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Harm Reduction Model of Care for Substance Use Disorder

Deborah Cooper

Paramedics are the general practitioners of out of hospital emergency medicine with knowledge spanning from cardiology to musculoskeletal injuries.  Being such polyvalent practitioners, paramedics are sometimes faced with treatment modalities or styles which they are not familiar.  One of these treatment modalities is that of harm reduction, an admittedly controversial and politically influenced treatment for individuals suffering in substance use disorders.  Despite the negative perceptions of harm reduction, it has been proven to be an effective tool in the treatment of substance use disorders 1. 

The harm reduction model of care for substance use disorders was first conceived of in the late 1980’s with the increasing rates of HIV infection among people who injected substances (1).  At the time of initial conception, the goal of harm reduction through the distribution of sterile needles to populations who inject drugs focused mainly on the decrease of transmission of disease (1).  The support for harm reduction programs, including safe injection sites, has ebbed and flowed through the years with the prevailing political leaning of Canada with greater federal support during the sitting of a Liberal government (1).  However, research has supported the use of harm reduction practices as an integral practice to support not just the people who use substances, but the society in which they live (2).

Why Harm Reduction

First and foremost, harm reduction recognizes that those individuals who use substances are equally deserving members of our society and human beings (2).  Basic human right including dignity and access to care, as well as the individual right to self determination and personal choice, even if those choices appear self destructive. Harm reduction removes the judgement regarding substance use and changes it to a fact about an individual, changing the understanding of their needs to whole health.  

Treatment of substance use disorders and success of these treatments vary from person to person (2). With the use of harm reduction as an overarching theory, we allow for individual differences and needs to be addressed.  Harm reduction maximizes the options for intervention and increases the chance that the individual may successfully reach their goals, whether that be sobriety or increased participation in society.

Substance use can be costly at a societal level too (2). Of note is the increased costs associated with illness and injury secondary to substance use disorders, noticeable in paramedicine with the increased use of 911 and emergency room visits for overdoses, and the increased risk of chronic illness among those who use substances. Within societal costs there is also the risk of increased poverty and use of social supports, and the public exposure to such things as discarded used needles. 

Forms of Harm Reduction and Harm Reduction Techniques

The overarching goal of harm reduction techniques is to support the individual to reduce adverse health, social, and economic consequences while they are actively using substances (2). Harm reduction does not remove the option for longer term treatment options such as abstinence but works to ensure that the induvial is alive and well enough when they are able to access these services. Substance use is known to co-occur with alienation and marginalization, and harm reduction strategies also help to improve connection and acceptance.

As the initial harm reduction strategies within Canada focused on the transmission of HIV and the associated risk factors of intravenous drug use and sexual intercourse, the tools offered to individuals followed transmission pathways (1). Condoms and single use sterile needles allowed for individuals to engage in safer practices and decreased their risk of disease. These practices still occur today as access to safe supplies serves an important role in harm reduction substances (2).

Watson et al. explored the expansion of harm reduction techniques to support the intersection of homelessness and substance use disorders.  Housing first is a form of harm reduction that allows for safe and appropriate housing without requiring abstinence from the individual (3).  Support (mental health, addiction, social, food, economic) to the individual occurs within the housing program and often co-exists in the housing complex itself.  Housing first models of support do not come without challenges but have been proven successful in decreasing homelessness and increasing engagement with support.

Harm reduction strategies extend to access pharmaceutical interventions for the treatment of withdrawal or dependence on substances (4, 5).  Low barrier access to overdose intervention medications such as naloxone supports the individual within their current social context to decrease morbidity and mortality and create a situation with the individual can access further supports (5). Another pharmaceutical harm reduction intervention is the access to suboxone and methadone programs to help the individual to decrease their use of illicit substances which run the risk of contamination and irregular concentrations of active substance. 

Supervised consumption sites have become more accessible since the legal proceedings in 2011 which asserted the provision of safe consumption sites as part of one’s right to life, liberty, and security of person under the Charter of Rights and Freedoms (1). Alongside supervised consumption sites, safe substances treatment has bene proposed (5). Here individuals identified as at considerable risk are offered regulated pharmaceutical grade alternatives such as oral slow-release morphine or injectable heroin or hydromorphone to use under medical supervision. The goal of such programming, as is with all harm reductions, is recognize the extreme risks that co-occur with substance use and protect the vulnerable members of society. Furthermore, alcohol dependence programs that offer supervised consumption of supplied alcohol can work to decrease use of “non-drinking” alcohol such as hand sanitizer and minimize the associated medical complications (4).  

Evidence of Successes and Research

While the social and political leanings of Canada mat impact overall support for harm reduction initiatives, scientific research examining harm reduction asserts it as an effective model of care for substance use disorders (2).  The Canadian Drug Policy Coalition outlines research supporting education and outreach, low threshold support services, needles exchange programs (safe supplies), methadone treatment, and supervised consumption sites 2. Prescription use of heroin is also supported by long term research notably out of the Netherlands where in 2002 results were published linking prescription heroin use and positive social and health outcomes.  

While some aspects are less on the forefront of available treatment in Canada, harm reduction is an established and overarchingly ethical, person-centred treatment model for substance use disorders. As paramedics are increasingly engaged with individuals who use substances, either with routine 911 calls or with supplemental work through community paramedicine initiatives, it is important to begin understanding how substance use disorders are treated.  The Basic Life Support Patient Care Standards asserts the duty of paramedics to alleviate pain and suffering as the first item in the Conduct Standard 6, and to be able to achieve this standard, paramedics need to first understand the purpose of a treatment standard so that they may support and reinforce this treatment.

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References

1. Hyshka E, Anderson-Baron J, Karekezi K, Belle-Isle L, Elliott R, Pauly B, et al. Harm reduction in name, but not substance: A comparative analysis of current Canadian provincial and territorial policy frameworks. Harm Reduction Journal. 2017;14(1). 

2. Canadian Drug Policy Coalition. Harm reduction [Internet]. Canadian Drug Policy Coalition. 2021 [cited 2022Apr10]. Available from: https://drugpolicy.ca/our-work/issues/harm-reduction/ 

3. Watson DP, Shuman V, Kowalsky J, Golembiewski E, Brown M. Housing first and harm reduction: A rapid review and document analysis of the US and Canadian open-access literature. Harm Reduction Journal. 2017;14(1). 

4. Crabtree A, Latham N, Morgan R, Pauly B, Bungay V, Buxton JA. Perceived harms and harm reduction strategies among people who drink non-beverage alcohol: Community-based qualitative research in Vancouver, Canada. International Journal of Drug Policy. 2018;59:85–93. 

5. Tyndall M. An emergency response to the opioid overdose crisis in Canada: A regulated opioid distribution program. Canadian Medical Association Journal. 2018;190(2). 

6.Emergency Health Regulatory and Accountability Branch Ministry of Health. Basic life support patient care standards – ontario [Internet]. [cited 2022Apr10]. Available from: https://www.health.gov.on.ca/en/pro/programs/emergency_health/edu/docs/bls_pcs_v3.3.pdf 

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Deborah Cooper

Deborah Cooper

Deborah Cooper, BA, MA, RP (Qualifying), PCP, has been a paramedic in Kingston Ontario since 2003.  She recently completed her Masters in Counselling Psychology and is a Registered Psychotherapist (Qualifying). Between working as a paramedic and seeing psychotherapy clients, Deb shares her advocacy for marginalized populations wherever possible. Contact Deb at deborah_e_cooper@icloud.com

Women in Paramedicine

Women in Paramedicine

Women in Paramedicine is compromised of dozens of women in the paramedical field across Canada. Since 2019, they have been sharing their research, point of view, thoughts, and strength to Canadian Paramedicine through their voice and words.

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