Harm reduction

Harm reduction is a philosophy of public health, intended to be a progressive alternative to the prohibition of certain potentially dangerous lifestyle choices in society.

The central idea of harm reduction is the recognition that some people always have and always will engage in behaviours which carry risks, such as casual sex, sex work, and drug use. The main objective of harm reduction is to mitigate the potential dangers and health risks associated with the risky behaviours themselves. Another objective of harm reduction is to reduce harm associated with, or caused by, the legal circumstances under which the behaviours are carried out (for example, prohibition of certain acts or substances can help create a black market where illicit trade flourishes and the quality of the product goes unchecked).

Harm reduction initiatives range from widely accepted ideas, such as designated driver campaigns, to more controversial initiatives, like the provision of condoms in public schools, needle exchange programs or supervised injection sites for intravenous drug users, drug legalization, and heroin maintenance programs.

Harm reductionists contend that no one should be denied services, such as health care or social security, merely because they take certain risks or exhibit certain behaviours that are illegal or are generally disapproved of by society as a whole. Further, harm reduction seeks to take a social justice stance in response to behaviours such as the use of illicit drugs or prostitution, as opposed to criminalising and prosecuting these behaviours. Often, harm reduction advocates hold the view that prohibition of drugs is discriminatory, ineffective and counter-productive. Among other arguments, they point out that the burden placed on the public health system and society as a whole from cannabis use and other illegal drugs are relatively low. They also contend that the substances are still widely used, despite extremely expensive attempts to enforce laws criminalizing them, and that the prohibition has the effect of criminalizing and marginalizing otherwise law-abiding drug user.

Critics of harm reduction contend that it appears to condone and even facilitate behaviours that are dangerous, socially destabilizing or considered immoral. For these reasons, harm reduction has been very controversial in the United States, where it has met more resistance than in Europe, Canada, Australia and New Zealand. In the United States, debate about harm reduction is very polarized. Advocates are often characterized as "pro-drug". Opponents of harm reduction are often criticised for ignoring the realities and circumstances of addictions, disregarding scientific evidence, marginalizing the basic human rights of affected persons, and responding from a position of "moral panic".

There is a third group that advocates an approach which is sometimes referred to as gradualism. Gradualism advocates are of the opinion that harm reduction programs are sometimes rooted in pessimism about the ability of addicts to stop their addictive behaviors and represent the "soft bigotry of low expectations." They are unlikely to categorize interventions as "good" or "bad". Rather, they tend to be more concerned that programs should urge clients toward abstinence when windows of opportunity open.

Drugs

See also: Responsible drug use

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, e.g. crimes that have victims instead of an individual breaking a law of prohibition.

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.

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

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 until 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.

Methadone

Some harm reductionists advocate the availability of the synthetic drug methadone (or, more recently, of buprenorphine) for users who are dependent on opioids (e.g. heroin, codeine). Methadone does not cause a strong euphoria in the user but reduces or eliminates cravings and the symptoms of opioid withdrawal. Therefore, harm reductionists maintain, methadone should be made widely available to people, temporarily or permanently, to promote the transition to a fulfilling and healthy lifestyle. Critics of methadone treatment claim that this is merely a substitution of one addiction for another, or that methadone treatment does not work. There is an international literature to show that methadone programmes can help opioid users stabilise their lifestyles by obtaining a legal, regulated substitute drug. This could potentially help them look after themselves, their families, and re-enter the work force or pursue further education. These are the building blocks for regaining dignity and self esteem and are imperative for those who want to become contributing members of society. Harm reduction is a flexible philosophy that stresses understanding of the needs of the drug user, and responding to these needs in a way as flexible and realistic as the local laws allow, working at the pace - and to achieve the goals - that the person wants. However, for those drug users who want to change their life, substitute medication should be complemented by psychological and practical support, enabling the person to reach their stated goals. In the UK prescribing methadone is seen as a way of reducing drug related-crime — the provision of substitute medication removes the need to buy drugs through the underground street market where it's quality is dubious at best.

Benefits of methadone treatment

These are benefits as stated by a Belgian Consensus Conference on Methadone Treatment, conducted by the Belgian Minister of Health. The following conclusions were sent to every Belgian doctor: 1.

• Methadone is an effective medication for the treatment of opioid addiction.
• Methadone (and any other suitable opioid medically prescribed for an addicted person) reduces illegal heroin consumption, especially injection, reduces mortality related to heroin addiction, reduces the risk of infection with HIV as well as hepatitis B and C, improves therapeutic compliance of HIV-positive drug addicts, facilitates detection of illness and health education strategies and is associated with an improvement in socio-professional aptitude along with a reduction in delinquency.
• Prolonged treatment with proper doses of methadone is medically safe. At present, methadone has not been shown to be toxic for any organ.
• There is no scientific reason to limit the overall number of heroin addicts admitted for methadone treatment.
• Methadone treatment availability should be increased in order to respond to the need for such treatment, including by private practitioners.
• Psycho-social support is not compulsory and should be adapted to the individual needs of patients.

Syringe exchange and related programs

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

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. Critics claim that these measures will encourage the use of illegal drugs by making it easier to inject them without endangering oneself, although 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.

A closely related harm-reduction-based initiative is the "safe injection" site (see below).

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. Critics of these services claim that such programs encourage immoral drug use by making it safer.

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.

An international service with its server in Holland called Bluelight was formed initially as an MDMA-focused harms reduction resource, and has since matured into a multi-substance harms reduction community. [1]

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.

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, if not most, 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 STDs. 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

There are many advocates of the legalization of prostitution in jurisdictions where it is illegal. Proponents state that there are several benefits:

• legalization allows prostitutes to escape the influence of pimps and organized crime
• legalization allows more effective public health measures against sexually transmitted diseases

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, substitute 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)

Safer injection sites

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.

The first and only 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.

There are some 47 safer injection sites in cities in Europe. Generally in Europe they are referred to as "safer consumption rooms".

Some facts about safer injection sites can be found at Drug War Facts.

Since opening in 2001, Sydney’s Medically Supervised Injecting Centre has treated thousands of potentially fatal Drug overdoses without a single fatality. [2]

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.

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. See the Reporton the Evaluation of the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts.

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 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.

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.

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 [3]

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 it's [sic] root of this philosophy lay [sic] an acceptance of drug use into the mainstream of society. ... The idea that we can safely use drugs is a dangerous one.

— Drug Prevention Network of Canada[4]

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‘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 [5]

See also

• Brief intervention
• Illicit drug use in Australia