Practical Harm Reduction Strategies

NAEH Annual Conference July 2015

Outline of Presentation

Harm Reduction: definitions and origins

Harm Reduction in the broader society

Typical Harm Reduction strategies employed with homeless individuals

Harm Reduction strategies in housing with case examples

Discuss audience examples

Overview of Harm Reduction: Definitions

Harm Reduction:

Reducing harm

associated with high

risk behaviors to

improve quality of life

Where Can We Apply Harm Reduction

Health Finances Social Relationships Mental Health Weight Loss Exercise Intimate Relationship

Person Sets Priorities (and society offers support)

Protective equipment (optional to required)

Harm Reduction in Everyday Life

Automobile Use/Abuse:

Environmental/passive protections: highway guard rails, air bags

Optional protections (possibly required): seatbelts, child seats, designated driver

Harm Reduction in Everyday Life

Harm Reduction: Substance Use

is a set of practical strategies to reduce the negative consequences of drug use (and symptoms) incorporates a spectrum of strategies from safer use to abstinence

Overview of Harm Reduction: Origins

1920s

British System and Rolleston Report

1960s -80s

The Dutch Model, users unions, and needle exchange

1989-present

Canada starts public policy based on harm reduction

Mid to late 1980s

US grassroots agencies start pursuing harm reduction models

Early to mid-1980s

The Mersey (Liverpool) Harm Reduction Model

Overview of Harm Reduction: Origins

www.desc.org

safety

drug traffic/trade

drug dealing

intoxication

Common Substance Use Concerns

What Harm Reduction is not

Passive

Anything goes

Don’t Ask Don’t Tell

Enabling

A hook to get people to treatment

A direct path to abstinence

Why Harm Reduction?

"My case manager

doesn't judge me."

"Even when I mess

up, my CDP doesn't

judge me...they just

support me."

Failure vs Small Successes

Harm Reduction with Client Buy-In

Needle exchange

Alcohol Monitoring

Methadone (substitution therapy)

Reducing amount used

Condom use

Harm Reduction with Client Buy-In

Using a screen or rubber tubing for crack use

Getting off the bus two stops earlier and walking

Paying Rent before buying substances

Changing use patterns

CD Groups/treatment with harm reduction focus

Harm Reduction without active client participation

Medication distribution Case Management Education around safer use practices Protective Payeeship

Outreach/engagement Welfare checks Coordination of care with PCP Room inspections/chore services Narcan/naloxone

Harm Reduction without active client participation

Harm Reduction example (with or without client buy-in)

Harm Reduction example (with or without client buy-in)

Harm Reduction example (with or without client buy-in)

Challenges for staff

Client Trust/Staff Turnover

Concern about “endorsing” substance use

How to balance positive regard for individual vs. accepting the behavior

Fear of doing the wrong thing

The need to see measurable success

Stress leads to desire for rules/structure

49 years old, highly personable and cooperative

HIV+, mobility impairment (has one leg)

alcohol dependent, pattern of violent outbursts when intoxicated

never hurts anyone badly, but over time creates increasingly stressful environment for all residents

staff reaction varies and drifts from “we need to keep him housed” to “he’s not working hard enough”

universal concern about him being homeless given health and mobility problems

Case Study: James

A. Discuss priorities with staff: housing preservation vs. insisting on behavior change

B. Wring hands and gnash teeth C. Make him homeless to teach him a lesson D. Teach assertiveness and limit setting to other residents E. Involve law enforcement

F. Prevail upon James’s sense of responsibility to the larger community, make him promise to do better

G. Use money control H. Interfere with bingeing - alcohol management I. Ask James to help with projects J. Involve James in sober social activities

What do you do?

43 years old, spunky and friendly, well known to agency staff

has schizophrenia, borderline PD, HIV, addiction to crack and alcohol

trades sex for drugs; sells personal property

brings predatory people into building

frequently assaulted on street, possibly also in building

usually refuses medical care

Case Study: Tammy

A. Focus interventions on harm reduction B. Negotiate visitor agreement C. Develop protocol to follow when having

visitors D. Eviction E. Provide STD education F. Tolerate behaviors G. Bolt TV to wall H. Appeal to men paying her

What do you do?

Resources

Marlatt, GA et al. (Eds.). Harm reduction: pragmatic strategies for managing high risk behaviors. Guilford Press, 2011. Denning, P. and Little, J. Practicing harm reduction psychotherapy: An alternative approach to addictions. Guilford Press, 2011. desc.org/research.html