Reducing harms for people who use drugs: Emerging approaches and time-honoured programs

Prevention in Focus PiF 2022 Spring

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PiF Reducing harms

Harm reduction is a crucial part of supporting the rights and health of people who use drugs. The harm reduction movement has been developing, implementing and advocating for programs that meet the evolving needs of people who use drugs for decades. This article provides a brief overview of emerging approaches and time-honoured programs that prevent deaths and reduce harms for people who use drugs. It briefly describes the approaches, discusses related evidence and provides a snapshot of their current status in Canada.

Reducing the harms of what?

People use drugs for a wide range of reasons, including to feel good, to relax, to experiment, to manage their health, to cope with stress and/or trauma and to avoid withdrawal. For the vast majority of people who use drugs, their use does not cause problems in their lives.1,2 However, using drugs can sometimes lead to health issues, often called drug-related harms. These can include drug poisoning deaths, blood-borne infections such as hepatitis C and HIV, bacterial and soft tissue infections, and other harms. It is important to note that many of these harms are not necessarily caused by simply using drugs or by drugs themselves. Rather, they are driven by social systems, laws and policies that marginalize people who use drugs and shape the contexts in which people use drugs.3

Harm reduction is a movement, a philosophy and a set of principles that inform policies, programs and practices. It promotes the human rights of people who use drugs and aims to reduce harms associated with drug use, drug policies and drug laws.4 It is an adaptable approach to meeting community and individual needs. People who use drugs have always been leaders in the harm reduction movement, which has aimed to address root causes of harm.5,6 This aim includes challenging social systems, laws, policies and practices that drive drug-related harms — such as the criminalization and marginalization of people who use drugs. However, changing harmful systems has proven challenging, and the harm reduction movement has often had to work within and against these systems to promote the rights and health of people who use drugs. Harm reduction approaches aim to support people who use drugs to stay alive, protect their health and make the changes they want to make in their lives. Each harm reduction program provides opportunities to make connections with people who have been marginalized, build trusting relationships, provide education and make referrals to other health and social services.

Canada is in the midst of a worsening drug poisoning crisis: over 24,626 people have died because of opioid toxicity since 2016.7 This crisis is being driven by the prohibition of drugs,8 which has led to an unregulated drug supply that is toxic and unpredictable. Within this crisis context, ongoing advocacy by people who use drugs and their supporters has been crucial to implementing and developing new interventions that aim to reduce harms for people who use drugs.

Emerging harm reduction approaches

The harm reduction movement has been advocating for many of the following approaches for decades. Owing to the severity of the drug poisoning crisis and harm reduction advocates’ unrelenting efforts, there has been increased discussion and implementation of the following approaches in Canada. This means that evidence about their effects is evolving and their scope may be contested.

Decriminalizing drugs

Decriminalizing drugs refers to removing criminal sanctions related to drug possession for personal use and necessity trafficking (i.e., sharing or selling drugs to support personal drug use costs or to provide a safe supply).9,10 There are various ways that criminal sanctions can be removed. Broadly speaking, these include changing how existing drug laws are applied to reduce their impacts (i.e., depenalization), changing the laws themselves (i.e., decriminalization) or directing people away from criminal charges toward other services, such as education or treatment (i.e., diversion).10 When criminal sanctions are removed, other penalties and sanctions are sometimes introduced (e.g., administrative sanctions, fines, mandatory treatment).11 Full decriminalization involves changing the laws themselves without introducing new penalties or sanctions and is the gold standard advocated for by many people who use drugs.12 Efforts to decriminalize drugs are part of a movement for the rights of people who use drugs and a recognition that criminalization has disproportionately harmed marginalized communities.13

Decriminalizing drugs has many potential health and social benefits.11 For example, Portugal changed its laws to decriminalize all drugs in 2001 and invested resources into education, treatment and harm reduction. This case has been studied over many years and these combined approaches have been associated with reduced rates of HIV transmission, reduced rates of drug-related death, reduced rates of incarceration and increased access to treatment.11,14 However, even in places where drug possession is no longer treated as a criminal offence, people who use drugs still report experiencing punishment, stigma, surveillance and other harms.15 This is because there are many factors that influence the impacts of changes that aim to decriminalize drugs.15 These include the way that criminal sanctions are removed, what happens if someone is found with drugs, the amount of drugs that is considered personal possession and many other factors.12

Efforts to decriminalize drugs may be gaining traction in Canada. A recent survey suggests that 59% of Canadians support decriminalizing all drugs.16 Health Canada’s Expert Task Force on Substance Use has recommended ending criminal penalties and all coercive measures (e.g., forced treatment) related to drug possession.17 Recently, federal government lawyers were told to avoid prosecuting simple drug possession charges when possible.18 But the impacts of this move may be limited because changing how laws are applied allows for discretion that can lead to inconsistent and inequitable enforcement19 (e.g., because of systemic racism, racialized people may be more likely to be charged).  

For full decriminalization to happen across Canada, the federal Controlled Drugs and Substances Act would need to be changed. The Canadian Association of People Who Use Drugs has filed a lawsuit against the federal government asking that the laws criminalizing drug use be struck down.20 In the absence of changes to federal law, some jurisdictions (the municipal governments of Vancouver and Toronto and the provincial government of British Columbia) have requested exemptions to the Controlled Drugs and Substances Act to decriminalize drugs within their boundaries.21

Safe supply

Safe supply refers to “a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market.”22 Safe supply aims to provide people who use drugs with legal and regulated drugs of known contents and potency so that they do not have to use toxic versions from unregulated markets — ultimately saving lives. Safe supply includes a range of drugs as well as various models for dispensing them. It aims to reduce barriers to access, and it is often envisioned that the drugs can be used without clinical supervision.23 Safe supply programs often include support to access other health services.

Evidence about safe supply is emerging. Research and preliminary evaluations have found that safe supply is effective at reducing the need to access drugs from the illicit market24 and preventing deaths among people who are prescribed safe supply.24,25 Opioids prescribed as safe supply can include immediate-release hydromorphone tablets (Dilaudid), diacetylmorphine (heroin) and fentanyl in tablet, patch or liquid form.25,26 Many other drugs may be prescribed as safe supply, including dextroamphetamine (a stimulant) and diazepam (a benzodiazepine).26 Safe supply programs have also been associated with other positive health outcomes, including improvements in health and well-being, engagement in primary care and engagement in HIV and hepatitis C testing and treatment, reductions in homelessness, reductions in survival sex work, improvements in pain management and reductions in money spent on drugs, leaving more for other necessities.24,27

Safe supply is a harm reduction approach that is expanding in Canada. The majority of safe supply programs have operated through medical models involving prescriptions from healthcare providers (e.g., doctors, nurses). However, these models rely on the availability and willingness of healthcare providers, and their regulatory bodies, to provide a safe supply to people who use drugs. There are also concerns about medical models, which can have rigid requirements and limited clinical capacity and can lack suitable drug options (e.g., strong enough doses, injectable formulations, stimulants). In addition to medical models, approaches that involve expanding low-barrier access to safe supply have also been proposed or piloted. These include public health dispensing models (e.g., using machines to dispense doses)28 community-led compassion clubs29 and the legalization and regulation of drugs so they can be made available for purchase without prescriptions in licensed and controlled venues.30

Drug checking

Drug checking refers to services that provide people with more information about the composition of their drugs to allow them to make informed decisions on use of the drug. These services can also be used to monitor the unregulated market and inform broader policy and program initiatives including informing public health alerts, harm reduction interventions and advocacy for safe supply.31 Monitoring the drug supply includes identifying expected and unexpected substances, detecting new substances and detecting drugs of concern.32 Some common approaches to drug checking include providing people with test strips to check their drugs for specific substances (e.g., fentanyl, benzodiazepines) or using advanced technologies to analyze the full chemical composition of drug samples.33

Most existing research about drug checking has focused on rave and party settings, but newer studies have presented evidence from community settings. A systematic review found that drug checking services can influence people’s intentions and actions by analyzing their drug samples.32 This influence appears to vary depending on the setting and the population.32 For example, for people who use opioids, information from drug checking (e.g., detecting fentanyl) has been found to change behaviour in ways that can reduce the chance of overdose (e.g., doing a test shot, reducing the dose, not using alone).32 Drug checking services are used by people who use and/or sell drugs, as well as by others on their behalf (e.g., friends and family, harm reduction workers).34,35 Service users report that for drug checking programs to be successful they should be free, anonymous, quick and nonjudgmental, they should engage with people who use drugs and they should provide knowledge that can reduce harms from using or selling the drugs.36

Drug checking services have existed in Canada for decades and have often been offered at nightclubs, festivals and other events. Drug checking has expanded in recent years because of the drug poisoning crisis. There are now stand-alone programs and services integrated into supervised consumption (SCS) and overdose prevention sites (OPS), and access to fentanyl test strips has expanded in some regions.37,38 However, access to drug checking services that use advanced technologies remains very limited across the country.

Spotting

Spotting is an informal practice among people who use drugs of “witnessing” or observing someone who is using drugs in person or remotely by phone, video chat or an app to provide help in case an overdose occurs. People who use drugs typically connect with trusted family and friends for both in person and remote (e.g., by phone or text) spotting.39

Research on remote spotting is emerging. People who use drugs report that remote spotting provides access to overdose response when and where they need it, and some find it more comfortable to use spotting than to access traditional services.39 Spotting can be done at all hours, including when other services are closed, and provides access to supervised consumption for people who cannot access an SCS or OPS (e.g., people who smoke drugs or people who live in areas without an SCS or OPS).39 Barriers to spotting include the potential for delayed response in the case of an overdose, concerns about police attending an overdose and lack of consistent access to a cellphone.39,40

There are formal programs that build on the practice of spotting using toll-free phone lines and mobile apps. Some of these programs have been implemented during the COVID-19 pandemic in an effort to support people who use drugs to stay safe while physical distancing. A National Overdose Response Service (NORS) has started to provide remote spotting for people across Canada and an evaluation is underway.41

Time-honoured harm reduction programs

Time-honoured programs are interventions that have existed in parts of Canada for many years. This means that there is often strong evidence about their effectiveness. It is important to note that many of these approaches were first developed by people who use drugs. People who use drugs and their supporters continue to lead innovations that reduce barriers to access.

Supervised consumption sites (SCS) and overdose prevention sites (OPS)

SCS and OPS are similar interventions. They both provide people who use drugs with new harm reduction equipment and a safe, supervised space to use their drugs. Service users are monitored for signs of overdose by staff who are trained to respond to overdoses and other adverse events. Staff also provide people with education about safer use, support to meet other basic needs and referrals to other services. SCS and OPS both started as unsanctioned, community-led approaches. Now, SCS are permanent health services that require an application to the federal government for approval. OPS (sometimes called “urgent public health need sites”) are temporary interventions that can be approved by eligible provincial or territorial governments.42,43 They can be implemented more quickly to help save lives in a specific area.

SCS have been proven to reduce numerous harms for people who use drugs. These include reducing overdose deaths44,45 within the site and the surrounding area,46 reducing unsafe substance use practices44,45 and improving access to health and social services.45 OPS are associated with numerous health benefits.47 They have been found to prevent overdose deaths and related trauma, reduce shame and stigma related to drug use and increase trust and relationships between staff and service users.48

Access to SCS and OPS has expanded in recent years because of the drug poisoning crisis but remains limited across Canada.49 There are many cities and towns where people cannot access a safe place to use. Many SCS and OPS in Canada now allow people to inject, snort or swallow their drugs, but few allow people to smoke. Implementing sites where people can smoke their drugs is important to reduce barriers to services50 and address the fact that smoking has become the leading method of consumption resulting in overdose in some regions.51,52 More people may be switching to smoking because of the common misconception that it carries a lower risk of overdose than injecting, alongside an increasingly potent and unpredictable drug supply.53 Service providers have recently been permitted to allow peer-assisted injection and splitting and sharing of drugs within SCS and OPS.54,55 Permitting peer-assisted injection within SCS and OPS allows people who use drugs to prepare and administer injections for others accessing the service. This change allows people who need help injecting to access supervised consumption. Permitting splitting and sharing of drugs allows people to separate or transfer their drugs within SCS and OPS, rather than having to do it outside. These changes can help reduce barriers and harms for marginalized people who use drugs.56,57

Overdose education and naloxone distribution

Overdose education and naloxone distribution programs, also called take-home naloxone, involve giving out naloxone kits and training people on how to use them. Naloxone (brand name Narcan) is an opioid antagonist, which means it temporarily blocks the effects of opioids. It is used to reverse opioid overdoses and prevent deaths. Naloxone comes in two forms: injectable or nasal spray. Naloxone does not work on substances that are not opioids.

Overdose education and naloxone distribution programs are effective at preventing opioid overdose deaths. Systematic reviews of these programs have found that they provide long-term improvement in knowledge about opioid overdose, they reduce opioid-related mortality and there is a strong association between naloxone distribution and overdose survival.58,59 High-dose nasal naloxone has been found to be as effective as injectable naloxone, but low-dose nasal naloxone is less effective.59

Naloxone distribution has expanded in recent years because of the drug poisoning crisis. Every province and territory has a publicly funded program that gives out free naloxone in injectable form, and some regions also offer nasal spray.60 Provinces and territories have made naloxone available through different organizations. Organizations that commonly serve as naloxone distribution sites include pharmacies, health centres, harm reduction programs, treatment centres and other services.60 However, access varies significantly between provinces and territories.60 Each province and territory has their own criteria for who is eligible to receive a free naloxone kit and who can distribute kits.60 There are also challenges related to naloxone transportation and distribution in rural and remote areas, and stigma continues to limit access in some regions.60

Opioid agonist treatment (OAT) and injectable opioid agonist treatment (iOAT)

OAT and iOAT are treatment approaches for people who have been diagnosed with an opioid use disorder. Both involve prescribing medications that are a substitute for illicit opioids.

OAT medications are long-acting opioids that help prevent withdrawal without providing psychoactive effects. In Canada, the most commonly available forms of OAT are methadone and buprenorphine.61 In some cases, slow-release oral morphine (Kadian) can also be prescribed as OAT.61 OAT medications are prescribed by healthcare providers. Most OAT medications are oral and taken daily. Long-acting buprenorphine is an OAT medication that can be injected under the skin by healthcare providers on a biweekly or monthly basis.

Medications used for injectable OAT (iOAT) include diacetylmorphine (heroin) or injectable hydromorphone. These can be prescribed by a physician to someone for whom standard OAT has not worked.62 With iOAT, people inject the medications themselves under clinical supervision, up to three times a day.

Both OAT and iOAT are effective at reducing multiple harms for people who use opioids. They have both been proven to support people who use drugs to reduce their need to use illicit opioids and reduce morbidity and mortality. 61,62 OAT has been found to reduce the risk of HIV and hepatitis C transmission,63,64 overdose deaths, and deaths from all causes.65 IOAT has also been found to reduce behaviours that can lead to HIV and hepatitis C transmission. 66

However, long-term retention in OAT is a challenge: between 46% and 65% of people who start OAT with methadone discontinue treatment within the first year, and only 30% to 60% of people who start OAT with buprenorphine stay in treatment after six months.67 Retention in iOAT is higher: between 67% and 88% of people who start iOAT with diacetylmorphine are still in treatment after 12 months.67 For iOAT with injectable hydromorphone, the retention rate is similar (77%).67

The capacity to provide OAT in Canada has increased dramatically over the past two decades.68 However, access is not universal as different provinces and territories have varying program requirements and capacity related to OAT.68,69 Access to iOAT in Canada is very limited. In 2019, only five cities had iOAT programs, with a total capacity to provide iOAT to 420 people.70 Regulatory barriers to iOAT have been reduced.71 However, more changes are needed. These include improving access to diacetylmorphine, covering high-concentration injectable hydromorphone under provincial and territorial drug plans and providing additional funding to reduce barriers to access and increase availability.70

Harm reduction equipment distribution

Harm reduction equipment distribution, sometimes called needle and syringe programs (NSPs), involves distributing new supplies for safer substance use, with no limit on how much an individual can take. NSPs also collect used supplies for safe disposal. Harm reduction equipment can be distributed in multiple ways,72 including from fixed sites, from satellite sites, through outreach, through the mail and through “peer-to-peer” (i.e., secondary) distribution.

When equipment used to inject, smoke or snort drugs is reused by another person, it can lead to the transmission of infections such as hepatitis C or HIV. Reusing equipment or using homemade supplies can also cause harms, including bacterial infections, vein damage from injecting and cuts and burns from smoking.

Distributing harm reduction equipment for safer injecting, smoking and snorting has been proven to be an effective way to prevent or reduce many potential harms, including behaviours that can lead to HIV and hepatitis C transmission.73–76 Programs that distribute harm reduction equipment can often be an important point of contact with the healthcare system for people who use drugs, and they can help people to access other services. Combining harm reduction equipment distribution with other programs can increase their effectiveness.76

There are inequities in access to harm reduction equipment in Canada. Each province and territory decides which equipment it will distribute and how much funding it will provide for harm reduction supplies. This means that people who use drugs can access certain equipment in some provinces and territories but not others. For example, all provinces and most territories distribute some safer injecting equipment but safer smoking and safer snorting equipment is not as widely available, even though drugs are smoked more often than they are injected.53

Policy implications for coverage and sustainability

In terms of coverage, access to some harm reduction programs has expanded in recent years and some barriers to access have been reduced. However, these approaches have not been adequately resourced or equitably implemented across the country to meet the scale of the crises that people who use drugs face. This inequity is often exacerbated in rural and remote communities, where there can be major gaps in services.77 Communities must be provided with resources and flexibility to implement approaches that meet their needs.

The sustainability of harm reduction in Canada remains a challenge.49 Implementing many harm reduction approaches often involves a combination of funding and approval from federal and regional governments. Shifting politics and priorities have influenced the availability, capacity and sustainability of many harm reduction programs.78 Relying too much on pilot funding also has the potential to undermine the sustainability and effectiveness of many harm reduction programs. Systems and strategies that can support effective pilot projects to continue, scale up, share knowledge and be replicated are urgently needed.79

Implications for service providers

The harm reduction movement is adapting to the increasing harms of the drug poisoning crisis, and service providers need to understand the approaches and services that can help to appropriately meet the needs of people who use drugs. Emerging and time-honoured harm reduction approaches each play important roles in reducing the harms of criminalization, prohibition and other social systems that marginalize people who use drugs. For service providers, each approach provides opportunities to make connections and build relationships with (and between) people who use drugs. These connections and relationships are often the basis for reducing harm; they can lead to building trust and support between people who have been marginalized and discriminated against and service providers. Service providers must prioritize the needs and perspectives of people who use drugs in the development, implementation and evaluation of all approaches that aim to serve them.

Resources

Best Practice Recommendations for Canadian Harm Reduction Programs

Decriminalization done right: a rights-based path for drug policy

Safe Supply: Concept Document

Drug Resource and Education Project

How to Spot Someone so They Never Use Alone

The drug toxicity and overdose crisis in Canada: a snapshot of what the current data tell us

Safe supply: What is it and what is happening in Canada?

Opioid agonist therapy: Does it have a role to play in helping to prevent hepatitis C and HIV?

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About the author(s)

Magnus Nowell is CATIE’s knowledge specialist in harm reduction. Magnus has previously worked in harm reduction research, community organizing and housing. He has a master’s degree in health promotion.

Externally reviewed by: Dr. Carol Strike & Jo Parker