Harm Reduction: An Overview

Harm Reduction and Geographies of Healthcare

• Harm reduction is defined as an evidence-based, client-centered approach, aimed at reducing the health and social harms associated with addiction and substance use.

• This approach recognizes abstinence may not always realistic or desirable, especially in the short term

• Harm reduction refers to interventions aimed at reducing the negative effects of health behaviors without necessarily requiring complete or permanent cessation

• Pragmatism characterizes harm reduction

  • Harm reduction is driven by the practical consequences of interventions
  • The usability of evidence-based interventions depends on a meticulous understanding of different contexts
  • Important considerations are the contexts where evidence is produced and applied, the people applying the intervention, and the current and future impact on local populations

• Harm reduction dates back to the early 1900's

• Harm reduction gained prominence during the 1970s and 1980s with the rise of blood-borne diseases like hepatitis B and HIV.

• In the context of substance use, harm reduction targets the negative consequences, not the substance use.

• Intravenous Drug Users (IDUs), sexual partners, and mothers through PMTCT were the targets for intervention in the context of HIV infection.

• Injection drug use (IDU) is specifically concerning due to severe impact on users and public health implications tied to transmitting blood-borne pathogens like HIV and hepatitis C.

• Harm reduction gained traction in Europe, especially the UK, due to HIV/AIDS & attention to the effects of drug prohibition instead of solely on AIDS.

Iron Law of Prohibition

• Efforts to suppress illicit drug supply ends up favoring more compact substitutes, as noted by Beletsky & Davis in 2017.
• Prohibition doesn't address underlying reasons for drug use, such as homelessness, pain, and SDOH

Harm Reduction in Practice

• Syringe exchange programs embody the harm reduction approach, this began in Europe in the mid-1980s, and spread worldwide.
• These exchanges help reduce HIV risk for those injecting drugs, given users may be unable or unwilling to stop
• Strategy involves providing information about changes and the means to achieve them, including sterile needles, syringes, and condoms.
• Needle exchange programs vary in Canada with formats that include limits on syringe numbers, requirements to exchange used syringes, and distribution via pharmacies or vending machines.
• Methadone maintenance is a recognized approach that substitutes oral methadone instead of illegal opiates to reduce reliance on illegal opiates often injected
  • Methadone maintenance helps users build personal and social resources and connect with wider health care and social services
  • Methadone maintenance programs operate across Canada.
• Drug substitution replaces illegal drugs with legal substances to reduce criminal activity, control the dosage and quality to promote safer use and access to health/social services.
  • Providing pharmaceutical grade heroin has been ongoing in the U.K. for many years and prescription dexamphetamine has been used as a substitute for cocaine.
• Peer-administered naloxone allows peers and outreach workers trained to administer naloxone which can reverse opiate overdoses.
  • Overdose mortality can be reduced by improving naloxone availability because witnesses don't seek medical help in fear of enforcement.

Key Principles of Harm Reduction

• Pragmatism acknowledges that some mind-altering substance use is inevitable and normal in a society, therefore, must be understood including the risks and benefits.
• Humanistic values accept people who use drugs and the drug user's decision, no judgements.
  • The user's dignity and rights are respected.
• Focusing on harms means that reducing the risks of negative consequences of drug use is priority, whether to the individual and other, and does not exclude or presume the long-term treatment goal of abstinence.
• Balancing costs and benefits include assessing the relative importance of problems, harms and the costs/benefits of an intervention when focusing resources on priority uses, while considering community and societal interests.
• Having a hierarchy of goals, the individual or community is engaged to address their pressing needs and is then viewed as a step towards risk-free use or abstinence.

Barriers to Harm Reduction

include idealism, war on drugs mentality, sociocultural/religious beliefs, legal obstacles, and relative ease of applying the intervention

Geographies of Healthcare

• Key elements include components of healthcare systems, disparities of service provision, demographic factors influencing access, and how individuals obtain healthcare.
• Health systems: all activities to promote, restore, or maintain health as defined by the World Health Organization (WHO, 2009)
  • Health systems also include population and public health activities, research, health promotion, policy, financing, and technology
• Health service delivery has three main categories: primary, secondary and tertiary with increasing specialisation
  • These levels are not always clear due to outside circumstances
  • Health care also takes place outside clinics/hospitals, including in nursing homes
  • Primary healthcare is provided at home or at clinics like the Somerset West Community Health in Ottawa with a focus on aspects of preventative medicine and health promotion
  • Secondary Healthcare is offered in settings like hospitals where longer treatments occur and care not accessed at the primary level like Ottawa Civic or the Children's Hospital of Eastern Ontario
• Health promotion includes education, action and lifestyle choices can prevent illness from happening, and differs across geological sciences

Healthcare & Prevention

• Health Promotion focuses on activities to prevent illness focused on activities and lifestyle choices. Education and behaviour change are guiding principles for health promotion in settings such as schools, workplaces, and communities.
• Health promotion differs across geographical scales, meaning prevention and health promotion for the global north (cancers, obesity, diabetes) differ from the prevention of infectious diseases for the global south.
• Alternative or complementary care refers to the use of non-conventional health interventions to complement Western medicine (natural products, mind-body or manipulative practices, holistic approaches) where use differs depending on social variables such as income, race, level of education and sex.
• "Public" and "private" are terms use to describe healthcare systems, both when delivered and how they are financed whereas "public sector" = government and "private sector" is anything that occurs beyond government (family, market).

Health Care Models

• There are main models for healthcare service delivery
  • Four profit and not profit is one way to describe institutions that run financing or healthcare insurers
    • For profit = share of companies that the government considers to be shared owners or corporations
    • Not profit = intent is not solely to make a profit but to also improve on social issues
    • Non-profit org (charities) = that benefits the overall community from tax exemptions
• Health policy reflects social justice and the level of government involvement US = health care is largely private UK = health care system mainly is financed and delivered by the public sector Canada = combination of some private, other public domains The Beveridge Model is a healthcare model developed in the 1940's and forms the basis of National Health System [NHS]
• It Established in 1948 and collective to ensure health care needs not influenced by individual abilities to contribute as this system is founded by both those in employment and through general revenue via universal coverage
  • Access based on a universal registration system where providers, hospitals and the majority of clinics are run through the state with GPs making external recommendations. The Bismarck Model began the the late 19th century includes private, with no singular, government source instead governed by a regulated system of shared contribution and not necessarily guaranteed to all
• The National Health Insurance model Canada has adopted is Solely funded by the government however, service providers are private with provinal/territory and federal responsibilities.
  • The provincial government makes the 10 decisions about the number of health system
  • This model comes with a caveat of non-universal accessibility for dental, vision and perscription needs
• The Canadian Health Act (1984) establishes 5 principles: Universality, Comprehensiveness, Accessibility, Portability and Public administration -All principles must be abided to gain transfer contributions, where access is not decided for financial reasons

Accessibility

• Provincial and territorial plans in Canada must provide residents access based on medical need, while universality is defined to include the full coverage and medical treatments

• Portability ensures coverage while travelling where there is a waiting grace period for travel outside of a residents local province

  Out – of – pocket model occurs in the United States with is tied to private health and employers securing income

  • Introduced in 1965 to lower cost services of medical for over 65s and welfare through medical care The main challenges is high cost, or lack of universal coverage for various components and treatments. -HMO has been made as an alternative in its place

• Disparities in healthcare delivery & increasing expenses in US lead to health maintenance organizations (HMOs) where people will pay premiums and have their healthcare delivered via consortium

Geographies of Rationing

• Resource allocation and service rationing may appear unconnected to geography; however, unequal allocation still exists with accessibility