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Page 4 of 34 Guideline

Overdose deaths are lower in contexts where harm Harm reduction principles for healthcare settings are listed. 7
reduction services are in place, compared with places • Humanism: Care is given without moral judgement and
where they are not. Harm reduction reduces the adverse with an understanding that choices are contextual.
health, social and economic consequences of drug use • Pragmatism: The priority is the here and now, and the
5
without necessarily reducing drug consumption. In 2018, mitigation of immediate risk is what matters most.
86 countries (11 in Africa) had at least one needle-and- • Individualism: People are different and have their own
syringe service and 86 (nine in Africa) had at least one needs and strengths.
opioid substitution therapy (OST) programme. • Autonomy: People have a right to make informed choices,
Harm reduction refers to policies, programmes and practices even against expert advice.
that aim to minimise negative health, social and legal impacts • Incrementalism: Any positive change is viewed as an
associated with drug use, drug policies and drug laws. Harm improvement on current circumstances.
reduction is grounded in justice and human rights – it focuses on • Accountability without termination: People have the
positive change and on working with people without judgement, right to make choices, without their access to services
coercion, discrimination, or requiring that they stop using drugs being denied in relation to their decisions.
as a precondition of support. Harm reduction encompasses a
range of health and social services and practices that apply to The application of these principles can improve patient–
illicit and licit drugs. These include, but are not limited to, drug clinician relationships. The impact of harm reduction is
consumption rooms, needle and syringe programmes, non- increased through community engagement and peer-led
abstinence-based housing and employment initiatives, drug
checking, overdose prevention and reversal, psychosocial services as well as removing barriers and increasing support.
support and the provision of information on safer drug use.
Approaches such as these are cost-effective, evidence-based and Key points
have a positive impact on individual and community health. • Harm reduction is an evidence, rights and public-health-
(Harm Reduction International). 6 based approach that reduces risks and improves the
health and well-being of people who use drugs and the
Key points broader community.
• Harm reduction is an evidence, rights and public-health-
based approach that reduces risks and improves the 1.2 Drugs and drug use
health and well-being of people who use drugs and the
broader community. 1.2.1 Patterns of use
• Long-term policies and interventions are needed to Depending on the drug, 8% – 15% of people who use drugs
address structural factors that contribute to harms related develop a problem with their use. Drug use occurs along a
to drug use. continuum and can shift according to various factors
(see Table 1).
BOX 1: South African policy.
South African health policy supports evidence-based interventions for people who 1.2.2 Methods of drug use
use drugs. For example, the South African National Drug Master Plan (2019–2024) Drugs can be taken by different administration modes, which
recommends access to the WHO-recommended package of comprehensive HIV
prevention, treatment and care services for people who inject drugs. Similarly, can lead to different effects and varying degrees of harm. For
the South African National Strategic Plan on HIV, TB and STIs (2017–2022) refers to
the provision of harm reduction services, specifically OST and needle-and-syringe instance, intravenous (IV) administration is associated with
programmes. The South African National Drug Master Plan (2019–2024) includes
these two interventions as part of the WHO-recommended package of services. rapid onset and peak of action, with elevated risks: for
The South African National Hepatitis Action Plan recommends access to viral hepatitis opioids, this includes overdose and for stimulants, such as
services that include access to harm reduction services for people who inject drugs.
cocaine, this includes arrhythmia. Common methods of drug
TB, tuberculosis; STI, sexually transmitted infection; OST, opioid substitution therapy; WHO,
World Health Organization. use are summarised here.
TABLE 1: Patterns of drug use.
Pattern of use Description
Experimentation Most young people will experiment with some activity that is outside of socially acceptable norms. Drugs are one of the ways people experiment.
Most people will experiment for a limited period and then stop.
Non-dependent adult use Many people consume alcohol in this way – it is used for social events, and largely remains non-problematic. Many people will use unregulated
drugs in the same way. 8
Conscious, regulated use Many drugs are used only in certain ways and circumstances, according to a set of cultural or individual rules and accepted norms. Cannabis use by
Rastafarians is an example, as is the planned use of hallucinogenic drugs to find answers to a specific problem. When someone makes a well-
informed conscious choice to use a specific drug in a specific way in specific circumstances, it will seldom become problematic.
Dependence The International Classification of Diseases and Related Health Problems (ICD) version 11 (ICD-11) defines this as ‘a disorder of regulation of
[specific drug] use arising from repeated or continuous use of [specific drug]. The characteristic feature is a strong internal drive to use [specific
drug], which is manifested by impaired ability to control use, increasing priority given to use over other activities and persistence of use despite
harm or negative consequences. These experiences are often accompanied by a subjective sensation of urge or craving to use [specific drug].
Physiological features of dependence may also be present, including tolerance to the effects of [specific drug], withdrawal symptoms following
cessation or reduction in use of [specific drug, notably with opioids], or repeated use of [specific drug] or pharmacologically similar substances to
prevent or alleviate withdrawal symptoms. The features of dependence are usually evident over a period of at least 12 months but the diagnosis
may be made if [specific drug] use is continuous (daily or almost daily) for at least 1 month.’ 9
Habituated use, commonly When someone appears to have little control over their drug use and they have learned to use drugs as the automatic response to problems they
called addiction face or this use is how they can feel alive and engaged, such use can become problematic to the individual and those around them. Habituated drug
use is also often dependent. This form of use is commonly called ‘addiction’. Addiction applies to an all-consuming relationship with a drug, person
or activity to the detriment of the individual.

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