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PubMed1995

Groundwork for a research programme on harm reduction in alcohol and drug treatment.

The aim of this article is to set out the groundwork for a research programme for harm reduction in alcohol and drug treatment. First, attitudes to science of those who work in the harm reduction field are discussed and it is argued that hostility to the introduction of conventional scientific methods to this field is seriously misguided. Harm reduction activity is then defined as an attempt to ameliorate the adverse health, social or economic consequences of mood-altering substances without necessarily requiring a reduction in the consumption of these substances, and this definition is amplified. Finally, issues relevant to the measurement of outcome from harm reduction interventions are discussed by comparing Newcombe's classification of drug-related harms with an existing instrument designed to measure outcomes from interventions in the drugs field (the Opiate Treatment Index).

Journal Article↗

PubMed2005

UN leadership and harm reduction: a rough road.

An unprecedented coalition of over 300 harm reduction, human rights and HIV/AIDS-focused NGOs from around the world worked together in support of harm reduction in the lead-up to the annual session of the UN Commission on Narcotic Drugs (CND) in March 2005.

HIV Infections↗

PubMed1999

Researching harm reduction--care and contradictions.

This paper sets out to identify why research is important in realizing the potential a harm-reduction framework has for informing policy and practice in relation to all psychoactive drugs. In doing so it includes examples of research about alcohol and tobacco, since legitimizing the harm-reduction approach requires strengthening the research foundation across both licit and illicit drugs. There are some practical as well as ethical and theoretical complexities in conducting research in this area, some of which are novel or exaggerated using harm-reduction principles. Potential impediments to research are identified. Articulation of these complexities might help to facilitate research which can help to determine the validity of harm reduction. The notion of the researchers "duty of care" might offer a way of deciding among competing accountabilities, but needs further articulation to be useful. [Translations are provided in the International Abstracts Section of this issue.]

Alcoholism↗

PubMed2004

Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP).

AIMS: The School Health and Alcohol Harm Reduction Project (SHAHRP study) aimed to reduce alcohol-related harm in secondary school students. DESIGN: The study used a quasi-experimental research design in which randomly selected and allocated intervention and comparison groups were assessed at eight, 20 and 32 months after baseline. SETTING: Metropolitan, government secondary schools in Perth, Western Australia. PARTICIPANTS: The sample involved over 2300 students. The retention rate was 75.9% over 32 months. INTERVENTION: The evidence-based intervention, a curriculum programme with an explicit harm minimization goal, was conducted in two phases over a 2-year period. MEASURES: Knowledge, attitude, total alcohol consumption, risky consumption, context of use, harm associated with own use and harm associated with other people's use of alcohol. FINDINGS: There were significant knowledge, attitude and behavioural effects early in the study, some of which were maintained for the duration of the study. The intervention group had significantly greater knowledge during the programme phases, and significantly safer alcohol-related attitudes to final follow-up, but both scores were converging by 32 months. Intervention students were significantly more likely to be non-drinkers or supervised drinkers than were comparison students. During the first and second programme phases, intervention students consumed 31.4% and 31.7% less alcohol. Differences were converging 17 months after programme delivery. Intervention students were 25.7%, 33.8% and 4.2% less likely to drink to risky levels from first follow-up onwards. The intervention reduced the harm that young people reported associated with their own use of alcohol, with intervention students experiencing 32.7%, 16.7% and 22.9% less harm from first follow-up onwards. There was no impact on the harm that students reported from other people's use of alcohol. CONCLUSIONS: The results of this study support the use of harm reduction goals and classroom approaches in school drug education.

Adolescent↗

PubMed2004

Harm reduction and the global drug control regime: contemporary problems and future prospects.

Countries committed to a harm-reduction approach to drugs have exploited the latitude which exists within the UN global drug control regime to implement strategies which deviate from the strict prohibition ethos of the conventions. These nations risk pressure being brought to bear through the UN drug control regime, principally by the United States, determined to prevent what it sees as foreign challenges to its domestic 'zero tolerance' approach and its internationalisation. In this paper, based on his presentation to the International Conference on the Reduction of Drug Related Harm in Melbourne this year, David Bewley-Taylor, describes the conventions and the 'wiggle room' which exists, but also imagines ways like-minded states might together challenge and reform the conventions so that harm reduction can be accepted and hard wired into the UN drug control system itself.

Acquired Immunodeficiency Syndrome↗

PubMed2006

Harm reduction services for British Columbia's First Nation population: a qualitative inquiry into opportunities and barriers for injection drug users.

BACKGROUND: Aboriginal injection drug users are the fastest growing group of new Human Immunodeficiency Virus cases in Canada. However, there remains a lack of comprehensive harm reduction services available to First Nation persons, particularly for First Nation people dwelling in rural and reserve communities. This paper reports findings from an exploratory study of current harm reduction practices in First Nation communities. The purpose of this study was to provide an overview of the availability and content of current harm reduction practices, as well as to identify barriers and opportunities for implementing these services in First Nation communities. METHODS: Key informant interviews were conducted with 13 addictions service providers from the province of British Columbia, Canada. RESULTS: Participants identified barriers to these services such as community size and limited service infrastructure, lack of financial resources, attitudes towards harm reduction services and cultural differences. CONCLUSION: It was recommended that community education efforts be directed broadly within the community before establishing harm reduction services and that the readiness of communities be assessed.

Journal Article↗

PubMed2006

Putting at risk what we know: reflecting on the drug-using subject in harm reduction and its political implications.

This paper provides a poststructuralist analysis of the cultural inscription of drug-using subjects in the neo-liberal discourses of contemporary harm reduction. We argue that although neo-liberal discourses downplay material constraints on individual human agency, divert policy and practice away from structural issues, limit the conception of effective strategies for harm reduction and ignore alternative formulations of the subject, they are also potentially empowering for drug users. Approximating the neo-liberal subject offers political benefits in terms of recognition, trust and legitimation, even as those values assume and reproduce understandings of behaviour, thought and sociality that fit only poorly the realities faced by many drug users. We explore this dilemma and consider three available directions in formulating the subject of harm reduction: (1) embracing the neo-liberal subject; (2) employing a more contextualised version of the neo-liberal subject; and (3) adopting alternative notions of subjectivity, extending the critique of the neo-liberal subject to all citizens, not solely drug users. To clarify some of these issues surrounding this strategic process, the paper considers another field in which struggles over the nature of the subject have been conducted--feminism. The intention is not to resolve the question of the most appropriate subject for harm reduction, but to sketch the political consequences of adopting particular models of the subject as a stimulus to further discussion and debate.

Culture↗

PubMed2006

Deconstructing anti-harm-reduction metaphors; mortality risk from falls and other traumatic injuries compared to smokeless tobacco use.

Anti-harm-reduction advocates sometimes resort to pseudo-analogies to ridicule harm reduction. Those opposed to the use of smokeless tobacco as an alternative to smoking sometimes suggest that the substitution would be like jumping from a 3 story building rather than 10 story, or like shooting yourself in the foot rather than the head. These metaphors are grossly inappropriate for several reasons, notably including the fact that they are misleading about the actual risk levels. Based on the available literature on mortality from falls, we estimate that smoking presents a mortality risk similar to a fall of about 4 stories, while mortality risk from smokeless tobacco is no worse than that from an almost certainly non-fatal fall from less than 2 stories. Other metaphors are similarly misleading. These metaphors, like other false and misleading anti-harm-reduction statements are inherently unethical attempts to prevent people from learning accurate health information. Moreover, they implicitly provide bad advice about health behavior priorities and are intended to persuade people to stick with a behavior that is more dangerous than an available alternative. Finally, the metaphors exhibit a flippant tone that seems inappropriate for a serious discussion of health science.

Journal Article↗

PubMed2006

Assessing the feasibility of harm reduction services for MSM: the late night breakfast buffet study.

BACKGROUND: Despite the leveling off in new HIV infections among men who have sex with men (MSM) in San Francisco, new evidence suggests that many recent HIV infections are linked with the use of Methamphetamine (MA). Among anonymous HIV testers in San Francisco, HIV incidence among MA users was 6.3% compared to 2.1% among non-MA users. Of particular concern for prevention programs are frequent users and HIV positive men who use MA. These MSM pose a particular challenge to HIV prevention efforts due to the need to reach them during very late night hours. METHODS: The purpose of the Late Night Breakfast Buffet (LNBB) was to determine the feasibility and uptake of harm reduction services by a late night population of MSM. The "buffet" of services included: needle exchange, harm reduction information, oral HIV testing, and urine based sexually transmitted infection (STI) testing accompanied by counseling and consent procedures. The study had two components: harm reduction outreach and a behavioral survey. For 4 months during 2004, we provided van-based harm reduction services in three neighborhoods in San Francisco from 1-5 a.m. for anyone out late at night. We also administered a behavioral risk and service utilization survey among MSM. RESULTS: We exchanged 2000 needles in 233 needle exchange visits, distributed 4500 condoms/lubricants and provided 21 HIV tests and 12 STI tests. Fifty-five MSM enrolled in the study component. The study population of MSM was characterized by low levels of income and education whose ages ranged from 18-55. Seventy-eight percent used MA in the last 3 months; almost 25% used MA every day in the same time frame. Of the 65% who ever injected, 97% injected MA and 13% injected it several times a day. MA and alcohol were strong influences in the majority of unprotected sexual encounters among both HIV negative and HIV positive MSM. CONCLUSION: We reached a disenfranchised population of MA-using MSM who are at risk for acquiring or transmitting HIV infection through multiple high risk behaviors, and we established the feasibility and acceptability of late night harm reduction for MSM and MSM who inject drugs.

Journal Article↗

PubMed2004

Nonpharmacological harm-reduction interventions in British substance-misuse services.

The present study was designed to assess the acceptability and availability of harm-reduction interventions, including needle exchange, education regarding safer drug-ingestion methods, complementary/alternative therapies, and safe places where problem drinkers and drug takers may stay after consumption or may consume substances on the premises. We surveyed a nationwide sample of agencies listed in directories of substance-abuse services in England, Wales, and Scotland. Seventy percent (436 of 623 eligible agencies) returned questionnaires. Except for the provision of a safe place where clients could consume their own alcohol and drugs, large majorities of responding agencies rated these harm-reduction options as somewhat or completely acceptable, but only harm-reduction education and alternative therapies were available from a majority of responding agencies.

Attitude of Health Personnel↗

PubMed2005

Harm reduction interventions, behaviours and associated health outcomes in France, 1996-2003.

AIMS: To track the effect of the French harm reduction programme targeted at intravenous drug users (IDUs) and associated health outcomes. MATERIAL: Since 1996, we have collected monthly sales of sterile syringes and substitution treatments (buprenorphine high dosage and methadone) sold to IDUs in the 23 000 pharmacies in France and collated these figures in a single data base (SIAMOIS). To this data base we have also added the number of syringes distributed through community associations, as well as methadone treatments prescribed in public drug dependence clinics. METHODS: For the period 1996-2003 we analysed syringe sales and prescribed substitution treatments as indicators of access to harm reduction services. We compared variations of these figures over time with trends in health outcome indicators [annual number of fatal overdoses, hepatitis C virus (HCV) and human immunodeficiency virus (HIV) prevalence among intravenous drug users], risk behaviour indicators (rate of syringe sharing or rate of syringe re-use) and legal indicators (heroin and cocaine use-related arrests). FINDINGS: The number of sterile syringes sold or distributed to IDUs increased from 1996 to 1999 (+ 21%) and then decreased dramatically from 1999 to 2003 (-40%). In 2003, we estimated that more than 100,000 drug users used substitution treatments. Between 1996 and 2003, a decrease in syringe sharing and syringe re-use was observed, HIV prevalence among IDUs decreased from 40% to 20% and HCV prevalence remained high (60-70%). From 1996 to 2003, arrests due to heroin use declined (from 17 328 to 4025) and deaths due to overdoses also decreased (from 465 to 89), whereas arrests for cocaine use increased from 1184 to 2511. CONCLUSION: Our results indicate that, since 1996 in France, IDUs have had greatly improved access to sterile syringes and substitution treatments. The decrease in syringe sharing and re-use practices and of HIV prevalence during the same time period indicates that the harm reduction policy implemented in France has had a positive impact. However, because of the persistent sharing and re-use of syringes and a remaining high HCV prevalence in IDUs, efforts to facilitate access to sterile syringes must continue, and targeting of at-risk groups must be improved. Behavioural surveys associated with HIV and HCV seroprevalence data are needed to further assess prevention of blood-borne infections among IDUs in France.

France↗

PubMed2004

Targeting HIV-related outcomes with intravenous drug users maintained on methadone: a randomized clinical trial of a harm reduction group therapy.

Methadone maintenance programs (MMP) have the potential to play an important role in reducing HIV risk, given the appropriate type and level of ancillary treatments. In this study, we investigated the efficacy of a 12-session harm reduction group intervention for injection drug users, based upon the Information-Motivation-Behavioral skills model of behavior change, that focused on reducing both drug and sex risk. Two hundred and twenty patients entering an MMP were randomized to receive either standard care (SC)-2 hours of counseling per month and a single-session risk reduction intervention-or SC plus the harm reduction group (HRG). Results showed that during treatment, patients receiving HRG were more likely to be abstinent from cocaine and to report fewer unsafe sexual practices. Post-treatment, HRG patients scored higher on a sexual risk quiz and reported increased self-efficacy in high risk sexual situations. Enhancing methadone maintenance with a weekly harm reduction group treatment was somewhat more expensive but can bring about positive changes in behaviors and attitudes that are associated with the transmission of HIV.

Adult↗

PubMed2001

Putting harm reduction into an adolescent context.

Drug use is now widespread amongst Australian youth. Substance abuse and dependence are becoming increasingly significant health problems. Approximately 50% of 17-year-old Australians report regular consumption of alcohol and nearly 30% report tobacco smoking. The age of onset of substance use is reported to be decreasing. Between 1993 and 1995 the proportion of heroin users who had used the drug before the age of 16 years increased from 2% to 14%. The debate about youth substance use tends to be polarized between the views of Zero Tolerance and Legalization of drugs. The harm reduction approach spans between these two extremes. Examples of harm reduction strategies, such as education campaigns on safe injecting and needle exchange programs, have been effective in curbing the spread of blood-borne viruses such as HIV amongst intravenous drug using youth. The harm reduction approach, taking social context and developmental stage of the individual into account, may also be applied to adolescents at the less extreme end of the substance use spectrum. It is proposed that the harm reduction framework used in this way enables a rational, relevant and consistent response to contemporary youth substance use, aiming to minimize drug related harm.

Adolescent↗

PubMed2006

Impact of a harm-reduction policy on HIV and hepatitis C virus transmission among drug users: recent French data--the ANRS-Coquelicot Study.

In France a harm-reduction policy was implemented in the late 1980s with the aim of reducing the prevalence of HIV and hepatitis C virus (HCV) infection among drug users. The ANRS-Coquelicot survey was designed to measure the prevalence of HIV and HCV infection among drug users and to examine determinants of at-risk behaviors. In 2002, information was collected from 166 drug users recruited in all types of services specializing in drug use intervention and harm reduction in Marseille, France. Self-reported HIV and HCV serostatus was compared with the results of serological tests done on capillary blood collected on filter paper. The self-reported and biologically documented prevalence rates of HIV infection were identical (22%). In contrast, the self-reported prevalence of HCV infection was 52%, whereas the biologically documented prevalence was 73%. Overall, 30% of HCV-infected drug users were unaware of their status. Forty-four percent of drug users under 30 years of age were HCV seropositive, suggesting that they had been infected early during drug use. The harm-reduction policy seems to have had a marked impact on HIV transmission among drug users but a much more limited impact on HCV transmission. The limitations and implications of the study are discussed.

Adult↗

PubMed2006

[Limited impact of the harm-reduction policy on HCV among drug-users. The ANRS-Coquelicot survey example].

BACKGROUND: In France, a harm-reduction policy was implemented in the late 1980s with the aim of reducing the prevalence of HIV and hepatitis C virus infection among drug users. The ANRS-Coquelicot survey was designed to measure the prevalence of HIV and HCV infection among drug users, and to examine determinants of at-risk behaviors. METHODS: In 2002, information was collected from 166 drug users recruited in all types of services specializing in drug use and harm reduction in Marseille, France. Self-reported HIV and HCV serostatus was compared with the results of serological tests done on capillary blood collected on filter paper. RESULTS: The self-reported and biologically documented prevalence rates of HIV infection were identical (22 %). In contrast, the self-reported prevalence of HCV infection was 52 %, while the biologically documented prevalence was 73 %. Overall, 30 % of HCV-infected drug users were unaware of their status. Forty-four per cent of drug users under 30 years of age were HCV-seropositive, suggesting that they had been infected early during drug use. CONCLUSION: The harm-reduction policy seems to have had a marked impact on HIV transmission among drug users, but a much more limited impact on HCV transmission.

Adult↗

PubMed2003

Drugs, prisons, and harm reduction.

The use of drugs in society raises important considerations for health and social policy. Critical health and social care issues arise when drugs are used inside prisons. This paper argues that there is an urgent need for prison drug policies to adopt the principles of harm reduction. However, current policy orthodoxy emphasises the control of drugs and punishment for drug taking. Key components of harm reduction are operationalised in this article by exploring the potential for harm reduction in prison within the context of English drug policy. Whilst the focus is on English policy debates, the discussion will have wider international resonance.

Community Health Services↗

PubMedDate not supplied

Integrating harm reduction therapy and traditional substance abuse treatment.

One-size-fits-all therapy has not worked well for a majority of substance users seeking help. New approaches to substance abuse treatment are desperately needed. Traditional models of service delivery offer little, if any, help to people who may not choose abstinence as a goal. To address this concern, the Bridging the Gap Conference was sponsored by the San Francisco Department of Public Health. The overall goals of the conference were to improve standards of care, develop best practice principles for integrating harm reduction approaches into traditional substance abuse services, and increase the accessibility of quality services to people in need of alcohol and drug treatment. G. Alan Marlatt gave a keynote address on the integration of harm reduction therapy into traditional treatment services, an expanded version of which is presented in this article. Such integration would broaden the scope of services available to a larger group of consumers of substance abuse treatment. Furthermore, harm reduction therapy would infuse traditional treatment practices with scientifically-based pragmatism that pays close attention to individual and community public health needs. Because of its tolerance of treatment goals other than abstinence, harm reduction therapy offers the greatest hope to expand the availability of substance abuse services to people who have not benefited from traditional abstinence-based treatment models.

Health Personnel↗

PubMed2001

Ignoring 'downstream infection' in the evaluation of harm reduction interventions for injection drug users.

Harm reduction interventions to reduce blood-borne disease incidence among injection drug users (IDUs). A common strategy to estimate the long-term impact of such interventions is to examine short-term incidence changes within a specific group of individuals exposed to the intervention. Such evaluations may overstate or understate long-term program effectiveness, depending upon the relationship between short-term and long-term incidence and prevalence. This short paper uses steady-state comparisons and a standard random-mixing model to scrutinize this evaluation approach. It shows that evaluations based upon short-term incidence changes can be significantly biased. The size and direction of the resulting bias depends upon a simple rule. For modest interventions, such analyses yield over-optimistic estimates of program effectiveness when steady-state disease prevalence exceeds 50% absent intervention. When steady-state prevalence is below 50%, such analyses display the opposite bias.

Blood-Borne Pathogens↗