Harm Reduction and Risky Behaviors

by

Sarah K. S. Shannon

• LAST REVIEWED: 24 May 2017
• LAST MODIFIED: 24 May 2017
• DOI: 10.1093/obo/9780195396607-0222

Introduction

Harm reduction is a pragmatic, humanistic approach to high-risk behaviors, such as drug use and sex work, that focuses on mitigating the harmful consequences of such behaviors rather than eliminating the behaviors themselves. While there is some debate over the definition of harm reduction (sometimes referred to as harm minimization, risk reduction, or risk minimization), in general this perspective takes for granted that people will engage in risky behavior and posits that high-stakes goals such as abstinence, while desirable, are not practical. Instead, harm reduction strategies use a public health framework to understand and address high-risk behaviors. As such, harm reduction policies and programs generally employ methods to minimize or mitigate the harmful effects of high-risk behaviors for individuals and communities. The harm reduction approach is an alternative to more traditional definitions of high-risk behavior, such as the moral/criminal or disease models. The moral/criminal perspective assumes that people engage in high-risk behaviors due to personal failings that must be corrected or punished, while the disease model posits biological or genetic pathology that must be overcome. Unlike these models, harm reduction takes a middle-range approach by addressing the harmful consequences (rather than causes) of high-risk behaviors. Moral/criminal and disease models have been predominant in the United States, most notably in the War on Drugs, but harm reduction strategies emerged in the 1970s and 1980s in Europe, Canada, and Australia initially in response to the link between HIV infection and injection drug use. Prominent examples of harm reduction approaches related to substance use include safe needle and syringe exchanges, methadone maintenance, and tolerance areas where, for example, drug users can gather and obtain clean injection equipment without facing reprisal. In addition to responding to public health concerns like disease transmission, other social harms such as criminalization and stigmatization are a focus of discussion and intervention. While the harm reduction approach developed first around substance use, harm reduction policies and practices have emerged in recent years to address other (though often overlapping) problems such as risky sexual behavior, homelessness, dual diagnosis mental health problems, and gambling.

General Overviews

There are several books and articles that give excellent summaries of the historical development and definitions of harm reduction, as well as broad coverage of harm reduction strategies. Marlatt and Witkiewitz 2010 provides an assessment of the state of research on harm reduction policies and interventions, particularly as it relates to drug and alcohol use. Marlatt, et al. 2012 is a similarly up-to-date edited volume covering a broader range of harm reduction efforts, including substance use but also risky sexual behavior and mental health. In another edited volume, Pates and Riley 2012 offers international perspectives on harm reduction efforts, including specific interventions in diverse regional contexts. Four additional works provide important historical context in the development of harm reduction strategies. Heather, et al. 1989 is an edited volume from an early conference on harm reduction held in Australia. Erickson, et al. 1997 presents a series of papers given at a seminal international conference on harm reduction in the mid-1990s, while Inciardi and Harrison 2000 is an effort to bridge international efforts and US drug policies. Drucker, et al. 2016 reviews the critical role that clinicians and clinical researchers have played in the international development of harm reduction strategies.

• Drucker, Ernest, Kenneth Anderson, Robert Haemmig, et al. 2016. Treating addictions: Harm reduction in clinical care and prevention. Bioethical Inquiry 13:239–249.

  DOI: 10.1007/s11673-016-9720-6

  This article summarizes the key role that clinical practitioners and clinical researchers have played internationally in establishing harm-reduction approaches to substance use.

• Erickson, Patricia G., Diane Riley, Yuet W Cheung, and Pat O’Hare, eds. 1997. Harm reduction: A new direction for drug policies and programs. Papers presented at the fifth International Conference on the Reduction of Drug Related Harm held in Toronto, Canada, 6–10 March 1994. Toronto: Univ. of Toronto Press.

  An edited volume of papers presented at one in a series of seminal international conferences on harm reduction in 1994. Provides important historical background on the development of harm reduction strategies across a variety of substances and countries.

• Heather, Nick, Jennifer Tebbutt, and Erol Digusto, eds. 1989. The effectiveness of treatment for drug and alcohol problems: An overview. Canberra City: Australian Government Publishing Service.

  An edited volume that summarizes a conference on harm reduction in Australia. Provides historical background as well as an international perspective.

• Inciardi, James A., and Lana D. Harrison, eds. 2000. Harm reduction: National and international perspectives. Thousand Oaks, CA: SAGE.

  An edited volume with chapters exploring the historical development of harm reduction efforts related to alcohol and substance use in international and US contexts.

• Marlatt, G. Alan, Mary E. Larimer, and Katie Witkiewitz, eds. 2012. Harm reduction: Pragmatic strategies for managing high risk behaviors. 2d ed. New York: Guilford.

  A very approachable edited volume spanning diverse harm reduction efforts including substance and alcohol use, but also high-risk sexual behavior and dual mental and chemical health disorders. This volume also provides a useful section on cultural-specific harm reduction interventions by race, ethnicity, and age.

• Marlatt, G. Alan, and Katie Witkiewitz. 2010. Update on harm-reduction policy and intervention research. Annual Review of Clinical Psychology 6:591–606.

  DOI: 10.1146/annurev.clinpsy.121208.131438

  An important review of current knowledge on harm reduction interventions for alcohol and substance use. Provides a summary of key concepts and policy issues as well as empirical evidence for prominent harm reduction practices.

• Pates, Richard, and Diane M. Riley, eds. 2012. Harm reduction in substance use and high-risk behaviour: International policy and practice. West Sussex, UK: Wiley-Blackwell.

  An edited volume that spans the breadth of harm reduction interventions in global context, notable for focal chapters on specific policies as well as diverse regional settings worldwide.