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Harm Reduction: A New Paradigm

David F. Duncan, Dr.P.H., C.A.S.1, Center for Alcohol and addiction Studies and Department of Community Health,
Brown University

Thomas Nicholson, Ph.D., M.P.H., Department of Public Health, Western Kentucky University

Patrick Clifford, Ph.D., Center for Alcohol and Addiction Studies and Department of Psychiatry, Brown University

Wesley Hawkins, Ph.D., Department of Mental Hygiene, Johns Hopkins University

Rick Petosa, Ph.D.Department of Health Education, Ohio State University

1 Address correspondence to Dr. Duncan at Center for Alcohol and Addiction Sudies, Brown University, Box G-BH, Providence, RI 02912 Published in: Journal of Drug Education, 1994, 24(4), 281-290.

ABSTRACT
Harm reduction is a new paradigm now emerging in the field of drug education. This strategy recognizes that people always have and always will use drugs and, therefore, attempts to minimize the potential hazards associated with drug use rather than the use itself. The rationale for a harm reduction strategy is presented, followed by an example of the kind of needs assessment which may be needed for planning a harm reduction strategy.

HARM REDUCTION

A major paradigm shift is underway in the field of drug education. It is the shift from a strategy of use-prevention to a strategy of abuse-prevention or harm-reduction. This new paradigm expands and transforms traditional concepts of the purposes and methods of drug education. It can serve as a model for a more rational and comprehensive organization of prevention resources likely to yield the greatest benefit to society.

Harm reduction is a policy of preventing the potential harms related to drug use rather than trying to prevent the drug use itself. Harm reduction accepts as a fact that drug use has persisted despite all efforts to prevent it and will continue to do so. Further, it recognizes that measures intended to prevent drug use have often had the unintended effect of increasing the harms associated with drug use. This strategy has also been called damage limitation, casualty reduction, or harm minimization.

EVOLUTION OF THE HARM REDUCTION STRATEGY

One of the earliest instances of this approach was an educational program carried out in 1972 by the senior author and his colleagues at an urban, Southwestern drug abuse treatment center confronting an epidemic of paint and solvent "huffing." Young adolescents were emptying cans of spray paint into plastic bags then inhaling the resulting fumes in order to get high.

Two deaths had occurred locally when boy's suffocated in the plastic bags after passing out; another boy had inhaled enough of the paint itself to coat the interior of part of his lungs resulting in severe edema, shock and brain damage; and another boy passed out near a space heater which ignited his "huffing bag" causing a fire in which he was fatally burned.

Against the background of these incidents, it was decided to place a priority on preventing deaths. Educational presentations to youth groups continued to deal with the hazards of "huffing" or "sniffing" solvents, but each presentation ended with a description of ways to reduce the risks associated with huffing -- such as using paper bags instead of plastic bags or using a toilet paper roll with a tissue paper filter as a "carburetor" for huffing.

In no way was huffing encouraged or endorsed, but the message was, "if you must huff, at least do it in a way that won't kill you." No further deaths occurred after this program went into effect and crisis calls related to huffing declined sharply, although there is no way to definitely attribute that outcome to the program.

Paradigm shifts are often so large in scope and incremental in implementation that they "arrive" without much notice. In the past decade considerable attention has been directed toward the human and social costs of accidents caused by intoxicated drivers. Many of the resulting policies and programs reflect the realistic assessment that people need transportation at times when they are intoxicated. Designated drivers, free cab rides, free coffee stops on freeways, and changing social norms regarding responsible drinking and responsible drink-serving are all examples of harm reduction.

The responsible use approach to alcohol education which emerged in the early 1970's was an early application of the harm reduction strategy to a licit drug 1. Room's 2 problem minimization approach to alcohol shows that this approach to alcohol is still alive. This approach has not been without its critics, especially within the federal bureaucracy. Editorial guidelines issued by the Office for Substance Abuse Prevention reject use of the term "responsible use" 3.

The earliest formal statement of this strategy also dealt with the problem of solvent sniffing. It was the "casualty-reduction" approach to glue sniffing adopted by the Institute for the Study of Drug Dependence in 1980 4. Another early statement of this approach was the proposal by Duncan and Gold 5 for "cultivating drug use" -- using the word cultivation in the sense of promoting healthy and productive development, while "weeding out" tendencies toward abuse.

In 1984, this strategy was given its most popular name in a report of the Home Office 6 of the British government which described two alternate goals for drug abuse prevention programs -- either reducing drug use or "harm reduction." Both were recognized as acceptable goals for prevention programs.

The recent International Conferences on the Reduction of Drug-Related Harm, held in Liverpool, England in 1990, Barcelona, Spain in 1991, Melbourne, Australia in 1992, and Rotterdam, the Netherlands in 1993 illustrated the rapid growth of this strategy in Western Europe and Australia. The 1994 conference in Toronto, Canada will bring greater awareness of this strategy to North Americans.

Whatever it is called, the essence of this strategy is the recognition that preventing drug abuse is a different task from preventing drug use and may be both a more justifiable and a more achievable goal. Mugford 7 says that the harm reduction approach takes the line that people will continue to use drugs and asks how they can do so most safely. Such a strategy is consistent with human experience. Historically, most cultures have included drug consumption and all attempts at prohibition have failed.

Marion Watson, Director of the Drug Research and Information Centre in Canberra, Australia, defines harm reduction as,
the philosophical and practical development of strategies so that the outcomes of drug use are as safe as is situationally possible. It involves the provision of factual information, resources, education, skills and the development of attitude change, in order, that the consequences of drug use for the users, the community and the culture have minimal hegative impact 8, p. 14.

A harm-reduction strategy may involve a wide variety of different tactics. Harm reduction may involve changing the legal sanctions associated with drug use. It may increase the availability of treatment services to drug abusers. It may attempt to change drug users' behavior through education. It may also strive to change public perceptions of drugs and drug users.

RATIONALE FOR A HARM REDUCTION STRATEGY

Traditional use-prevention programs have seldom taken on the impossible task of discouraging the use of all drugs. Instead they have dichotomized drugs into licit versus illicit, or those with abuse potential (i.e. "hard drugs") versus those without ("soft drugs") -- or simply the good versus the bad. Goodstadt 9 warned that such dichotomies "result in ambiguities and problems," since drugs in both categories can be abused and since all drugs are illegal under some circumstances. In arguing the harm reduction position, Jonas 10 asserts that current policy is binary as to drugs - licit and illicit - and unitary as to solutions - abstinence. A harm reduction policy, on the other hand, would be unitary as to drugs and multimodal as to solutions.

David Moore and Bill Saunders, of Australia's National Centre for Research into the Prevention of Drug Abuse, argue that, "... given the universality of drug use in human societies and the very real benefits that accrue from drug use, the usual prevention goal of abstinence from drug use for young people is unthinking, unobtainable and unacceptable" 11, p. 29. When you include alcohol, tobacco, prescription and over-the-counter psychoactive drugs in addition to the illicit drugs, almost no one in our society, or any other, is truly drug-free. A drug-free community would be as improbable as a sex-free community, and as unhealthy.

Many forms of recreational drug use are legally defined as licit for adults but illicit for adolescents. Petosa 12 has described how this situation results in a large number of adolescents perceiving the use of those drugs as helping them progress toward adult social roles. As a consequence, these young people are particularly resistant to drug abstinence messages. In these circumstances, harm reduction approaches will be more relevant and more likely to result in behavioral changes to reduce risk.

Just as it is a truth that any drug can be abused, it is a truth that any drug can be used without abuse. No drug is inherently abusive. Tobacco would appear to be the only drug for which it cannot be said that users outnumber abusers. Shedler & Block compared the psychological health of adolescents who were abstainers, experimenters or frequent users of illicit drugs.

They found that, "experimenters are the psychologically healthiest subjects, healthier than either abstainers or frequent users" 13, p. 625. Clifford, et al. 14 found a curvlinear relationship between illicit drug use and a broad measure of life satisfaction, with the highest levels of life satisfaction among moderate drug users and lower levels of life satisfaction among both non-users and heavy users. Hogan, Mankin, Conway & Fox 15 in another related instance, found that mariuana users had better social skills, a broader range of interests, and more concern for the feelings of others than did non-users. Bentler 16, likewise, found a "small but reliable association between marihuana use and the development of a positive self- concept."

Commenting on the failure of the traditional approach to differentiate between use and abuse, Moore and Saunders argue that:
"Because there are so few data on the extent of drug and alcohol-related problems among youth, stating that there is a youth drug problem is also somewhat perilous. Further, because most prevalence surveys do not measure harm but use, evaluating prevention programmes as failures or successes using the criterion of an increase or decrease in the overall number of people using a particular drug may be fallacious. Logically, it is possible for user rates to increase while, via appropriate interventions, harm rates fall." 11, p. 33

The risk of HIV infection associated with intravenous drug use has motivated many public health and drug abuse authorities to rethink their priorities in dealing with IV drug use, moving them toward harm reduction. Mugford 7 reports that Australian efforts to prevent the transmission of HIV among IV drug users have been based on: 1) the distribution of sterile hypodermic needles and syringes; 2) education of drug users on proper syringe hygiene; and 3) establishment of safe disposal points for used syringes in public restrooms. As a result of this harm-reduction strategy, the seroprevalence of HIV among IV drug users in Australia has been held down to only 2%. This compares with the 50-70% HIV seroprevalence among IV drug users in certain large U.S. cities such as New York where harm reduction approaches have been little used.

DATA REQUIREMENTS OF THE HARM REDUCTION STRATEGY

Jonas 10 asserts that a harm reduction strategy must be based on epidemiologic data about the actual incidence of real negative consequences of taking various drugs. Only once this is known, can we focus our efforts on reducing the actual negative consequences and on truthfully educating the public about those consequences which are irreducable. Unfortunately, there is very little such epidemiologic data available at present.

Martin, Duncan and Zunich 17 examined the reasons for discontinuing illicit drug use among 223 American college students who were former drug users. They found that concerns for physical health were the principal reasons for discontinuing cocaine use (55%), amphetamine use (30%), heroin use (29%), and marijuana use (24.%). The primary reason for discontinuing use of LSD (35%) was problems of a mental/emotional nature. In a later study of reasons for discontinuing hashish use among 237 Central European athletes Duncan 18 found that the most common reasons for discontinuing use were dislike for the effects (14.75%), requirements of an athletic training regimen (13.11%), health reasons (11.48%), and mental/emotional problems (11.48%).

Problems associated with the use of alcohol, aspirin and marijuana were studied by Duncan and Martin 19 in a 1% random sample (n = 132) of students at Southern Illinois University. The mean number of problems per alcohol user was 1.3; 0.26 per aspirin user; and 1.16 per marijuana user. The most common problem associated with alcohol was driving while intoxicated, which was reported by 59.6% of the drinkers. The problem most commonly associated with aspirin was daily use for pain (5.8%). The most common marijuana-associated problem was getting "stoned" "frequently" (24.6%). Either of these "problems" would probably provide little guidance in developing harm reduction measures.

Holcomb, Sarvela, Ritzel, Sliepcevich and Jellen 20 surveyed 3,348 secondary school students in two rural Illinois counties. Various negative consequences of "drinking or drug use" were reported by four to fourteen percent of the subjects. The greatest increase in incidence of negative consequences was seen between the eighth and ninth grades. The most frequently reported negative consequences were impaired self esteem (14.0%), family troubles (13.1%), getting into fights (12.9%) and hurt friendships (11.5%).

An example of data collection for harm-reduction planning can be provided by our survey of 1,335 secondary school students (664 females and 671 males) attending grades seven thru twelve in two rural Illinois unit school districts. This represented an 88.9% sample (89.8% of females; 88.0% of males) of all secondary school students, other than those in special education classes, in the two districts.

The survey instrument was a modification of that previously used by Duncan and Martin 19. Modifications were based largely on the experience of Holcomb, Sarvela, Ritzel, Sliepcevich, and Jellen 20 in surveying a similar population. It consisted of a demographic data sheet and twenty-one questions -- seven related to each of three commonly used drugs: alcohol, aspirin and marijuana. The first question in each set of seven was a screening question asking whether the respondent had used that drug during the past year; the remaining six items each dealt with a possible negative consequence of using that drug.

Two-thirds (67.3%) of the students -- 64.6% of the females and 69.8% of the males -- reported using alcohol during the preceding year. Usage levels ranged from a low of 33.5% in seventh grade to a high of 87.1% in eleventh grade, with the greatest increase from eighth (51.2%) to ninth (74.7%) grade.

Drinking students reported a mean of 1.07 problems each. Driving while intoxicated was the most frequently reported (21.5%) alcohol-related problem among the students in this study. Family troubles over alcohol and getting into fights while intoxicated were both reported by 15.2% of the students. Problems with school authorities related to alcohol were reported by 8.9%, while school absences due to alcohol were reported by 6.9%. Finally, 6.2% reported having had an accident while under the influence in which property was damaged or someone was injured.

Aspirin use during the past year was reported by 90% of the students -- 92.3% of the girls and 87.7% of the boys. The percent of persons using aspirin varied only slightly from grade to grade, but with a generally upward trend from a minimum of 84.1% in seventh grade to a maximum of 96.4% in twelfth grade. Aspirin use was essentially problem-free with a problem rate of 0.016 problems per aspirin user.

Almost one-third (29.9%) of the students -- 28% of the girls and 31.9% of the boys -- reported use of marijuana during the past year. Usage increased with grade level from a low of 10.7% in the seventh grade to a high of 52.9% in the twelfth grade. Marijuana users reported an average of 0.98 problems each, the most common of which was family trouble over marijuana use -- reported by 14.2%.

Trouble with the police over marijuana was reported by 6.1% of the students. Trouble with school authorities over marijuana and driving under the influence of marijuana were both reported by 3.9% of the students. Having had an accident while under the influence of marijuana in which property was damaged or someone was injured was reported by 1.1% of the students. Only one student (0.07%) reported experiencing shortness of breath after smoking marijuana.

Not surprisingly, the incidence of problems related to each of the three drugs found in this survey was lower than that found in the study of college students by Duncan and Martin 19. It isn't surprising that the greatest difference was in aspirin-associated problems since for most of our subjects aspirin is probably a parentally administered drug and is likely to be administered with due caution and regard for package instructions. The same cannot generally be said for their use of alcohol or marijuana.

It should come as no surprise to any drug educator that the greatest number of problems were associated with alcohol. Clearly, of these three drugs, alcohol is the one drug on which educators should focus their greatest efforts.

Alcohol use and all six alcohol-related problems showed their sharpest increase between eighth and ninth grades. The same pattern is observed for marijuana use and marijuana-related problems. This confirms previous findings, such as those of Sarvela, Newcomb, and Duncan, 21, that the greatest increase in problems with alcohol and marijuana typically occurs between the eighth and ninth grades.

These results suggest that eighth grade may be a critical period for proactive services, such as drug education, and ninth grade a critical period for reactive services, such as peer counseling services. This does not mean that drug education is not needed earlier than eighth grade. Certainly this could not be concluded from data which show 7.9% of seventh graders getting in fights while drunk or 5.6% having family troubles over their marijuana use.

Driving while intoxicated was the single drug-related problem which was most frequently reported in this study. It would seem to be a reasonable choice as the first priority of any harm reduction program developed for this population. Focusing on this problem behavior rather than on abstinence from alcohol would seem to be realistic, as has been pointed out previously by Beck, Summons and Hanson-Matthews 22.

Family troubles related to alcohol and marijuana use present another target for harm reduction. Family counseling and parent education would seem to be appropriate interventions for these problems. Fighting under the influence of alcohol would be another target. Training in refusal skills may be more effective in teaching kids how to keep out of fights, which most of them do want to keep out of, than it has been for drugs, which the kids at greatest risk didn't want to keep out of.

CONCLUSION
Over the past few decades various approaches have been tried as drug education. Early methods emphasized information provision and scare tactics. In the 1980's America embraced "Just Say No" campaigns.

The success of any of these approaches has been questionable at best. We feel that a major limiting factor of these approaches has been a faulty assumption -- namely, that all drug use is unhealthy and therefore that the goal of drug education should be the elimination of all drug consumption.

A harm reduction approach could offer a greater chance of mitigating the negative consequences of drug abuse in the future, because it considers the realistic dynamics of human drug consumption in our past.

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