Integrating Harm Reduction into Case Management 2010 CBAF Conference Corpus Christi, TX

1. IntegratingHarm Reduction intoCaseManagement2010 CBAF ConferenceCorpus Christi, TX Kevin Irwin September 16, 2010

2. Objectives • Convey a personal definition of harm reduction • Adopt a Harm Reduction framework in Case Management • Develop skills to assist people to identify potential sources of harm and tools with which they may reduce their risk for harm

3. Harm Reduction in 1842 • “Is it just to assail, condemn, or despise them? Men ought not in justice to be denounced for yielding to it in any case, or giving it up slowly, especially when they are backed by interest, fixed habits, or burning appetites.”

4. Abraham Lincoln, 22 February 1842 Address before the Springfield Washington Temperance Society

5. Harm Reduction Definitions • Harm reduction is NOT “anything goes” • Harm reduction is NOT “whatever happens, happens.” • Harm reduction is NOT simply “meeting the client where the client is at” (it’s helping them to change behavior) • Harm reduction is NOT “Helping a person who has gotten off drugs to start using again.” • Harm reduction is NOT condoning, endorsing, or encouraging drug use. • Harm reduction is NOT Legalization

6. Principles of Harm Reduction • Being clear about Harm Reduction • Harm reduction is a set of practical strategies that reduce the negative consequences of drug use and/or sex experienced by individuals and communities. • Harm reduction approaches incorporate a spectrum of strategies from safer use, to managed use, to abstinence. • Harm reduction strategies engage people, identify their needs, and work towards goals that are attainable.

7. Harm Reduction and Behavior • Safer Driving – speed limits, seat belts, intoxication limits, air bags, defensive driving, alternatives to driving…… • Safer Sex – condom use, avoidance of risky sexual practices, abstinence…… • Safer Drug Use – reduced use, avoidance of risky routes of administration, drug substitution, safe using partners (designated driver), abstinence…..

8. Compassionate Pragmatism • Harm Reduction is a philosophy, integrated into a variety of practices • There is no one right way • Most life changes are gradual • All chronic conditions are challenging • Reducing harm is the fundamental objective of responses to all chronic conditions • Any Positive Change

9. The A-word • Are abstinence and harm reduction compatible? • HOW are abstinence and harm reduction compatible? • Harm reduction and abstinence are highly congruent goals. • Harm reduction expands the therapeutic conversation, allowing providers to intervene with active users who are not yet contemplating abstinence. • Harm reduction strategies can be used at any phase in the change process.

11. Principles • Accepts, for better and for 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. • Understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others. • Establishes quality of individual and community life and well-being - not necessarily cessation of all drug use - as the criteria for successful interventions and policies. • Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm.

12. Principles, cont’d • Ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them. • Affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use. • Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people's vulnerability to and capacity for effectively dealing with drug-related harm. • Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use.

13. Major Endorsements • National Institutes of Health (1997) • American Public Health Association (1997) • US Surgeon General (2000) • Department of Health and Human Services (2000) • Institute of Medicine (2000) • Centers for Disease Control (2002) • National Institute on Drug Abuse (2002)

14. Objectives • Convey a personal definition of harm reduction • Adopt a Harm Reduction framework in Case Management • Develop skills to assist people to identify potential sources of harm and tools with which they may reduce their risk for harm

15. Case Management and Harm Reduction • Participant centered rather than Program centered • Participants capable of taking control of their lives • Participants strengths and capabilities • Shared, collaborative partnership • Participant is responsible for the Outcome • CM responsible for the Process • Engaging and supporting individuals in sustained efforts to improve their lives

16. Case Managers • Commitment to broaden and deepen our own toolkit • Broaden the options available to people we serve • Acceptance and Respect for Choices

17. Typical CM Models • Broker Model • Focuses on getting client connected to resources • Strengths Model • Focus on strengths rather than deficits • What Model are you?

18. Abstinence No use of legal or illegal drugs Experimentation Heavy Use/Drug Abuse Curiosity and willingness to act Continued use regardless of negative consequences Social/Recreational Chaotic Use/Addiction Periodic use with no established pattern Compulsive behavior Habitual Established patternof use The Cycle of Use 18

19. Precontemplation No awareness Contemplation Maintenance(including relapse) Aware andconsidering change Continuing the change process Preparation Action Thinking about takingsteps towards change Modifying behavior to overcome problem Stages of Change 19

20. Symptoms of Withdrawal • Lack of energy • Depression • Flashbacks • Heavy cravings • Erratic mood swings • Seizures • Sweating • Goose bumps • Vomiting • Diarrhea • Tremors How Might These Also Appear as Mental Health Symptoms?

21. Multiple Diagnosis • The Big Challenge: Integrating Care • Primary Care • Mental Health Care • Substance Use Care • Avoid Partitioning – “whack-a-mole” • Help Client adopt a Holistic Perspective • What are the barriers to integrating care? • What appropriate referrals exist for DD?

22. From Screening to Referral • Engagement • Safety is 1st • Risk Reduction (Risk to Self and Others) • Stages of Change • Assessment – Don’t Assume role of drugs • Motivational Interview Techniques • Building on Strengths, Positive Reinforcement • Identifying and Removing Obstacles • Referral and Follow-up

23. Drug, Set & Setting • Drug • Dose, Frequency, Routes, Concentration, Combinations • Set • Beliefs, Expectations, Rituals, Health • Knowledge: Drug Interactions, OD, • Setting • Risk Environment • Purchase, Possession • Who, Where, When

24. Objectives • Convey a personal definition of harm reduction • Adopt a Harm Reduction framework in Case Management • Develop skills to assist people to identify potential sources of harm and tools with which they may reduce their risk for harm

25. Cases

26. Values Clarification 1.     Poverty and oppression contribute substantially to substance use. 2.     The substance user is a victim of circumstance. 3.     Some substance users simply need to change their environment and their use of alcohol or other drugs will diminish. 4.     Dependence on substances is a symptom of an underlying emotional problem. 5.     Drug use is an understandable way to cope with depression and mental illness. 6.     The main goal of treatment is to gain insight about the reasons a person uses drugs. 7.     Alcohol or other drug use is an escape from reality. 8.     Some tenants find the streets more comfortable than their supportive housing units. 9.     Housing alone reduces the risks of drug use. 10.  People whose drug use is heavy or chaotic are not housing ready. 11.  Harm reduction is more permissive than other approaches to substance use. 12.  The goal of treatment planning is to help tenants manage their substance use.

27. Thank You! Kevin.Irwin@Tufts.Edu