Harm reduction: Keeping substance users safe

In 2012, I became an intravenous substance user.

Previously, I swallowed and snorted substances to maintain my dependence. Using needles, in my mind, was a level beyond the other methods of administration—not only because of the increased chance of overdose and disease, but because of the stigmas. For many who consider the use of substances a moral failure, injecting is the ultimate shortcoming. Only a culmination of crime, laziness, and self-indulgence could lead someone to abuse themselves in that way, the stigma goes.

Even among substance users, the stigma exists. Before I used needles, I compared myself to people who injected to feel better about my substance use: at least I wasn’t as bad as them. Until, one sunny summer afternoon, my friend and using partner Leah (not her real name) helped me inject cocaine behind the church in my Regina neighborhood. At 20 years old, I became “them.”

When the short-lived effects from the stimulant lessened, I began planning how I could get enough money to do it again. This was my reality no matter how I consumed substances.

I knew, at least to some degree, the risks involved with intravenous use: like how sharing needles could result in HIV or hepatitis. But we didn’t have to share needles. Leah had enough new ones for both of us to use, along with other supplies; tourniquets, alcohol swabs, sterile water packets.

She told me later that she got her supplies from a clinic that distributed new needles and would exchange used ones for new ones. Eventually, I went to the clinic myself. Without knowing it at the time, the program I was accessing was based on harm reduction.

What is harm reduction?

The Government of British Columbia describes harm reduction as “…programs and practices that aim to keep people safe and minimize death, disease, and injury from high-risk behaviour, especially psychoactive substance use. Harm reduction recognizes that the high-risk behavior may continue despite the risks.”

Dr. Bernie Pauly, an associate professor at the University of Victoria’s School of Nursing and a scientist with the Canadian Institute for Substance Use Research, says harm reduction is meant to “keep people safe when they are not able to stop using substances.”

“Or if they’re using substances, even if they don’t have a problem, we still want people to be safe,” Pauly adds.

The concept of harm reduction is present in everyday life, Pauly says, like how we wear seatbelts while driving to help protect us from the dangers of automobile accidents. While driving may seem drastically different than substance use, both are features of society and both are leading causes of injury and death. The concept of harm reduction is even intuitive when we approach the use of legal substances like alcohol.

“We actually say things like ‘don’t drink and drive’ because we want people to stay safe and we know alcohol is going to impair their ability to drive safely,” Pauly says.

When it comes to illegal substances, however, harm reduction can seem counterintuitive. Pauly says this is partly due to the criminalization of the substances people use. For some, accepting harm reduction as a viable option for people who use illegal substances is akin to accepting and normalizing crime.

Decriminalizing substances would help further establish harm reduction services in Canada, Pauly says, but she doesn’t see this as normalizing harmful behaviour. Rather, she sees it as a step towards reducing harmful behaviour.

In April 2018, the Canadian Mental Health Association (CMHA) released a policy paper that calls for decriminalization to help solve Canada’s opioid crisis.

“Criminalizing people who use drugs stigmatizes substance use, fosters a climate in which they feel unsafe in accessing life-saving interventions and treatment, and further marginalizes those living in poverty or at social disadvantage,” says Dr. Patrick Smith, CEO of CMHA, in a press release.

“We actually say things like ‘don’t drink and drive’ because we want people to stay safe and we know alcohol is going to impair their ability to drive safely,” Pauly says.

Pauly says harm reduction can also seem counterintuitive due to the influence of recovery models like twelve-step programs that promote an abstinence-only approach.

“In society, we’ve set abstinence as a goal, and we’ve set that as a standard for anyone who’s ever had a problem with substance use, but we set the standard to be something that’s not necessarily realistic for everyone at a particular moment.”

“Up until recently, a lot of our services for people with substance use were abstinence-based. I think it gets reproduced over and over again in our culture that if you have a problem, the only solution is abstinence, as opposed to ‘if you use drugs and alcohol, then there’s also harm reduction approaches as well as abstinence.’”

In addition to needle distribution, harm reduction services include (but are not limited to): supervised consumption sites that provide medical supervision to people consuming substances, substitution therapies that supply opioid users with a replacement substance, and the distribution of medications that reverse the effects of opioid overdose.

Pauly is leading a national study into managed alcohol programs, a harm reduction approach that involves administering regular doses of alcohol to people with a history of problematic alcohol use.

“Managed alcohol programs [are] for people who’ve been through detox and treatment many times [who] have a long history of problems with alcohol, often combined with homelessness. And for that group of people, they often cycle through shelters and hospitals and other types of services, but they aren’t really getting [the] care that they need.”

In 1996, Canada’s first managed alcohol program was established in Toronto following a coroner’s inquiry into the freezing deaths of three men who were denied access to a shelter because of their alcohol use. Today, there are over 20 managed alcohol programs in Canada.

“Often the community realizes that we need a more compassionate and dignified response to what’s happening to people on the street, for people who are at great risk of being assaulted and harmed,” Pauly says.

“People who are in managed alcohol programs experience fewer harms. Although they drink on a more regular basis, their consumption actually tends to go down. And I think as important is that in some of the programs, their quality of life and their ability to maintain housing improve as well.”

Why do people use substances?

When I first injected, I had access to new needles from a harm reduction clinic. While injecting cocaine is no doubt dangerous, using new needles instead of used ones (in addition to alcohol swabs and sterile water) virtually eliminated my chance of getting HIV or hepatitis. Thus, the harm of my behavior was reduced.

A simpler solution, some might suggest, would be to refrain from injecting cocaine—then, reusing needles wouldn’t be an issue. I understand this response, but it ignores the complex reasons people use substances and the inability of many to stop.

Trauma, marginalization, and mental illness are at the core of most substance use issues. For me, it was a combination of depression, anxiety, and isolation.

In 2005, my parents sent me to Luther College—a private high school across the city—after I graduated elementary. My older brother had excelled at Luther’s International Baccalaureate program, and my parents hoped I would too. My friends instead went to the public high school located in our neighborhood.

But I was extremely timid in the new environment, and I could hardly talk to either my fellow students or teachers. I became isolated and lonely, and I stopped talking to my childhood friends. I quit basketball, my lifelong passion, and I also quit trying at school. I eventually convinced my parents to let me switch schools two years later in 2007, but I had already started using substances to deal with my anxiety and depression.

At first, I drank alcohol and smoked cannabis. Then, I was using mushrooms and LSD. A few months later: MDMA, amphetamines, and cocaine. To maintain my dependency, I stole money from my parents. In addition, I pawned many of their belongings, including most of my dad’s expensive music equipment.

By 2012, I had relapsed after several detox and treatment attempts. My continued substance use was fueled by my growing shame. I had dropped out of high school years earlier, I couldn’t hold down a job, and my ability to maintain meaningful relationships was nonexistent. Every day, I was desperate to change the way I felt. If Leah had offered to share needles on the day I first injected, needles she could have already shared with someone else, I probably would have said yes. Thanks to a harm reduction clinic, we both used new ones.

Trauma, marginalization, and mental illness are at the core of most substance use issues.

In 2013, after attempting suicide and a subsequent stay in a psychiatry ward, my parents offered to send me to a private treatment centre in Nanaimo. After completing treatment nearly five years ago, I am still substance-free. But my recovery is not over; it’s both a one-day-at-a-time process and a lifelong journey. To remain substance-free, there’s work I do daily, including connecting with others to avoid isolation.

In many ways, I am lucky. I attended a private treatment centre and didn’t have to navigate the complex public system of detox and treatment with its long waiting times. I also never experienced homelessness, violence, or sexual assault. This is in contrast with the experiences of many with substance use issues.

Looking at Insite

The evidence in support of harm reduction as an effective health strategy is extensive, and listing each study and statistic is beyond the scope of this piece. Instead, let’s look at the effectiveness of Canada’s best-known harm reduction service, Insite, a supervised consumption site (SCS) in Vancouver that opened in 2003 in response to the city’s HIV and overdose epidemic.

The first SCS in North America, Insite provides medical supervision to people consuming self-obtained illegal substances. Since Insite’s opening, over 3.6 million clients have injected substances under medical supervision, and 6,440 overdose interventions have been provided by medical staff. The death total from all overdoses occurring at Insite: zero.

A 2010 cost-benefit analysis in International Journal of Drug Policy estimates that “…Insite, on average, prevents 35 new cases of HIV and almost three deaths each year,” and provides “a societal benefit in excess of $6 million per year.”

Another major feature of harm reduction services is offering referrals to other social and health services, including detox and treatment. In 2016, 5,321 such referrals were made at Insite, and 443 clients accessed Onsite, an adjoining detox facility.

One criticism against SCSs is that they increase drug-related crime in the surrounding area. A 2006 study in Substance Abuse Treatment, Prevention, and Policy examines the crime rates of the neighborhood where Insite is located, a year before and after its opening. The study shows there was no increase in drug trafficking, assaults, or robberies in the year after Insite opened—although, there was a decrease in vehicle break-ins and thefts (302 in 2003 vs. 227 in 2004).

Despite the evidence, of its success Insite has been a contentious issue for both the public and politicians charged with crafting health policy. In 2008, then-Minister of Health Tony Clement refused to extend the special exemption in the Controlled Drugs and Substances Act that allowed Insite to legally operate. After a constitutional challenge, however British Columbia’s Supreme Court ruled that Canada’s drug possession and trafficking laws were unconstitutional which allowed Insite to remain open.

Now, in the wake of Canada’s opioid crisis, Health Canada is approving new SCSs. For nearly 15 years, Insite was the only SCS in Canada. Today, over 20 SCSs are operating in Alberta, BC, Ontario, and Quebec. As high numbers of preventable overdose deaths continue, governments across Canada will be forced to confront two options: stick with the status quo or implement lifesaving harm reduction services.

Harm reduction in Nanaimo

I park on Franklyn Street in Nanaimo’s Old City Quarter neighborhood. The street is lined with businesses: a mortgage broker, a chiropractic practice, and a property management company. However, the character home just beyond my passenger window offers a different type of service.

The front door of the old house has a black sign that reads, “Harris House Health Clinic, entrance at back.” When I enter through the back door, I tell the woman at the front desk that I’m looking for Sandy McLean.

“Hi, I’m Sandy,” she says.

This is my first time meeting Sandy, yet her smile is familiar. The last time I walked through the door of a harm reduction clinic was in Regina while I was still using substances. I don’t remember all the nurses that served me as a client, but I remember how their smiles were just like Sandy’s: warm and compassionate. It’s the same smile I’m sure she offers to anyone who walks through the door.

Sandy directs me to a small conference room where we sit down and face each other across a table.

“My role here is nurse manager, and I’ve been here for a long time,” she says.

Harris House opened in the early 90s as the first needle exchange in Nanaimo. Today, in addition to providing harm reduction supplies like needles and smoking kits, Harris House provides HIV and hepatitis testing and treatment, vaccinations for hepatitis, STI testing and treatment, safe sex supplies, and referrals to other social and health services.

“Most people who have an addiction, no matter what their path is, have something missing that needs to be supported, filled, or dealt with. And of course we have a word for that now, and we call it trauma,” she says.

“Harm reduction for Harris House is small, achievable change. We’re not hung up on big goals. We just do one step at a time. Little steps. Even if [a client] comes to a place where we give them harm reduction supplies and they want to talk about change, that is part of it.”

Harris House has a philosophy of nonjudgmental support, says Sandy, which she uses a metaphor to describe: she allows the client to “drive the bus” while she sits behind and supports them “every way she knows how.”

“If people struggle or if their behavior isn’t the way we would like it to be, they may get a timeout, but they’re able to come back and try again. If people are breathing and are reasonable, and unless they are going to do harm to others, because legally we’re bound by that, they get opportunities.”

Sandy says because of the opioid crisis, Harris House is seeing three times the number of clients, most of whom are in “survival mode.” The influx of clients is affecting the care Harris House can provide.

“We used to do a lot more referrals, counselling, and encouraging people to get better. We’re less able to do those meaningful things. We get in survival mode too. Sometimes we see over 100 people in a day.”

Not only is there an opioid crisis in Nanaimo and many other communities in BC; there’s also a housing crisis. Sandy says it’s an uphill battle for her clients experiencing homelessness to access services.

“If people don’t have a home, it’s really hard to think about detox. It’s really hard to think about getting up when you have nowhere to shower, nowhere to eat. What do you do if you have an appointment and you haven’t eaten and you have to walk far and you haven’t showered and you just don’t feel good?”

Every day, Sandy asks herself this question: “What little thing could I do, what small, achievable thing can I do that is helpful in any way?”

“It might just be a shower. It might be to drive them to where they can get food. We have to be content these days with small achievements. But it’s still part of that process. Part of that journey of getting them well.”

Talking to Sandy, it’s clear that substance use is a complex issue affected by many other complex issues. It’s also clear that harm reduction is part of the solution. Harris House provides an invaluable health service to substance users in Nanaimo, many of whom are the city’s most vulnerable citizens. For people with substance use issues, harm reduction services are their first, and sometimes only, contact with medical professionals. I’m grateful for frontline nurses like Sandy, and for nurses like Dr. Pauly who advance harm reduction research and policy.

“I know there’ll always be people that end up in substance use,” Sandy says, “but it doesn’t mean they aren’t entitled to all the things that I have.”

*This article was originally published on <islandcrisiscaresociety.ca>