Translation: treating people as they are, providing education and options to reduce the harm associated with behavior (without changing behavior itself)
HR is not a moralistic concept which takes a stand on drug use but rather, it is a pragmatic solution to the very serious issues of HIV infection. In fact, Harm Reduction is intended to be a value neutral approach and makes no assumptions about drug use of persons who use drugs. The intention of Harm Reduction is to help drug users make informed decisions and empower themselves to reduce the risk of HIV infection. Canadian Aboriginal AIDS Network (CAAN) Service providers’ beliefs and attitudes can create barriers to access for the most vulnerable people in our communities. Harm Reduction asks us to look at ourselves and how we offer services. . .are we really open and accessible to those we want to reach. We need to take our social and moral beliefs out of the programs and services we offer Harm Reduction is a moral necessity and politically smart to do. Harm Reduction is needs based philosophy taking the individual and community into account.
Because HR strategies reflect specific individual and community needs, there is no universal definition of, or formula for, implementing HR. We know how many people will get hiv. Die from smokes. What culture gender age location demographics they are and we do the same things year to year. Wtf. Who has had a hiv test? Its a legal issue Its a health issue Or is it a social issue Some substances are legal. Some are illegal. Why? It is not related to harm. Bill c-10. How will they protect people from getting hiv and hcv. This is where the lawyers shud be advocating for hiv testing on the way in and on the way out. If the feds/prov don't protect u sue trhem.
Harm Reduction is a moral necessity and politically smart to do. Harm Reduction is needs based philosophy taking the individual and community into account. Need to challenge First Nations with new concepts and ways of dealing with new harms and disease processes. Leaders hold the power to help. Leaders should be more concerned about waging a battle against HIV than they are about their image.
HR new to First Nations, concepts need to be culturally appropriate and incorporate language, beliefs, and traditions Need to challenge First Nations with new concepts and ways of dealing with new harms. Leaders hold the power to help. The problematic use of drugs is not the “problem”, it is a symptom of much broader social problems that face First Nations, Inuit and Métis in Canada Leadership need to speak publicly about HIV/AIDS. First Nation communities need to hear their leaders talking about these issues and begin to take it more seriously. Actively engaging members of groups most affected by HIV/AIDS, respecting individual choices, inclusion of Aboriginal people in program planning, implementation, and evaluation Includes aboriginal, Métis, and first nations populations as well as youth, gay men, and women. Concentrating on respect and honour Holistic approach to address issues and factors that impact HIV/AIDS targeting not just the disease, but also the social determinants of health and economic circumstances. It is recognized that the whole family (broadly defined) is as impacted by the disease and needs healing just as the individual with HIV/AIDS needs care, treatment and support. Ethnic origin does not make anyone automatically more or less susceptible to HIV infection, so there must be other reasons for this imbalance. Poverty may be one factor which explains the increased HIV prevalence amongst Aboriginal populations. Studies have found an association between higher AIDS incidence and lower income People need empowerment to negotiate safe and responsible sexual relationships; gender inequalities must be confronted; and those who choose to have sex need access to condoms. Needle exchanges should be encouraged, as they have proven highly effective at preventing HIV transmission among injecting drug users.
Used in Vancouver and Toronto
Designated driver & server training Wet shelters Syringe exchange & availability Drug substitution treatment Education and outreach programs Law enforcement Tolerance areas Drug policy reform Moderation Management (moderate drinking program) Safer Tattooing & Body Art programs (prison)
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
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). http://www.vice.com/en_ca/read/my-methadone-clinic-is-the-happiest-place-on-earth
-non-judgemental, open and engaging -meet people where they are at -depersonalize the behaviour -support decisions by fellow staff -teach, proper drug preparation, injection technique, vein care -Naloxone and basic resuscitation -look after yourself. You work in high stress environments. Monitor your physical, mental, and emotional state. Debrief often. Maintain professional boundaries and know the difference between professional and personal relationships. Be flexible but set boundaries
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)
Good to include networks and user groups in program development To avoid an explosive and generalised epidemic HIV infection in IDU should be kept below 10%
http://www.americanindependent.com/172612/report-d-c-slows-fight-against-aids http://www.aidsmap.com/page/1437294/ The most widely implemented school-based prevention program, known as Drug Abuse Resistance Education (DARE), has also proven to be ineffective at reducing rates of illicit drug use. P19 http://www.icsdp.org/Libraries/doc1/Tools_for_Debate_-_US_Federal_Government_Data_on_Cannabis_Prohibition.sflb.ashx
“ My government will also respond to concerns about the province’s needle exchange program. There is a need to balance harm reduction and improved health outcomes with broader concerns for public safety. Therefore, my government will introduce changes to limit the proliferation of needles handed out by needle exchange programs. Ultimately, this program cannot be allowed to function as a source of unlimited free needles. My government will tighten controls around both the numbers of needles exchanged and distributed. We will cap the number of needles given out at any one time, thus creating more frequent contact with health professionals, which in turn means more frequent opportunity for intervention and treatment. Our goal should not simply be safer drug use. Our goals should be to reduce drug use, to break the deadly cycle of addiction and to better assure the safety of all. To that end, my government will fulfill its commitment to re-establish an independent provincial addictions agency and build on the work of the Ministry of Health, regional health authorities and their partners to strengthen the current system of prevention, education and treatment services.” Speech from the Throne, 2009 DARE Program, did it work? What did Montaner say….
Richard Elliott, the executive director of the Canadian HIV/AIDS Legal Network, which also intervened in the case, said the decision was not a good one for people living with HIV. His group's position is that either a low viral load or the use of a condom should be the required test to avoid being prosecuted, but not both, as the top court said in Friday's ruling. "We know from the science now that if either you use a condom or you have a low viral load, the risk of transmission is extraordinarily small," he said. Jessica Whitbread, who contracted HIV from a former boyfriend more than a decade ago, said she thought Friday's ruling was a step forward — at first. But upon closer examination, she said this ruling could make her the criminal. "I can still have a vindictive lover say that I did or didn't use a condom," she told CBC News. "It still becomes 'he said, she said. he said, he said.' …That can still play a very important role in the courts."
http://stopthedrugwar.org/chronicle/2011/feb/23/us_surgeon_general_gives_okay_ne "[NEPs] are widely considered to be an effective way of reducing HIV transmission among individuals who inject illicit drugs and there is ample evidence that [NEPs] also promote entry and retention into treatment," Benjamin said in making the determination. "The Surgeon General of the United States Public Health Service has therefore determined that a demonstration syringe services program would be effective in reducing drug abuse and the risk that the public will become infected with the etiologic agent for AIDS." Dr. Lisa Merlo, an University of Florida assistant professor of psychiatry and director of the Addiction Medicine Public Health Research Group, said individuals who attend needle exchange programs have significantly higher rates of participation in drug abuse treatment programs. Needle exchange programs refer many individuals to drug treatment programs who otherwise might not access those services, she said. Vs: http://washingtonexaminer.com/local/crime-punishment/2011/02/white-house-moves-fund-needle-exchanges-drug-treatment "It doesn't pass any serious test of rationality," said John P. Walters, the former drug czar under President George W. Bush. "It's like the surgeon general deciding that handing out lighters is a good way to help people to stop smoking. It's at least that absurd, and the consequences are even greater given the risks involved in IV drug use." Dr. Scott Teitelbaum, director of the University of Florida-run Florida Recovery Center, said, "Putting a needle in your arm is not recovery." Teitelbaum said he opposed taking money from legitimate treatment programs to pay for needle exchange. Debate the other options besides just needle exchanges: A more effective way is to spend the money to go into the shelters and communities hit hard by addictions and bring the addicts into treatment, said DuPont and other drug treatment experts. Critics say the new policy is a step toward European-style treatment where the government provides the drugs and a clean room to inject them.
Harm Reduction february 2013 Nursing Education Saskatchewan
Harm Reduction NEPS 325February 2013
Outline • Define Harm Reduction • Examples • Role of Nurse – Break • Special Populations • Current Scenario Discussion
How they define it…A neutral, non judgmental, lowthreshold approach, geared towardsindividual attributes and context as wellas social factors of behavior andpotential risk for harm Keane, 2003; Hathaway, 2002; Erikson, 2001
How they define it…• HR is not a moralistic concept• HR is a pragmatic solution to the very serious issues of HIV infection.• HR is intended to be a value neutral approach & makes no assumptions• The intention of HR is to help people make informed decisions & empower them to reduce the risk of HIV infection. Canadian Aboriginal AIDS Network http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=1954 “The lived experience of HIV-positive Aboriginal persons sits at the intersection of several systemic issues, including discrimination, poorer access to health services (including delayed uptake of HIV treatment), and addiction.”
ETHICS?The values of harm reduction are consistent with the valuesof professional nursing presented in the code of ethics: • the provision of safe, ethical, competent and compassionate care; •the promotion of health and well‐ being; •the promotion of and respect for informed decision‐ making; •the preservation of dignity, in which care is provided on the basis of need; and •the promotion of justice. Canadian Nurses Association March 2011
Harm Reduction & Substance UsePolicies and programs directed at reducing theharmful consequences of drug use while theperson continues to use ……compatible withabstinence. Riley et al, Substance Use & Misuse, 1999 & CCSA PP
Did You Know?• ~2000 people are using injectable drugs in RQHR• RQHR provides ~2 million needle/year• Injected drugs of choice in RQHR: cocaine, morphine,dilaudid, oxycontin•RQHR distributes and collects more needles that SHR and haslower HIV and HCV rates!
Guiding Principles• Pragmatism • Flexibility/Maximization• Humane of Intervention Options Values/Rights • Evaluation• Focus on Harms • Education• Prioritization of Goals • Informed Decision making CAMH, CCSA, Fisher 2006
Concerns• HR enables drug use and entrenches addictive behaviour• HR encourages drug use among non-users• HR drains resources from treatment services• HR is a Trojan Horse for decriminalization & legalization• HR increases disorder & threatens public safety & health Harm Reduction: A BC Community GuideShould we care what the public thinks, when the evidenceclearly supports HR as best practice?
Benefits• It saves lives through:• Reducing harm to those at high risk, and to their family, friends and society• Reduces the spread of HCV/HIV• Empowers people to choose what is best for them and when they are ready to take the next step,• Offers opportunity to stabilize their lives• Decreases crime (Harm Reduction in SK, A Resource Guide )
Culture• HR new to First Nations• Concepts need to be culturally appropriate• Leaders hold the power to help.• The problematic use of drugs is not the “problem”, it is a symptom of much broader social problems that face First Nations, Inuit and Métis in Canada
4 PillarsPrevention Treatment• Prevent or delay • Improve physical, emotional, and onset. psychological healthHarm Reduction Enforcement• Reduce harms for • Strengthen community individuals, families, and safety by responding to communities. crimes and community disorder issues.
Programs & Policies• Seatbelts, car seats, helmet programs• Safer Sex Programs• Methadone Maintenance Treatment• Needle Exchange Programs• Insite, Safer Injection Facility• Moderation Management• Safer Tattooing & Body Art
What Can YOU 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
Substitution Therapy• 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 Therapy21-year-old driver charged in fatal street racing accidentWhat could be substituted for street racing, that would allow the behaviour to continue, in a safer manner?
Role of Nurses • Code of Ethics • Developing therapeutic relationships • Involving current and former people who use drugs • Care planning • Referrals • Health promotion teaching and education • Overdose managementProfessional boundaries and self care
Key Components to BBI Testing Pilot• Increased awareness for staff and patients• Link to care• Offer routine HIV testing to ALL patients admitted to critical care – HCV and HBV offered at same time – Targeted testing = missed opportunities• Pilot will establish what works in practice in your unit
Cost Effectiveness?• Screening for HIV is cost-effective even where HIV prevalence is low (0.1-0.2%)• Routine testing every 5 years is as cost effective as yearly mammograms after age 50 (Ann Intern Med. 2009; 150:125-131)• ~25% of Canadians with HIV are unaware of their diagnosis
Substance Use and Acute Care• Assess patients fully and ask • Ask patients to tell you if they use about their use, how they • Don’t punish patients for using support their use, &if they are • Keep the door open –review your withdrawing AMA policy• It isn’t your life, so avoid • Be clear about what patients can judgment expect from you & what you• Manage withdrawal properly – expect from them withdrawal is a MEDICAL “They may have made some bad EMERGENCY choices but your job is to• Set realistic boundaries look after their needs” Remember• Understand the impact of Maslow???? trauma, pain and anxiety
Social Determinants of Health Maslow’s Hierarchy of Needs Where is your client at right now?Maslows hierarchy of needs and subpersonalitywork, Kenneth Sørensenhttp://two.not2.org/psychosynthesis/articles/maslow.htm
Special Populations • Concurrent Disorders (mental health & addictions) • Aboriginal • Remanded Populations • Women • Youth
“Insite saves lives. Its benefits have been proven.” With thatblunt statement, the Supreme Court of Canada cuts to theheart of the matter: by denying Vancouver’s safe-injectionfacility, Insite, a further exemption from laws prohibitingdrug possession, the federal government acts contrary tothe Charter of Rights and Freedoms.
Peer Support & CommunityMobilisation• Strengthens programs and policies• Involving current and former people who use drugs for: – Better program design – Better program implementation – Better effectiveness and coverage
Harm Reduction in Canada: Ambivalence, Denial, or Apathy?• Federally, in Canada, the window is either closed or very nearly• Coverage & capacity far too low (need 60%), implementation far too late.• Interventions with the lowest impact -supply reduction, legal constraints, detoxification & abstinence & awareness programs-are the most often practised.• Need to look at examples from around the world• Need to look at what works on the ground locally
Harm Reduction in the USA: Ambivalence, Denial, or Apathy?• US Surgeon General Gives Okay for Needle Exchange Funding• “Washington, DC has the highest rate of new AIDS cases in the country with an estimated 1 in 20 residents living with HIV.• HIV Travel Ban finally lifted, after 22 years• “The most widely implemented school-based prevention program, known as Drug Abuse Resistance Education (DARE), has also proven to be ineffective at reducing rates of illicit drug use.”
Current EventsThrone Speech 2009“Therefore, my government will introducechanges to limit the proliferation of needleshanded out by needle exchange programs.Ultimately, this program cannot be allowedto function as a source of unlimited freeneedles. ““My government will tightencontrols around both the numbers ofneedles exchanged and distributed. Wewill cap the number of needles given out atany one time, thus creating more frequentcontact with health professionals, which inturn means more frequent opportunity forintervention and treatment. “
Legal issues or Health issues• December 2011 AIDSLAW &bill c-10 – “With injection drug use as the single greatest category of exposure to HIV for Aboriginal persons, they are thus disproportionately vulnerable to policies that punish people who use drugs, such as the “tough-on-crime” law enforcement measures that Bill C-10 will impose and barriers to harm reduction services, both inside and outside of prison.” http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=1954• HIV disclosure ruling clarified by top court – People with low-level HIV and condoms neednt disclose infection – The court ruled Friday that the "realistic possibility of transmission of HIV is negated" provided the carrier of the virus has a low viral load and a condom is used during sexual intercourse. Otherwise… – HIV carriers have to disclose their status to their partners. http://www.cbc.ca/news/canada/story/2012/10/05/supreme-court-hiv-ruling.html
In Small Groups• Consider the ‘Ethical, Legal and Social’ Context• Consider how this may impact your practice across a variety of settings• Consider the RN as an Advocate, what is your role given the Code of Ethics?
Conclusions?• Evidence Informed Decision Making?• Morality vs best practice?• Interplay of Politics and Policy• Public Health vs Human Rights?
“Ultimately we know deeply that the other side of every fear is a freedom.” Marilyn Ferguson
Thank you for your time and attention. Please feel free to contact Sarah at:Sarah Liberman, RN, MN(306) 775-7987 firstname.lastname@example.orgGreg Riehl RN, MA(306) 775-7383 email@example.com
SK HIV/HCV Nursing Education Organization• The mission for the Saskatchewan HIV/HCV Nursing Education Organization is achieved through: – Providing accessible and affordable education and learning opportunities – Creating a network of members by which support and mentorship can occur – Serving as a provincial voice for issues related to HIV and Hepatitis nursing care – Advocating for the rights and dignity of people who are living with HIV/AIDS and/or HCV, or who are vulnerable to these infections – Supporting a collaborative professional practice environment – Promoting professional growth – Improving patient/client/resident outcomes