Harm Reduction: An Emerging New Paradigm for Drug Education
David F. Duncan, Dr.P.H., C.A.S.1
Center for Alcohol and Addiction Studies
and Department of Community Health
Thomas Nicholson, Ph.D., M.P.H.
Department of Public Health
Western Kentucky University
Patrick Clifford, Ph.D.
Center for Alcohol and Addiction Studies
and Department of Psychiatry
Wesley Hawkins, Ph.D.
Department of Mental Hygiene
Johns Hopkins University
Rick Petosa, Ph.D.
Department of Health Education
Ohio State University
1 Address correspondence to Dr. Duncan at Center for Alcohol and Addiction
Sudies, Brown University, Box G-BH, Providence, RI 02912 Published in: Journal of Drug
Education, 1994, 24(4), 281-290.
Harm reduction is a new paradigm now emerging in the field of drug education. This
strategy recognizes that people always have and always will use drugs and, therefore,
attempts to minimize the potential hazards associated with drug use rather than the use
itself. The rationale for a harm reduction strategy is presented, followed by an example
of the kind of needs assessment which may be needed for planning a harm reduction
A major paradigm shift is underway in the field of drug education. It is the shift from
a strategy of use-prevention to a strategy of abuse-prevention or harm-reduction. This new
paradigm expands and transforms traditional concepts of the purposes and methods of drug
education. It can serve as a model for a more rational and comprehensive organization of
prevention resources likely to yield the greatest benefit to society.
Harm reduction is a policy of preventing the potential harms related to drug use rather
than trying to prevent the drug use itself. Harm reduction accepts as a fact that drug use
has persisted despite all efforts to prevent it and will continue to do so. Further, it
recognizes that measures intended to prevent drug use have often had the unintended effect
of increasing the harms associated with drug use. This strategy has also been called
damage limitation, casualty reduction, or harm minimization.
EVOLUTION OF THE HARM REDUCTION STRATEGY
One of the earliest instances of this approach was an educational program carried out
in 1972 by the senior author and his colleagues at an urban, Southwestern drug abuse
treatment center confronting an epidemic of paint and solvent "huffing." Young
adolescents were emptying cans of spray paint into plastic bags then inhaling the
resulting fumes in order to get high. Two deaths had occurred locally when boy's
suffocated in the plastic bags after passing out; another boy had inhaled enough of the
paint itself to coat the interior of part of his lungs resulting in severe edema, shock
and brain damage; and another boy passed out near a space heater which ignited his
"huffing bag" causing a fire in which he was fatally burned. Against the
background of these incidents, it was decided to place a priority on preventing deaths.
Educational presentations to youth groups continued to deal with the hazards of
"huffing" or "sniffing" solvents, but each presentation ended with a
description of ways to reduce the risks associated with huffing -- such as using paper
bags instead of plastic bags or using a toilet paper roll with a tissue paper filter as a
"carburetor" for huffing. In no way was huffing encouraged or endorsed, but the
message was, "if you must huff, at least do it in a way that won't kill you." No
further deaths occurred after this program went into effect and crisis calls related to
huffing declined sharply, although there is no way to definitely attribute that outcome to
Paradigm shifts are often so large in scope and incremental in implementation that they
"arrive" without much notice. In the past decade considerable attention has been
directed toward the human and social costs of accidents caused by intoxicated drivers.
Many of the resulting policies and programs reflect the realistic assessment that people
need transportation at times when they are intoxicated. Designated drivers, free cab
rides, free coffee stops on freeways, and changing social norms regarding responsible
drinking and responsible drink-serving are all examples of harm reduction.
The responsible use approach to alcohol education which emerged in the early 1970's was
an early application of the harm reduction strategy to a licit drug 1. Room's 2
problem minimization approach to alcohol shows that this approach to alcohol is still
alive. This approach has not been without its critics, especially within the federal
bureaucracy. Editorial guidelines issued by the Office for Substance Abuse Prevention
reject use of the term "responsible use" 3.
The earliest formal statement of this strategy also dealt with the problem of solvent
sniffing. It was the "casualty-reduction" approach to glue sniffing adopted by
the Institute for the Study of Drug Dependence in 1980 4. Another early statement
of this approach was the proposal by Duncan and Gold 5 for "cultivating drug
use" -- using the word cultivation in the sense of promoting healthy and productive
development, while "weeding out" tendencies toward abuse.
In 1984, this strategy was given its most popular name in a report of the Home Office 6
of the British government which described two alternate goals for drug abuse prevention
programs -- either reducing drug use or "harm reduction." Both were recognized
as acceptable goals for prevention programs. The recent International Conferences on the
Reduction of Drug-Related Harm, held in Liverpool, England in 1990, Barcelona, Spain in
1991, Melbourne, Australia in 1992, and Rotterdam, the Netherlands in 1993 illustrated the
rapid growth of this strategy in Western Europe and Australia. The 1994 conference in
Toronto, Canada will bring greater awareness of this strategy to North Americans.
Whatever it is called, the essence of this strategy is the recognition that preventing
drug abuse is a different task from preventing drug use and may be both a more justifiable
and a more achievable goal. Mugford 7 says that the harm reduction approach takes
the line that people will continue to use drugs and asks how they can do so most safely.
Such a strategy is consistent with human experience. Historically, most cultures have
included drug consumption and all attempts at prohibition have failed.
Marion Watson, Director of the Drug Research and Information Centre in Canberra,
Australia, defines harm reduction as,
the philosophical and practical development of strategies so that the outcomes of drug use
are as safe as is situationally possible. It involves the provision of factual
information, resources, education, skills and the development of attitude change, in
order, that the consequences of drug use for the users, the community and the culture have
minimal hegative impact 8, p. 14.
A harm-reduction strategy may involve a wide variety of different tactics. Harm
reduction may involve changing the legal sanctions associated with drug use. It may
increase the availability of treatment services to drug abusers. It may attempt to change
drug users' behavior through education. It may also strive to change public perceptions of
drugs and drug users.
RATIONALE FOR A HARM REDUCTION STRATEGY
Traditional use-prevention programs have seldom taken on the impossible task of
discouraging the use of all drugs. Instead they have dichotomized drugs into licit versus
illicit, or those with abuse potential (i.e. "hard drugs") versus those without
("soft drugs") -- or simply the good versus the bad. Goodstadt 9 warned
that such dichotomies "result in ambiguities and problems," since drugs in both
categories can be abused and since all drugs are illegal under some circumstances. In
arguing the harm reduction position, Jonas 10 asserts that current policy is
binary as to drugs - licit and illicit - and unitary as to solutions - abstinence. A harm
reduction policy, on the other hand, would be unitary as to drugs and multimodal as to
David Moore and Bill Saunders, of Australia's National Centre for Research into the
Prevention of Drug Abuse, argue that, "... given the universality of drug use in
human societies and the very real benefits that accrue from drug use, the usual prevention
goal of abstinence from drug use for young people is unthinking, unobtainable and
unacceptable" 11, p. 29. When you include alcohol, tobacco, prescription and
over-the-counter psychoactive drugs in addition to the illicit drugs, almost no one in our
society, or any other, is truly drug-free. A drug-free community would be as improbable as
a sex-free community, and as unhealthy.
Many forms of recreational drug use are legally defined as licit for adults but illicit
for adolescents. Petosa 12 has described how this situation results in a large
number of adolescents perceiving the use of those drugs as helping them progress toward
adult social roles. As a consequence, these young people are particularly resistant to
drug abstinence messages. In these circumstances, harm reduction approaches will be more
relevant and more likely to result in behavioral changes to reduce risk.
Just as it is a truth that any drug can be abused, it is a truth that any drug can be
used without abuse. No drug is inherently abusive. Tobacco would appear to be the only
drug for which it cannot be said that users outnumber abusers. Shedler & Block
compared the psychological health of adolescents who were abstainers, experimenters or
frequent users of illicit drugs. They found that, "experimenters are the
psychologically healthiest subjects, healthier than either abstainers or frequent
users" 13, p. 625. Clifford, et al. 14 found a curvlinear
relationship between illicit drug use and a broad measure of life satisfaction, with the
highest levels of life satisfaction among moderate drug users and lower levels of life
satisfaction among both non-users and heavy users. Hogan, Mankin, Conway & Fox 15
in another related instance, found that mariuana users had better social skills, a broader
range of interests, and more concern for the feelings of others than did non-users.
Bentler 16, likewise, found a "small but reliable association between
marihuana use and the development of a positive self- concept."
Commenting on the failure of the traditional approach to differentiate between use and
abuse, Moore and Saunders argue that:
"Because there are so few data on the extent of drug and alcohol-related problems
among youth, stating that there is a youth drug problem is also somewhat perilous.
Further, because most prevalence surveys do not measure harm but use, evaluating
prevention programmes as failures or successes using the criterion of an increase or
decrease in the overall number of people using a particular drug may be fallacious.
Logically, it is possible for user rates to increase while, via appropriate interventions,
harm rates fall." 11, p. 33
The risk of HIV infection associated with intravenous drug use has motivated many
public health and drug abuse authorities to rethink their priorities in dealing with IV
drug use, moving them toward harm reduction. Mugford 7 reports that Australian
efforts to prevent the transmission of HIV among IV drug users have been based on: 1) the
distribution of sterile hypodermic needles and syringes; 2) education of drug users on
proper syringe hygiene; and 3) establishment of safe disposal points for used syringes in
public restrooms. As a result of this harm-reduction strategy, the seroprevalence of HIV
among IV drug users in Australia has been held down to only 2%. This compares with the
50-70% HIV seroprevalence among IV drug users in certain large U.S. cities such as New
York where harm reduction approaches have been little used.
DATA REQUIREMENTS OF THE HARM REDUCTION STRATEGY
Jonas 10 asserts that a harm reduction strategy must be based on epidemiologic
data about the actual incidence of real negative consequences of taking various drugs.
Only once this is known, can we focus our efforts on reducing the actual negative
consequences and on truthfully educating the public about those consequences which are
irreducable. Unfortunately, there is very little such epidemiologic data available at
Martin, Duncan and Zunich 17 examined the reasons for discontinuing illicit
drug use among 223 American college students who were former drug users. They found that
concerns for physical health were the principal reasons for discontinuing cocaine use
(55%), amphetamine use (30%), heroin use (29%), and marijuana use (24.%). The primary
reason for discontinuing use of LSD (35%) was problems of a mental/emotional nature. In a
later study of reasons for discontinuing hashish use among 237 Central European athletes
Duncan 18 found that the most common reasons for discontinuing use were dislike
for the effects (14.75%), requirements of an athletic training regimen (13.11%), health
reasons (11.48%), and mental/emotional problems (11.48%).
Problems associated with the use of alcohol, aspirin and marijuana were studied by
Duncan and Martin 19 in a 1% random sample (n = 132) of students at Southern
Illinois University. The mean number of problems per alcohol user was 1.3; 0.26 per
aspirin user; and 1.16 per marijuana user. The most common problem associated with alcohol
was driving while intoxicated, which was reported by 59.6% of the drinkers. The problem
most commonly associated with aspirin was daily use for pain (5.8%). The most common
marijuana-associated problem was getting "stoned" "frequently"
(24.6%). Either of these "problems" would probably provide little guidance in
developing harm reduction measures.
Holcomb, Sarvela, Ritzel, Sliepcevich and Jellen 20 surveyed 3,348 secondary
school students in two rural Illinois counties. Various negative consequences of
"drinking or drug use" were reported by four to fourteen percent of the
subjects. The greatest increase in incidence of negative consequences was seen between the
eighth and ninth grades. The most frequently reported negative consequences were impaired
self esteem (14.0%), family troubles (13.1%), getting into fights (12.9%) and hurt
An example of data collection for harm-reduction planning can be provided by our survey
of 1,335 secondary school students (664 females and 671 males) attending grades seven thru
twelve in two rural Illinois unit school districts. This represented an 88.9% sample
(89.8% of females; 88.0% of males) of all secondary school students, other than those in
special education classes, in the two districts.
The survey instrument was a modification of that previously used by Duncan and Martin 19.
Modifications were based largely on the experience of Holcomb, Sarvela, Ritzel,
Sliepcevich, and Jellen 20 in surveying a similar population. It consisted of a
demographic data sheet and twenty-one questions -- seven related to each of three commonly
used drugs: alcohol, aspirin and marijuana. The first question in each set of seven was a
screening question asking whether the respondent had used that drug during the past year;
the remaining six items each dealt with a possible negative consequence of using that
Two-thirds (67.3%) of the students -- 64.6% of the females and 69.8% of the males --
reported using alcohol during the preceding year. Usage levels ranged from a low of 33.5%
in seventh grade to a high of 87.1% in eleventh grade, with the greatest increase from
eighth (51.2%) to ninth (74.7%) grade.
Drinking students reported a mean of 1.07 problems each. Driving while intoxicated was
the most frequently reported (21.5%) alcohol-related problem among the students in this
study. Family troubles over alcohol and getting into fights while intoxicated were both
reported by 15.2% of the students. Problems with school authorities related to alcohol
were reported by 8.9%, while school absences due to alcohol were reported by 6.9%.
Finally, 6.2% reported having had an accident while under the influence in which property
was damaged or someone was injured.
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Aspirin use during the past year was reported by 90% of the students -- 92.3% of the
girls and 87.7% of the boys. The percent of persons using aspirin varied only slightly
from grade to grade, but with a generally upward trend from a minimum of 84.1% in seventh
grade to a maximum of 96.4% in twelfth grade. Aspirin use was essentially problem-free
with a problem rate of 0.016 problems per aspirin user.
Almost one-third (29.9%) of the students -- 28% of the girls and 31.9% of the boys --
reported use of marijuana during the past year. Usage increased with grade level from a
low of 10.7% in the seventh grade to a high of 52.9% in the twelfth grade. Marijuana users
reported an average of 0.98 problems each, the most common of which was family trouble
over marijuana use -- reported by 14.2%. Trouble with the police over marijuana was
reported by 6.1% of the students. Trouble with school authorities over marijuana and
driving under the influence of marijuana were both reported by 3.9% of the students.
Having had an accident while under the influence of marijuana in which property was
damaged or someone was injured was reported by 1.1% of the students. Only one student
(0.07%) reported experiencing shortness of breath after smoking marijuana.
Not surprisingly, the incidence of problems related to each of the three drugs found in
this survey was lower than that found in the study of college students by Duncan and
Martin 19. It isn't surprising that the greatest difference was in
aspirin-associated problems since for most of our subjects aspirin is probably a
parentally administered drug and is likely to be administered with due caution and regard
for package instructions. The same cannot generally be said for their use of alcohol or
It should come as no surprise to any drug educator that the greatest number of problems
were associated with alcohol. Clearly, of these three drugs, alcohol is the one drug on
which educators should focus their greatest efforts.
Alcohol use and all six alcohol-related problems showed their sharpest increase between
eighth and ninth grades. The same pattern is observed for marijuana use and
marijuana-related problems. This confirms previous findings, such as those of Sarvela,
Newcomb, and Duncan, 21, that the greatest increase in problems with alcohol and
marijuana typically occurs between the eighth and ninth grades. These results suggest that
eighth grade may be a critical period for proactive services, such as drug education, and
ninth grade a critical period for reactive services, such as peer counseling services.
This does not mean that drug education is not needed earlier than eighth grade. Certainly
this could not be concluded from data which show 7.9% of seventh graders getting in fights
while drunk or 5.6% having family troubles over their marijuana use.
Driving while intoxicated was the single drug-related problem which was most frequently
reported in this study. It would seem to be a reasonable choice as the first priority of
any harm reduction program developed for this population. Focusing on this problem
behavior rather than on abstinence from alcohol would seem to be realistic, as has been
pointed out previously by Beck, Summons and Hanson-Matthews 22.
Family troubles related to alcohol and marijuana use present another target for harm
reduction. Family counseling and parent education would seem to be appropriate
interventions for these problems. Fighting under the influence of alcohol would be another
target. Training in refusal skills may be more effective in teaching kids how to keep out
of fights, which most of them do want to keep out of, than it has been for drugs, which
the kids at greatest risk didn't want to keep out of.
Over the past few decades various approaches have been tried as drug education. Early
methods emphasized information provision and scare tactics. In the 1980's America embraced
"Just Say No" campaigns. The success of any of these approaches has been
questionable at best. We feel that a major limiting factor of these approaches has been a
faulty assumption -- namely, that all drug use is unhealthy and therefore that the goal of
drug education should be the elimination of all drug consumption. A harm reduction
approach could offer a greater chance of mitigating the negative consequences of drug
abuse in the future, because it considers the realistic dynamics of human drug consumption
in our past.
- J. S. Dolan, Observations about the responsible drinking theme and threshold. Journal
of Alcohol and Drug Education, 21(2), 20-29.
- R. Room, Concepts and strategies in the prevention of alcohol. Contemporary Drug
Problems, 9, pp. 9-48 1980.
- Office for Substance Abuse Prevention, OSAP Editorial Style Guidelines: Suggested
Terminology for Developing Materials about Alcohol and Other Drug Problems. Office for
Substance Abuse Prevention, Rockville, MD, 1991.
- Institute for the Study of Drug Dependence. Teaching about a volatile situation. Author,
- D. F. Duncan, & R. S. Gold, Cultivating drug use: A strategy for the Eighties. Bulletin
of the Society of Psychologists in Addictive Behaviors, 2(3), pp. 143-147, 1983.
- Home Office, Prevention: Report of the Advisory Council on the Misuse of Drugs. Her
Majesty's Stationery Office, London, 1984.
- S. Mugford, Panel discussion on the topic, "Should public health adopt a harm
reduction drug control strategy?" at the annual meeting of the American Public Health
Association, Atlanta, GA, Nov. 12, 1991.
- M. Watson, Harm reduction -- Why do it? International Journal on Drug Policy,
2(5), pp. 13-15, 1991.
- M. S. Goodstadt, Drug education: The prevention issues. Journal of Drug Education,
19, 197-208, 1989.
- S. Jonas, Panel discussion on the topic, "Should public health adopt a harm
reduction drug control strategy?" at the annual meeting of the American Public Health
Association, Atlanta, GA, November 12, 1991.
- D. Moore, & B. Saunders, Youth drug use and the prevention of problems. International
Journal on Drug Policy, 2(5), 13-15, 1991.
- R. Petosa, Developing a comprehensive health promotion program to prevent adolescent
drug abuse, in The prevention and treatment of adolescent drug abuse, G. Lawson and
A. Lawson (Eds.), Aspen Publishers Gaithersburg, MD. pp. 431-449, 1992.
- J. Shedler, & J. Block, Adolescent drug use and psychological health: A longitudinal
survey, American Psychologist, 45, 612-630, 1990.
- P. R. Clifford, E. W. Edmundson, W. R. Koch, & B. G. Dodd, Drug use and life
satisfaction among college students. International Journal of the Addictions, 26,
- R. Hogan, D. Mankin, J. Conway, & S. Fox, Personality correlates of undergraduate
marijuana use. Journal of Consulting and Clinical Psychology, 35, 58-63, 1970.
- P. M. Bentler, Drug use and personality in adolescence and young adulthood: structural
models with nonnormal variables. Child Development, 58, 65-79, 1987.
- C. E. Martin, D. F. Duncan, & E. M. Zunich, Students' motives for discontinuing
illicit drug-taking. Health Values, 7(5), 8-11, 1983.
- D. F. Duncan, Reasons for discontinuing hashish use in a group of Central European
athletes. Journal of Drug Education, 18, 49-53, 1988.
- D. F. Duncan, & C. E. Martin, Problems associated with three commonly used drugs: A
survey of college students. Psychology of Addictive Behaviors, 1, 70-73, 1987.
- D. R. Holcomb, P. D. Sarvela, D. O. Ritzel, E. M. Sliepcevich, and H. G. Jellen,
Self-reported negative consequences of drug use among rural adolescents. Health
Education, 21(4), 36-40, 1990.
- P. D. Sarvela, P. R. Newcomb, & D. F. Duncan, Drinking and driving among rural
youth. Health Education Research, 3, 197-201, 1988.
- K. H. Beck, T. G. Summons, & M. P. Hanson-Matthews, Monitoring high school drinking
patterns and influences: A preliminary focus group interview approach. Psychology of
Addictive Behaviors, 1, 154-162, 1987.