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Harm reduction, or harm minimisation, refers to a range of pragmatic and evidence-based public health policies designed to reduce the harmful consequences associated with drug use and other high risk activities .

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.

Drugs

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. Studies have proven the treatment to greatly improve the social and health situation of patients, while reducing costs incurred by delinquency, trials, incarceration and health interventions.

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. In a 2008 national referendum a majority of 68% voted in favor of continuing the program. See the Report on the Evaluation of the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts.

The Netherlandsmarker 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 major study on heroin maintenance was carried out in Germanymarker from 2002 until 2005 with over 1000 long-term heroin addicts receiving either oral methadone or i.v. diamorphine at treatment-centers in seven participating cities. The study proved diamorphine to be 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 been 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 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 first, and only, North American heroin maintenance project is being run in Vancouvermarker, B.C.marker and Montrealmarker, Quebecmarker. Currently some 80+ long-term heroin addicts who have not been helped by available treatment options are taking part in the NAOMI trials.

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 Havenmarker and 70% in New York Citymarker, though in some Canadian cities they have had little impact.

Safer injection sites

A clandestine kit containing materials to inject illicit drugs (or legitimate ones illegitimately).
Note that it is quite common for an injector to use a single needle repeatedly or share with other users.
It is also quite uncommon for a sterilizing agent to be used.
Compare this legitimate injection kit obtained from a needle-exchange program to the user-compiled one above.


"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, Insitemarker, opened in Vancouvermarker, BCmarker Canadamarker, in September 2003. The conservative federal government is currently (2008) attempting to force the closure of this facility.

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

Since opening in 2001, Sydneymarker’s Medically Supervised Injecting Centre has treated thousands of potentially fatal Drug overdoses without a single fatality. [20572]

Cannabis

Some harm reductionists favor outright legalization of cannabis, allowing its sale e.g. through Dutchmarker-style "coffee shop". 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 Belgiummarker, Germanymarker, United Kingdommarker, Portugalmarker, and Spainmarker, where some measures have been taken towards lifting the ban on cannabis. The recent development in the Netherlandsmarker 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

Alcohol

Traditionally, homeless shelters ban alcohol. In 1997, as the result of an inquest into the deaths of two homeless alcoholics two years earlier, Torontomarker'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 Ottawamarker'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.

DanceSafe and related programs

DanceSafe is a not-for-profit organization in the United Statesmarker, 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 Sydneymarker in 1993 by the NSW USers & AIDS Association as a part of the TRIBES project. In Melbournemarker 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 Walesmarker 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.

Sex

Safer sex programs

Many schools now provide safer sex education to teen and pre-teen students, some of whom engage in sexual activity. Given the premise that some 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 STI. This runs contrary to the ideology of abstinence-only sex education, which holds that telling kids about sex can encourage them to engage in it.

Supporters of this approach cite statistics which they claim demonstrate that this approach is significantly more effective at preventing teenage pregnancy and STDs than abstinence-only programs; opponents disagree with these claims—see the sex education article for more details on this controversy.

Legalized prostitution

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

Sex work and HIV

Despite the depth of knowledge of HIV/AIDS, rapid transmission has occurred globally in sex workers. The relationship between these two specific lifestyles greatly increases the risk of transmission among these populations, and also to anyone associated with them, such as non-IDU sexual partners, children of IDUs, and eventually the population at large.

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in IDUs and sex-workers. HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease. Peer education as a harm reduction strategy has especially reduced the risk of HIV infection, such as in Chad, where this method was the most cost-effective per infection prevented.

Decriminalization

The threat of criminal repercussions drives sex-workers and IDUs to the margins of society, often resulting in high-risk behavior, increasing the rate of overdose, infectious disease transmission, and violence. Decriminalization as a harm-reduction strategy gives the ability to treat drug abuse solely as a public health issue rather than a criminal activity. This enables other harm-reduction strategies to be employed, which results in a lower incidence of HIV infection.

Self-harm

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

Other forms of harm reduction initiative

Other harm reduction programs to be expanded on:
  • Encouragement of the use of safer smoking alternatives such as vaporizers, as opposed to water pipes, cigarettes and straight pipes
  • Encouragement of the use of smokeless systems of nicotine delivery, known as Tobacco harm reduction, as opposed to the much riskier method of burning and inhaling tobacco.
  • Promote the use of safer modes of use such as safer crack pipes (as opposed to use of a pipe which may burn or cut the users mouth, increasing risk of transmittable diseases) Use of screens which are safer than the use of a brillo pad which may embed metal particles into the lungs.
  • Promote various safer use strategies such as having a chronic alcoholic have a chaser of water between drinks.
  • Advocate the use of a Substitute Decision Maker or Power of Attorney so a person's rent is paid before the drug of choice, ensuring the person always has housing.
  • Provide vitamins to ensure a person's physical needs are somewhat met
  • Lessen the use of mouthwash, gravol, etc as a substance to use, 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)


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.

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 .

See also



References

  1. http://www.parl.gc.ca/37/1/parlbus/commbus/senate/Com-e/ille-e/presentation-e/ucht-e.htm
  2. http://www.ncbi.nlm.nih.gov/pubmed/17602126
  3. http://www.swissinfo.ch/eng/front/Swiss_to_agree_heroin_scheme_but_say_no_to_dope.html?siteSect=105&sid=10032560
  4. http://www.ncbi.nlm.nih.gov/pubmed/17602126
  5. http://www.ihra.net/Assets/1828/1/Presentation_20th_C12_Michels.pdf
  6. http://relaunch.bundestag.de/bundestag/ausschuesse/a14/anhoerungen/113/stllg/ZIS.pdf
  7. http://stopthedrugwar.org/chronicle/588/germany_approves_heroin_maintenance
  8. http://www2.canada.com/victoriatimescolonist/news/story.html?id=d9a53de5-f4e7-437c-9dfd-5d3bdb990532
  9. McKeen, Scott, "'Wet' shelter needs political will: Toronto project could serve as model for Edmonton", Edmonton Journal, March 7, 2007
  10. 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
  11. Condoms 'not the answer to AIDS': Pope
  12. The papal position on condoms and HIV. Douglas Kamerow, BMJ 2009 338: b1217
  13. Roehr, B. (2009). Pope claims that condoms exacerbate HIV and AIDS problem. Published 25 March 2009, doi:10.1136/bmj.b1206


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