HARM REDUCTION TRAINING MANUALA Manual for Frontline Staff Involved with HarmReduction Strategies and ServicesJanuary 2011

i) Letter to ReaderThis manual has been provided as a tool to assist you in your service to help reduce theharms associated with drug use to individuals, families and within your community. Weencourage using and sharing these tools and information provided to promote growth in theknowledge and understanding of harm reduction within your communities. Harm reductioncontinuously changes and we encourage you to follow the web links provided to remain up todate on the changes, information, policies, and forms.ii) Current/ updated informationThe latest:BC Harm Reduction Strategies and Services Policy and GuidelinesHarm Reduction Program: Supply Requisition FormCan be found fault.htmHealth link BC – Health files can be accessed mNote about footers and updates: Footer dates will only be changed on those pagesthat have been amended; all other footers will remain unchanged.Pages to be removed and replaced along with date of modification will be recordedon the last page of the manual.Updated January 2011

TABLE OF CONTENTSINTRODUCTION .41. HARM REDUCTION .5DEFINITIONS OF HARM REDUCTION.5GUIDING PRINCIPLES OF HARM REDUCTION .5HARM REDUCTION IN CANADA AND INTERNATIONALLY .42. INFECTIONS .7HIV/AIDS .8HEPATITIS .8SEXUALLY TRANSMITTED INFECTIONS .9Chlamydia .9Genital Herpes .9Gonorrhea .9Human Papillomavirus (HPV) .10Syphilis.103. DRUG EFFECTS.124. SAFER SUBSTANCE USE.155. MENTAL HEALTH .186. WORKING WITH INDIVIDUALS.18PERSONAL VALUES, ATTITUDES AND MISCONCEPTIONS .19INDIVIDUAL ENGAGEMENT STRATEGIES .19RESPONDING TO A HISTORY OF ABUSE .20FAMILIES, INDIVIDUAL AND COMMUNITY.20ABORIGINAL COMMUNITIES .22REFERRING CLIENTS TO OTHER SERVICES .22ADVOCATING FOR CLIENTS.23YOUTH .23LESBIAN, GAY, TRANSGENDERED, BISEXUAL, QUEER (LGTBQ) .237. APPENDICES .231. HARM REDUCTIONHarm Reduction: History of Harm Reduction in British Columbia1A: Harm Reduction Definitions, Reducing Harm: Treatment and Beyond. Four Pillars DrugStrategy1B: Harm Reduction: A British Columbia Community Guide1C: Harm Reduction health files #102a#102b1D: BC Harm Reduction Strategies and Services Policy and Guidelines1E: BC Harm Reduction Strategy and Services (HRSS) CommitteePrimary, Secondary and One-off Distribution Site Policy1F: Strategies – Harm Reduction Strategies and Services newsletters2. INFECTIONS (BC health files #)2A: HIV/AIDS #08m2B: Hepatitis A vaccine #33; hepatitis B vaccine #25a; hepatitis C virus #40a; Living wellwith hepatitis C infection #40b2C: Chlamydia #08l2D: Genital Herpes #08dUpdated January 2011

2E: Gonorrhea #08a2F: Human Papillomavirus (HPV) #101a2G: Syphilis #08e3. DRUG EFFECTS3A: Street Definitions4. SAFER SUBSTANCE USE4A: Harm Reduction Program: Supply Requisition Form4B: Harm Reduction Supply Ordering at the BCCDC4C: Rationale for crack pipe mouthpiece distributionQuestions and Answers: Female condoms Sterile water Cookers and Injection Drug Use Stericup cooker: Cooker instructions Acidifier (Ascorbic acid) and Injection Drug Use Crack pipe push sticks Crack pipe mouthpieces4D: More than just needles: an evidence –informed approach to enhancing harm reductionsupply distribution in British Columbia4E: Best Practices for British Columbia Harm Reduction Supply Distribution Program(September 2008)4F: Harm Reduction Learning Series Pamphlets6. WORKING WITH INDIVIDUALSABORIGINAL6A: Walk With Me: Pathways to Health; Harm Reduction Service Delivery Model6B: Community Readiness: A Handbook for Successful Change: Please download fromwebsiteLESBIAN, GAY, TRANSGENDER, BISEXUAL AND QUEER6C: List of Suggested Readings6D: Glossary of Terms7. ACTIVITY AND ENGAGEMENT EXCERCISES7A: Client engagement / role play activity7B: 5-min elevator pitch7C: Peer engagement: benefits and challenges activity8. RESOURCESUpdated January 2011

IntroductionThe purpose of this manual is to build on the knowledge, skills, and attitudes necessary to maximize thedistribution of products to reduce harms associated with substance use; and to engage, educate, andadvocate for individuals. The manual outlines and encourages the use of best practice to colleagues andpeers within their specific agencies and organizations. It provides a reference to what support andtreatment resources are available to which they can refer individuals. Specifically frontline staff will beable to use the manual as a guide and reference tool for: Individual engagement Encourage and support needle collection and return (at the individual and community levels) Inform individuals about reducing risks of blood borne pathogen transmission, and safer drugusing and sexual practices Engage with individuals to provide effective education regarding harm reduction practicesassociated with routes of use, substances used, and social use practices. Respond to individuals who report a history of past or recent trauma, abuse or violence Refer individuals (e.g. social services, housing, addiction and mental health treatment) Advocate for individuals Respond to community pressures and concerns.Updated February 20104

1. Harm ReductionAt the end of this section, you will be able to explain: Definition for harm reductionEveryday examples of harm reductions interventions.The guiding principles of harm reductionThe history of harm reduction within Vancouver and globallyIt is important to acknowledge that harm reduction is not a new concept. Harm reduction principles havebeen applied for many decades in many areas outside the field of addiction. Day to day strategies suchas using a seatbelt while driving a car, wearing sunglasses while outside, or using hand rails whenwalking down stairs are all examples of an intervention to help reduce harm. What are some examples of harm reduction strategies that you use in your everyday life?Definitions of Harm ReductionHarm reduction has a variety of meanings to different people, which has made developing one generaldefinition very difficult. Regardless of the definition, harm reduction is a philosophy, approach, and a setof principles that combined help achieve certain social and political goals. As per the BC Harm ReductionStrategies and Services Policy and Guidelines:Harm reduction involves taking action through policy and programming to reduce theharmful effects of behaviour. It involves a range of non-judgmental approaches andstrategies aimed at providing and enhancing the knowledge, skills resources andsupports for individuals, their families and communities to make informed decisions to besafer and healthier.For further definitions of Harm Reduction and Reducing Harms: Treatment and Beyond see Appendix 1A.Guiding Principles of Harm ReductionThe principles of harm reduction as outlined in the Harm Reduction: British Columbia Community Guide(2005) (Appendix 1B) are summarized below.PRAGMATISM - Harm reduction recognizes that drug use is a complex and multi-facetedphenomenon that encompasses a continuum of behaviors from abstinence to chronicdependence and produces varying degrees of social harm. Harm reduction accepts that the nonmedical use of psychoactive or mood altering substances is a universal phenomenon. Itacknowledges that, while carrying risks, drug use also provides the user and society with benefitsthat must be taken into account.HUMAN RIGHTS - Harm reduction respects the basic human dignity and rights of people whouse drugs. It accepts the drug user’s decision to use drug and no judgment is made either tocondemn or support the use of drugs. Harm reduction acknowledges an individual drug user’sright to self-determination and supports informed decision making in the context of active druguse.Emphasis is placed on personal choice, responsibility and management.Updated February 20105

FOCUS ON HARMS - The fact or extent of an individual’s drug use is secondary to the harmsfrom drug use. The priority is to decrease the negative consequences of drug use to the user andothers, rather than decrease drug use itself. While harm reduction emphasizes a change to saferpractices and patterns of drug use, it recognizes the need for strategies at all stages along thecontinuum of drug use.MAXIMIZE INTERVENTION OPTIONS - Harm reduction recognizes that people who use drugsbenefit from a variety of different approaches. There is no one prevention or treatment approachthat works reliably for everyone. It is providing options and prompt access to a broad range ofinterventions that helps keep people alive and safe. Individuals and communities affected bydrug use need to be involved in the creation of effective harm reduction strategies.PRIORITY OF IMMEDIATE GOALS - Harm reduction starts with “where the person is” in theirdrug use, with the immediate focus on the most pressing needs. It establishes a hierarchy ofachievable interventions that taken one at a time can lead to a fuller, healthier life for drug usersand a safer, healthier community. Harm reduction is based on the importance of incrementalgains that can be built on over time.DRUG USER INVOLVEMENT - Harm reduction acknowledges that people who use drugs are thebest source for information about their own drug use, and need to be empowered to join theservice providers to determine the best interventions to reduce harms from drug use. Harmreduction recognizes the competency of drug users to make choices and change their lives. Theactive participation of drug users is at the heart of harm reduction.For further information on harm reduction and its benefits refer to Appendix 1C: Harm Reduction HealthFile #102a Understanding Harm Reduction and File #102b Harm Reduction for Families and Caregivers.Harm Reduction in Canada and InternationallyHarm reduction started in Merseyside, England in the mid-1980s. As a result of the increasingly obviousconnection between injecting drug use and the rise of HIV and hepatitis C virus (HCV) infections, harmreduction initiatives started emerging in Canada in the late 1980’s with the establishment of needleexchanges, methadone maintenance and sexual health education programs. Needle exchanges,supported by provincial policy, began in BC in 1988.During the 1990s in Vancouver, the drug market underwent a significant shift. Cocaine became availablein large amounts which coincided with the increase of individuals with low incomes and mental illness inthe Downtown Eastside (Kerr, Woods, 2006). In 1997, the local health authority in Vancouver declared apublic health emergency when the rate of HIV infections became the highest in the Western World alongwith the rise in HCV infections.Today, the prevalence of drug use and persons who use drugs in Vancouver’s downtown eastside putsharm reduction in the forefront of health related issues. As a result, BC is seen as a leader within theNorth American context but looks internationally to research outcomes of harm reduction where harmreduction strategies are more developed.Since 2004 the BC Centre for Disease Control has tracked the distribution of products funded by theprovincial government and subsidized by Provincial Health Service Au