Harm%20Reduction

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Harm Reduction

• G. Alan Marlatt, Ph.D.
• University of Washington
• Addictive Behaviors Research Center
• abrc_at_u.washington.edu
• http//depts.washington.edu/abrc/

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Harm Reduction History

• U.K. Model
• Medicalization Approach
• Netherlands
• Normalization Approach
• Junkie bond

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Dutch Model

• Realistic and pragmatic
• Social/health approach
• Openness, Normalization leads to access,
  control
• Distinction between soft and hard drugs
• Low threshold treatment policies

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Dutch vs. American Drug Policies

• Low vs. High threshold access to prevention and
  treatment programs
• Public health vs. Criminal justice approach
• Tolerance vs. Zero-tolerance
• Normalization vs. Denormalization policies

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Harm Reduction Central Assumptions

• Public health alternatives to moral/criminal and
  disease models of drug use and addiction
• Recognizes abstinence as an ideal outcome, but
  accepts other alternatives
• Often partners with the group to obtain input on
  programs

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Harm Reduction Overview

• Harmful consequences of drug use can be placed on
  a continuum
• Goal to move along this continuum by taking
  steps to reduce harm

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Harm Reduction

• Habit is habit and not to be flung out of the
  window by any man, but coaxed downstairs a step
  at a time.
• Mark Twain,
• Puddnhead Wilsons Calendar,
• Chapter 6

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Harm Reduction Methods

• Safer route of drug administration
• Alternative, safer substances
• Reduce frequency of drug use
• Reduce intensity of drug use
• Reduce harmful consequences of drug use

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Harm Reduction Behavior Change

• Individual
• Environment
• Policy

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How was I supposed to know that the apple was a
controlled substance?
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Young Heavy Drinkers

• Heaviest drinking period in life
• Problems common, yet more isolated
• Development in adulthood?
• Problems associated with peer influence,
  impulsivity, conduct history
• Do not see drinking as a problem

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Spectrum of Intervention Response
Thresholds for Action
No Problems
Mild Problems
Severe Problems
Moderate Problems
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Social Norms and the Prevention of Alcohol Misuse
in Collegiate Contexts H. WESLEY PERKINS,
PH.D. Department of Anthropology and Sociology,
Hobart and William Smith Colleges, Geneva, New
York 14456 [phone] perkins_at_hws.edu
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Alcohol Skills Training ProgramComponents of
Skills Training Program for Secondary Prevention

• Training in self-monitoring of blood alcohol
  levels and drinking moderation techniques
• Training to anticipate and prepare for situations
  involving increased risk of heavy drinking (e.g.
  social pressure, or negative emotional states)
• Training to recognize and modify alcohol outcome
  expectancies (i.e. placebo vs. drug effects)
• Training to alternate stress coping skills (e.g.
  relaxation aerobic exercise)
• Training in relapse prevention to enhance
  maintenance of drinking behavior change

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Peak Blood Alcohol Concentration by Group
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ProjectBrief Alcohol Screening
and Intervention for College Students
BASICS
G. Alan Marlatt, Ph.D John S. Baer, Ph.D. Daniel
R. Kivlahan, Ph.D. Lori Quigley, Ph.D. Mary E.
Larimer, Ph.D. Sally Weatherford, Ph.D. Dan
Irvine, BS Ken Weingardt, MS Lisa Roberts,
MA Lizza Miller, BA Jason Kilmer, MS Linda
Dimeff, MS
Principal Investigator Co-Principal
Investigator Co-Principal Investigator Project
Coordinators Research Coordinator Research Study
Assistant Graduate Research Assistant Funding
By The National Institute of Alcohol Abuse and
Alcoholism Grant 5R37-AA05591
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Stages of Change Intervention Strategies
Assessment Treatment Matching
Precontemplation a Contemplation a Preparation a
Action a Maintenance a Relapse
Motivational Enhancement Strategies
Relapse Prevention Relapse Management
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Prevalence of Alcohol-Related Consequences Among
Fraternity and Sorority Members
50.0 Neglected your responsibilities 47.8 Missed
a day (or part of a day) of school or
work 41.7 Not able to do your homework or study
for a test 40.0 Got into fights, acted bad, or
did mean things 39.2 Felt you needed more
alcohol . . . to get same effect 38.9 Caused
shame or embarrassment to someone 36.8 Had a
fight, an argument or bad feelings with a
friend 36.6 Drove shortly after having more than
two drinks 36.3 Had blackouts 33.7 Noticed a
change in your personality 29.8 Passed
out 24.2 Missed out on things . . . spent too
much . . . on alcohol 21.9 Drove shortly after
drinking more than four drinks 16.2 Went to work
or school high or drunk 16.1 Felt that you had a
problem with alcohol 8.1 Felt physically or
psychologically dependent 7.9 Felt you were
going crazy 7.5 Had withdrawal symptoms
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BASICS Design Freshman Year of University
Spring Autumn
Winter Spring Autumn Quarter
Quarter Quarter
Quarter Quarter
Feedback And Advise Assessment
Stepped Care Options Assessment
Stepped Care Options Assessment
Select and assess high-risk sample (random assignm
ent)
Treatment
No Treatment
Assessment
Assessment
Assessment
Screen all incoming Freshman
Select and assess control sample
Assessment
Assessment
Assessment
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Participant Recruitment
BASICS

• 4000 Screening Questionnaires mailed
• 2179 Returned Questionnaires (54)
• 2041 Usable Questionnaires interested in
  participation (51)
• 508 High-risk identified (25)
• 366 High-risk agreed to participate
• - 11 clinical cases
• - 7 late responders
• - 348 randomized for intervention
• 174 High-risk control
• 174 High-risk intervention
• 151 Randomized control group selected
• - 115 agreed to participate
• (overlap of 26 with high-risk group)

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Constructs and Measures
BASICS

• Drinking Measures
• Construct Measure Time Frame___
• Alcohol Quantity (6pt) All points
• Consumption Frequency (7pt)
• Peak (6pt)
• Daily Drinking Questionnaire Baseline FU
• Alcohol Negative Rutgers Alcohol Problem Index
  (RAPI) All points
• Consequences Alcohol Dependence
  Scale Baseline FU
• DSM IIIr Dependency Scale (SCID) Baseline FU
• Collateral Report Quantity, Frequency,
  Problems Baseline FU

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Cues for Overdrinking
BASICS

• The people you are with
• The place where you are drinking
• The Time and Day
• Hunger and Thirst
• Special Situational Factors
• Emotional Factors

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Five General Principles
Motivational Interviewing

• Express Empathy
• Develop Discrepancy
• Avoid Argumentation
• Roll with Resistance
• Support Self-Efficacy

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Therapist tasks during PRECONTEMPLATION
Motivational Interviewing

• Raise doubt about current behavior
• Increase the clients awareness of the risks of
  current behavior
• Increase the clients awareness of the problems
  caused by current behavior

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Therapist tasks during CONTEMPLATION
Motivational Interviewing

• Tip the balance
• Evoke reasons to change
• Highlight the risk of not changing
• Strengthen the clients self-efficacy for
  changing the current behavior

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Negotiating a Plan for Change
Motivational Interviewing

• Settings Goals
• Considering Options
• Arriving at a Plan
• Encouraging Action

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BASICS
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Blood Alcohol Concentrationas a Function of
Drinks Consumedand Time Taken to Consume
Number of Hours
Number of Drinks
for a MALE, 185 lbs.
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Strategies to Reduce
Alcohol Consumption
BASICS

• Keep Track
• Slow Down
• Space Your Drinks
• Select Different Types of Drinks
• Drink for Quality instead of Quantity
• Enjoy Mild Effects

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Graphic Feedback
BASICS
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Frequency of Alcohol Consumptionfrom High School
to College
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BASICS
Four Year Outcome ResultsDrinking Problems
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BASICS
Four Year Outcome ResultsDrinking Rates
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for Young Heavy Drinkers
Harm Reduction

• Low Threshold
• - Avoids Labels
• - Avoids Rules
• Public Health Model
• -Treats young people as adults
• -Tolerates illegal activity
• Flexible
• -Tailored to personal history
• -Tailored to risk status

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3-D Model
The Three Dangerous Drives in Adolescent
Motivation
Drinking Dating
Driving
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Are YOU are Harm Reduction therapist?

• Are you a licensed or certified health care
  provider, or work under the supervision of one?
• Do you provide health services to individuals who
  suffer from drug-related harm?
• Are your health services guided by the principles
  of compassion, engagement, collaboration,
  self-determination, and pragmatism?
• Are your health services ethical, culturally
  competent, evidence-based, and guided by an
  assessment of your clients specific needs,
  goals, strengths, and resources?
• 5. Are you willing to deliver low-threshold
  health service that reduce drug-related harm to
  clients who are unable or unwilling to stop
  using, and to their loved ones?

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Are YOU are Harm Reduction therapist?
If you answered Yes to all five questions, then
you ARE a harm Reduction Therapist, and we would
like to invite you to join your colleagues as a
member of the Association for Harm Reduction
Therapy (AHRT)!
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Thank You.