Harm reduction in the addiction continuum of care
Addiction, especially opioid addiction, doesn’t have a one-size-fits-all approach. Most chronic diseases don’t. For me, harm reduction is the foundation of all substance-use care. It is the lens through which we provide programs, policies and services, such as needle distribution, safe consumption sites, overdose prevention and education.
Nurses know these approaches provide low-barrier access points into the health-care system. They are the parachutes that can be used every day, in a crisis or when a relapse occurs. They are morally and ethically necessary.
But what happens after the person lands on the ground? Or, as is often the case with opioid addiction, what if there is no safe place to land?
Historically, Canada’s approach to addiction treatment has been to compartmentalize — separating harm reduction, abstinence-focused programs and services, medical treatment (i.e., opioid agonist therapy such as methadone) and recovery-oriented programs. But silos are, well…silos. They don’t overlap, they don’t support each other and they can hinder progress. They pit each approach against the others.
I like to think that all health-care providers have the same objective when caring for people who are struggling with substance use: to assist them in obtaining their health and wellness goals. They may want to stop using opioids altogether, use less or use safer, reduce cravings, find a safe place to live, get ID or a bus pass. The scope of the goals should not hinder the quality of care they are able to access. Working in silos doesn’t help us get them closer to their goals.
For too long, we have been providing care that is ineffectual and, in some cases, does more harm than good. For example, withdrawal management (detox) may be the first point of contact with the health-care system for many people who use drugs. For those who use opioids, quickly tapering off these substances and being discharged to a living environment with no medical or psychosocial supports can be detrimental. After these short tapers, people are at extremely high risk of an overdose or of getting an infectious disease like HIV or hepatitis C through risky drug use. For many of these individuals, there is no soft landing. The truth of the matter is that we know through empirical scientific data that detox alone doesn’t work; yet I can pretty much guarantee that this scenario is happening right now in your community.
If harm reduction is the parachute for people who use drugs, we need to ensure they have a safe place to land. In my opinion, this means creating a substance-use care system that is built on the foundation of harm reduction and continually moves people toward a path of recovery. Does it matter how they get there? Not in my opinion. They can enter a residential treatment program and participate in peer support. Or they can see their family doctor and start on medication to treat cravings and withdrawal to improve their chances of long-term success. Do they need something more? They can start on a specialized treatment such as slow-release oral morphine or injectable opioid agonist therapy. We all need more tools in our toolkit to address substance use and addiction.
It is time for nurses to reframe and re-evaluate the continuum of care for people who use drugs, especially in light of the alarming increase in opioid overdose deaths. Harm reduction is the foundation of everything we do. It’s the parachute and the soft landing spot. It isn’t better or worse than other approaches that promote health and wellness for people who use drugs. The care we provide must be integrated, because these approaches are stronger when used in combination rather than alone. It’s all harm reduction to me.