#14 Harm Reduction

It is necessary to have read last week's Post #13 Stages of Addiction and Homelessness to put my views about Harm Reduction in context. I think it is a valuable strategy to help those in 4th stage addiction. They are without homes, living lives of oblivion and not really caring if they live or die. They don't seem to have the moments of clarity we commonly call a bottom. I was initially resistant to Harm Reduction until being exposed to the levels of addiction in Vancouver's DTES and the inability to help with traditional methods.

Harm Reduction aims to meet substance abusers “where they are at” as opposed to immediately imposing abstinence. It helps prevent unnecessary hospitalizations due to preventable infections and diseases. It is trying to keep people alive and healthy while working to engage them in treatment for their addiction. It is doing things for the addict they are unable to do for themselves which is different than enabling. Criticism of harm reduction typically centers on concerns that tolerating risky or illegal behavior sends a  message to the community that these behaviors are acceptable. Again, I am recommending Harm Reduction strategies only for 4th stage addiction.

To be effective Harm Reduction needs to be part of a "Four Pillars" approach which includes Prevention, Treatment, and Enforcement (Protection over Prosecution). Decriminalization for using drugs and limiting prosecution to drug related crimes (including manufacturing and sales) would drastically lower prison populations where sadly there are few treatment programs. There are many who abuse drugs but do not break other laws. The National Institute of Health estimates that only 9% of alcoholics end up in prison or homeless.

The Housing First model is simple: provide housing first, and then combine housing with supportive services in the areas of mental and physical health, substance abuse treatment, education, and employment. Housing is provided in apartments scattered throughout a community. This "scattered site" model fosters a sense of home and self-determination, and it helps speed the reintegration of clients into the community. 

Providing housing and support services for homeless addicts costs less than leaving them on the street, where taxpayer money goes towards police, shelter and emergency health care. Residents are required to pay about 30% of their income including welfare towards rental. Housing First restores dignity and offers space and encouragement for change to take place. Imagine the addict thinking, "why should I go through treatment when I have no place to live but the street and its drug culture when I leave!"

Research in major cities shows lifting the ban on alcohol use in homeless projects lowered consumption 40%. The Pennsylvania Hotel experiment in Vancouver provides 8 ounces of alcohol per day which keeps residents from going into the Delirium Tremens of withdrawal and the associated risks of drinking Illicit alcohol (any alcohol not bought in a liquor store like rubbing alcohol, mouthwash, hand cleaner etc). Last year their research showed a 62% decrease in the consumption of alcohol.

What is encouraging, is that many 4th stage addicts who participate in these Harm Reduction programs go into remission to 3rd stage addiction where moments of clarity are possible and opens the possibility of recovery. With the Housing First initiatives, they become part of a social - cultural  community necessary for recovery (blogs #5 and #6: Proxemics).

Probably the most controversial Harm Reduction approach in Vancouver's DTES is InSite, the only legal supervised injection site in North America. It provides a safe and health-focused location for drug injection. The clinic does not supply any drugs but registered nurses supervise the injection and are prepared to handle any emergencies. In1996 there were 2,100 cases of HIV reported in the DTES. After the formation of InSite, in 2006 there were only 30 new cases of HIV. There have been 2,492 clinical medical treatment interventions, and 6,242 referrals to other social and health facilities (mostly for detox and addiction treatment). Of the referrals, 40% began treatment and it has been shown that InSite users are 2X as likely to engage in treatment than non-Insite IV users. 

In 2009 484 overdoses occurred with no fatalities, due to intervention by the medical staff.  There is also a government sponsored Detox center called OnSite upstairs. Of 411 admissions last year, 55% completed detoxification which is a remarkable statistic.

Much resistance to InSite has come from the evangelical church. This was addressed in a lecture last year by Dr John Stackhouse and Nurse Meera Bai from Regent College Seminary in Vancouver. I think understanding addiction in 4 stages and restricting Harm Reduction to the 4th stage would lower resistance from the evangelical community. 

Methadone clinics were started in the 60's primarily to address the crime rate associated with the heroin epidemic. It did reduce the crime rate however the federal government did not follow up with recovery programs that were supposed be included. Without integration with other harm reduction programs I feel methadone clinics mostly fail 4th stage addicts. Methadone is harder to withdraw from than heroin. Many 4th stage addicts take their oral methadone daily at clinics or pharmacies to prevent opiate withdrawal, but then pursue other drugs including alcohol through the day. 

Methadone is currently being prescribed as a common pain killer for its benefits as a pain killer and its low cost. For many, this adds to the current opiate addiction epidemic when not regulated closely. In its pill form it can be powdered and injected making it valuable on the street. The cost of today's China White heroin (very pure) today is cheaper on the streets than scripts of methadone and heroin becomes attractive with prescription addicts.

What has been helpful and encouraging is the advent of Suboxone in pill form for opiate addiction. It stops the horrible withdrawal as an agonist and if opiates are taken they have no effect as Suboxone blocks the receptors as an antagonist. It requires monthly involvement with a specially licensed physician, and the good ones insist the person be involved in some type of recovery. The treatment ideally is limited from 3-6 months as the Suboxone dosage is gradually titrated.

My next blog will explore the role of genetics in addiction.