Harm Reduction Philosophy Research Articles

Attitudes towards harm reduction amongst social work professionals in three geographical areas in Sweden

ABSTRACT Professionals’ understandings of substance use interventions and treatment goals impact treatment recommendations. We aimed to explore social work professionals’ (SWP) attitudes towards harm reduction philosophy and measures in three areas of Sweden with very differing development of their harm reduction: Malmö (most developed), Gothenburg (moderately developed), Gävleborg (least developed). We conducted a survey of SWP working with people who use drugs, utilizing the Harm Reduction Acceptability Scale (HRAS). An ANOVA with Bonferroni post-hoc correction was performed to assess for differences in mean HRAS score. There were 208 valid survey responses (Malmö: 79, Gothenburg: 82, Gävleborg: 47). The overall mean score indicated positive attitudes towards harm reduction. Means differed based on geographic location, with Malmö and Gothenburg scores indicating significantly more positive attitudes towards harm reduction than scores in Gävleborg. Opinions on implementation of new harm reduction measures such as heroin assisted treatment, supervised consumption sites, and decriminalization of drugs for personal use were more negative overall. These opinions followed the above trend, with regard to differences based on geography. Differences indicated that SWP who are more exposed to harm reduction have more positive attitudes. Increased knowledge of harm reduction among SWP could lead to improved access to interventions and reduced risks for people who use drugs.

Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation

BackgroundIn Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of...

Association of hospital-based substance use supports on emergency department revisits: a retrospective cohort study in Sudbury, Canada from 2018 to 2022

BackgroundThis study compares emergency department (ED) revisits for patients receiving hospital-based substance-use support compared to those who did not receive specialized addiction services at Health Sciences North in Sudbury, Ontario, Canada.MethodsThe study is a retrospective observational study using administrative data from all patients presenting with substance use disorder (SUD) at Health Sciences North from January 1, 2018, and August 31, 2022 with ICD-10 codes from the Discharge Database (DAD) and the National Ambulatory Care Database (NACRS). There were two interventions under study: addiction medicine consult services (AMCS group), and specialized addiction medicine unit (AMU group). The AMCS is a consult service offered for patients in the ED and those who are admitted to the hospital. The AMU is a specialized inpatient medical unit designed to offer addiction support to stabilize patients that operates under a harm-reduction philosophy. The primary outcome was all cause ED revisit within 30 days of the index ED or hospital visit. The secondary outcome was all observed ED revisits in the study period. Kaplan–Meier curves were used to measure the proportion of 30-day revisits by exposure group. Odds ratios and Hazard Ratios were calculated using logistic regression models with random effects and Cox-proportional hazard model respectively.ResultsA total of 5,367 patients with 10,871 ED index visits, and 2,127 revisits between 2018 and 2022 are included in the study. 45% (2,340/5,367) of patient were not admitted to hospital. 30-day revisits were less likely among the intervention group: Addiction Medicine Consult Services (AMCS) in the ED significantly reduced the odds of revisits (OR 0.53, 95% CI 0.39–0.71, p < 0.01) and first revisits (OR 0.42, 95% CI 0.33–0.53, p < 0.01). The AMU group was associated with lower revisits odds (OR 0.80, 95% CI 0.66–0.98, p = 0.03). For every additional year of age, the odds of revisits slightly decreased (OR 0.99, 95% CI 0.98–1.00, p = 0.01) and males were found to have an increased risk compared to females (OR 1.50, 95% CI 1.35–1.67, p < 0.01).InterpretationWe observe statistically significant differences in ED revisits for patients receiving hospital-based substance-use support at Health Sciences North. Hospital-based substance-use supports could be applied to other hospitals to reduce 30-day revisits.

A new innovative method to measure the cost of war: future with fewer conflicts via harm reduction approaches

BackgroundThe destruction of World War I (WWI) and World War II (WWII) changed the world forever. In this analysis, the economic costs of WWI and WWII are considered via a harm reduction approach to highlight the cost of war via the mortality of military personnel. The harm reduction philosophy and homeostasis of a biological cell are utilized as a pragmatic approach and analogy to give a greater context to the findings, despite the omission of civilian casualties and military disabilities.MethodsTangible (e.g., loss of wages, productivity, and contributions) and intangible (e.g., quality of life) costs are estimated based on the value of each military personnel derived from secondary data and a mathematical model. This is the first study to estimate the cost of war based on soldier’s mortality during the first and second World War.ResultsBased on the tangible value, the WWI and WWII cost for the military personnel was US$43.204 billion ($13 billion ≤ α ≤ $97 billion) and US$540.112 billion ($44 billion ≤ α ≤ $1 trillion). When the intangible cost is considered, it is estimated that the WWI cost was beyond US$124 trillion ($43 trillion ≤ β ≤ $160 trillion), and the WWII cost was above US$328 trillion ($115 trillion ≤ β ≤ $424 trillion). The sensitivity analyses conducted for WWI and WWII demonstrate different ranges based on tangible and intangible values.ConclusionsIn the current climate of increasing hostilities, inequalities, global warming, and an ever-changing world, economic prosperities are directly linked to peace, stability, and security. Therefore, any future decisions for military conflicts need to increasingly consider harm reduction approaches by considering the cost of life and potential disabilities for each nations’ soldiers, sailors, and pilots.

Integrating Hospital-Based Harm Reduction Care-Harnessing the Nursing Model.

Hospitals are risk environments for people who use drugs, and most hospitals are unprepared to deliver substance use disorder (SUD) care, including harm reduction (HR) interventions. HR philosophy clashes with traditional hospital hierarchy and norms, and staff may resist HR interventions due to stigma, fear of enabling substance use, legal and safety concerns. Nurses are central to hospital culture and care and could promote and deliver HR care. Our US hospital has an inter-professional addiction consult service (ACS) that includes medical providers, social workers, and peers. We developed and launched a hospital-based registered nurse-(RN) led HR intervention, including distributing safe-use supplies (eg, syringes). We describe model development and early experience, using an Exploration, Preparation, Implementation, and Sustainment framework. ACS experiences and community HR interventions informed our exploration phase. In the preparation phase we secured funding from Medicaid payers for a 2-year pilot, including full-time RN salary and HR supplies. We elicited buy-in from hospital executive leaders, partly by partnering with nurse champions who described unmet patient care and staff education needs. We consulted hospital lawyers and developed an institution-wide media campaign targeting staff, including in-person booths distributing naloxone and materials promoting international overdose awareness day (eg, "#EndOverdose" buttons). We collaborated with local and national experts to develop the intervention, which includes RN bedside HR education and staff trainings. The Implementation was from September 2022 to March 2023. We trained 459 staff (over 15 trainings) and conducted 209 patient encounters. Generally, patients and staff embraced the HR RN role, including previously controversial safe-use supply distribution. Sustainment efforts include engaging stakeholders in continuous improvement and evaluation efforts. A nurse-led hospital-based HR intervention can expand patient services, support staff, and bridge HR and medical models.

The Patient Perspective of an Inpatient Addiction Medicine Unit Implemented in an Urban Northern Acute Care Hospital in Ontario, Canada.

An Addiction Medicine Unit (AMU) represents a promising approach to enhancing hospital care for individuals who use substances, but there is limited research to understand patients' perspectives on AMUs. Therefore, the study objectives involved exploring patients' experiences with the AMU. Qualitative semi-structured interviews were conducted with 17 patients to gather their perspectives about the AMU. The AMU offers specialized inpatient addiction support, integrating medical and psychosocial interventions while facilitating connections to community supports to stabilize patients and manage addiction-related issues using a harm reduction philosophy. Factors identified by patients that lead to positive experiences with the AMU included: efficient access to high-quality acute medical care, specialized addiction care, and additional support for non-medical needs. Patients emphasized the benefits of having peer support workers on staff, the overall positive interactions with staff, and how different these experiences were from their hospital admissions outside of the AMU. Factors identified by patients that should be considered in an AMU included: the ease of access to substances, negative interactions with other patients, and self-stigma/internalized discrimination. Also, the patient perspective reflected varied views on harm reduction. Patients' perception of the impact of an AMU overall reflected that the AMU is an effective way to deliver comprehensive treatment, to address the needs of PWUS, both medical and substance-use-related issues. They identified that the unit's intentional harm reduction philosophy facilitated access to care and positive patient-staff interactions, emphasizing the unit's progress in reducing fear and judgment and rebuilding trust in the healthcare system. The introduction of a new AMU in a Northern urban acute care hospital in Ontario has yielded positive patient experiences. The AMU model shows potential to re-establish trust between patients and providers, but ongoing efforts are needed to address underlying stigma to be more effective.

Opioid treatment program culture and philosophy: Views of OTP staff and state officials on implementing interim methadone treatment

IntroductionPeople seeking treatment at opioid treatment programs (OTPs) can face admission delays. Interim methadone (IM) treatment, an effective approach to expedite admissions when programs lack sufficient counseling staff, has been seldom implemented. A study of implementation facilitation to spur the use of IM was conducted among six OTPs and their state opioid treatment authorities (SOTAs) in four US states. Between study recruitment and launch, organizational changes at three OTPs eliminated their need for IM. Two OTPs' requests to their states to provide IM (one prior to study launch and one following launch) were deferred by the states due to internal issues that required resolution to comply with federal IM regulations. During the study, another OTP's delays resolved, and one OTP streamlined its admissions procedures. MethodsVirtual interviews were conducted with 16 OTP staff and SOTAs from six OTPs in four US states following their participation in the parent study. Interviews focused on the feasibility and acceptability of the implementation intervention for IM. We analyzed data using a constant comparative approach. ResultsTwo overarching themes emerged from the qualitative data with respect to the role that organizational culture plays in OTP staff views of efforts to implement interim methadone: (1) the contrasting views of interim methadone based on whether staff adopt a traditional treatment vs. harm reduction philosophy and (2) the importance of reconciling these philosophies in addressing the culture shift that would accompany the process of implementing IM. ConclusionsOrganizational treatment philosophy and program culture emerged as important factors determining the OTPs' staff's willingness to adopt new approaches to expedite admissions. Participants noted a tension between traditional treatment and harm reduction philosophies that impacted their views of IM, in part based on when they entered the drug treatment field. While understanding and addressing treatment philosophy and organizational culture and willingness to change is of importance when implementing new approaches in OTPs, leadership at the state and OTP level are powerful drivers of change.

How has the media framed the introduction of the supervised injecting room in Victoria? A comparison of editorials of The Age and Herald Sun 2017–2022

AbstractInfluenced by a harm reduction philosophy, the then Victorian Labor Government announced the establishment of the state's first medically supervised injecting room (MSIR) in North Richmond in late 2017. But, public and political opinion remains sharply divided as to the merits of the MSIR. One influence on policy development appears to be media commentary on the MSIR and the wider illicit drugs policy debate. This paper compares the official editorials of the two daily Melbourne newspapers, the Herald Sun and The Age regarding the MSIR, from November 2017 until November 2022. Based on 33 articles (Herald Sun, N = 28; The Age, N = 5), our findings identify philosophical differences between the two newspapers as reflected in their sources of information, language and highlighted issues. The Age was mostly supportive of both the introduction of the North Richmond MSIR and proposals for a second site. The Herald Sun's position was more ambiguous, ranging from qualified support for the North Richmond MSIR to strong opposition to further sites.

Labeled as "drug-seeking": nurses use harm reduction philosophy to reflect on mending mutual distrust between healthcare workers and people who use drugs.

Over 50 years of approaching drug use from the "War on Drugs" has led to ignoring the systemic structural and social determinants of health, enforced drug use stigma, and damaging stereotypes of people who use drugs or are labeled as "drug-seeking," and sorely failed to support those needing assistance. People who use drugs are often disenfranchised and pathologized by being labeled as "a drug addict," which then serves as a rationalization for mistreatment by healthcare providers. This is in opposition to a harm-reduction approach. Harm reduction philosophy is an epistemic valuation necessary for drug use stigma and our moral obligation to reduce harm from interlocking systems of power that perpetuate harm. We have encountered many clients who use drugs that report harmful interactions with healthcare providers. Harm reduction is an issue of health equity, social justice, and fundamental human rights. This paper presents three vignettes, the author's experiences of being labeled as-and advocating for family members labeled as "drug-seeking." To better serve as healthcare providers, workers must be equipped to work with people who use drugs and reinforce the social justice commitment against medical stigma, neglect, racism, and inadequate pain coverage and withdrawal treatment. Nurses and our epistemic lens can meet the challenge of complex intersectional issues affecting our use of power to develop more just and equitable health systems and advance our rebuilding of a trusting relationship with the people we serve.

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

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

Integrating harm reduction into acute care: A single center's experience

ObjectiveInjection drug use (IDU) is prevalent in North America and is associated with presentations with infective endocarditis. Supporting patients who present with infective endocarditis related to IDU through harm reduction, a pragmatic approach to reduce secondary harms of a health behavior, helps address the underlying IDU. We share a case exemplar of how one acute care facility integrated harm-reduction practices into daily patient care. MethodsWe took a 3-stage approach to integrate harm-reduction practices into daily patient care. In stage 1, we raised awareness and knowledge of harm reduction through education. In stage 2, we provided explicit support for harm reduction. In stage 3, we provided tangible tools to support harm reduction. ResultsMore than 300 staff attended education sessions and reported increased knowledge related to substances, harm reduction, and engaging patients who use substances in conversations. Staff requested the hospital explicitly support harm reduction, which led to stage 2. The creation of a harm-reduction philosophy statement provided permission to engage in harm-reduction practices. Stage 3 included the creation of a harm-reduction supply distribution program and consultations with Addictions Medicine and treatment programs. The implementation of harm-reduction supply distribution was successful and is being spread across the facility. ConclusionsEngaging in harm-reduction practices within an acute care facility is possible through a multistage process focused on education, explicit support, and tangible tools. Spreading harm-reduction integration and working with patients who used substances to evaluate effectiveness are key next steps.

Implementing Wet Services in Montréal for Highly Vulnerable People Experiencing Homelessness who Use Alcohol

Context: People experiencing homelessness and alcohol dependence are highly marginalized as they struggle to access various health and social services. This study is part of a broader feasibility study on the implementation of "wet services" in Montréal, Canada. Methods: Four focus groups were conducted with 20 participants working in the field of homelessness. The objectives of this study were to gather their perspectives on the need for wet services in Montréal, define the main purpose of such services, and identify the key factors promoting their success. Results: All participants felt that wet services could meet several critical needs of many people experiencing homelessness in Montréal, and most argued that they should also be implemented without delay. According to most participants, these services should be grounded in a harm reduction philosophy, take a low-threshold approach and be accessible to the target population at all times. Participants argued that wet services should primarily aim to offer a safe place to consume alcohol whilst also serving as a place where people experiencing homelessness could meet their basic needs, reconnect socially, and access various health and social services. However, participants cited a number of financial, logistical, and organizational constraints, such as control-related mechanisms (e.g., eligibility criteria, rigid bylaws, or the institutionalization and medicalization of services), which they feared could stand in the way of achieving the objectives of wet services or perpetuate the exclusion of people experiencing homelessness. To avoid these potential problems, most participants felt that wet services should be delivered by well-established and well-funded community-based organizations, accompanied by a variety of partnership arrangements, including those with health services. Conclusion: This qualitative study contributes to the growing body of evidence on alcohol-related harm reduction services. Its findings may serve to inform the eventual implementation of wet services in Montréal and in other locations.

Caring for People Who Use Drugs: Best Practices for EMS Providers.

People who use drugs (PWUD) face stigmatizing treatment and substandard care during all stages of their health care journey, including in the prehospital setting by Emergency Medical Services (EMS) providers. Drawing on the professional and lived experience of the authors, we have developed a training with an intended audience of Emergency Medical Technicians (EMTs) and Paramedics in Massachusetts that will orient them to harm reduction philosophy. The training is delivered online through an asynchronous platform housed at Boston University School of Public Health and centers around several themes including the impact of fentanyl on the drug supply, the role of harm reduction in mitigating the impacts of drug criminalization, and ensuring that EMS providers have access to tools and best practices for improving overdose response, pain management, documentation, and respectful language. The training has been approved for Massachusetts Office of Emergency Medical Services (OEMS) continuing education credit and will be offered for free. We plan to evaluate changes in participant knowledge and attitudes and overall acceptability of the training among EMS providers in Massachusetts.

Utilizing SBIRT as a Framework for Transforming How We Think About Prevention and Early Intervention for Youth and Young Adults

Utilizing SBIRT as a Framework for Transforming How We Think About Prevention and Early Intervention for Youth and Young Adults

The Experience of Implementing a Low-Threshold Buprenorphine Treatment Program in a Non-Urban Medical Practice

Background To respond to the U.S. opioid crisis, new models of healthcare delivery for opioid use disorder treatment are essential. We used a qualitative approach to describe the implementation of a low-threshold buprenorphine treatment program in an independent, community-based medical practice in Ithaca, NY. Methods We conducted 17 semi-structured interviews with program staff, leadership, and external stakeholders. Then we analyzed these data using content analysis. We used purposeful sampling aiming for variation in job title for program staff, and in organizational affiliation for external stakeholders. Results We found that opening an independent medical practice allowed for low-threshold buprenorphine treatment with less regulatory oversight, but state-certification was ultimately required to ensure financial sustainability. Relying on health insurance reimbursement alone led to funding shortfalls and additional funding sources were also required. The practice’s ability to build relationships with licensed substance use treatment programs, community organizations, the legal system, and government agencies in the region differed depending on how much these entities supported a harm reduction philosophy compared to abstinence-based treatment. Finally, expanding the practice to a second location in a different region, co-located with a syringe service program, required adapting to a new cultural and political environment. Conclusion The results from this study provide insight about the challenges that independent medical practices might face in delivering low-threshold buprenorphine treatment. They support policy efforts to address the financial burdens associated with providing low-threshold buprenorphine therapy and inform the external relationships that other providers would need to consider when delivering novel treatment models.

“It’s a place that gives me hope”: A qualitative evaluation of a buprenorphine-naloxone group visit program in an urban federally qualified health center

Background: Medication for opioid use disorder (MOUD) with buprenorphine is effective in treating opioid use disorder yet remains underutilized. Scant research has examined the experience of patients, clinic staff, and providers in a “low-threshold” group-based MOUD program. This study evaluates a “low-threshold” MOUD program at a federally qualified health center (FQHC) in Philadelphia, Pennsylvania through the perspectives of its key stakeholders. Methods: This qualitative study involved focus groups of patients, providers, and clinic staff. Focus groups were conducted between October 2017 and June 2018. Grounded theory was used for analysis. Results: There were a total of 10 focus groups, including 20 patient participants and 26 staff members. Program participants noted that a strength of the program is its person-centered harm reduction approach, which is reflected in the program’s policies and design. Program participants discussed the programmatic design choices that facilitated their participation and engagement in the program: ease of access, integration into primary care, and group-based visit model. Challenges in program implementation included varying acceptance and understanding of harm reduction among staff, the unpredictability of clinic volume and workflow, and the need to balance access to primary care and MOUD. Conclusion: This group-based MOUD program’s philosophy of person-centered harm reduction, low-barrier approach, the structure of group-based visits, and integrated care contributes to increased patient access and retention. Understanding the strengths and challenges of the program may be useful for other safety-net clinics considering a MOUD program.

The Missing Link: Exploring the History of Harm Reduction Nursing in Canada 1998-2018 to Provide Recommendations for Inpatient Mental Health Nurses.

Harm reduction is becoming integrated into the hospital setting, yet there is a dearth of published academic literature on the topic of harm reduction in mental health nursing practice. No results were found in a literature search focused specifically on harm reduction policies in the inpatient psychiatric settings using the databases CINAHL, Google Scholar, and PubMed. The purpose of this article was to provide a historical overview of harm reduction in Canadian nursing from 1998 to 2018. The aim was to help direct care nurses, educators, and administrators understand past and present trends and to identify future possibilities for integration in inpatient mental health care. A historical perspective was used to identify and explore Canadian harm reduction literature published from 1998 to 2018 to establish the significance to inform nursing practice. The exploration began with a brief description of outreach nursing in early Canada. Focus shifted to the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic of the 1980s and 1990s, on to the 2000s when a broader lens of harm reduction was adopted, looking beyond the goal of reducing sexually transmitted illnesses. Literature published in the mid-2000s focused on marginalized populations, highlighting the connection between ethical practice and harm reduction philosophy. At the beginning of the 2010s, the Canadian Nursing Association released position statements that explicitly identified the role of harm reduction in nursing practice. Toward the end of the 2010s, the opioid overdose crisis promoted harm reduction nurses taking a broader focus, entering the hospital settings.

COVID-19 Social Restrictions: An Opportunity to Re-visit the Concept of Harm Reduction in the Treatment of Alcohol Dependence. A Position Paper.

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.

The Ethical Defensibility of Harm Reduction and Eating Disorders

Eating disorders are mental illnesses that can have a significant and persistent physical impact, especially for those who are not treated early in their disease trajectory. Although many persons with eating disorders may make a full recovery, some may not; this is especially the case when it comes to persons with severe and enduring anorexia nervosa (SEAN), namely, those who have had anorexia for between 6 and 12 years or more. Given that persons with SEAN are less likely to make a full recovery, a different treatment philosophy might be ethically warranted. One potential yet scarcely considered way to treat persons with SEAN is that of a harm reduction approach. A harm reduction philosophy is deemed widely defensible in certain contexts (e.g. in the substance use and addictions domain), and in this paper we argue that it may be similarly ethically defensible for treating persons with SEAN in some circumstances.

Toward a Philosophy of Harm Reduction.

In this paper, I offer a prolegomenon to the philosophy of harm reduction. I begin with an overview of the philosophical literature on both harm and harm reduction, and a brief summary of harm reduction scholarship outside of philosophy in order to make the case that philosophers have something to contribute to understanding harm reduction, and moreover that engagement with harm reduction would improve philosophical scholarship. I then proceed to survey and assess the nascent and still modest philosophy of harm reduction literature that has begun to emerge. I pay particular attention to two Canadian philosophers who have called for the expansion of harm reduction beyond the realm of so-called "vice" (that is, addiction, intoxicants and sex work). Finally, I sketch some of the most interesting and important philosophical issues that I think the philosophy of harm reduction must grapple with going forward.