Harm reduction

Harm reduction (or Harm minimisation) refers to a range of public health policies designed to reduce the harmful consequences associated with recreational drug use and other high risk activities. Harm reduction is put forward as an useful perspective alongside the more conventional approaches of demand and supply reduction.

Many advocates argue that prohibitionist laws criminalize 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. While its critics are concerned that tolerating risky or illegal behaviour sends a message to the community that these behaviours are acceptable.

Drugs

See also: Responsible drug use

Heroin maintenance programs

Main article: Heroin assisted treatment

Providing a medical prescription for pharmaceutical heroin (diamorphine) to heroin addicts has been seen in some countries as a way of solving the ‘heroin problem’ with potential benefits to the individual addict and to society. Studies have proven the treatment to greatly improve the social and health situation of patients, while reducing costs incurred by delinquency, trials, incarceration and health interventions.

In Switzerland heroin assisted treatment is fully a part of the national health program. There are some 38 centers throughout the country at which dependent persons can receive heroin maintenance. The Swiss heroin maintenance program is generally regarded as a success and a valuable component of that country's overall approach to managing drug use in a harm decreasing manner. In a 2008 national referendum a majority of 68% voted in favor of continuing the program. See the Report on the Evaluation of the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts.

The Netherlands is another country which has had several successful studies of medically supervised heroin maintenance. Results of two major clinical studies involving 547 heroin treatment patients are available from the CCBH (Central Committee on the Treatment of Heroin Addicts) website.

Another major study on heroin maintenance was carried out in Germany from 2002 until 2005 with over 1000 long-term heroin addicts receiving either oral methadone or i.v. diamorphine at treatment-centers in seven participating cities. The study proved diamorphine to be 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 been continued in the cities that participated in the pilot study, until heroin maintenance was permanently included into the national health system in May, 2009.

The British have had system of heroin maintenance since the 1920s. It was de-emphasized somewhat during the 1960s-1980s as a result of the U.S. led "war on drugs". However, in recent years the British are again moving toward heroin maintenance as a legitimate component of their National Health Service. This is because evidence is clear that methadone maintenance is not the answer for all opioid addicts and that heroin is a viable maintenance drug which has shown equal or better rates of success in terms of assisting long-term users establish stable, crime-free lives. Access a British report on heroin maintenance entitled Prescribing Heroin: what is the evidence?

The first, and only, North American heroin maintenance project is being run in Vancouver, B.C. and Montreal, Quebec. Currently some 80+ long-term heroin addicts who have not been helped by available treatment options are taking part in the NAOMI (North American Opiate Medication Initiative) trials. However, critics have alleged that the control group gets unsustanably low doses of methadone, making them prone to fail and thus rigging the results in favor of heroin maintenance.

More general criticisms towards heroin maintenance, such as those lauded by Drug Free Australia include the high costs to the tax-payer. Another issue is the contagious job of straighting out the rules that should govern a program. John Kaplan uses the analogy of "a blanket on a cold night. It may be good enough to cover part of the matter adequately, but when it does it leaves other parts dangerously exposed." Examples of this is the leakage issue when heroin are given by prescription relative to the social disruption when the addicts are required to go to a clinic several times a a day to receive the needed doses.

Needle and syringe exchange and related programs

A bin allowing for safe disposal of needles in a public toilet in Caernarfon, Wales.

Main article: Needle-exchange programme

The use of heroin and certain other illicit drugs can involve hypodermic syringes. 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, one user's infection (such as HIV or Hepatitis C) can spread to other users through the reuse of syringes contaminated with infected blood.

The principles of harm reduction propose that syringes should be easily available (i.e. without a prescription) or at least available trough a Needle and Syringe Exchange (NSE) program. 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. It has been shown in the many evaluations of needle-exchange programs that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programs have reduced HIV incidence by 33% in New Haven and 70% in New York City.

Critics of this harm reduction intervention, such as Drug Free Australia, point to the US Institute of Medicine's 2006 review of needle exchange programmes, with its extensive panel of 24 scientists, medical practitioners and reviewers. Although the study recommends that, "[g]iven consistent evidence that multi-component HIV prevention programs that include sterile needle and syringe is associated with reductions in drug-related HIV risk behavior, such programs should be implemented where feasible", they found the evidence that NSE would have an effect on the incidence of HIV to be "limited and inconclusive" and notes the need for further research. They also state that "multiple studies show that NSEs do not reduce transmission of [Hepatitis C]," which they note, "has been attributed to the apparent failure of NSEs to provide enough ancillary injecting equipment such as sterile cotton, water, and alcohol wipes."

Safe injection sites

A clandestine kit containing materials to inject illicit drugs (or legitimate ones illegitimately). Note that it is quite common for an injector to use a single needle repeatedly or share with other users. It is also quite uncommon for a sterilizing agent to be used.

Compare this legitimate injection kit obtained from a needle-exchange program to the user-compiled one above.

Main article: Safe injection site

Safe injection sites (SIS), or Drug consumption facilities (DCF), are legally sanctioned, medically supervised facilities designed to reduce to address public nuisance associated with drug use and provide an 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 programs 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.

Evaluations generally find them successful in reducing injection-related risks and harms, including vein damage and overdose. They also appear to be generally successful in reducing public order problems associated with illicit drug use, including improper syringe disposal and publicly visible illegal drug use.

There are about 90 Drug consumption facilities in at least 59 cities within Europe, namely in Germany, the Netherlands, Switzerland, Luxembourg, Spain and Norway. Since opening in 2001, Sydney’s Medically Supervised Injecting Centre has treated thousands of potentially fatal Drug overdoses without a single fatality. The first safe injection site in North America, Insite, opened in Vancouver, BC Canada, in September 2003.

Cannabis

Further information: Legal issues of cannabis, Health issues and the effects of cannabis, Removal of cannabis from Schedule I of the Controlled Substances Act, and Drug policy of the Netherlands

Some harm reductionists favor outright legalization of cannabis, allowing its sale e.g. through Dutch-style "coffee shops". Others think the best option would be some degree of decriminalization, such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, while concentrating law-enforcement resources on more serious crimes.

Cannabis decriminalization has been a hotly debated issue in many parts of the world, especially in many Western European countries such as Belgium, Germany, United Kingdom, Portugal, and Spain, where some measures have been taken towards lifting the ban on cannabis. The recent development in the Netherlands is that more and more Cannabis coffee shops are closed by local authorities.

Alcohol

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 program 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 program participants cut their alcohol use from an average of 46 drinks a day when they entered the program 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, programs. 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 program saved tax-payers more than $4 million dollars 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 program 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.

DanceSafe and related programs

DanceSafe is a not-for-profit organization in the United States, wherein volunteers situated at raves and similar events perform free-of-charge tests on pills that participants bought on the assumption they contained 3,4-methylenedioxy methylamphetamine, or MDMA, commonly known as "Ecstasy", "X", "rolls", or "E". These tests are viewed by proponents as a viable means of Harm Reduction because pills sold as Ecstasy on the black market are commonly fake, containing unknown chemicals other than MDMA that may present greater risk to users. DanceSafe does not sell Ecstasy or other drugs; rather, they perform chemical tests after being provided with a sample of a pill by its owner. Harm reductionists support these programs as a means for drug users to obtain information about the authenticity of their drugs, thus decreasing the possibility of adverse drug reactions and other drug-related emergencies. Similar programs have been proposed and, in some cases, implemented to test the authenticity of other drugs.

In North America the first harm reduction program geared towards the dance music community was the TRIP! Project [4]. TRIP! was born in 1995 out of a need for appropriate drug and sex information within the Toronto raves. The act of partying often implies use of drugs, most often hallucinogens such as cannabis, MDMA, LSD, and psilocin, along with ethanol, and promiscuous, unsafe sexual activity. These activities, on their own as well as together, put people at risk for drug dependencies, sexually transmitted diseases, HIV and more. A recruitment process began with a community picnic, organized by Kim Stanford, at the time an HIV Educator working for Toronto Public Health. From there came the volunteers from within the community, who contributed their time, energy and creativity into making TRIP a unique and innovative drug and sex education project.

The idea of harm reduction was relatively new to the general public at this time in North America, although it had been widely practiced in Europe for some time and with great success. It was a concept that ravers were into as it was new and different, and it challenged social constructs and empowered individuals to make their own decisions around their lives and how to live them—with awareness. TRIP! blossomed into a huge community success and the following years, the North American rave scene would see several other rave-based harm reduction projects sprout up in communities across the continent. We can't take credit for creating rave-based harm reduction—several European groups and one South African project had already been at it for some time. Much respect to them as they have pioneered a strong and influential movement that continues to this day.

TRIP! provides several services to the dance community and beyond. Most notably the project is known for its onsite outreach booths, a vendor-style setup staffed by 2-3 TRIP workers and volunteers, which offers a display of safer drug use and safer sex information and supplies. It is here that partyers can find a place to chill out and talk, pick up earplugs to minimize harm from music exceeding 120dB, condoms and vaginal lubricant to minimize the risks of unsafe sexual contact, utilize needle exchange services to minimize the risks associated with needle sharing and re-use, such as blood-borne diseases such as Hepatitis C and HIV, and "cotton fever" and endocarditis, respectively, and talk to TRIP! staff about sexual relations, the recreational use of drugs, and partying. All TRIP staff and volunteers are trained in basic counseling, crisis intervention, how to handle drug-related emergencies, and CPR. Therefore, TRIP's presence adds first responders in the event of an emergency, which increases the safety of all in attendance at any given event.

In Australia the first program targeting those attending raves was Ravesafe, conducted in Sydney in 1993 by the NSW USers & AIDS Association as a part of the TRIBES project. In Melbourne ravers self-organised Ravesafe Melbourne in 1995. This project received government funding in 1997.

Drunk driving and alcohol-related programs

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 programs are reducing the number of drunk-driving accidents. Many cities have free-ride-home programs 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 programs 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 program which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behavior.

The HAMS Harm Reduction Network is a program 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.

Tobacco

Main article: Tobacco harm reduction

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. These measures include:

• Smoking safer cigarettes
• Switching to Swedish or American smokeless tobacco products
• Switching to 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.

Sex

Safer sex programs

Many schools now provide safer sex education to teen and pre-teen students, some of whom engage in sexual activity. Given the premise that 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 the ideology of abstinence-only sex education, which holds that telling kids about sex can encourage them to engage in it.

Supporters of this approach cite statistics which they claim demonstrate that this approach is significantly more effective at preventing teenage pregnancy and STDs than abstinence-only programs; opponents disagree with these claims—see the sex education article for more details on this controversy.

Legalized prostitution

Main article: Legality of prostitution

Since the 1990s some countries are classifying prostitution as a form of exploitation of women, or violence against women. Laws to this effect have been enacted in Sweden (1999), Norway (2009) and Iceland (2009), where it is illegal to pay for sex, but not to be a prostitute (the client commits a crime, but not the prostitute). Denmark is considering to adopt the "Swedish model".

In contrast, since 1999 other 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 organizations are involved here in trafficking women, drugs, killings and other criminal activities" .

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 specific lifestyles greatly increases the risk of transmission among these populations, and also to anyone associated with them, such as non-IDU sexual partners, children of IDUs, and eventually the population at large.

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in IDUs 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.

Decriminalization

The threat of criminal repercussions drives sex-workers and IDUs to the margins of society, often resulting in high-risk behavior, increasing the rate of overdose, infectious disease transmission, and violence. Decriminalization 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.

Self-mutilation

Main article: Self-mutilation

Harm reduction programs work with people who are at risk of harming themselves (e.g. cutting, burning themselves with cigarettes, etc.) Such programs aim at education and the provision of medical services for wounds and other negative consequences. The hope is that the harmful behavior will be moderated and the people helped to keep safe as they learn new methods of coping.

Other forms of harm reduction initiative

Other harm reduction programs to be expanded on:

• Encouragement of the use of safer cannabis smoking devices/cannabinoid delivery systems such as vaporizers, as opposed to water pipes, cigarettes and straight pipes
• Encouragement of the use of smokeless systems of nicotine delivery, known as Tobacco harm reduction, as opposed to the much riskier method of burning and inhaling tobacco.
• Promote the use of safer modes of use such as safer crack pipes (as opposed to use of a pipe which may burn or cut the users mouth, increasing risk of transmittable diseases) Use of screens which are safer than the use of a brillo pad which may embed metal particles into the lungs.
• Promote various safer use strategies such as having a chronic alcoholic have a chaser of water between drinks.
• Advocate the use of a Substitute Decision Maker or Power of Attorney so a person's rent is paid before the drug of choice, ensuring the person always has housing.
• Provide vitamins to ensure a person's physical needs are somewhat met
• Lessen the use of mouthwash, Gravol, isopropanol etc. in poverty-stricken chronic alcoholics as a source of an alcohol, and replace with something less destructive, such as ethanol without toxic additives, and eliminate the use of isopropanol.
• Allowing young people decision making power and access to contraceptives
• Allowing young people decision making power to terminate a pregnancy.
• State regulated production and distribution of formerly illegal drugs (legalization)

Criticism of harm reduction

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 behaviors can be partaken safely, such as illicit drug use, that it may lead to an increase in that behavior by people who would otherwise be deterred. There is no empirical evidence or peer-reviewed literature to support these arguments, and much to refute them. Little anecdotal evidence supports them beyond the arguments and claims put forth by anti-harm reduction groups themselves.

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 [5]

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 on 'Harm Reduction Ideology'

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 [6]

Pope Benedict XVI has strongly criticized 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

• Brief intervention
• Recovery housing
• Illicit drug use in Australia

External links

• Template:Dmoz
• TNI on Harm Reduction
• International Harm Reduction Association