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HARM REDUCTION
VS. BEST INTEREST
OF THE CLIENT
By: Ashley Herman
and
Samantha Engelman
WHAT IS HARM REDUCTION?
There are various definitions of harm reduction, a few might include:
“Harm reduction is a public health strategy that was developed initially for
adults with substance abuse problems whose abstinence was not
feasible. Harm reduction approaches have been effective in reducing
more morbidity and mortality in these adult populations”
The International Harm Reduction Association (2002) describes harm reduction as:
“Policies and programs which attempt primarily to reduce the adverse health,
social and economic consequences of mood altering substances to individual drug
users, their families and communities, without requiring decrease in drug use”
Harm reduction places emphasis
on the social and economic
outcomes and the overall
measurement of health, versus the
amount or measurement of ones
drug abuse
“Harm reduction refers to policies,
programs and practices that aim to
reduce the harms associated with the
use of psychoactive in people unable or
unwilling to stop. The defining features
are the focus on the prevention of harm,
rather than on the prevention of drug
use itself, and the focus on people who
continue to use drugs”
Guiding Principles of Harm Reduction
PRAGMATISM - Harm reduction recognizes that drug use is a complex and multi-faceted phenomenon that
encompasses a continuum of behaviours from abstinence to chronic dependence and produces varying
degrees of social harm. Harm reduction accepts that the non-medical use of psychoactive or mood altering
substances is a universal phenomenon. It acknowledges that, while carrying risks, drug use also provides
the user and society with benefits that must be taken into account.
HUMAN RIGHTS - Harm reduction respects the basic human dignity and rights of people who use drugs. It
accepts the drug user’s decision to use drug and no judgment is made either to condemn or support the use
of drugs. Harm reduction acknowledges an individual drug user’s right to self-determination and supports
informed decision making in the context of active drug use. Emphasis is placed on personal choice,
responsibility and management.
FOCUS ON HARMS - The fact or extent of an individual’s drug use is secondary to the harms from drug use.
The priority is to decrease the negative consequences of drug use to the user and others, rather than
decrease drug use itself. While harm reduction emphasizes a change to safer practices and patterns of drug
use, it recognizes the need for strategies at all stages along the continuum of drug use.
MAXIMIZE INTERVENTION OPTIONS - Harm reduction recognizes that people who use drugs benefit
from a variety of different approaches. There is no one prevention or treatment approach that works
reliably for everyone. It is providing options and prompt access to a broad range of interventions that helps
keep people alive and safe. Individuals and communities affected by drug use need to be involved in the
creation of effective harm reduction strategies.
PRIORITY OF IMMEDIATE GOALS - Harm reduction starts with “where the person is” in their drug use,
with the immediate focus on the most pressing needs. It establishes a hierarchy of achievable interventions
that taken one at a time can lead to a fuller, healthier life for drug users and a safer, healthier community.
Harm reduction is based on the importance of incremental gains that can be built on over time.
DRUG USER INVOLVEMENT - Harm reduction acknowledges that people who use drugs are the best source
for information about their own drug use, and need to be empowered to join the service providers to
determine the best interventions to reduce harms from drug use. Harm reduction recognizes the
competency of drug users to make choices and change their lives. The active participation of drug users is
at the heart of harm reduction.
THE BACKGROUND ON HARM REDUCTION
Harm reduction has progressed and changed over
time. In the 1960s and 1970s, activists, workers,
programmes, doctors and policy-makers
dedicated politically and socially to "opposing the
legal suppression of drug use and the oppression
of drug users" (Roe, 2005, p. 243). Harm
reduction was initially recognized as a model in
the 1980s as an option to abstinence-only
centered interventions for adults suffering from
addictions. At the time, it was acknowledged that
complete abstinence was not a rational or
pragmatic goal for those people with an addiction
PRESENT DAY...

To this day, there is an abundance of research
and evidence suggesting that harm reduction
advancements significantly lessen the morality
and morbidity connected with dangerous health
behaviours. An example may include the
constant annual decrease of HIV contraction in
areas that have implemented the needleexchange program, in comparison to areas that
do not have such a program
STATISTICS


“One of the most definitive studies of needle exchange
programmes was carried out in 1997, focusing on 81
cities worldwide. It found that HIV infection rates
increased by 5.9 percent per year in the 52 cities
without needle exchange programmes, and decreased
by 5.8 percent per year in the 29 cities that did
provide them”
“According to an Australian government study,
investment in needle exchange programmes from
1991 to 2000 averted 25,000 HIV infections and
21,000 hepatitis C infections. A later Australian study
examining the impact of needle exchanges in the
following decade revealed they had prevented 32,000
HIV infections and almost 100,000 hepatitis C
infections”
NUMBER OF REPORTED AIDS CASES IN
CANADA, BY YEAR OF DIAGNOSIS, 1979-2011
ONE EXAMPLE OF A HARM REDUCTION
APPROACH PRACTICED IN
VANCOUVER, BC - INSIGHT
From January 1 to December 31, 2010, there were:
•
•
•
•
•
•
•
312,214 visits to by 12,236 unique individuals
An average of 587 injections daily
221 overdose interventions with no fatalities
3,383 clinical treatment interventions
26 per cent of participants were women
17 per cent of participants identified as Aboriginal
Principle substances reported were heroin (36% of
instances), cocaine (32%) and morphine (12%);
• 5,268 referrals to other social and health services,
the vast majority of them were for detox and
addiction treatment;
• 458 admissions to Insite detox
KEY BENEFICIAL ETHICAL CONCERNS
Research shows harm reduction activities can:
 Reduce HIV infection and hepatitis
 Reduce overdose deaths and other early deaths among
people who use substances
 Reduce injection substance use in public places, and reduce
the number of used needles in public
 Reduce the sharing of needles and other substance use
equipment
 Educate about safer injecting and reduce injecting
frequency
 Educate about safer sex and sexual health and increase
condom use
 Reduce crime and increase employment among people who
use substances Increase referrals to treatment programs
and health and social services
ETHICAL CRITICISMS AND ISSUES OF
HARM REDUCTION...
Many politicians are not in support of harm reduction approaches because the
impacts of addiction on society as a whole

A great deal of politicians (and members of society) do not see harm reduction as “moral”.
This causes them to take a “tough on drugs” approach in dealing with all addictions
Many people believe that harm reduction programs (such as the needle exchange
program) promote intravenous drug use and are a waste money

The goal and message should be complete abstinence from substance
Critics argue that harm reduction strategies teach addicts how to use “properly”

Which again, they suggested is a waste of resources
A common concern for many individuals may be that harm reduction entrenches
and facilitates addictive behaviour

This idea is rooted in the principle that individuals with an addiction must hit their “rock
bottom” before they can discontinue their addictive patterns. These critics believe that
harm reduction strategies protect addicts/alcoholics from this “rock bottom” experience
ETHICAL CRITICISMS AND ISSUES OF
HARM REDUCTION...
Another belief among harm reduction critics is that this model encourages addiction
amongst individuals who are not addicts

People not in favour of harm reduction would suggest that this strategy sends out the
“wrong signals”. From this perspective, harm reduction is promoting the idea that drug
users can stay alive and can reduce their exposure to danger; causing addiction to be
portrayed as more appealing to non-substance users
Opposing ideas of this strategy might suggest that harm reduction drains resources
from treatment services

This author concludes, “Harm reduction interventions are relatively inexpensive and cost
effective. They increase social and financial efficiency by interrupting the transmission of
infectious disease at a lower cost, rather than waiting to treat complications of advanced
illness at a much higher cost”
A final concern worth mentioning is the idea that critics believe harm reduction
amplifies addiction disorders, while placing the public safety and health at risk

This idea would assume that the approach utilized by harm reduction becomes a focus and
attraction to drug dealers. Further, drug dealers will then compromise the overall welfare
and safety of the neighbouring communities
HARM REDUCTION SERVICES:
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Impaired driving prevention campaigns: Create awareness
of the risks of driving under the influence of alcohol and other
legal or illegal substances
Peer support programs: Groups for people who use substances
- to improve their quality of life and to address gaps in services
Needle distribution programs: Distribute clean needles and
other harm reduction supplies and educate on their safe disposal
Outreach and education: Make contact with people who use
substances to encourage safer behaviour
Substitution therapies: Substitute illegal heroin with legal,
non-injection methadone or prescription heroin
Supervised consumption facilities: Prevent overdose deaths
and other harms by providing a safer, supervised environment for
people using substances
ETHICAL GUIDELINES
CLIENTS BEST INTEREST
The Canadian Counselling and Psychotherapy
Association (2007) describes that,
“Counsellors have a primary responsibility to
respect the integrity and promote the welfare of
their clients. They work collaboratively with
clients to devise integrated, individualized
counselling plans that offer reasonable promise of
success and are consistent with the abilities and
circumstances of clients.”
WHY ARE THESE ETHICAL ISSUES
IMPORTANT?
The ethical issues of best interest of the client and the harm
reduction approach has many levels and arguments. Firstly,
individuals who are using a harm reduction approach rather
than total abstinence may be seen as if they are still in harm
by using. Society may not see harm reduction as a effective
approach as it allows individuals to still use, they also may
argue that this approach is not in the best interest of the
client. For the counsellors who support the harm reduction
approach, we could argue that this harm reduction approach is
actually in the best interest of the client. The reason we could
argue this is because although the client may not be totally
abstinent, they are reducing/safely using reducing many other
negative aspects of using drugs/alcohol. Some clients cannot
physically or mentally become abstinent from using, therefore
this is the first step by having the client reduce their using or
use safely. If the client has already reached out for your
helped, they have already taken a step towards recovery. As a
counsellor/professional you can help the client reduce/use
safely while working with them towards total abstinence.
SKILLS AND SENSITIVITES ADDICTION
COUNSELLORS MUST POSSESS WHILE
UTILIZING THE HARM REDUCTION
APPROACH
Imperative harm reduction techniques and attitudes which therapists must
hold and be sensitive to include…

Accept and respond to improvement
A majority of treatment centers require the addict/alcoholic to immediately discontinue
their substance(s), and rejects people who are unable to do so. According to Peele
(2002), this is the “cherry-picking” of clients; choosing to only work with clients who
can maintain complete abstinence, and refusing all others. Peele, “Substance abuse
counsellors who wish to work with this large majority need to define intermediate
goals and to recognize such positive steps when these occur”

Improvement includes any lessening of harms the person experiences
Substance abuse counsellors should look at the client’s improvement in any form.
Counsellors should not be too rigid in identifying what is successful for that client.
Perfectionism (or abstinence), is not always realistic and successful for all clients at
certain periods of their recovery process

Humility (versus perfectionism) is a clinical skill
Peele (2002) states, “When people say, ‘I will not tolerate any kind of drinking in
therapy, and therapists who do endanger the lives of their clients,’ their own patients
must surely have perfect compliance. Not! It's just that they insisted on abstinence,
so that any failures were those of their clients, and not their own. While this may
assuage therapists' consciences, it is not effective therapy”
SKILLS AND SENSITIVITES ADDICTION
COUNSELLORS MUST POSSESS WHILE
UTILIZING THE HARM REDUCTION APPROACH
Anticipate and incorporate continued harms in therapy
According to Peele (2002), there are a lot of delusions around the idea that a client should
solely depend on their counsellor for any improvements they make. In actuality their
improvements entail learning and experiencing the pain of their past mistakes. As
substance abuse counsellors, we need to consider, recognize and acknowledge all the year’s
addicts and alcohols have spent developing and feeding into their addiction, and that
positive changes may take the same time of trial and error to get it just right. This might
mean that we should consider continued use may occur while working with clients in
achieving their goals while reducing harm to themselves

Learning to take care of oneself is a skill, a value, and an attitude
Peele (2002) states it perfectly in that, “To say one accepts that human beings are imperfect
does not mean that you endorse their imperfection. You want to encourage those you are
helping to greater heights and larger successes. But it is the recognition and
encouragement of smaller successes that lead to such progress. In particular, helping
people to think about how to take care of themselves, even if they continue to drink and
take drugs, may be an entirely new attitude for some people. When they first start getting
medical care for health problems, or eating well or avoiding infection, or staying out of legal
trouble, or getting a place to live, or accumulating money, etc., this new attitude can grow
so that it crowds out all problem drug use or drinking”

SKILLS AND SENSITIVITES ADDICTION
COUNSELLORS MUST POSSESS WHILE
UTILIZING THE HARM REDUCTION
APPROACH
According to the Non Prescription Needle Use Initiative (2007), when
working
with clients using the harm reduction approach, substance use counsellors
need
to utilize strategies such as…


Offer support that helps people become aware of their substance use and
take steps to reduce the harm
 With a genuine approach, take the time to establish trust
 Meet people where they are, taking into account readiness to change, education
level, resources and self-esteem. This could include reviewing pamphlets and
other written information together to explain and answer questions
 Set the stage for individuals to talk openly and honestly about their substance
use. Let them know you accept and care for them
Help people with basic resources and life skills to make it less likely they
will fall back. As a social worker or counsellor, you are often helping people
build skills to handle day-to-day tasks. When people who use drugs try to
take positive steps forward but lack basic skills and resources others take
for granted, they are in a vulnerable position to slide back into old patterns
 Support people with skills as fundamental as paying bills, filling out forms,
knowing what groceries to buy and doing laundry
SKILLS AND SENSITIVITES ADDICTION
COUNSELLORS MUST POSSESS WHILE
UTILIZING THE HARM REDUCTION
APPROACH

Recognize that relapse is part of recovery. Relapse is part of recovery –
almost nobody changes their behaviour the first time. Many people have a
series of ups and downs, just like a person trying to lose weight. People who
relapse often feel shame and guilt that can lead to more substance use
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Tell the person you believe in their ability to make positive changes in their life
Work together to create an individual plan for relapse to minimize the harm
Use a relapse as an opportunity to ask the person to identify what they have
learned from the experience and to plan how to do things differently next time
Be supportive at whatever stage of change the person is at
Don’t take the individual’s relapse personally
Advocate for people’s needs. People using alcohol or other drugs are often
not treated as well as others when they seek social or medical supports. As
an advocate, you can broker situations and reduce barriers between
individuals and formal systems

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Where needed and possible, accompany individuals to appointments, e.g.
meetings with parole officers, lawyers and landlords
Your role can be to make sure their questions are asked and to assist them in
accessing supports for which they are eligible (e.g. completing forms)
Help others understand that people with substance use problems deserve and
are entitled to care and services
Advocate for systems and changes to policies that may place the people you
serve at risk
Canadian Harm Reduction
Network
RELEVANT
WEBSITES:
EDUCATIONAL
www.canadianharmreduction.com
RESOURCES
A virtual
meeting place for individuals and organizations dedicated to reducing the social, health and

economic harms associated with drugs and drug policies. The site hosts forums, provides links to news
articles, publications, and links to other web-based resources related to drug use

Canadian Centre on Substance Abuse
www.ccsa.ca
The Canadian Centre on Substance Abuse provides national leadership and evidence-informed analysis and
advice to mobilize collaborative efforts to reduce alcohol and other drug-related harms

City of Vancouver Four Pillars Drug strategy
http://vancouver.ca/fourpillars/fs_fourpillars.htm
Outline of the four pillars of the City of Vancouver drug strategy: prevention, treatment, harm reduction, and
enforcement. The site includes fact sheets for

Burnet Institute Centre for Harm Reduction (Australia)
www.chr.asn.au/resources/factsheets
Fact sheets based on scientific evidence, current practice and latest research explaining key topics on
working with people who use drugs. Intent is to prevent the transmission of HIV/AIDS. Intended for a
broad audience, including field workers, public health practitioners, police, journalists, politicians and
policy makers

Drug Policy Alliance
www.dpf.org
Harm-reducing alternatives to current anti-drug strategies

Harm Reduction Coalition
www.harmreduction.org
Overview of the principles of harm reduction and the need for harm reduction approaches to drug use and
drug-related problems. Health information for users, news, policy research, and links to other drug-
RELEVANT WEBSITES: EDUCATIONAL
RESOURCES

Harm Reduction Policy Paper
http://www.albertahealthservices.ca/Researchers/if-res-policy-harm-reduction-background.pdf
This paper was created by Alberta Health Services (formally AADAC) in 2007. The information
provided includes principles of harm reduction, harm reductions history/context, examples of
harm reduction and evidence proving its effectiveness, key considerations as well as further
reading materials

British Columbia – Ministry of Health
http://www.health.gov.bc.ca/cdms/harmreduction.html
This website offers a detailed description of what harm reduction entails. This website also
offers further links to additional information regarding harm reduction
RELEVANT WEBSITES: HARM REDUCTION IN
PRACTICE
o Insite, Vancouver Coastal Health
www.vch.ca/sis
Description of North Americas first supervised injection site in Vancouver, BC. News articles and brochures are
available to download. Links to research conducted by the British Columbia Centre for Excellence in HIV/AIDS are
provided
o Ontario Needle Exchange Programs: Best Practice Recommendations
www.ohtn.on.ca/compass/Best_Practices_Report.pdf
Thorough report on best practices for needle exchange programs, with a review of the effectiveness literature to
demonstrate evidence superior Points Harm Reduction Program Manual designed for staff and volunteers of
Superior Points Harm Reduction Program (Thunder Bay District Health Unit). Applicable for other agencies
providing harm reduction services, already running and not yet operational
o Toronto Harm Reduction Task Force - Peer Manual, A Guide for Peer Workers and
Agencies
www.canadianharmreduction.com/readmore/ichip_peerManual.pdf
Generic “map”; researched, written, designed and produced by drug users/ex-users for peer workers and agencies
delivering services from a harm reduction model. The guide covers a range of topics related to peer work and
includes illustrative case scenarios and sample documents
o Vancouver area Network of Drug users (VaNDu)
www.vandu.org
VANDU case study reports and other information on supervised injection sites, and evaluation studies
o Chicago Recovery Alliance
www.anypositivechange.org
Description of services offered by the Chicago Recovery Alliance to support injection drug users in making positive
changes, as defined the user him/herself. Information on vein care, overdose, and hepatitis is available to
download
RELEVANT WEBSITES: ALBERTA
INITIATIVES ON HARM REDUCTION
Alberta Harm Reduction Conference
www.albertaharmreduction.ca
The goal of the annual Alberta Harm Reduction Conference is to raise awareness in
Alberta about the application of harm reduction principles amongst service providers
who deal with populations vulnerable to hepatitis C and HIV/AIDS and to build
capacities within those vulnerable communities. Conference participants typically
include professionals from a diversity of sectors (e.g. health care, social work,
addictions, corrections, police services, public health) and community members who
use harm reduction services (e.g. people who use(d) drugs, current and former sex
trade workers, people living with HIV/hepatitis C). An ideal forum to share best
practices and experiences related to harm reduction and a variety of areas including
drug use, addictions issues, sexual health, sex work, Aboriginal communities, public
policy development etc

Non-Prescription Needle use (NPNu) Initiative
The NPNU Initiative is a multi-sectoral alliance of government, community agencies,
and associations that share common vision and action to move harm reduction
forward in Alberta, Canada. Since 1995, the NPNU Initiative has evolved to become
a shared responsibility between many departments, levels of government, and
community agencies. Policy makers meet with field level staff and other stakeholders
to identify issues, develop a shared plan of action, and respond to recommendations
to reduce the harms associated with injection drug use, particularly as they relate to
the transmission of HIV and hepatitis C. A 37-member, multi-sectoral Consortium, a
17-member Steering Committee, seven theme-specific task groups, needle exchange
agencies and a Provincial Coordinating Committee on opioid Dependency are the
working components of the Initiative

CASE ILLUSTRATION
Sarah just found she is 2 months pregnant. She is an active alcoholic
and drinks on average 5 drinks a day. She has contacted you at the
pregnancy support center in regards to being pregnant and the fear
that she will not be able to quit drinking but not wanting to harm her
unborn child. The two of you meet and Sarah tells you that she will
not be able to be completely abstinent from drinking during her
pregnancy but does not want to have an FASD child. As a
professional you share with Sarah the effects of drinking while
pregnant and explore with Sarah her patterns of drinking. The first
step you take with Sarah is working with her to help reduce her
drinking.
1. As a professional is this in the best interest of your client?
2. What other ways would you work with Sarah regarding this
issue?
3. Although it would be in best interest of your client and her
child to completely quit drinking, what are the benefits of
having Sarah reduce her drinking while pregnant?
4. If your supervisor came to you and said that you are being
completely unethical by using a harm reduction approach in
this circumstance, how would you argue that what you are
doing is truly in the best interest of the client?
Alberta Health Services. (2007). Harm reduction policy background paper. Retrieved from
http://
www.albertahealthservices.ca/Researchers/if-res-policy-harm-reduction-background.pdf
REFERENCES
Averting HIV and Aids. (n. d.). Needle exchange and harm reduction. Retrieved from
http://www.
avert.org/needle-exchange.htm
BC Centre for Disease Control. (2013, March 8). Harm reduction. Retrieved from http://www.bc
cdc.ca/prevention/HarmReduction/default.htm
British Columbia – Ministry of Health. (n. d.). Harm reduction. Retrieved from
http://www.health.
gov.bc.ca/cdms/harmreduction.html
Canadian Counselling and Psychotherapy Association (2007). Code of ethics. Ottawa, ON:
Author.
D’Angelo, A. M. (2012, March 7). Harm reduction program benefits many at North America’s
only supervised injection site. Canada’s Health Newspaper. Retrieved from
http://www.hospital
news.com/ harm-reduction-program-benefits-many-at-northamerica%E2%80%99 s-onlysupervised-injection-site/
Harm Reduction. (n. d.). A British Columbia community guide. Retrieved from
http://www.health.
gov.bc.ca/library/publications/year/2005/hrcommunityguide.pdf
Leslie, K. M. (2008). Harm reduction: An approach to reducing risky health behaviours in
adolescents. Canadian Paediatric Society, 1, 53-56.
Non Prescription Needle Use Initiative. (2007). Working with people who use drugs: A harm