Come with us to understand a little more about what Harm Reduction is, the practice that is characterized by strategies to minimize the effects and the use of substances, focusing on education and care.
“Good or bad, legal and illegal drugs are part of this world and (harm reduction) chooses to work to minimize their harmful effects rather than simply ignoring or condemning them”
(Harm Reduction Coalition, 2002-2003)
When we think about the constitution of the field of health care related to drug use in Brazil and in the world, we cannot leave aside the entire historical context covered. This provides us with elements to understand the practices related to this theme. The criminalization and social and moral disqualification of individuals who use drugs were built following the social, cultural and historical processes of the respective societies in which they are inserted. The debate on health problems resulting from drug use and on policies that criminalize users is extensive.
So, we ask: what is worse for the user of psychoactive substances, the drug itself or the prohibitionist policy?
Origin of Harm Reduction
As for the origin of the concept: the first time that the term Harm Reduction was used occurred in England, in 1926 (Ministry of Health, 2001), in a document called “Rolleston Report”. A new method of treatment was emerging. Doctors could then prescribe opioids to addicts to manage users’ withdrawal syndromes and control drug use. In this way, users could lead a more stable life and participate better in social life (O’HARE, 1994).
Unlike the possible forms of care within the prohibitionist policy – which is based on repressive and punitive measures in relation to users of illicit drugs, as well as treatments based on abstinence – Harm Reduction (DR) is characterized by pragmatism and a proposal methodological health care. This aims to reduce risks and damage in relation to the complex phenomenon of drug use, whether illicit or not. RD works from a set of practices related to the care and well-being of users, which do not necessarily have abstinence as their objective. It is known that people can have different ways of relating to drugs. Their use is certainly not problematic (Santos, Soares and Campos, 2010). The idealistic nature of the prohibitionist model believes in the ideal of a drug-free society, demonstrating an extremely utopian, unattainable and even undesirable idea.
RD believes that “good or bad, legal and illegal drugs are part of this world and choose to work to minimize their harmful effects instead of simply ignoring or condemning them” (Harm Reduction Coalition, 2002-2003). The basic principles of Harm Reduction echoes a social movement that seeks justice, respect and the guarantee of rights for drug users.
The empowerment of the individual as an agent of his own history is widely valued. The Harm Reduction strategies adopted by users must produce meaning for them, so that the objectives and goals established by them can be successful. For a Harm Reducer, letting go of all your convictions and moral judgments is fundamental for forming bonds with individuals, enabling: i) reflections and discussions about harmful drug use, ii) awakening in the other the adoption of strategies of self-care, of means to improve their quality of life and even the insertion of the user in any health program, if they wish.
As Elisangela Melo Reghelin (2012) maintains:
“Some principles and actions that make up the harm reduction strategy:
- ‘It is a‘ social policy that aims to mitigate the negative effects of drug use ’;
- it is a policy of preventing potential harm related to drug use, instead of trying to prevent the use of drugs’;
- ‘Based on public health principles, harm reduction offers a set of pragmatic, yet compassionate, strategies that are designed to reduce the harmful consequences of addictive behavior, both for consumers and for the communities in which they live’. ”
Considering the consolidation of Harm Reduction practices in a global perspective, even though the origin of Harm Reduction was in 1926, it was only in the late 1970s and early 1980s that the principles of this proposal were systematized in forms of programs. Between 1986 and 1987 (Derricott, Preston & Hunt, 1999), the first centers for the distribution and exchange of needles and syringes appeared in the Netherlands and England. AIDS has led to a new look in relation to the phenomenon of drug use. As a result of the threat of transmission of the virus among intravenous drug users, preventive actions that were not aimed at abstinence – as this means greater adherence to treatment – were introduced.
The first harm reduction center in England was called the Maryland Center, in Liverpool. In it, a program by Dr. John Marks – which followed the guidelines of the Rolleston Committee – performed syringe and needle exchange, distribution of heroin to substance dependents and substitution therapies. With the controlled availability of heroin, it was possible to reduce overdose deaths, keep users away from the criminal sphere and also have quality control of the substance.
As we will see below, the Netherlands was a pioneer in the Harm Reduction policy. In the 70s, even before the boom of diseases transmissible by intravenous means, the country already developed practices of this aspect. What denotes the vanguard of Holland in the health care of its citizens, because the policies of DR do not ignore the reality, entering in opposition to prohibitionism.
Since 1976, the Netherlands has adopted anti-prohibitionist policies regarding the possession and planting of recreational cannabis. The trade of this substance and that of its derivatives was permitted in a regulated manner, and its consumption could take place both in certain coffees (coffeeshops) and in the user’s home. This initiative meant that they did not frequent the same environment where the drug trade was considered to be more harmful to health, such as heroin, avoiding the exposure of the marijuana user to these so-called “heavier” substances and also removing him from the criminal sphere .
Subsequently, in view of the increase in heroin dependents, the transmission of hepatitis and also AIDS, strategies were created to reduce the contagion of diseases transmissible by intravenous drugs. It is worth mentioning that the participation of the association of injecting drug users, Junkiebond. This league of users was created in 1980, and its participants helped, together with the State, in the formulation of public policies focused on the theme. This participation was of great importance in order to accept the idea of exchanging used needles and syringes for new ones, in specific places, so that there was no disposal in inappropriate places.
In 1998, there was already a drastic decrease in the incidence of these diseases among intravenous drug users. This strategy, in addition to reducing the damage that the drug brought, made it possible to get closer to users to address other issues that were not just the use of the drug itself. It is noticed that in this case Harm Reduction is presented as a broader strategy, allowing the creation of non-institutional bonds and the approach to see other existing demands of this group of individuals.
Harm Reduction in Brazil
In Brazil, it was only in 1989, in Santos, that the first attempt to make a Harm Reduction project arose. Coordinated by doctor Fábio Mesquita, from a program of the Department of Hygiene and Health, they distributed equipment for the safe use of injectable drugs, with the aim of curbing the spread of HIV / AIDS. According to Bastos & Mesquita (2001), in 1983, in the city of Santos, one in four registered cases of AIDS had as a probable origin the use of injectable drugs. Soon, the action was interrupted by the Public Ministry, as it was understood as something that encouraged the use of drugs.
In 1994, Harm Reduction became, in the field of health, a strategic policy for SUS. It begins with the objective of preventing viral hepatitis and AIDS (Acquired Immunodeficiency Syndrome) in a population that is vulnerable to the transmission of these viruses, which occurs through the sharing of contaminated syringes to make use of injectable drugs. In the same year, the National STD / AIDS Program, designed by the Ministry of Health, in partnership with the World Bank and UNDCP (Now known as the United Nations Office on Drugs and Crime – UNODC), resumed the DR strategy that consisted of changing disposable syringes. This was a subproject, which was later approved in its entirety by the Federal Narcotics Council (CONFEN) (Flach, 1996).
Nowadays, in Brazil, it is more rare to encounter the use of drugs intravenously, so that the Harm Reduction policy began to be used for health promotion together with users of psychoactive substances on the streets and in institutions (NIEL, SILVEIRA, 2008). It can be seen that RD strategies have evolved a lot, expanding to other contexts, including NGOs with social centers and interventions in electronic music parties.
In 1998, “É de Lei” (freely translated as It’s from Law), the first social center for drug users, was created in São Paulo. The emphasis of the Harm Reduction work is associated with the use of crack, with the objective of preventing STDs / AIDS. Together with the users, strategies were created to minimize the damage resulting from the use of crack. The members of the Centro de Convivência work with the objective of “contributing to a change in the culture in the field of drugs, aiming at reducing stigma and prejudice towards drug users and, as a result, reducing health problems, marginalization , violence and human rights violations. ” (It’s from Law, 2015)
From the É de Lei project, ResPire Harm Reduction was created, which makes interventions in the context of a party. The “acute” use of drugs is frequent.
Breathe Harm Reduction
ResPire is a project that was born in 2010 from the É de Lei Community Center, taking the Harm Reduction approach to the context of parties. Initially, the project was called “Saúde em festa”, and it was a public notice that was financed by the Department of Hepatitis of the Ministry of Health, United Nations Office on Drugs and Crime (UNODC) and UNESCO. The project was born after the Balance collective, in 2008, called some damage reducers from the Centro de Convivência É de Lei to get to know this work of information and care in relation to the use of substances in the context of parties in Bahia. The start of ResPire was inspired by Balance, after their voluntary work.
With this project, actions are carried out with the objective of reducing unwanted effects after drug use – such as “bad trips”, developing bonds with these users, promoting self-care strategies, and also carrying out prevention and health promotion within the environment to decrease vulnerabilities and STD transmission. Party goers do not have access to information on how to reduce the possible damage caused by substances that are ingested in that context. It is believed that, with the dissemination of information on how to make safer use, there is a fall in risk situations.
The intervention takes place by setting up a stand, InfoStand, in electronic music parties, previously selected, to access people who use drugs. In this location, harm reducers promote debates and talk openly about drug use. This conversation is free of moralistic judgments and opinions, the opposite of the scenario of a reality experienced daily. The regulars can exchange knowledge about the different substances, reflect on the form of use, quantity, etc., which makes it possible to prevent uses that represent a greater risk to the subject.
The work of the harm reducer in the bond and reception established with those who are under their care is based on an ethical relationship and respect for the user in his / her choices, especially those of consuming the substances. There is also work on the prevention of STDs and viral hepatitis. There is graphic material for free distribution with information in terms of harm reduction on several drugs commonly present, such as: Marijuana, Cocaine, Amphetamines, LSD, Ecstasy, Power Plants, Inhalants, Alcohol and Tobacco.
In addition, for people who use substances that can be inhaled, we deliver and present the Sniff Kit. This input consists of a condom, an information card with instructions to reduce the vulnerability to the transmission of hepatitis B and C, a clean metallic surface to “stretch” the drug to be ingested, a block with leaves to roll straws, plus one of silicone, in order to avoid the use of contaminated materials and also the sharing of straws between users to vacuum the dust.
InfoStand can also be used to welcome people who are experiencing negative experiences due to substance use. The service is called “S.O.S. Psychedelic ”, which can often be essential to contain outbreaks and is an attempt to decrease vulnerabilities. The space reserved for the care of people who are going through difficult experiences due to the use of substances has mats, pillows and blankets, and support from the on-call team, so that it is a warm and comfortable environment to continue your trip from one best way. This work can also be called therapeutic monitoring and is adapted to each specific situation; help go to the bathroom, meet friends, etc. It is important to emphasize that the dialogue with the medical center is always present. If vital signs are not ideal, the individual needs to be moved to the nearest medical facility.
The purpose of the harm reduction in relation to those who are under their care is to foster the autonomy of this individual, stimulating their self-care and also those around them. In this sense, the party goer learns tips to reduce the damage in relation to the use of substances and passes this knowledge on to his peers, so that this knowledge is multiplied.
This work was and has been carried out in an innovative and experimental way by É de Lei, it is composed of a multiprofessional team of damage reducers, with different experiences and professional backgrounds (Psychology, Anthropology, Social Sciences, Pharmacy / Biochemistry, Nursing, Biology), some visitors to the electronic scene, having as main values: Well-being, Temperance, Autonomy, Freedom, Prevention, Responsibility, Respect, Anti-prohibition, Balance.
It is worth mentioning that the professional who acts as a damage reducer needs to have a great game of belt in this context, so that he can deal with the greatest variability of situations.