December 11, 2023

Hand in Hand:

Prevention and Harm Reduction by Will Matteson

In the short time I've been doing this job—which is to say that I'm no top expert here—I have noticed a subtle tension I would like to draw out a bit. The tension is between two fields within the landscape of substance use care: Prevention and Harm Reduction. These two deeply connected fields are often discussed as separate, even opposing, categories. Many people seem to find one inconsistent with the other. I am here to argue that they are not so much separate categories as two sides of the same coin. Here in Lincoln County, we are fortunate to have many incredible partners working across all sectors of substance use care. These partners cheerfully work together across sectors all the time. But I think a lot of us feel an internal pressure to identify either with Prevention or Harm Reduction, as though the two were incompatible.

First let's define our terms, because a lot of people who don't work with this stuff all day may still not have a clear understanding of what Prevention or Harm Reduction are in the first place. Both fields are collections of Public Health theory and initiatives with the shared goal of reducing the risks and harms associated with substance use. 'Harm Reduction' is a set of practical strategies designed to reduce the negative consequences of active substance use. These strategies emphasize meeting people where they are, offering non-judgmental services to people who use drugs even if they have no intention of seeking treatment or recovery. 'Prevention' is a set of practical strategies designed to educate parents and children about the risks of substance use, to delay the initiation of substance use in young people, and prevent substance use disorder. One is about providing care to people who use drugs; the other is about education, supporting families, and community development. We need both! Not either.

I think the tension has to do with stigma. Stigma is this big raincloud that is always casting its shade over the world of substance use care; it moves in different directions and divides us from each other. Early forms of Prevention bear some of the blame for the tension because they transmitted so much stigma. Early 20th century prevention messages took the form of scary propaganda that associated drug use with criminals, minorities, and poor people. Later, in the 1980s, this propaganda culminated in programs that advocated abstinence only, or "just say no." The problem with abstinence-only prevention is that it doesn't work, at least not for everybody. And then, by definition, it categorizes the people who say 'yes' as other, or outside our realm of care.

But, at least from what I can see here in Maine, the field of Prevention deserves some credit for how far it's come since those days. As I've been learning it, Prevention is rooted in non-judgmental care for all youth, even if they have initiated substance use. It is about finding ways to empower youth to make their own decisions and see themselves as mattering in the community. These strategies are rooted in thinking and practice that grew out of the harm reduction movement, which itself grew out of movements dedicated to civil rights, women's and minority health, and behavioral health care. The quintessential example of this was the distribution of clean syringes to prevent the spread of HIV/AIDS among people who inject drugs. Modern Prevention is aligned with Harm Reduction in that it recognizes that a certain portion of the population will use substances, while also agreeing that we can and should take measures to reduce the worst outcomes of that use.

Sadly, stigma does still cause a backlash against Harm Reduction. Many people still see Harm Reduction as enabling of destructive or illegal behavior and insist on an abstinence-only footing. I haven't met any of these people in Prevention circles, though. Most Prevention people seem to recognize the need for early education and intervention PLUS Harm Reduction resources. Between the early stigma in Prevention, and the current backlash against Harm Reduction, I think many Harm Reduction folks are still distrustful of Preventionists. But most of those same harm reduction folks also recognize that harm reduction alone is not enough, that we should work toward a world where there is less opportunity, and fewer reasons to initiate dangerous substance use in the first place. Our society deserves both full-time people dedicated to caring for people in active use, and full-time people dedicated to community prevention. The people working in these roles need to see each other as allies and support each other's work.

We ultimately share the same goal, which is to reduce the harm caused by substance use. Not only is the goal the same, but the work of each actively contributes to the other. Successful Prevention reduces the number of people who will need Harm Reduction services and improves society's support of the recovery community. Reduction in deaths by overdose and other substance-related mortalities in turn becomes a protective factor for the community. When the stigma, despair, and physical suffering caused by substance use is reduced by Harm Reduction at a community level, the next generation is more likely to avoid similar outcomes. Thus, Prevention reduces harm, and Harm Reduction prevents substance use. Same team.

At HLC we are always working on community collaboration, and we are so lucky to have so many amazing partners who don't hesitate to show up and support us when we need it. We are not the only one, but we hope to always be a bridge between these two important fields. What's needed is combined effort from those of us in Prevention as well as those of us in Harm Reduction to focus on reducing stigma in the wider community. Together we can shed light on each other's work to provide better care and outcomes for people who use drugs, while also providing a robust education for all children, who deserve equal access to knowledge of the risks associated with substance use.

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