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Monday, 23 June 2014

Harm reduction comes of age as both a clinical and prevention service.

One of our favourite blog posts was the analysis of the use of the terms “harm reduction” since the Harper government took power DrPHealth Harm reduction and politics of language June 2012.   It even appears that the government of Canada search engine has been modified to preclude an extension of the analysis by eliminating searches restricted by dates.

Despite the multitude of barriers to harm reduction, use of such services continues to grow at a steady consistent pace.  A BC colleague recently reviewed provincial distribution information noting a consistent annual increase of about 5% per year over the past few years.   For whatever inexplicable reason, such information is not readily available (sic) and would be welcomed to be posted by DrPHealth (email dphealth@gmail.com).

Nonetheless, harm reduction has yet to gain mainstream acceptance as a clinical service.  Perhaps it has quietly been sneaking in the back door. 

A significant obstacle is the language used, with a broad range of activities falling under the single rubric of harm reduction.  Worse, is some people that attempt to redefine fringe clinical services like providing “housing” as a form of harm reduction rather than acknowledging it as a basic prerequisite of health. 

Some key aspects of harm reduction – while often limited to substance use rhetoric, it is sometimes any activity that involves risk for which the risk is being mitigated and not eliminated (seat belts for car occupants, helmets for bikers).  Operationally it seems to also be about an approach that accepts people where they are without judgment or expectation yet this is not part of the definitions in circulation.

Its purposes are many fold.  Initially it was about reducing the spread of transmissible illnesses.  It now includes reducing overdoses, unwanted pregnancy, injuries and illnesses such as liver cirrhosis. Many will see a purpose in harm reduction services as an entry point to develop therapeutic relationships prior to engaging clients in effective definitive treatment.

The tools have also broadened from condoms and needles, to a wide range of materials for which on review there is no taxonomy.  May we at least propose one?

1.       Replacement therapies (methadone, nicotine replacement, alcohol maintenance, other opiate substitues etc.)
2.       Safer materials (condoms, safety gear like helmets, injection supplies, inhalant supplies, naloxone distribution, etc)
3.       Safer environments (safer drug consumption, access in corrections facilities, alcohol tolerant housing etc) 
4.       Population level harm reduction (moving to regulated substances policies, HIV treatment to prevent spread to others)

While the classification is not pure, its purpose is to stimulate the discussion – so please discuss.

On a side note, with the business of harm reduction thriving, a handful of cities are lining up to submit proposals for supervised drug consumption, and for the most part politicians are trying hard to avoid discussions in public forums.   Harper’s   Respect for Communities (DrPHealth review) Act died on the 2013 order paper, only to be inserted into an Act to amend the Controlled Drugs and Substances Act (currently through first reading and known as Bill C-2). (Read the DrPHealth posting on Respect for Communities for what was the predicted course over the past year).

Harm reduction has become an integral component of managing risk, reducing health care system burdens, and part of a continuum of health interventions. While Harper’s government has been effective in muzzling the conversation, those providing the service have done a marvelous job of expanding services as a health intervention and need full commendation for their efforts. 

Well done to those public health workers who have kept the needs of some of the most needy foremost in mind. 

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