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PubMed2004

A cross-national comparison of risk and protective factors for adolescent substance use: the United States and Australia.

PURPOSE: To compare risk and protective factors that influence youth substance use in Australia and the United States. The two countries have different policy orientations toward substance use: Australia has adopted harm-reduction policies, and the United States has adopted abstinence-focused policies. METHODS: Cross-sectional survey data were collected from independent samples of adolescents in the states of Maine (N = 16,861; 53% female, 7% Non-white) and Oregon (N = 15,542; 51% female, 24% Non-white) in the United States and Victoria in Australia (N = 8442; 54% Female, 11% Non-white) in 1998 (Maine and Oregon) and 1999 (Victoria). Chi-square tests, t-tests, effect size comparisons, and logistic regression analyses that accounted for age and gender were used to investigate cross-national similarities and differences in: (a) rates of cigarette, alcohol, and marijuana use; (b) levels of risk and protective factors; and (c) magnitudes of associations between risk and protective factors and substance use. RESULTS: More adolescents in Victoria reported using cigarettes and alcohol, whereas more of the U.S. adolescents reported using marijuana. Exposure to risk and protective factors was generally similar in the cross-national samples. However, adolescents in Maine and Oregon perceived handguns to be more readily available, reported more participation in religious activities, and were higher in sensation-seeking and social skills; and adolescents in Victoria had more favorable attitudes toward drug use and reported community norms and parental attitudes more favorable to drug use. Most of the risk and protective factors were strongly associated with substance use to a similar degree in Victoria, Maine, and Oregon. However, among adolescents in Maine and Oregon peer/individual risk and protective factors associated with social detachment were more strongly related to substance use, and among adolescents in Victoria, family protective factors were less strongly related to alcohol use. CONCLUSIONS: Inter-country influences on youth substance use are generally similar despite different policy directions. Existing differences suggest that the abstinence policy context is associated with higher levels of illicit drug use and stronger relations between individual indicators of social detachment and substance use, whereas the harm reduction policy context is related to more cigarette and alcohol use, possibly from exposure to normative influences that are more tolerant of youth drug use.

Adolescent↗
PubMed1997

Needle exchange and reduction of harm: an anthropological view.

Overwhelming evidence from all over the world confirms that needle exchange programs (NEPs) in widely varied forms have value in prevention of HIV infection among injecting drug users (IDUs). Unfortunately, the United States has relatively few active NEPs because of political opposition to adoption of any policy that would give the appearance of condoning use of illegal drugs. Some additional opposition comes from the affected communities themselves. NEPs that assiduously construct links with affected communities have highest probabilities of effectiveness. Studies of NEPs, with some notable exceptions, still lack anthropological evaluations of their impact, and this deficiency needs more attention in future efforts to frame, implement, and evaluate NEPs.

Acquired Immunodeficiency Syndrome↗
PubMed1994

A comparison of HIV risk between women and men who inject drugs.

Although there is growing evidence of differences between women and men who inject drugs (IDUs) in terms of level of risk for HIV infection, very little research has been conducted specifically addressing the risk practices of women IDUs. This study formed part of a national study of HIV infection risks in IDUs and the purpose of the present analysis was an exploration of gender differences in HIV risk practices, focusing on the HIV risk practices of IDU women. 1,245 IDUs from the inner city area of Sydney took part in this study. Of these, 908 were men and 331 were women. Notable results were that female respondents were more likely to report sharing needles, they injected heroin more times in a typical using month and were more likely to have shared with someone they later found out was HIV seropositive. Female respondents also reported more sexual partners than men, were more likely to engage in prostitution, and were more likely to have sexual partners who were themselves IDUs. The results provide support for the proposition that women who inject drugs may be at greater risk of HIV infection through both their drug taking and their sexual practices. Further research is needed to explore the reasons underlying the risk practices of women who inject drugs and an understanding of these factors needs to be incorporated into HIV risk-reduction and drug harm-reduction policies and programs.

Adolescent↗
PubMed2000

Practical experiences in smoking reduction and cessation.

Tobacco use is a major cause of cardiovascular, respiratory and oncological disease. Quitting smoking significantly benefits health, but for highly dependent smokers, unable to overcome their nicotine dependence, the concept of smoking reduction as a method of harm reduction is gaining ground. The University Hospital of Basle, Switzerland, has run double-blind, placebo-controlled smoking cessation and smoking reduction studies: the CEASE trial evaluated the efficacy of the nicotine patch in achieving abstinence, and the Rosette study is evaluating the efficacy and tolerability of the nicotine oral inhaler in smokers who do not wish to quit. Smokers were instructed either to quit smoking (CEASE) or to reduce cigarette consumption by > 50% (Rosette). In both studies, success rates for active treatment versus placebo at 4 months demonstrated that nicotine replacement therapy (NRT) is effective in achieving both smoking cessation and reduction. Current approaches to smoking cessation and reduction at our clinic are discussed. Combination NRT rather than monotherapy is commonly used to achieve both smoking reduction and cessation. Treatment appears to be most effective if subjects are allowed to select their preferred NRT product. There are clear differences in patient populations aiming to quit or reduce, the cessation population being more motivated. Smoking cessation remains the ultimate aim but, if unfeasible, a significant reduction in cigarette consumption is a valid goal.

Double-Blind Method↗
PubMed2004

Incomplete compensation does not imply reduced harm: yields of 40 smoke toxicants per milligram nicotine in regular filter versus low-tar cigarettes in the 1999 Massachusetts Benchmark Study.

The yields of 40 toxic smoke constituents per mg nicotine were computed in three matched pairs of higher- and lower-tar cigarettes tested in the 1999 Massachusetts Benchmark Study. In the three pairs, 19, 20 and 17 compounds, respectively, exhibited significantly greater yields per mg nicotine in the lower-tar than the corresponding higher-tar brand. Based on the assumption that toxicant yields per mg nicotine were independent of smoking intensity, the minimum degree of nicotine compensation necessary to obtain equal or greater dosages of these toxic compounds from the lower-tar cigarette ranged from 0% to 73%. A smoker who compensates only incompletely for nicotine may thus obtain a higher dosage of a specific smoke toxicant from a lower-tar cigarette than from a higher-tar cigarette. From the toxicological standpoint, incomplete compensation for nicotine does not necessarily translate into harm reduction.

Administration, Inhalation↗
PubMed2005

Risk modifying effect of social capital on measures of heavy alcohol consumption, alcohol abuse, harms, and secondhand effects: national survey findings.

STUDY OBJECTIVE: To examine associations between social capital and individual risk for alcohol abuse and harms and identify protective effect mechanisms. DESIGN: Multilevel multivariate analysis with individual level data from a national panel survey of drinking and a contextual measure of social capital reflecting college mean aggregate reports of student volunteerism. Outcomes include heavy episodic (binge) drinking, frequent drinking, frequent drunkenness, diagnosable alcohol abuse, intentional drunkenness, acquisition of binge drinking, harms, secondhand effects from others' drinking. SETTING: United States, 119 four year colleges. PARTICIPANTS: Representative samples of youth ages 18-24 surveyed in 1997 and 1999 using an anonymous mailed questionnaire (total n = 27 687). MAIN RESULTS: Students from colleges with higher levels of social capital reported reduced risks for binge drinking (adjusted OR 0.38, 95% CI 0.20 to 0.69, p = 0.002), frequent drunkenness (adjusted OR 0.58, 95% CI 0.34 to 0.98, p = 0.04), acquisition of binge drinking in college (adjusted OR 0.48, 95% CI 0.24 to 0.95, p = 0.03), and alcohol abuse (adjusted OR 0.55, 95% CI 0.34 to 0.91, p = 0.02) in multilevel multivariate analyses that controlled for individual volunteering, the measure on which social capital was based. Higher levels of social capital protected against multiple drinking related harms (adjusted OR 0.51, 95% CI 0.29 to 0.90, p = 0.02) and secondhand drinking effects (adjusted OR, 0.30, 95% CI 0.16 to 0.58, p = 0.0003). Significant cross level interactions exist between fraternity/sorority membership and social capital for measures of risky drinking. Harm reduction primarily reflects consumption modification. CONCLUSIONS: Social capital exerts strong protective effects on alcohol abuse and harm in college including among high risk students.

Adolescent↗
PubMed2004

[Reduction of nicotinic risk--is it possible?].

To decrease the health consequences of tabagism pandemic, quitting is still the only goal. The size of the problem leads to question if harm reduction is possible. Today, this concept, which was successful with illegal drugs, cannot be applied to tobacco because of a lack of proof. There is no safe cigarette and all brands have the same toxicity. Arguments in favor of smokeless tobacco are still insufficient for a public health decision. A voluntary decrease of tobacco consumption does not decrease morbidity and mortality of heavy smokers. A long-term use of nicotine replacement therapy is acceptable to reduce the daily smoking under medical supervision in smokers with chronic tobacco related disease who have previously failed in attempts to quit smoking.

Harm Reduction↗
PubMed2005

Isla evangelista-a story of church and state: Puerto Rico's faith-based initiatives in drug treatment.

This article describes the debates leading to Puerto Rico's Mental Health Law of 2000, which defined addiction as a spiritual and social problem rather than a mental disorder, in order to trace three competing approaches to addiction in Puerto Rico: evangelist, biomedical, and harm-reductionist. Highlighting the ways in which the evangelist approach of Puerto Rican street ministries challenges the individualism underlying US faith-based initiatives and the punitive approach of the US War on Drugs, this article concludes that the virtues of the evangelist approach to addiction would be best supported by public funding for biomedical and harm-reduction approaches within a pluralistic system of treatment for addiction.

Christianity↗
PubMed2004

To help and not to harm: ethical issues in the treatment of chronic pain in patients with substance use disorders.

Patients with both chronic pain and substance use disorders are increasingly encountered in a variety of treatment settings. The treatment of these patients raises a number of ethical and patient care issues. Consultation-liaison psychiatrists possess the knowledge and skills to constructively address these issues. This chapter provides clinicians with a review of clinical and ethical dilemmas related to opioid treatment of chronic pain in patients with substance use disorders. The core conflict of beneficence and nonmaleficence will be explored in relation to the concepts of autonomy, justice, respect for persons, confidentiality, and informed consent. The thesis of this discussion focuses on the clinician's desire to provide compassionate care and relieve suffering, which sometimes conflicts with the clinician's desire to improve functioning, extend longevity, and enrich quality of life. A harm reduction model for clinical decision making is summarized.

Analgesics, Opioid↗
PubMed2006

Does additional support by nurses enhance the effect of a brief smoking cessation intervention in people with moderate to severe chronic obstructive pulmonary disease? A randomised controlled trial.

BACKGROUND: Smoking cessation is the primary disease modifying intervention for chronic obstructive pulmonary disease (COPD). SETTING: A Regional Respiratory Centre (RRC) out-patient department in Northern Ireland. METHODS: A randomised controlled trial (RCT) evaluated the effectiveness of brief advice alone or accompanied by individual nurse support or group support facilitated by nurses. Smoking status was biochemically validated and stage of change, nicotine addiction and dyspnoea were recorded at 2, 3, 6, 9 and 12 months. PARTICIPANTS: Ninety-one cigarette smokers with COPD were enrolled in the study (mean age 61 years, 47 female). RESULTS: After 12 months cessation rates were not significantly different between groups (p=0.7), but all groups had a significant reduction in their nicotine addiction (p=0.03-0.006). No changes in subjects' motivation or dyspnoea were detected over the 12 months. CONCLUSION: Patients with COPD were unable to stop smoking regardless of the type of support they received. Harm reduction may be a more appropriate goal than complete cessation for intractable smokers and nurses must evaluate their role in this arena.

Analysis of Variance↗
PubMed2003

What can the Swiss and Dutch trials tell us about the potential risks associated with heroin prescribing?

Following on from last edition's Harm Reduction Digest on drug consumption facilities this Digest investigates what can be learnt from the Swiss and Dutch trials of heroin prescribing about the unintended consequences of this controversial intervention to reduce heroin-related harm. The authors of the paper bring considerable experience in the implementation and evaluation of such schemes in Europe and their consideration in Australia. The paper systematically addresses concerns about heroin prescribing and suggests further research to respond to some unanswered questions.

Adolescent↗
PubMed2006

Would alternate tobacco products use be better than smoking?

Tobacco use is dominated by cigarette smoking. Most toxicity due to cigarette smoking is related to the burning process. Several observations suggest that unburned or oral tobacco is less harmful than cigarette smoking. Up to now, physicians have advised a policy based on two ideas: (i) young people should not start smoking and (ii) the only choice for smokers is to quit. However, numerous smokers cannot or do not want to give up; eventually, one out of two lifelong smokers will die from smoke-related diseases. Thus, it is legitimate to ask if alternate nicotine containing product use would be better than cigarette smoking and limit the tobacco death toll. However, the logic leading to the concept of tobacco harm reduction (THR) turns out to be much more complex than it looks at a first glance.

Behavior, Addictive↗
PubMed2006

Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol.

BACKGROUND: People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. Harm reduction is a policy to decrease the adverse consequences of substance use without requiring abstinence. The shelter-based Managed Alcohol Project (MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm; its effect upon consumption of alcohol and use of crisis services is described as proof of principle. METHODS: Subjects enrolled in MAP were dispensed alcohol on an hourly basis. Hospital charts were reviewed for all emergency department (ED) visits and admissions during the 3 years before and up to 2 years after program enrollment, and the police database was accessed for all encounters during the same periods. The results of blood tests were analyzed for trends. A questionnaire was administered to MAP participants and staff about alcohol use, health and activities of daily living before and during the program. Direct program costs were also recorded. RESULTS: Seventeen adults with an average age of 51 years and a mean duration of alcoholism of 35 years were enrolled in MAP for an average of 16 months. Their monthly mean group total of ED visits decreased from 13.5 to 8 (p = 0.004); police encounters, from 18.1 to 8.8 (p = 0.018). Changes in blood test findings were nonsignificant. All program participants reported less alcohol consumption during MAP, and subjects and staff alike reported improved hygiene, compliance with medical care and health. INTERPRETATION: A managed alcohol program for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease ED visits and police encounters.

Alcoholism↗
PubMed2006

Evidenced-based treatment of opioid-dependent patients.

OBJECTIVE: To provide an overview of treatment options for opioid-dependent patients. METHOD: We screened all published studies on the treatment of opioid dependence, with a special focus on systematic literature reviews, formal metaanalyses, and recent trials. RESULTS: Both clinical experience and neurobiological evidence indicate that opioid dependence is a chronic relapsing disorder. Treatment objectives depend on the pursued goals: crisis intervention, abstinence-oriented treatment (detoxification and relapse prevention), or agonist maintenance treatment. The high quality of solid evidence in the literature demonstrates that there are numerous effective interventions available for the treatment of opioid dependence. Crisis intervention, frequently necessary owing to the high overdose rate, can be effectively handled with naloxone. Abstinence-oriented interventions are effective for only a few motivated patients with stable living conditions and adequate social support. Agonist maintenance treatment is considered the first line of treatment for opioid dependence. Numerous studies have shown efficacy for methadone and buprenorphine treatment, while maintenance with other agonists is also becoming available to a greater extent. Maintenance treatment with diamorphine should be made available for the small group of treatment-resistant, severely dependent addicts. Other harm-reduction measures can serve to engage individuals with opioid addiction who are not in treatment. CONCLUSION: Opioid dependence is a chronic relapsing disease that is difficult to cure, but effective treatments are available to stabilize patients and reduce harm, thereby increasing life expectancy and quality of life.

Evidence-Based Medicine↗
PubMed2005

Indoor tanning by adolescents: prevalence, practices and policies.

Despite known acute and chronic health effects from the use of indoor tanning, including the potential for all forms of skin cancer, the practice is popular in the United States (US) and Europe. A review of the scientific literature that examines adolescents and indoor tanning use was undertaken, summarising what is known about prevalence and practices among adolescents, characteristics associated with adolescent use, and policies that regulate adolescent access to indoor tanning facilities. The prevalence of indoor tanning is consistently found to be higher among girls than boys and to increase with age in both Europe and the US. An examination of other demographic characteristics, skin cancer risk factors, knowledge, attitudes and social factors points to higher prevalence of the behaviour among adolescents with positive attitudes towards tans and whose friends or parents also tan indoors. Adolescent access to indoor tanning is rarely regulated in the US or Europe, and where regulations exist, business compliance is low. In addition, businesses actively market their product to adolescents as they organise to limit further regulations prohibiting adolescent access. Pricing, licensure, advertising restrictions and media campaigns, in combination with adolescent-targeted interventions, are possible strategies that could be tested for their effectiveness to reduce adolescent indoor tanning use. Harm reduction policies, such as eye protection, that reduce risk for adolescents who choose to tan indoors, are also important.

Adolescent↗