Harm reduction

Harm reduction (or harm minimisation) refers to a range of public health policies designed to reduce the harmful consequences associated with recreational drug use and other high risk activities. Harm reduction is put forward as 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. Its critics are concerned that tolerating risky or illegal behaviour sends a message to the community that these behaviours are acceptable.

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. 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. In a 2008 national referendum a majority of 68% voted in favor of continuing the program.

The Netherlands has studied medically supervised heroin maintenance. A German study of long-term heroin addicts demonstrated that diamorphine was 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 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 a 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.

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 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. A substantial part of the money for buying heroin is obtained through criminal activities, such as robbery or drug dealing. Proponents say 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.

Critics 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 the lowest illicit drug use levels in the developed world, a model in which rehabilitated users present no further maintenance costs to their community, as well as reduced ongoing health care costs.

Needle and 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.

The principles of harm reduction propose that syringes should be easily available (i.e. without a prescription) or at least available through a Needle and Syringe Exchange (NSE) program. Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries users are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name. It has been shown in the many evaluations of needle-exchange programs that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programs have reduced HIV incidence by 33% in New Haven and 70% in New York City.

A 2010 review of reviews led by Norah Palmateer, which examined systematic reviews and meta-analyses on the topic, concluded that there is insufficient evidence that NSP prevents transmission of the Hepatitis C virus, tentative evidence that NSP prevents transmission of HIV and sufficient evidence that NSP reduces self-reported injecting risk behaviour. However, the Palmateer review’s tentative support for HIV effectiveness relies on a number of studies which critics have challenged as either invalid or inconclusive. Kall et al has contended that the 1993 Heimer study studied returned needles which cannot be translated directly into a population, the 2000 Monterosso study is self-proclaimed as statisitically insignificant and therefore inconclusive, and that the 1991 Ljungberg study’s own author noted that there was no significant difference in HIV incidence between the city with needle exchange and Stockholm with no needle exchange by the time the study was being recorded.

Safe injection sites


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 the Bundestag provided a legal exemption in 2000.

In Europe, Luxembourg, Spain and Norway have opened facilities after year 2000. As did the two existing facilities outside Europe, with Sydney's Medically Supervised Injecting Center (MSIC) established in May 2001 as a trial and Vancouver's Insite, opened in September 2003. In 2010, after a nine-year trial, the Sydney site was confirmed as a permanent public health facility. As of late 2009 there were a total of 92 professionally supervised injection facilities in 61 cities.

A European Monitoring Centre for Drugs and Drug Addiction's latest systematic review from April 2010 did not find any evidence to support concerns that DCR might "encourage drug use, delay treatment entry or aggravate problems of local drug markets." Jürgen Rehm and Benedikt Fischer explained that while evidence show that DCR are successful, that "interpretation is limited by the weak designs applied in many evaluations, often represented by the lack of adequate control groups." Concluding that this "leaves the door open for alternative interpretations of data produced and subsequent ideological debate."

The EMCDDA 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 facilitates "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 behaviour 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." Concluding with that "there is suggestive evidence from modelling studies that they may contribute to reducing drug-related deaths at a city level where coverage is adequate, the review-level evidence of this effect is still insufficient."

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, but this is likely due to more than 60 extra police assigned to the area.

Cannabis
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 European Monitoring Centre for Drugs and Drug Addiction (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.

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.

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 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.

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 over the first year of operation. During the first six-months, even after considering the cost of administering the housing, 95 residents in a Housing First program in downtown Seattle, the study reported an average cost-savings of 53 percent—nearly US $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among homeless alcoholics.

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

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

The idea of harm reduction was relatively new to the general public at this time in North America, although it had been widely practiced in Europe for some time and with great success. It was a concept that ravers were into as it was new and different, and it challenged social constructs and empowered individuals to make their own decisions around their lives and how to live them—with awareness. TRIP! blossomed into a huge community success and the following years, the North American rave scene would see several other rave-based harm reduction projects sprout up in communities across the continent.

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

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

Drunk driving and alcohol-related programs
A high amount of media coverage exists informing users of the dangers of driving drunk. Most alcohol users are now aware of these dangers and safe ride techniques like 'designated drivers' and free taxicab programs are reducing the number of drunk-driving accidents. Many cities have free-ride-home programs during holidays involving high alcohol abuse, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In New South Wales groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programs including the aforementioned 'designated driver' and 'late night patron transport' schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.

Moderation Management is a program which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behavior.

The HAMS Harm Reduction Network is a program which encourages any positive change with regard to the use of alcohol or other mood altering substances. HAMS encourages goals of safer drinking, reduced drinking, moderate drinking, or abstinence. The choice of the goal is up to the individual.

Tobacco
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.

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
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 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.

Decriminalization
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.

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

Psychiatric Medications
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.

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

Criticism
Critics, such as Drug Free America Foundation and other members of network International Task Force on Strategic Drug Policy, state that a risk posed by Harm Reduction is by creating the perception that certain behaviors can be partaken safely, such as illicit drug use, that it may lead to an increase in that behavior by people who would otherwise be deterred. There is no empirical evidence or peer-reviewed literature to support these arguments, and much to refute them. Little anecdotal evidence supports them beyond the arguments and claims put forth by anti-harm reduction groups themselves.

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:

Critics furthermore reject harm reduction measures for allegedly trying to establish certain forms of drug use as acceptable in society:

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.