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PubMed2005

A room for reflection: self-observation and transformation in participatory HIV prevention work.

This article looks at HIV prevention projects in which established stigmatized and stigmatizing roles were actively reversed and manipulated in pursuit of HIV harm reduction. In two Norwegian projects, sex workers and drug users carried out harm-reduction activities with other drug users and sex workers. Although HIV-related harm reduction was the aim of the projects, termination or reduction of drug use or sex work was not. Such changes nevertheless occurred among the sex workers and drug users who took active part in the project. The article considers these changes in order to reflect on the meanings and roles of participation in HIV prevention work. In particular, the discussion theorizes on possible ways in which alteration of roles and subject positions may produce self-reflective effects with transformative potentials.

Data Collection↗

PubMed2005

Smoking reduction treatment with 4-mg nicotine gum: a double-blind, randomized, placebo-controlled study.

BACKGROUND: Smoking reduction may provide a harm-reduction alternative treatment for smokers who are not ready to quit smoking. This study evaluated the efficacy of nicotine gum in helping smokers reduce or quit smoking. METHODS: This randomized, double-blind, placebo-controlled trial involved 364 smokers who were not ready to quit but were willing to reduce their smoking intensity. Participants received either 4-mg nicotine gum (n = 184) or placebo gum (n = 180) as desired for up to 12 months. The primary outcome was sustained smoking reduction, which was defined as a decrease in daily cigarette consumption of at least 50% compared with baseline. Secondary measures included point-prevalence abstinence, intention to quit, and cardiovascular risk markers. RESULTS: At 4 months, the sustained smoking reduction rate in the nicotine gum group was twice that of the placebo group (15.8% versus 6.7%, P = .008). Point-prevalence abstinence was 6.6% for the nicotine gum group and 2.2% for the placebo group (P = .07). At 13 months, there was a significant difference in the smoking reduction rate for the nicotine (8.2%) and placebo (2.8%) groups (P = .036). At month 13, the abstinence rates were 12% and 4.5% for the nicotine and placebo groups, respectively (P = .012). Concomitant use of nicotine gum and cigarette smoking was well tolerated. Carbon monoxide levels decreased significantly (P = .01). CONCLUSION: Nicotine gum may be an efficacious harm-reduction alternative for smokers who are not ready to quit and may promote smoking cessation, the ultimate goal in the treatment of tobacco dependence.

Administration, Oral↗

PubMed2000

A continuing concern: HIV and hepatitis testing and prevalence among drug users in substitution programmes in Zurich, Switzerland.

Phase I of the Zurich Prometheus Study is a cross-sectional study focusing on an up-to-date serology for HIV and hepatitis B/C and associated risk factors for all clients in four participating clinics offering opiate substitution in Zurich, Switzerland. The mean age of the 603 respondents is 30.7 years (SD = 6.2) and 38% of them are women. Seventy-five per cent of the respondents have a history of injecting drug use (IDU), and over half have injected within the past six months. Laboratory-confirmed seroprevalence for HBV (50%) and HCV (57%) is twice that of HIV (24%). There is an 80% risk reduction for all three viral infections among those starting IDU after 1991--when harm reduction efforts were in full swing--compared to those who began before 1988--before clean needles were widely available. These findings suggest a strongly protective effect of harm reduction measures. But while a stabilization in HIV prevalence at 15% can be seen among drug users who started injecting after 1991, prevalence rates for HBV and HCV still remain several times higher. The prevalence data in this study support data showing continued high incidence rates for HBV and HCV, even among new injectors in the harm reduction era.

Adult↗

PubMed2003

A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users.

This study randomized 90 HIV-seropositive, methadone-maintained injection drug users (IDUs) to an HIV Harm Reduction Program (HHRP+) or to an active control that included harm reduction components recommended by the National AIDS Demonstration Research Project. The treatment phase lasted 6 months, with follow-ups at 6 and 9 months after treatment entry. Patients in both treatments showed reductions in risk behaviors. However, patients assigned to HHRP+ were less likely to use illicit opiates and were more likely to adhere to antiretroviral medications during treatment; at follow-up, they had lower addiction severity scores and were less likely to have engaged in high risk behavior. Findings suggest that enhancing methadone maintenance with an intervention targeting HIV-seropositive IDUs increases both harm reduction and health promotion behaviors.

Acquired Immunodeficiency Syndrome↗

PubMed2006

Smoking among low-income pregnant women: an ethnographic analysis.

This article presents findings from a qualitative study of 53 low-income women who were smokers at the onset of pregnancy. Study participants were interviewed during pregnancy to document smoking trajectories and factors contributing to, or undermining, harm reduction and quit attempts. Thirty percent of women quit smoking completely, 43% engaged in sustained harm reduction, and 26% reduced their smoking levels intermittently. Case studies of women are presented to illustrate reasons for quitting, harm reduction practices, and factors influencing relapse and smoking continuation. Women's motivations to quit are highlighted. Moral identity as a mother was found to be a key motivating factor behind women's quit attempts. Future programs targeting this population would do well to acknowledge moral identity as an issue and recognize the challenges of quitting for women with limited social support and little control over their immediate environment.

Adolescent↗

PubMed2003

European Union policy on smokeless tobacco: a statement in favour of evidence based regulation for public health.

RATIONALE: This statement is an updated version of one released by the same authors in February 2003. The statement was produced to follow up the Royal College of Physicians (RCP) Tobacco Advisory Group report "Protecting smokers, saving lives: the case for a tobacco and nicotine regulatory authority", which argued for an evidence based regulatory approach to smokeless tobacco and harm reduction and posed a series of questions that regulators must address in relation to smokeless tobacco. The purpose of this statement is to provide arguments of fact and principle to follow the RCP's report and to outline the public health case for changing existing European Union (EU) regulation in this area. A review of regulation in relation to harm reduction and regulation of tobacco products other than cigarettes is required in Article 11 of EU directive 2001/37/EC, and this is a contribution towards forming a consensus in the European public health community about what policy the EU should adopt in the light of this review, or following ongoing legal action that may potentially strike out the existing regulation altogether. PUBLIC HEALTH CASE: We believe that the partial ban applied to some forms of smokeless tobacco in the EU should be replaced by regulation of the toxicity of all smokeless tobacco. We hold this view for public health reasons: smokeless tobacco is substantially less harmful than smoking and evidence from Sweden suggests it is used as a substitute for smoking and for smoking cessation. To the extent there is a "gateway" it appears not to lead to smoking, but away from it and is an important reason why Sweden has the lowest rates of tobacco related disease in Europe. We think it is wrong to deny other Europeans this option for risk reduction and that the current ban violates rights of smokers to control their own risks. For smokers that are addicted to nicotine and cannot or will not stop, it is important that they can take advantage of much less hazardous forms of nicotine and tobacco-the alternative being to "quit or die". and many die. While nicotine replacement therapies (NRT) may have a role in harm reduction, tobacco based harm reduction options may reach more smokers and in a different, market based, way. Chewing tobacco is not banned or regulated in the EU but is often highly toxic, and our proposal could remove more products from the market than it permitted. REGULATORY OPTIONS: We believe that the EU policy on smokeless tobacco should adapt to new scientific knowledge and that the European Commission should bring forward proposals to amend or replace Article 8 of directive 2001/37/EC with a new regulatory framework. Canada has developed testing regimens for tobacco constituents and these could be readily adapted to the European situation. A review of EU policy in this area is required no later than December 2004, and we believe the Commission should expedite the part of its review that deals with harm reduction and regulation of tobacco products other than cigarettes so as to reconsider its policy on smokeless tobacco. We held this view before Swedish Match brought its legal proceedings to challenge EU legislation and we will continue to hold these views if its action fails.

European Union↗

PubMed2005

Prisoners who inject drugs: public health and human rights imperatives.

This article examines the human rights and public health implications of injection drug use in prisons with a specific focus on HIV and hepatitis C (HCV) viruses. The authors argue that prisoners who inject drugs have a right to access harm reduction measures--those that reduce the harmful consequences of drug use without necessarily reducing drug consumption. Moreover, states that fulfill their obligation to provide prisoners with harm reduction measures such as access to bleach, substitution therapy, and sterile injection equipment implement sound public health policy with a positive impact for a population particularly vulnerable to HIV and HCV. Ultimately, this approach benefits not only prisoners but also prison staff and the public, and does not entail lessening of the safety and security of prisons.

AIDS Serodiagnosis↗

PubMed2005

Use of the femoral vein ('groin injecting') by a sample of needle exchange clients in Bristol, UK.

BACKGROUND: Use of the femoral vein for intravenous access by injecting drug users (IDUs) (commonly called 'groin injecting') is a practice that is often observed but on which little is written in the literature. The purpose of this study was to describe self-reported data from a sample of groin injectors on the natural history and rationale regarding their groin injecting, to inform future research and the development of appropriate harm reduction strategies. METHODS: A convenience sample of groin injectors willing to participate in a semi-structured interview were recruited through the Bristol Drugs Project Harm Reduction Service. The interviews were conducted over the period of one week. Data on transition to groin injecting, rationale for use and incidence of problems were collected. RESULTS: Forty seven IDUs currently injecting in their femoral vein ('groin') were interviewed, 66% (n = 31) male and 34% (n = 16) female. Their mean age was 31 yrs (range 17 to 50 yrs; SD = 7.7). The mean length of time since first injecting episode was 9.6 yrs (range 6 mths to 30 yrs; SD = 7.0). The mean length of time since use of the groin began was 2.6 years (range 1 mth to 15 yrs; SD = 3.3). The mean length of time between first injection and first use of the groin was 7.0 yrs (SD = 7.0). One person had used no other area for venous access prior to using the groin, nine people had used one, nine people had used two, 10 people had used three, five people had used four and 13 people had used more than four areas. The main reason given for starting to inject in the groin was that 'no other sites were left'. However further discussion identified this meant no other convenient sites were accessible. Practises such as the rotation of injecting sites, as advocated in many harm reduction leaflets, were reported to be difficult and unreliable. The risk of missing the vein and subsequently losing the 'hit' was considered high. Use of the non-dominant hand to administer injections was problematic and deterred rotation between arms. The groin site was reported to be convenient, provide quick access, with little mess and less pain than smaller more awkward veins. The formation of sinuses over time facilitated continued use of the groin. Approximately two thirds of participants had experienced difficulty gaining IV access at their groin. Common problem included scar tissue occlusion, swelling and pain. Some reported infections and past history of deep vein thrombosis. CONCLUSION: Use of the groin was perceived to be convenient by the study group. Problems following safer injecting advice were identified, including dexterity difficulties leading to fear of losing the 'hit'. Health problems at the groin site did not deter use. These results suggest further qualitative work is needed to explore the difficulties in following safer injecting advice in more detail and inform the development of more appropriate advice. Further quantitative work is necessary to establish the prevalence of groin injecting amongst IDUs and the incidence of associated problems. There is a need for a longitudinal study to examine the relationship between injecting technique and loss of patency of veins. If protective factors could be identified, evidence-based safer injecting advice could be established to preserve peripheral veins and reduce use of the groin site, which is high risk and associated with serious adverse consequences.

Journal Article↗

PubMed2003

Pharmacological treatments for heroin and cocaine addiction.

AIMS: To provide an overview of the pharmacological options for the treatment of heroin- and cocaine-dependent patients based on known biochemical pathways to addiction and the chronic disease model as a starting point for treatment planning. RESULTS: Recent pre-clinical and clinical studies indicate that different brain structures and different neurotransmitters are involved in different stages of the addiction process. In addition, clinical experience shows that heroin and cocaine addiction can best be conceptualised and treated as a chronic, relapsing disorder with the following treatment goals: crisis intervention, cure or recovery (detoxification, relapse prevention) and care or partial remission (stabilization and harm reduction). The various high-quality studies, systematic literature reviews and formal meta-analyses clearly demonstrate that today many proven effective interventions are available for crisis intervention, detoxification, stabilization and harm reduction for heroin-dependent patients. Interventions directed at relapse prevention are still problematic and only effective in a minority of motivated patients in stable living conditions and adequate social support. In contrast, no proven effective pharmacological interventions are available for the treatment of cocaine-dependent patients, maybe with the exception of some patient groups that seem to benefit from treatment with disulfiram or amantadine. Treatment innovations are primarily based on experimental animal studies. Newly developed cannabinoid receptor antagonists and cortisol synthesis inhibitors show great promise. CONCLUSION: Heroin addiction is a chronic relapsing disease that is difficult to cure, but stabilization and harm reduction can greatly increase the life time expectancy and the quality of life of the patient, his direct environment and society as a whole. Currently, no proven effective pharmacological interventions are available for cocaine addiction, and treatment has to rely on existing cognitive behaviour therapies combined with contingency management strategies.

Chronic Disease↗

PubMed2004

The cost-effectiveness of HIV preventive measures among injecting drug users in Svetlogorsk, Belarus.

AIM: To undertake a cost-effectiveness analysis of a harm reduction and HIV prevention project for injecting drug users (IDUs) in Eastern Europe. Economic evaluation methods were adapted to consider the effect of an 8-month financing gap that negatively impacted on project implementation. DESIGN: Financial and economic costs of implementing the intervention were analysed retrospectively. The data were also modelled to estimate the costs of a fully functioning project. Estimates of the intervention impact on sexual and drug injecting behaviour were obtained from existing pre- and post-intervention behavioural surveys of IDUs. A dynamic mathematical model was used to translate these changes into estimates of HIV infections averted among IDUs and their sexual partners. Projections of the potential effect of the shortfall in funding on the impact and cost-effectiveness of the intervention were made. SETTING: Svetlogorsk, Belarus, where in 1997 the IDU HIV prevalence was 74%. FINDINGS: The intervention averted 176 HIV infections (95% CI 60-270) with a cost-effectiveness of 359 dollars per HIV infection averted (95% CI 234-1054 dollars). Without the 2311 dollars reduction (7%) in financing, the estimated cost-effectiveness ratio of the project would have been 11% lower. The costing methods used to measure donated mass media can substantially influence cost and cost-effectiveness estimates. CONCLUSIONS: Harm reduction activities among IDUs can be cost-effective, even when IDU HIV prevalence and incidence is high. Relatively small shortfalls in funding reduce impact and cost-effectiveness. Increased and consistent allocation of resources to harm reduction projects could significantly reduce the pace of the HIV epidemic in Eastern Europe.

Cost-Benefit Analysis↗

PubMedDate not supplied

Potential reduction exposure products and FDA tobacco and regulation: a CNS call to action.

A new generation of tobacco harm reduction products is stirring controversy and confusion among healthcare providers. These products, known as "potential reduction exposure products" (PREPs), can be described in terms of reported scientific evidence, as "the good, the bad, and the ugly." On the good side, there is sufficient scientific evidence to support the use of Commit, a new over-the-counter nicotine lozenge PREP, approved for smoking cessation. On the bad side, there is no scientific evidence to support the use of Ariva, another over-the-counter nicotine lozenge PREP, marketed as an alternative to cigarettes when smoking is restricted. On the ugly side, both of these PREPs are nicotine delivery systems with "candy-like" appearances; however, one (Commit) has the Food and Drug Administration (FDA) approval and the other (Ariva) does not. This article provides an overview of PREPs and strategies to help clinical nurse specialists (CNSs) address tobacco harm reduction issues.

Candy↗

PubMed1995

The role of law enforcement in minimizing the harm resulting from illicit drugs.

Illicit drugs have become a major global problem in recent decades following considerable recent political change, including the collapse of communism and the formation of international super-states to increase trade. Despite increasing collaboration between law enforcement authorities in different countries, illicit drug problems appear likely to increase in the future because of the vast profits available, continuing (and increasing) demand and more permissive attitudes concerning drugs among young people. While rejecting legalization or decriminalization, the search for more effective responses by law enforcement authorities and the community generally must be stepped up. Police services continue to play an important role restricting the availability of illicit drugs but increasing emphasis needs to be given to reducing demand, including more available and more effective preventive drug education in schools. Police also need to work with harm reduction approaches devised to reduce the negative consequences of drug use for those who continue to use illicit drugs. New measures proposed in Britain are outlined. These stress the importance of a multi-sectoral approach operating at both national and local levels with the objective of reducing drug-related crime, reducing the acceptability and availability of illicit drugs and reducing the harmful consequences of illicit drug use. Harm reduction requires a commitment for close collaboration between police and drug treatment services to maximize the effectiveness of needle-exchange schemes and other harm reduction approaches. Cautioning, now commonly used in Britain for selected minor drug offences, has a number of benefits including reducing criminal justice costs. Greater emphasis must be placed on diversion schemes involving close links between police and drug treatment services. Future progress requires firm commitments to providing adequate and effective drug treatment services, conducting research to develop and evaluate more effective diversion schemes, improving collaboration between sectors and effective leadership. In addition to the major costs of illicit drug use to the community, the huge cost to individuals must remain a major focus driving the search for more effective responses to the problems resulting from illicit drugs.

Journal Article↗

PubMed2026

Changes in heroin-related ambulance attendances following the introduction of a medically supervised injecting room in Victoria, Australia.

BACKGROUND: Injecting drug use contributes significantly to morbidity, mortality and broader social harms globally. Supervised Injecting Facilities (SIFs) are harm reduction interventions that reduce overdose risk and facilitate access to health services for marginalised individuals. While international evidence supports the effectiveness of SIFs, Australian population-level surveillance data quantifying their impact on emergency medical service utilisation remain limited. METHODS: Using data from the National Ambulance Surveillance System, we conducted a retrospective, interrupted time series analysis of heroin-related ambulance attendances within the local catchment of the Medically Supervised Injecting Room (MSIR) between January 2015 and December 2023. Supplementary analysis included comparisons with central Melbourne suburbs and the broader state of Victoria. Key intervention timepoints, including the opening of the MSIR on 30 June 2018, expansion of its operating hours in July 2019, and the COVID-19 pandemic from April 2020 to October 2021, were examined to assess changes in heroin-related attendances over time. Segmented regression models were used to assess changes in heroin-related ambulance attendance trends over time. RESULTS: At the time the MSIR opened, the model-predicted heroin-related ambulance attendance rate within the MSIR catchment was 123 per 100,000 population per month, equivalent to approximately 48 heroin-related ambulance attendances per month. Prior to implementation, the attendance rate was increasing by an estimated 0.74 per 100,000 population per month. Following the opening of the MSIR, the previously increasing trajectory reversed, with ambulance attendance rates declining by approximately 2.3 per 100,000 population per month relative to the pre-intervention trend. By the end of the study period (December 2023), the predicted monthly heroin-related ambulance attendance rate had declined to 36 per 100,000 population (approximately 14 attendances per month), representing an overall reduction of 70.7% from the time of MSIR implementation. These reductions persisted throughout the COVID-19 lockdown period and were sustained after restrictions lifted. Supplementary analysis showed no comparable reductions in the central Melbourne region or the remainder of Victoria. CONCLUSIONS: The introduction of the MSIR in Richmond was associated with a sustained reduction in heroin-related ambulance attendances within its catchment area. These findings provide strong population-level evidence that SIFs reduce acute heroin-related harms requiring emergency ambulance response, reinforcing their role as an effective harm reduction strategy within the Australian context.

Humans↗

PubMedDate not supplied

Towards the integration of treatment systems for substance abusers: report on the second International Symposium on Substance Abuse Treatment and Special Target Groups.

The central ideas of this article are the result of intensive discussions during a symposium that was organized following structural changes in European substance abuse treatment. Therapeutic communities were concerned about their approach being replaced by other treatment modalities. Participants focused on the question of whether the emerging harm reduction paradigm could be combined with the principle of recovery and how its integration in a comprehensive treatment system could be beneficial or detrimental to therapeutic communities. This article defines integrated treatment systems for substance abusers from a conceptual, etymological, ethical and ideological point of view. In addition, it focuses on old but ongoing contradictions and discussions between drug-free, methadone-maintenance and harm reduction approaches. Several prerequisites for the integration of treatment systems are discussed, and parallels and discrepancies between the American and European situation are explored. An integrated and comprehensive system of treatment services is put forward as an alternative to the present-day gap between conventional abstinence-oriented programs and harm reduction initiatives. Participants maintain that collaboration between these apparently incompatible treatment paradigms will depend on mutual respect, the introduction of a common language and a thorough analysis of clients' treatment demands.

Delivery of Health Care, Integrated↗

PubMed2005

Witch-hunt.

Beginning two years ago, the US Dept of Health and Human Services began "special reviews" of all current research grants that involved harm reduction, sex and drugs, and continues its ban on funding of needle exchange. With Bush's second term, the campaign was extended to all US funded international programs that dealt with these issues and populations. And, most recently, the US has again undertaken to dominate the discourse within international organizations charged with drug control and AIDS policies - especially those of the UN. But the international harm reduction and human rights community is fighting back in several important ways, including "An Open Letter to the delegates of the Forty-eighth session of the Commission on Narcotic Drugs (CND) of the UN" prepared by a group of 334 well respected public health experts and human rights advocates, protesting U.S. pressure on the U.N. to withdraw its support from harm reduction. This editorial includes the letter and signatures as well as French, Spanish, and Russian versions of the letter as additional files.

Journal Article↗

PubMed2006

Secondary syringe exchange as a model for HIV prevention programs in the Russian Federation.

Effective prevention of syringe-borne transmission of HIV and the hepatitis viruses can be undermined if contact between injection drug users and the staff of prevention programs is impeded by police harassment, limited program resources, and the absence of an open "drug scene." All these are commonplace in the Russian Federation. In response, "Project Renewal," the harm reduction program of the AIDS Prevention and Control Center of the Tatarstan Ministry of Health in Kazan, has created a hybrid syringe exchange program that as its primary focus recruited and trained volunteers to provide secondary syringe exchange. To compensate for operational barriers, the program staff identified private venues and trained responsible individuals to work through their own and related networks of injectors to provide clean syringes, other harm reduction supplies, and educational materials, while facilitating the collection and removal of used and potentially contaminated syringes. Program staff developed a detailed set of tracking instruments to monitor, on a daily and weekly basis, the locations and types of contacts and the dissemination of trainings and materials to ensure that the secondary distribution network reaches its target audience. Data show that these secondary exchange sites have proven more productive than the primary mobile and fixed-site syringe exchanges in Kazan. Beginning in 2001, Project Renewal has trained other harm reduction programs in the Russian Federation to use this model of reaching injectors, identifying and training volunteers, and monitoring results of secondary syringe exchange.

Adult↗

PubMed2006

A randomized study of four cards designed to prevent problems during college students' 21st birthday celebrations.

OBJECTIVE: The purpose of this study was to examine the efficacy of sending cards designed to prevent alcohol-related problems during 21st birthday celebrations. METHOD: College students were randomly assigned to receive cards with one of the following messages: (1) a neutral birthday greeting; (2) harm reduction information; (3) messages designed by the Be Responsible About Drinking (B.R.A.D.) Foundation, including harm reduction information and a description of the tragic death of Brad McCue during his 21st birthday celebration; (4) social norming messages designed to correct misperceptions of drinking; or (5) the combination of messages from Cards 2 and 4. A total of 994 students completed a post-21st birthday phone survey. Effects were evaluated in two cohorts with 444 and 550 students, respectively. RESULTS: There were no significant effects of the cards on drinking or alcohol-related problems. CONCLUSIONS: These null findings, plus some unexpected trends in our data, highlight the importance of carefully evaluating mailed interventions before deploying them on a large scale.

Adult↗

PubMed2006

Current trends in international tobacco control.

The tobacco control policy tools developed in a few rich countries in the 1970s, 1980s, and 1990s are currently being implemented widely in many poorer countries, thanks in part to the astonishing success of the Framework Convention on Tobacco Control (FCTC). With smoking rates already high in most of the Third World, however, the projections for the twenty-first century are grim: up to 1 billion tobacco-caused deaths, which raises the issue of what more can be done, particularly to help people who already are addicted to nicotine. Only massive and effective smoking cessation programs could reduce this death toll significantly, at least in the short-term. Tobacco control's existing tools, if widely applied, likely will reduce premature deaths significantly but can be expected to leave unacceptably high levels of tobacco-related mortality. This finding has sparked fierce discussions among anti-tobacco activists about the role of harm reduction in curbing death and disease. This article discusses whether harm reduction is possible with the tobacco industry subject to a largely unregulated environment for tobacco products.

Global Health↗