Harm Reduction History and Definitions
"Harm Reduction is anything that reduces the risk of injury whether or not the individual is able to abstain from the risky behavior. Inherently, it is a staged form of behavioral change, which is consistent with all the prevalent models of sexual and drug use behavior change and all the models of behavior change in these areas that have been shown to have some benefit."
-- David Ostrow, M.D., Ph.D.
"Harm Reduction differs from current models in that it does not require individuals to remove their primary coping mechanism until new coping mechanism are in place. Thus, creating an easier more obtainable avenue for desired behavioral change."
-- Michael Scavuzzo, Harm Reduction Advocate
Harm Reduction is a relatively new social policy which has gained popularity in Britain, the Netherlands and currently the United States. Although Harm Reduction can be used as a framework for all drugs, including alcohol, it has primarily been applied to injection drug use (IDU) as a way of slowing the spread of AIDS.
The first priority of Harm Reduction is to decrease the negative consequences of drug use. By contrast, drug policy in North America has traditionally focused on reducing the prevalence of drug use. Harm Reduction establishes a hierarchy of goals, with the more immediate and realistic ones to be achieved as first steps toward risk-free use or, if appropriate, abstinence.
Drug taking behaviors result in effects that are either beneficial (as in the case of life saving medication), neutral or harmful. Assigning a positive or negative value - a benefit or a harm - to such effects is subjective and open to controversy, but a Harm Reduction framework at least offers a pragmatic means by which consequences can be objectively evaluated.
In the UK, Harm Reduction can be traced back to the old "British System", which emerged as a result of recommendations of the Rolleston Committee of the1920s. This group of leading British physicians concluded that in certain cases maintenance on drugs may be necessary to help drug abusers lead useful lives.
To this day, injectable opiates are prescribed on a take home basis in Merseyside, a center for Harm Reduction policy serving the area around the port city of Liverpool. The Merseyside model developed in response to an epidemic spread of drug use, particularly heroin, in the early 1980s. The Merseyside clinics, pharmacists and police force worked together to establish a unique model of Harm Reduction, a comprehensive approach involving prescription of drugs, syringe exchange and helping rather than punishing drug users.
In the early 1980s Amsterdam recognized that drug use is a disorder and that medical and social care must be provided to clear the path toward natural recovery. The city's first needle exchange program in 1984 was operated by the "Junky Union", a recognized organization of injection drug users. Taking a pragmatic and non-moralistic attitude toward drug use, the city developed a variety of Harm Reduction programs.
While Harm Reduction is a relatively novel idea in North America, one of its earliest forms of methadone maintenance programs has operated here since the 1960s. Methadone maintenance for injection drug users was seen as Harm Reduction for society, usually in terms of reducing crime or restoring drug users to the work force. Today, the spread of AIDS in opiate users has led to an urgent re-examination of existing methadone programs.
A number of countries and organizations have now adopted Harm Reduction as both policy and practice. The British Advisory Council on the Misuse of Drugs (AMCD) concluded that the spread of HIV is a greater danger to individual and public health than drug misuse.
The World Health Organization has expressed a similar opinion, stating that attempts to reduce drug use must not compromise measures against the spread of AIDS. In 1987, the Canadian government adopted Harm Reduction as the framework for Canada's National Drug Strategy (CDS). It defined harm as "sickness, death, social misery, crime, violence and economic costs to all levels of government".
Injection Drug Use
In the United States, more than 30 per cent of reported AIDS cases are directly associated with a history of IDU, and in some areas of Europe, IDU accounts for as many as 60 per cent of cases. IDU is now associated with the most rapid transmission of the AIDS virus in many countries of the world.
The extremely rapid spread of HIV (Human Immunodeficiency Virus, thought to be necessary for AIDS) is a concern for IDUs and their sexual partners. Studies in the US and the UK have shown that 60-100 per cent of heterosexually acquired HIV is related to IDU, and that at least 40 per cent of IDUs are in relationships with non-users. In addition, more than 50 per cent of all pediatric AIDS cases in the US are associated with injection drug use by one or both parents.
Needle exchanges are a form of Harm Reduction applied to the enormous risks associated with IDU, arising primarily from the sharing of needles. Injectors frequently report sharing syringes because of difficulties in obtaining them. This is especially true where laws prohibit syringe possession, or where syringes are unavailable when needed (late at night, when buying drugs, or in prison).
Needle exchanges recognize that many IDUs are unable or unwilling to stop injecting, and that intervention must occur to reduce the risk of HIV infection. This type of strategy is based on a knowledge and means approach to behavioral change: people are provided with information about the changes that are needed and also with the means to make these changes - in this case, sterile needles, syringes and other "works" for administering drugs, and condoms.
In the US exchanges began to appear in 1988 and today there are more than 75 syringe exchange programs. In Canada, exchanges were opened unofficially in Toronto in 1987, and officially in Vancouver in 1989. There are now more than 30 exchanges operating across Canada.
There is reasonable evidence that injectors who attend syringe exchanges reduce their risk behavior. In Montreal, the Cactus exchange reported a decrease in use of dirty needles from 37 per cent to 26 per cent over six months, and an increase in cleaning (with bleach) from 83 per cent to 93 per cent of occasions. The Edmonton exchange reported that the longer users attended the service, the less likely they were to practice risky behaviors such as sharing of dirty needles.
Because of the time lag between behavior and detection of infection there is as yet only limited direct evidence that increasing the availability of clean injection equipment reduces the spread of HIV. However, there is ample evidence of what happens when clean needles are in short supply. HIV rates in New York City, for example, where syringe exchange is still illegal, have reached 60 percent among IDUs.
There is now also good evidence that syringe exchanges are successful at reaching large numbers of IDUs, many of whom are not in touch with other services and who have had little help in the past with drug problems. Increasingly cocaine and amphetamine users are coming to the services - a significant point since stimulant users are not often attracted to formal treatment services.
There are understandable concerns that Harm Reduction for IDUs will encourage existing use and help to recruit new drug users. As with methadone maintenance (see below), however, there is no evidence of increased drug use in any of the communities where syringe exchanges are operating. Estimates from around the world suggest that new recruits are not attracted into drug use and that the mean age of injection drug users has increased over time.
Methadone Treatment - A Drug Substitution Scheme
Methadone substitution therapy was pioneered in the United States in the early1960s. A synthetic opiate generally taken orally in the form of a liquid, methadone has many of the same properties as heroin and morphine although it is much longer lasting (24-48 hours versus 8 or less). The primary advantage of methadone is that it can reduce users contact with crime, the black market, and contaminated drugs. Because of its long lasting effects, methadone helps to keep users stabilized so that use becomes less frequent.
Methadone keeps clients in treatment, whereas there is a high drop-out rate with other forms of treatment such as psychotherapy. Proponents of methadone argue that the routine imposed on the user's life in obtaining methadone helps to eliminate a lifestyle that makes other rehabilitation efforts fail.
Methadone maintenance is a good means of preventing health problems such as hepatitis and AIDS. Evidence now suggests that heroin users enrolled in methadone treatment programs may have lower HIV seroprevalence than users not enrolled in treatment. There are data which support the effectiveness of methadone in reducing high-risk injecting behavior as well as reducing the risk of acquisition of HIV.
It is clear that methadone has a significant role to play in slowing the spread of AIDS, in reducing drug-related crime and associated costs and in the treatment of opiate dependence. However, some informed observers have argued that if methadone programs are to be truly cost-effective, some changes are needed to attract and retain clients, and to keep them from using other drugs.
For example, since methadone does not provide a "buzz", some clients look for this experience elsewhere, using methadone to keep them stable. One approach to this problem might be to supply sufficiently high levels of methadone to prevent injection. For those who still inject, supplying injectable methadone ampoules, with plenty of clean injection equipment, might be a solution. This approach is working successfully in Merseyside, England.
However, neither of these approaches has met with much approval in places where progress in methadone treatment is equated with low doses of methadone instead of with the patient's overall adjustment regardless of dose level. In a review of the role of drug treatment in AIDS prevention in the US, Edith Springer characterizes current methadone programs in North America as punitive applications of the "reward and punishment system" which sets up clients to lie to staff and prevents staff from counseling clients properly on their drug use and sexual behaviors.
Oral methadone is the only route of administration provided and staff are often poorly trained, especially in counseling. And yet, ". . . while the success rates for drug treatment are abysmally low, the staff and administrations continue to blame the clients rather than examine the treatment modalities and admit their crudeness and lack of relevance to their clients".
In Holland, methadone had been used in a Harm Reduction framework for several years before the peak of the AIDS epidemic, with the result that the rate of spread of HIV in drug users and their partners is now lower than it otherwise would have been. In Amsterdam, methadone is provided with a minimum of impediments in order to contact heroin users, to stabilize them, and to detoxify and treat them. A "methadone bus" program is used to distribute methadone throughout the drug-using community, but no take-home dosages are provided.
Clients are also assisted with problems concerning housing, financial and legal matters. They are also provided with regular medical examination.The primary disadvantages of some of the Dutch programs are reported to be that, like some of the US programs, they do not maintain all clients on levels of methadone high enough to prevent use of heroin, and they provide nothing other than oral methadone.
In all countries, one of the key factors underlying the success of methadone as a Harm Reduction measure is that it brings users back into the community rather than treating them like outsiders or criminals. This not only allows for rehabilitation of users, but it also breaks the drugs and crime cycle.
In Canada, several academics have suggested that methadone programs be expanded and made more accessible, flexible and liberal. This does not mean that treatment standards should be lowered. They cite research from around the world indicating that inflexible, low-level programs do not reduce injection drug use. The World Health Organization has recommended that wherever methadone maintenance is practiced additional programs be provided with less ambitious goals and objectives for injection drug users who may not be willing or able to enter other programs.
Policy makers and programmers are increasingly exploring the need for methadone programs in prisons and the advantages of offering methadone treatment as an alternative to imprisonment. Closer links between methadone clinics, general hospitals and AIDS clinics are viewed as a means of ensuring a more efficient response to the needs of the HIV-infected population.
Comprehensive Programs: The Mersey Model
At present, the only truly comprehensive Harm Reduction programs are in Merseyside, England. These include not only syringe exchange and outreach education, but also prescription of drugs other than methadone, and police involvement at several levels. In Merseyside, Harm Reduction services comprise needle exchange, counseling, prescription of drugs, including heroin, and employment and housing services. Many levels of service and a wide variety of agencies are involved and services are integrated to provide drug users with help when they need it.
Pharmacists play a vital role in the workings of the Merseyside system. Some pharmacists now fill prescriptions for smokable drugs in the form of "reefers" which provide an alternative to injection and produce the "buzz" that some IDUs crave. To prepare reefers, drugs such as heroin and methadone are injected into either herbal or regular cigarettes. Clients who have received injectable prescriptions for more than 10 years are now voluntarily switching to reefers in an attempt to stop injecting. In addition to reefers, the pharmacists dispense drugs in the form of ampoules, liquid, and aerosols.
At the end of June 1991, Mersey Region had the second lowest rate of HIV positive IDUs of all 14 English regions: eight per million population compared with an English national rate of 34, and a top rate of 136 per million in North-West Thames; the rate for the UK as a whole was 51, with Scotland registering a rate of 183 HIV-positive IDUs per million population. The Merseyside programs have also been successful in reducing crime. In 1990 and 1991, the Merseyside police were the only force in the UK to register a decrease in crime rates.
Health Promotion and Education
Harm Reduction acknowledges that policy makers, educators and health promoters can tell drug users how and why they should prevent harm, and provide them with the means to do it, but only the users themselves can actually prevent the harm. Research has clearly shown that users will change their behavior in response to information about safer use, and that this change is greater if skills training as well as the means to ensure safety are provided.
Until the 1980s (and even currently in the US), the main response to drug use among young people in many countries has been school and media drug education programs based on a primary prevention ("Say No to Drugs") approach. These approaches usually present information intended to demonstrate the adverse consequences of drug use. Criticism has been leveled at this process because of its tendency to exaggerate the dangers and to perpetuate certain convenient stereotypes. In addition, the "just say no" approach assumes, against evidence to the contrary, that a child's decision not to use drugs becomes much easier once he or she is acquainted with the consequences.
In fact, evaluations of primary prevention have shown that it has little or no impact on whether young people use drugs. Indeed, some studies suggest that excessive use of primary prevention may actually encourage drug use by creating a sense of mystique around the subject which appeals to children's natural curiosity.
Primary prevention assumes that drug use is abnormal and that drug users are deficient in knowledge, self esteem or skills. Yet some studies show that it is those with high self-esteem who are more likely to experiment with drugs. Moreover, research indicates that experimentation is an extremely poor predictor of long-term use or abuse. Primary prevention approaches also ignore the pleasure and other benefits of drug use and fail to acknowledge that decisions to try drugs are often expressions of independence.
This "deviancy amplification" divides users and non-users, and works against meaningful dialogue with adults. It does nothing to decrease harm and increase safety.The Harm Reduction approach to education focuses on non-judgmental information about different drugs, their properties and effects, about the law and legal rights, about how to reduce risks, and where to get help if needed. It helps youth to develop a wide range of skills in assessment, judgment, communication, assertiveness, conflict resolution, decision-making and safer use.
A number of countries have begun to apply the principles of Harm Reduction education to all drugs. For example, a wide-reaching Harm Reduction model of drug education and prevention is being developed in the UK. It is grounded in the realities of young people's drug use, and has realistic and practical aims. It recognizes that Harm Reduction education is about drugs rather than against drugs. Teaching begins in early years around familiar substances other than drugs, and emphasizes that most of the things we consume have the potential for both harm and benefit depending on the way we use them.
Harm Reduction education is based on humanitarianism, pragmatism and a scientific public health approach. The principles of Harm Reduction drug education are that drug use is normal; it is associated with benefits as well as risks; it cannot be eliminated altogether, but the harms can be reduced; many young people grow out of drug use; education should be non-judgmental; it requires an open dialogue with the young and respect for people's right to make their own decisions; and it emphasizes positive peer support, not divisiveness.
Law Enforcement Options
Problem-Solving Policing in Montreal
An innovative pilot project mounted by police to help a Montreal neighborhood troubled by drug-related crime appears to have struck a good balance between suppression of the drug supply and reduction of demand. The Montreal UrbanCommunity (MUC) police program in the city's Parc Extension district uses a get-tough approach with people caught selling drugs while offering treatment instead of jail to those found in simple possession.
"Parc Ex", as the area is known, was overrun with petty crime, drug trafficking and delinquency when the MUC police launched the program in April, 1992. A random survey conducted in the neighborhood indicated that residents were immobilized by fear and that an escalation in crime rates was inevitable. A special team of officers trained in "problem-solving policing" was put in place full time to attempt to reverse the neighborhood's downward spiral into crime, and to give residents a greater sense of personal safety.
The police visited drug treatment centers in the area to develop a better understanding of how they work and to meet addicts in treatment - the district has a high proportion of heroin users. On the street, police offered drug users support and assistance as an alternative to arrest for possession. Agreements were struck with detox and treatment centers in the area to allow people needing help to be referred there by police.
Evaluations carried out during the year-long pilot project indicated such a high level of success that the Parc Ex program has been renewed and is being extended to other neighborhoods.
Cautioning in Merseyside
The Merseyside police in the UK have become national leaders in developing a cooperative Harm Reduction strategy with the regional health authority to improve the prevention and treatment of drug problems, particularly with respect to the spread of HIV infection among IDUs. The police sit on health authority drug advisory committees and employ health authority officers on police training courses involving the drugs/HIV issue. They have also agreed not to conduct surveillance on treatment centers, to refer arrested drug offenders to services, to not charge for possession of syringes to be exchanged, and to publicly support syringe exchange.
A key feature of the Merseyside police strategy has been to use resources to deal with drug traffickers while operating a cautioning policy toward drug users. Cautioning involves taking an offender to a police station, confiscating the drug, recording the incident, and formally warning the offender that any further unlawful possession of drugs will result in prosecution in court. The offender must also meet certain conditions, such as not having a previous drug conviction and not having an extensive criminal record. The offender is also given information about treatment services in the area, including syringe exchanges.
The first time offenders are cautioned, they are not given a criminal record. On the second and third occasions they are sent to court and fined for possession of small quantities or sentenced for possession of large amounts. If an addict becomes registered by getting in touch with service agencies, then he or she is legally entitled to carry drugs for personal use. The overall effect of this policy is to steer users away from crime and possible imprisonment.
Interest in Harm Reduction world-wide has increased greatly in recent years, in part because of the advent of the International Conference on the Reduction of Drug-Related Harm in Liverpool, England, in 1990.
At the Fourth International Conference in Rotterdam in March, 1993, Dr. Marcus Grant of the World Health Organization (WHO) acknowledged the progress that Harm Reduction approaches have made toward "acceptability, even respectability". A mark of that new-found respectability is the fact that the Conference is coming to North America for the first time in March, 1994.
Harm reduction is a humane, cost-effective and ultimately sensible way to deal with drug-related problems. However, much work remains to be done to bring it to all who need it. Many barriers stand in the way of this effort. In his address to the Fifth International Conference, Dr. Grant emphasized that Harm Reduction is "for the whole world, not just the rich". One of the challenges for the future is to bring Harm Reduction to the developing world. Dr. Grant also expressed concern that society is too "battle-fatigued" by drug issues to look beyond the extremes of prohibition and blanket legalization.
Both options are too drastic, whereas Harm Reduction can provide a balance which does not now exist. Among barriers to acceptance of Harm Reduction in many countries is a widespread devotion to a limited definition of idealism. Harm Reduction accepts that some harm is inevitable, whereas the "ideal" of zero-tolerance excludes all compromise and sets impossible goals. In North America, total abstinence has long been seen as the only acceptable goal of treatment for abuse of legal drugs and the only acceptable "normal" state with respect to illicit drugs.
Harm Reduction expands those options, but in no way precludes the possibility of abstinence. Society's reluctance to view drug use as a legitimate form of risk taking poses another significant barrier to acceptance of Harm Reduction.
While societies tolerate and even encourage some far more dangerous forms of risk-taking (such as car racing, mountain climbing, boxing and bungee jumping), drugtaking is singled out as something inherently and primordial evil. Harm reduction, because it accepts the possibility of drug-taking under certain circumstances, is often viewed as promoting intolerable behavior.
Religious opposition, public apathy and confusion around drug policy, and a growing inability of nations to intervene in domestic social issues because of international trade and other agreements all present obstacles to the adoption of Harm Reduction principles. Because it operates in the gray areas between extremes, Harm Reduction is not easily defined and promoted.
It raises many legitimate questions: Who decides what constitutes a "harm" and in what order should harms be reduced? The prescribing of injectable drugs, for example, can reduce the risk of HIV and the rate of acquisitive crime, but other evidence suggests it might also prolong the habit of injecting.
Which course of action is more desirable and for whom? Harm Reduction does not provide clear-cut answers and quick solutions, but it has the capacity, if properly applied, to address difficult problems while not compromising the quality and integrity of human life in all its rich and diverse complexity.
As the motivating principle behind Canada's Drug Strategy, it charts a pragmatic and realistic course for this country with respect to drug policy. Italso obligates us to more clearly define Harm Reduction approaches and to carefully evaluate their impact. In the end, these approaches will stand as both a product and a measure of our humanity.
Chicago has also been grappling with the novel approaches born in harm reduction practice for years. Like other places, the biggest challenge for assimilation of Harm Reduction practice is the critical examination of the current system which is often based on abstinence-only.
Abstinence as the single and demanding focus of intervention with drug users has endured although it is not supported by research, common principles of human relating or effectiveness. Once subject to critical examination and comparison, many opt for the more compassionate and effective practice of harm reduction.
In Chicago, service providers continue to seek out information on harm reduction practice as they become open to another perspective. Hopefully, this tendency to critically evaluate our work will continue to be motivated by the HIV pandemic as well as the simple desire for effective options.