EXPRESS: Marketing and Economics of Harm Reduction: Evidence from Conservation Field Experiments

Self-cutting and harm reduction: Evidence trumps values but both point forward.

A scoping review of harm reduction practices and possibilities among indigenous populations in Australia, Canada, and the United States.

Background and rationaleThe HIV epidemic in Vietnam has from its start been concentrated among injecting drug users. Vietnam instituted the 2006 HIV/AIDS Law which includes comprehensive harm reduction measures, but these are unevenly accepted and inadequately implemented. Ward police are a major determinant of risk for IDUs, required to participate in drug control practices (especially meeting quotas for detention centres) which impede support for harm reduction. We studied influences on ward level police regarding harm reduction in Hanoi to learn how to better target education and structural change.MethodsAfter document review, we interviewed informants from government, NGOs, INGOs, multilateral agencies, and police, using semi-structured guides. Topics covered included perceptions of harm reduction and the police role in drug law enforcement, and harm reduction training and advocacy among police.ResultsPolice perceive conflicting responsibilities, but overwhelmingly see their responsibility as enforcing drug laws, identifying and knowing drug users, and selecting those for compulsory detention. Harm reduction training was very patchy, ward police not being seen as important to it; and understanding of harm reduction was limited, tending to reflect drug control priorities. Justification for methadone was as much crime prevention as HIV prevention.Competing pressures on ward police create much anxiety, with performance measures based around drug control; recourse to detention resolves competing pressures more safely. There is much recognition of the importance of discretion, and much use of it to maintain good social order. Policy dissemination approaches within the law enforcement sector were inconsistent, with little communication about harm reduction programs or approaches, and an unfounded assumption that training at senior levels would naturally reach to the street.DiscussionWard police have not been systematically included in harm reduction advocacy or training strategies to support or operationalise legalised harm reduction interventions. The practices of street police challenge harm reduction policies, entirely understandably given the competing pressures on them. For harm reduction to be effective in Vietnam, it is essential that the ambiguities and contradictions between laws to control HIV and to control drugs be resolved for the street-level police.

Evidence-based medicine is being applied to decisions in a range of contexts beyond one-to-one patient care. Yet considerable disagreement persists regarding the defining components of evidence-based decision-making, particularly in institutional and public health contexts. This article reviews the key elements of evidence-based decision-making for clinical medicine, and adapts those key elements and argues for their broad applicability to a variety of decision-making contexts including institutional, public health, and self-care decision-making contexts. Conceptual Analysis. Results Evidence based decision-making involves research evidence, "social and institutional circumstances", and "values" of stakeholders. Furthermore, evidence-based decision-making includes "judgment" exercised by experts to appropriately weigh and integrate the various decision-making elements. Asking critical questions about the purposes and context of a specific decision, basic principles of evidence-based reasoning can be appropriately applied beyond the bedside.

Vaccination yields a direct effect by reducing infection, but also has the indirect effect of herd immunity: If many individuals are vaccinated, the immune population will protect unvaccinated individuals (social benefit). However, due to a vaccination's costs and risks, individual incentives to free-ride on others' protection also increase with the number of individuals who are already vaccinated (individual benefit). The objective was to assess the consequences of communicating the social and/or individual benefits of herd immunity on vaccination intentions. We assume that if social benefits are salient, vaccination intentions increase (prosocial behavior), whereas salience of individual benefits might decrease vaccination intentions (free-riding). In an online-experiment (N = 342) the definition of herd immunity was provided with one sentence summarizing the gist of the message, either making the individual or social benefit salient or both. A control group received no information about herd immunity. As a moderator, we tested the costs of vaccination (effort in obtaining the vaccine). The dependent measure was intention to vaccinate. When a message emphasized individual benefit, vaccination intentions decreased (free-riding). Communication of social benefit reduced free-riding and increased vaccination intentions when costs to vaccinate were low. Communicating the social benefit of vaccination may prevent free-riding and should thus be explicitly communicated if individual decisions are meant to consider public health benefits. Especially when vaccination is not the individually (but instead collectively) optimal solution, vaccinations should be easily accessible in order to reach high coverage.

Illicit drug use and harms in Australia in the context of COVID-19 and associated restrictions: Anticipated consequences and initial responses.

Evidence suggests that harm reduction, a public health strategy aimed at reducing the negative consequences of a risky health behavior without requiring elimination of the behavior itself, may be a promising approach for minimizing drug-related harms while engaging individuals with substance use disorders (SUDs) in care. However, philosophical clashes between the medical and harm reduction models may pose barriers to adopting harm reduction approaches within medical settings. To identify barriers and facilitators to implementing a harm reduction approach toward care within healthcare settings. We conducted semi-structured interviews with providers and staff at three integrated harm reduction and medical care sites in New York. Qualitative study using in-depth and semi-structured interviews. Twenty staff and providers across three integrated harm reduction and medical care sites across New York state. Interview questions focused on how harm reduction approaches were implemented and demonstrated in practice and barriers and facilitators to implementation, as well as questions based on the five domains of the Consolidated Framework for Implementation Research (CFIR). We identified three key barriers to the adoption of the harm reduction approach that surrounded resource constraints, provider burnout, and interacting with external providers that do not have a harm reduction orientation. We also identified three facilitators to implementation, which included ongoing training both within and external to the clinic, team-based and interdisciplinary care, and affiliations with a larger healthcare system. This study demonstrated that while multiple barriers to implementing harm reduction informed medical care existed, health system leaders can adopt practices to mitigate barriers to adoption, such as value-based reimbursement models and holistic models of care that address the full spectrum of patient needs.

BackgroundHarm reduction refers to interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely. The vast majority of the harm reduction literature focuses on the harms of drug use and on specific harm reduction strategies, such as syringe exchange, rather than on the harm reduction philosophy as a whole. Given that a harm reduction approach can address other risk behaviors that often occur alongside drug use and that harm reduction principles have been applied to harms such as sex work, eating disorders, and tobacco use, a natural evolution of the harm reduction philosophy is to extend it to other health risk behaviors and to a broader healthcare audience.MethodsBuilding on the extant literature, we used data from in-depth qualitative interviews with 23 patients and 17 staff members from an HIV clinic in the USA to describe harm reduction principles for use in healthcare settings.ResultsWe defined six principles of harm reduction and generalized them for use in healthcare settings with patients beyond those who use illicit substances. The principles include humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. For each of these principles, we present a definition, a description of how healthcare providers can deliver interventions informed by the principle, and examples of how each principle may be applied in the healthcare setting.ConclusionThis paper is one of the firsts to provide a comprehensive set of principles for universal harm reduction as a conceptual approach for healthcare provision. Applying harm reduction principles in healthcare settings may improve clinical care outcomes given that the quality of the provider-patient relationship is known to impact health outcomes and treatment adherence. Harm reduction can be a universal precaution applied to all individuals regardless of their disclosure of negative health behaviors, given that health behaviors are not binary or linear but operate along a continuum based on a variety of individual and social determinants.

Symposium: alcohol y reducción de daños*

Harm reduction is a conceptual framework and set of practices that focus on the minimization of the physical, social, and legal harms substance users do to themselves and to society as a whole. Its application to community mental health settings is relatively new, and can create controversies and ethical dilemmas if not properly designed, implemented, and evaluated. Building on the harm reduction literature, the community mental health literature, and the authors' experiences with a community mental health program that uses a harm reduction approach, the authors offer five guidelines for its successful implementation. The authors conclude that when properly integrated with other recovery-based services, and when appropriately applied to the individual client's stage of change, harm reduction can effectively be used, and should be used, in community mental health settings with clients with co-occurring substance use and psychiatric disorders.

The purpose of this study is to examine the importance of harm reduction practices in substance use treatment and to explore the views of professionals working in substance use treatment on harm reduction. Interviews with 16 professionals using semi-structured forms revealed four main themes: Perspectives on Harm Reduction in Substance Use Treatment, Harm Reduction Strategies Applied as a Treatment Method, Perceptions and Challenges of the Harm Reduction Approach, and Suggestions for the Harm Reduction Approach. Findings show that while some professionals find harm reduction effective, others believe it is not suitable for advanced cases. Generally, the harm reduction approach is seen as a diverse and holistic model in addiction treatment. It is valued for its motivational benefits and effectiveness for individuals with concurrent substance use and psychiatric disorders, offering strategies like reducing use and transitioning to less harmful alternatives. Techniques such as mindfulness for developing conscious responses to triggers, as well as the role of education, research, and awareness in advancing harm reduction strategies, are highlighted. Addressing the knowledge gaps in communities and families can enhance social integration and support processes. These results underline the importance of strategies to increase the effectiveness and acceptability of the harm reduction approach in addiction treatment.

The spread of HIV infection among injection drug users (IDUs) one of the most challenging and tenacious aspects of the drug problem plaguing the United States. Injection drug use represents a major public health challenge because of the multiple health, psychological, and social problems that must be overcome to address this addictive behavior and disease transmission (Office of National Drug Control Policy [ONDCP], 2000). National statistics indicate that injection drug use continues unabated with an estimated 1.1 to 1.5 million IDUs in the United States (Holmberg, 1996). The twin epidemic of injection drug use and AIDS has exacted a tremendous strain on the U.S. health care system, with the estimated treatment costs for IDUs infected with HIV and in the later stages, AIDS, totaling $3.7 billion (Harwood, Fountain, & Livermore, 1998). According to the Centers for Disease Control and Prevention (2000), 753,907 cumulative cases of AIDS were reported in the United States as of June 2000. Approximately 36 percent (n = 270,721) of the reported AIDS cases occurred among IDUs, their sexual partners, and their children. Because HIV can be transmitted both sexually and perinatally, drug injectors are also placing their potential children at increased risk. This evidenced by 8,804 cumulative pediatric AIDS cases reported by midyear 2000, with more than half of these cases caused by injection drug use by the mother, or by the mother having sex with an IDU. A disproportionate number of members of racial and ethnic minority groups being ravaged by the disastrous consequences of AIDS, with African Americans and Latinos accounting for 76 percent of the injection-related AIDS cases in the United States. Until a cure for AIDS found, or a vaccine for HIV developed, there a critical need to reduce the spread of HIV transmission among individuals who choose to inject illicit substances. Harm-reduction interventions and policies have emerged as viable strategies to ameliorate the adverse health, social, or economic consequences associated with injection-related behaviors (Brettle, 1991; Des Jarlais, 1995; Des Jarlais & Friedman, 1993; Inciardi & Harrison, 2000; Marlatt, 1998; Nadelmann, 1998). PRAGMATIC LESSONS FROM A PUBLIC HEALTH MODEL Harm reduction, also called damage limitation, risk reduction, and harm minimization, a goal of public health policies and interventions aimed at decreasing the deleterious consequences spurred by illicit drug use (Marlatt, Somers, & Tapert, 1993; Newcombe, 1992; Single, 1995). Present drug control measures and treatment philosophies in the United States deem abstinence as the most effective means of reducing the individual and public health risks associated with injection drug use (ONDCP, 2000). Harm reduction a point of departure from these traditional beliefs. Proponents of the harm reduction model do not view abstinence as the only desirable objective for drug users. By acknowledging the prevalence of illicit drug use in our communities and that drugs may not always be used in a safe manner, harm reduction seeks to remedy these problems through pragmatic, incremental, and nonjudgmental interventions and policies (Des Jarlais, 1995; Des Jarlais, Friedman, & Ward, 1993; Schilling & El-Bassel, 1998). Harm reduction measures do not ascribe to a specific formula, but should reflect specific individual and community needs. Therefore, practitioners should always be conscious of starting where the client is during the course of the therapeutic process. The common principles that are central to harm-reduction practice are as follows: * The harm-reduction approach does not attempt to minimize or ignore the pervasive public health consequences associated with injection drug use, but rather accepts that the nonmedical use of psychoactive drugs an inevitable occurrence in a society that has access to such drugs (Des Jarlais, 1995). …

Lost lives and opportunities for the legacy of harm reduction in Scotland, UK

The COVID-19 pandemic is presenting significant challenges for health and social care systems globally. The implementation of unprecedented public health measures, alongside the augmentation of the treatment capacity for those severely affected by COVID-19, are compromising and limiting the delivery of essential care to people with severe substance use problems and, in some cases, widening extreme social inequities such as poverty and homelessness. This global pandemic is severely challenging current working practices. However, these challenges can provide a unique opportunity for a flexible and innovative learning approach, bringing certain interventions into the spotlight. Harm reduction responses are well-established evidenced approaches in the management of opioid dependence but not so well-known or implemented in relation to alcohol use disorders. In this position paper, we explore the potential for expanding harm reduction approaches during the COVID-19 crisis and beyond as part of substance use treatment services. We will examine alcohol use and related vulnerabilities during COVID-19, the impact of COVID-19 on substance use services, and the potential philosophical shift in orientation to harm reduction and outline a range of alcohol harm reduction approaches. We discuss relevant aspects of the Structured Preparation for Alcohol Detoxification (SPADe) treatment model, and Managed Alcohol Programs (MAPs), as part of a continuum of harm reduction and abstinence orientated treatment for alcohol use disorders. In conclusion, while COVID-19 has dramatically reduced and limited services, the pandemic has propelled the importance of alcohol harm reduction and created new opportunities for implementation of harm reduction philosophy and approaches, including programs that incorporate the provision of alcohol as medicine as part of the substance use treatment continuum.

Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review