Harm minimisation is a big topic and in August of this year (2016) there was a round-table, cross party summit on the topic. This then led to a call for a harm minimization version of the historic 1999 drug Summit that set the compass for the next 20 years of treatment. I remember that, everyone was fired up.... and outcomes are not a hell of a lot better now: In my practice I still see people living under bridges, malnourished, no ID, no health care and doing what they need to to come up with the $100 or so required to pay for their opioid of choice. If this situation was any group except drug addicts there would be a nationwide outcry.
Harm minimisation obviously does not mean absence of harm and people who are not familiar or comfortable with the activities and behaviours in the drug-using community may find that difficult to accept. Doctors, nurses and others in this field may come across things that they find distasteful or hard to accept. This is not glamorous medicine, but we are paid to leave our judgements at the door - they have no use here, they are unhelpful and can be an obstacle for people entering or remaining on the program.
For an example, a not uncommon scenario could be someone who's dealer has gone to jail. This person is opioid dependent and will soon go into withdrawal unless they get opioids. They are up front with the clinicians at the the treatment centre and tell them that they only want methadone until they can source another supply of heroin. A common response to this for instance is outrage that someone would use the program like this; come into treatment and not "be serious" about getting help.
That is flawed thinking. Firstly the person IS making the healthy decision for themselves (and the community). They don't want to access potentially unsafe drugs from suppliers they don't trust, putting themselves at risk on many levels.
Just having a break from active illicit using can be helpful. As I see it, this is an opportunity to give the person a really great experience of OTP so that a) they may choose to stay in treatment and b) when they run into problems in future they know where to turn to for help because last time they were treated appropriately. This an opportunistic moment to engage someone in treatment who would not otherwise have accessed the program. Far from the program being used inappropriately, I believe from a harm minimisation perspective the person is making the best choice they are able to. If we react negatively to this person we almost guarantee they will not engage in treatment and may prefer to access their opioids from another source.
In order to engage someone like this, the prescriber and the treatment facility need to value a quality collaborative therapeutic relationship with this person otherwise they miss a great deal of the information they need to keep the patient safe.
In many ways, pharmacotherapy is just another choice in the marketplace for opioids. It has benefits and it has costs. We have the dark web to compete with now and once people find out how to convert dollars to bitcoins, then quality-grade drugs are delivered to the door every day.
I understand that harm reduction may be difficult to accept, but as I have mentioned, its what we are paid to do. We don't have to like it or condone it but we have to face it.
Genuine harm minimisation is more than just lip service, it is courageous health policy and social justice in action - it is not for the timid or the gutless, but requires us to learn about and witness the drug-using world and develop treatment strategies based on real-world harm. The people we clinically care for are drug addicts and should be treated like any other minority group: our treatment should be tailored to fit with their lives beliefs and culture.
How can we begin to reduce harm if we do not face the statistics and the realities of those who live in that world. Here is an often quoted parallel which I think is useful to present here. Consensual underage sex is a difficult topic for most people but if we do not face the reality of it and provide education and contraception then we promote harm rather than reduce it. Punishing teenagers for having sex will not work. The same is true of the drug using community, what they do may be unpalatable for many, but harm minimisation tells us that we must put in place strategies that reduce risk, not punish the use. I bring that to my personal clinical practice and much of my decision making process is informed by it.
Australia's Needle and Syringe Exchange Program was hotly contested and opposed and is now accepted as an intervention that saved thousands of lives. The Medically Supervised Injecting Centre in Kings Cross has likewise been an intervention based on real-world harm.
Genuine harm reduction rewards people for the risk reduction they have implemented it should not punish them for the remaining risks they cannot yet deal with. Too often I see clinicians who believe they operate in a harm minimisation paradigm, but by punishing patients for the remaining risky behaviours, they push many people away from treatment. One of the advantages of being at this stage in my career is that I have witnessed and learned what works and doesn't work, what saves lives and what doesn't