Annotated Bibliography


Harm Reduction Therapy with Families and Friends of People with Drug Problems

Journal: Journal of Clinical Psychology
Authors: Denning, Patt (2010)

This article describes and illustrates the ongoing development of a treatment for working with families and friends of drug users using harm reduction principles. The author was instrumental in applying harm reduction principles to substance abuse and has used these same principles to help families deal with the pessimism, pain, and grief that accompany their relationship to a person with an active substance abuse problem. The treatment involves learning decision-making processes based on both self-care and love for the substance abuser and is based on the values of harm reduction, caring, and incrementatism, rather than those of codependency, tough love, and abrupt behavior change. A long-term family therapy group and two family consultations illustrate the treatment and its applications.

Expanding Conceptualizations of Harm Reduction: Results from a Qualitative Community-Based Participatory Research Study with People who Inject Drugs

Journal: Harm Reduction Journal
Authors: Boucher et al., (2017)

The perspectives of people who use drugs are critical in understanding why people choose to reduce harm in relation to drug use, what practices are considered or preferred in conceptualizations of harm reduction, and which environmental factors interfere with or support the use of harm reduction strategies. This study explores how people who inject drugs (PWID) think about harm reduction and considers the critical imperative of equity in health and social services delivery for this community. Methods: This community-based participatory research study was conducted in a Canadian urban center. Using a peer-based recruitment and interviewing strategy, semi-structured qualitative interviews were conducted by and with PWID. The Vidaview Life Story Board, an innovative tool where interviewers and participant co-construct a visual “life-scape” using a board, markers, and customized picture magnets, was used to facilitate the interviews. The topics explored included injection drug use and harm reduction histories, facilitators and barriers to using harm reduction strategies, and suggestions for improving services and supports. Results: Twenty-three interviews with PWID (14 men and 9 women) were analysed, with a median age of 50. Results highlighted an expanded conceptualization of harm reduction from the perspectives of PWID, including motivations for adopting harm reduction strategies and a description of harm reduction practices that went beyond conventional health-focused concerns. The most common personal practices that PWID used included working toward moderation, employing various cognitive strategies, and engaging in community activities. The importance of social or peer support and improving self-efficacy was also evident. Further, there was a call for less rigid eligibility criteria and procedures in health and social services, and the need to more adequately address the stigmatization of drug users. Conclusions: These findings demonstrated that PWID incorporate many personal harm reduction practices in their daily lives to improve their well-being, and these practices highlight the importance of agency, self-care, and community building. Health and social services are needed to better support these practices because the many socio-structural barriers this community faces often interfere with harm reduction efforts. Finally, “one size does not fit all” when it comes to harm reduction, and more personalized or de-medicalized conceptualizations are recommended.

Starting Where the Client Is: Harm Reduction Guidelines for Clinical Social Work Practice

Journal: Clinical Social Work Journal
Authors: Vakharia, et al., (2017)

Harm reduction has gradually entered social work discourse and is now seen as a promising approach for treating individuals with drug and alcohol problems. However, beyond statements and data supporting the utility of a harm reduction approach, few guidelines for clinical practice have been detailed in the social work literature. This lack of concrete detail regarding how harm reduction is actually practiced limits the potential implementation of the model into day-to-day clinical work. This article reiterates that harm reduction is a viable approach to clinical social work practice with individuals who have drug- and alcohol-related problems and for whom traditional approaches may be inappropriate. It focuses on harm reduction therapy as an emerging treatment model that can be implemented by clinical social workers and mental-health and substance use treatment providers. The article identifies and elaborates several basic tenets that can be incorporated into clinical social work. It is hoped that social workers who learn how harm reduction is implemented in clinical practice will be more apt to incorporate its principles into their work.

Needle Exchange as a Safe Haven in an Unsafe World

Journal: Drug and Alcohol Review
Authors: MacNeil & Pauly, 2011

The purpose of this paper is to describe the meaning of needle exchange programs from the perspectives of users who access such programs. Design and Methods. We conducted observations, 33 semistructured interviews and two focus groups with users at four needle exchange sites. Qualitative description was used to analyze the data. Results. Participants described experiences of trauma, abuse, violence and physical injuries that had damaged their lives and led to the use of drugs to numb the pain. Respect for persons and the development of trust with outreach staff for clients who use injecting drugs supported clients to feel safe in what for many was an unsafe world. Participants described the important role that needle exchange services play in reducing and countering negative stigma, as well as in providing access to clean supplies and to other services. Discussion and Conclusions. The findings attest to the benefits of having trusted, safe needle exchange services that not only reduce risk behaviors that prevent infections, such as HIV and hepatitis C, but also open the door to other services.This finding is particularly important given that the majority of those interviewed were homeless and living in poverty.The need for both fixed sites and the integration of harm reduction services as part of a broader network of primary health-care services was reinforced.

Students as Effective Harm Reductionists and Needle Exchange Organizers

Journal: Substance Abuse Treatment, Prevention, and Policy
Authors: Barbour et al., 2017

Needle exchange programs are safe, highly effective programs for promoting health among people who inject drugs. However, they remain poorly funded, and often illegal, in many places worldwide due to fear and stigma surrounding drug use. Continued advocacy, education, and implementation of new needle exchanges are thus essential to improve public health and reduce structural inequality. Commentary: We argue that students, and especially professional and graduate students, have the potential to play an important role in advancing harm reduction. Students benefit from the respect given to the professions they are training to enter, which gives them leverage to navigate the political hurdles often faced by needle exchange organizers, especially in areas that presently lack services. In addition, due to their relative simplicity, needle exchanges do not require much of the licensing, clinical knowledge, and infrastructure associated with more traditional student programs, such as student-run free medical clinics. Students are capable of learning harm reduction cultural approaches and techniques if they remain humble, open-minded, and seek the help of the harm reduction community. Consequently, students can generate tremendous benefits to their community without performing beyond their appropriate clinical limitations. Students benefit from organizing needle exchanges by gaining applied experience in advocacy, organization building, and political finesse. Working in a needle exchange significantly helps erode stigma against multiple marginalized populations. Students in health-related professions additionally learn clinically-relevant knowledge that is often lacking from their formal training, such as an understanding of structural violence and inequality, root causes of substance use, client-centered approaches to health services, and interacting with clients as peers, rather than through the standard hierarchical medical interaction. Conclusion: We therefore encourage students to learn about and consider organizing needle exchanges during their training. Our experience is that students can be successful in developing sustainable programs which benefit their clients, the broader harm reduction movement, and themselves alike.

Harm Reduction Strategies for Injection Drug Use

Journal: Psychiatric Annals
Authors: Azores-Gococo et al., 2017

People who inject drugs (PWIDs) (of whom there are approximately 16 million worldwide) are at a high risk for severe health consequences, including HIV, hepatitis C virus, and death from overdose. Strategies to reduce the harms associated with injection drug use have been implemented on a global level and have demonstrated success in reducing HIV transmission, risky injection practices (eg, needle sharing), and illicit drug use. This article reviews the evidence base for three widely implemented and well-validated harm-reduction strategies for PWIDs: (1) needle- and syringe-exchange programs, (2) medication-assisted therapy for opioid use disorder, and (3) HIV testing and counseling. We also highlight barriers to service for PWIDs, particularly among marginalized populations. This article concludes with recommendations for addressing those barriers and for further research.

Decreased Odds of Injection Risk Behavior Associated with Direct Versus Indirect Use of Syringe Exchange: Evidence from Two California Cities 

Journal: Substance Use & Misuse
Authors: Behrends et al., 2017

While there is substantial evidence that syringe exchange programs (SEPs) are effective in preventing HIV among people who inject drugs (PWID), nearly all the evidence comes from PWID who obtain syringes from an SEP directly. Much less is known about the benefits of secondary exchange to PWID who get syringes indirectly from friends or acquaintances who visit an SEP for them. Objectives: We evaluated the effectiveness of direct versus indirect syringe exchange in reducing HIV-related high-risk injecting behavior among PWID in two separate studies conducted in Sacramento and San Jose, California, cities with quite different syringe exchange models. Methods: In both studies associations between direct and indirect syringe exchange and self-reported risk behavior were examined with multivariable logistic regression models. Study 1 assessed effects of a “satellite” home-delivery syringe exchange in Sacramento, while Study 2 evaluated a conventional fixed-site exchange in San Jose. Results: Multivariable analyses revealed 95% and 69% reductions, respectively, in high-risk injection associated with direct use of the SEPs in Sacramento and San Jose, and a 46% reduction associated with indirect use of the SEP in Sacramento. Conclusions/Importance: The very large effect of direct SEP use in Sacramento was likely due in part to home delivery of sterile syringes. While more modest effects were associated with indirect use, such use nevertheless is valuable in reducing the risk of HIV transmission of PWID who are unable or unwilling to visit a syringe exchange.

Influence of Peer-Based Needle Exchange Programs on Mental Health Status in People Who Inject Drugs: A Nationwide New Zealand Study   

Journal: Frontiers in Psychiatry
Authors: Hay et al., 2017

Alleviating the personal and social burden associated with substance use disorders requires the implementation of a comprehensive strategy, including outreach, education, community interventions, psychiatric treatment, and access to needle exchange programs (NEP), where peer support may be available. Given that substantial research underscores the potential benefits of peer support in psychiatric interventions, we aimed to conduct a national survey to examine key domains of mental health status in people who inject drugs (PWID) in New Zealand. PWID were recruited from 24 pharmacies and 16 dedicated peer-based needle exchanges (PBNEs) across the country. We focused on two mental health outcomes: (1) affective dysregulation, across the three emotional domains of the Depression Anxiety Stress Scale, due to its role in the maintenance of continued drug use, and (2) positive cognition and effective health- and drug-related information exchange with the provider, using the Satisfaction with Life Scale and an ad hoc questionnaire, respectively, in view of their association with improved mental health outcomes. We hypothesized that access to peer support would be associated with mental health benefits for PWIDs. Remarkably, the results of a multistep regression analysis revealed that irrespective of sex, age, ethnicity, main drug used, length of drug use, and frequency of visits to the NEP, the exclusive or preferential use of PBNEs predicted significantly lower depression and anxiety scores, greater satisfaction with life, and increased health-related information exchange with the service provider. These findings demonstrate for the first time an association between access to peer support at PBNEs and positive indices of mental health, lending strong support to the effective integration of such peer-delivered NEP services into the network of mental health services for PWID worldwide.

Relationships Between Needle and Syringe Programs and Police: An Exploratory Analysis of the Potential Role of In-Service Training

Journal: Drug and Alcohol Dependence
Authors: Strike & Watson, 2017

Training police on the public health benefits of needle and syringe programs (NSPs) is viewed as a best practice to facilitate more collaborative relationships between police and these programs. To date, while the limited published literature contains promising cases of harm reduction in-service training for police, evaluative evidence is preliminary. Using an online survey, we asked NSP managers across Canada about their programs and the quality of their NSP-police relationships. We analyzed data from the responses of 75 program managers among whom 69% reported that their program had a “positive” or “mostly positive” relationship with the police. In-service training about topics such as needle-stick injury prevention and NSP effectiveness was provided by less than 50% of the programs surveyed. Seventy-five percent reported no established protocols to resolve conflicts between NSP staff and police. Four variables, all related to in-service training, were significantly related to positive NSP-police relationships, including training about: NSP program goals (OR 7.7; 95% CI 2.0, 33.1); needle-stick injury prevention and basics of blood-borne virus transmission (OR 4.0; 95% CI 1.1, 15.34); the health and social concerns of people who use drugs (OR 3.9; 95% CI 1.1, 13.5); and evidence about the impact of injection equipment distribution (OR 3.9; 95% CI 1.1, 13.5). Development of in-service training for police that is focused on harm reduction goals and initiatives is a new and evolving area. We highly encourage NSPs to offer and evaluate any such in-service training programs.

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