Harm Reduction: The Realist’s Approach to Drug Treatment

Harm Reduction is a difficult topic to explain to people: parents, educators, lawmakers don’t always understand why I can be satisfied with a youth lowering their drug use when they really need to stop their drug use. Harm reduction can sound like a clinician is giving in – the second to last step before giving up, in many people’s opinion.

Here is how I explain the rationale for harm reduction as the best approach to managing substance use disorder in adolescence. Harm reduction strategies are client-centred and nonjudgmental. There is overwhelming evidence that harm reduction approaches decrease overdose deaths, improve mental health treatment and improve the quality of life for people struggling with addiction. They also prevent many of the worst illnesses related to drug use, illnesses like Hepatitis C and HIV.

Harm reduction strategies are rooted in social justice, recognizing that social determinants of health like housing, culture, income and employment all have an impact on drug use. Harm reduction strategies recognize that many of these are not always under our control – especially if you’re a young person.

In my practice, composed entirely of people under 21, an approach that is nonjudgmental and youth-centred is vital. Many people arrive at their appointments accompanied by their parents, but it is the youth themselves who must do the hard work of therapy and recovery. Harm-reduction approaches recognize this.

When I see someone who is using drugs, I try very hard not to lecture them about stopping. This is not always easy for me. I find out from them the impact they believe the drugs are having. Perhaps they think marijuana helps them sleep or that alcohol helps them relax. This is their observation, and it will be hard to convince them otherwise, in my experience.

I do tell them the impact of what they are using on their physical and mental health and ask if we can investigate whether they are experiencing any of these effects. I am a doctor, I remind them, and they usually let me show them the information and references that I have about the impact of what they’re using. If they are suffering from anxiety or depression, or if they have symptoms of psychosis, I will discuss with them the impact of any substances they are using. Most psychoactive substances can affect an underlying mental health condition as well as any medications that can assist in the treatment of a mental health condition.

If someone asks me directly if I think they should stop using drugs, I do tell them that this would be best, and, once again, I show them the evidence supporting this. I try to do this gently, without judgment, keeping my “lecturing voice” turned off as best as I can. If someone leaves my office thinking about their drug use, still willing to return to see me or their therapist, that is a beginning.

I also emphasize to youth and their families that, like any doctor, I am going to address the riskiest elements of an illness first. An endocrinologist focusses for on blood sugar levels before diet and other lifestyle changes. In the same way, I am absolutely categorial about drinking and driving, or exchanging sex for drugs. If someone is at particular risk because they are homeless or living in an abusive situation, I treat that like the emergency it is. I am very lucky to have great social work colleagues to support my patients. I don’t hesitate to send people to an emergency room or an emergency shelter. An important principle of a harm reduction approach is to prevent the worst consequences of an illness, and then work with a patient to improve the rest.

A harm reduction approach to substance use disorders suits me. I am pragmatic and realistic, and I do strive to be nonjudgmental. I often wish I was as successful with nonjudgmental as I am with pragmatic and realistic, but I admit that it really bothers me at times that people find it so difficult to understand that the evidence supports a harm reduction approach over the “abstinence now” approach. I would like people with substance use disorders to JUST STOP NOW, but that approach doesn’t work as well as harm reduction.