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Prevention
Interventions intended to prevent or delay the initiation of substance use and/or progression to more frequent, regular or harmful use. The targets are people who have not used the substance(s) concerned or not used them in these ways and may never do so. At one end are universal approaches which target whole populations. At the other are interventions focused on individuals (‘indicated’ prevention) or groups (‘selective’ prevention) identified as at high risk of initiating these forms of substance use.
Because the aim is to intercept the development of problems before they begin, typically the targets for preventive interventions are young. Young people are most easily reached en masse in schools, so this is the typical site for such interventions, and educational approaches are the typical modality. However, there is a strong argument that education should primarily be judged against educational objectives, and that it is both inappropriate and largely futile to expect behaviour change in the form of substance use prevention. That on this site education is gathered under the prevention theme is not a pronouncement on this argument one way or the other but merely reflects the fact that most studies test education against preventive objectives and most site visitors will expect to find it there.
Other preventive approaches seek to influence risk factors across a whole community (including but not limited to the schools) and/or to affect children via their parents.
Reducing harm
Interventions intended to reduce the harm resulting from substance use even if use continues and often even if it continues at the same level. The harms may be to the user or to the community and they may be medical, psychological social or economic in nature. Because these approaches presuppose that significant (ie, worth investing in an intervention to reduce it) harm is already occurring, the ultimate targets are typically people already using substances in a way which results in the harms being addressed. Typically the aim is to change the way they use those (or those types of) substances so harms are reduced.
Among the greatest harms are overdose fatalities and infectious diseases caused by viruses like HIV and hepatitis C. Common interventions include needle exchanges providing infection-free injecting equipment and educational and skills training intended to ensure that substance users avoid particularly risky practices. ‘Wet' centres which reduce nuisance to the community and provide services for treatment-resistant alcoholics by allowing them to drink on the premises are another example.
Interventions which substitute a prescribed drug of the same type for the original (and usually illegally obtained) substance often have both harm reduction and treatment objectives and take place in a medical context. These can be accessed under the Medical treatment theme and also under this theme if they have a strong harm reduction ethos.
Harm reduction activities such as substitute prescribing and needle exchange may take place in a criminal justice context, in which case they are accessible under this theme and under the Safeguarding the community theme.
Treatment
Treatment presupposes an individual already experiencing problems related to their substance use serious enough to cause them to seek to stop, reduce or substantially alter their use, who feels in need of formal help to do so, and whose problems are also seen by the broader society and/or by the treatment provider as warranting that help. Inability to resolve problems without formal help is associated with being dependent on (or addicted to) the substance(s) concerned and lacking the psychological, social or practical resources to overcome that dependence.
Treatment focuses on the client’s or patient’s welfare and quality of life, improvements in which usually require interventions to overcome their dependence. While ethically that must be the treatment provider’s focus, their work may be organised and funded by authorities whose primary motivation is to safeguard the wider community. In these cases treatment is offered not because the substance user has sought it, but because the authorities believe the individual has substance use problems susceptible to treatments which could result in benefits to the community. Typically these individuals are offenders whose crime is thought to be driven by the need to fund dependent substance use. These interventions can be accessed both under this theme and under Rehabilitating offenders in the Safeguarding the community theme. Some types of treatment feature strong Reducing harm objectives and/or effects or shade in to Prevention approaches which seek to prevent problems developing or becoming serious among high risk groups.
Medical treatment
Treatment conducted in a medical context, usually involving medications. The essential aim is to overcome dependence or at least overcome dependence on particularly damaging and/or illegal substances, but other ‘comorbid’ medical conditions may also treated. Often these are psychiatric in nature (perhaps part of the reason why the patient was unable to resolve their substance use problems without treatment) but they may also be physical ailments related to substance use such as infectious diseases and alcohol-related deficiencies. Withdrawal symptoms may be one of those ailments and interventions may seek to reduce these without seeking to overcome the dependence which caused them, but ideally both aims are pursued.
Substituting less harmful prescribed drugs for the drugs which caused the patient’s problems is sometimes seen primarily as a way of Reducing harm in the form of death and disease, and sometimes as a Treatment intervention aiming to improve health and quality of life by overcoming dependence on the original substances. Whatever the objective, studies of such interventions are indexed under this theme and, if harm reduction is a major and explicit objective, also under that theme.
Psychosocial therapies
Treatment modalities which may or may not take place in medical settings, but which are based on psychological principles and methods such as learning theories and theories of motivation, on the harnessing of social influences such as in group and family therapies and community living arrangements. Also includes more practical interventions such as training, housing, vocational rehabilitation, and activities which build self-esteem, confidence and social skills and provide an alternative, dependence-free lifestyle.
These types of processes are also thought to account for ‘natural’ recovery without formal help of any kind and to underpin the effectiveness of mutual aid networks. For convenience these topics are also gathered under this theme.
Safeguarding the community
Typically the ‘safeguarding’ is from crime and from the injuries and harms those crimes cause, harms seen as serious enough to warrant legal sanctions and criminal justice or other coercive interventions. These may involve straightforward enforcement of laws restricting substance use, enforcement as one element within a broader attempt to engage the community in combating substance-related crime (eg, city centre strategies to address alcohol-related violence), offering Treatment instead of or as well as penal sanctions in order to rehabilitate offenders, or implementing Reducing harm interventions in prisons in recognition of continuing substance use.
Drink driving one of the major crimes addressed because of alcohol’s adverse effects on driving performance. For convenience other performance-related coercive measures such as workplace testing for substance use are gathered under the same sub-theme.
Intervention infrastructure
To make the interventions outlined above work or work better, national or local policies need to set the framework and ensure all the elements work in harmony to meet social objectives, services need to be funded and commissioned, and the workforce needs to be trained. These and other infrastructure issues are dealt with under this theme along with cost-benefit and other economic studies which provide a basis for deciding whether and which interventions to fund and commission.
UK Harm Reduction Alliance
statement on
the meaning of ‘harm reduction’
Introduction
Many responses to drug use have been defined at some time as ‘harm reduction’, and this has led to some confusion as to what harm reduction actually is.
In order to clarify the situation, UKHRA – the UK’s leading organisation campaigning for a rational, harm reduction oriented response to drug use – has prepared a definition of harm reduction, and identified the core principles of harm reduction.
Definition of harm reduction
Harm reduction is a term that defines policies, programmes, services and actions that work to reduce the:
• health;
• social; and
• economic
harms to:
• individuals;
• communities; and
• society
that are associated with the use of drugs (Newcombe 1992) .
The principles of harm reduction:
The following principles of harm reduction are adapted from those set out by The Canadian Centre on Substance Abuse (CCSA 1996) , and Lenton and Single 1998 :
Harm reduction:
• Is pragmatic: and accepts that the use of drugs is a common and enduring feature of human experience. It acknowledges that, while carrying risks, drug use provides the user with benefits that must be taken into account if responses to drug use are to be effective. Harm reduction recognises that containment and reduction of drug-related harms is a more feasible option than efforts to eliminate drug use entirely.
• Prioritises goals: harm reduction responses to drug use incorporate the notion of a hierarchy of goals, with the immediate focus on proactively engaging individuals, targetting groups, and communities to address their most compelling needs through the provision of accessible and user friendly services. Achieving the most
immediate realistic goals is viewed as an essential first step toward risk-free use, or, if appropriate, abstinence.
• Has humanist values: the drug user's decision to use drugs is accepted as fact. No moral judgment is made either to condemn or to support use of drugs. The dignity and rights of the drug user are respected, and services endeavor to be ‘user friendly’ in the way they operate. Harm reduction approaches also recognise that, for many, dependent drug use is a long term feature of their lives and that responses to drug use have to accept this.
• Focuses on risks and harms: on the basis that by providing responses that reduce risk, harms can be reduced or avoided. The focus of risk reduction interventions are usually the drug taking behaviour of the drug user. However, harm reduction recognises that people’s ability to change behaviours is also influenced by the norms held in common by drug users, the attitudes and views of the wider community Harm reduction interventions may therefore target individuals, communities and the wider society.
• Does not focus on abstinence: although harm reduction supports those who seek to moderate or reduce their drug use, it neither excludes nor presumes a treatment goal of abstinence. Harm reduction approaches recognise that short-term abstinence oriented treatments have low success rates, and, for opiate users, high post-treatment overdose rates.
• Seeks to maximise the range of intervention options that are available, and engages in a process of identifying, measuring, and assessing the relative importance of drug-related harms and balancing costs and benefits in trying to reduce them.