Harm reduction has been defined as “policies, programmes and practices that aim to minimise negative health, social and legal impacts associated with drug use, drug policies and drug laws. Harm reduction […] focuses on positive change and on working with people without judgement, coercion, discrimination, or requiring that they stop using drugs as a precondition of support.”77 Although most often associated with the use of illegal substances, harm reduction approaches can also be applied to any activity that increases risk of adverse health, social, or legal consequences for an individual.78
At its core, a harm reduction approach to opioid use supports any steps taken by patients to improve their health and wellbeing, and seeks to meet patients “where they are at” in terms of willingness and ability to change.78 Although it is understood that the only way to fully avoid all negative consequences associated with unregulated opioid use is abstinence, it is also recognized that not all patients are able or have a goal to discontinue or substantially reduce their substance use.78 Harm reduction requires the care provider to set aside prejudice and support patients’ safety and well-being to any extent possible while accommodating each individual’s goals, expectations, circumstances, and abilities. Most importantly, it means that the patient can trust that their care team will not abandon them, even if they make decisions that are contrary to the guidance from their care team.
Clinicians should promote strategies to minimize opioid-related harms rather than presenting abstinence from opioid use as the only desirable outcome of treatment. There is substantial evidence that uptake of harm reduction services is associated with significant decreases in substance-related harms, including risky behaviours, HIV and hepatitis C infection, and overdose deaths.79-86 In addition, research has shown that participation in harm reduction services can promote entry into addiction treatment.87-90 In BC, established harm reduction initiatives for unregulated opioid use include needle/syringe distribution programs, overdose prevention sites, take-home naloxone, supervised injection or consumption services, drug-checking services, and take-home fentanyl testing. A current listing of harm reduction services can be found on the Toward the Heart website. Clinicians should be aware of harm reduction programs offered in their local area and provide information to patients about these services. Information about harm reduction services should be offered to all patients, including those who are currently not using unregulated substances.
2.7.i Indigenous Harm Reduction
An Indigenous approach to harm reduction recognizes the social and systems-level factors that impact and shape opioid use by Indigenous peoples. This involves care providers engaging on a personal level with the realities of colonialism and structural racism and its impacts on their patients on an individual level, as well as critically reflecting on and working towards dismantling their own prejudices. In addition, clinicians should aim to work in partnership with their patients, understanding that the health system has been a site of significant harm for many Indigenous people, and endeavouring to mitigate the power dynamic between provider and person seeking care. Indigenous harm reduction practices are imbued with Indigenous knowledges and concepts of holistic and relational wellness, and are not focused on an individuals’ opioid use behaviours. Indigenous harm reduction is defined as having the following characteristics91:
- Decolonizing—goes beyond addressing individual behaviours and interrogates the neo-colonial systems and structures that shape and constrain the lives of Indigenous peoples by centering power and control in places where it has been systematically removed. In the context of substance use care, this involves providing services that are community-led, peer-led, trauma- and violence-informed, and culturally safe
- Indigenizing—supporting programs and policies that are grounded in Indigenous knowledges, traditions, teachings, ceremonies, land, and languages
- Holistic and wholistic—creating the conditions in which Indigenous peoples can be mentally, physically, emotionally, and spiritually well by addressing social determinants of health including housing, education, cultural practices, and other psychosocial supports
- Inclusive—actively opposing “hierarchies of worthiness” imposed by colonial value structures. This involves respectful and non-judgemental care regardless of age, gender, sexuality, literacy levels, socioeconomic status, criminal backgrounds, spiritual belief, and substance use behaviours
- Innovative and evidence-based—combining Indigenous and mainstream approaches into effective and culturally grounded care
Within BC, the First Nations Health Authority (FNHA) has developed Indigenous harm reduction principles and practices.92 Under the FNHA model, Indigenous harm reduction is a process of incorporating Indigenous knowledges and values into harm reduction policies and programs. The four key components of this model are:
- Relationships and care, represented by the Wolf
- Knowledge and wisdom, represented by the Eagle
- Strength and protection, represented by the Bear
- Identity and transformation, represented by the Raven.
Each of these components can be incorporated into substance use care for Indigenous patients by clinicians, care teams, and staff.
The Wolf reflects the importance of building relationships with patients.92 Clinicians, care teams, and staff can incorporate this component through offering culturally safe, person-centred, inclusive, and trauma-informed outreach care; acknowledging the importance of relationships, community, and land; and recognizing social, economic, and environmental conditions as well as the ongoing impact of colonialism.
The Eagle reflects the ongoing nature of healing and the need for continuous support.92 Clinicians, care teams, and staff can incorporate this component through providing trauma-informed and evidence-based services that support individuals and communities where they are at and recognize the impact that shame and stigma can have on Indigenous peoples who use drugs.
The Bear reflects a strengths-based approach to care that recognizes the importance of culture as a strength.92 Clinicians, care teams, and staff can incorporate this component by ensuring Indigenous patients have access to Indigenous Elders, cultural practices, and holistic services in their substance use care.
Finally, the Raven signifies that wellness is a journey in which individuals explore and accept their identity.92 Clinicians, care teams, and staff can support Indigenous patients in this journey by viewing substance use as a health issue and in the context of the determinants of health, rather than a moral or criminal issue.