Harm Reduction

Needle exchange

Harm reduction 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 behavior sends a message to the community that these behaviors 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 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.

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. The treatment greatly improves the social and health situation of patients, while reducing costs incurred by delinquency, criminal trials, incarceration and health interventions. In Switzerland, heroin assisted treatment is fully a part of the national health program. There are several dozen centers throughout the country at which heroin-dependent people can receive heroin in a controlled environment. The Swiss heroin maintenance program is generally regarded as a successful and valuable component of the country’s overall approach to minimizing the harms caused by drug use. A German study of long-term heroin addicts demonstrated that diamorphine was significantly more effective than methadone (a synthetic opioid) 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 2009.

The British have had a system of heroin maintenance since the 1920s. Drug addiction was seen as an individual health problem in Britain; drug addiction to opiates was rare in the 1920s and mostly limited to middle-class people who had easy access to opiates 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, through legal prescribing of excessive quantities of addictive drugs, to the alarming increase of drug addicts in the UK This gave the method a bad reputation and the UK switched to a more restrictive drug law. However, in recent years the British are moving again toward heroin 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.

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 programs 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 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, making it cost-effective even without perfect outcomes.

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 programs (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, (needle exchanges).

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 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 (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 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. 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 provided with a legal exemption in 2000.

A EMCDDA (European Monitoring Center for Drugs and Drug Addiction) 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 their establishment ‘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 behavior 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.’

Critics of this intervention, such as drug prevention advocacy organizations, 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.

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 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 decriminalization  such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, would alleviate these harms. Where decriminalization 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. However, 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 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. The program moves a homeless individual or household immediately from the streets or homeless shelters into their own apartments.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’ in 2009. This first US controlled assessment of the effectiveness of Housing First specifically targeting chronically homeless alcoholics and showed that the program saved tax-payers more than $4 million over the first year of operation. 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 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.

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 smokeless tobacco products; and 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.

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 educating children about sex can encourage them to engage in it. Safer sex programs have been found to decrease risky sexual behavior and prevent sexually transmitted diseases. They also reduce rates of unwanted pregnancies. Abstinence only programs, however, do not appear to affect HIV risks in developed countries.

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 organizations 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.

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 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.

Some harm reduction programs work with people who are at risk of self-harm (e.g. cutting, burning, 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. 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 of harm reduction programs, such as Drug Free America Foundation and other members of network International Task Force on Strategic Drug Policy (ITFSDP), state that a risk posed by harm reduction is creating the perception that certain behaviors can be partaken of safely, such as illicit drug use, that it may lead to an increase in that behavior by people who would otherwise be deterred. ITFSDP released a statement declaring: ‘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.’

Critics furthermore reject harm reduction measures for allegedly trying to establish certain forms of drug use as acceptable in society. According to the Drug Prevention Network of Canada: ‘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.’

At the World Forum Against Drugs in Stockholm in 2008 a declaration was made, stating in part: ‘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’ programs are not substitutes for demand reduction programs 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.’ However, these critics generally do not provide any hard evidence in support of their positions, which are primarily based on speculation and ideology rather than sound science. And since there has never existed a ‘drug-free world,’ their views on drug issues can be described as utopian as opposed to pragmatic.

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 criticized for misrepresenting and oversimplifying the role of condoms in preventing infections.

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