For many but not all people who become homeless, the use of different substances, both legal (alcohol and cigarettes) and illegal, is common. In some cases, substance use can be highly problematic, and addictions can ensue. It is worth pointing out that while addictions can sometimes be a cause of homelessness, for many individuals the use of substances is a response to the stresses and trauma of homelessness and street life.
Harm reduction is an approach or strategy aimed at reducing the risks and harmful effects associated with substance use and addictive behaviours for the individual, the community and society as a whole. It is deemed a realistic, pragmatic, humane and successful approach to addressing issues of substance use. Recognizing that abstinence may be neither a realistic or a desirable goal for some users (especially in the short term), the use of substances is accepted as a fact and the main focus is placed on reducing harm while use continues.
Why harm reduction and not abstinence only? It is important to acknowledge that for many people, substance use is not necessarily harmful. For others, addictions can be debilitating, and can undermine relationships, health and survival. However, considerable research on addictions points to the fact that when you put people in treatment who do NOT want to quit, or are in the ‘precontemplative’ stage of change, the success rates are very low. Different people need different supports and solutions. The key here is to work with a person where they are at, and to give them choices and options.
Such interventions aim to heal the person as a whole. Rather than just addressing substance use on its own, treatment interventions also need to address other problems that may have either led to or arisen from the use of substances. In thinking about addressing substance use and addictions, it is also important to consider and address broader structural factors that underlie and produce harms. For instance, it makes no sense to force a homeless person into treatment if the factors that contribute to their addictions – their homelessness and poverty – are not addressed. We do know from the At Home/Chez Soi (Housing First) project, that if you house people who are chronically homeless and who have complex problems, their addictions issues often decline.
In addition, while law enforcement is understandable if crime threatens individual or community safety, we need to question the broader use of law enforcement as a response to substance use. One can argue that the ‘War on Drugs’ approach actually produces harm, as large numbers of individuals become needlessly incarcerated for simple possession of illicit substances. This is an expensive response that has a clearly negative impact on individuals, families and communities.
In some quarters, harm reduction remains controversial, as some believe it means ‘giving people drugs’, or is seen as denying abstinence as an option. These views are influenced by misconceptions about the concept, as well as highly polarized and moralizing debates about the use of substances in our society. So clarity about what Harm Reduction means is important. For instance, harm reduction does not exist in opposition to the notion of abstinence and treatment, but rather to a philosophy that sees abstinence as the only option (where people do NOT have a choice). Since harm reduction is about choice, some people may choose not to quit, while others may choose treatment and abstinence. And a harm reduction approach to a person's substance use in the short term does not rule out abstinence in the longer term. Harm reduction approaches are often the first step towards the eventual cessation of substance use, and many participants may eventually seek treatment options or abstinence.
There are a wide range of practices that fall under the umbrella of harm reduction. This may include on-site and mobile equipment supply distribution programs (e.g., needle exchanges, safe crack use kits, safer sex supplies, biohazard containers, etc.) intended to reduce injury and the spread of diseases. It may also include safe injection and consumption sites, and overdose prevention and treatment, as well. Providing simple information such as the amount of alcohol in a standard serving of wine, beer, and spirits can help people make decisions about what and how much they drink. Motivational interviewing, a special counselling technique, can support change in small increments, over time. At a more fundamental level, people may need to hear the message that it matters whether they live or die, and therefore it matters that they use clean needles and safer practices. Other people may need to secure basic needs like safe housing and food before they can even contemplate other changes. Evidence suggests treatment needs to be individualized and grounded in the real life circumstances and situation of a substance user.
Harm Reduction Programming
Several key components of harm reduction programming have been identified by Shout Clinic in Toronto, and include:
There is considerable evidence for the effectiveness of harm reduction. There is also growing acceptance of harm reduction as an important tool and strategy for working with people who are homeless (or those at risk) who are struggling with addictions. Moreover, many Canadian communities such as Toronto and Vancouver have emerged as leaders in terms of the practice of Harm Reduction.
The Insite program in Vancouver is perhaps one of the best known harm reduction programs in the country. While such programs are common in many European countries, Insite is north America’s first legal supervised injection site. It is considered to be a safe, health-focused place where people are able to inject drugs, and at the same time connect to health care services, addiction counseling and treatment,as well as housing and community supports. The evidence for the effectiveness of supervised injection sites such as Insite are quite compelling. Studies have identified that INSITE doesn’t promote or lead to increased use or crime, but rather has had the impact of reducing HIV risk behaviours, improving public order and has led many participants to addictions treatment.
Policy and practice should follow from good evidence. Many communities in Canada have emerged as strong leaders in Harm Reduction, yet our misunderstanding, fear and prejudice often get in the way of wider adoption.
From forthcoming: Gaetz, S. (2014). Coming of Age - Reimagining the Response to Youth Homelessness in Canada. Homeless Hub Research Report Series.
Photograph by Flavie H.