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PubMed2005

Trends and issues in the international drug control system--Vienna 2003.

The April, 2003 meeting of the Commission on Narcotic Drugs, and the meetings and other efforts to influence it sponsored by interested parties before and around the Commission meeting, are described and analyzed. The 2003 meeting was seen as significant because it was the occasion for assessments of progress on the process goals set out in the United National General Assembly Special Session on drugs in 1998. Debate and discussion of the text of resolutions in the Commission meetings are analyzed in terms of the major points of conflict in 2003 between national delegations--cannabis policies, harm reduction, substitution therapy, and preferences for dramatizing or matter-of-fact language. Also discussed are the drift toward a crime rubric for the drug control system, and the increasing distance between the focus of the system on policing and the focus of most Western European governments on drugs as welfare or health issues. It is concluded that the system seems to be at a stalemate.

Drug and Narcotic Control↗

PubMed2006

Drug users' participation in addiction care: different groups do different things.

This study allocated 201 (nearly) daily users of heroin and/or crack into four groups, depending on their addiction care participation. Earlier studies have compared treatment groups and nontreatment groups. In this study the treatment group is divided into three categories: (1) drug users in contact with only treatment agencies--i.e., methadone maintenance, clinical and ambulant drug treatment; (2) drugs users in contact with only care agencies--i.e., day and night shelters and drug consumption rooms, which have no explicit aims to change patterns of drug use; and (3) drug users in contact with both treatment and care agencies. This allocation intro three different groups fits the notion of harm reduction, one of the policy aims in The Netherlands. The fourth group consists of drug users in contact with neither treatment nor care agencies. The results show that it is useful to distinguish these four categories, instead of two. The four groups are different from each other with respect to some of their characteristics (e.g. debt situation, prostitution, homelessness) and their drug use (e.g. drug use in public, use of crack, and use of other drugs). A much clearer distinction can be made between the "care" group and the "treatment and care" group. Treatment and care agencies can thus better match their services to their clients or patients.

Adult↗

PubMed2006

Integrated residential treatment for persons with severe and persistent mental illness: lessons in recovery.

This retrospective study examines 24-month outcomes for 38 participants with histories of chronic homelessness and hospitalizations in an urban, residential integrated treatment (IT) program and compares characteristics of those who stayed in the program 24 months with those who left within their first year of residence. Informed by an Assertive Community Treatment approach, characterized by outreach (or what might better be referred to as inreach), low staff to consumer ratio, and meeting of basic needs, the residential program emphasized harm reduction and motivational interventions. The longitudinal study design was supplemented with a comparative analysis of treatment completers and noncompleters. There were significant differences between the two groups at baseline in terms of engagement with treatment, alcohol use severity, and mental health diagnosis. Additionally, those who stayed with the program showed significant reductions in alcohol and drug use, significant reduction in hospitalizations, and advances in treatment engagement.

Adult↗

PubMed2003

Maintaining respectability and responsibility: gendered labor patterns among women injection drug users.

Gender-related factors and the social and economic conditions that impact the lives and health of women injection drug users (IDUs) in Chicago are described. Although study participants are highly imaginative and resourceful in terms of income-generating self-sufficiency, they engage in a variety of behaviors that put them at risk of contracting infectious diseases such as HIV and hepatitis B and C viruses. We point out that labor inequalities experienced by women IDUs, together with the gender ideologies that support those inequalities, provide reduced opportunities to practice harm reduction and other health care options.

Adaptation, Psychological↗

PubMed2005

Health risks of smoking compared to Swedish snus.

Interest in tobacco harm reduction strategies has raised the question of the comparative health risks of cigarette smoking and use of other tobacco products. Although there appears to be a general belief that a unique smokeless tobacco product called Swedish snus has fewer health risks than cigarettes, no one has systematically reviewed the literature and compared the data on health risks in a quantitative manner. We reviewed the literature to identify all analytic epidemiologic studies that provided quantitative risk estimates associated with Swedish snus and cigarette smoking in a single population, using a common reference group. Seven studies were identified that addressed eight health outcomes. Although few in number, these seven studies do provide quantitative evidence that, for certain health outcomes, the health risks associated with snus are lower than those associated with smoking. Specifically, this is true for lung cancer (based on one study), for oral cancer (based on one study), for gastric cancer (based on one study), for cardiovascular disease (based on three of four studies), and for all-cause mortality (based on one study). This review has likely omitted many of the adverse effects of cigarettes, but probably few of the potential health effects of snus. Continued investigation of the reduced health risks of Swedish snus compared to cigarette smoking is warranted.

Cardiovascular Diseases↗

PubMed2006

Health trends among drug users attending needle exchange programmes in Switzerland (1994-2000).

As a part of an assessment of the Swiss drug harm-reduction policy, cross-sectional surveys were conducted in 1994, 1996 and 2000 among attenders of all needle exchange programmes (NEP) in Switzerland to assess changes in specific aspects of their health related to drug use. Data were gathered in each NEP over one week, using a questionnaire completed partly with an interviewer and partly self administered. The questionnaire covered socio-demographic characteristics, drug consumption, risk, prevention behaviour and state of health. Over a 6-year period (1994-2000), the average age of NEP attenders rose by 4 years. The prevalence of reported HIV remained fairly stable at around 10%. Reported level of Hepatitis C prevalence was high (59%). Incidence of used injection equipment sharing during the last 6 months was low and stable (9% in 1994, 12% in 2000); however, other forms of risk behaviour linked to intravenous drug use, such as sharing spoons, cotton or water, were more frequently reported. The HIV epidemic among NEP attenders seems to be contained, but this is not the case with Hepatitis C, and more attention should be paid to its prevention.

Adult↗

PubMed2006

Barebacking websites: electronic environments for reducing or inducing HIV risk.

Barebacking, or intentional unprotected anal intercourse (UAI), among men who have sex with men (MSM) has been a growing concern for the public health community because of UAIs link to HIV incidence and sexually transmitted infections (STIs). Men who bareback have created online spaces through websites that host thousands of profiles throughout the US and world. Adapting two domains from person-environment theory, this study contrasted the health messages surrounding the risks of UAI within two mainstream US-based barebacking websites. One website developed intensive systems to promote harm reduction, such as encouraging frequent HIV-testing, discussing STIs with partners, and limiting the number of partners. In contrast, the other site analysed negated the seriousness of HIV and STIs, which can have clear negative outcomes for patrons whom relied on this information. This analysis implicates the need to explore electronic environments as viable tools for HIV prevention and programme development.

HIV Infections↗

PubMed2005

Needle sharing and sex-related risk behaviours among drug users in Shenzhen, a city in Guangdong, southern China.

Intravenous drug users (IDUs) are at high risk of contracting HIV, but there is a geographic bias in such research efforts in China. The aim was to study the pattern of needle sharing and sex-related risk behaviours among drug users in southern China. About 260 drug users in a detoxification centre completed an anonymous questionnaire (response rate=87.3%). The results show that needle sharing among IDUs was prevalent (60.6% and 45.3% for male and female IDUs, respectively); the sharers were often friends, spouses, and acquaintances. Few IDUs sterilized the used needles properly. Commercial sex behaviours (males: 44%; females: 60%) as well as multiple partnership (males: 60%; females: 53%) were also prevalent among all male and female drug users studied. Inconsistent condom use with commercial sex partners, spouses, and regular sex partners was also very common. Yet, few of all drug users studied perceived the susceptibility of contracting HIV (11%) or sexually transmitted diseases (24%) in the future. A better HIV-related knowledge level was associated with lower levels of risk behaviours. It is concluded that harm reduction programmes are urgently warranted in China.

Adolescent↗

PubMed2003

Drug consumption facilities: an update since 2000.

The topic of drug consumption facilities or rooms (DCRs) was reviewed by Dolan, Kimber and others in Harm Reduction Digest 10, published in the September 2000 issue of DAR. As one of the first English language papers on the topic this paper has been cited extensively. Now, 3 years on, these authors and have brought together an international team of experts to revisit the topic. In this update they: (i) highlight where DCRs are operating or under consideration, (ii) review briefly new literature and (iii) discuss future directions. This Digest is a 'must read' for policy makers, advocates and practitioners in the drug field.

Drug Monitoring↗

PubMed2002

Interpreting changes in heroin supply in Melbourne: droughts, gluts or cycles?

In this Harm Reduction Digest Paul Dietze and John Fitzgerald provide another possible way of understanding what has come to be referred to as Australia's heroin 'drought'. They examine evidence from Melbourne, Victoria and suggest that the apparent downturn in heroin availability in 2000 may, in part, be the result of an end of a heroin 'glut' and that perceptions of this phenomenon may be coloured by the development of more sophisticated indicators of the heroin market. They conclude with claims that the reasons for the reduction in drug consumption and adverse health outcomes, such as those attributed to interdiction, are thus premature

Heroin↗

PubMed2004

Can drug injectors be encouraged to adopt non-injecting routes of administration (NIROA) for drugs?

Drug use by injection can cause problems specific to this form of administration. Problems include an increased risk of drug overdose, drug dependence, the transmission of HIV, hepatitis B and hepatitis C and vein damage. Shifting drug injectors from injecting to another route of administration may minimize these problems. The aims of the study were to develop and trial an intervention to assist willing injecting drug users (IDUs) to shift to non-injecting routes of administration (NIROA) and to explore the acceptability and practicality of facilitating NIROA. IDUs were assessed and suitable subjects entered a cognitive behavioural trial consisting of five 1-hour sessions of individual therapy with a registered psychologist. Forty-two subjects were assessed (22 males and 20 females). Thirty subjects entered treatment. The mean age was 36 years. Twenty-one subjects were followed-up at 3 months and 10 subjects at 6 months. At 3 and 6 months, the proportion of subjects who had commenced using NIROA was 30% and 50%, respectively. This pilot study showed that it was possible to assist a minority of drug injectors to move from injecting to the non-injecting administration of drugs. However, many of these appeared to be already motivated to cease using drugs and adopting NIROA was one way of assisting this. Poor follow-up rate, lack of control group, questions about cost-effectiveness and the impact of market factors which possibly constrain shifting to NIROA suggest that further research is needed before it could be said that NIROA should be recommended as a viable harm reduction strategy in the Australian context.

Adult↗

PubMed2004

Injecting and non-injecting cocaine use in Sydney, Australia: physical and psychological morbidity.

This study aimed to examine the physical and psychological harms of cocaine use and investigate the role of injecting versus non-injecting routes of administration in the severity of such harms. Two hundred and twelve cocaine users from inner-city and south-western Sydney were administered a structured interview containing sections on demographics, drug treatment history, drug use history, cocaine use patterns, cocaine dependence and physical and psychological problems associated with cocaine use. Serious physical and psychological symptoms were prevalent among both injecting and non-injecting cocaine users. The prevalence and extent of symptoms was greater among injecting cocaine users, however route of administration did not prove to be a significant independent predictor of harm when other factors, such as frequency of use and level of dependence, were taken into account. While the level of physical and psychological harm was greater among cocaine injectors, it would appear that factors engendered by injecting, such as more frequent use and higher levels of dependence, result in higher levels of harm, rather than the route of administration per se. Physical and psychological problems were also reported among infrequent users, suggesting that cocaine can cause harm irrespective of frequency or method of use. Harm reduction initiatives should be targeted towards all cocaine users, not just those who seek treatment for dependence or present with acute medical complications.

Administration, Inhalation↗

PubMed2005

The stages of the international drug control system.

This paper argues that the history of the international drug control system of the League of Nations/United Nations can be divided into three cumulative stages. The first stage, the supply stage, dates back to early part of the 20th century, and aimed to reduce the supply of drugs through careful monitoring and trade regulations. This has remained the dominant control strategy. In the middle of the century, demand control, in the form of treatment and criminalization of the individual user, began to appear. This was the least successful stage. Finally, in the 1980s, the dangers of the drug traffic assumed an important place on the international agenda and measures to reduce drug-related organized crime were enacted. To date, this has been a process of proliferation of regulatory strategies. Recently, new challenges to the international drug control system have emerged, including well-funded non-governmental organizations critical of the war on drugs, and the adoption of harm reduction measures in national policies around the world.

Asia↗

PubMed2006

Comparison of needle and syringe programme attendees and non-attendees from a high drug-using area in Sydney, New South Wales.

The aim of this study was to compare demographic and drug use profiles of non-needle and syringe programmes (NSP) attendees with NSP attendees from the same geographic area. Two data sources were used. One was from an annual national survey of injecting drug users (IDU) at NSP and analysis was restricted to survey sites in Kings Cross and Kogarah in 2003 (NSP survey). The other was from a survey of IDU who do not use NSP as their primary source of injecting equipment within the same broad geographical region (Access survey). Of the total 264 survey participants, 102 had never attended a NSP (non-NSP attendees) and 162 had previous experience of NSP (NSP attendees). Compared with NSP attendees, non-NSP attendees were less likely to report severe drug problems and more likely to report lower prevalence of HIV, hepatitis B and hepatitis C infection. Nevertheless, about 20% of non-NSP attendees reported re-use of needles and syringes after someone else in the previous month. Compared to NSP attendees, a lower rate of usage of health services was reported by non-NSP attendees. Strategies to promote access to NSP and harm reduction services, including testing for blood-borne viruses, information provision and consideration of referral to treatment among non-NSP attendees are recommended.

Adult↗

PubMed2006

Civil society-a leader in HIV prevention and tobacco control.

Many civil society organisations (CSOs) have been at the forefront of identifying new ideas and implementing innovative models regarding health and health systems around the world. Their activities become highly charged, however, when they engage in advocacy efforts designed to influence change in policies and systems linked with more controversial or complicated public health issues. Policies, laws and regulations regarding illicit drugs and tobacco fall directly into that category. There is no doubt that the use of both kinds of substances can have the same health consequences-including ill health and death-yet they are approached in widely different ways. Smoking is legal to some extent in every country in the world, and is generally considered a matter of personal choice. Many people believe that efforts to limit tobacco use are coercive and impede on individual rights. Those who use illicit drugs such as heroin, meanwhile, are with few exceptions considered social deviants, misfits and lawbreakers. Many CSOs support comprehensive, government-funded prevention strategies coupled with non-punitive, non-judgmental programmes designed to help users change behaviour. Such strategies are designed to reflect and respond to the medically addictive nature of both tobacco and many illegal drugs. Proponents argue that not only are the public health benefits of expansive, well-conceived interventions potentially vast, but so too are the social and economic benefits accruing from lower rates of debilitating disease and premature death. To that end, many international, national and local CSOs are identifying the direct and indirect health consequences of tobacco and illegal drug use; proposing and advocating for strategies to limit their impact; and sharing information and resources with like-minded organisations elsewhere. This leadership role has helped influence and shape policy, especially in recent years. This paper examines civil society's involvement in efforts to change drug and tobacco policy in selected countries in Central and Eastern Europe and the former Soviet Union (CEE/FSU). It concludes that in Poland and Kazakhstan, in terms of tobacco control, and increasingly in Ukraine and parts of Central Asia in terms of harm reduction, multi-sectoral approaches are the most effective way to engage citizens and to implement comprehensive strategies to change behaviour by supportive measures, not punitive ones.

Asia↗

PubMed1991

Least bad solutions to the 'drugs problem'.

This paper examines the current difficulties being faced in Australia by policy-makers attempting to regulate the non-medical use of illegal drugs, and it is suggested that the difficulties centre upon two aspects. First, existing prohibitions are unsuccessful, with use levels rising and, in some arenas (e.g. cocaine use in the USA), quite out of control. On the other hand, a move towards decriminalization or legalization is difficult because past propaganda has been so vehement that a change now apparently risks sending the wrong messages to young people. This dilemma means that there is no solution, including inertia, which is risk-free, nor is there one free of difficulties. It is thus relevant to think in terms of 'least bad' rather than 'best' when formulating a system to face these problems. The exploration of what this least bad solution might be begins with the examination of the prominent myths (such as 'the drug-free society', 'the evil pusher', 'the user as victim' and 'the young person as cultural dope') that hinder our reasoning. Secondly, by suggesting that, in a climate of increasing crime related to drugs, inability of prohibitions to control that use and escalating health risks attendant on use (including the AIDS problem), the central policy thrust must be harm reduction and damage minimization rather than illusory goals such as widespread abstinence. The paper concludes with a discussion of some relevant evidence on alternative options.

Journal Article↗

PubMed1995

Heterosexual anal intercourse, health risks and drug use: a review with special attention to drug users.

Research studying HIV risk-taking behaviour has tended to focus on specific populations who are characterized by particular behaviours. Such practices include the extent of unprotected anal intercourse among homosexual men, the sharing of injecting equipment among drug users and unprotected vaginal intercourse among female sex workers. There is often a failure among both researchers and practitioners to address specific risk behaviours outside of the defined risk group. Reviewed here are studies of heterosexual anal intercourse, with special attention to drug users and female sex workers. Among the general population, the reporting of heterosexual anal intercourse varies greatly across time and cultural groups. However, a body of recent research suggests that, despite some geographical differences, rates in most countries are relatively high. Many studies have also found that associated condom usage is low. Although unprotected anal intercourse is known to be an efficient method for the transmission of HIV and other viral infections, it has rarely been addressed outside cohorts of men who have sex with men. Of particular concern is the interaction of risk behaviours among drug users and women engaging in prostitution, many studies having found high levels of unprotected anal intercourse among these groups. Harm reduction interventions must address all the health risk behaviours their target groups are engaging in, if the challenge of reducing the transmission of HIV and other viral infections is to be met.

Journal Article↗

PubMed1996

Unravelling the preventive paradox for acute alcohol problems.

Kreitman's discussion of the preventive paradox in relation to the prevention of alcohol problems has had profound implications for alcohol policy and has generated considerable controversy [1]. It is argued here that although Kreitman should be credited with the important observation that alcohol-related harm is not confined to a few dependent drinkers, none the less an apparent paradox is not an ideal platform from which to recommend policy. Furthermore, Kreitman's own data and data from an Australian survey of drinking are used to demonstrate that a commonplace truth underlies his apparently paradoxical findings. It is shown that the preventive paradox disappears when consideration is given to the amount of alcohol consumed on either (i) the day of highest alcohol intake out of the last four, or (ii) the day on which acute alcohol-related harm occurred. Episodic heavy consumption by people whose average alcohol intake can be classified as 'low' or 'medium' risk contributes to the bulk of such experiences of harm. It is suggested that the importance of intoxication as a public health and safety issue has been neglected. This neglect is compounded when public education campaigns and prevention policy are only based on average rates of alcohol consumption. Advice regarding the low risk levels of consumption for different types of harm should form one component of a comprehensive harm reduction policy. Other elements of such a policy should include a variety of other measures of proven effectiveness in relation to reducing levels of intoxication and related problems.

Journal Article↗