Harm Reduction Guide
What Is Harm Reduction?
Harm reduction is a set of policies and practices intended to reduce the negative effects of drug and alcohol use.
Harm reduction programs exist for several types of drugs, including opioids, alcohol, stimulants, Ecstasy, and marijuana. They range from needle exchange sites to managed alcohol programs to drug-testing kits at music festivals.
Studies have found many of these methods to be effective.
But critics see the programs as encouraging drug use and keeping people addicted to drugs.
Below is information on common programs, tips for safe use, and links to more resources.
Harm reduction is a broad term that applies to policies, programs, and practices that aim to minimize the health, social, and economic consequences of substance abuse.1 The idea behind harm reduction is not to necessarily eliminate substance abuse but to diminish its harmful effects.
Harm reduction acknowledges that many people will continue to abuse drugs and engage in other dangerous behaviors despite prevention efforts. It also accepts that many people are unwilling or unable to seek treatment. But while some people who use substances may not necessarily require treatment, it is helpful for them to be aware of resources that can help minimize harm from their drug use.1
Heroin and Other OpioidsHarm reduction for heroin and other opioids is designed to reduce the risk of overdose and decrease the transmission of bloodborne viruses associated with needle drug use. It also includes referring heroin and opioid users for addiction treatment and medical care.2
- Injection sites, which are facilities focused on preventing overdose and the contraction of infectious diseases through medical supervision of people who use heroin and other injectable drugs. Other services include education on safer injection, medical care and counseling, and referrals to treatment. Staff do not provide drugs, and employees do not inject users.3 Sites are located in Europe, Australia, and Canada. Time magazine reports that Philadelphia may be the first U.S. city to have an injection site, while Seattle, San Francisco, Ithaca, and Denver are also considering them.4
- Needle exchange programs (NEP), also referred to as syringe services programs (SSP) or needle-syringe programs (NSP), which are community-based programs that offer free sterile needles and syringes. They also help dispose of used needles and syringes. By using a clean and sterile needle and syringe, IV users can significantly reduce the risk of HIV, hepatitis, and other bloodborne infections.5
- Opioid treatment programs (OTP). These are programs that dispense prescription medications and provide comprehensive treatment, including counseling and other rehabilitative methods, to help people overcome opioid addiction. This type of treatment is often referred to as MAT, or medication-assisted treatment. MAT can reduce the risk of contracting HIV and hepatitis C, lower opioid use, increase survival rates, improve treatment retention rates, improve odds of finding and maintaining employment, and reduce criminal activity.6
The medications used in MAT are:7
- This is one of the most widely used medications for treating opioid addiction. It is available in several different forms, but many patients take it orally as a liquid. It is a long-acting drug that alleviates cravings and withdrawal symptoms. Methadone is only available at certified OTPs. It is an effective tool in managing heroin and other types of opioid dependence, but can cause some unpleasant side effects (e.g., nausea, constipation, sedation)
- This is a medication taken daily as an orally disintegrating tablet or film or an implant that slowly releases the medication over 6 months. Physicians who have completed a training and certification process can dispense buprenorphine, so you can receive it at a doctor’s office or at an OTP. As a partial opioid agonist, the risk of overdose is lower than with methadone, and withdrawal symptoms may be somewhat less severe. Buprenorphine is sometimes combined with naloxone (trade name: Suboxone), a drug that helps discourage misuse of this treatment medication should it dissolved and injected
- This medication blocks the effects of opioids to minimize the high if you use. By reducing the rewarding effects of opioids, it may be easier for you to stop using. Naltrexone does not help with withdrawal symptoms, and you cannot begin taking it until 7-10 days after your last opioid use because it can cause the onset of or worsen withdrawal. It is also available in an extended-release injectable formulation that lasts for 30 days
- This FDA-approved opioid antagonist medication is used to quickly reverse an overdose. Naloxone blocks opioid receptor sites and helps to restore breathing. It is available as an injectable (which requires professional training), a nasal spray, and an auto-injectable. Naloxone is a prescription drug in many states, but it can be obtained in a pharmacy without a prescription in some parts of the country. People (and their families) who use heroin or other opioids might want to consider keeping naloxone in their homes in case of overdose.8
AlcoholHarm reduction for alcohol aims to minimize harm due to alcohol use and abuse which, in addition to potentially developing an alcohol use disorder, includes increased risk for cancer, heart disease, liver cirrhosis, stomach problems, mental health issues, and injuries and accidents.9
- HAMS, a free peer support group that stands for Harm reduction, Abstinence, and Moderation Support. The aim of this group is to meet people “where they are at,” minimize the harmful effects of alcohol, and help people change their drinking habits. People choose their own goals, whether that means quitting alcohol or reducing consumption. HAMS uses 17 elements to help people develop and choose goals—they can complete the elements in any order and stop whenever they want.10
- Managed alcohol programs (MAPs), which are designed to minimize harm due to chronic alcohol abuse among the homeless. MAPs provide small and regular doses of alcohol, and housing, in a treatment facility setting. The amount of alcohol provided is not enough to get drunk but helps prevent withdrawal.11 MAPs can increase stability by reducing interactions with emergency services and police as well as hospital admissions, detox episodes, and police contacts leading to custody. 12
- Naltrexone, a medication that may help people control their drinking because it reduces some of the pleasurable effects associated with alcohol use and may reduce alcohol cravings. Studies among the chronically homeless have shown that extended-release naltrexone and harm reduction counseling promote reductions in alcohol use and alcohol-related harm and support patient-driven goal setting.13
- Designated driver programs, which are services provided by for-profit companies (which means you need to pay) and non-profit organizations (which often offer free services) to help both you and your car get home safely if you are intoxicated. There are two approaches to this type of program. One is known as “Team Lift,” where two people come to you and your vehicle—one drives you home in your car while the other follows in their car. The “Scooter” approach involves a person coming to you with a special folding scooter; the person drives you home and leaves on the scooter.14
Tips for safer drinking include:10
- Giving car keys to someone before you start drinking
- Eating before drinking and stay hydrated when drinking
- Taking vitamins to replace those lost through drinking
- Going out with a friend who can monitor your behavior and consumption
- Bringing condoms when you go out drinking.Scheduling at least one abstinence day a week
- Reducing the number of days you drink per week or month
As with harm reduction for other substances, stimulant harm reduction efforts are aimed at meeting users where they are, proving education on drug use, and preventing harm associated with stimulant use, including dental problems, STDs, psychosis, and poor hygiene.15
- Safer injecting supplies (such as distributing sterile injecting equipment) and accurate information about how to safely use
- Referrals to treatment and how to access other necessary services, such as cognitive behavioral therapy and motivational interviewing
- Education about and tools for proper hygiene, such as toothbrushes and toothpaste
- Water, juice, and healthy food, particularly to those who are homeless or impoverished
- Distribution of condoms and lubricant
- Discussion about body image and the fear of gaining weight if you stop using, as some people, especially women, use stimulants as a form of weight control
- Calming a person who is experiencing delusions, paranoia, anxiety, or hallucinations by giving them an appropriate dose of benzodiazepines or anti-psychotic medication, if needed
Some tips for reducing harm based on the mode of use include:16
- Knowing the source of your pills (if swallowing tablet-form stimulants). If you mix them with a drink, make your own cocktail
- Chopping the pills finely (if snorting tablet-form stimulants) and avoiding sharing straws when using any stimulant intranasally
- Using your own pipe and deciding how much to use beforehand (smoking)
- Having a top-use condom, using clean water to dissolve the meth, and avoiding shared “booty bump” syringes
- Using your own glass stem (hot railing)
- Using sterile water for mixing, ensuring that you use clean cotton balls, rotating and cleaning injection sites, and using a clean needle for each use (slamming/injecting)
The aim of Ecstasy (MDMA) harm reduction is to prevent harms associated with Ecstasy use, which can include anxiety, trouble concentrating, fatigue, insomnia, depressed mood, hypersomnia, difficulty concentrating, decreased appetite, and dizziness.17
RollSafe is an organization that publishes online information about MDMA and how to safely use it. Their website includes research on side effects, ingredients, test kits, doses, tips for safe use, and more.
DanceSafe is a similar organization that provides education about Ecstasy and other drugs in the electronic music scene, as well as on-site pill purity testing at events. Other on-site services include ear plugs, free water, and safe sex tools.
Tips to reduce the harm caused by Ecstasy use include:18
- Avoiding taking Ecstasy with other substances
- Staying hydrated, but being careful not to drink too much because you can develop hyponatremia, a condition caused from overconsumption of water that can be fatal.17
- Having a friend to talk to if you feel anxious, depressed, or other negative emotions
- Reducing the amount of Ecstasy you consume in one session
- Using a test kit or consulting an online drug checking database to determine the purity of your Ecstasy
Harm reduction for marijuana is designed to promote safety, health and well-being, and informed decision-making regarding use.19
- Risk of developing cannabis use disorder
- Risk of cognitive or memory problems, especially if started at an early age
- Respiratory problems, such as coughing, wheezing, shortness of breath, and chronic bronchitis
- Mental health issues, such as depression or anxiety
- Driving accidents, since marijuana impairs your psychomotor and cognitive performance
- Risks during pregnancy, such as low birth weight and negative effects on the baby’s cognitive functioning, behavior, and mental health
- Risk of transmitting infections due to sharing pipes, joints, or bongs
In anticipation of Canada’s legalization of marijuana, the Canadian Nurses Association published a harm reduction guide for marijuana use.
Some of the methods they recommend for lowering the risks of marijuana use include:19
- Avoiding use until early adulthood
- Reducing your frequency of use
- Trying to stop if you begin to have trouble controlling your use
- Minimizing respiratory problems by not smoking marijuana with tobacco, avoiding deep inhalations, and using a vaporizer instead of smoking
- Not combining marijuana with alcohol or other drugs
- Avoiding driving while you’re high
- Not using large or highly concentrated amounts
- Minimizing lip contact with other users to avoid infections
- Abstaining from use if you are pregnant or have a family history of psychosis
How Effective Is Harm Reduction?
A number of studies on harm reduction for specific substances have demonstrated its effectiveness.
- Safe injection sites. Studies on safe injection sites show they help reduce drug overdose deaths, prevent public drug use, and improve community health through preventing the transmission of bloodborne disease. For example, one 2011 study in The Lancet showed Vancouver’s overdose deaths decreased by 35% two years after their safe injection site opened.4
- A clinical review in Psychiatric Services in Advance on the effectiveness of methadone in MAT showed methadone use is associated with improved treatment retention and reduced opioid use in individuals with opioid addiction; reductions in drug-related HIV risk behaviors, mortality, and criminality; and improvements in fetal outcomes in pregnant women with opioid addiction.20
- A National Institute on Drug Abuse study that examined the effectiveness of buprenorphine and naloxone in people who were addicted to opioids found that half were abstinent 18 months after they started MAT. After 3.5 years, the number of people who were abstinent rose to 61% and less than 10% met the criteria for opioid use disorder (addiction).21
- Managed alcohol programs. Several small studies have demonstrated the effectiveness of MAPS. For example, one study published in the Canadian Medical Association Journal showed that residents of a MAP had a decrease in interactions with the police and emergency services. Another study in the Harm Reduction Journal showed that people in MAPs had fewer admissions to hospitals, detox treatments, and arrests.11
- Naltrexone for alcohol reduction. A study in the journal Substance Abuse found that extended-release naltrexone combined with harm reduction counseling was effective at reducing alcohol use and alcohol-related harm in homeless alcoholics.13
Critics argue that medication-assisted treatment drugs such as buprenorphine can themselves be addictive and are essentially keeping the person dependent on opioids (substituting one drug for another). They also point out that the drugs can be diverted and sold on the black market.22
Further, some have suggested that needle exchange programs lead to more dirty needles on the street and overdoses if the programs are not properly controlled.23 Another common criticism is that they encourage drug use and make it easier for addicts to remain addicted and continue to commit crimes.24
Similar claims have been made about supervised injection sites. And a recent study found that the available research on the sites was not well-conducted. The quality studies did not find any noticeable effect on overdose deaths or needle-sharing.25
Still, researchers who studied an injection site in Vancouver, Canada found that it led to significant increases in the number of people who sought methadone and other addiction treatments. Other reviews have found that injection sites improve health in users and do not increase drug trafficking or crime. The question is whether sites that open in other cities, like in the U.S., will see these same results.4,25
- You may be able to find a harm reduction program by talking to your health care provider, an addiction counselor, or searching the online listings (available by state) from the Harm Reduction Coalition
- To find a needle exchange program, you can browse online listings from the North American Syringe Exchange Network
- To find a designated driver program, you can search for a program by state on the website of the National Directory of Designated Driver Services
- To find an authorized buprenorphine doctor, you can search the Substance Abuse and Mental Health Administration’s database, available by state
- To find a methadone or opioid treatment program, enter your location on the Behavioral Health Treatment Services Locator to enter your location and then use the drop-down menu on the right-hand side of the map. Make sure that you check “substance abuse.”
- Harm Reduction International. What is harm reduction?
- Government of Western Australia Drug and Alcohol Office. (2014). Is someone you care about seeking treatment for heroin or other opiate use?
- City of Toronto. Supervised Injection Sites
- Ducharme, J. (2018). The Country’s First Safe Injection Facility May Soon Open in Philadelphia. Here’s What You Need to Know. Time
- Centers for Disease Control and Prevention. (2018). Syringe Services Programs
- Substance Abuse and Mental Health Services Administration. (2015). Medication and Counseling Treatment
- Substance Abuse and Mental Health Services Administration. (2016). Decisions in Recovery: Medications for Opioid Use Disorder. [Electronic Decision Support Tool] (HHS Pub No. SMA-16-4993).
- National Institute on Drug Abuse. (2018). Opioid Overdose Reversal with Naloxone (Narcan, Evzio)
- Witkiewitz, K. and Marlatt, G. (2006). Overview of harm reduction treatments for alcohol problems. The International Journal of Drug Policy, 17(4), 285-294.
- The HAMS Harm Reduction Network, Inc. (2015). HAMS: Harm Reduction for Alcohol and Alcohol Harm Reduction Cheat Sheet
- Chapin. S. (2018). Could Managed Consumption Be a Better Form of Treatment for Alcoholism? Pacific Standard.
- Substance Abuse and Mental Health Services Administration. (2016). Alcohol Management as Harm Reduction
- Collins, S., Duncan, M., Smart, B., Saxon, A., Malone, D., and Ries, R. (2014). Extended-release Naltrexone and Harm Reduction Counseling For Chronically Homeless People with Alcohol Dependence. Substance Abuse, 36(1), 21-33.
- DrinkingandDriving.org. (2018). NDDDS: National Directory of Designated Driver Services
- Harm Reduction International. (2015). A Global Review of the Harm Reduction Response to Amphetamines: A 2015 Update
- Hojilla, J. (2017). An Overview of Methamphetamine Use: NASTAD/UCHAPS Webinar on Methamphetamine Use and Harm Reduction. NASTAD
- RollSafe.org. Side Effects of MDMA (Molly/Ecstasy)
- Davis, A. & Rosenberg, H. (2017). Specific harm reduction strategies employed by 3,4-methylenedioxymethamphetmine/ ecstasy users in the United States and the United Kingdom. Drug Science, Policy and Law, 3 (online).
- Canadian Nurses Association. (2017). Harm Reduction for Non-Medical Cannabis Use.
- Fullerton, C., Kim, M., Thomas, C., Lyman, R., Montejano, L., and Delphin-Rittman, M. (2014). Medication-Assisted Treatment With Methadone: Assessing the Evidence. Psychiatric Services in Advance, 65(2), 146-157.
- National Institute on Drug Abuse. (2015). Long-Term Follow-Up of Medication-Assisted Treatment for Addiction to Pain Relievers Yields “Cause for Optimism”
- Macy, B. (2016). Addicted to a Treatment for Addiction. The New York Times
- Russell, J. (2018). Public health officials applaud needle-exchange programs, but critics remain. Indianapolis Business Journal
- Ingraham, C. (2015). Politicians need to get over their squeamishness about needle exchange programs. The Washington Post
- Gordon, E. (2018). What’s the Evidence That Supervised Drug Injection Sites Save Lives? NPR