was 607. The average visits per person was 11. Methadone: substituting methadone for illegal drugs helps users establish a level of stability free from the use of injectable drugs. Street outreach: drug users often have limited access to health services and street outreach programs allow them to have access to clean syringes, testing, etc. Safe crack pipe programs: helps reduce the transmission of blood borne pathogens. Also gives users a chance to interact with health care professionals to provide education on reducing the risks. Other HR strategies that people don’t consider: seatbelts, bike helmets, low fat food
Historically, methadone maintenance programs underwent a political struggle. Methadone was available in Canada in the 1960’s but was only used for three to six percent of the injection drug using population. In the mid 1990’s government regulations changed increasing treatment availability which resulted in up to 24 percent of the injection drug using population receiving treatment in 1998 (Fisher, Rehm, & Blitz-Miller, 2000). Fisher et al., (2000) stated that. “…there were clear, instructive lessons… yet Canada’s policy-makers failed for the longest time to implement appropriate and sufficient measures to prevent and minimize injection drug use related harms” (p. 1712).
Focus on IDU because this is the method that causes the most HIV cases in Aboriginal pop’n however there are other methods. In total pop’n of Canadians, the method is MSM. (2007) Of all AIDS cases in FN 45% is attributed to IDU. Need to take a HOLISTIC approach and consider the social determinants of health. Illicit drug use among FN is double the rate of the general Canadian pop’n. https://mymail.siast.sk.ca/owa/attachment.ashx?attach=1&id=RgAAAACgBUjceA6RSIRe%2bXueIDitBwAs61ZeCi5PQrAmj7cmGBezADcScG0qAAAs61ZeCi5PQrAmj7cmGBezAEu946WTAAAJ&attid0=EACnk8wYziYtSp0OF5N6FADw&attcnt=1
In no particular order. All these result in physical, emotional, mental and spiritual pain. Aboriginals have social disadvantages and these put them more at risk to use illicit drugs. Poverty, low education, unstable family structure, physical abuse and poor social support network. (64% say they were raised in violent homes) They also suffer from culture barriers to health care services (language, lack of culturally appropriate services). Overall infection rate of HIV/AIDS is 2.8 times higher in FN than non-FN. (2007 stat) Alcohol abuse was a factor in 70% of homes. 126 Aboriginal IDUs themselves, say they may have ended up on the streets and turned to IDU b/c of the legacy of abuse they have gone through (Joining the Circle) Joining the Circle (from Abor. IDUs) : Alcohol 70% Violence 64% Suicide 50% Incest 44% Sexual abuse or assault in men 50% + Low education level 17% (<gr.9)
The most important element of developing and providing harm reduction services to FN people is incorporating traditional Aboriginal practices. Culturally appropriate services include: Aboriginal culture itself (medicine wheel), language, history and increased awareness of FN people among service providers. Harm reduction services need to be culturally appropriate in order for them to be accessed. IN a study, FN people identified they would like to see additional services provided (education along with needle exchange) in conjunction with HR services. Elders and community leader’s support is crucial. These people are respected by the community and hold the power to help. Similarities include: importance of links between the community and the individual. CAAN’s model (presented later) Healing journey is more in depth than in Western practices. Healing process includes: information, prevention activities, crisis interventions, counselling and follow-up. Difference includes the incorporation of community practices, customs, beliefs, ceremonies and use of Elders and Traditional medicine people. Using these culturally appropriate services is a key element in increasing pride and self-esteem.
Mood altering substances are incompatible for some Aboriginal peoples’ traditions, customs and cultural ways. (seen as out of balance) HR does not focus on abstinence, rather is looks at decreasing the risks, not specifically discontinuation. This has been seen as a barrier to offering Aboriginal people harm reduction services. For some Aboriginal communities, there is a stigma attached that HR in that it is seen as an indication of failure. This reason also makes FN peoples hesitant to access health care. There is a fear of discrimination and judgement among everyone, but this fear is even higher among Aboriginals. There is an absence of funded HR services in Aboriginal communities (specifically reserves and rural) which forces people to travel long distances and make other arrangements.
B/c of the settings nurses work in. They are in a unique pos’n to prevent many of the harms associated with drug use. Using HR strategies in nursing practice creates future opportunities to promote the health and well being of those experiencing substance use. Underlying principles of HR reflect the CNA’s code of ethics (2002)
Must look at the issue through a population health approach gov’ts at all levels can facilitate and create conditions within the social and physical environment that support and enhance health (Health Canada, 2001). The lack of these determinants of health may precede or exacerbate drug misuse. Strategy should include measures that address the underlying factors associated with drug misuse and measures to address the more immediate risk factors. Drug misuse: using drugs improperly Abuse: excessive use
Principles of Harm Reduction pragmatism human rights focus on harms maximize intervention options priority of immediate goals drug user involvement Why consider harm reduction programming? Many social, economic, mental health and personal reasons why people engage in higher risk behaviour Not all people are able to make the immediate changes necessary to eliminate risk
We now know the definition of harm reduction and its goals. There are several HR strategies that can be implemented to decrease adverse consequences of IDU. The risk factors are different from people in the Western culture
Dispelling the Myths: The WhiteTape of Harm ReductionGreg Riehl December 5th, 2012Thunder Bay District Health Unit
• Define harm reduction• Identify the goals of harm reduction• Explore harm reduction among key populations• Identify myths and misconceptions• Values, choice, culture and harm reduction.• Discuss your role with harm reductionObjectives
• Practical non-judgemental services that seek to minimize drug related harm to the individual in society• Originated in Amsterdam and UK in the 1980s by drug users themselves in response to rising HIV rates• Needle exchange, Methadone maintenance• Abstinence is one of many strategies and services that can be provided.Harm Reduction
International Harm Reduction Association (2002):“Policies and programs which attempt primarily toreduce the adverse health, social and economicconsequences of mood altering substances toindividual drug users, their families and communities,without requiring decrease in drug use”.Harm Reduction (As cited in Ministry of Health, 2005)
A neutral, non judgmental, lowthreshold approach, gearedtowards individual attributes andcontext as well as social factors ofbehavior and potential risk forharmKeane, 2003; Hathaway, 2002; Erikson, 2001Harm Reduction
The GOAL of harm reductionis to help users makeinformed decisions andempower themselves toreduce the potential harmfrom drug use.
Principles of Harm Reduction• Humanistic Values• Focus on Harms• Priority of Immediate Goals• Pragmatism• Balancing costs and benefits to individuals and society Ministry of Health, 2005 Beirness, Jesseman, Notarandrea & Perron, 2008
More About Harm Reduction• Reduces sharing of needles• Saves lives by reducing drug-related health risks.• Improves quality of life• Reduces the spread of HIV• Reduces OD deaths• Opportunity for education and referrals Health Canada, 2001
Medical Model is to treateveryone the sameTrue or False
Special Populations • Concurrent Disorders (mental health and addictions) • Remanded Populations • Youth • Women
National Anti-Drug Strategy•Government of Canada Launches New Anti-drugCampaign: New Ads Latest in Effort to Help ParentsKeep their Children Drug-free•This was October 2007 Knowledge does not equal behaviour changehttp://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2010/2010_196-eng.phphttp://www.nationalantidrugstrategy.gc.ca/sp-dis/2007_10_04_1.html
• There is a disconnect with what is being said and what is being practiced• Compare federal, provincial, regional, local practices.• Who decides what we do? Unfortunately not our clients.Cultural Disconnect
“We have major concerns with some of the initiatives,falling under the banner of Harm Reduction, that donot include abstinence as a goal. Rather than reduce,they only prolong the misery caused by addiction.Whereas, properly funded, prevention andabstinence-based treatment programs actually reducethe number of people addicted and the relatedharms.” C.D.(Chuck) Doucette President Drug Prevention Network of CanadaDrug Prevention Network of CanadaPrevention Education Treatment
Nature of Harm Reduction• Harm reduction is not a black & white subject• Harm reduction is not something you either know or don’t know• Harm reduction involves thinking and feeling, study and practice, knowledge and intuition
Harm Reduction Does Not…• Provide rules of ethical or moral behavior for every circumstance• Offer guidance about which values should take priority or how they can be balanced in practice
When Do Values Collide?• When one’s personal, professional or institutional values conflict• When an individual’s values conflict with the values of another individual
MYTHS• HR enables drug use and encourages drug use among non- drug users• HR drains resources from treatment services• HR increases disorder and threatens public safety and health BC Community Guide, 2005
Saskatchewan Registered Nurses’ Association:“Focus is on the assumption that harmsassociated with certain behaviours can bereduced without the elimination of thebehaviour”Harm Reductionists accept abstinence asa goal along a continuum… SRNA Position Statement, 2008
Nurses have a responsibility to provide non-judgmental care to individuals and families affectedby substance use, regardless of setting, social class,income, age, gender or ethnicity, and they caninfluence the development of organizational andgovernmental harm reduction policies related to druguse.CNA CANACJoint Position Statement
4 Pillars TreatmentPrevention • Improve physical, emotional, and• Prevent or delay onset. psychological healthHarm Reduction Enforcement• Reduce harms for • Strengthen community individuals, families, and safety by responding to communities. crimes and community disorder issues.
Harm Reduction StrategiesRelated to Drug Use• Needle exchange• Supervised injection sites• Methadone• Street outreach programs• Safe crack pipe programs Beirness, Jesseman, Notarandrea, & Perron, 2008
• Methadone Reduces • Illicit opiate use • Overdose deaths • Frequency of injecting • Needle sharing • HIV/HCV/HBV transmission • Criminal activity, recidivism T Kerr, R Jürgens. Methadone Maintenance Therapy in Prisons: Reviewing the Evidence. Montreal: Canadian HIV/AIDS Legal Network, 2004.Substitution Therapy
• Assess patients fully and ask about their use, how they support their use, &if they are withdrawing• It isn’t your life, so avoid judgment• Manage withdrawal properly –withdrawal is a MEDICAL EMERGENCY• Set realistic boundaries• Understand the impact of trauma, pain and anxiety• Ask patients to tell you if they use• Don’t punish patients for using• Keep the door open• Be clear about what patients can expect from you & what you expect from them“They may have made some bad choices but your job is tolook after their needs” Remember Maslow????Substance Use and Care
Maslow’s Hierarchy of Needs Where is your client at right now? Social Determinants of HealthMaslows hierarchy of needs and subpersonality work, Kenneth Sørensenhttp://two.not2.org/psychosynthesis/articles/maslow.htm
• Aboriginal injection drug users are the fastest growing group of new HIV cases in Canada.• An estimated 6,380 Aboriginal people were living with HIV (including AIDS) in Canada at the end of 2011 (8.9% of all prevalent HIV infections) which represents an increase of 17.3% from the 2008 estimate of 5,440.• The estimated prevalence rate among Aboriginal people in Canada in 2011 was 544.0 per 100,000 population.Epi in First Nations
Risk Factors for HIV in First Nations • Injection Drug Use • Unsafe sex • Many sexual partners • Sexual and physical abuse • Incarceration • Alcohol Abuse • Lack of knowledge • Low self esteem • Residential school syndrome • Loss of culture and spirituality All Nations Hope, 2002 Joining the Circle, CAAN
•Culturally appropriate services •There is a lack of harm reduction services to First Nations (rural and on-reserve) Wardman & Quartz, 2006 & Dell & Lyons, 2007)“Programs and services for First Nations, Métis and Inuit people must‘first and foremost, show respect and honour for all Aboriginal beliefs,practices and customs’ and reflect the ‘pride and dignity thatAboriginal heritage demands” Culture and Harm Reduction
• Not all harm reduction measures are applicable to all people, groups, or communities.• Many Aboriginal communities adhere to models of abstinence and prohibition and do not allow for moderate substance use.• Stigma and discrimination• Absence of services Dell & Lyons, 2007
Community and Public Health• What is your role in providing care, treatment, and support for those who use illicit drugs and are at risk for contracting .• Nurses have a duty to provide safe, competent, ethical care.• Protect dignity and choice• Enact social justice CNA, 2007
Population Health Approach• Consider underlying conditions that put people at risk of using, abusing, and misusing drugs (ie. marginalization, poor support networks, lack of access to health services, poor coping skills).• Consider determinants of health: Income and social status Social support networks Education Employment Coping skills Culture Physical environments Health services Health Canada, 2001
What CanYOU Do?• HIV and HCV are PREVENTABLE• Consider harm reduction within framework ofproviding medical care • goal is to minimize harm with a patient-first approach • maximize intervention options • Knowledge ≠ behaviour
Summary• As health care practitioners, we must provide culturally competent care to our clients and citizens of our communities.• Western culture tends to blame the victim.• Harm reduction can improve the quality of people’s lives.• Some people are faced with several risk factors that put them at risk for harm.• We need to implement cultural elements when working with our clients and with our partners.
“Ultimately we know deeply that the other side of every fear is a freedom.” Marilyn Ferguson
Greg Riehlgreg.email@example.com@sasktel.net1.306.775.7383• Thank you for your participation.Questions? Comments?
References• All Nations Hope AIDS Network. (2002). Harm reduction in Saskatchewan: A resource guide. Regina, SK: Author.• Beirness, D.J., Jesseman, R., Notarandrea, R., & Perron, M. (2008). Harm reduction: What’s in a name? Ottawa, ON: Canadian Centre of Substance Abuse.• British Columbia Centre for Disease Control. (2003). The needs of someone living with HIV. Vancouver: Author.• Canadian Aboriginal AIDS Network. (2007). Walk with me pathways to health: Harm reduction service delivery model. Ottawa: Author.• Canadian Aboriginal AIDS Network. Joining the Circle: An Aboriginal harm reduction model. Retrieved July 10 th, 2008 from http://www.healingourspirit.org/pdfs/publications/joincircle.pdf• Canadian AIDS Treatment Information Exchange. (2007). Study looks at underlying causes of HIV, hepatitis C and substance use in Aboriginal youth. Retrieved July 8, 2008 from http://www.catie.ca/catienews.nsf/news/F78C7BC9B71F09388525733100608E31?OpenDocument• Canadian Nurses’ Association. (2007). Promoting equity through harm reduction in nursing practice. Ottawa: Author• Dell, C. A., & Lyons, T. (2007). Harm reduction policies and programs for persons of Aboriginal descent. Ottawa, ON: Canadian Centre on Substance Abuse.• Health Canada. (2001). Reducing the harm associated with injection drug use in Canada. Ottawa: Author.• Health Canada. (2001). Harm reduction and injection drug use: An international comparative study of contextual factors influencing the development and implementation of relevant policies and programs. Ottawa: Author.• International Harm Reduction Association. (2002).• Ministry of Health. (2005). Harm reduction: A British Columbia community guide. British Columbia: Author.• McLeod, A. (2004). As the wheel turns: The HIV/AIDS medicine wheel. The Positive Side, 6(4), 14-16.• Saskatchewan Registered Nurses’ Association. (2008). SRNA position statement: Promoting equity through harm reduction in nursing practice. Regina: Author.• Wardman, D. & Quantz, D. (2006). Harm reduction services for British Columbia’s First Nation population: A qualitative inquiry into opportunities and barriers for injection drug users. Harm Reduction Journal, 3(30), 1- 6.