Harm Reduction

Best Practice information sheet on Harm Reduction (PDF version)

People always have used (and likely always will use) alcohol even though it may adversely affect them in some way. For some people, this leads to problems with their health, their relationships, or their finances. In the past, abstinence ("giving up drinking") has been seen as the only way of addressing an alcohol problem.

Many seniors (and people who work with them) consider abstinence as a very limiting goal. The alcohol problem may not be that severe. Or it may be severe, but there are many other major problems in the senior’s life. Or the senior may see the abstinence approach as another example of how his or her independence is rapidly being eroded or controlled by others. Over the last 20 years, a different and complementary approach to requiring abstinence before helping has been developing, and it seems to hold a lot of promise for some seniors. It is called harm reduction.

According to the Canadian Centre on Substance Abuse:

"Harm reduction is a public-health approach to dealing with alcohol-related issues that places first priority on reducing the negative consequences of alcohol use rather than on eliminating alcohol use or ensuring abstinence."(1)

Harm reduction attempts to minimize the potential hazards associated with the alcohol, rather than focussing exclusively on the alcohol use itself. Harm reduction starts with focussing on immediate harms and realistic goals. These are often the first steps toward risk-free use or, if appropriate, abstinence. Harm reduction does not remove a person's primary coping mechanisms such as alcohol or prescription medications, until other means of coping are in place.

Harm reduction philosophy addresses a person’s immediate needs, such as food and shelter; traditional and alternative medical care and mental health treatment.(2) The approach stresses the need to be non judgmental, and to provide help that is accessible and culturally specific. These are central to harm reduction philosophy

Understanding "Harms"

The alcohol literature describes a broad range of harms. Some are directly attributed to alcohol and behaviours related to their use. Other harms result as unintended consequences of efforts to deter alcohol use. For example, a family member or professional might demand that the senior stop drinking, or "you can’t see me again." Having given the ultimatum, they may find the senior chooses to drink (or simply cannot stop at this point). The potential harms increase, unabated.

In harm reduction approaches, the use of alcohol is accepted as a fact and focus is placed on reducing harm while alcohol use continues. Abstinence from alcohol use is not a prerequisite for help. The first priority is on reducing the negative consequences of alcohol use for the individual, the community and society. A harm reduction approach to a person's alcohol use in the short term does not rule out abstinence in the longer term. Indeed, this approach is often seen as the first step toward the eventual cessation of alcohol use.

Features of Harm Reduction

The essence of harm reduction is: "If a person is not willing to give up his or her alcohol use, we should assist them in reducing harm to himself or herself and others". Harm reduction approach is pragmatic and humanistic. The senior’s decision to use alcohol is accepted as fact. This doesn't indicate approval of the alcohol use. However, there is no moral judgment to condemn or to support its use. The dignity and rights of the alcohol user are respected. Options are presented in a non-judgmental, non-coercive way, respectful of the person’s competence to make choices and changes in his or her life.(3)

In harm reduction, the immediate focus is on working with the senior to address his or her most pressing needs. Achieving the most immediate and realistic goals is usually viewed as first steps toward risk-free use, or, if appropriate, abstinence.

According to the Canadian Centre on Substance Abuse:

"The harms addressed can be related to health, social, economic or a multitude of other factors, affecting the individual, the community and society as a whole. Therefore, the first priority is to decrease the negative consequences of alcohol use to the user and to others, as opposed to focusing on decreasing the alcohol use itself.
 

Harm reduction neither excludes nor presumes the long-term treatment goal of abstinence. In some cases, reduction of level of use may be one of the most effective forms of harm reduction. In others, alteration to the mode of use may be more effective."

Not Really New

Harm reduction has been a common approach to preventing and treating alcohol problems for decades, but people may not have used that precise term themselves. People are likely familiar with one type of harm reduction -- prevention programs such as designated driver and server intervention programs.

These programs recognize that 

1) people will drink, sometimes to excess; and 

2) when they do, unintended harmful consequences such as impaired driving can happen. 

The programs aim at preventing a specific harm – in this case, this risk of injury to self or others as a result of impaired driving. The focus is on reducing the likelihood of impaired driving occurring.

Another common form of harm reduction that is used in treatment is teaching controlled drinking. These programs attempt to teach people to consume alcohol in a moderate or sensible manner—spacing their drinks; substituting soft drinks; drinking lower alcohol beverages; and not drinking in response to stress.(4) (5)

Some people will cynically suggest that this approach is "poppycock"— that "alcoholism" is a disease and progressive, and that people must stop drinking completely if they have an alcohol problem. Over the last two decades, alcohol research has found that when it comes to drinking, human nature is far too complicated to be distilled down to this simple credo. Some people do cut down on their drinking; some abstain for long periods, and then go to moderate drinking; some receive help coping with the other problems in their lives, and gradually the alcohol problem becomes less pronounced.

Another harm reduction approach is "outreach". (6) In contrast with traditional counselling, where a person comes to a clinic or office as a sign of his or "motivation" and willingness to change, outreach attempts to get people moving in the direction of change, whether or not the person is "motivated" to stop drinking.

Outreach recognizes that a person may be in too poor health, be too isolated, or have too many other problems to ever make it to the clinic door. The outreach worker does not wait in an agency for the senior with an alcohol problem to arrive. Instead, the worker goes to the senior (with the senior’s permission) and offers aid. The question becomes "How can we help you?" as opposed to "Here’s how I can help you."

2 Important Principles

1. The basic principle behind the harm reduction approach is

- work with the person (in other words, with his or her permission and consent)

- on the needs that are most pressing for the person.

2. When working with seniors make sure the "solution" is no worse (from the senior’s perspective) than the original problem.

What Are Some of The Alcohol- Related Harms that Seniors Can Face?

A. Poor nutrition

When a senior drinks, he or she is less likely to care about eating. This is because alcohol provides calories without much nutrition. Also, some seniors find that eating interferes with the "full effect" of the alcohol, so they don’t eat.

Chronic alcohol consumption can cause serious gastro-intestinal irritation, so that the person does not feel like eating, or vomits when he or she does.

Alcohol consumption can also interfere with vitamin and mineral absorption. This can lead to serious malnutrition.

Reducing the Harm of Malnutrition:

• First, ensure that the senior is getting all the financial benefits that he or she is entitled to—so that there is adequate money for food.
• Help ensure the senior has food on a regular basis. That may involve helping the senior receive programs such as Meals on Wheels and Gold Card catering (where food is brought to the senior); Wheels to Meals (where the senior is taken to the meal).
• Develop cooking groups where seniors can learn how to cook for one (and don’t assume that older women always know how to cook). These can also provide the seniors with opportunities to socialize and make friends.

 If the senior is drinking:

• Encourage the senior to eat something. Even  small amounts of food can help. When food is in the stomach, alcohol passes into the small intestine more slowly; thus, the absorption of alcohol is also slowed down.
• Encourage the senior to take vitamin supplements to compensate for the vitamin and mineral absorption problems. A lack of folate in particular can lead to significant memory problems and increased risk of depression  among  seniors who drink heavily.

B. Violence or Abuse from Others

Alcohol abuse is commonly identified as a risk factor for "senior abuse" or "elder abuse" by those working in the elder abuse field. There is a strong connection between two. (7) (8) Sometimes the perpetrator has the problem. To pay for his or her addiction, a "friend" or neighbour, or caregiver exploits the senior by stealing or skimming off the money. The senior also runs the risk of physical violence by being robbed. Seniors living in disadvantaged neighbourhoods are at particular risk of physical harm.

In other cases, the senior has the alcohol or medication abuse problem. A senior’s memory may be less reliable as a result of the drinking or medication abuse. This makes it harder to identify whether "he forgot what he did with it" or if "someone ripped him off". And it makes it easier for others to discount what the senior says. This can leave a senior very vulnerable to exploitation by others, particularly to financial exploitation. Seniors in these situations are not usually mentally incompetent, which means that they are not suitable for guardianship or committeeship. But they do need help to reduce the potential for exploitation.

Reducing the Harms of Financial and Other Forms of Abuse

It is essential to remember that having control over their own money is extremely important to any adult, and that obviously includes seniors.

• Help the senior put other safeguards in place— e.g. direct deposit (having cheques go directly into the bank); automatic bill payment (bills directly paid from the bank).
• Monitor the situation (especially the potential abuser) by having home support in place. The senior may not want any "interference" at this point, but it will help determine if the situation is deteriorating.
• Alert the bank to any potential problem (they can "red flag" accounts or put other protective measures in place).
• Seek out non-profit societies willing to take on the responsibility of administering the person’s money on a daily basis.
• Explore alternatives  with the senior such as an  "Undertaking to administer" under Old Age Security Act or Canada Pension Plan; Trustee of government pension- no fee for service; or Representative payee. The senior  will need a trustworthy person to take on these responsibilities.
• Raise the level of awareness about elder abuse issues among those who work with alcohol treatment for seniors. Also raise awareness of alcohol issues among those who work with elder abuse issues of the role of alcohol.

C. Health- Related Harms

As noted in the webpages on Alcohol and Seniors Health, there are many serious health consequences to seniors from drinking.

Reducing the Health- Related Harm

• Promote the senior using other mechanisms than alcohol to relax, deal with pain or anxiety.
• Help the senior to access the appropriate medical resources—e.g. dentist, eye doctor, or audiologist for medical problems that can otherwise isolate the person, make the person feel anxious, or leave them prey to malnutrition. That may mean making the appointment, and helping them get to it.
• Encourage the use of lower alcohol alternatives, such as low alcohol and de-alcoholized beer.
• Help the senior identify his or her "slippery areas", the times and places when he or she is tempted to drink.
• Work with the senior  to help them make the health connection between their drinking and mobility, or their drinking and memory problems.
• Inform and occasionally remind the person of the health consequences of drinking (Avoid "nagging").
• Encourage the person to try lower alcohol beverages or alternate with no alcohol.
• Encourage drinking less (maybe one drink instead of the usual two).
• Encourage alternate drinking days.
• Determine the source of the supply (friend, family member, neighbour, "Dial a Bottle") to see if it is possible to remove the source in light of the fact that the person is trying to cut down or stop. Make the source aware of the serious health consequences to the person.

In some cases, the type of alcohol creates problems. For example, cooking rice wine had a  very high sodium content  to make it "non-potable". However it  became  a cheap  source of liquor in parts of Vancouver in the 1990s. It caused confusion,  extremely high  blood pressure, especially for the older consumers. Other "non- traditional" alcohol sources (mouthwash, Lysol) also  cause significant health problems.  In  some communities,  making cheap wine available so that the person does not have to rely on these others sources  has been  as one of the ways to reduce the  collateral harms that the type of "drink" was having.

D. Harms from Medication Problems

As noted in the webpages on this site on drug- alcohol interactions , one of the biggest problems that seniors face may not be the alcohol or the medications, but the potentially adverse interaction between the two.

Reducing the Medication-Related Harms

• Be aware of the actual level of alcohol consumption, e.g. discrepancies or inconsistencies between what the person says he or she is drinking, and what other indicators seem to suggest.
• Identify which drugs the senior is taking, including over the counter drugs. Ensure that the physician is aware of all of these, as well as potential interactions. Sometimes there is new information on specific interactions that doctors may not have heard.
• Work with the physician to identify which drugs are appropriate, in light of the fact that the person is drinking.
• Be very clear with instructions…"do not use with alcohol"… To a senior whose memory is impaired and who is thinking concretely, that may be interpreted as "don’t wash it down with alcohol" or "I can take a drink an hour or two later".
• If the problem is abuse of the medications (perhaps taking too many at once), check out the possibility of working with the neighbourhood pharmacy- so that the senior is picking up medicines a couple of times a day.
• Rely on appropriate medications that are less likely have an adverse drug- alcohol interaction. E.g. among ulcer medications, Ranitidine has serious adverse consequences, but some of the newer ulcer medications don’t.
• In some jurisdictions, there is a "last ditch" effort called restricted entitlement.

E. Harms from Isolation

There is a strong relationship between alcohol and social isolation (by which we mean a lack of meaningful relationships in the person’s life). Many of the health problems that seniors experience, especially those limiting mobility, can mean the person stays at home without contact with others for extended periods of time. The person may drink in response to the stress and boredom of that isolation.

But drinking can reduce a senior’s desire to go out— the person may not want to be seen in this state. Alcohol makes the person withdraw into himself or herself. Also, when family and friends see the person inebriated, they may tend to stay away.

Reducing the Isolation-Related Harms

• Help develop age-specific support groups.
• Ensure that any program or service you develop to help provides transportation for the seniors. (See section on Environmental Barriers)
• Encourage the development of telephone support and the use of friendly visitors.
• Help rebuild the social support network (e.g. family members, peer groups and self help organizations)
• Consider the possibility of peer counsellors for specific issues or problems that the senior is facing, other than alcohol.

F. Housing Troubles

Seniors can encounter many different types of housing problems or harms connected to their drinking. Sometimes neighbours are the problem—they are the dealers or the source of the alcohol or medications.

Sometimes, the seniors live in inadequate housing. They may be fearful of going out in their neighbourhood, and become socially isolated. Sometimes, seniors face eviction as a result of non- payment; behaviour problems; or incontinence or self- neglect.

Reducing the Housing-Related Harms

• Help educate building managers about alcohol issues, and in particular how to distinguish "normal aging" from an alcohol problem.
• Encourage the development of alcohol support programs in the building (so that seniors who have mobility problems can more easily access them).
• Encourage the establishment of tenants relations coordinator to help work out some of the social issues among tenants ("What to do when 'Old Joe' drinks and becomes belligerent, or Mrs. Henderson starts neglecting herself?")
• Work with the building manager on how to deal with specific concerns about the senior --such as careless smoking when drinking; leaving the burner on; or pest control. Or what do when a tenant is inebriated and she continually leaves the main door open to anyone?

G. Harms to Relationships with Family or Friends

Family relationships and friendships can become seriously undermined because of a drinking problem. In some cases, people withdraw away from the senior. The senior becomes more and more isolated, or their only "friend" is the person delivering the alcohol.

In some instances, the harm is caused by the fact that the family member or friend stays involved, but is unable to set personal boundaries. She or he inadvertently "enables" the problem. As a result, the person is not helped to take responsibility for self and consequences. Older women typically have a lot more "enablers" than older men.

Reducing the Harm to Relationships

• Helping family survive --help the family or friend learn that it is okay to unplug the phone if the senior tends to call at all hours when drinking . Help them deal with common concerns like : "But what if she fell and needed help, but I didn’t answer?"
• Help family or friends establish personal boundaries. That may involve helping people to say:

"Mom, I won’t talk to you when you are actively drinking. We both get too frustrated. We can talk tomorrow."

• Help rebuild connections. Sometimes there has been a long time split between the senior and certain family members. The senior may like to reconnect, but isn’t sure how the other person feels. Sometimes the senior needs a "go-between".

H. Memory-Related Problems

As noted in the Senior Health Study, memory impairments are common among seniors who have alcohol or other substance abuse problems. Most of this seems to involve short term memory. Some seniors fall into in a "grey area"- they are not mentally incompetent, but they are marginally so; or their mental competence fluctuates dramatically.

This can cause all sorts of unintended consequences or harms for the senior. They may forget to pay their bills (and as a result have their utilities cut off); they may forget that they have an appointment with the counsellor or doctor. For counselling, this may be misconstrued as the senior "being in denial" or "being resistant" and may lead to be being prematurely discharged from counselling. With respect to doctors’ appointments, it may mean an important health problem is not addressed.

Some of these memory problems will decrease when the senior drinks less. Some types of memory problems, unfortunately, may never go away.

Reducing the Memory-Related Harms

• For financial matters, help the senior take advantage of direct deposit or automatic bill payment.
• To aid with day to day matters, help put in place memory aids, such as large calendars; notes attached to the refrigerator.
• Use modern technologies for people who can afford it, e.g. programmed phones, alarm watches, bell timers and beepers.
• For appointments, call the morning of the appointment to ensure the senior remembers it.
• For safety matters (e.g. fires, unattended pots on the stove), have the senior use safety aids such as appliances equipped with an automatic shut-off (e.g. irons, kettles) .
• Encourage the senior to drink less (see the section on How to Cut Down)

I. Harms Related to Pain Management

As noted in the webpage on Alcohol and Chronic Pain, some seniors drink as a way of self-medicating the chronic pain they are experiencing. They may be concerned that if they stop drinking, they will be stuck with the uncontrolled pain.

Reducing the Pain-Related Harms

• Help the senior check out pain management alternatives such as a local pain management clinic, but make sure the clinic is familiar and comfortable with working with older adults.
• Encourage the person to attend the local arthritis support group.
• Provide the senior books or any literature on pain management alternatives (particularly large print materials or cassettes). Follow up and find out if any of these were helpful to the person.

J. Harms Related to Fire Risk

It is common to see what some service providers refer to as “nesting behaviour”- where a person has a favourite chair in front of television with liquor and cigarettes beside on side table. The person watches television drinking, the cigarette drops into the chair, it smolders and catches fire later while the person sleeps. The smoldering materials can render people unconscious, thus putting them at greater risk of injury or death from the ensuing fire.

Fires started by the careless use of smokers' materials are the leading known cause of fire-related death in Canada, on average killing more than 70 people per year. Cigarette fires are typically the result of careless handling of lit cigarettes such as leaving a lit cigarette unattended, smoking in bed or smoking while under the influence of alcohol, illicit drugs or medication. Anywhere from 25 and 60 percent of cigarette-fire deaths can be attributed to persons smoking while intoxicated.  Older people who have mobility problems are higher risk of injury or death if a fire happens.

Reducing the Fire-Related Harms

People often try to reduce that risk of harm in several different ways, including:

• monitoring their own behaviour (trying to avoid smoking if tired or if drinking)
• using deep coffee cans with sand to extinguish their cigarettes
• having a good, working smoke detector (checking the batteries)
• having surfaces immediately around the chair made of materials that are less likely to burn
• smoking cigarettes with filters (these apparently are somewhat less likely to cause fires).

L. Potential Harms from Premature Institutional Placement

Our Canadian health care system has been very successful at helping seniors live independently in the community for as long as possible. But for seniors who have health consequences of alcohol problems that go unaddressed, the risk of being placed in a care facility is high. No matter how good the care provided there is, the move to a care facility is intimidating and overwhelming for the senior. It represents the culmination of important losses to the senior—loss of physical health, loss of cognitive ability, and loss of independence.

Facilities can inadvertently create a whole different set of harms and stresses (see The Care Facility Study) for the senior. Many Canadian’s facilities have very restrictive policies on alcohol use very different from what people take for granted in community living, and the policies can lead to staff- resident conflicts. In light of the high level of prescribed sedation in facilities today, the senior with an alcohol problem also faces the risk of prescription abuse as well.

Reducing the Potential Harm or Premature Institutional Placement:

This can be accomplished by helping to address each of the issues noted above. Unaddressed, each of the harms mentioned above increases the probability of institutional placement.

• Help the senior stabilize or improve his or her health so that premature institutional placement does not have to become an option at this point in time.
• Help reduce his or her safety risks.
• Work with family (when present) and long term care assessors to understand the nature of alcohol problems among seniors.
• Plan creatively.

What Do Doctors Think of Harm Reduction?

Many physicians are not as familiar with harm reduction as an approach as they are with approaches that start  and end with abstinence. In a study in the mid 1990s with physicians, 92% of the B.C. physicians surveyed felt that abstinence was the appropriate goal for seniors who have alcohol problems.

The reaction is understandable--- doctors commonly see the adverse health consequences of drinking. Sixty–eight percent (68%) of the physicians believed that "Nothing can be done for the person unless he or she takes responsibility for change." Also, today’s medical curricula gives scant attention to alcohol treatment issues. Ten, twenty or thirty years ago, this was even more the case.

But, the big question for a physician or other health care professional is: What if the senior never acknowledges the problem? Does that mean you can never help? Do you have to wait until the person "hits rock bottom"? The obvious answer is "Of course not. For many seniors, waiting for "rock bottom" is often a death sentence. But you can help by working from where the senior is…..and that is harm reduction.

This article on "Harm Reduction" grew out of an early presentation by Charmaine Spencer, to the Substance Abuse Coordinating Committee, Justice Institute, Vancouver, June 21, 1996. (c)

References and Internet Resources

(1) Canadian Centre on Substance Abuse (CCSA) National Working Group on Policy. Harm Reduction: Concepts and Practice-A Policy Discussion Paper   www.ccsa.ca/

(2) Harm Reduction Coalition (HRC)  www.harmreduction.org/

(3) Moderation Management www.moderation.org/

(4) National Institute on Alcohol Abuse and Alcoholism. How to Cut Down on Your Drinking  www.health.org/govpubs/ph372/

(5) Robert Westermeyer, Harm Reduction and Outreach Interventions www.cts.com/crash/habtsmrt/outreach.html

Page last updated: Saturday June 26, 2004

(c) 2003, Charmaine Spencer, Seeking Solutions.