Harm reduction

Harm reduction, or harm minimisation, refers to a range of public health policies designed to reduce the harmful consequences associated with drug use and other high risk activities.

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. The approach is met with resistance from various organisations who believe that tolerating harmful behaviours condones them .

Drugs

See also: Responsible drug use

Heroin maintenance programs

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.

Critics of this intervention cite the high costs to any community providing heroin maintenance programs. For instance, the British heroin trial initiated in 2005 costs the British government £15,000 pounds per participant per annum. The trial claims that the illicit heroin use of participants is reduced from £300 to £50 per week, that is from £15,600 acquisitive crime per year to £2,600 per year. Yet for the £15,000 investment, the community is still £2,000 worse off in terms of ongoing acquisitive crime. Alternatively, Sweden’s investment in a policy of compulsory rehabilitation of drug addicts has yielded the lowest illicit drug use levels in the developed world.

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, and the repeated use of a non-sterilised syringe by a single user also bears a significant infection risk.

The principles of harm reduction propose that syringes should be easily available (i.e. without a prescription). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. Harm reductionists also argue that users should be supplied free of charge at clinics set up for this purpose: so-called needle-exchange programmes. 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, though in some Canadian cities they have had little impact.

Critics of this harm reduction intervention claim that NSPs do not lower harms associated with injecting drug use and simple condone the behaviour.

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 rooms" are legally sanctioned, supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use.

Safe injection rooms provide sterile injection equipment, information about drugs and 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.

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

There are over 47 safer injection sites in cities in Europe. Generally in Europe they are referred to as "safer consumption rooms". Since opening in 2001, Sydney’s Medically Supervised Injecting Centre has treated thousands of potentially fatal Drug overdoses without a single fatality [5]. The first safe injection site in North America, Insite, opened in Vancouver, BC Canada, in September 2003. The conservative federal government is currently (2008) attempting to force the closure of this facility.

Critics of this intervention point to evaluations of safe injection sites. For example, the 2003 evaluation of the Sydney Medically Supervised Injecting Centre found that that there was no evidence that the injecting room reduced the number of overdose deaths in the area, no improvement in ambulance overdose attendances in the area, no improvement in ambulance overdose attendance during hours the injecting room was open, no improvement in overdose presentations at hospital emergency wards (p. 60). Later research balanced these initial findings, noting that "the Sydney MSIC reduced the demand for ambulance services, freeing them to attend other medical emergencies within the community" (but it is also noted that data from this later study uses the data for the same ambulance services as the 2003 evaluation, but with obviously conflicting data for the years 2001 and 2002) .

The 2003 evaluation further indicated no improvement re HIV infections (p. 71) no improvement in Hep B infections (p. 72) either worse or no improvement (depending on the suburb studied) in new Hep C notifications (p. 80) discarded syringe counts on street reduced only in line with reductions in numbers handed out due to heroin drought (p. 123) and drug-related loitering and drug dealing worsened at the station entrance immediately opposite the centre (pp 146, 147).

A Drug Free Australia analysis of this evaluation by an epidemiologist, addiction medicine practitioner, and social researchers and practitioners found overdose levels in the MSIC 36 times higher than on the surrounding streets of Kings Cross, with clients averaging only one in every of their 35 injections in the room, evidencing low utilization rates in light of the ever-present risk of fatal overdose to each heroin user. Testimony of ex-clients of the MSIC reported to the NSW Legislative Council alleged that the extremely high overdose rates were due to clients experimenting with poly-drug cocktails and higher doses of heroin in the knowledge that staff were present to ensure their safety. The 2003 evaluation noted that, “In this study of the Sydney injecting room there were 9.2 heroin overdoses per 1000 heroin injections in the centre. This rate of overdose is higher than amongst heroin injectors generally. The injecting room clients seem to have been a high-risk group with a higher rate of heroin injections than others not using the injection room facilities. They were more often injecting on the streets and they appear to have taken greater risks and used more heroin whilst in the injecting room. It is this injecting room effect of increasing the trade for local drug dealers that has been condemned by critics.

Cannabis

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.

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

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 methylenedioxymethamphetamine, or MDMA, commonly known as Ecstasy. 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 [6]. TRIP! was born in 1995 out of a need for appropriate drug and sex information within the Toronto raves. The act of partying often meant using drugs, and for some, being promiscuous. These activities, on their own as well as together, had the potential to 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, condoms and lube, utilize needle exchange services, and talk to TRIPsters about sex, 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-harm

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 smoking alternatives 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, etc as a substance to use, replace with something less destructive to the human body.
• 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.

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 [7]

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 [8]

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

• Harm reduction at Curlie
• TNI on Harm Reduction
• International Harm Reduction Association