Harm reduction
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Harm reduction, or harm minimisation, refers to a range of pragmatic and compassionate public health policies designed to reduce the harmful consequences associated with drug use and other high risk activities [1].
Many advocates argue that prohibitionist laws cause harm, because, for example, they oblige prostitutes to work in dangerous conditions and oblige drug users to obtain their drugs from unreliable criminal sources.
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[edit] Principles of harm reduction
[edit] Drugs
[edit] 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. 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
[edit] 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.[2] 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.[3]
[edit] 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. Another study on heroin maintenance was carried out in Germany from 2002 until 2005. Since then, treatment has been continued in the 5 cities that participated in the pilot study, but heroin maintenance has not yet been included into the national health system due to resistance from the conservative christian democrats.
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.
[edit] Syringe exchange and related programs
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.[4]
[edit] Safer injection sites
"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[5] 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".
Since opening in 2001, Sydney’s Medically Supervised Injecting Centre has treated thousands of potentially fatal Drug overdoses without a single fatality. [1]
[edit] 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 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. [2]
[edit] 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.
[edit] Sex
[edit] 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.
[edit] Legalized prostitution
There are many advocates of the legalization of prostitution in jurisdictions where it is illegal.[citation needed] 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
- legalization removes a victimless crime[citation needed]
[edit] Sex work and HIV
Despite the depth of knowledge of HIV/AIDS, rapid transmission has occurred globally in sex workers.[4] 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.[4]
Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in IDUs and sex-workers.[6] HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease.[6] 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.[6]
[edit] 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.[7] 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.[6]
[edit] 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.
[edit] 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)
[edit] 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. 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 [5]
[edit] References
- ^ Alan Marlatt, G. (2002). "One". in G. Alan Marlatt. Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. Guilford Press. pp. 3. http://books.google.com.au/books?id=n-XmJZ5cvnwC.
- ^ McKeen, Scott, "'Wet' shelter needs political will: Toronto project could serve as model for Edmonton", Edmonton Journal, March 7, 2007
- ^ Patrick, Kelly, "The drinks are on us at the homeless shelter: Served every 90 minutes: Managed alcohol program reduces drinking", National Post, January 7, 2006
- ^ a b c Hilton BA, Thompson R, Moore-Dempsey L, Janzen RG (February 2001). "Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature". J Adv Nurs 33 (3): 357–70. PMID 11251723. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0309-2402&date=2001&volume=33&issue=3&spage=357.
- ^ http://www2.canada.com/victoriatimescolonist/news/story.html?id=d9a53de5-f4e7-437c-9dfd-5d3bdb990532
- ^ a b c d Rekart ML (December 2005). "Sex-work harm reduction". Lancet 366 (9503): 2123–34. doi:. PMID 16360791. http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67732-X.
- ^ Hathaway AD, Tousaw KI (February 2008). "Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver". Int. J. Drug Policy 19 (1): 11–6. doi:. PMID 18164610.
