Harm reduction and 12 steps: complementary, oppositional, or something in-between?

A qualitative exploration of harm reduction in practice by street-based peer outreach workers

BACKGROUND

Despite the widespread use of the phrase "harm reduction" and the proliferation of programs based on its principles during the current opioid epidemic, what it means in practice is not universally agreed upon. Harm reduction strategies have expanded from syringe and needle exchange programs that emerged in the mid-1980s primarily in response to the HIV epidemic, to include medication for opioid use disorder, supervised consumption rooms, naloxone distribution, and drug checking technologies such as fentanyl test strips. Harm reduction can often be in tension with abstinence and recovery models to address substance use, and people who use drugs may also hold competing views of what harm reduction means in practice. Street-based outreach workers are increasingly incorporated into harm reduction programs as part of efforts to engage with people more fully in various stages of drug use and nonuse.

METHOD

This paper explores how peer outreach workers, called "members," in a street-based naloxone distribution program define and practice harm reduction. We interviewed 15 members of a street-based harm reduction organization in an urban center characterized by an enduring opioid epidemic. Inductive data analysis explored harm reduction as both a set of principles and a set of practices to understand how frontline providers define and enact them.

RESULTS

Analysis revealed that when members talked about their work, they often conceptualized harm reduction as a collection of ways members and others can "save lives" and support people who use drugs. They also framed harm reduction as part of a "path toward recovery." This path was complicated and nonlinear but pursued a common goal of life without drug use and its residual effects. These findings suggest the need to develop harm reduction programs that incorporate both harm reduction and recovery to best meet the needs of people who use drugs and align with the value systems of implementers.

Ethical Issues in Treating Substance Use Disorders: Counselor Perspectives

Ethical issues arise frequently in the treatment of substance use disorders (SUD). Counselors need guidance to navigate ethical dilemmas but receive limited training in resolving ethical issues. To narrow the gap between the ethical dilemmas counselors face and their training, this qualitative study assessed ethical issues that counselors encounter, how they resolve them, and desired training. We conducted qualitative individual interviews with 20 front-line counselors working in two SUD treatment programs, presenting brief vignettes that depicted the ethics code of the national organization representing SUD counselors. The interviews asked open-ended questions about how counselors dealt with issues and their ideas for future ethics training. All participants had encountered ethical dilemmas. Areas of concern included confidentiality and privacy, mandatory reporting, fairness/equity, client-counselor boundaries, tensions between workplace and client welfare, and meeting clients' complex needs. Ways participants resolved ethical issues included consultations, using direct approaches to resolve ethical dilemmas, and commitment to providing client-centered care. Useful training in the workplace was sparse. Participants expressed needs for ongoing support to resolve workplace ethical dilemmas. Although the importance of ethical issues is widely acknowledged in treating SUD, this study underscores the need for ongoing and interactive training and supervision about ethical issues.

Need for strategic communications and stakeholder engagement to advance acceptability of an overdose preventing vaccine targeting fentanyl

BACKGROUND

Fentanyl is a synthetic opioid, exposure to which has led to hundreds of thousands of overdose deaths. Novel vaccines are being developed that might protect against fentanyl overdose. Proactive attention to strategic communications and stakeholder engagement may smooth uptake of a novel vaccine given known challenges around vaccine hesitancy and concern for stigma related to substance use.

METHODS

Qualitative interviews (N = 74) with a purposive sample of adolescents/young adults with opioid use disorder (OUD), family members of persons with OUD, experts in substance use treatment and harm reduction, and community members were conducted and thematically analyzed to discern attitudes toward a fentanyl vaccine, and directions for communications and engagement.

RESULTS

Major themes reflected personal concerns for biomedical risk and system-level concerns for alignment and integration of an overdose preventing vaccine with prevailing beliefs about addiction and associated frameworks and philosophies for treatment and response.

CONCLUSION

Acceptability and implementation of a novel fentanyl vaccine targeting overdose will need precision communications that address biomedical, moral/spiritual, and structural perspectives about the nature of addiction. Education about the purpose and limits of a fentanyl vaccine, partnerships with diverse stakeholders from throughout the opioid response ecosystem and interweaving of a vaccine strategy into comprehensive prevention and treatment are recommended.

A survey of educator perspectives toward teaching harm reduction cannabis education

INTRODUCTION

Substance use is common among youth which can adversely affect youth health. Despite the legalization of cannabis in Canada and much of the United States, there is a lack of harm reduction cannabis education in schools. In addition, educators may not feel prepared to teach students about cannabis.

METHODS

A cross-sectional survey explored educator perceptions toward teaching harm reduction substance use education to students in grades 4-12. Data analysis included descriptive statistics to evaluate demographic variables, ANOVAs to identify subgroup differences, and inductive thematic analysis to establish themes from open-ended responses. From the sample of 170 educators, the majority were female (77%) and worked as classroom teachers (59%).

RESULTS

Ninety-two percent of educators felt harm reduction was an effective approach to substance use education, and 84% stated that they would feel comfortable teaching cannabis harm reduction education to students. While 68% of educators believed they would be able to recognize if a student was under the influence of cannabis, only 39% felt certain about how to respond to student cannabis use, and just 8% felt that their current teacher training allowed them to intervene and prevent cannabis-related harms. Most educators (89%) expressed interest in harm reduction training, particularly interactive training (70%) and instructor-led lessons (51%). Online curriculum resources were preferred by 57%. Responses differed by gender and age group, with females of any age and educators under 40 reporting greater support of harm reduction approaches and more interest in training.

CONCLUSION

Educators expressed considerable support for harm reduction substance use education, but many felt unprepared to address this topic with students. The findings identified a need for educator training on harm reduction substance use education, so that educators can help students make informed choices around substance use, thereby promoting youth health and safety.

The Potential for Managed Alcohol Programmes in Scotland during the COVID-19 Pandemic: A Qualitative Exploration of Key Areas for Implementation Using the Consolidated Framework for Implementation Research

People experiencing homelessness and alcohol dependence are at increased risk of a range of harms, including from COVID-19. Managed Alcohol Programmes (MAPs) are an alcohol harm reduction intervention specifically for this group. In this paper we report on qualitative findings of a mixed methods study investigating the potential utility of MAPs during the COVID-19 pandemic in Scotland. Interviews, conducted with 40 participants, explored potential views of implementing MAPs during the pandemic. Theoretically, we drew on the Consolidated Framework for Implementation Research (CFIR) to inform data collection and analysis. Six themes were identified which mapped onto three CFIR domains: perceptions of MAPs and the evidence base; necessary components of MAPs; changing culture of alcohol harm reduction; MAPs as a moral and ethical grey area; addressing a service gap; and securing buy-in and partnership working. Participants were generally positive about MAPs and viewed them as a key intervention to address a service gap. Several necessary components were identified for successful implementation of MAPs. Securing buy-in from a range of stakeholders and partnership working were deemed important. Finally, MAPs require careful, long-term planning before implementation. We conclude that MAPs are needed in Scotland and require long-term funding and appropriate resources to ensure they are successful.

A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study

BACKGROUND

For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues.

OBJECTIVES

The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial.

DESIGN

A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures.

SETTING

The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England.

PARTICIPANTS

Participants were people experiencing homelessness and problem substance use (n = 68) (intervention).

INTERVENTION

This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support.

MAIN OUTCOME MEASURES

Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure.

RESULTS

The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies.

LIMITATIONS

Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited.

CONCLUSIONS

A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention.

FUTURE WORK

A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments.

TRIAL REGISTRATION

This trial is registered as ISRCTN15900054.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.

Stigmatization of medications for opioid use disorder in 12-step support groups and participant responses

Background: 12-step groups are the most common approach to managing opioid use disorder (OUD) in the U.S. Medications for OUD (MOUD) are the most effective tool for preventing opioid misuse and relapse. Previous research has identified stigma of MOUD in 12-step groups. Objectives: We sought to identify how MOUD stigma is operationalized in 12-step groups and to identify responses to stigma. Methods: We recruited individuals with both MOUD experience and 12-step group experience from three syringe exchange programs in the U.S. using snowball sampling. We conducted individual telephone semi-structured interviews during 2018 and 2019. We coded data in Dedoose software and conducted thematic analysis using iterative categorization. Results: We recruited 30 individuals meeting our inclusion criteria. The following stigma operationalization methods were identified: prohibiting people using MOUD from speaking at meetings; encouraging shortened duration of MOUD treatment; refusing to sponsor people using MOUD; and refusing to let people using MOUD claim recovery time. Responses to stigma included the following: feeling shame; feeling anger; shopping around for different groups, leaving the group, or forming a new group; not revealing MOUD utilization or only telling a sponsor; speaking out on behalf of MOUD; and using cognitive approaches to avoid stigma internalization. Cognitive approaches included believing that anti-MOUD stigma is contrary to 12-step principles; disregarding statements as inaccurate based on one's experience of MOUD benefits; and accepting that all groups of humans have some ignorant people. Conclusion: Healthcare systems should help address MOUD stigma experienced by patients in 12-step groups, such as by offering non-12-step alternative groups and encouraging MOUD healthcare providers to prepare patients for potential stigma they may face. Some stigma response options, like shopping around for different groups, may not be feasible in rural areas or for participants newer to recovery.

An Apologetic Interpretation of Alcoholics Anonymous (AA): Timeless Wisdom, Outdated Language

BACKGROUND

The Twelve Steps of Alcoholics Anonymous (AA) has proven to be an effective aid in recovery for many people with alcohol use disorder. While constructive criticisms of AA can be beneficial to the organization, other criticisms have merely served as rhetorical devices intent on discrediting the 12-step approach.

OBJECTIVES

This paper examines six prominent critiques of AA, paying special attention to the premises, tone, and factual basis of the statements. Interpretations grounded in AA literature are offered to address claims or critiques around prominent themes, which are organized into two main classes: purported causes of alcoholism and factors maintaining alcoholism.

RESULTS

Findings reveal tenuous statements in the AA literature that appear contradictory and thereby invite a misreading. These statements, some of which misrepresent the tenets of AA and its founders, underscore certain vocal criticisms that are not entirely unfounded. While many pages of the AA literature are imbued with timeless wisdom, even the most apologetic interpretations-distilled into benefit-of-the-doubt renderings-largely falter in defending the nature of the language that originated in the early 1900s at odds with 21st century understandings of alcohol use disorder. Conclusions/Importance: The AA literature essentially presents a valid target for critics, fueling resistance to this free community-based resource that may prevent people who could benefit from AA from seeking the help of the 12-steps.

"We know the streets:" race, place, and the politics of harm reduction

This paper explores how a peer-and street-based naloxone distribution program (Bmore POWER) reshapes narratives and practices around drug use and harm reduction in an urban context with an enduring opioid epidemic. Data collection included observations of Bmore POWER outreach events and interviews with peers. Bmore POWER members create a sense of community responsibility around overdose prevention and reconfigure overdose hotspots from places of ambivalence to places of grassroots action. It expands a harm reduction approach to Black communities that have not traditionally embraced it and that have been underserved by drug treatment programs. Policy makers should consider ways to use peers grounded in specific communities to expand other aspects of harm reduction, such as syringe and support services.

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Background

People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group.

Methods

Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model.

Results

Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user’s perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people’s lives.

Conclusion

This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted. The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals’ complex lives.

A home for body and soul: substance using women in recovery

BACKGROUND

We report on an in-depth qualitative study of 28 active and former substance addicted women of low or marginal income on the core components of a harm reduction-based addiction recovery program. These women volunteered to be interviewed about their perceptions of their therapeutic needs in their transition from substance addiction to recovery.

METHOD

Data were gathered about women's experiences and essential needs in addiction recovery, what helped and what hindered their past efforts in recovery, and their views of what would constitute an effective woman-centred recovery program. The research was based upon the experience and knowledge of the women in interaction with their communities and with recovery programs. The study was informed by harm reduction practice principles that emphasize the importance of individual experience in knowledge construction, reduction of harm, low threshold access, and the development of a hierarchy of needs in regard to addiction recovery.

RESULTS

Three core needs were identified by study participants: normalization and structure, biopsychosocial-spiritual safety, and social connection. What hindered recovery efforts as identified by participants was an inner urban location, prescriptive recovery, invidious treatment, lack of safety, distress-derived distraction, problem-focused treatment, coercive elements of mutual support groups, and social marginalization. What helped included connection in counselling and therapy, multidisciplinary service provision, spirituality focus, opportunities for learning and work, and a safe and flexible structure. Core components of an effective recovery program identified by women themselves stand in contrast to the views of service providers and policymakers, particularly in regard to the need for a rural location for residential programs, low threshold access, multidisciplinary service provision of conventional and complementary modalities and therapies for integrated healing, long-term multi-phase recovery, and variety and choice of programming.

CONCLUSION

A key barrier to the addiction recovery of women is the present framework of addiction treatment, as well as current drug laws, policies and service delivery systems. The expectation of women is that harm reduction-based recovery services will facilitate safe, supportive transitioning from the point of the decision to access services, through independent living with community integration.