Addiction and Harm Reduction Recap

Dynamic graphic by the Austin Harm Reduction Coalition

As promised, I’m uploading Gwen’s and Aida’s mp3’s from last week’s session on addiction and harm reduction, aptly titled “Addiction, Illness, Death, Dying and Redemption.” The songs are too big to be uploaded onto the OpenLab, so I’ve added links to the songs (most are videos):

Ben Folds, Brick

The Eagles, Life in the Fast Lane

Dr. Hook and the Medicine Show, Penicillin Penny

Jim Carroll, People Who Died

Ben Folds, The Secret Life of Morgan Davis

Ben Folds and Nick Hornby, Picture Window

Neil Young, The Needle and The Damage Done (with some nice personal intro)

TLC, Waterfalls

And here’s my contribution to the addiction-theme songs: Jane’s Addiction, Jane Says

Following our discussion of these songs, I did a quick search on the concept of harm reduction, which seems a logical practice to address addiction. I was surprised to learn that it seems to be a relatively new strategy from the late-twentieth century and there’s resistance to its implementation. I found an article by a G. Alan Marlatt, “Harm Reduction: Come As You Are,” Addictive Behaviors 21, 6 (1996): 779–788 that seems to summarize the harm reduction approach. I’m not sure how fundamental his work is to the field but he provides a good overview, plus I like his title, which seems appropriate following our music session since it also alludes to a Nirvana song.  Another relevant article is Bernadette Pauly’s “Shifting moral values to enhance access to health care: Harm reduction as a context for ethical nursing practice,” International Journal of Drug Policy, 19, 3 (2008): 195–204 that highlights the disconnect of implementing strategies of harm reduction and real-world healthcare practice, and the larger question of ethics for practicing nurses.  I’ve included the abstracts below.

Marlatt Abstract:
The purpose of this paper is to describe what harm reduction is, how it developed, how it works, and why it is becoming a major approach in the addictive behaviors field. Based on principles of public health, harm reduction offers a pragmatic yet compassionate set of strategies designed to reduce the harmful consequences of addictive behavior for both drug consumers and the communities in which they live. To illustrate how harm reduction has been applied to both the prevention and treatment of addiction problems, highlights of a national conference on harm reduction are presented. The historical roots of harm reduction programs in Europe (Netherlands and the United Kingdom) are described. The paper concludes with a discussion of four basic assumptions central to harm reduction: (a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addiction; (b) it recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm; (c) it has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “topdown” policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches.
Click here for PDF of Marlatt article

Pauly Abstract:
Background
People who are street involved including those experiencing homelessness and substance use are at increased risk of morbidity and mortality. Such inequities are exacerbated when those facing the greatest inequities in health have the least access to health care. These concerns have rarely been addressed in bioethics and there has been a lack of explicit attention to the dominant societal and organizational values that structure such injustices. The purpose of this paper is to describe the underlying value tensions that impact ethical nursing practice and affect equity in access to health care for those who are street involved.

Methods
In this paper, findings from a larger qualitative ethnographic study of ethical practice in nursing in the context of homelessness and substance use are reported. The original research was undertaken in two ‘inner city’ health care centres and one emergency department (ED) to gain a better understanding of ethical nursing practice within health care interactions. Data were collected over a period of 10 months through face-to-face interviews and participant observation.

Results
In order to facilitate access to health care for those who are street-involved nurses had to navigate a series of value tensions. These value tensions included shifting from an ideology of fixing to reducing harm; stigma to moral worth; and personal responsibility to enhancing decision-making capacity. A context of harm reduction provided a basis for the development of relationships and shifted the moral orientation to reducing harm as a primary moral principle in which the worth of individuals and the development of their capacity for decision-making was fostered.

Conclusions
Implementation of a harm reduction philosophy in acute care settings has the potential to enhance access to health care for people who are street involved. However, explicit attention to defining the harms and values associated with harm reduction is needed. While nurses adopted values consistent with harm reduction and recognized constraints on personal responsibility, there was little attention to action on the social determinants of health such as housing. The individual and collective role of professional nurses in addressing the harms associated with drug use and homelessness requires additional examination.
Click here for PDF of Pauly article