What does Harm Reduction Mean?

The harm reduction movement emerged from the work primarily of activists but also health workers who, in the 1960s and 1970s, opposed the increasing criminalization of drug use and drug users [2]. In contradistinction to the dominant popular narrative of drugs as a danger to society, their work focused on the amelioration of risks at the level of the individual consumer. Parallel to this was the emergence of epidemiologic research on drugs, particularly alcohol. A 1976 analysis of drinking patterns among men following treatment for alcohol use disorder found that the majority returned to controlled drinking without the negative consequences that compelled their initial treatment [3]. These findings were met with resistance as they problematized the assumption of abstinence, the goal of alcohol treatment. These two threads combined in the response public health crisis of HIV/AIDS in the 1980s (specifically in the Netherlands and Great Britain) where the recognition of the failure of existing, abstinence-based models of care led to a more productive approach to substance use disorder treatment: harm reduction [4].

Almost every human society has used psychoactive substances as part of their cultural practice; however, addiction and its negative consequences is a more recent and modern development [5]. Prioritizing abstinence, an approach that may ignore psychosocial contributors to substance use, may be counterproductive [4], and can lead to penalizing people who use drugs [3]. In contrast, proponents of harm reduction accept that the use of alcohol and other drugs is part of society and that individuals have a multiplicity of reasons for use. Harm reduction rests upon the principle that care should be nonjudgmental and noncoercive and begin with an acceptance of people at their individual state of change. This includes abstinence as a possibility but not as a prerequisite for accessing services or the sole goal of care [6]. Traditional examples of harm reduction strategies include syringe exchange, overdose training and naloxone dispensing, and safe injection facilities. However, any approach that prioritizes the needs of the patient and meets them where they are, such as condoms, contraception, and pre- (and post-) exposure prophylaxis for HIV, should also be considered harm reduction.

The beneficiaries of harm reduction are not just people directly involved in programs [7]. Syringe exchange programs are not only cost effective in terms of savings in cases of HIV prevented, but safe disposal of syringes also minimizes the risk of needle-stick injuries from improperly disposed of syringes in the community. Additionally, harm reduction benefits not just people with addiction, but anyone who uses drugs or alcohol [8]. Key features of harm reduction programs include utilizing client desires to shape the programs, lowering thresholds to services, reducing stigma, working to mitigate effects of more than one high-risk behavior, and providing multifaceted services to address more than just substance use and its consequences [9].

Key characteristics of harm reduction services:

• 
  

  Nonjudgmental and noncoercive

  
  
• 
  

  Low threshold

  
  
• 
  

  Multiple points of entry

  
  
• 
  

  Located in areas convenient to clients

  
  
• 
  

  Collaborative program and individual goals

  
  
• 
  

  Holistic services

  
  
• 
  

  Client-staff relationships lack strict hierarchy

  
  
• 
  

  Anonymous services (when possible and if desired)

Harm Reduction as a Response to the War on Drugs

Since 1971, the primary response to drug use and addiction in the United States has been through the so-called War on Drugs, a policy that has been termed “harm induction” as it promotes criminalization over counseling for people who use drugs [10]. Indeed, federal drug control spending has continued to emphasize enforcement, prosecution and incarceration domestically, and interdiction, eradication, and military escalation abroad although investments in treatment reduce crime and are more cost-effective [11, 12].

Criminalization of illicit substance use leads to disenfranchisement, overutilization of custody for nonviolent offenders, and repercussions such as exclusion from public housing [13]. The emphasis on criminalization in the United States led to a 10-fold increase in incarceration for drug-related offenses between 1980 and 1990 without any decrease in addiction or substance-related problems in society – a time frame in which both emergency room visits for issues related to substance use and incidence of HIV and hepatitis among people who inject drugs rose as well [14]. Abstinence-related prevention approaches, particularly the D.A.R.E., a program for school-aged children, have demonstrated similar lack of effectiveness; a meta-analysis of D.A.R.E. programs did not show lasting positive effects [15]. Despite its ineffectiveness, D.A.R.E. has enjoyed more positive publicity and support than syringe exchange programs [16]. Pregnant women who use drugs have also been specific targets of “harm inducing” policies. In 2014, for example, Tennessee passed a law allowing for the criminal prosecuting of pregnant women who use drugs for exposure and, if they suffered a miscarriage, they could be prosecuted for homicide as well [17]. Rather than decreasing substance use, this law led to women avoiding prenatal care, presenting late to prenatal care, delivering across state lines, and delivering at home [18]. Due in part to the fact that neonatal abstinence rates did not decrease, the law was allowed to sunset in 2016.

Harm Reduction in the Context of Treatment for Pregnant Women

People who use drugs are subject to great societal inequalities and burdens: poverty, trauma, racism, stigma associated with mental health condition, and other inequities. Moreover, the stigmatization of addiction, which is even stronger among pregnant women than the population at large, can drive people who use drugs away from treatment and other services [19]. People with other recognized medical issues such as cancer or heart disease benefit from organized, publicized nonprofits that contribute to research and amelioration of suffering secondary to these illnesses. However, given the stigma associated with drug use, there are fewer advocacy organizations for people with addiction [9].

Women who use drugs, particularly in pregnancy, are more stigmatized and experience greater discrimination than other women and men with addiction [20]. Society and the law disproportionately target and penalize these women often under the banner of fetal protection and at the expense of the woman’s human rights [21]. Such actions are barriers to initiating and continuing prenatal care [22, 23]. Women who use drugs may also hesitate to seek care for fear that their children will be removed from their care [24] and may be pressured to have abortions [22].

Holistic and harm reduction approaches to service for women with opioid use disorder, particularly those who already have children, may lead to improved outcomes for women and their children. A synthesis of qualitative literature found that involving children in women’s recovery programs was associated with better motor, social, and language skills for the children. For the mothers, confidence in parenting and parenting skills increased, leading to more positive interactions with their children [25]. Pregnancy and birth among women who use drugs must be normalized. Instead of treating care episodes as opportunities for crisis intervention (thereby reinforcing stigma and bias), women should be safe to disclose and discuss their substance use without fearing it will jeopardize their access to care, take away their ability to parent, or result in their incarceration [4].

There are many ways to lower the barriers to services for pregnant women who use drugs: eliminating abstinence as a prerequisite for services; creating mobile services; and utilizing input from clients to tailor services to their expressed needs, not providers’ perceptions of clients’ needs. When services are run or designed by people who use or used to use drugs, the balance of power between providers and clients becomes more equal, stigma is reduced, and clients are empowered. Using harm reduction services to address multiple facets of clients’ lives allows for the focus to be not just on drug use, but on other priorities expressed by clients: housing, food, health care, and relationships with family, for example [26].

Peer services are important to consider in treatment programming for pregnant women who use drugs. Peers can serve not only as patient-navigators, but can role-model healthy behavior as well [27]. Compared with professional staff, peers were better able to reduce inpatient use and improve recovery outcomes among individuals with serious mental illness [28]. Additionally, peer service programs provide workforce opportunities for women in recovery who may not have the education or work experience for many jobs.

Examples of Harm Reduction for Women with Opioid Use Disorders in Pregnancy

Syringe Exchange Programs

In response to a pharmacy’s refusal to sell injection equipment to people who injected drugs in Amsterdam, syringe exchange programs (SEPs) were developed in the early 1980s [16]. These SEPs were sponsored by governments in collaboration with private organizations of people who injected drugs. The first syringe exchange in the United States was implemented in Tacoma, Washington, in 1988 [29]. In one study, HIV incidence in people who inject drugs dropped by 6 percent per year in cities with SEPs and increased by 6 percent per year in cities without SEPs [30]. Since initiation of SEPs in Philadelphia, the percent of new HIV cases attributed to intravenous drug use dropped from 51 percent in 1992 to 17.5 percent in 2007 [8]. A cost estimate study incorporating SEPs, pharmacy sales, and syringe disposal programs found that each HIV infection averted would cost an estimated $34,278; in comparison, the lifetime cost of treating HIV infection at the time of the publication (1998) was $108,649 [31].

The role of SEPs for pregnant women with opioid use disorder can be even more crucial. In addition to the individual level risk of HIV/HCV acquisition, pregnant women can transmit illness vertically – to the fetus/newborn at the time of delivery. Making SEPs accessible and friendly to pregnant women is crucial, both in terms of overcoming the added stigma of gender and pregnancy and in the additional harm reduction of serving pregnant women. One strategy to make programming more accessible for women is to have “ladies’ nights.” Dedicating services to people who identify as women-only is appreciated by participants, who see these as safe, empowering places [32].

Although many SEPs are in buildings, some SEPs are mobile, further reducing the threshold to services. A mobile SEP in Baltimore targets a section of town with multiple exotic dance clubs. A baseline survey performed as part of the mobile SEP’s programming found that 75 percent of women seeking SEP services through the program were not accessing reproductive health services [33]. This program was established in 2008 and expanded to include reproductive health services in 2009 [34]. Through the mobile services, women access syringe exchange, pregnancy testing and options counseling, contraceptive counseling and methods, and vaccinations. Of women seeking injectable contraception through the mobile services, those seeking additional services (e.g. vaccines or emergency contraception) were more likely to continue that contraception [34]. This illustrates that making multiple services available in one location, particularly via outreach, can increase uptake of complementary services.

Special Needs in Pregnancy Service

In the mid-1980s, Dr. Mary Hepburn established a clinic in Glasgow, Glasgow Women’s Reproductive Health Services, to offer woman-centered care through a harm reduction approach. The clinic, now known as Special Needs in Pregnancy Service, offers prenatal care to women who use drugs, and has been a model for clinics elsewhere in Great Britain [4]. Providing help with nonmedical issues at Hepburn’s clinic improved women’s attendance at antenatal care [35]. The clinic utilizes social workers not just for crisis management, but for preventive assistance. Women can refer themselves to the clinic and be seen without a fee [35]. Pregnant women need not commit to either abstinence or opioid agonist maintenance to participate in programming at the clinic. Those who want to attempt detoxification are also supported, as are those who continue drug use. The program focuses on meeting women “where they are” with respect to their substance use. Thanks to Dr. Hepburn’s work, the UK’s maternity strategy recognizes that substance use and other poverty-related issues need to be addressed within routine prenatal care [23].