Harm Reduction Gaining Acceptance Within Treatment Community, but Hurdles Remain

Longstanding beliefs within the United States about substance use have prevented harm reduction from gaining the acceptance it has attained in other parts of the world. The opioid crisis has sparked a change in attitudes for many treatment providers and legislators, but significant work remains, said John de Miranda, EdM, CRC, executive director of Peninsula Health Concepts in San Mateo California.

On Friday at the West Coast Symposium, de Miranda delivered a session on the next steps required for integrating harm reduction practices within addiction treatment. Ahead of de Miranda’s presentation, Addiction Professional caught up with him to discuss how harm reduction has been viewed historically, how the practice can help build trust between individuals with substance use disorders and treatment providers, and steps that organizations can take to educate staff and clients.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: How has harm reduction been viewed historically within the treatment community? And is that something that's changing now?

John de Miranda: In order to understand our approach to harm reduction, you have to go back a long way. Harm reduction originated in Liverpool, England, and Amsterdam almost simultaneously. In Europe, there is a less of a moralistic approach to drugs. Here in the United States, there's a very moralistic perspective on drugs. In fact, I have here the New York Times April 26 Opinion section--almost the whole section was devoted to harm reduction. The title is revealing: “One Year Inside a Radical New Approach.” Well, it's not a radical new approach. And using the term radical is again, demonizing harm reduction or giving it this sense of edginess.

In that article, one of our best researchers from Stanford makes the statement that today, the American public still has a deep hatred for people who use drugs. I think that's where we start from. So harm reduction originated across the pond and never really emerged out of the shadows in the United States because of the drug war. The drug war was in full swing through the 1980s and 1990s, and harm reduction became one of the demonized dirty words of the drug war. If you were working in this field as I was back then, and you embraced or even talked about harm reduction, you could get into some serious trouble with your employer and with others, as I did. That's another story you don't have time for.

So harm reduction has always been in the shadows. There's always been a kind of silo around harm reduction versus treatment professionals., and those 2 silos never really never met. I remember many years ago attending the first National Harm Reduction Conference. It happened to be here in my backyard in Oakland. I didn't know much about the concept of harm reduction, so I went to this conference and I was very surprised. There was nobody there from the alcohol and drug field. It was full of young people who were handing out clean needles in back alleys. And they saw me as the problem. They saw the traditional alcohol and drug field as stopping and undermining harm reduction strategies, which were intended to save lives.

They couldn't understand why we as a field placed things like sending the wrong message above saving lives. As the drug war, I think, became more and more discredited, harm reduction kind of emerged out of the shadows. There was a period where an exception was created around the HIV/AIDS epidemic, but that exception was largely in the public health community, not in the alcohol and drug community. You had the Centers for Disease Control and Prevention (CDC) supporting needle exchange, but never anything over at the Substance Abuse and Mental Health Services Administration (SAMHSA) or National Institutes of Health (NIH) or National Institute on Drug Abuse (NIDA) looking at harm reduction any real way. You could still lose your job over on that side by embracing harm reduction.

So what happened? As the demonization of harm reduction decreased, 2 things happened to really change the game. One was the opioid epidemic. First, the opioid epidemic hit us hard. We tried a lot of things that didn't seem to bring the numbers down. The second thing was Joe Biden was elected president, and for the very first time in the history of the White House, the term harm reduction appeared in his first set of drug policy priorities that he sent to Congress during the first 2 months of his administration.

One of those policies was to embrace harm reduction as a way of stemming the opioid crisis, followed by some money and grants for programs. But for the most part, the field has responded to that call with what I call “harm reduction light.” Harm reduction light is handing out Narcan, talking about Narcan distribution, preventing opioid overdoses, and maybe doing some community education, but it is not about fundamentally and systematically changing how treatment programs look at harm reduction. They're still very wary of it with a few exceptions.

So that's where we are. What I think really needs to happen is for the field to take on a more public health approach that includes harm reduction strategies. But I also think it really needs to lead the way in trying to help the public move away from what Keith Humphreys at Stanford calls the public's deep hatred for people who use drugs. The alcohol and drug field has traditionally wanted to embrace people who were either in recovery or seeking recovery. Those people who use drugs who were not interested in abstinence were shunned by the alcohol and drug field—we didn't really want those people. Well, I think that's got to change. We as treatment professionals need to be out on the streets with a mobile van and a place where people who live on the streets can get a shower and use a clean bathroom and pick up some supplies, not just food, but also supplies to help them use more safely. That's the challenge for the field, is to really integrate harm reduction systemwide on scale.

AP: Is the thought process behind that, that if, as a treatment professional, you can establish a relationship with someone who's engaging in substance use and isn't interested in engaging in treatment right now, maybe if you build trust with them now, it might improve the odds of them seeking treatment down the road?

de Miranda: I think that's the real endgame for the opioid crisis, that we are still practicing kind of retail healthcare. If we learned one thing from the COVID-19 pandemic, it's that we cannot treat our way out of these pandemics. We have to have a harm reduction prevention strategy. And that was masks and distancing and lockdowns to really get ahead of the epidemic.

With the opioid epidemic, we've been playing catch up, and the most recent catch up is Narcan distribution. That's going to help with the overdoses, but that's really not going to help with the scale of opioid addiction in the country. So if we can really take the outpatient system nationwide and move it to take a more harm reduction approach, like you say, get out there, engage people, not with a prerequisite that they have to come into abstinence-based treatment, but simply engage them where they are, which is the principle of harm reduction, then many of them over time will decrease their use.

We know that when people get healthier, they use less. Then, it’s likely that many of them will either enter abstinence, enter treatment, but more importantly enter abstinence or enter significantly reduced use, which should be a goal as well as abstinence recovery. Historically, we’ve wanted everybody to be abstinent. If you go back even a couple of years, 2 years ago at the West Coast Symposium, one of the presentations that was supposedly about harm reduction really turned out to be, well, harm reduction is a way to find clients for your treatment program. And it was like, come on, there's more to harm reduction than that.

So that's my spiel, and I think we still have a long way to go to really embrace harm reduction. Frankly, if the administration changes and we get another conservative administration, harm reduction could go right out the window, and back to kind of drug war thinking that we need to incarcerate more of these people and drug use is illegal and blah, blah, blah.

AP: In the meantime, are there any other steps that treatment and recovery organizations should be taking right now to help educate their staff and even their clients in terms of how you're integrating harm reduction into your operations?

de Miranda: Well, I think training staff is a necessary first step. We're beginning to see conferences like the West Coast Symposium implement workshops about harm reduction, but for every one of those, there are a hundred about dual-diagnosis treatment, for example. We're not seeing the scale we need. We're not doing anything to introduce harm reduction into the curricula that alcohol and drug counselors must take—and by the way, that curricula is terribly outdated. The curricula, which all the education programs that train alcohol and drug counselors follow, is from SAHMSA, and it's 25 years old. It doesn't mention harm reduction, it doesn't mention things that it should.

So, training at that level is important too. I've been trying to convince UC Berkeley, and now UC San Diego, where I teach alcohol and drug counselors to offer at least an elective on harm reduction because I think practitioners, even people already certified as alcohol drug counselors can use a course on harm reduction—what is harm reduction and how do you use it in your program? So yes, training staff, but also getting treatment programs out in the community, more talking about their clients, talking about the fact that people that use drugs are like you and me, not people that we need to demonize and hate. As that article in the New York Times pointed out, there's still a long way to go.

Reference

de Miranda J. Treatment and recovery discover harm reduction: next step – integration. Presented at West Coast Symposium on Addictive Disorders; June 1-3, 2023; Palm Springs, California.