The best clinical outcome will be gained by weighing up the costs and benefits of these strategies along with careful review of the impact on the presenting problem.

The overall aim is to ensure that the key harms, particularly those that are related to your agency (eg lack of accommodation, child neglect, etc)  are reduced regardless of choice of intervention.

Harm reduction clinical steps

Some high priority drug-related harms

Two examples of harm reduction approaches

Problem solving

First do no harm

Summary

Clinical Steps Which Incorporate Both Moving to Cessation and
Harm Reduction Strategies

1. Where drug use is causing problems or is in a range where it is likely to be causing problems, the client should be asked if s/he is considering cutting down or stopping drug use.
2. Motivational Interviewing at this stage is useful not only to help in decision making, but also for client and counsellor to identify both problems and functions of drug use.
3. Those who are considering cutting back or stopping their drug use should be given further options to do so. (See Treatment Steps)
4. Identify the connection between the presenting problem and drug use. Are there any other specific drug-related harms (possibly identified during motivational interviewing).
5. Addressing the possible impact of the drug use on themselves and/or their ability to care for their child/ren.
6. Addressing these problems directly may be useful for the following:

   	Those who don't want to, or are unable to stop or reduce drug use
   	Those for whom reducing drug use would pose greater dangers (See: First Do No Harm)
   	Those who are cutting down but still have problems associated with drug use
   	Those who are quitting drug use, but may relapse and/or have residual problems (such as drug induced loss of trust in relationships or health problems such as hepatitis C).

Overdose

Suicide

Domestic Violence

Child abuse or neglect

Blood borne viruses (HIV, Hepatitis C & B)

Motor vehicle accidents if client is intoxicated & driving

Problem 1:

A parent is bingeing on alcohol on a weekly basis. A young child is at risk of neglect or abuse during the period of intoxication and hangover.  The parent does not want to give up the binge drinking.  In other respects assessment has shown the parenting to be adequate.

Possible  Harm Reduction Options:

Have a sober partner or other care-giver look after the child while parent is bingeing and recovering.

Help the parent develop skills and strategies to avoid child violence or neglect in the context of stress such as during a hangover.

Teach parent the value of drinking lots of water after a drinking session to reduce hangover.

Work with the child/ren regarding protective behaviours in relation to physical, sexual or emotional harm.

Consider referral to the Child Protection Team.

Problem 2.

A heroin user (single father) was neglecting his child.  He had agreed to stop using heroin and was going into a detoxification unit in two weeks.

Possible Treatment Support Options:

Follow-up on changes to parenting practices before, during and after detoxification.

Ensure strategies are in place for safe care of the child prior to the detoxification program.

To minimise the impact of separation during the detoxification period, provide direct support to the child, organise visits, and help the parent prepare the child for a period of separation.

Possible Harm Reduction Options:

Make sure the parent has a management strategy in case of relapse which not only reduces risks to the parent, but also to the safe care of the child, which is age appropriate.

PROBLEM SOLVING

A problem solving approach can clearly identify drug-related harm, develop concrete steps to reduce this harm and use feedback methods to review changes.

Problem solving steps:

1. Identify the actual drug-related problem(s)/harm(s)

   	Liver, Lover, Livelihood, Law
   	Intoxication, Regular Use, Dependence (see Drug Models)

For child protection issues, see:
Risk assessment tool for drug using parents

2. Prioritise which require attention first taking into account

   	Importance & Confidence about issue
   	Degree of harm
   	Realistic possibility of change

3. Brainstorm solutions

   	Quantity and creativity important
   	Do not judge at this stage

4. Choose the best solution(s)

   	Weigh up costs and benefits of each option
   	Use SMART (Specific, Meaningful, Assessable, Realistic, Timed) short-term goal setting

5. Do it
6. Review it

   	Set a date with client for review
   	Re plan

   

Harm maximisation can result from both stopping drug use as well as strategies which may seem like harm reduction.

Examples of therapy induced harm and risk of harm:

How to minimise the possibility of unintentional harm:

These examples point out the need to answer the following questions prior to any drug-related intervention:

What is the exact relationship between drug use and the presenting behaviour?

What functions does the drug use have?

What are the possible range of consequences should drug use be reduced or stopped?

What additional services need to be included to assist the individual/family to reduce risk associated with drug use?

Will it be possible to identify and measure desired changes?

The above examples do not mean that drug use issues should be ignored.  A range of clinical interventions should be considered to minimise potential risk (such as providing alternative child care while a mother is detoxifying; consulting with the chemical dependency unit for pregnant women; providing strong social supports for clients on naltrexone; limit solvent education to known users & teach others about avoiding intoxication, etc).

1. Where Safe & Possible, Reduce Use. It is clinically useful to consider reducing overall drug use where possible if it is causing or likely to be causing problems.
2. Understanding Functions & Problems of drug use may assist in: reducing harm; not causing more harm; and possibly reducing consumption through improved decision making.
3. Problem solving will assist in the clear identification of harm and provide a simple strategy for reducing this harm.
4. Useful for most clients.  Harm reduction strategies are appropriate particularly for those who continue to use drugs. However, they are also useful for those who are cutting down or stopping drug use.
5. Review outcome.  Ensure that initial harms and risks (especially to the child) are reduced as well as any unintentional harms are minimised.