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PubMed1996

Harm reduction: a realistic approach toward injection drug users.

The injection use of illicit drugs is a major mode of HIV transmission in the heterosexual population. Indeed, because HIV is transmitted from injection drug users to their sexual partners and their children, there is widespread acknowledgement that controlling HIV infection in the general community may depend on controlling it in injection drug users. Unfortunately, a moralistic attitude toward illicit drugs and their users all too often deters health professionals from taking preventive action. This impractical attitude holds that stopping illicit drug use is the only answer. In today's age of AIDS, it's a dangerously simplistic stance.

HIV Infections↗
PubMed2006

Risk and benefit perceptions of party drug use.

A cross-sectional survey of 372 regular ecstasy users was conducted to examine the benefits and risks perceived to be associated with the use of party drugs. A wide range of benefits and risks were reported across six drug types with some considered drug-specific. Commonly perceived risks included physical and psychological harms that were consistent with current harm reduction messages. Harm reduction campaigns may need to acknowledge benefits of drug use to ensure health promotion messages are considered credible and acceptable to users.

Adolescent↗
PubMed2005

Enabling environments and the reduction of drug-related harm: re-framing Australian policy and practice.

In this paper Moore & Dietze use data from their study of street-based injecting drug users and sex workers in the Melbourne suburb of St Kilda to challenge the dominant emphasis of drug policy in Australia. They remind us that while existing harm reduction strategies that encourage individual behaviour change should be continued, these measures need to be complemented and extended by further attention to the environmental aspects of drug-related harm. This is a timely call. Responses targeting individual behaviour change are relatively easy to implement and less politically challenging. However, if we are really serious about reducing drug-related harm in the Australian community, then broader systemic and structural barriers which undermine these efforts must be addressed.Simon LentonEditor, Harm Reduction Digest.

Adult↗
PubMed2003

On "Gradualism" and the building of the harm reduction-abstinence continuum.

This paper makes the case that a perspective called "Gradualism" could serve as a foundation for building a therapeutic continuum between the harm reduction and abstinence-oriented treatment worlds. In contrast to other integrationist writers (Denning, 2001; Marlatt, Blume, & Parks, 2001), this paper argues for the incorporation of abstinence into harm reduction approaches. The goal is to build on the strengths of both perspectives while reducing their weaknesses, and examples of each are provided. Lastly, with the frequent occurrence of relapse among addicted patients, building a continuum could also serve to provide a therapeutic "safety net" for those in need.

Harm Reduction↗
PubMed2006

Public injecting and the need for 'safer environment interventions' in the reduction of drug-related harm.

BACKGROUND: One key structural dimension in the distribution of drug-related harm associated with injecting drug use is the injecting environment. Epidemiological evidence associates elevated blood-borne viral risk with injecting in 'public' and 'semipublic' environments. Yet the quality of evidence on public injecting and related viral risk is variable, and is lacking in many countries such as the United Kingdom. AIM: This commentary considers the micro-injecting environment as a critical dimension of risk, exploring the need for 'safer injecting environment interventions'. METHODS: We draw upon published research evidence and qualitative case examples. RESULTS: We note the limits in epidemiological evidence on public injecting and emphasize the need for ethnographic research to determine the 'social relations' of how drug users and risk practices interact with injecting environments. We identify three main forms of 'safer environment intervention': purpose-built drug consumption rooms; interventions within existing spatial relations; and spatial programming and urban design. While drug consumption rooms find evidence-based support, they are not a panacea. We emphasize the potential of interventions embedded within existing spatial and social relations. These include low-cost pragmatic interventions enhancing facilities and safety at public and semipublic injecting sites and, primarily, peer-based interventions, including peer-supervised injecting sites. We caution against spatial programming and urban design interventions which can cause the displacement of socially marginalized populations and the redistribution of harm. CONCLUSIONS: Public health interventions in the addictions field have in the past focused upon individual behavioural change at the cost of social interventions and environmental change. We wish to focus greater attention on reducing risks related to public injecting and encourage greater debate on 'safer environment interventions' in harm reduction.

Environment↗
PubMedDate not supplied

Substance use management: a harm reduction-principled approach to assisting the relief of drug-related problems.

Disease (particularly HIV) has increased our motivation to reconsider how the current help system deals with drug-related problems. A more concrete focus on disease prevention as an additional goal has, for many, lead to a reevaluation of the goals of drug help work. Such a critical examination shows how much there is to improve within the system even in the absence of blood borne disease. Integrating the heart of harm reduction--respecting work on any positive change as a person defines it for his/herself--into treatment fashions a health sensitive alternative to the predominant practice of abstinence-only assistance for the relief of drug problems. This new approach is called substance use management (SUM), as it no longer requires abstinence but instead focuses on a range of options for improvements while still including abstinence among the possible self-selected outcomes. SUM is suggested as a framework for change within the treatment system that would maximize treatment's constructive impact, cost-effectiveness and maturation as a distinct discipline that can appropriately attract support and gain stature for making society healthier. This article describes a formalized system for applying some of the main principles of harm reduction within the treatment system. Viable options for a SUM treatment focus are suggested herein as well as a critical process, based on respect and collaboration, for use with these options.

Disease Management↗
PubMed1997

Cannabis policy in Australia and New Zealand.

This paper describes and compares current developments in policies to deal with cannabis in Australia and New Zealand. Both countries are bound by international conventions to control cannabis and in each case cannabis use, possession, cultivation and supply is illegal. In both countries almost all the supply is grown locally and patterns of use and health concerns appear to be similar. Strategies used to deal with cannabis include: demand reduction through enforcement of legislation, drug education and treatment; supply reduction through enforcement of legislation and crop recovery operations; and harm reduction through diversion of some offenders from the courts system, lenient enforcement policies for users and, in Australia, the formal decriminalization of cannabis use in two states/territories and de facto decriminalization in another. Australia has had a co-ordinated national drugs policy with a stated harm reduction focus for over a decade, while in New Zealand efforts to co-ordinate policy have been delayed by ongoing debates about cannabis's harm potential and what constitutes an appropriate approach. However, a national drugs policy with a professed harm reduction focus is currently being finalized. Despite these developments, government cut-backs and international and local prohibitionist influences on policy in both countries suggest that a harm reduction model may not necessarily be secure.

Journal Article↗
PubMed2003

Regulatory strategies to reduce tobacco addiction in youth.

Preventing tobacco addiction and achieving cessation in established users are the cornerstones of efforts to reduce tobacco use and disease. It has been increasingly recognised that reducing tobacco toxin exposure has theoretical potential to reduce disease in continuing tobacco users. This has been controversial because such approaches also carry the potential to undermine prevention and cessation. As complicated as harm reduction issues are for adults, they are still more complicated for youth. Harm reduction is not a singular approach, but rather a concept that encompasses an extremely diverse array of potential approaches. These carry equally diverse potential risks and benefits. The regulatory framework (for example, whether or not the Food and Drug Administration regulates the approach) is also predicted to be a major factor in determining the consequences of harm reduction approaches. This paper examines the various issues and potential approaches concerning the application of harm reduction to youth. We conclude that although some carry great risk, others may actually support broader tobacco control efforts to prevent tobacco use and foster cessation in youth and adults.

Adolescent↗
PubMed2004

A comparison of urinary biomarkers of tobacco and carcinogen exposure in smokers.

Recently, several potential harm reduction strategies, such as reduction in the number of cigarettes smoked and the use of modified cigarette products, have been discussed as possible means by which to reduce tobacco-related disease. To assess any potential reduction in harm by either of these approaches requires an accurate assessment of tobacco toxin exposure. We have recently completed a cigarette reduction study in which smokers were required to reduce the number of cigarettes smoked by 75%. This reduction took place over a 6-week period. We report here the comparison of urinary concentrations of tobacco alkaloid and tobacco carcinogen biomarkers in a subset of these same smokers during a 7-week period prior to any reduction in cigarette consumption. Urine samples were collected at four time points and analyzed for 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and its glucuronide, 1-hydroxypyrene, anatabine, free nicotine, total nicotine (free plus glucuronidated), free cotinine, total cotinine (free plus glucuronidated), and total trans-3'-hydroxycotinine (free plus glucuronidated). Anatabine is a minor alkaloid that may be useful in assessing tobacco exposure in individuals using nicotine replacement therapies. Urinary anatabine levels were well correlated (P < 0.0001) with both free and total nicotine (r = 0.753 and 0.773, respectively). Anatabine levels were also correlated with free cotinine (r = 0.465; P < 0.001), total cotinine (r = 0.514; P < 0.001), and total NNAL (r = 0.633; P < 0.001). These data support the role of anatabine as a biomarker of tobacco exposure. 1-Hydroxypyrene is a biomarker of polycyclic aromatic hydrocarbon exposure, but unlike NNAL it is not tobacco specific. Whereas urinary concentrations of 1-hydroxypyrene were consistent across the four visits, the levels were not correlated with NNAL, anatabine, nicotine, or any nicotine metabolites.

Adult↗
PubMed2001

Sexual transmission of HIV-1 among injection drug users in San Francisco, USA: risk-factor analysis.

BACKGROUND: Many new HIV-1 infections in the USA occur in injection drug users (IDUs). HIV-1seroconversion of IDUs is mainly associated with injection-related risk factors. Harm- reduction programmes concentrate on injection-risk behaviour. We aimed to establish whether injection or sexual risk factors, or both, were associated with HIV-1antibody seroconversion of street-recruited IDUs in San Francisco, from 1986 to 1998. METHODS: IDUs were enrolled every 6 months from four community sites. We did a nested case-control study comparing 58 respondents who seroconverted between visits with 1134 controls who remained seronegative. Controls were matched with cases by sex and date. Adjusted odds ratios and 95% CI were calculated for men and women by use of conditional logistic regression. FINDINGS: Men who had sex with men were 8.8 times as likely to seroconvert (95% CI 3.7-20.5) as heterosexual men. Women who reported having traded sex for money in the past year were 5.1 times as likely as others to seroconvert (95% CI 1.9-13.7). Women younger than 40 years were more likely to seroconvert than those 40 years or older (2.8 [1.05-7.6]), and women who reported having a steady sex-partner who injected drugs were less likely to seroconvert than other women (0.32 [0.11-0.92]). INTERPRETATION: HIV-1 seroconversion of street-recruited IDUs in San Francisco is strongly associated with sexual behaviour. HIV-1risk might be reduced by incorporation of innovative sexual-risk-reduction strategies into harm-reduction programmes.

Adult↗
PubMed2006

Times and places: Process evaluation of a peer-led HIV prevention intervention.

Here we present results from a process evaluation of a peer-led HIV prevention intervention. The Risk Avoidance Partnership, conducted from 2001 to 2005, trained active drug users to be peer health advocates (PHAs) to provide harm reduction materials and information to their peers. Results indicate that PHAs actively conducted harm reduction outreach both when partnered with staff and on their own time. Although PHAs conducted most of their outreach in public locations, they also provided drug users with harm reduction materials at critical moments in places where HIV risky behaviors were likely to occur. PHAs were credible and trusted sources of information to their drug-using peers who sought PHAs out for HIV prevention materials. Process evaluations of successful HIV prevention interventions are necessary to understand how and why such interventions work for further intervention refinement.

Adult↗
PubMed2001

Ecstasy pill testing: harm minimization gone too far?

Harm reduction has become the focus of public health initiatives and therapeutic intervention in the management of dependent drug use over the last 20 years. The last decade has seen such approaches being extended to recreational drug use. Most harm reduction initiatives have aimed to inform users about risks and ways of minimizing risk. The concept of providing illicit drug users with quality assessment of their chosen drug is one possible harm reduction intervention that until recently has received little attention. In response to well-publicized 'ecstasy'-related deaths organizations in some European countries and the United States have chosen to provide a 'pill testing service' for users. There are two broad categories of pill testing offered. Simple colour reagent test kits (Marquis Reagent and colour charts) form the most widely used on-site pill testing method. Less frequently, but more accurately, laboratory personnel with access to sophisticated chromatographic equipment (high performance liquid chromatography (HPLC) or gas chromatography-mass spectrometry (GC-MS)) may provide analysis of a pill. Pill testing kits have been advocated as a 'tool to protect yourself against the polluted XTC market'. We refute this line of reasoning. Of the different tests only techniques such as GC-MS can identify satisfactorily the psychoactive constituents present in ecstasy pills. Colour tests based on an interpretation of a colour response in the presence of a drug are, at best, subjective. Pill testing of any description does not guarantee safety, or protect the consumer against individual responses to pills. At best it gives an artificial 'shine of safety' to a group of diverse drugs that remain both illicit and potentially harmful. Other simpler harm reduction mechanisms are likely to be more effective.

Chromatography, Gas↗