Harm reduction (or less commonly known as harm minimization) refers to a range of public health policies designed to reduce the harmful consequences associated with human behaviors, even if those behaviors are risky or illegal. Examples of behaviors targeted for harm reduction policies include recreational drug use and prostitution. Criticism of harm reduction typically centers on concerns that tolerating risky or illegal behaviour sends a message to the community that these behaviours are acceptable.
In the case of recreational drug use, harm reduction is put forward as a useful perspective alongside the more conventional approaches of demand and supply reduction. Many advocates argue that prohibitionist laws criminalise people for suffering from a disease and cause harm, for example by obliging drug addicts to obtain drugs of unknown purity from unreliable criminal sources at high prices, increasing the risk of overdose and death.
Heroin maintenance programmes 
Providing medical prescriptions for pharmaceutical heroin (diacetylmorphine) to heroin-dependent people has been employed in some countries to address problems associated with the illicit use of the drug, as potential benefits exist for the individual and broader society. Evidence has indicated that this form of treatment can greatly improve the health and social circumstances of participants, while also reducing costs incurred by criminalisation, incarceration and health interventions.
In Switzerland, heroin assisted treatment is an established programme of the national health system. Several dozen centres exist throughout the country and heroin-dependent people can administer heroin in a controlled environment at these locations. The Swiss heroin maintenance programme is generally regarded as a successful and valuable component of the country's overall approach to minimising the harms caused by illicit drug use. In a 2008 national referendum, a majority of 68 per cent voted in favour of continuing the Swiss programme.
The Netherlands has studied medically supervised heroin maintenance. A German study of long-term heroin addicts demonstrated that diamorphine was significantly more effective than methadone in keeping patients in treatment and in improving their health and social situation. Many participants were able to find employment, some even started a family after years of homelessness and delinquency. Since then, treatment had continued in the cities that participated in the pilot study, until heroin maintenance was permanently included into the national health system in May 2009.[dated info]
A heroin maintenance programme has existed in the United Kingdom (UK) since the 1920s, as drug addiction was seen as an individual health problem. Addiction to opiates was rare in the 1920s and was mostly limited to either middle-class people who had easy access due to their profession, or people who had become addicted as a side effect of medical treatment. In the 1950s and 1960s a small number of doctors contributed to an alarming increase in the number of drug-addicted people in the U.K. through excessive prescribing—the U.K. switched to more restrictive drug legislation as a result. However, the British government is again moving towards a consideration of heroin prescription as a legitimate component of the National Health Service (NHS). Evidence has clearly shown that methadone maintenance is not appropriate for all opioid-dependent people and that heroin is a viable maintenance drug that has shown equal or better rates of success.
A committee appointed by the Norwegian government completed an evaluation of research reports on heroin maintenance treatment that were available internationally. In 2011 the committee concluded that the presence of numerous uncertainties and knowledge gaps regarding the effects of heroin treatment meant that it could not recommend the introduction of heroin maintenance treatment in Norway.
The first, and only, North American heroin maintenance project is being run in Vancouver, B.C. and Montreal, Quebec. Currently, over 80 long-term heroin addicts who have not been helped by available treatment options are taking part in the North American Opiate Medication Initiative (NAOMI) trials. However, critics have alleged that the control group gets unsustainably low doses of methadone, making them prone to fail and thus rigging the results in favor of heroin maintenance.
Critics of heroin maintenance programmes object to the high costs of providing heroin to users. The British heroin study cost the British government £15,000 per participant per year, roughly equivalent to average heroin user's expense of £15,600 per year. Drug Free Australia contrast these ongoing maintenance costs with Sweden's investment in, and commitment to, a drug free society where a policy of compulsory rehabilitation of drug addicts is integral, which has yielded the one of the lowest reported illicit drug use levels in the developed world, a model in which successfully rehabilitated users present no further maintenance costs to their community, as well as reduced ongoing health care costs.
A substantial part of the money for buying heroin is obtained through criminal activities, such as robbery or drug dealing. King's Health Partners notes that the cost of providing free heroin for a year is about one-third of the cost of placing the user in prison for a year.[dead link]
Needle exchange programmes 
The use of some illicit drugs can involve hypodermic needles. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, users of heroin and other drugs frequently share the syringes and use them more than once. As a result infections such as HIV or hepatitis C can spread from user to users through the reuse of syringes contaminated with infected blood. The principles of harm reduction propose that syringes should be easily available or at least available through a needle and syringe programmes (NSP). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries users are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name.
A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour. It has been shown in the many evaluations of needle-exchange programmes that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programmes have reduced HIV incidence by 33% in New Haven and 70% in New York City.
The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated for a protracted time period. Research organisation the Burnet Institute completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum, City of Yarra and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. During the period between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the local government area the City of Yarra, of which Richmond and Abbotsford are parts of, 1550 syringes were collected each month from public syringe disposal bins in 2012. Furthermore, ambulance callouts for heroin overdoses were 1.5 times higher than for other Melbourne areas in the period between 2011 and 2012 (a total of 336 overdoses), and drug-related arrests in North Richmond were also three times higher than the state average. The Burnet Institute's researchers interviewed health workers, residents and local traders, in addition to observing the drug scene in the most frequented North Richmond public injecting locations.
Targeted and low-threshold primary health care outlet 
NSP and Opioid Substitution Therapy (OST) outlets in some settings offer basic primary health care. These are known as 'targeted primary health care outlet'- as these outlets primarily target people who inject drugs and/or 'low-threshold health care outlet'- as these reduce common barriers clients often face when they try to access health care from the conventional health care outlets. For accessing sterile injecting equipment clients frequently visit NSP outlets, and for receiving pharmacotherapy (e.g. methadone, buprenorphine)they visit OST clinics; these frequent visits are used opportunistically to offer much needed health care. These targeted outlets have the potential to mitigate clients' perceived barriers to access to healthcare delivered in traditional settings. The provision of accessible, acceptable and opportunistic services which are responsive to the needs of this population is valuable, facilitating a reduced reliance on inappropriate and cost-ineffective emergency department care.
Safe injection sites 
Safe injection sites (SIS), or Drug consumption rooms (DCR), are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers.
The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programmes prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be injection drug users, but generally in Europe they don't exclude addicts who consume by other means.
The Netherlands had the first staffed injection room, although they did not operate under explicit legal support until 1996. Instead, the first center where it was legal to inject drug was in Berne, Switzerland, opened 1986. In 1994, Germany opened its first site. Although, as in the Netherlands they operated in a "gray area", supported by the local authorities and with consent from the police until the Bundestag provided a legal exemption in 2000.
In Europe, Luxembourg, Spain and Norway have opened facilities after year 2000. As did the two existing facilities outside Europe, with Sydney's Medically Supervised Injecting Center (MSIC) established in May 2001 as a trial and Vancouver's Insite, opened in September 2003. In 2010, after a nine-year trial, the Sydney site was confirmed as a permanent public health facility. As of late 2009 there were a total of 92 professionally supervised injection facilities in 61 cities.
The European Monitoring Centre for Drugs and Drug Addiction's latest systematic review from April 2010 did not find any evidence to support concerns that DCR might "encourage drug use, delay treatment entry or aggravate problems of local drug markets." Jürgen Rehm and Benedikt Fischer explained that while evidence show that DCR are successful, that "interpretation is limited by the weak designs applied in many evaluations, often represented by the lack of adequate control groups." Concluding that this "leaves the door open for alternative interpretations of data produced and subsequent ideological debate."
The EMCDDA review noted that research into the effects of the facilities "faces methodological challenges in taking account of the effects of broader local policy or ecological changes", still they concluded "that the facilities reach their target population and provide immediate improvements through better hygiene and safety conditions for injectors." Further that the facilitates "does not increase levels of drug use or risky patterns of consumption, nor does it result in higher rates of local drug acquisition crime." While its usage is "associated with self-reported reductions in injecting risk behaviour such as syringe sharing, and in public drug use" and "with increased uptake of detoxification and treatment services." However, "a lack of studies, as well as methodological problems such as isolating the effect from other interventions or low coverage of the risk population, evidence regarding DCRs — while encouraging — is insufficient for drawing conclusions with regard to their effectiveness in reducing HIV or hepatitis C virus (HCV) incidence." Concluding with that "there is suggestive evidence from modelling studies that they may contribute to reducing drug-related deaths at a city level where coverage is adequate, the review-level evidence of this effect is still insufficient."
Critics of this intervention, such as drug prevention advocacy organisations, Drug Free Australia and Real Women of Canada point to the most rigorous evaluations, those of Sydney and Vancouver. Two of the centers, in Sydney, Australia and Vancouver, Canada cost $2.7 million and $3 million per annum to operate respectively, yet Canadian mathematical modeling, where there was caution about validity, indicated just one life saved from fatal overdose per annum for Vancouver, while the Drug Free Australia analysis demonstrates the Sydney facility statistically takes more than a year to save one life. The Expert Advisory Committee of the Canadian Government studied claims by journal studies for reduced HIV transmission by Insite but “were not convinced that these assumptions were entirely valid." The Sydney facility showed no improvement in public injecting and discarded needles beyond improvements caused by a coinciding heroin drought, while the Vancouver facility had an observable impact. Drug dealing and loitering around the facilities were evident in the Sydney evaluation, but not evident for the Vancouver facility.
Naloxone distribution 
Formal programmes, in which the opioid inverse agonist drug naloxone (used to reverse opiate overdose) is distributed, have been trialled and implemented. Established programmes distribute naloxone to drug users, their peers, family members, and others, and operate in the United Kingdom (U.K.), the United States (U.S.), Canada, Germany, Georgia, Russia, Spain, Norway, Afghanistan, China, Kazakhstan, Tajikistan, and Vietnam. As of March 2013, trial programs have also commenced in the Australian states of New South Wales (NSW) and the Australian Capital Territory (ACT).
Specific harms associated with cannabis include increased accident-rate while driving under intoxication, dependence, psychosis, detrimental psychosocial outcomes for adolescent users and respiratory disease. Strategies recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) to deal with those include roadside drug-testing to deter intoxicated driving and education about patterns of use that increases the risk for dependence, mental health and respiratory problems. Some safer cannabis usage campaigns including the UKCIA (United Kingdom Cannabis Internet Activists) encourage methods of consumption shown to cause less physical damage to a users body, including oral (eating) consumption, vaporization, the usage of bongs which cool and to some extent filters the smoke, and smoking the cannabis without mixing it with tobacco.
The fact that cannabis possession carries prison sentences in most developed countries—although rarely imposed—is also pointed out as a problem by EMCDDA, as the consequences of a conviction for otherwise law abiding users arguably is more harmful than any harm from the drug itself. For example by adversely affecting professional or travel opportunities and straining personal relationships. Some people like Ethan Nadelmann of the Drug Policy Alliance have suggested that organized marijuana legalization would encourage safe use and reveal the factual adverse effects from exposure to this herb's individual chemicals.
The way the laws concerning cannabis are enforced is also very selective, even discriminatory. Statistics show that the socially disadvantaged, immigrants and ethnic minorities have significantly higher arrest rates. Drug decriminalisation, such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, would alleviate these harms. Where decriminalisation has been implemented, such as in several states in Australia and United States, as well as in Portugal and the Netherlands no, or only very small adverse effects have been shown on population cannabis usage rate. The lack of evidence of increased use indicates that such a policy shift does not have adverse effects on cannabis-related harm while, at the same time, decreasing enforcement costs.
In the last few years certain strains of cannabis with higher concentrations of THC and drug tourism have challenged the former policy in the Netherlands and led to a more restrictive approach; for example, a ban on selling cannabis to tourists in coffeeshops suggested to start late 2011. Sale and possession of cannabis is still illegal in Portugal and possession of cannabis is a federal crime in the United States.
Traditionally, homeless shelters ban alcohol. In 1997, as the result of an inquest into the deaths of two homeless alcoholics two years earlier, Toronto's Seaton House became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, homeless alcoholics opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities. The programme has been duplicated in other Canadian cities and a study of Ottawa's "wet shelter" found that emergency room visit and police encounters by clients were cut by half. The study, published in the Canadian Medical Association Journal in 2006 found that serving chronic street alcoholics controlled doses of alcohol also reduced their overall alcohol consumption. Researchers found that programme participants cut their alcohol use from an average of 46 drinks a day when they entered the programme to an average of 8 drinks and that their visits to emergency rooms drop to an average of eight a month from 13.5 while encounters with the police fall to an average of 8.8 from 18.1.
Downtown Emergency Service Center(DESC), in Seattle Washington, operates several Housing First, harm reduction model, programmes. University of Washington researchers, partnering with DESC, found that providing housing and support services for homeless alcoholics costs tax-payers less than leaving them on the street, where tax-payer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation appeared in the Journal of the American Medical Association April, 2009. This first US controlled assessment of the effectiveness of Housing First specifically targeting chronically homeless alcoholics showed that the programme saved tax-payers more than $4 million over the first year of operation. During the first six-months, even after considering the cost of administering the housing, 95 residents in a Housing First programme in downtown Seattle, the study reported an average cost-savings of 53 percent—nearly US $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among homeless alcoholics.
A high amount of media coverage exists informing users of the dangers of driving drunk. Most alcohol users are now aware of these dangers and safe ride techniques like 'designated drivers' and free taxicab programmes are reducing the number of drunk-driving accidents. Many cities have free-ride-home programmes during holidays involving high alcohol abuse, and some bars and clubs will provide a visibly drunk patron with a free cab ride.
In New South Wales groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programmes including the aforementioned 'designated driver' and 'late night patron transport' schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.
Moderation Management is a programme which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behaviour.
The HAMS Harm Reduction Network is a programme which encourages any positive change with regard to the use of alcohol or other mood altering substances. HAMS encourages goals of safer drinking, reduced drinking, moderate drinking, or abstinence. The choice of the goal is up to the individual.
Harm reduction in alcohol dependency could be instituted by use of naltrexone, in the Sinclair Method developed by Professor J.D. Sinclair. The aim is to take naltrexone daily before having alcohol and reduce the endorphin reward caused (it is an opiate antagonist) leading to more moderate intake and the possibility of replacing alcohol with healthy endorphin-releasing activities on non-drinking days. Research suggests 60-80% of people completing 3 months of treatment reduce their intake to <24 units a week by the end.
Tobacco harm reduction describes actions taken to lower the health risks associated with using tobacco, especially combustible forms, without abstaining completely from tobacco and nicotine. Some of these measures include switching to safer (lower tar) cigarettes, switching to snus or dipping tobacco, or using a non-tobacco nicotine delivery systems.
It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, there is a considerable population of inveterate smokers who are unable or unwilling to achieve abstinence. Harm reduction may be of substantial benefit to these individuals.
Safer sex programmes 
Many schools now provide safer sex education to teen and pre-teen students, who may engage in sexual activity. Since some adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STIs. This runs contrary to abstinence-only sex education, which teaches that educating children about sex can encourage them to engage in it.
These programmes have been found to decrease risky sexual behaviour and prevent sexually transmitted diseases. They also reduce rates of unwanted pregnancies. Abstinence only programmes do not appear to affect HIV risks in developed countries with no evidence available for other areas.
Legalized prostitution 
Since 1999 some countries have legalized prostitution, such as Germany (2002) and New Zealand (2003). Those who support the prohibition of the sex trade also say that legalized prostitution does nothing to improve the situation of the prostitutes and leads only to an increase in criminal activities and human trafficking. For example, Netherlands, a country which has legal and regulated prostitution, has severe problems with human trafficking (it is listed by UNODC as a top destination for victims of human trafficking), and, in response to these problems has decided in 2009, to close 320 prostitution "windows", after having closed numerous other prostitution business during the past years. The mayor of Amsterdam, Job Cohen said about legal prostitution in his city: "We've realized this is no longer about small-scale entrepreneurs, but that big crime organisations are involved here in trafficking women, drugs, killings and other criminal activities". According to the anti-prostitution group CATW, ever since the 1990s there has been a steady increase in the number of trafficking victims in that country, with each year seeing a higher number of victims than the previous year: in 1994 (when brothels were illegal) there were 168 recorded trafficking victims; by 2004 there were 405 (brothels were legalized in 2000); by 2008 there were 826; and by 2010 there were 993. Of course, it is also possible that the putative increases were simply an artifact of the police doing a better job of detecting human trafficking, or that actual increases in trafficking have occurred for reasons unrelated to the legalization of prostitution in 2000.
Sex work and HIV 
Despite the depth of knowledge of HIV/AIDS, rapid transmission has occurred globally in sex workers. The relationship between these two variables greatly increases the risk of transmission among these populations, and also to anyone associated with them, such as their sexual partners, their children, and eventually the population at large.
Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in injecting drug users and sex-workers. HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease. Peer education as a harm reduction strategy has especially reduced the risk of HIV infection, such as in Chad, where this method was the most cost-effective per infection prevented.
The threat of criminal repercussions drives sex-workers and injecting drug users to the margins of society, often resulting in high-risk behaviour, increasing the rate of overdose, infectious disease transmission, and violence.[not in citation given] Decriminalisation as a harm-reduction strategy gives the ability to treat drug abuse solely as a public health issue rather than a criminal activity. This enables other harm-reduction strategies to be employed, which results in a lower incidence of HIV infection.
|This section does not cite any references or sources. (March 2012)|
Harm reduction programmes work with people who are at risk of self-harm (e.g. cutting, burning, etc.) Such programmes aim at education and the provision of medical services for wounds and other negative consequences. The hope is that the harmful behaviour will be moderated and the people helped to keep safe as they learn new methods of coping.
Psychiatric medications 
With the growing concern about psychiatric medication adverse effects and long-term dependency, peer-run mental health groups Freedom Center and The Icarus Project published the Harm Reduction Guide to Coming Off Psychiatric Drugs. The self-help guide provides patients with information to help assess risks and benefits, and to prepare to come off, reduce, or continue medications when their physicians are unfamiliar with or unable to provide this guidance. The guide is in circulation among mental health consumer groups and has been translated into Spanish and German.
Critics, such as Drug Free America Foundation and other members of network International Task Force on Strategic Drug Policy, state that a risk posed by harm reduction is by creating the perception that certain behaviours can be partaken of safely, such as illicit drug use, that it may lead to an increase in that behaviour by people who would otherwise be deterred.
We oppose so-called 'harm reduction' strategies as endpoints that promote the false notion that there are safe or responsible ways to use drugs. That is, strategies in which the primary goal is to enable drug users to maintain addictive, destructive, and compulsive behavior by misleading users about some drug risks while ignoring others.—"Statement on so-called 'Harm Reduction' polices" made at a conference in Brussels, Belgium by signatories of the drug prohibitionist network International Task Force on Strategic Drug Policy
...some organizations and local governments actively advocate the legalization of drugs and promote policies such as “harm reduction” that accept drug use and do not help drug users to become free from drug abuse. This undermines the international efforts to limit the supply of and demand for drugs. “Harm reduction” is too often another word for drug legalization or other inappropriate relaxation efforts, a policy approach that violates the UN Conventions.—"Declaration of the World Forum Against Drugs Stockholm Sweden, September 10, 2008
However, in Switzerland the incidence of heroin abuse has declined sharply since the introduction of heroin assisted treatment. As a study published in The Lancet concluded:
The harm reduction policy of Switzerland and its emphasis on the medicalisation of the heroin problem seems to have contributed to the image of heroin as unattractive for young people."— Nordt, Carlos, and Rudolf Stohler, "Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis,"
Critics furthermore reject harm reduction measures for allegedly trying to establish certain forms of drug use as acceptable in society:
Harm reduction has come to represent a philosophy in which illicit substance use is seen as largely unpreventable, and increasingly, as a feasible and acceptable lifestyle as long as use is not 'problematic'. At its root of this philosophy lay an acceptance of drug use into the mainstream of society. We reject this philosophy as fatalistic and faulty at its core. The idea that we can safely use drugs is a dangerous one. ... It is in fact an unsafe choice that brings great harm to individuals, families, and communities across. And it sends the wrong message to the most valuable yet vulnerable group of Canadians – our children and youth.—Drug Prevention Network of Canada
Even though the world is against drug abuse, some organizations and local governments actively advocate the legalization of drugs and promote policies such as 'harm reduction' that accept drug use and do not help drug users to become free from drug abuse. This undermines the international efforts to limit the supply of and demand for drugs. 'Harm reduction' is too often another word for drug legalization or other inappropriate relaxation efforts, a policy approach that violates the UN Conventions.
There can be no other goal than a drug-free world. [...]We support the INCB statement that 'harm reduction' programmes are not substitutes for demand reduction programmes and should not be carried out at the expense of other important activities to reduce the demand for illicit drugs, such as drug prevention activities.— Declaration of World Forum Against Drugs, Stockholm, 2008, a conference with participation from 82 countries 
Pope Benedict XVI has strongly criticised harm reduction policies with regards to HIV/AIDS, saying that "it is a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems". This position has been widely criticised for misrepresenting and oversimplifying the role of condoms in preventing infections.
See also 
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