Substance use disorder is a disease that affects the brain. As with all chronic conditions, it affects every person who faces the disease differently.

While some people with addiction successfully manage their condition, others don’t always have the resources, the support, or even the desire to seek treatment and enter recovery. That’s where harm reduction comes in.

The Journal of Clinical Psychology defines harm reduction as an “umbrella term for interventions aiming to reduce the problematic effects of behaviors…. Interventions provide additional tools for clinicians working with clients who, for whatever reason, may not be ready, willing, or able to pursue full abstinence as a goal.”1

As it applies to substance use disorder, harm reduction may include everything from the prevention of diseases like HIV and Hepatitis C, needle and syringe exchange, medication-assisted treatments, overdose prevention, wound care, and more.2

According to the US Surgeon General’s recent report,3 more than 27 million Americans use illicit drugs or misuse prescriptions drugs, and 66 million Americans reported binge drinking in the last month.4 However, only 1 in 10 people seek any kind of specialized treatment for a substance use disorder. 5

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In his report, former Surgeon General Vivek Murthy supports the use of harm reduction, saying:

These programs work with populations who may not be ready to stop substance use – offering individuals strategies to reduce risks while still using substances. Strategies include outreach and education programs, needle/syringe exchange programs, overdose prevention education, and access to naloxone to reverse potentially lethal opioid overdose. These strategies are designed to reduce substance misuse and its negative consequences for the users and those around them, such as transmission of HIV and other infectious diseases. They also seek to help individuals engage in treatments to reduce, manage, and stop their substance use when appropriate.6

In accordance with the Surgeon General and many other organizations, including the American Medical Association7, the United Nations8, and the Joint United Nations Program on HIV/AIDS9, Shatterproof believes harm reduction is a necessary element in a comprehensive strategy for the treatment of a substance use disorder.

In this section, you’ll find more information about specific harm reduction programs, including how they work, the scientific evidence that supports them, and the success stories that reveal their real-world impact.

How it works

Harm reduction isn’t a new idea. While the term can be dated back to 1987,10 the idea of minimizing the harm caused by substance use disorder can be traced to the 1920s, when the Rolleston Report addressed opiate dependence and how to medically maintain users who had become addicted.11 In 1990, the first Conference on the Reduction of Drug Related Harm was held, and the International Harm Reduction Association was founded in 1996.

Harm reduction focuses on reducing the negative effects of substance use, rather than trying to prevent or stop the usage itself. This may take place in many different ways, depending upon the organization or municipality that has created the harm reduction program, but most harm reduction techniques can be organized into two general categories: education and resources.

  • Education: Harm reduction education seeks to educate both substance users and those who treat them. Users may be given practical information about anatomy, the long-term effects of substance use, drug-related diseases, preventing and recognizing overdose, and other aspects of drug use.12 Professionals who work with those who have substance use disorders may be given training to overcome known or unknown biases against drug users,13 to recognize substance use disorder as a disease14 just like asthma or diabetes, and to be more prepared to address drug use-related healthcare issues.15
  • Resources: In the Surgeon General’s report, he noted the inability of many people who use substances to access or afford care, treatment, or screening.16 Some harm reduction programs seek to make resources that reduce the harm caused by drug use more accessible, even if the individual doesn’t wish to seek treatment for their disorder. Depending upon the program, harm reduction resources might include anything from needle and syringe exchange to testing for disease, prenatal care for people who use drugs, the availability of overdose treatment kits, and medication-assisted treatment.

Research has shown that when implemented correctly, these core principles of harm reduction are effective at preventing large-scale infection transmissions and reducing drug user death rates.17 Programs like needle exchanges and medication-assisted treatments also show promising signs of effectiveness in terms of reaching some drug users and encouraging them to take steps toward treatment.18

Harm reduction works to meet those with substance use disorder “where they are,” accepting that drug use is their current reality, rather than forcing treatment or abstinence.19 Practitioners work with these individuals to take steps that reduce the harm caused by drug use. Becoming substance-free is not the ultimate goal.20 Even small changes are viewed as a victory, as the person with a substance use disorder becomes healthier, safer, and, possibly, able to manage their condition.

Cost-effectiveness

The Surgeon General’s report on addiction estimates the cost of alcohol misuse to be $249 billion annually, while illicit drug use has a yearly economic impact of $193 billion. There have been numerous research studies that show that harm reduction programs are cost-effective when weighed against the costs of treating the harms of substance use disorder, like HIV infections.

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It’s estimated that the average cost of a needle syringe program is between $23 and $71 per person per year.21 A research study showed that cities with Syringe Access Programs showed a 5.8% decrease in HIV prevalence22, which is estimated to save between $3,32423 and $7,000 per case of HIV that prevented.24

Medication-assisted treatment has also been found to be cost-effective when preventing HIV. One study found 54% reduction in HIV risk for those on methadone maintenance.25 While the costs were more expensive, between $1,236 and $3,167 per patient,26 it’s still less than the previously mentioned costs of treating someone with HIV. Medication-assisted treatments also have wider economic and quality of life benefits, with one study finding that those in methadone maintenance use other health care services less frequently.27

Multiple studies agree that the most cost-effective harm reduction programs are those that implement a variety of approaches rather than focusing on just one strategy.28,29,30 Researchers also agree that scaling up harm reduction efforts will make these programs more cost-effective—and more effective overall.31

Human rights

For some people with substance use disorders, the consequence of the disease goes far beyond the physical effects of drug use. As drug possession is a crime in many countries, people using drugs may face stigma, discrimination, criminalization, and other negative repercussions.32 Many harm reduction organizations emphasize ensuring the human rights of those with substance use disorders.33

In the U.S., drug possession penalties vary, ranging from fines to prison time.34 Other consequences may include disqualification from student financial aid eligibility;35 denial of grants, loans or licenses;36 denial of Social Security Disability Income;37 a lifetime ban on Food Stamps;38 denial of federally subsidized housing;39 and more. In other countries around the world, punishment for drug use includes everything from forced labor and denial of meals40 to caning41 and police brutality.42

Harm reduction seeks to protect the human rights of those with substance use disorders through education that reduces the stigma of drug use,43 resources for people who are struggling,44 and policy changes45 regarding the criminalizing of drug use and the benefits and services available to for people with addiction. Harm reduction recognizes the person facing the disease, and takes steps to protect them.

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1. J Clin Psychol. 2010 Feb; 66(2): 201–214. doi: 10.1002/jclp.20669
2. Medsurg Nurs. 2013 Nov-Dec; 22(6): 349–358. Robin Bartlett , PhD, RN, Laura Brown , BSN, RN, Mona Shattell , PhD, RN, Thelma Wright , BS, and Lynne Lewallen , PhD, RN, ANEF
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10. The Reduction of Drug-Related Harm By E. C. Buning, E. Drucker, A. Matthews, R. Newcombe, P. A. O'Hare, 1987
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12. Medsurg Nurs. 2013 Nov-Dec; 22(6): 349–358.Harm Reduction: Compassionate Care Of Persons with Addictions Robin Bartlett , PhD, RN, Laura Brown , BSN, RN, Mona Shattell , PhD, RN, Thelma Wright , BS, and Lynne Lewallen , PhD, RN, ANEF
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16. http://harmreduction.org/blog/surgeon-general/ November 17, 2016 Surgeon General’s Report on Alcohol, Drugs, and Health Vivek H. Murthy, MD, MBA JAMA. Published online November 17, 2016. doi:10.1001/jama.2016.18215
17. Neil Hunt, Mike Trace, Dave Bewley-Taylor. (2005) Reducing drug related harms to health: an overview of the global evidence. [Online]. Available from: http://www.thehealthwell.info/node/66156
18. Neil Hunt, Mike Trace, Dave Bewley-Taylor. (2005) Reducing drug related harms to health: an overview of the global evidence. [Online]. Available from: http://www.thehealthwell.info/node/66156
19. Harm Reduction Coalition: http://harmreduction.org/about-us/principles-of-harm-reduction/
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24. Wammes et al., 2012 Wammes, J.J. et al. Cost-effectiveness of methadone maintenance therapy as HIV prevention in an Indonesian high-prevalence setting: A mathematical modeling study. International Journal of Drug Policy . 2012; 23: 358–364
25. MacArthur et al., 2012 MacArthur, G.J. et al. Opiate substitution treatment and HIV transmission in people who inject drugs: Systematic review and meta-analysis. British Medical Journal . 2012; 345: pe5945
26 Schwartlander et al., 2011 Schwartlander, B. et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet . 2011; 377: 2031–2041
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29. Strathdee et al., 2012 Strathdee, S.A. et al. Towards combination HIV prevention for injection drug users: Addressing addictophobia, apathy and inattention. Current Opinion in HIV and AIDS . 2012; 7: 320–325
30. Degenhardt et al., 2010 Degenhardt, L. et al. Prevention of HIV infection for people who inject drugs: Why individual, structural, and combination approaches are needed. Lancet . 2010; 376: 285–301
31. The cost-effectiveness of harm reduction Wilson, David P. et al. International Journal of Drug Policy , Volume 26 , S5 - S11
32. “Drug User Peace Initiative: Violations of the Human Rights of People Who Use Drugs” International Network of People Who Use Drugs 2014: https://www.unodc.org/documents/ungass2016/Contributions/Civil/INPUD/DUPI-Violations_of_the_Human_Rights_of_People_Who_Use_Drugs-Web.pdf
33. Harm Reduction International: https://www.hri.global/advocacy-human-rights
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35. US News and World Report: http://www.usnews.com/education/blogs/student-loan-ranger/2015/04/15/drug-convictions-can-send-financial-aid-up-in-smoke
36. Denial of Federal Benefits Program: https://www.bja.gov/ProgramDetails.aspx?Program_ID=57
37. Public Law 104-121: https://www.congress.gov/bill/104th-congress/house-bill/3136
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43. Harm Reduction Coalition http://harmreduction.org/about-us/principles-of-harm-reduction/
44. Harm Reduction Coalition http://harmreduction.org/about-us/principles-of-harm-reduction/
45. Harm Reduction Coalition: http://harmreduction.org/our-work/policy-advocacy/