The first time I heard of harm reduction was in 1993 when I was a member of ACT UP (AIDS Coalition to Unleash Power) fighting with California legislators for a needle exchange program in the Bay Area. At the time, needle exchange was an innovative and controversial HIV prevention program that provided syringes, outreach and education to injection drug users in order to stop the rising infection rate. In San Francisco and Oakland, underground exchange programs existed with passionate AIDS activists and former drug users who were committed to providing prevention options to highly stigmatized addicts on the street. The exchangers called their grass-roots programs harm reduction.
Needle exchange history
In ’93, needle exchange was not new, having begun in the ‘80s, but the overall concept was definitely contentious as advocates, providers and policy makers butted heads on the appropriateness and legality of such programs. Those opposed felt that providing needles condoned drug use. But advocates felt that any forced approach was counter-intuitive to help people reach goals of safer usage and prevention of infection. Abstinence was only one possible goal.
A “just say no” mandate was seen as a rather arrogant and insensitive viewpoint in the overall scheme of the complex nature of drug use and addiction. Realistically, the programs actually provide a guilt-free, healthy alternative to meet the users where they are at.
Today there is direct medical evidence that needle exchange reduces HIV infection, and those on the streets fighting for the programs have no doubt that exchanges are vital. One study in The Lancet medical journal found that in 29 cities worldwide where needle exchange programs are in place, HIV infection dropped by an average of 5.8% a year among drug users. In 51 cities that had no needle exchange plans, drug-related HIV infection rose by 5.9% a year. The former U.S. Surgeon General David Satcher agreed that there is conclusive evidence for syringe ex change.
Needle exchange programs have grown to become larger coalitions where users can be led to counseling, further education, STI (sexually transmitted infection) and HIV testing, and yes, abstinence programs. In the U.S., the number of programs are hard to count as they open and close depending on funding and the police. TPAN’s drop-in needle exchange site is sponsored by the Chicago Recovery Alliance (CRA). Chicago has a second exchange, Community Outreach Intervention Project (COIP), through the University of Illinois.
The harm reduction belief
Needle exchange is only one example of harm reduction techniques meant to prevent the risk of contracting HIV, hepatitis C and other infections.
Today harm reduction is a comprehensive spectrum of many ways to promote better holistic health. The concept is not punitive, black or white, yes or no, but a positive way of reducing an individual’s harm.
Harm reduction is more of a gray concept, in other words, the taking of small steps, or incremental goals that may lead to a discovery or realization that drug use may not be in the user’s best interest per se. Programs are non-judgmental about users, which ensures trust between the worker and the user.
According to Robert Westermeyer, a psychologist and Ph.D. from San Diego, harm reduction is based on three central beliefs:
1. “Excessive behaviors occur along a continuum of risk, ranging from
minimal to extreme. Addictive behaviors are not an all-or-nothing phenomena. Though a drug or alcohol abstainer is at less risk of harm than a drug or alcohol user, a moderate drinker is causing less harm than a binge drinker, a crystal methamphetamine smoker or sniffer is causing less harm than a crystal injector.”
2. “Changing addictive behavior is a stepwise process, total abstinence being the final step. Those who embrace the harm reduction model believe that any movement in the direction of reduced harm, no matter how small, is positive in and of itself.”
3. “Sobriety simply isn’t for everybody. This bold statement requires the acceptance that many people live in horrible circumstances. Some are able to cope without the use of drugs, and others use drugs as a primary means of coping. Until we are in a position to offer an alternative means of survival to these folks, we are in no position to cast moral judgment.”
Westermeyer maintains, “that the health and well being of individuals is of primary concern, that if these individuals are unwilling or unable to change their addictive behaviors, they should not be denied services.” Advocates agree with his position.
One by one
As with any health care situation, we are dealing with individuals who have individual needs. With some people abstinence is doable, with others it is unattainable and a waste of needed resources. There is no clear-cut road to recovery with harm reduction. Harm reduction does not seek to impose one strategy against a person’s wishes, but works together with them to make changes.
Today, harm reduction can mean everything from wearing condoms for preventing HIV transmission and STIs to learning about safer injection techniques to preventing abscesses. It may be learning how to clean the works used to cook heroin, or even learning how to take HIV medicines appropriately to prevent drug resistance. Some people would consider dieting a form of harm reduction. Thus, the term can be used very generally or specifically to describe any positive strategy, change or plan to reduce harm and improve health.
In fact, since there is not one concrete definition of harm reduction, there is a great misunderstanding about it. There is a certain mystique about it, something clandestine or shady, probably because it is a progressive program that accepts people using illicit drugs where they are coming from.
It is not something absolute. Abstaining from using drugs or sex may be one goal of harm reduction, but so is wearing condoms, or smoking marijuana instead of shooting heroin. Other goals can also be strategies, such as using crystal meth every six months instead of every month. Or, learning how to put on a condom, or ways to lessen alcohol intake.
Crystal meth and harm reduction
The right wing has perpetuated an abstinence-based philosophy that has crept into the mindset of the most innocent and well-intentioned in many unfortunate ways. Recently, I had an encounter with a person in recovery for crystal methamphetamine who vehemently opposed harm reduction, and chastised me and TPAN for the work we do. TPAN sponsors weekly Crystal Methamphetamine Anonymous meetings (CMA) that are based on a twelve-step abstinence model—however, we also have trainings on harm reduction for gay men using crystal.
I had to sit him down and explain that harm reduction is not a program that excuses drug use, but seeks to lead people to safer options while they receive education about the harmful effects of drug use. It may appear to some that the programs allow for drug use, but in the minds of those who believe in harm reduction, the reality is that the use of drugs is along a continuum where use starts and stops. Our current administration’s narrow-minded, abstinence-based philosophies will affect the lives of the most stigmatized and forgotten in our society.
Some believe that harm reduction with crystal methamphetamine is impossible. However, when you look at the bottom line of harm reduction, you see that small steps of any positive change may lead a person to stopping even a drug as insidious as crystal. Still, the use of crystal methamphetamine varies from person to person. There is a lot of attention on the addict, but we can also help those who have not become addicted or are casual users.
Much like AIDS, our community has been shaken by crystal methamphetamine that has caused some to close their eyes to all available options for slowing and stopping the epidemic. This can only be seen as counter-productive, close-minded, and judgmental despite the devastation we are experiencing.
Nancy, curb your dogma
We can look back and say that Nancy Reagan’s dogmatic campaign against drug abuse “Just say no” was just a big failure. That was 20 years ago at the height of the AIDS epidemic where a narrow-minded administration couldn’t even utter the word AIDS let alone use appropriate drug messages. But today, most agree that we are seeing a resurgence of this narrow mindset that will most certainly lead us to a rising infection rate and a growing death toll.
“In essence, a policy of harm reduction requires an approach of pragmatism rather than purism—an acceptance that it may sometimes be better to go for a probable silver than a possible gold.”—John Strang
Editor's note: See the upcoming September/October 2005 issue for a step-by-step recovery process for crystal meth.
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