Peter R. Martin: Historical Vocabulary of Addiction, Vol. II
Harm Reduction
The noun harm reduction does not appear in the Oxford English Dictionary (OED). However, the importance of harm reduction as a public health approach to management of drug and alcohol use disorders makes a discussion of this issue highly relevant. The meaning and historical development of this term in the field of addiction can be obtained by examining those of the contributing elements, harm and reduction. Additionally, identifying mentions of harm reduction in discussions of other conceptually related words in OED, such as needle and safe, are also informative.
The noun and verb harm were inherited from the Germanic via “Old English hearm…Old Saxon harm, Old High German harm, haram (modern German harm), Old Norse harmr [meaning] grief, sorrow, rarely harm, hurt.” The relevant meaning of harm is defined in OED as: “Evil (physical or otherwise) as done to or suffered by some person or thing; hurt, injury, damage, mischief.” The noun reduction is of multiple origins, partly a borrowing from the French reduction and from the Latin reductiōn-, reductiō. The word is defined in OED as: “The action of reducing the amount, quantity, extent, etc., of something; the action or fact of becoming smaller; diminution, lessening; cutting down, curtailment; an instance of this.” Therefore, combining the words harm and reduction in reference to addiction denotes changes that can be implemented at any level to diminish the harm caused by the disorder to the individual or in the population. Typically harm reduction refers to helpful interventions other than total abstinence.
The noun harm was first used in Old English circa 1000 in Beowulf,an epic poem in the tradition of Germanic heroic legend (Mitchell 2017): “No he mid hearme of hliðes nosan gæs[tas] grette.” The use of harm as it is utilized in relation to addiction is exemplified by a quote of Thomas Babington Macaulay (1800–1859), a British historian and Whig politician, from History of England (Macaulay 1849): “Aware that the divulging of the truth might do harm.” The noun reduction was first used in the English language in the field of Surgery (defined in OED as: “The action of reducing a fracture, hernia, dislocated part, etc.; an instance of this”) as in a translated quotation of the French physician and surgeon Guy de Chauliac (c. 1300–1368) in his Chirugia Magna (de Chauliac 1659): Here shal noȝt be put but grosse & materiale anathomie which may directe a Cirurgien wirchyng in inscisions & reduccions [?c.1425 Paris settynges togedre; L. reductionibus] of membrez.” An example of the first use in English of reduction as relevant to the present discussion is exemplified by a quotation from William Twisse (1578–1646), an English clergyman and theologian, in his Discovery of D. Iacksons Vanitie (Twisse 1631): “This piercing of time, or reduction of many yeares into a small space being as utterly impossible as the penetration of dimension in magnitude, if not much more.”
Mention of the term harm reduction can be found in OED in relation to the noun needle, with reference to the noun needle exchange, which is defined as: “a service making sterile hypodermic needles available to intravenous drug users, in order to reduce transmission of blood-borne infections; a place in which such a service is based.” An example of an early quotation that refers to the role of needle exachange in harm reduction is found in the British Medical Journal (Moss 1987): “The needle exchange is part of an overall ‘harm reduction’ approach to addiction.” Additionally, under the adjective safe, a related adjective safe-injection, is defined in OED as: “originally and chiefly North American designating a place where intravenous drug users may inject drugs under supervision of medical staff, as in safe-injection facility, safe-injection room, safe-injection site, etc.” An example of a quotation that describes the relation of safe-injection to harm reduction is found in Foreign Affairs (Nadelmann 1998): “Harm reduction innovations include… establishing ‘safe-injection rooms’ so addicts do not congregate in public places or dangerous ‘shooting galleries’.” The fact that this quotation appeared in an American magazine of international relations and U.S. foreign policy underlines that harm reduction combines medical, legal and political strategies to address an immense societal problem that is arguably medical at its base (addiction).
Using the then newly available technological innovation, the hypodermic needle (Rynd 1845), injection of “morphia” for treatment of pain and other ills became widely disseminated in the second half of the 19th century (Kane 1880). About a decade after Lister introduced the concept of antisepsis (Lister 1867), it was suggested that spreading infection by injection with the hypodermic needle was a distinct possibility after self-administration of morphia. A case was described in The Lancet (Anonymous 1876) of a woman who: “had been taught the use of the hypodermic syringe [to inject morphia] some years before for the relief of the vomiting of pregnancy, and there was some reason to believe that she had practiced the injection surreptitiously where no actual occasion for it existed.” The intertwining of injection drug use and infectious diseases was firmly established in subsequent decades (Cherubin and Sapira 1993) and became the scientific rationale for harm reduction via needle exchanges programs.
Harm reduction was formalized and implemented as a public health strategy in the 1980s as emergence of the HIV/AIDS epidemic brought a sense of urgency to the need for new approaches to address the spread of the virus, particularly among injection drug users (Drummond, Edwards, Glanz et al. 1987):
“Persuading the injecting drug misuser to change from dangerous to safer behaviour is a difficult but potentially promising approach which will require sustained and multiple strategies. It must embrace a range of specific strategies bearing on such issues as persuading individuals to desist from sharing apparatuses, to change from injected to oral drug use, or to modify dangerous sexual behaviour. Considerable research experience has been gained over recent years in the study of ‘health behaviour’ and particularly useful analogies might be drawn with cigarette smoking. The background climate of opinion is likely to be highly important in proposing and supporting personal changes in behaviour, and this suggests that public health campaigns on the connection between HIV and drug misuse may be worthwhile if they are well-designed, sustained and appropriately targeted. A second broad strategy for encouraging behavioural change consists in offering easily accessible and acceptable alternatives, which in this case would imply free needles and syringes, longer-term and perhaps higher-dose methadone prescriptions than have recently been usual, and free condoms. A third strategy relies on persuasion in the one-to-one counselling context, and here there are many questions of great potential importance relating to how the relevant messages are in this instance to be phrased and given, who is to give them, and how the necessary training is to be provided.”
Reseachers in the field have long recognized that reducing the supply and demand for illicit drugs are very useful public health interventions (Powell 1989). However, such population-based interventions are insufficient to reduce the very many harmful consequences of drugs and alcohol in the individual. Accordingly, personalized clinical strategies based on understanding of addiction as a biopsychosocial disorder (Martin, Weinberg and Bealer 2007) and focused on reducing the complications of alcohol/drug use in the individual are also very much needed (Tongue and Turner 1988).
The work of the American psychoanalyst and psychiatrist Norman Zinberg (1922–1989) contributed the conceptual underpinnings for harm reduction as an approach that aims to minimize the negative consequences of drug use in the individual as described in his book Drug, Set, and Setting: The Basis for Controlled Intoxicant Use (Zinberg 1984). Zimberg argued that instead of focusing on drug use as a moral failing or criminal issue, this disorder should be considered as a complex phenomenon that involves multiple factors, including the drug itself, the individual’s characteristics and experiences and the social and cultural context of drug use. Zimberg’s understanding of addiction was highly compatible with the then emerging biopsychosocial model. This was a general theory of illness and healing formulated by the American internist and psychiatrist George Engel (1913–1999), which has evolved to become central to how psychiatrists now view mental illnesses (Engel 1977).
The American sociologist Talcott Parsons (1902–1979) had earlier promulgated a social perspective of illness in his book The Social System (Parsons 1951), reasoning that individuals who are sick or have a health problem should be given a “sick role” that exempts them from certain social responsibilities and expectations. While this model did not specifically address drug use or addiction, it did lay the groundwork for a more compassionate and understanding approach to individuals with health problems (which those suffering from addiction most certainly have).
These converging viewpoints now have come to incorporate the challenging issues of responsibility, stigma and blame as they apply to our understanding of addiction and its medical management (Pickard 2017). Syntheses of these constructs of illness and acceptance of addiction as a mental illness indicate that reducing the amount of drug/alcohol self-administered and/or using in a more safe manner per idem are worthwhile goals that should not be eschewed for a primary objective of complete abstinence.
The first harm reduction interventions were implemented in Europe in the mid-1980s with the establishment of needle exchange programs in the Netherlands (Engelsman 1989) and Switzerland (Haemmig 1995). Dutch approaches were inspired by an emerging understanding that repressive, prohibitive approaches as practiced internationally have often led to unintended adverse consequences for both the individual and society. Specifically, Dutch public health experts extrapolated from the example of cannabis use in many countries at the time, namely that users suffered greater harm from criminal proceedings forced upon them than they experienced from the use of the drug itself (Erickson 1992). These first European programs were groundbreaking examples of harm reduction, providing sterile needles and syringes to injection drug users in order to prevent the spread of HIV and other infectious diseases and became a model for similar programs in other parts of the world.
The first needle-exchange program was approved in the United States in New York City (Raymond 1988), but not without opposition from many quarters, in large part due to pressure from those who advocated for abstinence-based approaches as the only viable means to effectively treat addiction (McLean 2011). Harm reduction eventually gained prominence in the U.S. as the country began to experience a surge in injection drug use and related health issues such as HIV/AIDS and hepatitis C in the 1990s. Advocacy groups and public health officials began to call for the widespread implementation of harm reduction strategies. However, the discord between proponents of abstinence-based self-help and mutual support (Martin 2020a,b) and the public health perspective of harm reduction could not easily be reconciled (Pendery, Maltzman and West 1982; Toumbourou and Hamilton 1994).
Harm reduction has become an established and widely practiced public health strategy in many parts of the world (Riley, Sawka, Conley et al. 1999). Harm reduction is based on the perspective that individuals have a right to make their own decisions about their lives and acknowledges that complete abstinence from high-risk behaviors may not always be achievable. Instead, harm reduction seeks to reduce the negative consequences associated with these behaviors by providing information, resources, and support to individuals. Harm reduction approaches have been successful in reducing rates of HIV transmission and other blood-borne infections among injection drug users and reducing overdose deaths through the distribution of naloxone (Heimer 1998; Centers for Disease Control and Prevention 2012).
Harm reduction has also been successful in improving access to healthcare and social services for marginalized populations. For example, harm reduction programs may provide referrals to medical and mental health services, housing assistance and legal support. In addition to these tangible outcomes, harm reduction can also have a significant impact on reducing stigma and discrimination against individuals who engage in high-risk behaviors. By acknowledging the reality of these behaviors and offering support and resources rather than punishment or judgment, harm reduction can help to build trust and strengthen relationships between individuals and the healthcare system.
There is a growing body of research supporting the effectiveness of harm reduction in reducing the negative consequences associated with high-risk behaviors, in general, not simply those associated with intravenous drug use, for which this approach was originally developed. For example, harm reduction strategies have been adapted to manage alcohol use disorders (Donovan and Marlatt 1993), the transmission of diseases by sexual activity and other potentially harmful behaviors as over-eating, poor nutrition and heart disease (Keil 2000).
Harm reduction is a general approach that can be adapted to address maladaptive behaviors and practices of all sorts in a compassionate and pragmatic manner. Harm reduction can be used to address complex public health challenges operating either within or outside the formal medical system and thus can be made available to marginalized and stigmatized populations at relatively little cost. The goal is not to eliminate the behaviors that may cause harm, but rather to minimize the risk of harm to individuals and society through better understanding the underpinnings and consequences of the pathological behaviors in question.
Harm reduction approaches were applied to management of alcohol use disorder considerably later than for other conditions (Donovan and Marlatt 1993). In North America, the abstinence-based approach to alcoholism has a very long tradition. There has been considerable resistance to harm reduction with reputable scientific debate but no resolution of the issue, e.g., whether a form of harm reduction, “controlled drinking,” is an acceptable approach to alcoholism treatment (Pendery, Maltzman and West. 1982; Sobell and Sobell 1984). All the same, several harm avoidance strategies have been implemented and utilized in management of mild, moderate or severe alcoholism: moderation; safer drinking practices; and medication-assisted treatment. Clinicians do agree that the most severe forms of alcoholism with end-organ damage should strive to attain abstinence (Singal and Mathurin 2021).
The notion of moderation is based on recognition that some individuals may be able to reduce their alcohol consumption without quitting entirely. Moreover, such an approach has been found to improve health and overall functioning and thus, seems a worthwhile therapeutic undertaking (Witkiewitz, Maltzman, West et al. 2020). Harm reduction approaches may focus on helping individuals to set goals for moderate drinking, and providing support and resources to help them achieve those goals. Of course, if moderation is not found to be effective in a particular patient it may need to be upgraded to a goal of abstinence, especially if the patient deteriorates clinically due to harmful levels of alcohol consumption.
Harm reduction approaches may also focus on teaching individuals safer drinkingpractices, such as avoiding drinking on an empty stomach, alternating alcoholic drinks with non-alcoholic drinks, avoiding driving or operating heavy machinery while under the influence and prophylactically taking medication that can reduces craving (see below) just prior to situations when the risk of heavy, out-of-control consumption presents itself.
The newest approach to treatment of alcohol use disorder is medication-assisted treatment (MAT), especially for the most severely affected individuals, which is intended to help achieve abstinence or to reduce consumption by mitigating cravings and withdrawal symptoms (Garbutt, West, Carey et al. 1999; Witkiewitz, Roos, Mann et al. 2019). Medications such as naltrexone, acamprosate and disulfiram have been shown to be effective in reducing alcohol consumption and promoting abstinence. For the longest part of the history of searching for pharmacotherapeutic strategies for treatment of alcohol use disorder, the goal had been to achieve total abstinence and treatment efficacy was only considered in those terms. More recently, reduction of amount consumed has started to be considered a positive outcome and this may open the possibility of finding medications that did not pass the higher bar, but may still be useful for reducing use in some patients. Additionally, combinations of medications and intermittent treatment can also be beneficially used under certain circumstances (Froehlich, O’Malley, Hyytiä et al. 2003; Pettinati, Oslin, Kampman et al. 2010).
In summary, harm reduction approaches focus on reducing the negative consequences associated with substance use, rather than on achieving abstinence. These approaches are based on the recognition that substance use is a complex and multifaceted issue, and that different individuals may benefit from different approaches to care. In general, harm reduction has gained acceptance and recognition as an effective public health approach over the past several decades, particularly in the field of substance use. The World Health Organization (WHO), for example, recognizes harm reduction as an important component of a comprehensive response to alcohol/drug use and has called for its increased implementation in many countries.
However, there are still some critics of harm reduction who argue that it enables or condones risky behavior and that abstinence-based approaches are the only effective way to address certain issues. There is no one-size-fits-all approach to treating alcohol and drug use disorders. Some individuals may benefit from a harm reduction approach, while others may require abstinence-based treatment. The choice of treatment approach depends on the individual's specific needs, preferences, and circumstances. As it is recognized that harm reduction and abstinence-based treatments are not mutually exclusive, the approach is perceived as desirable and effective, especially in medicine.
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May 11, 2023