Reflection: Harm Reduction

In preparing acupuncture students to tackle safety issues in their future practices, there’s a category of topics I think of as pre-safety, or concepts to spend some time with before diving into trying to implement safety by means of policies, manuals, etc. Being an acupuncturist and a small business owner requires you to put yourself out in the world in all sorts of ways; your work is as personal as an artist’s. Creating safety in your practice is like an investment; it helps protect you, your patients, and also your long-term commitment to your work. It’s worth spending the time to develop a solid internal foundation for your approach to safety, as opposed to just going through the motions to be externally compliant.

Like trauma informed care, harm reduction is a public health approach that employs a non-punitive concept of safety.

Harm Reduction International uses the term to refer to “policies, programs, and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop.” Harm reduction encompasses interventions such as: needle exchange programs (to prevent the spread of HIV and Hepatitis C among people who use drugs); supervised/safer injection sites (to prevent overdoses as well as preventing the spread of bloodborne pathogens); medication assisted treatment (providing methadone or buprenorphine to people in recovery from opiate use to prevent relapses); and Housing First programs, which offer housing and support services that aren’t contingent on abstinence from alcohol and/or drugs.

Harm reduction advocates are clear that harm reduction practices save lives (the lives of people who use drugs are as valuable as everyone else’s) -- and benefit the whole community, not just people who use drugs. Harm reduction is a great example of making imperfect safety.

Let’s look at how harm reduction can inform our approach to acupuncture safety.

The National Harm Reduction Coalition defines eight principles of harm reduction. Three of those are:

Harm reduction accepts, for better or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them;

harm reduction understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe use to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others;

harm reduction does not attempt to minimize or ignore the real and tragic harm and danger that can be associated with illicit drug use.

These principles suggest that safety and risk aren’t binary, they’re on a continuum. Creating safety does not require the elimination of risk, which in fact isn’t possible. Creating safety requires accepting and working with risk, rather than denying or condemning it.

These principles also suggest that safety is not a reward for good/compliant behavior. Safety is an end in itself, not part of a behavior modification technique. When I went to acupuncture school, lo so many years ago, I was taught to approach access to acupuncture as a reward for good behavior; for example, if I had a patient who was smoking cigarettes or ate what I perceived as unhealthy food, at some point I was supposed to confront them and tell them that I wouldn’t continue to treat them unless they changed their habits. If I didn’t do this, I was “enabling” them. Unfortunately I’m pretty sure this approach is still around in the acupuncture profession, and obviously it’s the opposite of harm reduction.

It connects to other negative attitudes about safety. One of the worst examples in recent years has been licensed acupuncturists who don’t want physical therapists to do dry needling trying to prevent those physical therapists from getting access to acupuncture needles, so that they would be forced to use syringes instead, thus causing more pain (and possibly injury) to patients and consequently deterring patients from seeking treatment from physical therapists. Because licensed acupuncturists’ objection to physical therapists doing dry needling was ALL about how we don't want patients getting hurt, remember?

(How are we supposed to teach safety to our students in such an atmosphere? I ask you.)

The goal of harm reduction is safer rather than safe. Because sometimes trying to make everyone perfectly safe creates worse outcomes than just trying to make them safer (see also, the War on Drugs). According to harm reduction advocates, “People who use drugs should be provided with options to help them to minimize the risks associated with continuing drug use, including the risk of harming themselves or others. Keeping drug users alive and healthy is the highest priority in harm reduction”-- as opposed to keeping them perfectly safe from the risks of drugs via abstinence. In fact, abstinence comes with its own severe risk of fatal relapse.

These themes -- that safety and risk are on a continuum, that safety is an end in itself rather than a reward for good/compliant behavior, and that the goal is safer as opposed to absolutely safe -- all can be used to approach acupuncture safety and risk management. In my experience, they’re particularly helpful for acupuncture practices whose goal is inclusion rather than exclusion. For almost any safety/risk issue that might arise in the context of acupuncture, I think a harm reduction lens can make a huge positive difference.

Next up on the pre-safety reflection list: boundaries.

Edited: Zeynep Tufekci wrote these excellent paragraphs about harm reduction, COVID, and public health messaging:

Harm reduction is the recognition that if there is an unmet and yet crucial human need, we cannot simply wish it away; we need to advise people on how to do what they seek to do more safely. Risk can never be completely eliminated; life requires more than futile attempts to bring risk down to zero. Pretending we can will away complexities and trade-offs with absolutism is counterproductive. Consider abstinence-only education: Not letting teenagers know about ways to have safer sex results in more of them having sex with no protections.

As Julia Marcus, an epidemiologist and associate professor at Harvard Medical School, told me, “When officials assume that risks can be easily eliminated, they might neglect the other things that matter to people: staying fed and housed, being close to loved ones, or just enjoying their lives. Public health works best when it helps people find safer ways to get what they need and want.””

Another problem with absolutism is the “abstinence violation” effect, Joshua Barocas, an assistant professor at the Boston University School of Medicine and Infectious Diseases, told me. When we set perfection as the only option, it can cause people who fall short of that standard in one small, particular way to decide that they’ve already failed, and might as well give up entirely. Most people who have attempted a diet or a new exercise regimen are familiar with this psychological state. The better approach is encouraging risk reduction and layered mitigation—emphasizing that every little bit helps—while also recognizing that a risk-free life is neither possible nor desirable.