Getting clean and harm reduction: adversarial or complementary issues for injection drug users Abstinência versus redução de danos: questões conflitantes ou complementares entre usuários de drogas injetáveis

Many contemporary HIV prevention interventions targeting injection drug users (IDUs) have been implemented using Harm Reduction as a theoretical framework. Among drug-using individuals, however, the abstinence-based “getting clean” models espoused by Narcotics Anonymous and other widely adopted approaches to drug treatment are often more readily accepted. This paper describes an ethnographic examination of the ideological dichotomy between Harm Reduction and abstinence-based “getting clean” treatment model which emerged during the piloting phase of an HIV prevention intervention in Baltimore City, Maryland, USA. This paper describes how the conflict was identified and what changes were made to the intervention to help resolve the participants’ dichotomous thinking concerning their substance abuse issues. Street Drugs; Drug Abuse; Harm Reduction Traditionally, in the United States, the predominant approaches to drug policy and drug treatment have been characterized by such phrases as “zero tolerance” and the “war on drugs”. This abstinence-based political and ideological view emerges from the substance use treatment approach embedded within the principals of the moral model 1. This approach supports the belief that abstinence is a prerequisite for substance users to modify their behavior. On the other hand, Harm Reduction, and its application within the HIV prevention and substance-use treatment arena, has met with a broad range of acceptance throughout the world 2, particularly among contemporary researchers. Harm Reduction is defined as a set of practical strategies that are used to reduce the negative consequences of substance use. Harm Reduction involves incorporating a continuous spectrum of strategies, ranging from safer use, to managed use, to complete abstinence from drugs. Harm Reduction tailors behavior change to the unique conditions of substance use along with the substance users, themselves (Ptah A. Speech presented to the Community Planning Leadership Summit by Director of Policy Harm Reduction Coalition. March 2003). Proponents of Harm Reduction have been accused of supporting continued drug use, sabotaging efforts toward achieving abstinence, undermining recovery, contradicting current social policy, and selling out or giving in to the Peterson J et al. 734 Cad. Saúde Pública, Rio de Janeiro, 22(4):733-740, abr, 2006 presence of illicit drug use in the society. However, those who adopt the principles of Harm Reduction do so with the understanding that drug use is a complex problem related to other quality of life issues such as poverty, class, racism, social isolation, and discrimination. They espouse that an approach to drug use that attempts to mitigate its negative effects on the drug-using individuals, their families, and the communities where they live, should include non-coercive intervention strategies 3 and should not paint an overly simplistic picture of the problem. In addition, Harm Reduction allows for the creation of a non-adversarial and supportive milieu that engages drug-using individuals in a process where rewards and continued supports are not just the consequence of fundamental change, but are the incentives for incremental gains. Based on a vast body of empirical research, harm reduction is widely accepted among public health professionals as the cornerstone of HIV prevention among substance abusers. For many substance users, however, an understanding of recovery from substance use is derived from the philosophy of self-help organizations such as Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) which promote an all-or-nothing belief concerning drug use. The NA philosophy posits that complete abstinence from all mood-changing chemicals is the mark of success and anything less than that is tantamount to failure; in a way, it can be thought of as an individual level of the “zero tolerance” policy. In this article we present salient lessons learned while conducting an ethnographically informed process evaluation during the pilot phase of an HIV prevention intervention trial aimed at injection drug users (IDUs) in Baltimore City, Maryland. We will discuss three key points which emerged during the course of our process evaluation: (1) the program participants’ abstinence orientation, which dominated their views of drug use and initially created tension with the program’s Harm Reduction orientation; (2) how the contradictions between these two orientations manifested themselves in group interactions; and (3) how the facilitators and program planners, along with the participants, augmented the intervention’s language, highlighting the similarities between the two approaches and reducing the tensions within group sessions. Piloting “STEP”: an HIV prevention intervention The “STEP” study, the Harm Reduction program in question, is a network and peer-oriented HIV prevention intervention seeking to train individuals engaged in the injection-drug-using community in Baltimore City. The study’s short-term goal is the promotion of HIV prevention behaviors among the program’s participants and their drug and sexual network members. Based on our previous intervention efficacy research 4,5,6,7, STEP utilizes social influence theory to promote the philosophy of Harm Reduction among social network members. The study design is a controlled phase II efficacy trial with an equal attention control condition. The STEP program consists of four group sessions (peer mentor training sessions), one individual session, one drug (or sex) dyad session, and periodic booster sessions up to six months after completion of the intervention. The STEP intervention was tested and revised through five waves of piloting, which occurred over the eight-month period proceeding formal program implementation. The process evaluation (upon which this paper was based) utilized ethnographic methods and was implemented during the eight-month piloting phase.