Substance Abuse Harm Reduction Programs they have been – and continue to be – the spearhead of a realistic and compassionate approach to drug addicts.
By harm reduction we mean a set of practical strategies aimed at reducing the negative consequences of drug use, incorporating methods ranging from safer use, controlled use or abstinence.
The role of health education
We begin by recalling that it is about health education and its relation to harm reduction in the field of drug addiction.
Health education (PHE) is a planned and systematic process of communication and teaching-learning aimed at facilitating the acquisition, choice and maintenance of healthy practices and at making risky practices difficult. In all the definitions of the EPS a common objective is established, the search for the modification of the knowledge, attitudes and behaviors of the individual components of the community, in the direction of a positive health
In 1975, by the Fourth Task Force of the “National Conference on Preventive Medicine” in the United States, led by Anne Sommers, it was established that EPS should be:
“A process which informs, motivates and helps the population to adopt and maintain healthy practices and lifestyles, advocates the environmental changes necessary to facilitate these objectives and directs vocational training and research towards these same objectives”
Risk reduction strategies they can be defined as a set of socio-health measures, individual or collective, which aim to reduce the negative effects (physical, mental or social) linked to drug use.
These measures and strategies tend to diversify the offer of care, by developing new therapeutic methods or new psychosocial devices. In addition, and strategies recognize that legal or illicit drug use is part of our world and resolve to minimize harmful effects, rather than simply condemning or ignoring them.
Regarding drug users, the World Health Organization, member states have stated that “effective public health interventions must take a step-by-step, hierarchical and pragmatic approach”.
Protection for the most vulnerable population groups
A public health intervention emphasizes the need to focus on the reduction and prevention of risk factors, especially among the most “exposed” populations.
The spread of injecting drug use, blood and sexually transmitted diseases has led to the abandonment of maximalist abstinence goals as a priority in many countries and the promotion of proposals with intermediate or priority goals.
What is Harm Reduction in Addiction Problems?
The concept of “harm reduction” as intervention strategy for drug addiction problems began in the late 1980s. He is originally from the province of Merseyside (England), one of the British regions with a high epidemic of heroin use and a high prevalence of heroin infection. HBV.
Noting that the traditional repressive model adopted to combat this situation had served more to aggravate the situation than to minimize the problem, they decided to try a new approach to the phenomenon of drug addiction: harm reduction. The development of effective reality interventions stemming from this new working philosophy has fostered international recognition of the “Mersey model of harm reduction”.
The main reasons for implementing harm reduction programs in our environment are:
- The increase in infectious diseases intravenous or sexual transmission, the fact that marginalization and behaviors associated with illicit drug use are a risk factor for tuberculosis, the high incidence of AIDS cases among injecting drug users (IDU) and their partners, occupying in recent years, twenty times higher than in the Netherlands.
- The discovery that people with disabilities do not go to health centers social or social welfare for their institutional rejection.
- The existence of a high collective that does not have an efficient resource and over the years, he moves from one center to another looking for the palliative benefits of his situation.
The objectives of these programs
The general objectives of a program of this nature are summarized in the following five points:
- To increase the quality of life of drug users, that is to say to improve the state of health and the social situation of this group.
- Decrease transmission of HIV, HBV and HCV infection from, to and from
- drug users.
- Increase the awareness of drug users of the risks and harms associated with their consumption.
- Reduce or eliminate the risks and harms associated with drug use, as well as risky sexual behavior among people who use drugs.
- Encourage and encourage the emergence of safe behaviors in the face of HIV, HBV and HCV infection.
Mitigate the negative effects of drugs
As Alan Marlatt, author of Relapse Prevention and a leader in addiction treatment, argued, these programs are not so much about abstinence from drug use, but acknowledging the difficulty of achieving that goal for some people, and as there are a large number of drug users, try to reduce the damage or consequences caused by this consumption.
The importance of minimizing the harms associated with the administration of intravenous drugs is recognized as a strategy for the prevention of HIV infection, and harm reduction has been shown to be compatible with primary prevention of drug use. . Damage reduction programs are an effective alternative to prevent HIV infection and transmission, As well as HBV and HCV in addition to being in themselves a model of approach and treatment of problems caused by drug use.
Why is it useful in this perspective of health intervention?
The model accepts evidence that people will continue to use drugs, that not all drug users are able to access drug treatment, and that many who use them do not seek out existing health services. nor contact them.
Policies and programs they cannot be based on utopian ideals about a “drug-free society” or a society in which everyone is always safe to use drugs. In this line, drug use should be defined as a complex and multicausal phenomenon, which is a “continuum” from severe dependence to abstinence; which implies extending interventions at all times of the process.
These programs obviously cannot solve all the problems associated with drug use and should therefore be considered as integrated programs as part of a comprehensive policy broader action on drug use (which also includes treatments aimed at obtaining abstinence from users, support for families, etc.).
It should be noted that the potential risk associated with drug use depends on the type of drug consumed, its frequency and quantity, the manner in which it is administered and the physical and social circumstances of this use. It is important to note that in some cases, policies aimed at reducing such consumption may increase the risk associated with drug use, for example when drug users are not informed of available health services or when only services intended to drugs are offered.
Levels of intervention
Reduction interventions damage they cover different levels: individual, community and socio-political. From this model, interventions are proposed that have an impact at each level aimed at modifying social norms and perceptions, knowledge, attitudes and behaviors of people, identifying and overcoming existing obstacles.
Many risks associated with drugs can be eliminated without necessarily reducing drug consumption. An obvious example is intravenous use with sterile injection equipment versus this type of use with HIV-infected equipment.
The harms associated with drug use are multidimensional. The recipient of the damage may be the individual himself, his close social context (family, friends, neighbors) or society as a whole.
A model that seeks participation
These programs are characterized by an attitude of approach to drug users by those involved in these interventions, which allows the involvement of users in them.
Only then can these programs be expected to have adequate contact with a significant portion of the “hidden” user population and to become “bridge” programs. other health services.
Harm reduction is in keeping with the belief that everyone has the right to use drugs if they want to. However, harm reduction recognizes the possibility that drug use can impair judgment and that many drugs can lead to physiological and psychological dependence.
CDs should be treated with the respect that every human being deserves and, moreover, they should be integrated into society instead of being excluded and marginalized from it. Many risks associated with drug use they are the result of social stigma drug users rather than their own use.
In search of empowerment
It promotes the competence and responsibility of drug users themselves, including, but not limited to, the consumption of these substances. for that the opinion of consumers themselves is sought when designing policies and programs created to meet their needs and active participation.
At the same time, it is recognized that situations of social precariousness, isolation, marginalization and poverty affect people’s autonomy and their ability to reduce harm and act healthily.
The effects of damage reduction
According to the World Health Organization, such interventions seek several effects.
Change the person’s behavior
First a change in individual behavior, Which often manifests itself in an interpersonal context and is affected by a number of elements that go beyond mere information; for example, a person’s beliefs about the health risks of a particular habit, the intentions and motivations for changing that behavior, and their ability to make the change.
A collective change
On the other hand, meaningful change is also sought not only at the individual level, but also at the collective and group level, which recognizes that the person’s attempts to change behavior are influenced by the opinions and actions of social groups. through which people usually move, as well as through the social circles in which substance use and sexual behaviors occur. This is called a “subjective or peer rule”.
The rules of the peer group they influence the way people behave. Peer rules are important because they determine whether a behavior is acceptable or normal for the individual and the group. For example, it is common in some communities of injection drug users (IDU), the false belief that having the syringe before the drug brings them bad luck, so they always try that before the syringe, sharing more easily. “at hand”.
Therefore, individual change is facilitated by changing standards on a peer-to-peer basis. Working with peers changes their norms of sexual behavior and drug use, and envisions group and individual behavioral changes.
Types of programs
There are several types of damage reduction programs.
Programs with opioid substitutes
Programs with opioid substitutes such as fixed and mobile high and low threshold methadone maintenance programs (PMMs), or controlled heroin distribution programs.
Methadone maintenance patients they offer lower HIV seroconversion rates than those who are not on treatment or who participate in other treatment programs. There is also a decrease in overdose episodes and risk behaviors (less use of the injectable route and less shared use of injection equipment), with much lower mortality rates than untreated ones.
These programs have reported lower levels of heroin use in people on PMM than in those on other types of treatment limited to abstinence 26, 29, 34 and better conditions of use.
Opioid substitution programs have also had a significant impact on reducing crime with fewer crimes, fewer arrests and more time in prison. currently the use of methadone is guaranteed for its safety in opioid tolerant individuals, no significant adverse effects or toxicity were found in follow-up studies of ten to twenty-five years.
Heroin programs are one of the resources that have received the most attention among harm reduction programs. Its controlled distribution from the health care network has the immediate benefits of other programs and it also has medium and long term advantages by moving their consumption away from exclusion (reduces collective crime linked to illegal markets, stabilizes or reduces the number of consumers by avoiding the drug trade).
Programs against risky behavior
At a second level, there are programs aimed at reducing “collateral” risk behaviors, directly or indirectly associated with substance use.
To avoid high risk practices against transmission of HIV, HBV and HCV, As part of a damage reduction strategy, different types of programs have been developed
Less risky consumer programs
Among them: syringe exchange and distribution programs that can be carried out from different places (pharmacies, mobile equipment with educators and “health workers” in the street, primary care centers, emergency service hospitals, specific centers, etc.).
Safer sex promotion programs
An example is the “Safer Sex Workshops” (TSMS) that provide health education on sexuality and prevention, as well as programs or campaigns that promote access to condoms. While in most countries harm reduction programs have been developed primarily around injecting drug use, their scope is much broader and its methodology is applicable to all types of drug users and to various types of drug users. damage.