HARM REDUCTION: HOW DO WE MEASURE SUCCESS?

Justin Logan, Soo Chan Carusone, Matthew Barnes, Sagar Rohailla, and Carol StrikeMay 28, 2014Canadian Public Health Association Conference 2014

OBJECTIVES1. Define harm reduction2. Discuss public health interventions for harm

reduction in the Canadian context3. Determine how such programs are

evaluated and potential gaps in evaluation4. Provoke thought and discussion on new and

different ways to evaluate harm reduction programs

BACKGROUND

CASEY HOUSE

Specialty HIV/AIDS hospital in Toronto (founded 1988) 13 in-patient beds Community programs Interdisciplinary care Day program in development

CASEY HOUSE POPULATION HIV+ Demographics:

81% male, 19% female 61% homosexual

Housing and Income: 20% unstable housing, 89% on disability

Mental Health: 93% of patients > 1 Axis I diagnosis

Substance Use: 63% Substance Misuse Disorder Cocaine > Marijuana > Alcohol

Schaefer-McDaniel, Halman, et al.

WHAT IS HARM REDUCTION? “Harm reduction seeks to minimize the risks

and negative consequences associated with alcohol and illicit drug use or other high-risk activities through various public health measures, intervention programs, or individual counseling.”8

Marlatt and Witkiewicz 2010

PUBLIC HEALTH AGENCY OF CANADA:POPULATION HEALTH PROMOTION MODEL

http://www.phac-aspc.gc.ca/ph-sp/php-psp/php3-eng.php

RESEARCH QUESTION AND METHODS

RESEARCH QUESTION:1) What outcomes are reported in the

literature to evaluate harm reduction programs in adult and adolescent populations?

Important in Casey House’s development of evaluation protocols for its harm reduction programs

METHODS: LITERATURE REVIEW Purpose: to identify outcomes used to

evaluate four types of harm reduction programs Opioid Maintenance Therapy Needle Syringe Programs Safe Crack User Kit Programs Alcohol-related programs

METHODS: LITERATURE REVIEW PsycINFO and SCOPUS databases

Inclusion Criteria English Language Adolescent/Adult Population Published since 2008 Evaluating 1 of the 4 above-listed interventions Primary research or program evaluation

Database Search

• 686 Papers Identified

Abstract Screenin

g• 97 Papers Included

Outcomes

Recorded

• Excel Chart

Data for Analysis

RESULTS AND ANALYSIS

OMTEt-OHNSPSCUK

OMT(46%)

Et-OH(35%)

NSP(13%)

SCUK(5%)

Studies by Intervention (n = 97)

OMT = Opioid Maintenance TherapyEt-OH = Alcohol-related InterventionsNSP = Needle Syringe ProgramsSCUK = Safe Crack User Kits

GEOGRAPHIC DISTRIBUTION OF STUDIES (N = 97)

(12)

48

14

00

710102

6

MORE FREQUENTLY REPORTED OUTCOMES (N=85)

Outcome Total # Studies

Et-OH OMT NSP SCUK

Decreased Use 49 (58%) 30 18 1Use-related conseq 18 (21%) 18Psychiatric Illness 18 (21%) 7 11Use of Services 16 (19%) 2 9 2 3BBV Risk Behavior 15 (18%) 4 5 6Toxicology 11 (13%) 3 8Infectious Disease 11 (13%) 7 1 3Binge Pattern Use 10 (12%) 7 3Incarceration/Crime

9 (11%) 9

Satisfaction 9 (11%) 8 1OMT = Opioid Maintenance Therapy Et-OH = Alcohol-related Interventions

NSP = Needle Syringe Programs SCUK = Safe Crack User Kits

LESS FREQUENTLY REPORTED OUTCOMES (N = 85)

Outcome Total # Studies

Et-OH MMT NSP SCUK

Social dysfunction 8 (9%) 2 5 1Survival 7 (8%) 7Physical Health 6 (7%) 1 4 1Employment/Finance 5 (6%) 4 1Overdose 3 (4%) 3Academic 1 (1%) 1Healthcare Accessibility

1 (1%) 1

OMT = Opioid Maintenance TherapyEt-OH = Alcohol-related Interventions

NSP = Needle Syringe ProgramsSCUK = Safe Crack User Kits

KEY DETERMINANTS OF HEALTH Income and Social Status (ISS) Social Support Networks (SSN) Education/Literacy(EL) Employment/Working Conditions (EWC) Social Environments (SE) Physical Environments (PE) Personal Health Practices and Coping Skills

(PHPCS) Biology and Genetic Endowment (BGE) Healthy Child Development (HCD) Health Services (HS) Gender (G) Culture (C)

STRATIFYING OUTCOMES BY THE KEY DETERMINANTS OF HEALTH Determinants without any related outcomes

Gender Culture Healthy Child Development

Determinants most frequently related to outcomes Personal Health Practices and Coping Skills Biology and Genetic Endowment Health Services

ISS SSN EL EWC PE SE PHPCS HS BGE0

10

20

30

40

50

60

70

80

SCUKNSPMMTEt-OH

STRATIFYING OUTCOMES BY KEY DETERMINANTS OF HEALTH

# o

f Out

com

es

OMT = Opioid Maintenance Therapy Et-OH = Alcohol-related InterventionsNSP = Needle Syringe Programs SCUK = Safe Crack User Kits

USER SATISFACTION AS AN OUTCOME Not easily related to any of the key

determinants of health Measured in 7 studies, all of them Methadone

Maintenance Therapy

QUALITATIVE STUDIES 12 qualitative studies included, 10 mixed

studies with a qualitative component Common Themes

Satisfaction and quality of program Access to program

Barriers including stigma Patterns of use Lending Practices/Risk Behaviors Overall Health Socioeconomic health

DISCUSSION

WHAT HARMS? SUBSTANCE USE-RELATED HARMS1) Health Consequences

Infection Mental Health Effects on overall health/nutrition

2) Social ConsequencesInterpersonal relationships, family, stigma

3) Personal DevelopmentEducation, Happiness, Legal Issues

4) Economic and Physical WellbeingEmployment, Housing, Incarceration

References: 3, 9, 13, 20, 24, 25

ISS SSN EL EWC PE SE PHPCS HS BGE0

10

20

30

40

50

60

70

80

SCUKNSPMMTEt-OH

STRATIFYING OUTCOMES BY KEY DETERMINANTS OF HEALTH

# of O

utcomes

STRATEGY:PUBLIC HEALTH AGENCY OF CANADA:POPULATION HEALTH PROMOTION MODEL

http://www.phac-aspc.gc.ca/ph-sp/php-psp/php3-eng.php

HEALTHCARE ACCESS AS AN IMPORTANT OUTCOME Drug Users in the healthcare system

High need for healthcare services (McCoy et al. 2001)

Poor access (McCoy et al. 2001) Worse experiences (Edlin BR et al. 2005)

Harm reduction programs allow users to be engaged by the healthcare system instead of invisible to it

(Rachilis et al. 2001)

HEALTHCARE ACCESS AS AN IMPORTANT OUTCOME: How was access measured?

Health Services = 19 (22%) total outcomes9 measured one-time use of particular service

6 measured retention in treatment3 measured hospitalizations1 measured primary care access

Why is this important?

SUMMARY As part of a health promotion strategy, harm

reduction seeks to make an impact across many key determinants of health

Yet evaluations consistently measure outcomes related to only a few determinants Personal Health Practices and Coping Skills Biology and Genetic Endowment

Outcomes related to other determinants are used far less frequently• Socioeconomic Status• Social Support Networks• Social Environment

• Employment/Working Conditions

• Education and Literacy• Physical Environment

RECOMMENDATIONS This represents a gap in evaluation Development of outcomes which capture

benefits related to wide range of determinants

Measures of health care access Must recognize practical limitations of harm

reduction research Funding Personnel and Expertise

THANK YOUSoo Chan Carusone, Ph.D.Casey HouseMcMaster University

Carol Strike, Ph.D.University of Toronto

Matthew BarnesUniversity of Toronto

Sagar RohaillaUniversity of Toronto

REFERENCES:1. Harm Reduction Training Manual. Toronto, Ontario: Casey House; 2012.

2. Babor TF, Higgins-Biddle JC, Dauser D, et al. Brief interventions for at-risk drinking: patient outcomes and cost effectiveness in managed care organizations. Alcohol and Alcoholism. 2006;41(6):624-631.

3. Galea S and Vlahov D. Social Determinants and the Health of Drug Users: Socioeconomic Status, Homelessness, and Incarceration Public Health Reports. 2002;117(S1):135-145. 4. Ivsins A, Roth E, Nakamura, N, et al. Uptake, benefits of and barriers to safer crack use kit (SCUK) distribution programmes in Victoria, Canada-A qualitative exploration. International Journal of Drug Policy. 2011;22(4):292-300. 5. Havnes I, Bukten A, Gossop M, Waal H, Stangeland P, Clausen T. Reductions in convictions for violent crime during opioid maintenance treatment: A longitudinal national cohort study. Drug Alcohol Depend. 2012;124(3):307-310.

REFERENCES:6. Hays RD, Cunningham WE, Sherbourne CD, et al. Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV cost and services utilization study. The American Journal of Medicine. 2000; 108(9):714-722).

7. Kim JW, Choi YS, Shin KC, et al. The effectiveness of continuing group psychotherapy for outpatients with alcohol dependence: 77-month outcomes. Alcoholism: Clinical and Experimental Research. 2012;36(4):686-692.

8. Marlatt GA and Witkiewitz K. Update on harm-reduction policy and intervention research. Annual Review of Clinical Psychology. 2010;(6):591–606 9. McCoy CB, Mesch LR, Chitwood DD, and Miles C. Drug use and barriers to use of healthcare services. Substance Use and Misuse. 2001;36(6&7): 789-806. 10. Neale J , Sheard L, and Tompkins CN. Factors that help injecting drug users to access and benefit from services: A qualitative study. Substance Abuse Treatment, Prevention, and Policy. 2007; 2:31-44.

REFERENCES:11. Pauly, B. Shifting moral values to enhance access to health care: Harm reduction as a framework for ethical nursing practice. International Journal of Drug Policy. 2008;(19):195-204. 12. Rachilis BS, Kerr T, Montaner JS, Wood E. Harm reduction in hospitals: is it time? Harm Reduction Journal. 2009; 6:19.

13, Regier DA, Farmer ME, Rae DS, et al. Comorbidity of Mental Disorders With Alcohol and Other Drug Abuse: Results From the Epidemiologic Catchment Area (ECA) Study. The Journal of the American Medical Association. 1990;264(19):2511-2518.

14. Shanahan CW, Beers D, Alford DP, Brigandi E, Samet JH. A transitional opioid program to engage hospitalized drug users. Journal of General Internal Medicine. 2010;25(8):803-808.

15. Schaefer-McDaniel N, Halman M, Carusone SC, Stranks S, and Stewart A. Complex care of patients with late stage HIV disease: A Retrospective Study. International Conference on Urban Health. March 2014.

REFERENCES:16. What Makes Canadians Healthy or Unhealthy?. Public Health Agency of Canada Web site. http://www.phacaspc.gc.ca/phsp/determinants-eng.php#personalhealth. Updated August 21, 2012; Accessed November 14, 2012.

17. Wolitski RJ, Kidder DP, and Fenton KA. HIV, homelessness, and public health: critical issues and a call of increased action. AIDS and Behavior. 2007;11(S2):167-171. 18. Wood E, Kerr T, Tyndall MW, Montaner JS. A review of barriers and facilitators of HIV treatment among injection drug users. AIDS. 2008;22(11):1247-1256. 19. Wood E, Montaner JS, Chan K, et al. Socioeconomic status, access to triple therapy, and survival from HIV-disease since 1996. AIDS. 2002;16(15):2065-2072.

REFERENCES:20. Laupland KB and Embil JM. Reducing the adverse impact of injection drug use in Canada. Can J Infect Dis Med Microbiol. 2012 Autumn; 23(3): 106–107.

21. Erickson et al. CAMH and Harm Reduction: A Background Paper on its Meaning and Application for Substance Use Issues. CAMH web site. May 2002. Accessed April 25, 2014.

22. An integrated model of population health and health promotion. Public Health Agency of Canada web site. http://www.phac-aspc.gc.ca/ph-sp/php-psp/php3-eng.php. Updated December 8, 2001. Accessed April 20th, 2014.

23. Edlin BR, Krevina TF et al. Overcoming Barriers to Prevention, Care, and Treatment of Hepatitis C in Illicit Drug Users. Clin Infect Dis. (2005) 40 (Supplement 5): S276-S285.

24. Grant JD, et al. Associations of alcohol, nicotine, cannabis and drug use/dependence with educational attainment: evidence from cotwin-control analyses. Alcoholism: Clinical & Experimental Research, Early View vol. 36 (8), August 2012.

REFERENCES:25. Nutt D, King LA, Saulsbury W, and Blakemore C. Development of a rationale scale to assess the harms of potential drugs of misuse. The Lancet. 2007;369(3): 1047–53.

QUESTIONS?

Justin Logan justin.logan@mail.utoronto.ca

Soo Chan Carusoneschancarusone@CaseyHouse.on.ca

SUBSTANCE USE IN CANADA Prevalence of substance use:

9.1% of Canadians 15+ used Cannabis in past year

4.8% of Canadians 15-24 reported using cocaine, speed, hallucinogens, ecstasy, or heroin in past year Males twice as likely to use compared to females

78% of Canadians drank alcohol in past year 100,000 intravenous drug users in Canada in

2012 Prevalence of harm:

1.8 % of Canadians (5.8% aged 15-24) reports experiencing at least 1 harm in past year due to illicit drug use