Photo courtesy of MSF
In Sri Lanka, People Who Use Drugs (PWUD) and those struggling with addiction to either substances or behaviours are often caught in-between a binary of use and abstinence where the medical and moral models through which we view addiction allows for little else. While there may be some wisdom in promoting complete abstinence as a preferred outcome of treatment and rehabilitation the stigma, shame, judgment and coercion that often accompanies abstinence-based treatment programmes creates further harm, re-traumatises already traumatised individuals and perpetuates cycles of pain. What if there was another way – one rooted not in coercion and compulsory abstinence but in human dignity, compassion and safety? What if we focused on keeping people alive and respecting their autonomy and sense of agency while intervening at policy, programme, community and individual levels to reduce negative effects of alcohol and substance use/misuse? The philosophy and principles behind Harm Reduction (HR) offers an alternative to traditional responses to addiction and other potentially risky health behaviours, especially in the health sector in Sri Lanka.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA) in the US, addiction can be understood as a chronic, relapsing disorder consisting of compulsive and continued use of substances (and engaging in certain behaviours) despite harmful consequences and enduring changes in the brain. However, complexities surround addiction including the influence of conditions in which people are born, grow, live, work and age (social determinants of health), Adverse Childhood Events (ACEs), trauma and other biological, psychological and social factors require attention and appreciation, especially in the context of HR.
According to a report authored by Ambika Satkunanathan titled “A Broken System: Drug Control, Detention and Treatment of People Who Use Drugs in Sri Lanka” she quotes the director of the National Dangerous Drugs Control Board (NDDCB) stating that the causes for substance dependence include unemployment, relationship difficulties, the high usage of the internet and limited time for recreational activities. While one can question whether something as complex as addiction can be simplified in the above manner, it is also important to note that predominant attitudes surrounding PWUD, especially amongst high level decision makers, medical professionals and counsellors include them having a “weak personality”, “being selfish and stubborn”, “amoral”, “an inconvenience to society” and “a danger to the nation’s children”. Therefore, the state itself has sanctioned the dehumanising of those struggling with substance misuse and dependence through arbitrary arrests, compulsory “rehabilitation”, the use of violence and coercion at certain rehabilitation centres (run by the government and private entities), and its blatant refusal to provide for example, Opioid Substitution/Agonist Therapy in the form of methadone and buprenorphine, as addiction is essentially as quoted by a colleague “bad behaviour in a cash strapped economy”. The intolerable pain of going through withdrawal from opioids such as heroin without appropriate medical supervision and compassion in certain hospitals, prisons and rehabilitation centres are meant to “teach them a lesson”. So it should not come as a surprise that those who undergo “rehabilitation and correction” often relapse in the first week after being released and end up either back in police custody or state enforced rehabilitation. The cycle of trauma and pain along with the need for immediate relief from pain in the form of alcohol, drugs and certain behaviours continues. Hence, we need a system where people are empowered to take control of their health while accepting the reality that drug use is and will be a part of our world, no matter how much we (I say we because we enable the state to engage in human rights violations of vulnerable populations without accountability) try to “beat” drugs out of society. So, I wonder then whether we need to shift our energy to a public health approach rooted in trauma-informed evidence-based treatment and prevention approaches including HR as opposed to an obviously failing militarised, moralised, medicalised and spiritualised model that we seem to be riding on.
HR according to Harm Reduction International can be understood as “policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs, without necessarily reducing consumption”. It targets the negative consequences of drug use rather than drug use itself. The reader might view the above with speculation, and while that is acceptable in a context like Sri Lanka where HR may be viewed as enabling drug use and therefore causing greater harm to the community, another perspective to consider is that HR may actually save lives that would otherwise fall through the cracks. The history of HR dates back to the 1970s and 80s where Hepatitis B and HIV were major public health issues in predominantly the western world. It was found that safe injection facilities including needle and syringe exchange programmes (NSPs) for injecting drug users reduced the transmission of HIV while promoting HR for those not able/willing to stop using their choice of drug/s. HR is rooted in humanism, where the healthcare provider respects and upholds the dignity of their patients while acknowledging that there is always a context and a function for why a person may use substance/s, It is also recognised that pragmatically, none of us will ever achieve perfect health behaviours and therefore abstinence is not prioritized as a goal by the provider for the patient. Acknowledging and affirming a person’s strengths and their inherent right to make choices while celebrating any sign of positive change as a step towards improved health and well-being are integral parts of the overall philosophy behind HR. It is also important especially in connection to the context in Sri Lanka to note that form a HR perspective, providers can help their patients understand the consequences of their actions while not firing them from rehabilitation or treatment for not achieving abstinence. HR requires a shift in mindset where we meet people where they are and walk alongside them instead of expecting them to toe the line.
There is evidence of HR being practiced especially by the National STD/AIDS Control Programme (NSACP) and the Family Planning Association (FPA) where NGOs and key members from communities such as the LGBTIQA+ community have been empowered to carry out needle and syringe exchange programmes while providing peer education and support to injecting drug users. This initiative while encouraging safe injecting will also contribute to the reduced transmission of Sexually Transmitted Diseases/Infections (STD/I’s).
Another area that requires our focus is the use of drugs in sexualised settings, also known as chemsex, where substances such as methamphetamine, mephedrone and Gamma-Hydroxybutyrate (GHB) and other locally produced substances may be used to enhance sexual pleasure and perhaps performance. The risk of unintentional overdose, the transmission of STD/I’s, bodily injury through lodged objects, allergic reactions and sexual assault are some scenarios that require an HR approach. Men who have sex with men, transgender individuals who inject drugs and have sex, people who exchange sex for money or drugs and others who engage in chemsex require sources of non-judgmental and factual information on how they can safeguard themselves and others. Certain western countries promote naloxone (a medication that rapidly reverses an opioid overdose) to be used by the general public and training in its use is included in first aid courses. While similar initiatives might not yet be a viable option in Sri Lanka, education should be provided on how to respond to an overdose, as some vulnerable individuals may hesitate in seeking medical attention. HR includes educating people about how different substances interact with each other and the potential harm mixing multiple substances together can cause, including death.
In the context of chemsex and sexual health, information must be readily available as to where people can find pre-exposure prophylaxis and post-exposure prophylaxis in the event of potential exposure to HIV. Similarly, education around symptoms and testing for other STD/I’s including herpes, syphilis and gonorrhea must be provided. Condoms and lubrication being readily available for men who have sex with men and other vulnerable groups like those who exchange sexual services for money/drugs is another example of HR. Conversations around consent and how that might change when high on substances need to be had and we need to talk about how a lot of the substances available for use may be adulterated with other ingredients, potentially causing harmful health consequences. Open conversations around HR can actually promote informed decision making and be life affirming for PWUD and others.
The state, the state sponsored NDDCB, the military (who double as counsellors and rehab staff), healthcare providers, counsellors and spiritual treatment providers require a transformation in mindset where coercion and judgment do not continue to be the norm but compassion and humanism do. There is a crucial need to incorporate multi-disciplinary evidence-based approaches in all treatment centres and not just agro-therapy, physical exercise, spiritual confessions and inhumane punishment. Individuals should not be experiencing withdrawal from substances alone, locked up in dark, dingy rooms, their hands and legs chained to the walls but withdrawal should be in a supportive environment with properly trained medical staff supervising. Providing Opioid Substitution/Agonist Therapy should be considered by the state. The intersections between substance use/misuse, sexual health, mental health, physical health, spiritual and social health must be acknowledged as one does not use substances in a vacuum. At the end of the day, all of the above is harm reduction and potentially incremental gradual steps towards helping someone achieve positive health and well-being.
If you are affected by the contents of this article or would like to seek help for difficulties surrounding alcohol and substance misuse, please reach out to Mel Madura at 60, Horton Place, Colombo 7. Tel: 0112 694665.