Harm Reduction in Drug Addiction

Drug addiction harm reduction programs They have been - and continue to do so - the spearhead of a realistic and compassionate approach to people with drug addiction.

By harm reduction we understand a set of practical strategies aimed at reducing the negative consequences of drug use, by incorporating methods ranging from drug use minor risks, controlled use or withdrawal.

• Related article: "Addiction: disease or learning disorder?"

The role of Health Education

Let's start by remembering what Health Education is and its relationship with harm reduction in the field of substance addictions.

Health Education (EPS) is a planned and systematic communication and teaching-learning process oriented to make it easy to acquire, choose and maintain healthy practices and to make risky practices difficult. In all the definitions of the EPS a common objective is established, the search for the modification of the knowledge, attitudes and behaviors of the individual components of the community, in the sense of a health positive

In 1975, by the IV Working Group of the “National Conference on Preventive Medicine”, in the United States, led by Anne Sommers, it was established that EPS should be:

“A process that informs, motivates and helps the population to adopt and maintain healthy practices and lifestyles, advocates the environmental changes necessary to facilitate these goals, and directs professional training and research towards those same objectives"

Risk reduction strategies can be defined as a set of socio-sanitary measures, individual or collective, that aim to reduce the negative effects (physical, mental or social) associated with drug use.

These measures and strategies tend to diversify the healthcare offer, developing new therapeutic modalities or new psychosocial devices. In addition, the strategies recognize that the licit or illicit use of drugs is part of our world, and resolves to focus on minimizing harmful effects, rather than simply condemning or ignoring them

With regard to drug users, the World Health Organization, MS has indicated that “Effective public health interventions must have a tiered, hierarchical and pragmatic".

Protection of the most vulnerable population groups

A public health intervention emphasizes the need for actions to focus on the reduction and prevention of risk factors, especially among populations that are most “exposed”.

The spread of injected drug use and blood and sexually transmitted diseases has led to the spread of drug abuse in many countries The maximalist objectives of abstinence were abandoned as a priority and proposals with intermediate or intermediate objectives were promoted. prioritized

What is Harm Reduction for drug addiction problems?

The concept "Damage Reduction" as intervention strategy for problems derived from drug abuse It started in the late 80s. It originates from the province of Merseyside (England), one of the British areas that suffered a strong epidemic of heroin use and a high prevalence of HBV infection.

As a consequence of observing that the traditional repressive model adopted to fight this situation had served more to aggravate the situation that to minimize the problem, they decided to try a new approach to the phenomenon of drug dependence: the reduction of damage. The development of effective interventions on reality derived from this new work philosophy has promoted international recognition of the “Mersey Model of Harm Reduction”.

The main reasons for the implementation of risk reduction programs in our environment are:

• The increase in infectious diseases transmissible intravenously or sexually, the fact that marginality and behaviors associated with the consumption of illegal drugs is a risk factor for tuberculosis, the high incidence of AIDS cases in Injected Drug Users (IDU) and in their partners, occupying the highest rates in Europe in recent years, twenty-two times higher than in other countries. Low.

• The finding that those affected with deterioration do not go to care centers welfare or social due to its institutional rejection.

• The existence of a large group that lacks effective recourse and throughout the years he goes from one center to another pursuing the palliative benefit of his situation.

The objectives of these programs

The general objectives of a program of these characteristics are summarized in the following five points:

1. Increase the quality of life of drug users, that is, improve the health and social situation of this group.
2. Decrease the transmission of HIV, HBV and HCV infection from, between and to
3. drug users.
4. Increase the awareness of drug users about the risks and harms associated with their use.
5. Reduce or eliminate the risks and damages associated with drug use, as well as risky sexual behaviors among drug users.
6. Encourage and favor the appearance of risk-free behaviors in the face of HIV, HBV and HCV infection.

Damping the negative effects of drugs

As Alan Marlatt, author of Relapse Prevention and a reference in the treatment of addictions, argued, these programs aim not so much for abstinence in the drug use, but admitting the difficulty of reaching this goal for some people, and since there are a significant number of drug users, try to reduce the damage or consequences caused by this consumption.

The importance of minimizing the harm associated with intravenous drug administration is recognized as a strategy in the prevention of HIV infection, and risk reduction is shown to be compatible with primary prevention of the use of drugs Harm Reduction programs constitute an effective alternative to prevent HIV infection and transmission, as well as HBV and HCV, apart from being in themselves a model for approaching and treating problems caused by drug use.

Why is this health intervention perspective useful?

The model accepts the evidence that people will continue to use drugs, that not all drug users are fit for purpose. to carry out a detoxification treatment and that many of those who consume do not approach or contact health services existing.

Policies and programs cannot be based on utopian ideals about a “drug-free society” or a society in which all people always use drugs safely. Along these lines, drug use should be defined as a complex and multi-causal phenomenon, which supposes a “continuum” from severe dependence to abstinence; which entails extending the interventions to all of the moments of the process.

These programs, obviously, cannot solve all the problems associated with drug use and must, therefore, be considered as integrated programs within the framework of a global policy broader action against drug use (which also includes treatments aimed at obtaining abstinence for users, care for families, etc.).

It should be taken into account that the potential risk derived from drug use depends on the type of drug used, the frequency and quantity, how it is administered, and the physical and social circumstances of this use. It is important to note that in some cases policies to reduce this use may increase the risk associated with drug use, such as when drug users are not informed about the health services available or when only services are offered aimed at the abstinence.

The levels of intervention

Harm reduction interventions span different levels: individual, community and socio-political. From this model, interventions are proposed that have an impact on each of the levels aimed at modifying the norms and social perceptions, knowledge, attitudes and behaviors of people, identifying and overcoming obstacles existing.

Many of the risks associated with drugs can be eliminated without necessarily reducing drug use. An obvious example is intravenous use with sterile injection equipment versus this type of use with HIV-contaminated equipment.

The harms associated with drug use are multidimensional. The recipient of the damage can be the individual himself, the social context close to him (family, friends, neighbors) or society in general.

A model that seeks participation

These programs are characterized by an attitude of approach to drug users on the part of the workers of these interventions, that allows the involvement of users in them.

Only in this way can adequate contact with a significant part of the community be expected from these programs. “hidden” population of users, which could become “bridge” programs to other services socio-sanitary.

Harm reduction supports the belief that everyone has the right to use drugs if he or she wants to. However, harm reduction does recognize the possibility that drug use can impair judgment, and that many drugs can lead to physiological and psychological dependence.

Fighting stigma

CDs should be treated with the respect that every human being deserves, and they should also be integrated into society instead of being excluded from it and marginalized. Many of the risks associated with drug use are the result of social stigmatization of drug users more than of the consumption itself.

Looking for empowerment

The competence and responsibility of drug users themselves is promoted, including, but not limited to, the consumption of these substances. For it the opinion of the consumers themselves is requested in the design of policies and programs created to respond to your needs and your active participation in them.

At the same time, it is recognized that situations of social precariousness, isolation, marginalization and Poverty affect the autonomy of people and their capacities to reduce damage and act in a healthy.

The Effects of Damage Reduction

According to the World Health Organization, these types of interventions seek various effects.

Modify the person's behavior

First an individual behavior change, which manifests itself many times in an interpersonal context and is affected by a series of elements that go beyond simple information; For example, the person's beliefs about the risks of a certain habit to their health, the intentions and motivations to modify that behavior, and the capacity they have to carry out said change.

A collective change

On the other hand, a significant change is also pursued not only at the individual level, but at the collective and group level, which recognizes that the person's attempts to change behavior are influenced by the opinions and actions of the social groups by which individuals, as well as individuals, tend to move through the social circles in which substance use and behaviors occur sexual. This is what is called the “subjective or peer norm”.

The norms of the peer group they influence the way people behave. Peer norms are important as they determine whether a behavior is acceptable or normal for the individual and the group. For example, in some communities of injecting drug users (IDUs), the false belief that having the syringe before the drugs bring them bad luck, which is why they always seek it before the syringe, making it easier to share a syringe that is “at hand".

Therefore, individual change is facilitated by change in the norms of equals. Working with peers makes their norms evolve in matters of sexual behavior and drug use, and contemplates both changes in behavior in the group and in individuals.

Types of programs

There are several types of Harm Reduction programs.

Opioid Substitute Programs

Programs with opioid substitutes such as low and high threshold Methadone Maintenance (PMM) Programs, fixed and mobile, or controlled dispensing programs of heroin.

Patients on Methadone Maintenance they offer lower HIV seroconversion rates than those not in treatment or in other treatment programs. Likewise, the episodes of overdose and risk behaviors decrease (less use of the injectable route and less shared use of injection equipment), with much lower mortality rates than those who are not in treatment.

In these programs, lower levels of heroin use have been recorded in those in PMM than in who are in other types of treatments limited to abstinence 26, 29, 34 and better conditions of consumption.

Opioid substitute programs have also had a significant impact on reducing the crime with fewer criminal acts, fewer arrests and stays in prison. At the moment, the use of methadone is guaranteed for your safety in opioid-tolerant people, no significant adverse effects or toxicity having been found in 10 to 25-year follow-up studies.

Heroin programs are one of the resources that has received the most attention among risk reduction programs. Its controlled distribution from the social health care network presents the immediate advantages of other programs and it also has benefits in the medium and long term by moving their consumption away from exclusion (it reduces collective crime linked to illegal markets, stabilizes or reduces the number of users by not needing to traffic in drugs).

Programs against risky behaviors

At a second level are programs aimed at reducing “collateral” risk behaviors, directly or indirectly associated with substance use.

To avoid high-risk practices against the transmission of HIV, HBV and HCV, within a Harm Reduction strategy, several types of programs have been developed

Less risky consumer programs

These include: syringe exchange and distribution programs that can be carried out from various locations (pharmacies, medical teams, mobiles with educators and "health agents" in the street, primary care centers, hospital emergency services, specific centers, etc.).

Safer sex promotion programs 

An example is the "Safer Sex Workshops" (TSMS) that provide health education on sexuality and prevention, as well as programs or campaigns that promote access to condoms. Although in most of the countries Harm Reduction programs have basically been developed around drug use injectables, its field of action is much broader and its methodology is applicable to any type of drug user and to various types of damage.