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Harm Reduction: How Do We Measure Success?

Harm Reduction: How Do We Measure Success?. Justin Logan , Soo Chan Carusone , Matthew Barnes, Sagar Rohailla , and Carol Strike May 28, 2014 Canadian Public Health Association Conference 2014. Objectives. Define harm reduction

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Harm Reduction: How Do We Measure Success?

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  1. Harm Reduction: How Do We Measure Success? Justin Logan, Soo Chan Carusone, Matthew Barnes, SagarRohailla, and Carol Strike May 28, 2014 Canadian Public Health Association Conference 2014

  2. Objectives • Define harm reduction • Discuss public health interventions for harm reduction in the Canadian context • Determine how such programs are evaluated and potential gaps in evaluation • Provoke thought and discussion on new and different ways to evaluate harm reduction programs

  3. Background

  4. Casey House • Specialty HIV/AIDS hospital in Toronto (founded 1988) • 13 in-patient beds • Community programs • Interdisciplinary care • Day program in development

  5. Casey House Population • HIV+ • Demographics: • 81% male, 19% female • 61% homosexual • Housing and Income: • 20% unstable housing, 89% on disability • Mental Health: • 93% of patients > 1 Axis I diagnosis • Substance Use: • 63% Substance Misuse Disorder • Cocaine > Marijuana > Alcohol Schaefer-McDaniel, Halman, et al.

  6. What is Harm Reduction? • “Harm reduction seeks to minimize the risks and negative consequences associated with alcohol and illicit drug use or other high-risk activities through various public health measures, intervention programs, or individual counseling.”8 Marlatt and Witkiewicz 2010

  7. Public Health Agency Of Canada:Population Health Promotion Model http://www.phac-aspc.gc.ca/ph-sp/php-psp/php3-eng.php

  8. Research Question and Methods

  9. Research Question: • What outcomes are reported in the literature to evaluate harm reduction programs in adult and adolescent populations? • Important in Casey House’s development of evaluation protocols for its harm reduction programs

  10. Methods: Literature Review • Purpose: to identify outcomes used to evaluate four types of harm reduction programs • Opioid Maintenance Therapy • Needle Syringe Programs • Safe Crack User Kit Programs • Alcohol-related programs

  11. Methods: Literature Review • PsycINFO and SCOPUS databases • Inclusion Criteria • English Language • Adolescent/Adult Population • Published since 2008 • Evaluating 1 of the 4 above-listed interventions • Primary research or program evaluation

  12. Results and Analysis

  13. OMT = Opioid Maintenance Therapy Et-OH = Alcohol-related Interventions NSP = Needle Syringe Programs SCUK = Safe Crack User Kits

  14. Geographic Distribution of Studies (N = 97) 2 (12) 48 7 10 10 6 0 0 14

  15. More Frequently Reported Outcomes (N=85) OMT = Opioid Maintenance Therapy Et-OH = Alcohol-related Interventions NSP = Needle Syringe Programs SCUK = Safe Crack User Kits

  16. Less Frequently Reported Outcomes (N = 85) OMT = Opioid Maintenance Therapy Et-OH = Alcohol-related Interventions NSP = Needle Syringe Programs SCUK = Safe Crack User Kits

  17. Key Determinants of Health • Income and Social Status (ISS) • Social Support Networks (SSN) • Education/Literacy(EL) • Employment/Working Conditions (EWC) • Social Environments (SE) • Physical Environments (PE) • Personal Health Practices and Coping Skills (PHPCS) • Biology and Genetic Endowment (BGE) • Healthy Child Development (HCD) • Health Services (HS) • Gender (G) • Culture (C)

  18. Stratifying Outcomes by the Key Determinants of Health • Determinants without any related outcomes • Gender • Culture • Healthy Child Development • Determinants most frequently related to outcomes • Personal Health Practices and Coping Skills • Biology and Genetic Endowment • Health Services

  19. Stratifying Outcomes by Key Determinants of Health # of Outcomes OMT = Opioid Maintenance Therapy Et-OH = Alcohol-related Interventions NSP = Needle Syringe Programs SCUK = Safe Crack User Kits

  20. User Satisfaction as an Outcome • Not easily related to any of the key determinants of health • Measured in 7 studies, all of them Methadone Maintenance Therapy

  21. Qualitative Studies • 12 qualitative studies included, 10 mixed studies with a qualitative component • Common Themes • Satisfaction and quality of program • Access to program • Barriers including stigma • Patterns of use • Lending Practices/Risk Behaviors • Overall Health • Socioeconomic health

  22. Discussion

  23. What Harms? Substance Use-Related Harms • Health Consequences • Infection • Mental Health • Effects on overall health/nutrition • Social Consequences • Interpersonal relationships, family, stigma • Personal Development • Education, Happiness, Legal Issues • Economic and Physical Wellbeing • Employment, Housing, Incarceration References: 3, 9, 13, 20, 24, 25

  24. Stratifying Outcomes by Key Determinants of Health # of Outcomes

  25. Strategy:Public Health Agency Of Canada:Population Health Promotion Model http://www.phac-aspc.gc.ca/ph-sp/php-psp/php3-eng.php

  26. Healthcare Access as an Important Outcome • Drug Users in the healthcare system • High need for healthcare services (McCoy et al. 2001) • Poor access (McCoy et al. 2001) • Worse experiences (Edlin BR et al. 2005) • Harm reduction programs allow users to be engaged by the healthcare system instead of invisible to it (Rachilis et al. 2001)

  27. Healthcare Access as an Important Outcome: • How was access measured? • Health Services = 19 (22%) total outcomes • 9 measured one-time use of particular service • 6 measured retention in treatment • 3 measured hospitalizations • 1 measured primary care access • Why is this important?

  28. Summary • As part of a health promotion strategy, harm reduction seeks to make an impact across many key determinants of health • Yet evaluations consistently measure outcomes related to only a few determinants • Personal Health Practices and Coping Skills • Biology and Genetic Endowment • Outcomes related to other determinants are used far less frequently • Socioeconomic Status • Social Support Networks • Social Environment • Employment/Working Conditions • Education and Literacy • Physical Environment

  29. Recommendations • This represents a gap in evaluation • Development of outcomes which capture benefits related to wide range of determinants • Measures of health care access • Must recognize practical limitations of harm reduction research • Funding • Personnel and Expertise

  30. Thank You SooChan Carusone, Ph.D.Casey HouseMcMaster University Carol Strike, Ph.D. University of Toronto Matthew Barnes University of Toronto SagarRohailla University of Toronto

  31. References: 1. Harm Reduction Training Manual. Toronto, Ontario: Casey House; 2012. 2. Babor TF, Higgins-Biddle JC, Dauser D, et al. Brief interventions for at-risk drinking: patient outcomes and cost effectiveness in managed care organizations. Alcohol and Alcoholism. 2006;41(6):624-631. 3. Galea S and Vlahov D. Social Determinants and the Health of Drug Users: Socioeconomic Status, Homelessness, and Incarceration Public Health Reports. 2002;117(S1):135-145. 4. Ivsins A, Roth E, Nakamura, N, et al. Uptake, benefits of and barriers to safer crack use kit (SCUK) distribution programmes in Victoria, Canada-A qualitative exploration. International Journal of Drug Policy. 2011;22(4):292-300. 5. Havnes I, Bukten A, Gossop M, Waal H, Stangeland P, Clausen T. Reductions in convictions for violent crime during opioid maintenance treatment: A longitudinal national cohort study. Drug Alcohol Depend. 2012;124(3):307-310.

  32. References: 6. Hays RD, Cunningham WE, Sherbourne CD, et al. Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV cost and services utilization study. The American Journal of Medicine. 2000; 108(9):714-722). 7. Kim JW, Choi YS, Shin KC, et al. The effectiveness of continuing group psychotherapy for outpatients with alcohol dependence: 77-month outcomes. Alcoholism: Clinical and Experimental Research. 2012;36(4):686-692. 8. Marlatt GA and Witkiewitz K. Update on harm-reduction policy and intervention research. Annual Review of Clinical Psychology. 2010;(6):591–606 9. McCoy CB, Mesch LR, Chitwood DD, and Miles C. Drug use and barriers to use of healthcare services. Substance Use and Misuse. 2001;36(6&7): 789-806. 10. Neale J , Sheard L, and Tompkins CN. Factors that help injecting drug users to access and benefit from services: A qualitative study. Substance Abuse Treatment, Prevention, and Policy. 2007; 2:31-44.

  33. References: 11. Pauly, B. Shifting moral values to enhance access to health care: Harm reduction as a framework for ethical nursing practice. International Journal of Drug Policy. 2008;(19):195-204. 12. Rachilis BS, Kerr T, Montaner JS, Wood E. Harm reduction in hospitals: is it time? Harm Reduction Journal. 2009; 6:19. 13, Regier DA, Farmer ME, Rae DS, et al. Comorbidity of Mental Disorders With Alcohol and Other Drug Abuse: Results From the Epidemiologic Catchment Area (ECA) Study. The Journal of the American Medical Association. 1990;264(19):2511-2518. 14. Shanahan CW, Beers D, Alford DP, Brigandi E, Samet JH. A transitional opioid program to engage hospitalized drug users. Journal of General Internal Medicine. 2010;25(8):803-808. 15. Schaefer-McDaniel N, Halman M, Carusone SC, Stranks S, and Stewart A. Complex care of patients with late stage HIV disease: A Retrospective Study. International Conference on Urban Health. March 2014.

  34. References: 16. What Makes Canadians Healthy or Unhealthy?. Public Health Agency of Canada Web site. http://www.phacaspc.gc.ca/phsp/determinants-eng.php #personalhealth. Updated August 21, 2012; Accessed November 14, 2012. 17. Wolitski RJ, Kidder DP, and Fenton KA. HIV, homelessness, and public health: critical issues and a call of increased action. AIDS and Behavior. 2007;11(S2):167-171. 18. Wood E, Kerr T, Tyndall MW, Montaner JS. A review of barriers and facilitators of HIV treatment among injection drug users.AIDS. 2008;22(11):1247-1256. 19. Wood E, Montaner JS, Chan K, et al. Socioeconomic status, access to triple therapy, and survival from HIV-disease since 1996. AIDS.2002;16(15):2065-2072.

  35. References: 20. LauplandKB and Embil JM. Reducing the adverse impact of injection drug use in Canada. Can J Infect Dis Med Microbiol. 2012 Autumn; 23(3): 106–107. 21. Erickson et al. CAMH and Harm Reduction: A Background Paper on its Meaning and Application for Substance Use Issues. CAMH web site. May 2002. Accessed April 25, 2014. 22. An integrated model of population health and health promotion. Public Health Agency of Canada web site. http://www.phac-aspc.gc.ca/ph-sp/php-psp/php3-eng.php. Updated December 8, 2001. Accessed April 20th, 2014. 23. Edlin BR, Krevina TF et al. Overcoming Barriers to Prevention, Care, and Treatment of Hepatitis C in Illicit Drug Users. ClinInfect Dis. (2005) 40 (Supplement 5): S276-S285. 24. Grant JD, et al. Associations of alcohol, nicotine, cannabis and drug use/dependence with educational attainment: evidence from cotwin-control analyses. Alcoholism: Clinical & Experimental Research, Early View vol. 36 (8), August 2012.

  36. References: 25. Nutt D, King LA, Saulsbury W, and Blakemore C. Development of a rationale scale to assess the harms of potential drugs of misuse. The Lancet. 2007;369(3): 1047–53.

  37. Questions? Justin Logan justin.logan@mail.utoronto.ca Soo Chan Carusone schancarusone@CaseyHouse.on.ca

  38. Substance Use in Canada • Prevalence of substance use: • 9.1% of Canadians 15+ used Cannabis in past year • 4.8% of Canadians 15-24 reported using cocaine, speed, hallucinogens, ecstasy, or heroin in past year • Males twice as likely to use compared to females • 78% of Canadians drank alcohol in past year • 100,000 intravenous drug users in Canada in 2012 • Prevalence of harm: • 1.8 % of Canadians (5.8% aged 15-24) reports experiencing at least 1 harm in past year due to illicit drug use

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