[MUSIC] Now we're going to talk a bit about harm reduction. As defined by the International Harm Reduction Association, harm reduction is policies and programs which attempt primarily to reduce the adverse health, social, and economic consequences of mood-altering substances to individual drug users, their families, and communities, without requiring a decrease in drug use. It's interesting because if this were written today, it wouldn't reference drug users, rather people who use drugs. Because like many areas, person-centered language is more respectable and less stigmatizing. So I think it's really important to focus on one particular part of this, without requiring decrease in drug use. Harm Reduction squarely focuses on harmful policies, harmful environments, harmful conditions without the ultimate goal of reducing drug use. Many programs have been found to be associated with a reduction in drug use, including things you're going to hear during this class. Syringe services programs, utilizing safe consumption spaces, both have been found to be associated with a reduction in drug use, particularly an extensive literature on syringe services programs. But that's not the first goal of harm reduction. It's also important to mention that harm reduction also includes drug treatment. Oftentimes harm reduction and drug treatment are seen, viewed, discussed as being opposites. But of course, that's not true because one way to reduce the adverse health, social, and economic consequences of drug use is by ceasing drug use. I just talked about a definition, which is also on the website of the National Harm Reduction Coalition, a great resource for information about a range of topics that we're going to be talking about in this class. As well as trainings for furthering education around harm reduction for practitioners. But I want to delve a little bit deeper to talk about the principles of harm reduction practice. The first principle is that for better or for worse, licit and illicit drug use is a part of the world, and harm reduction is around minimizing the effects rather than ignoring or condemning drug use. In this current opioid epidemic, there's so much negative language, harsh comments about people who use drugs, a focus on criminal justice, a focus on cessation and prevention, as opposed to really focusing on the fact that there always has and will be people that use and abuse drugs. And so harm reduction focuses on working with people while they're actively using drugs and accepting them wherever they are. Harm reduction always really understands the very complex, multifaceted nature of drug use from very distal structural determinants broad economic context. So sometimes when you focus on people needing to quit drugs, oftentimes people need to address issues like homelessness, mental health, trauma. Things that are really the underlying drivers of drug use. So just saying quit, just say no doesn't really fit that bill, and harm reduction acknowledges this broader complex environment. One of the most central tenants of harm reduction is that of respecting individuals wherever they are in their drug use, respecting them and treating them with dignity as well. And that also feeds the importance of establishing a quality of individual's life and community's life, even if they are using drugs. So providing safe consumption spaces, which meets both the needs of communities that are plagued with drug use, as well people who use drugs. Syringe services programs, which enhances people's quality of life, as well as access to services. That is one of the reasons it's a perfect example of a harm reduction program. In the delivery of all services, it's very important not to be judgmental, not to be coercive, not to have language that's stigmatizing. Coercive in the sense that people can only receive services if they contingent upon going into treatment, taking information, things of that nature. A central component of harm reduction programming that's effective and authentic is making sure that there is a space for people who use drugs to impact the conversation, the programs themselves. And this is something that is challenging, not only do you have to set the table in a way that people can come, you also need to prepare people to be at that table, so to speak. And this is an ongoing process to make to sure that people with lived experiences are included in the process of any kind of service delivery. Empowerment is an important part of harm reduction, it's not meant to be paternalistic. That is also connected to being non-judgmental and person-centered, in that people, when you give them the tools, whether it's clean syringes, information about wound care, or reducing overdose, giving people Naloxone, or giving people a space in which they can use illicit substances. All of these are things we're going to be talking about in this class. These are empowering options for individuals to make choices about how they use drugs, and oftentimes, that empowerment and empowering relationship is the first step in people making healthier decisions. As I mentioned before, harm reduction acknowledges is the complexity of the reasons why people use drugs. It really places in the foreground the importance of poverty, the unequal distribution of wealth, racism, isolation, past and current trauma, sexism and discrimination, and other social inequalities that affect people's vulnerability to using drugs. And also their capacity for change, or cessation of drugs, or their ability to reduce drug-related harm in their own life. And lastly it's important, and hopefully you'll get this sense throughout the course, we know that people who have problematic drug use didn't dream one day of becoming a problematic drug user, that there are lots of problems associated with drug use. And so by no way is this class meant to condone drug use, rather we acknowledge the existence of drug use over time and focus on ways that people can reduce harm. That acknowledges the complexities of the reasons why people use drugs, and also the respect that's needed for people to feel themselves in order to move along a pathway either to stay safe, whether that be ceasing drug use or not. So to underscore, harm reduction is not anything is fine, that there's no such thing as problematic drug use, that is gross depiction and not the case based on what I just told you. I think I've already talked about the fact that harm reduction does not endorse drug use or high risk behaviors. Yet, harm reduction believes in a hierarchy of risk so that if people, for example, in the world of safer sex can't use condoms, there is ways to reduce the risk even with unprotected sex when a condom is not present. And to underscore again, abstinence-based treatment or medication-assisted treatment are absolutely a part of harm reduction. So now we're going to move from the practice world to talk about two different research projects. One is a series of studies that Carl and Karen are intimately involved and run, and then I'll talk about a center in southwest Baltimore, both of which are examples of research that are based upon the principles of harm reduction. >> So the Lighthouse Studies at Peer Point is a community-based harm reduction-oriented research clinic that's located just a couple blocks away from the School of Public Health. We have been in operation for nearly 20 years, if not more, and we have been working with key populations that include people who use drugs, people living with HIV, people living with hepatitis C, and men who have sex with men. And so you're going to hear throughout this course about a lot of examples of the research studies that we've conducted as a way to generate evidence to support the fact that harm reduction can work to improve health and reduce health disparities. >> You'll hear later in the quarter some of my research focused on cisgendered sex workers and their HIV and risk associated with drug use. But another example that is connected to that is the SPARC Center. SPARC stands for sex workers promoting action, risk reduction, and community mobilization. And the goal of SPARC, which is literally a drop-in center, is to enhance community capacity among cisgendered female sex workers in Baltimore through the creation of a full service harm reduction drop-in center and well-trained cadre of peer outreach workers. SPARC is funded by the NIH primarily, by the National Institutes of Drug Use, with an increasing number of local foundation in the state of Maryland. In order for the services to exist beyond the five-year grant that is basically evaluating the impact of SPARC and peer outreach on HIV and other morbidities among female sex workers. SPARC was established in November of 2017, and has a number of services that are provided by other healthcare, mental health organizations. As well as low barrier typical drop-in center services, such as showers, lockers, laundry, a place to sit, a place to walk in and watch TV, a place to get snacks. Any woman is welcome at SPARC, although through outreach, we promote to women engaged in sex work. But there are lots of women in the neighborhood where SPARC is located that have needs who haven't necessarily sold sex or are not currently selling sex. We offer a range of services, it's one-stop shopping. One day a week we have reproductive health from a nurse practitioner, HIV, STI testing, STI treatment, and that's from the Baltimore City Health Department. We also have a mental health provider who comes in once a week to run groups and provide individual therapy. Although we do have a case manager on staff who's there all of the days that we are open who also provides those services. We had Buprenorphine induction and maintenance from an organization called Behavioral Health Leadership Initiative. Every other week we have lawyers that come in and provide free legal advice. And then we actually have just gotten funding to have a nurse full-time who will provide PrEP, Pre-exposure prophylaxis, for women, as well as wound care and other services. And she'll be there the 30 hours that we're open ever week. We also provide overdose prevention training and Naloxone distribution, as we do for all of our studies, as all studies connected to the Lighthouse. We've begun, now that it's legal, providing drug testing strips for Fentanyl, Fentanyl testing strips and Fentanyl risk reduction education at SPARC. And the ultimate goal, besides these kind of foundational services, medical, and legal, and mental health services, as well as soft services, the drop-in services, is is for women to start to build a sense of themselves as a part of a broader community, to start to feel ownership of SPARC. Those are things that we'll be measuring in the study that's going to be evaluating SPARC. I can give a whole lecture on how we implement harm reduction in a center like this, where women come in all different states of withdrawal or being high. Sometimes people are disruptive, how we have to make decisions about people being able to stay or asking people to leave, how we deal with strife between the guests that come in. I'll say that for me, someone who's been doing research with people who use drugs and sex workers for the last 20 years, it's been very interesting opening a space that really challenges me in how you provide services in a context that's respectful to everyone. >> Anything very related to Susan's last comment. On this slide, what you see is a picture of a poster that we have of group rules for the research participants at the Lighthouse. One of the signature activities that we conduct at the Lighthouse are conducting rigorous trials to evaluate impact of peer-based interventions and interventions that aim to really change and leverage social networks. And so in the same vein of Susan's last comments, these were rules that we've developed over the course of years of conducting these studies with input from the participants themselves about what limits and what guidelines they need to be able to feel comfortable and safe to be able to participate. But also where we needed to figure out what is the line with regards to what is important to ensure that everybody gets what they came to get. Our center sees folks in various stages of being high and withdrawn. And so three of the group guidelines I wanted to just point out, and you'll hear lots of examples of how we do these programs throughout this quarter, is really, well, I guess we better start with the first one, which is confidentiality. And I think confidentiality is a norm, a rule, a guideline that everybody, I think, universally understands what that means. But how you actually implement it is important. And so we spend a lot of time talking about how folks in our groups are here to learn from each other, but we have to keep everybody's stories in the rooms. And we've had a really good track record, both with our participants and with our staff, of respecting confidentiality to the utmost. This even extends to the security guards that are posted at the entrance level of our building, and doing lots of training with them to ensure that they understand what confidentiality means and respect means. So that if people come into our building and ask if so and so's been there, that none of us are going to confirm or deny the presence of anyone because that would be a violation of this rule, and I think really undermine our ability to work with and engage with the populations. Our guideline or rule of managing your drug use is really an important foundation of all of our work. Whether it's conducting the surveys and conducting interviews or doing the peer-based trainings that we conduct, we explain to our participants that everyone knows what they need to be able to feel okay and not feel too sick. So stick in that zone, for some people that means taking a pill in the morning, for some people it means waiting until after group to go and get your dose or to get out of the gate. And we let people decide on their own what that looks like. And even when they're not successful, our response to them is we understand, things happen, try again tomorrow, you're always welcome back. Which leads me to the very last bullet point on this poster, which is this idea of getting kicked out. And really being able to implement and engage in harm reduction practices as a researcher and also as a public health practitioner, it is so common to encounter people who have gotten doors, and windows, and everything slammed in their faces because they didn't comply. Because they didn't meet the condition that was set up for them. And we have had to do a lot of work with our staff to really figure out, do we have conditions, and if we do, what are they? And what we've really come to agree upon, endorse, and do on a daily basis is that you are always welcome, even if you cussed me out the last time. I think the lines that we draw are really around weapons and violence. And even for those types of situations, because the streets are dangerous, we have protocols so that folks can be in our space, they have to check their weapons at the door. But acknowledging that all of this is part of their life and part of their reality, we wouldn't be able to call ourselves a harm reduction oriented research center if we weren't able to really develop and then implement these with rigor. And so hopefully as the course proceeds on, you will hear additional examples of how we are all trying to find that balance of being able to generate using rigorous methods the evidence to continue to support harm reduction and its positive impacts on community health, while also really meeting the communities where they are. So this final slide are just some snapshots from the Lighthouse, and these are some of my staff who are engaged in the different research in harm reduction oriented activities. And one of the points I guess I'd like to make about it is that I think that harm reduction benefits from diversity, all types of diversity. And so we really strive to make sure the different perspectives are represented because the participants benefit as a result. So we look forward to your participation, your questions, your responses on the critical reflections. We have put together a course that we are really excited about. You'll be hearing from lots of very interesting leaders in the field of harm reduction and be exposed to lots of different examples of how this work can be done. It is our hope that at the end of it you are very equipped to be able to use evidence, find evidence, and generate evidence to continue to promote harm reduction policies and practices to benefit the communities that you're coming from. >> We also really encourage, some of the things we're going to be talking about you might not agree with may bring up judgments. And honestly, the conversations are most interesting when people share their perspectives, even if you think it's not agreeing with us. We want to create a place where people feel comfortable to share their thoughts, and also we can learn and grow with each other. [MUSIC]
