Harm Reduction: Policy and Practice

Diane Riley & Pat O'Hare

Diane Riley
Canadian Foundation for Drug Policy
& International Harm Reduction Association
P.O. Box 84596, 2336 Bloor Street West
Toronto, Ontario M6S 1T0 Canada
Tel: 416 604 1752 email: [email protected]

Pat O'Hare
International Harm Reduction Association/International Journal of Drug Policy
United Kingdom

The Nature and Origins of Harm Reduction

Harm-reduction is a relatively new social policy with respect to drugs which has gained popularity in recent years, especially in Australia, Britain and the Netherlands, as a response to the spread of Acquired Immune Deficiency Syndrome (AIDS) among injection drug users. Although harm reduction can be used as a framework for all drugs, including alcohol, it has primarily been applied to injection drug use (IDU) because of the pressing nature of the harm associated with this activity.

Harm-reduction has as its first priority a decrease in the negative consequences of drug use. This approach can be contrasted with abstentionism, the dominant policy in North America, which emphasizes a decrease in the prevalence of drug use. According to a harm-reduction approach, a strategy which is aimed exclusively at decreasing the prevalence of drug use may only serve to increase various drug-related harms. Harm reduction tries to reduce problems associated with drug use and recognizes that abstinence may be neither a realistic nor a desirable goal for some, especially in the short term. This is not to say that harm reduction and abstinence are mutually exclusive but only that abstinence is not the only acceptable or important goal. Harm reduction involves setting up a hierarchy of goals, with the more immediate and realistic ones to be achieved in steps on the way to risk-free use or, if appropriate, abstinence; it is consequently an approach which is characterized by pragmatism.

Harm reduction has received impetus over the last decade because of the spread of AIDS: drug use is one of the risk behaviors most frequently associated with HIV. In some areas, injection drug use (IDU) has become the main route of drug administration, and globally it is now one of the primary risk factors for HIV infection. In some areas of the world, injection of drugs accounts for more than 80% of AIDS cases. What is more significant still is the rate at which HIV can spread amongst injection drug users. In cities such as Barcelona, Edinburgh, Milan and New York, between 50 and 60% of drug users have become infected. In Thailand, where less than 1% of users were infected in January of 1988, over 40% were positive by September of that year, with a monthly incidence rate of 4 per cent. In Canada, prevalence rates among injection drug users have reached 35% in Vancouver and 20% in parts of Montreal; incidence rates in several Canadian cities are above 10%, some of the highest levels in the developed world.

In all countries, HIV infection is not just a concern for the drug users themselves but also for their sexual partners. Worldwide, between 60 and 100% of heterosexually acquired HIV is related to IDU; at least 40% of IDUs are in relationships with non-users. Because of sexual spread from injection-drug using partners and because approximately one third of IDUs are female, vertical spread to newborn children occurs. The possibility of transmission to the non-injecting community is increased by the fact that prostitution is sometimes used as a means of obtaining money for drugs and many prostitutes are regular or occasional injectors. In addition, IDUs are a potential source of perinatal transmission: most pediatric AIDS cases in the United States are associated with injection drug use by one or both parents.

AIDS has thus been a catalyst for the rise in popularity of harm reduction but in North America in particular harm reduction attracted attention because of effects of drug prohibition other than the spread of AIDS alone. The violent crime, gang warfare, prison over-crowding and police corruption associated with prohibition have reached a level such that policy makers, practitioners and members of the public alike are seeking alternatives to prohibitionist drug policy. It has been claimed that attempts to legislate and enforce abstinence are counterproductive and that there are harms due to these measures which are far worse than the effects of the drugs themselves. The harm reduction approach attempts to identify, measure and minimize the adverse consequences of drug use at a number of levels: individual, community (family, friends, colleagues etc.) and societal.

The roots of harm reduction as we now know it are in the United Kingdom, the Netherlands and North America. In the 1980s, three important factors led to the establishment of the Mersey model of harm reduction in the UK: the ability of physicians to prescribe drugs, including heroin; the early establishment of syringe exchanges; and the cooperation of the local police. All of the available evidence on HIV infection among IDUs in Merseyside suggests that the Mersey HIV prevention strategy for IDUs is very effective, with extremely low levels of HIV in drug users and a decrease in drug-related acquisitive crime in many parts of the region, while the national rate is increasing.

In the early 1980s Amsterdam recognized that drug use is a complex, recurring behavior and that reduction of harm means providing medical and social care in order to avoid some of the more harmful consequences of injection drug use. Needle exchange began in 1984 and since then many Dutch cities have taken a pragmatic and non-moralistic attitude toward drugs that has resulted in a multifaceted system which offers a variety of harm reduction programs. Police in the Netherlands focus attention and resources on drug traffickers, not users.

Methadone maintenance programs for opiate users began in Canada in the late 1950s and in the United States in the early 1960s. The spread of AIDS in opiate users has led to expansion and liberalizing of methadone programs in a number of countries with good results, but many other countries, including Canada and the United States, are slow to provide an adequate response to the AIDS crisis.

A number of countries or regions have adopted harm reduction as both policy and practice. For example, the British Advisory Council on the Misuse of Drugs has stated: "we have no hesitation in concluding that the spread of HIV is a greater danger to individual and public health than drug misuse. Accordingly, services which aim to minimize HIV risk behavior by all available means should take precedence in developmental plans" (1988; para. 2.1). The World Health Organization has expressed a similar opinion, stating that policies aimed at reduction of drug use must not be allowed to compromise measures against the spread of AIDS (WHO, 1986).

Features of Harm Reduction
The main characteristics or principles of harm reduction are:
Pragmatism: Harm reduction accepts that some of use of mind-altering substances is inevitable and that some level of drug use is normal in a society.
Humanistic Values: The drug user's decision to use drugs is accepted as fact, as his or her choice; no "moralistic" judgment is made either to condemn or to support use of drugs, regardless of level of use or mode of intake. The dignity and rights of the drug user are respected.
Focus on Harms: The extent of a person's drug use is of secondary importance to the harms resulting from use.
Balancing Costs and Benefits: Some pragmatic process of identifying, measuring, and assessing the relative importance of drug-related problems, their associated harms, and costs/benefits of intervention is carried out in order to focus resources on priority issues. The framework of analysis extends beyond the immediate interests of users to include broader community and societal interests.
Hierarchy of Goals: Most harm-reduction programs have a hierarchy of goals, with the immediate focus on addressing the most pressing needs.

At present there is no agreement in the addictions literature or among practitioners as to the definition of harm reduction. Harm reduction can be viewed as both a goal and a strategy. A more narrow definition of harm reduction as a strategy rather than as a goal removes some of the confusion. As a specific strategy, the term harm reduction generally refers to only those policies and programs which aim at reducing drug-related harm without requiring abstention from drug use. Thus defined, harm reduction strategies would not include strategies such as abstinence-oriented treatment programs or the criminalization of illicit drug use. So while drug policies and programs may be aimed at reducing drug-related harm, not all policies and programs with a goal of harm reduction are harm reduction strategies. A harm reduction approach to a person's drug use in the short term does not rule out abstinence in the longer term. Indeed, harm reduction approaches are often the first step towards the eventual cessation of drug use.

Harm Reduction Programs and Policies

Syringe Exchange and Availability
Needle and syringe exchange programs were first established in a few European countries in the mid-1980s and, by the end of the decade, were operating in numerous cities around the world. The rationale behind syringe exchanges is that many people who are currently injecting are unable or unwilling to stop, and intervention strategies must help reduce their risk of HIV infection and transmission to others. Provision of sterile needles and syringes is a simple, inexpensive way to reduce the risk of spreading HIV infection. It is also a way of providing contact with drug users through outreach services.

Methadone Programs
Methadone is a synthetic substitute for opiates which is much longer lasting in its effects, thereby reducing the need for the user to resort to street drugs. There have been numerous studies on the effectiveness of methadone and the vast majority of these have shown that it reduces deaths, reduces the users' involvement in crime, curbs the spread of HIV and hepatitis and helps drug users to gain control of their lives.

Prescribing of Drugs other than Methadone
In a tradition dating back to the 1920s, physicians in the United Kingdom prescribe drugs to users. The majority of clients receive oral methadone, but some receive injectable methadone, others injectable heroin, and a small number receive amphetamines, cocaine or other drugs. Based on the success of the British model in reducing drug-related harms, Switzerland has carried out a national experiment with prescribing of heroin to users over a three-year period. Results of the experiment show that a heroin maintenance program can be efficacious in that the health and well being of the users in the programs clearly improved. The authorities concluded that heroin causes very few, if any, problems when it is used in a controlled manner and is administered in hygienic conditions. Holland began a heroin maintenance experiment in 1998 and several German cities plan to begin programs. The feasibility of carrying out an experimental program of heroin prescription in North American cities is currently underway.

Education and Outreach Programs
Educational materials about drugs that have a harm reduction focus are readily available in a number of countries including the United Kingdom, Holland and Australia, but they remain extremely controversial and often unavailable, in most others. While not promoting drug use, such materials tell the user how to reduce the risks associated with using drugs, teaching such things as safer injecting practices.

Law Enforcement Policies
Merseyside Police in the northwest of England have devised a harm reduction approach known as "Responsible Demand Enforcement". Merseyside Police developed 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 injection drug users. The police are represented on Health Authority Drug Advisory Committees and employ Health Authority officers on police training courses involving the drugs/HIV issue. They have also supported the Health Authority by agreeing not to conduct surveillance on them, referring arrested drug offenders to services, not prosecuting for possession of syringes which are to be exchanged, and publicly supporting syringe exchange.

One of the most important features of the Merseyside Police strategy has been its emphasis on using resources to deal with drug traffickers while operating a cautioning policy toward drug users. "Cautioning", which has now been adopted to some extent by all Police Authorities in Great Britain, has been recommended by the Attorney General of the UK as an appropriate option for some classes of offense such as drug possession.

The overall effect of this policy is to steer users away from crime and possible imprisonment. In recent years the approach has been extended to ecstasy, amphetamine and cocaine as well as heroin. In the Netherlands, police have long been supportive of harm reduction programs, including de facto decriminalization of marijuana and tolerance zones; enforcement efforts are concentrated on large-scale traffickers and on ensuring a safe and peaceful environment. Some police stations in Amsterdam will provide clean syringes on an exchange basis. In Hamburg, Germany, a recent policy shift to harm reduction has been reflected in co-operation between police, health officials and drug users groups working together to help drug users access social services.

"Tolerance Areas"
One innovative harm reduction approach being practised in several European cities involves toleration by authorities of facilities known as "injection rooms", "health rooms", "contact centers" or similar terms. These are facilities where drug users can get together, and obtain clean injection equipment, condoms, advice, medical attention and so forth. The majority of these places allow users to remain anonymous. Some include space where drug users, including injectors, can take drugs in a comparatively safe environment. This is regarded as better than the open injection of illicit drugs in public places of consumption of drugs in "shooting galleries" that are usually unhygienic and controlled by drug dealers. The Sisters of Charity in Sydney, Australia, will open safe injection rooms on a pilot basis in early 2000.

Alcohol Programs
Moderate drinking programs: One means of reducing the harms associated with alcohol is to teach people to consume alcohol in a moderate or sensible manner.
Standard drink labels: "Standard serving" information involves stating the amount of ethyl alcohol in the container in relation to the amount of alcohol in a normal or "standard" serving.
Server intervention programs: One way to reduce the harms associated with immoderate alcohol consumption is to train servers to recognize and intervene to limit impairment in their patrons.

Nicotine Policies and Programs
Harm reduction approaches to nicotine products focus on reducing the harms to the user as well as to the inhaler of second-hand smoke. They include a wide range of approaches ranging through policies controlling smoking in public places to delivery of nicotine through gum, patches, inhalers and smokeless cigarettes.

Marijuana Policies
Several countries or parts thereof, including the Netherlands, South Australia and Germany have introduced de facto decriminalization of small amounts of cannabis as a harm reduction strategy. In each of the cases where marijuana law reform has occurred, the final decision was based on the fact that the costs associated with the existing system were seen to be too high by many segments of society and too many people were seen as being adversely affected by the existing laws. In all of the cases where de facto decriminalization of marijuana has occurred, reduced financial and social costs were achieved without an increase in the risks to the community associated with drug use in general. Other, longer term, benefits have stemmed from the separation of high and low risk drug markets.

The popularity of harm reduction on an international scale is evidenced by the increasing support for the International Conference on the Reduction of Drug Related Harm, now in its tenth year, and by the formation of the International Harm Reduction Association (IHRA). Despite the increase in popularity amongst workers in the field, many health and addictions agencies in North America and elsewhere remain ambivalent about harm reduction as it pertains to alcohol and other drugs. Harm reduction raises some difficult questions, but it is evident that it is better to debate these openly rather than to ignore them as has been done all too often in the past. Comprehensive harm-reduction programs that are culturally sensitive are necessary: harm reduction must be multifaceted, not just a singular intervention. The data regarding such drug-related consequences as AIDS make it clear that we need a long-term plan for harm reduction. Risk reduction is a social process, it is not something that public health officials can impose; an effective programs must provide multiple means for behavior change and needs to be conducted on a long-term basis.

Harm reduction, in the final analysis, is concerned with ensuring the quality and integrity of human life, in all its wonderful, awful complexity. Harm reduction does not portray issues as polarities, but sees them as they really are, somewhere in between; it is an approach that takes into account the continuum of drug use and the diversity of drugs as well as of human needs. As such, there are no clear-cut answers or quick solutions. Harm reduction, then, is based on pragmatism, tolerance and diversity: in short, it is both a product and a measure of our humanity.
Riley, D., & O'Hare, P., Harm Reduction: Policy and Practice, Prevention
Researcher, 7(2), 4-8, 2000