Harm Reduction

September 2015
David Vlahov

A June 2015 report from the Trust for America’s Health and the Robert Wood Johnson Foundation found drug overdose is now the leading cause of deaths from injury in the United States. Rural Indiana recently found itself wrestling with an outbreak of HIV among drug users.

These findings and events represent human tragedies; what’s worse is that in many cases, the deaths and HIV transmissions were either preventable or, at least, ripe for mitigation. The problem is that as a country we are still trying to get comfortable with an approach to substance abuse known as “harm reduction.”

In this month’s Science of Caring, we ran a story about faculty at our School who are working to advance this strategy, which is based on minimizing risk through policies, programs and/or individual practices. It is an approach that meets people where they are rather than making judgments about where they should be in terms of their personal health or lifestyle.

Take the case of the illicit drug user who is vulnerable to or can transmit HIV infection but can’t stop his or her drug dependence. For many years, the approach to these individuals was often some combination of “just say no” and incarceration. Yet when the HIV epidemic came along, harm reduction emerged as an alternative strategy. The idea was to make drug abuse treatment accessible, but to also give illicit drug users access to sterile needles and bleach for syringe disinfection. To move in that direction, communities needed to learn and embrace what harm reduction strategies could offer, and legislators at various levels needed to change policies.

My own research and that of numerous others has found that harm reduction strategies are very effective in reducing the rate of new HIV infection among drug users. Yet before these data could be turned into policy, we needed to address politicians’ concerns. In my work, we responded to political concerns by conducting studies on the possible negative consequences of community-based access to sterile syringes. Our data from pilot projects showed that access to sterile needles in communities did not increase drug use, nor did it increase sharing of needles, reduce the rate of users going into drug treatment, leave contaminated needles on the street, encourage youth to start drug use or increase crime. That was a turning point. Communities came to see the value of harm reduction, and policies and programs changed. Outreach and education have now enabled these programs to become more widespread.

In short, harm reduction is highly effective in preventing death and containing harmful behaviors associated with using drugs. We know as well that harm reduction strategies – such as public education campaigns to safely store medications away from children, and the distribution of naloxone to police and medics to rapidly reverse the effects of opioid overdose – can be very effective in preventing drug overdose deaths.

Nevertheless, the acceptance of harm reduction remains incomplete, despite evidence of its success in many areas, including some that transcend the transmission of HIV or drug overdose. For example, to prevent automobile-related injuries and deaths, we’ve implemented multiple forms of harm reduction, from public information campaigns against drunk driving to engineering solutions such as the placement of taillights at the view level of the driver behind a braking car, crumple zones for crashes, air bags, and collapsible guardrails and streetlight poles. Such strategies have worked.

It’s likely and understandable that the reluctance to apply harm reduction strategies to illicit drug use comes from a complex social psychology tied to concerns that we are somehow sanctioning the use of these drugs. It is time, however, to recognize the evidence. We have had success in reducing needle transmission of HIV and complications related to drug overdose. We have faculty who are expanding this work, making progress on addressing challenges and creating promising strategies to reduce HIV risk related to binge drinking. It is time for health care professionals to incorporate harm reduction as an important, evidence-based public health tool that we should use whenever our clinical judgment deems it necessary.


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