Although there are variations in the definition of prevention, there are some key elements of all definitions that are based on the natural history of a health behavioral issue. These elements include intervening to prevent onset and progression of disease or symptoms. For example, the Cambridge dictionary defines prevention as “the act of stopping something from happening or of stopping someone from doing something” (1) while the Center for Disease Control and Prevention (CDC) defines prevention as “activities to stop people from getting diseases or to stop a disease from getting worse” (2).
The CDC further defines the activities around prevention as:
1. Primary Prevention—intervening before health effects occur, through measures such as vaccinations, altering risky behaviors (poor eating habits, tobacco use), and banning substances known to be associated with a disease or health condition.8,9
2. Secondary Prevention—screening to identify diseases in the earliest stages, before the onset of signs and symptoms, through measures such as mammography and regular blood pressure testing.10
3. Tertiary Prevention—managing disease post diagnosis to slow or stop
disease progression through measures such as chemotherapy, rehabilitation, and screening for complications (3)
With growing epidemiological information regarding factors that put people at risk for or protected them from diseases, a new way of thinking about prevention guided a new nomenclature developed by Robert S. Gordon, Special Assistant to the Director
National Institutes of Health that focused more on those at risk but who were not having any symptoms or disability due to a health issue. He laid out the terms: universal, selective, and indicated. He defined the terms which would later be incorporated into the Institute of Medicine framework. In 1994, the Institute of Medicine (IOM) published Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research which outlined this new nomenclature that would soon be embraced by the field of prevention.
“A universal preventive measure is a measure that is desirable for everybody in the eligible population…The benefits outweigh the cost and risk for everyone. Examples include those outlined by Gordon, e.g., use of seat belts, prevention of smoking, many forms of immunization, and prenatal care.
A selective preventive measure is desirable only when the individual is a member of a subgroup of the population whose risk of becoming ill is above average…Examples include special immunizations, such as yellow fever, for individuals who travel to areas of the world where the disease is still prevalent, and annual mammograms for women with a positive family history of breast cancer.
An indicated preventive measure applies to persons who, on examination, are found to manifest a risk factor, condition, or abnormality that identifies them, individually, as being at high risk for the future development of a disease…Examples of indicated measures include medical control of hypertension and frequent, careful examination of persons from whom a basal cell skin cancer has been removed …”(IOM, 1994).
In the field of prevention there are many evidence-based programs available that have been developed to address each of these groups. Using substance use as a prevention target, examples of universal prevention programs include LifeSkills Training, Good Behavior Games or Triple P; examples of selective prevention programs include Project Towards No Drug Abuse or Strengthening Families 10-14; and examples of indicated prevention programs include Brief Alcohol Screening and Intervention for College Students and Multisystemic Therapy.
Defining Harm Reduction As Applied to Substance Use
What do we mean by ‘harm reduction’ and how does harm reduction interventions fit into the prevention framework for substance use? The National Harm Reduction Coalition states on its website (4)
“Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.”
The introduction of Harm Reduction interventions for substance use provides an opportunity to begin building a national service delivery system based on need, and availability and support of evidence-based interventions. If we look at the general population using the public health framework based on the natural history of substance use, we can define several ‘needs’ in regard to the full spectrum of community services, as seen in the graphic below.
This array of needed services was suggested by the National Academy of Sciences (2009) that presented a spectrum of services that we see here ranging from health promotion and universal prevention through aftercare and rehabilitation post-treatment. And of course, health promotion underlies and supports all these services.
How does harm reduction fit into this ‘service need’ paradigm? Harm reduction would overlap with indicated services through treatment and maintenance (See purple shading to the left).
Let’s now look at the 8 service ‘needs’ groups who can be addressed by the spectrum of services and how harm reduction fits into that paradigm. No harm reduction services are needed for the first 2 needs groups:
1. General population who do not use substances and are not ‘vulnerable’ but who need prevention programming to reinforce their ‘no use’ status;
2. General population who do not use substances and are vulnerable such as children of substance users, those stressed because of poverty or abuse etc.;
Harm reduction services can be offered starting with the following groups who may begin to experience consequences related to their substance use. Some of these services can include: providing clean needles; information about “street drug’ formulations’ that might be dangerous; overdose prevention kits; information on where medical and treatment services are available; and supervised drug administration with emergency staff available in case of overdose, etc.
3. General population that initiated use and may or may not experience consequences;
4. General population that meet a DSM diagnosis for substance use and need treatment but do not utilize treatment;
5. General population who sought treatment but didn’t receive treatment;
6. General population who meet a DSM diagnosis for substance use treatment and utilize treatment;
7. General population who received treatment but didn’t complete it;
8. General population who received treatment and are in recovery.
Understanding the full spectrum of services needed for those at risk for and experiencing substance use and related health, emotional, or social problems is important for prevention professionals. Our goals are to address the range of community needs and to prevent the onset of the use of psychoactive substances and if such use is initiated, to prevent the negative consequences of these challenging behavioral disorders.
References
Gordon R. S., Jr (1983). An operational classification of disease prevention. Public Health Reports, 98(2): 107–109.
National Research Council. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, DC: The National Academies Press, 1994; updated
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