top of page

Another Great Article by Dr. Jay Bouldin

Three Major Prevention Frameworks for the Addiction Professional Harm Reduction:

The term harm reduction is sometimes referred to as harm minimization and is used with variety of interpretations. Harm reduction is better considered as a difference in emphasis rather than a radical departure from conventional responses. The essence of harm reduction is a mainly focused on reducing adverse consequences of drug use. Some are now saying this framework when in place can impact drug consumption and may even regarded it as a lower priority to some. “In contrast to harm reduction, supply control reduction as a model has dominated approaches with regard to a reduction of consumption as the primary objective, with any reduction of adverse consequences considered a bonus”(Holder, HD) The idea of harm reduction is founded in the notion that the better result in reduced harm and it is seen as important throughout public health as well as many other areas of public policy. Harm reduction is one of the main constituents in the on going development of federal and local drug policy and procedure. The risk-compensation hypothesis in psychology and the concept of moral hazard in economics and finance resemble this concept of harm reduction. Harm reduction objectives are often ranked in a hierarchy with the most feasible and reasonably acceptable options preferred over the non-achievable more desirable options. For example, 'the least-worst option from an human immunodeficiency virus (HIV) prevention perspective for injecting drug users unable or unwilling to abstain from injecting drugs is ensuring the use of sterile injecting equipment on every drug-injecting occasion. In contrast, the sharing of needles and syringes is the worst option.' Chapter 31, PoAM. A more expanded view of harm reduction emphasizes the maximization of the potential benefits as an aim additional to minimizing potential harms of substance abuse. Accordingly, emphasis is given to more judicious use of dependence-producing medications. For example, 'the common practice of sub-optimal prescription of opioids in the management of cancer and chronic nonmalignant pain often results in considerable distress from inadequate pain relief.' (Chapter 31, PoAM) This excessive fear of inducing drug dependence despite a cancer patient's limited life expectancy is often times a significant factor in the decision to prescribe sub-therapeutic doses of analgesics. Similarly, the evidence that medicinal use of cannabis is relatively safe and has many worthwhile benefits is growing and becoming commonplace. The benefits of THC Therapy can include amelioration of distressing symptoms of cancer chemotherapy and AIDS patients which are sometimes unrelieved by conventional medications, yet availability of medicinal cannabis is still limited. These types of concerns many harm reduction supporters who favor policy based on the same kind of rigorous evaluations found within the costs and the benefits of harm reduction approaches as seen in other attempts to prolong life or alleviate suffering. Harm reduction does not exclude abstinence as a goal for individuals who are dependent but it does provide people with more pragmatic choices through education and support where the beneficiaries include people who use drugs as well as their families and the communities which they live. Harm reduction approaches are not intended primarily to reduce consumption of drugs but it is often the unintended long term result however. Though harm reduction frameworks have grown largely out of public health concerns it has become an increasingly important in the larger consideration on drug policy found in Washington as well as in state legislatures.

Environmental Approaches:

The environmental approach to the prevention of drug use targets the physical, social, and economic factors that will actually contribute to drug abuse. A variety of channels may be used in this approach include; the media, policymakers, and legislators. One well known examples of environmental approaches include the increasing of prices and taxes on legal drugs such as alcohol to limiting days and hours during which alcohol can be sold. These policies have shown to be effective and are becoming increasingly popular.

Communities have begun to go beyond public drug policy to affect their environments. In the case of alcohol consumption local policymakers may establish the priorities for community action to reduce risky behavior involving drinking which may, in turn, reduce the number of alcohol-involved problems. For example, 'local alcohol policies can make it a priority to enforce laws against drinking and driving, violence, or sales of alcohol to youth; to mandate server training for bars, pubs, and restaurants; or to promote written policies and training for responsible alcoholic beverage service by licensed retail establishments'.(Ch 25 PoAM). Existing national and state laws provide the legal basis for many local policymakers can land will enable local communities to prioritize and monetize the use of existing resources found within these legal frameworks in order to achieve specific objectives. In short, national as well as local, regional laws often establish the base for local policies which include but are not limited to; legal drinking ages, regulation of alcohol outlets, the legal blood alcohol level for driving after drinking, advertising restrictions, and service to obviously intoxicated persons and underage persons. Additionally, local policies often address the implementation and enforcement of these existing laws. Environmental prevention strategies appear to have a critical role in reducing alcohol problems. 'Such strategies have demonstrated effectiveness in terms of population-level outcome measures (e.g., reductions in alcohol-involved motor vehicle crashes) and drinking among both heavy and moderate users and have been characterized by maintained effects extending beyond the initial implementation periods.'(Ch 25 PoAM). Environmental interventions are proving to be politically feasible because they do not target specific subgroups in a discriminatory manner. In general, they are cost-effective because they do not require case finding, service provision, or cost maintenance. Moreover, 'environmental prevention strategies provide a number of levers for change, including tax codes, alcohol beverage control laws, laws regulating drinking and driving and minimum drinking ages, administrative regulation of outlets, planning and zoning regulations and conditional use permits, and law enforcement policies.' (Chapter 31, PoAM)

Environmental approaches to the reduction of alcohol and drug problems share a number of important characteristics and contrast sharply to more traditional approaches that focused on individuals and abstinence or treatment. First,' environmental approaches seek to change community systems that are related to substance use and the occurrence of related problems. Such efforts often include changing formal institutions (e.g., reducing hours and days of sale of alcohol) but also may include attempts to change informal systems (e.g., breaking up markets for illegal drugs)' (25). The second way in which the two approaches differ is in their use of the media. Traditional approaches target individuals whereas environmental approaches typically target policymakers or gatekeepers such as state legislators, law enforcement agencies, or even parents within families. It is presented that changes in community systems cannot be accomplished without the support of relevant gatekeepers to systems that enable prevention efforts. Thus, media efforts in environmental prevention programs often are intended to motivate gatekeepers to pursue activities that are extensions of their normal efforts. Environmental approached interventions can also use media to increase public awareness or to influence social norms where the community is viewed as a resource to mobilize for structural and system change with a subsequent focus on policy interventions for newer drug policy.

Community Coalitions:

Community-based prevention programs aim for broad outreach by integrating several strategies in multiple settings. Interventions include programs in schools, religious institutions, businesses, and other community settings. They often use a cognitive-behavioral approach to educate young adults while attempting to promote life skills such as coping strategies for dealing with peer pressure. Community-based prevention strategies are among the most common approaches to substance use prevention. The most effective prevention programs are those that are appropriately timed, comprehensive in content, theory driven, socioculturally relevant, well-staffed, and focused on skill development

Community-based drug abuse prevention programs typically have multiple components, including some combination of school-based programs, family or parenting components, mass media campaigns, and public policy components such as restricting youth access to alcohol and tobacco as well as other types of community organization and activities. The multiple components of a community-based intervention may be managed by a coalition of stakeholders including; parents, educators, and key leaders in the community.

A recent Cochrane Review examined community-based programs to prevent smoking initiation in children and adolescents. 'This qualitative narrative synthesis included RCTs and studies using quasi-experimental designs including a control or comparison group in which the effectiveness of multi-component intervention were compared to no intervention, to a school-only program, or to another single-component intervention. Seventeen studies were included in the review.' (35) Among the 13 studies that compared community interventions to no intervention controls only two programs produced lower smoking prevalence in the intervention versus control groups. One of two studies that compared a community intervention to school-only program found behavioral effects on smoking. Two studies found behavioral effects on smoking for multi-component community interventions compared to mass media-only campaigns. The authors subsequently concluded that there may be some limited support for the effectiveness of a coordinated multi-component community prevention program in reducing smoking among young people and that programs with multiple components prevent smoking behavior more effectively than do programs with a single component.

Despite the progress that has been made in the field of drug abuse prevention for children and adolescents, there are several factors that reduce the public health impact of effective school, family, and community prevention programs. Most schools still use non-evidence-based prevention programs, effective family programs often do not reach the families in greatest need and community programs require substantial financial and human resources. In addition to refining our understanding of the risk and protective factors for substance abuse as well as translating this knowledge into improved interventions, future research is necessary to find ways to effectively disseminate the most promising prevention programs into our schools, families, and communities.

In summary, multi-component community-based prevention programs can be effective in preventing adolescent substance use, particularly when the different components focus on a coordinated, comprehensive message. A limitation of community-based programs is the expense and high degree of coordination is needed to implement and evaluate the type of comprehensive programs that will most likely be effective.

Physicians and Drug Policy:

Physicians and other health professionals should have a basic understanding of drug policy at the very least. In my opinion, physicians should have a comprehensive and detailed knowledge of federal and state drug policies and procedures. As I have said before, physicians are the first line of defense against drug abuse. I have seen this first hand on elective in primary care clinics in many different places where prescription drug abuse is an epidemic in this country. A basic knowledge should be built further with continuing education of drug policy which will serve to enhances the physicians role in the war on addiction. Not only can physicians execute their knowledge of good policy for the welfare of their patients, but to their staff as well. Additionally, physicians can will will continue to learn how to prescribe pain medications safely and effectively. CME courses provide practical guidance for clinicians when screening their pain patients for risk factors before and after prescribing. They also help medical professionals identify substance abuse issues and longer term substance use disorders when patients are using and abusing their medications. Physicians may provide literature and educational videos that model effective communication about sensitive issues like substance abuse without losing sight of addressing pain. Gil Kerlikowske, Director of National Drug Control Policy says, “It’s no coincidence that our strategy to address our nation’s prescription drug abuse epidemic begins with education. She goes on further to say that All of us, parents, patients, and prescribers have a shared responsibility to learn more about this challenge and act to save lives. Prescribers in particular play a critical role in this national effort and I strongly encourage them to take advantage of this training to ensure the safe and appropriate use of painkillers.”(11)

Drug Policy can be viewed as the very foundation upon which society will act within their communities. Drug use and abuse affects every sector of society, our economy, our healthcare and our criminal justice systems endangering the futures of our communities, especially our young people. While many challenges remain, overall drug use in the United States has dropped substantially over the past thirty years. I am agree to the belief that this success is in part by accurate implementation and proper execution of ethical drug policy which are founded in the frameworks of prevention.

References: Chapters 21,30, 96 Principles of Addiction Medicine

25. Holder HD. Alcohol and the community: a systems approach to prevention. Cambridge: Cambridge University Press, 1998.

26. Hawkins JD, Catalano RF, Miller JY. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention. Psychol Bull 1992;112(1):64–105.

6. International Harm Reduction Association. Organization Web site, 2006. Retrieved July 10, 2008, from http:// Whatisharm reduction.

7. Select Committee on Science and Technology, House of Lords. Cannabis: the scientific and medical evidence (report to the United Kingdom Parliament). London: The Stationery Office, 1998.

8. Joy JE, Watson SJ, Benson JA. Marijuana and medicine: assessing the science base. Washington DC: National Academy of Sciences, Institute of Medicine, 1999.

9. Lurie P, Reingold AL, Bowser B, et al. The public health impact of needle exchange programs in the United States and abroad, vol. I. San Francisco: University of California, 1993.

10. Heimer R. Can syringe exchange serve as a conduit to substance abuse treatment? J Subst Abuse Treat 1998;15:183–191.

11. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Journal of the American Medical Association 1998;280(22):1936–1943.


bottom of page