Harm minimisation – strategy or goal?

by Peta Dale B.B.Sc. (Hons.); Dip. Psychotherapy and Alison Campbell Rate, B.Ed

updated November 2016

“One of the fundamental weaknesses of this strategy is that it is divorced from the underlying values that may prompt behaviour change.”

Origins of Harm Minimisation concept.
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Its use as a treatment approach for drug users.
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Limitations in school settings.
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Alternative prevention strategies.
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Resources

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Contents

Introduction

The growth of concern over the spread of HIV/AIDS in the mid-80s served to lend political acceptability to policy development that was based on a Harm Minimisation approach. In the 90s, the original purpose was broadened to include other health issues and now targets a range of students within various health related programs. The education community has readily adopted Harm Minimisation, with schools being encouraged to implement the concept as a health promoting strategy. Educators and students may benefit from an awareness of the risks and limitations of the Harm Minimisation approach.

Assumptions

Question: Does the term ‘harm minimisation’ refer to a broad aim (that of minimising harm to individuals) or does it refer to an actual strategy or policy adopted by a government or other body towards a public health problem? The first describes a generalised goal or desired outcome for all, a health value, if you will; the second describes a particularised approach to a specific health issue, an approach which is necessarily shaped by its own limits, basic assumptions and the nature of the target group which is its focus. Clarity in defining the term ‘harm minimisation’- whether aim/value or approach/strategy – helps us assess the appropriateness of specific health promotion approaches for any particular individual or group.

The Concept

Harm Minimisation began as a movement by public health specialists in the 1980s attempting to deal with the threat posed by AIDS to illicit drug users and has formed the basis of Australia’s National Drug Strategy since its inception in 1985. Approaches such as needle exchange programs and calls for safe injecting rooms were developed with this aim in mind. “Based on the three pillars of demand reduction, supply reduction and harm reduction, [the movement] aims to build safe and healthy communities by minimising the harms to individuals, families and communities from alcohol, tobacco and other drugs use” (ADCA, accessed 4/9/13).

One main premise behind the argument for the strategy is that some drug users cannot be expected to cease their drug use at the present time and that drug use is seen by the user to be normal, rational and beneficial. The task is to minimise the risk, or occurrence, of harm in the situation. This involves manipulating the drug taking environment, the how, when and where of the drug taking rather than the drug use itself.

A treatment approach

Harm Minimisation, as originally developed therefore, is fundamentally a treatment approach, an overall strategy and set of policies aimed towards a target group with the specific intention of reducing harm in an already harmful situation. In essence, Harm Minimisation is a strategy to ameliorate the adverse consequences of drug use while, in the short-term, drug use continues.

But in reality there are a variety of individual drug policies and programs, from abstinence-orientated to methadone replacement through to imprisonment. All these approaches attempt in some way to ‘minimise harm’ (the generalised aim) but important distinctions between these approaches and their individual target groups become lost when confused with an overall strategy of the same name. For example within the overall definition above, abstinence-oriented programs and the use of criminal law to deter drug use would be considered as prevention and deterrent measures respectively, not as Harm Minimisation.

So it becomes necessary to differentiate between ‘the minimisation of harm’ and a ‘Harm Minimisation Approach’ in order to cater appropriately for different groups in the community, not only in drug policy but for any health promotion.

The initial reference point determines and guides the development of our goals. When the reference is the drug itself rather than the person, we see the aims to control the drug through supply and demand and in harm reduction measures for users. This approach may have led to the terminology of “war against drugs” as often seen in news reports and the concern that this war may become a war against the drug users themselves.

Another reference point may be the individual, the person who has desires, thoughts and behaviour in relation to drugs. From this reference point our aims might be placed in terms of preventing abuse, eliminating use or minimising harm. Perhaps a useful way to categorise treatment approaches is in terms of the target group and the appropriate treatment for that group.

A diagram below illustrates examples of different approaches to drug education in light of the stages in the process of drug-taking behaviour and emphasises the differences between Harm Minimisation and other approaches.

 

Several other approaches can be seen as falling under the headings of either preventative or abstinence approaches. These are information based, personal and social development based and social skill training based. Within the education environment these approaches are not usually presented in isolation. However, the distinction between these approaches can be made in terms of the relevance and appropriateness of the approach for the individual and his or her stage in the drug taking process.

Limitations

A concern expressed about Harm Minimisation drug strategies is their potential for communicating an unintended message to the wider community, particularly young people, condoning and encouraging drug use. In this we see the problem of distinguishing between what is an appropriate Harm Minimisation approach for a particular target group (‘ways for drug users to use drugs more safely’) and what is a general harm minimisation aim/value for the wider community (‘ways not to use drugs at all’).

Formation of drug policy in the late 1980s was shaped by the urgency engendered by the potential spread of HIV in the community via injecting drug users. As such the public health sector’s overriding interest in reducing immediate drug related harm, even if this involved some risk or could be seen as condoning drug use, was an understandable response to the perceived crisis.

Similarly ‘safe(r) sex’ education which originated as a targeted Harm Minimisation approach for a particular group (sexually active gay men at risk of contracting HIV) has over the years become synonymous with the generalised aim of minimising sex related harm in the wider community. This confusion of targeted strategy and generalised aim/value has led to the current situation where the principles of ‘safe(r) sex’ underpin school based sex education curricula, a development which has also drawn criticism from those who see it as condoning and encouraging sexual activity for adolescents.

Is the risk of condoning drug use and sexual activity necessary or warranted in the school situation in order to ‘minimise’ harm?

Looking at schools

The historical context from which the Harm Minimisation strategy developed, the limitations and the target group, all have some bearing on the usefulness and appropriateness of this strategy in the educational setting.

A problem with Harm Minimisation as a health promoting strategy for the classroom is that it targets all teenagers. It sets up the expectation that all teenagers are using drugs which is not the reality for the majority, except in the case of alcohol use which over recent years has seen a dramatic increase. The Australian Drug Foundation reports the following statistics for 12 – 17 year olds:

  • 40% have had a full serve of alcohol *
  • 17% have tried inhalants **
  • 14.8% have tried cannabis **
  • 3% have tried hallucinogens **
  • 2.9% have tried amphetamines **
  • 2.7% have tried ecstasy **
  • 2.0% have tried non prescribed steroids **
  • 1.7% have tried cocaine **
  • 1.6% have tried heroin **

* 2010 National Drug Strategy Household Survey report

** 2011 Australian School Students Alcohol and Drug Survey

(Australian Drug Foundation, 2013)

These figures show that other than alcohol, the vast majority of teenagers have not used drugs. Experience and research also shows regular or problematic use of drugs is likely to be linked to other troubled behaviours. US researchers, for example, have found that teenagers who drink in order to reduce negative feelings (as opposed to drinking for social reasons such as copying friends’ behaviour or avoiding social rejection), were more likely to show problematic patterns of drug and alcohol use (Kuntsche et al, 2005).

In the case of sexual activity, by the age of 16 just over 1 in 4 and by age 19 50% of Australian teens are sexually active, meaning that the majority of school age teenagers are not (Smith et al 2008). Early sexual activity has been linked to a history of abuse, family dysfunction, alcohol and drug use and other issues including increasingly sexualised cultural pressures (see – Teen Pregnancy: Causes and Solutions). Does a Harm Minimisation approach benefit teenagers whose behaviour is to a greater or lesser extent influenced by underlying problems and cultural pressures? Does it benefit teenagers who are currently abstinent?

The original intention of Harm Minimisation reflects a compassionate and realistic approach of “being tolerant of the frailty of people who may be harming themselves but who aren’t capable of changing their behaviour” (Bevan, 1993). This approach may not be appropriate for teenagers who particularly need clear messages conveyed to them, nor for those most in need of help who may be least likely in the long term to benefit from such a permissive message.

The Harm Minimisation drug strategy is only one approach, an approach that is appropriate to those already taking drugs and who cannot be expected to cease their present drug use. Presenting an approach that indicates or suggests tolerance to harmful drug taking gives that message to all students. To take it a step further, there may be a possibility that a false sense of security is given inadvertently through the Harm Minimisation approach, for example, educating on how to give and gain assistance in the case of an overdose.

The aim of the Harm Minimisation approach is not to minimise the use but the harm – the message conveyed does not discourage the habit. One of the fundamental weaknesses of this strategy is that it is divorced from the underlying values that may prompt behaviour change. Teenagers need guidance as to the safest behaviours. Simply giving them information about how to reduce drug-related or sex-related risks is not enough.

Harm Minimisation deals with the consequences of the act and the final outcome. It does not deal with underlying reasons for drug misuse or sexual activity and doesn’t effectively communicate a ‘say no’ message to this age group. If health education is to work at this level, the bridge between intention, knowledge and action must not be cut. The message must be sufficient to be able to influence the intention to avoid smoking, drinking or drug misuse and to delay sexual activity.

Children and adolescents have a developmental need for guidance and boundaries which take into account their immature cognitive functions and capacity to judge complex situations. If guidance and support is what is needed in such situations then Harm Minimisation may not be the ideal starting point. By presenting a ‘safe(r) sex’ message, a Harm Minimisation strategy may just miss the mark. A preventive message that addresses the holistic needs of the adolescent may be more appropriate and beneficial in the long term.

Maximise the potential

Primary prevention is no doubt the best starting point for young people. The long-term goals of enhancing protective factors and making a positive contribution to the wellbeing of young people reflect a primary prevention approach that targets the whole population.

Schools are in a position to be able to implement preventative strategies of this nature. Programs which enhance resilience, self-esteem and life-skills as well as the quality of social relationships and environments, will work preventatively to maximise potential in contrast to the message given through the inherent limits of a harm minimisation approach for young people.

Resources from Open Doors Education

Resilient Kids

  • 2 CD-ROM Set – Primary and Secondary
  • interactive, engaging
  • complete Teacher’s Guide
  • Building resilience and life skills to overcome emotional depression

References

Australian Drug Foundation – theothertalk.org.au/wp-content/uploads/2013/07/ADF_Infographics_Landscape1.pdf, accessed 17/10/2013

Bevan, G. (1993) In a Spiritual Vacuum: The Religious Dilemma of Harm Minimisation. Connexions 13:6.

Smith A, Agius P, Mitchell A, Barrett C, Pitts M. 2009. Secondary Students and Sexual Health 2008, Monograph Series No. 70, Melbourne: Australian Research Centre in Sex, Health & Society, La Trobe University.

Kuntsche, E., Knibbe, R., Gmel, G. & Engels, R. (2005) Why do young people drink? A review of drinking motives. Clinical Psychological Review, 25(7), 841-861.

www.adca.org.au/advocacy/harm-minimisation, accessed 4/9/13.

 

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