Summary of Week 1

We have now reached the end of Week 1. By now you should have a clearer understanding of how ‘harm reduction’ can be defined as well what it means in practice. You should have a general understanding of how ideas of harm reduction relate to public health, and why a public health oriented approach to drug use gives priority to harm reduction interventions.

In this first week, we have heard from a range of experts, including UN representatives, researchers and community representatives. Each have reflected on what harm reduction means to them and to public health. We can see a consensus around some of the core principles of harm reduction, including: pragmatism; evidence-based programming; a non-judgemental approach; a holistic person centred approach; and putting the community at the heart of the response.

We have drawn attention to thinking about harm reduction as a set of interventions which not only target individuals and populations with the access to materials and services (such as clean injecting equipment, or access to drug treatment) but which also seek to modify the environments which shape drug harms and people’s capacity to use drugs more safely. We have therefore introduced the ideas of ‘risk’ and ‘enabling’ environments.

Stigma is one aspect of the social environment affecting people who use drugs. In Week 1, we heard from two community representatives about the ‘intersectionality’ of being exposed to ‘double stigma’. Intersectionality is a framework which helps look at how the intersections across social categories such as gender, race, ethnicity, sexuality, and class, can exacerbate, as well as deepen, lived experiences of stigma linked to drug use. Stigma presents itself as a significant social harm related to drug use which intersects with various other forms of ‘structural’ inequalities. This is why it is important to understand drug use in its social and structural context as an issue of ‘intersectionality’.

The reduction of social stigma related to drug use is a key concern in a harm reduction strategy. Importantly, the social stigma felt and experienced by people who use drugs is an effect of the social and policy environments that enact drugs as a ‘social problem’. Stigma is not an attribute of people or the substances they use, but a feature of the environment in which drugs are used.

Week 1 has also illustrated some concrete examples of harm reduction interventions in a public health approach. We heard, for example, about the development of opioid therapy and how this started in a real-world setting. We also heard the example of one of the first needles exchange programs in Liverpool, as a HIV prevention measure. Or more recently, crack-pipe distribution as a COVID prevention measure. Harm reduction adapts to each context with its specific public health priorities.

These examples also spotlight the principles of pragmatism and evidence-based programming. This can further be seen in the compelling ‘stories from the field’ you will encounter in the coming two weeks.

We heard from Annette Verster, from the World Health Organization, on the global scale of health and harm reduction associated with drug use, and how an evidence-based approach can inform global policy responses. Here, harm reduction is emphasised as a package of ‘combination interventions’ working together. Individual harm reduction interventions address specific risks that can be found on the spectrum of the risk environment framework. These services are most effective if it is comprehensive enough to allow for a person-centred approach, adapting to each individuals’ specific needs and preferences. One of the most recognised combinations is the provision of Opioid substitution and needle provision, being much more efficient once combined. For further reading on this, you can find a Cochrane Review and meta-analysis here

Through case study, we also considered some of the practical challenges of integrating harm reduction into health systems. Here, we heard from Louise Vincent about a community-led harm reduction response to fighting the overdose crisis in North-Carolina. This case study offers an excellent case for understanding how community response and community-led change is an integral feature to creating a health enabling environment for people who use drugs.

Next week, we will look at harm reduction in a ‘human rights’ perspective. We will hear how harm reduction can be viewed in relation to internationally accepted universal human rights declarations. We will also consider how problems of drug harm can connect to broader globalised efforts to tackle drug use, efforts which constitute a ‘war on drugs’ which can transform into a ‘war on people who use drugs’.

We will also continue exploring the ‘intersectionality’ and ‘risk environment’ of drug harms by focusing on the examples of harm reduction in prison and women who use drugs.

Next week we will also look at building on ideas of community and community involvement. We will hear directly from those engaged in community actions, about the powerful work they do and how they turn harm reduction principles into practical action. You will start to see some of the key themes introduced in Week 1 coming together through topics we will explore next week.

If there are topics from Week 1 that you are not confident in, please do return to the previous steps. If you haven’t already done so, you may find it helpful to read the optional resources in some of the steps.

We look forward to joining you in Week 2!

Self-reflection:

• What have been the most important learning points for you this week?
• Have you had any new ideas to apply to your setting?
• Have you made new contacts?

Optional

For learners interested in learning more about stigma in the field of drug use, we suggest here a recent review of qualitative research on stigma linked to hepatitis C among people who inject drugs. Published in the International Journal of Drug Policy, Harris and colleagues (2021) conclude that: “There is a tendency for qualitative, empirical research to focus on risk factors shaping individual behaviour change, rather than on risk contexts and socio-structural change”.