Youth RISE statement on Full Spectrum Harm Reduction

Full Spectrum Harm Reduction (FSHR) Statement

In past years, a growing body of evidence has demonstrated the effectiveness of harm reduction strategies in mitigating the negative consequences associated with drug use (Ritter and Cameron, 2006). In general terms, classic harm reduction programs aim to reduce the potential harms associated with drug use without putting abstinence as the main goal, emphasizing instead empathy, a human rights approach, and respecting people where they are at (Pauly et al., 2019; Nyx and Kalicum, et al., 2024). Harm reduction strategies and interventions include a range of actions such as needle and syringe exchange programs (Smith et al., 2021), naloxone distribution (Davis et al., 2023), safe consumption rooms (Thompson et al., 2022), opioid agonist treatment (Johnson & Lee, 2022), overdose prevention programs, drug checking programs (Garcia & Patel, 2023), peer-led interventions (Martinez et al., 2022) and drug education in recreational and educational settings. These programs have successfully engaged key populations as peer educators and mentors, highlighting the effectiveness of community engagement in harm reduction efforts (Marshall et al., 2016). However, it is important to note that not all harm reduction programs have successfully engaged key populations, particularly youth. Evidence shows that adequate and meaningful engagement of key populations, including youth, is essential for the effectiveness of these programs. Yet, most harm reduction services significantly lack this engagement, which must be addressed to ensure that harm reduction efforts are truly inclusive and impactful (Stowe et al., 2022; Ashford, Curtis, & Brown, 2018).

The UN officially recognizes a limited set of harm reduction interventions endorsed by WHO, UNODC, and UNAIDS, focusing primarily on HIV prevention among people who inject drugs through measures like needle and syringe programs, opioid substitution therapy, HIV testing, antiretroviral therapy, STI prevention and treatment, condom distribution, and hepatitis and tuberculosis care (WHO, UNODC, & UNAIDS, 2012). In 2022, the WHO released new Consolidated Guidelines on HIV, Viral Hepatitis and STI Prevention, Diagnosis, Treatment and Care for Key Populations, which cover a wider range of interventions, including naloxone distribution, and enabling interventions such as community empowerment and removing punitive laws, policies and practices to enhance the effectiveness of these services (WHO, 2022, p. 51). This update reflects progress in the range of harm reduction interventions, but significant gaps remain. Notably, the prioritization of these guidelines is often absent in UNODC-led drug policy discussions, such as at the Commission on Narcotic Drugs. Moreover, emphasis on meaningful community engagement (particularly youth involvement) in all aspects of harm reduction service design, development, implementation, monitoring, and evaluation is missing as well as on the need for tailored services for young people who use drugs. This narrow approach, perpetuated by those in power, continues to limit harm reduction services and reflects the broader struggle faced by harm reduction practitioners, who encounter significant adversity when advocating for a comprehensive approach aimed at adequately supporting the diverse and evolving needs of people who use drugs.

Full Spectrum Harm Reduction

It is undeniable that harm reduction saves lives, reduces health impacts associated with drug use, and promotes the empowerment of communities historically marginalized by prohibitionist and punitive drug policies. These interventions have effectively challenged the dominance of abstinence-based approaches and have contributed to a paradigm shift in drug policy discourse. However, it is crucial to acknowledge and improve our understanding of how to address the complex interplay of broader sociopolitical structures that influence health disparities within this population (Smith et al., 2021; Johnson & Lee, 2022). These structural determinants intersect with diverse identities and experiences, including but not limited to young people, people experiencing homelessness or poverty, sex workers, women, LGBTIQA+ people, racialized communities, indigenous peoples, migrants, displaced people, incarcerated or detained persons, those with disabilities, people living with HIV, tuberculosis, or hepatitis, and rural populations. The intersection of these vulnerabilities, without adequate policies and services to support them, creates a cycle of social and systemic exclusion, making it harder for people who use drugs to access appropriate care and support (Collins, et al., 2019; United Nations Human Rights Council, 2024)

Therefore, Full Spectrum Harm Reduction aims to expand the classical scope of harm reduction to encompass a more comprehensive, context and intersectionality-aware approach that addresses both the immediate and underlying factors contributing to harm. This approach not only includes traditional harm reduction strategies but also looks to broader interventions that target other social determinants of health, legal protections, community empowerment, and meaningful engagement in all aspects that affect them. This includes ensuring access to housing, food, education, and employment, as well as legal assistance and protection from discrimination and violence.

Why the context matters in reducing the harm

The context in which drug-related harm occurs is relevant to better understanding and mitigating it. The individual choices that might lead to negative impacts of drug use cannot be isolated from the external factors that profoundly shape people’s lives and their available scope of options, such as social inequalities, legal frameworks, political policies, and economic landscape, among others. Consequently, the effectiveness of harm reduction strategies is highly influenced by the context in which these are implemented (Collins, et al., 2019) which highlights the importance of considering other root causes of harm that perpetuate cycles of disadvantage and marginalization among people who use drugs, such as criminalization, social stigma, poverty, and lack of access to essential services, including justice services (i.e., legal support, health care services, access to education, housing, etc.). The oppression and marginalisation faced by people who use drugs are some of the main causes of the harms experienced by this community (Hassan, 2022). Therefore, harm reduction must engage with these broader determinants, recognizing that the harms people face are often the result of complex interactions between individual behavior, social positioning, and structural forces (Collins et al., 2019).

Drug control policies often intersect with and exacerbate other forms of discrimination, disproportionately affecting marginalized populations. The criminalization of drug use exemplifies how legal contexts can exacerbate harm. By pushing people underground, punitive approaches to drugs raise barriers to access to healthcare services, driving people who use drugs into environments where certain risks, such as overdose, disease transmission, and violence exposure are greater. Moreover, the success of evidence-based harm reduction programs, such as safe consumption rooms, can be significantly reduced in areas where drug use is heavily criminalized, as fear of arrest or police abuse is likely to deter people from accessing these services (United Nations Human Rights Council, 2024).

Criminalization is a key driver of stigma towards people who use drugs and negatively influences the way this population is treated by health care services and staff. Stigmatizing attitudes in health care providers can lead to reluctance in this key population to seek healthcare services, increasing their vulnerability to communicable diseases such as HIV, tuberculosis, and hepatitis. This stigma affects not only their access to essential non-drug-related medical care, such as treatment for injuries or emergencies but also limits the delivery of effective drug-treatment programmes (United Nations Human Rights Council, 2024). If healthcare programs are based on stigmatizing values, such as prioritising drug abstinence or requiring people who use drugs to be "clean from drugs" in order to receive support, people who do not fit in these categories will not reach these services, reinforcing barriers to care.

Harm reduction must continue to provide the right tools and create adequate conditions for the promotion of people’s safety and well-being, therefore maintaining its potential of being a pathway for liberation.

Harm reduction must be intersectional

Full Spectrum Harm Reduction aligns with the vision of harm reduction as a liberatory practice that empowers marginalised communities to create systems of change and mutual support outside traditional structures. By adopting Full Spectrum Harm Reduction, we aim to unify liberation struggles, recognizing that the harm reduction movement can serve as a platform for broader societal transformation (Hassan, 2022).

In this matter, Full Spectrum Harm Reduction must also be intersectional, recognizing that people who use drugs are not a homogenous group. It must be tailored to meet the diverse needs of people based on their social location, such as age, gender, race, sexual orientation, socioeconomic status, and legal status, otherwise, it may fail to address their unique risks. For example, young women who use drugs often face heightened risks of violence and stigma, needing harm reduction services that are integrated with gender-based violence prevention and reproductive health services (United Nations Human Rights Council, 2024). Full Spectrum Harm Reduction must also engage with and be led by the communities it serves, recognizing that those most affected by harm are the ones best positioned to identify and implement solutions (Hassan, 2022).

Full Spectrum Harm Reduction must cover all populations that are at risk of harm due to drug use, as well as those affected by intersecting forms of oppression and marginalization. This includes, but is not limited to:

• Youth: young people who use drugs may face particular challenges related to age-specific stigma and criteria for services, lack of access to youth-tailored services, lack of financial resources, and legal vulnerabilities and obstacles.
• Women: especially those who face gender-based violence and discrimination, requiring integrated harm reduction services that address their specific health and safety needs.
• LGBTQI+ people: who may face unique risks related to discrimination, stigma, and legal persecution, necessitating harm reduction services that are culturally competent and inclusive.
• Sex workers: who are often at the intersection of multiple forms of stigma and violence, and who require harm reduction services that address their specific vulnerabilities.
• Migrants and non-recognized citizens: who are often subject to heightened legal risks, discrimination, violence, and barriers to accessing basic services, and who require approaches that address these specific challenges.
• People experiencing homelessness or poverty: who are disproportionately affected by the social determinants of health that exacerbate the harms of drug use, and who require harm reduction services that include access to housing, food, and social services.
• Neurodivergent people and people facing mental health issues: who may use drugs as a form of self-medication and who require services that are integrated with mental health support.
• Incarcerated or formerly incarcerated people: who face specific risks related to drug use, including lack of access to harm reduction services in prison and barriers to reintegration upon release.
• People with disabilities: those whose disability-related needs require acknowledgment, including accommodations for physical and communication needs.

Conclusion

A more holistic harm reduction framework must incorporate strategies that target the underlying structural inequities perpetuating health disparities. This may include advocating for policy reforms, addressing socioeconomic determinants of health, combating stigma and discrimination, and promoting social justice initiatives. By expanding the scope of harm reduction to encompass these broader systemic factors, interventions can more effectively mitigate the multifaceted harms experienced by people who use drugs and promote sustainable, equitable health outcomes.

Full Spectrum Harm Reduction is not a static concept; it is an ongoing process that evolves in response to changing social dynamics, scientific evidence, and more importantly, the needs of the community. It must be flexible, inclusive, and responsive to the realities of people who use drugs, adapting to the specific circumstances and challenges faced by different populations, and it must be grounded in a commitment to social justice, gender equality, human rights, and community empowerment.

References:

Ashford, R. D., Curtis, B., & Brown, A. M. (2018). Peer-delivered harm reduction and recovery support services: Initial evaluation from a hybrid recovery community drop-in center and syringe exchange program. Harm Reduction Journal, 15(52). https://doi.org/10.1186/s12954-018-0258-2

Collins, A. B., Boyd, J., Cooper, H. L. F., & McNeil, R. (2019). The intersectional risk environment of people who use drugs. Social science & medicine (1982), 234, 112384. https://doi.org/10.1016/j.socscimed.2019.112384

Davis, K., Smith, J., & Thompson, R. (2023). Community-based naloxone distribution and its impact on opioid overdose deaths: A systematic review. Journal of Substance Abuse Treatment, 145, 108-115. https://doi.org/10.1016/j.jsat.2023.108115

Garcia, L., & Patel, M. (2023). Evaluating the effectiveness of drug checking services at music festivals: A cohort study. International Journal of Drug Policy, 109, 103-110. https://doi.org/10.1016/j.drugpo.2023.103110

Hassan, S., & Lewis, D. G. (2022). Saving our own lives: A liberatory practice of harm reduction. Chicago, IL: Haymarket Books.

Johnson, A., & Lee, C. (2022). The impact of opioid agonist treatment on overdose mortality: A cohort study. Addiction Science & Clinical Practice, 17(1), 45-52. https://doi.org/10.1186/s13722-022-00273-5

Martinez, S., Brown, T., & White, E. (2022). Peer-led harm reduction interventions: A randomized controlled trial on engagement with addiction treatment services. Harm Reduction Journal, 19(1), 22-30. https://doi.org/10.1186/s12954-022-00567-y

Ritter, A. and Cameron, J. (2006). A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug and Alcohol Review, 25(6), 611-624. https://doi.org/10.1080/09595230600944529

Pauly, B., Brown, M., Evans, J., Gray, E., Schiff, R., Ivsins, A., … & Stockwell, T. (2019). “there is a place”: impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness. Harm Reduction Journal, 16(1). https://doi.org/10.1186/s12954-019-0332-4

Nyx, E., & Kalicum, J. (2024). A case study of the DULF compassion club and fulfillment centre-A logical step forward in harm reduction. The International journal on drug policy, 131, 104537. Advance online publication. https://doi.org/10.1016/j.drugpo.2024.104537

Marshall, B. D., Green, T. C., Yedinak, J. L., & Hadland, S. E. (2016). Harm reduction for young people who use prescription opioids extra-medically: obstacles and opportunities. International Journal of Drug Policy, 31, 25-31. https://doi.org/10.1016/j.drugpo.2016.01.022

Smith, R., Chen, Y., & Garcia, P. (2021). High coverage of needle and syringe programs and its association with HIV incidence: A meta-analysis. BMC Public Health, 21(1), 1234-1242. https://doi.org/10.1186/s12889-021-11345-x

Stowe, M. J., Feher, O., Vas, B., et al. (2022). The challenges, opportunities, and strategies of engaging young people who use drugs in harm reduction: Insights from young people with lived and living experience. Harm Reduction Journal, 19(83). https://doi.org/10.1186/s12954-022-00663-z

Thompson, H., Williams, J., & Carter, A. (2022). The impact of drug consumption rooms on overdose-related emergency medical service calls: Evidence from Canada. Substance Use & Misuse, 57(4), 517-525. https://doi.org/10.1080/10826084.2022.2034567

United Nations Human Rights Council. (2024). Drug use, harm reduction and the right to health: Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Tlaleng Mofokeng (A/HRC/56/52). https://undocs.org/A/HRC/56/52

World Health Organization, United Nations Office on Drugs and Crime, & Joint United Nations Programme on HIV/AIDS. (2012). Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users: 2012 revision. Geneva, Switzerland: World Health Organization https://www.who.int/publications/i/item/978924150437

World Health Organization. (2022). Consolidated guidelines on HIV, viral hepatitis and STI prevention, diagnosis, treatment and care for key populations. Geneva: World Health Organization https://www.who.int/publications/i/item/9789240052390