Harm reduction
Encyclopedia
Harm reduction 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.
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. Drug addiction was in the so called British system seen as an individual health problem, 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 U.K. This gave the method a bad reputation and the U.K. 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. A Norwegian evaluation of internationally available research reports on maintenance treatment with heroin concluded, in 2011, that there are so many uncertainties and knowledge gaps about the effects of heroin treatment that they would not recommend the introduction of maintenance treatment with heroin in Norway.
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. 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 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.
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.
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 programmes (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, hence the name.
A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour. 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
.
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.
The 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.
, 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. 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 herbs 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.
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.
s 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.
s' 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.
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.
s 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.
These 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 effect HIV risks in developed countries with no evidence available for other areas.
(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". Ever since the 90's there has been a steady increase in the number of trafficking victims, 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.
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.
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.
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 of 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.
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
policies designed to reduce the harmful consequences associated with recreational drug use
Recreational drug use
Recreational drug use is the use of a drug, usually psychoactive, with the intention of creating or enhancing recreational experience. Such use is controversial, however, often being considered to be also drug abuse, and it is often illegal...
and other high risk activities. Harm reduction is put forward as a useful perspective alongside the more conventional approaches of demand
Demand reduction
Demand reduction refers to efforts aimed at reducing public desire for illegal and illicit drugs. This drug policy is in contrast to the reduction of drug supply, but the two policies are often implemented together...
and supply reduction
Supply reduction
Supply reduction is one approach to social problems such as drug addiction. Other approaches are demand reduction and harm reduction.In the case of illegal drugs, supply reduction efforts generally involves attempts to disrupt the manufacturing and distribution supply chains for these drugs, by...
.
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
Heroin assisted treatment
Heroin assisted treatment, or diamorphine assisted treatment, refers to the prescribing of synthetic, injectable heroin to opiate addicts that do not benefit from or cannot tolerate treatment with one of the established drugs used in opiate replacement therapy like methadone or buprenorphine...
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
Netherlands
The Netherlands is a constituent country of the Kingdom of the Netherlands, located mainly in North-West Europe and with several islands in the Caribbean. Mainland Netherlands borders the North Sea to the north and west, Belgium to the south, and Germany to the east, and shares maritime borders...
has studied medically supervised heroin maintenance. A German study
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
of long-term heroin addicts demonstrated that diamorphine was significantly more effective than methadone
Methadone
Methadone is a synthetic opioid, used medically as an analgesic and a maintenance anti-addictive for use in patients with opioid dependency. It was developed in Germany in 1937...
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. Drug addiction was in the so called British system seen as an individual health problem, 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 U.K. This gave the method a bad reputation and the U.K. 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. A Norwegian evaluation of internationally available research reports on maintenance treatment with heroin concluded, in 2011, that there are so many uncertainties and knowledge gaps about the effects of heroin treatment that they would not recommend the introduction of maintenance treatment with heroin in Norway.
The first, and only, North American heroin maintenance project is being run in Vancouver
Vancouver
Vancouver is a coastal seaport city on the mainland of British Columbia, Canada. It is the hub of Greater Vancouver, which, with over 2.3 million residents, is the third most populous metropolitan area in the country,...
, B.C.
British Columbia
British Columbia is the westernmost of Canada's provinces and is known for its natural beauty, as reflected in its Latin motto, Splendor sine occasu . Its name was chosen by Queen Victoria in 1858...
and Montreal
Montreal
Montreal is a city in Canada. It is the largest city in the province of Quebec, the second-largest city in Canada and the seventh largest in North America...
, Quebec
Quebec
Quebec or is a province in east-central Canada. It is the only Canadian province with a predominantly French-speaking population and the only one whose sole official language is French at the provincial level....
. 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. 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 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.
A substantial part of the money for buying heroin is obtained through criminal activities, such as robbery or drug dealing. King's Health Partners
King's Health Partners
-External links:* * * * *...
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.
Needle exchange program
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 HIVHIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...
or hepatitis C
Hepatitis C
Hepatitis C is an infectious disease primarily affecting the liver, caused by the hepatitis C virus . The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years...
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 programmes (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, hence the name.
A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour. 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
New York City
New York is the most populous city in the United States and the center of the New York Metropolitan Area, one of the most populous metropolitan areas in the world. New York exerts a significant impact upon global commerce, finance, media, art, fashion, research, technology, education, and...
.
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
Sydney
Sydney is the most populous city in Australia and the state capital of New South Wales. Sydney is located on Australia's south-east coast of the Tasman Sea. As of June 2010, the greater metropolitan area had an approximate population of 4.6 million people...
's Medically Supervised Injecting Center (MSIC) established in May 2001 as a trial and Vancouver
Vancouver
Vancouver is a coastal seaport city on the mainland of British Columbia, Canada. It is the hub of Greater Vancouver, which, with over 2.3 million residents, is the third most populous metropolitan area in the country,...
's Insite
Insite
Insite is the only legal supervised injection site in North America, located at 139 East Hastings Street, in the Downtown Eastside neighbourhood of Vancouver, British Columbia. The DTES had 4700 chronic drug users in 2000 and has been considered to be the centre of an "injection drug epidemic"...
, 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.
The European Monitoring Centre for Drugs and Drug Addiction
European Monitoring Centre for Drugs and Drug Addiction
The European Monitoring Centre for Drugs and Drug Addiction is an agency of the European Union. Established in 1993, the EMCDDA is located in Lisbon, Portugal.-Mission and role:...
's latest systematic review
Systematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
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
Drug detoxification
Drug detoxification is a collective of interventions directed at controlling acute drug intoxication and drug withdrawal. It refers to a purging from the body of the substances to which a patient is addicted and acutely under the influence...
and treatment services
Drug rehabilitation
Drug rehabilitation is a term for the processes of medical or psychotherapeutic treatment, for dependency on psychoactive substances such as alcohol, prescription drugs, and so-called street drugs such as cocaine, heroin or amphetamines...
." 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
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...
or hepatitis C
Hepatitis C
Hepatitis C is an infectious disease primarily affecting the liver, caused by the hepatitis C virus . The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years...
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.
Cannabis
Specific harms associated with cannabis include increased accident-rate while driving under intoxication, dependenceCannabis dependence
Cannabis dependence is a condition defined in DSM-IV applying the general concept of substance dependence to cannabis.Despite cannabis being one of the most widely used illicit drugs in the world, controlled trials for cannabis use disorder have only been reported in literature in the last 15 years...
, psychosis, detrimental psychosocial outcomes for adolescent users and respiratory disease
Cannabis-associated respiratory disease
Cannabis-associated respiratory disease can refer to neoplastic processes or to structural damage to the lung.It is often compared to the damage done by tobacco, but it is the subject of much less study...
. Strategies recommended by the European Monitoring Centre for Drugs and Drug Addiction
European Monitoring Centre for Drugs and Drug Addiction
The European Monitoring Centre for Drugs and Drug Addiction is an agency of the European Union. Established in 1993, the EMCDDA is located in Lisbon, Portugal.-Mission and role:...
(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. 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 herbs 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
Decriminalization
Decriminalization or Decriminalisation is the abolition of criminal penalties in relation to certain acts, perhaps retroactively, though perhaps regulated permits or fines might still apply . The reverse process is criminalization.Decriminalization reflects changing social and moral views...
, 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
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
and United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, as well as in Portugal
Portugal
Portugal , officially the Portuguese Republic is a country situated in southwestern Europe on the Iberian Peninsula. Portugal is the westernmost country of Europe, and is bordered by the Atlantic Ocean to the West and South and by Spain to the North and East. The Atlantic archipelagos of the...
and the Netherlands
Netherlands
The Netherlands is a constituent country of the Kingdom of the Netherlands, located mainly in North-West Europe and with several islands in the Caribbean. Mainland Netherlands borders the North Sea to the north and west, Belgium to the south, and Germany to the east, and shares maritime borders...
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.
In the last few years certain strains of cannabis
Cannabis
Cannabis is a genus of flowering plants that includes three putative species, Cannabis sativa, Cannabis indica, and Cannabis ruderalis. These three taxa are indigenous to Central Asia, and South Asia. Cannabis has long been used for fibre , for seed and seed oils, for medicinal purposes, and as a...
with higher concentrations of THC
THC
THC commonly refers to tetrahydrocannabinol, the main active chemical compound in Cannabis.THC may also refer to:* Tan Holdings Corporation...
and drug tourism
Drug tourism
Drug tourism is travel for the purpose of obtaining or using drugs for personal use that are unavailable or illegal in one's home jurisdiction. Drug tourism can be also defined as the phenomenon by which one's travel experience involves the consumption and usage of drugs that are considered to be...
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
Cannabis coffee shop
Coffeeshops are establishments in the Netherlands where the sale of cannabis for personal consumption by the public is tolerated by the local authorities ....
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.
Alcohol
Traditionally, homeless shelterHomeless shelter
Homeless shelters are temporary residences for homeless people which seek to protect vulnerable populations from the often devastating effects of homelessness while simultaneously reducing the environmental impact on the community...
s ban alcohol. In 1997, as the result of an inquest
Inquest
Inquests in England and Wales are held into sudden and unexplained deaths and also into the circumstances of discovery of a certain class of valuable artefacts known as "treasure trove"...
into the deaths of two homeless alcoholics two years earlier, Toronto
Toronto
Toronto is the provincial capital of Ontario and the largest city in Canada. It is located in Southern Ontario on the northwestern shore of Lake Ontario. A relatively modern city, Toronto's history dates back to the late-18th century, when its land was first purchased by the British monarchy from...
's Seaton House
Seaton House
Seaton House is the largest homeless shelter in Toronto, Ontario, Canada. It is located at 339 George Street near Dundas Street East, several blocks from Yonge Street. The facility provides temporary lodging, food, clothing, medical care, for single men and also attempts to provide tools for...
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
Ottawa
Ottawa is the capital of Canada, the second largest city in the Province of Ontario, and the fourth largest city in the country. The city is located on the south bank of the Ottawa River in the eastern portion of Southern Ontario...
'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
Canadian Medical Association Journal
The Canadian Medical Association Journal is a general medical journal that is published biweekly by the Canadian Medical Association . It covers research and ideas aimed at improving health for people in Canada and globally. CMAJ publishes original clinical research, analyses and reviews, news,...
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
Housing first
Housing First, also known as "rapid re-housing", is a relatively recent innovation in human service programs and social policy regarding treatment of the homeless and is an alternative to a system of emergency shelter/transitional housing progressions...
, 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.
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 driverDesignated driver
The terms "designated driver" and "designated driving" refer to selecting a person to remain sober, as the driver of a vehicle, while others are allowed to drink to excess . A designated driver is a person who abstains from alcohol on a social occasion in order to drive his/her companions home safely...
s' 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
New South Wales
New South Wales is a state of :Australia, located in the east of the country. It is bordered by Queensland, Victoria and South Australia to the north, south and west respectively. To the east, the state is bordered by the Tasman Sea, which forms part of the Pacific Ocean. 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
Moderation Management
Moderation Management is a secular non-profit organization providing peer-run non-coercive support groups for anyone who would like to reduce their alcohol consumption...
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 damDental dam
A dental dam or rubber dam is a rectangular sheet of latex used in dentistry, in particular endodontic therapy, to reduce contamination, and where dental composite are being placed, due to the need for the area to remain dry during filling placement...
s to protect against unwanted pregnancy and the transmission of STIs. This runs contrary to the ideology of abstinence
Sexual abstinence
Sexual abstinence is the practice of refraining from some or all aspects of sexual activity for medical, psychological, legal, social, philosophical or religious reasons.Common reasons for practicing sexual abstinence include:*poor health - medical celibacy...
-only sex education, which holds that telling kids about sex can encourage them to engage in it.
These 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 effect HIV risks in developed countries with no evidence available for other areas.
Legalized prostitution
Since 1999 other countries have legalized prostitution, such as GermanyProstitution in Germany
Prostitution in Germany is legal, and so are brothels. In 2002, the government changed the law in an effort to improve the legal situation of prostitutes. However, the social stigmatization of prostitutes persists and many prostitutes continue to lead a double life...
(2002) and New Zealand
Prostitution in New Zealand
Prostitution , brothel keeping, living off the proceeds of someone else's prostitution and street solicitation are legal and regulated in 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
Human trafficking
Human trafficking is the illegal trade of human beings for the purposes of reproductive slavery, commercial sexual exploitation, forced labor, or a modern-day form of slavery...
. For example, Netherlands
Netherlands
The Netherlands is a constituent country of the Kingdom of the Netherlands, located mainly in North-West Europe and with several islands in the Caribbean. Mainland Netherlands borders the North Sea to the north and west, Belgium to the south, and Germany to the east, and shares maritime borders...
, a country which has legal and regulated prostitution, has severe problems with human trafficking
Human trafficking
Human trafficking is the illegal trade of human beings for the purposes of reproductive slavery, commercial sexual exploitation, forced labor, or a modern-day form of slavery...
(it is listed by UNODC
United Nations Office on Drugs and Crime
The United Nations Office on Drugs and Crime is a United Nations agency that was established in 1997 as the Office for Drug Control and Crime Prevention by combining the United Nations International Drug Control Program and the Crime Prevention and Criminal Justice Division in the United Nations...
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
Amsterdam
Amsterdam is the largest city and the capital of the Netherlands. The current position of Amsterdam as capital city of the Kingdom of the Netherlands is governed by the constitution of August 24, 1815 and its successors. Amsterdam has a population of 783,364 within city limits, an urban population...
, Job Cohen
Job Cohen
Marius Job Cohen is a Dutch social democratic politician and former legal scholar of Jewish background. Since 2010 he has been the leader of the Labour Party and since June 17, 2010 he has been a member of the House of Representatives, where he also is the Parliamentary group leader of the Labour...
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". Ever since the 90's there has been a steady increase in the number of trafficking victims, 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.
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 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.
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 harm
Harm reduction programs work with people who are at risk of self harm (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 CenterFreedom Center (mental health organization)
Founded by Oryx Cohen and Will Hall, the Freedom Center is a Northampton, Massachusetts-based support, activism, and human rights community run by and for people diagnosed with severe mental illness, such as schizophrenia, bipolar disorder, borderline personality disorder and obsessive-compulsive...
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.
Criticism
Critics, such as Drug Free America FoundationDrug Free America Foundation
The Drug Free America Foundation or DFAF is a 501 non-profit organization that currently describes itself as "committed to developing, promoting and sustaining global strategies, policies and laws that will reduce illegal drug use, drug addiction, drug-related injury and death." The organization...
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 of 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
The Lancet
The Lancet is a weekly peer-reviewed general medical journal. It is one of the world's best known, oldest, and most respected general medical journals...
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.
See also
- Brief interventionBrief interventionA Brief intervention is a technique similar to an intervention used to help reduce alcohol misuse. It works in two ways:*by getting people to think differently about their alcohol use so that they begin to think about or make changes in their alcohol consumption.*by providing those who choose to...
- Demand reductionDemand reductionDemand reduction refers to efforts aimed at reducing public desire for illegal and illicit drugs. This drug policy is in contrast to the reduction of drug supply, but the two policies are often implemented together...
- Recovery housingRecovery housingRecovery housing is social justice housing that provides low-income and emergency shelter to individuals in need of safe and temporary living environments....
- Supply reductionSupply reductionSupply reduction is one approach to social problems such as drug addiction. Other approaches are demand reduction and harm reduction.In the case of illegal drugs, supply reduction efforts generally involves attempts to disrupt the manufacturing and distribution supply chains for these drugs, by...
- Illicit drug use in AustraliaIllicit drug use in AustraliaIllicit drug use is a social issue in Australia that creates a 6.7 billion Australian Dollars per year illegal market.-History:Prior to Australian Federation, there was little policy response to the use to illicit substances. Opium was mostly unregulated, with most government interventions taking...