Harm Reduction

Harm reduction refers to practicing a set of strategies designed to reduce the harmful consequences associated with engaging in particular behaviors, such as substance use. Harm reduction strategies acknowledge that individuals who use substances initially may be unwilling or unable to reduce or stop their use. As such, harm reduction strategies place greater priority on reducing harm to the health of the individual using substances, as well as the general public, than on abstinence [99]. Among other assumptions of the harm reduction perspective is the assumption that many of the harmful consequences of substance use (e.g., overdose, acquisition and transmission of HIV and/or HCV, motor vehicle accidents) can be eliminated without achieving abstinence [100].

Harm reduction policies and practices have been utilized with success in several Western European countries since the 1920s. However, it more recently became adopted in the United States among HIV/AIDS service providers in response to the association of HIV/AIDS risk and injection drug use [100]. In this regard, HIV/AIDS prevention took priority over substance use prevention because of the idea that the preventable harm of HIV/AIDS was more important than the need to adhere to an abstinence-based approach to substance use [100]. The most notable harm reduction strategy associated with substance use includes needle and syringe programs (also referred to as needle exchange programs), with strong evidence that this approach is effective in reducing HIV and HCV-risk behaviors [101]. However, other harm reduction interventions include methadone and other opioid replacement therapies for individuals with opiate dependence, heroin prescribing (though this is not currently legal in the United States), information/education, “drug consumption rooms” which is a term describing rooms that are provided for substance use to avoid associated harms, and early warning systems which can act at sentinel systems within communities that alert substance users to hazards to contaminated or adulterated drugs (see [101] for full review).

However, with respect to harm reduction among behavioral medicine patients who also have a comorbid substance use disorder, an additional goal will likely be developing strategies to reduce the harm associated with not engaging in medical treatment due to one’s alcohol or substance use (e.g., non-adherence to medication, checking blood-glucose levels, attending clinic appointments). Here, motivational interviewing can be practiced to help the patient recognize and acknowledge the pros of properly engaging in care and the cons of not properly engaging in care. Additionally, education can be provided regarding the ways in which alcohol and substance use can interfere with effective management of one’s medical condition, as well as disease course. Last, problem-solving strategies can be utilized to identify common times when the patient is non-adherent with treatment, especially due to alcohol and substance use, and brainstorm strategies for overcoming these obstacles.

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