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     

Housing and harm reduction: What is the role of harm reduction in addressing homelessness?

Homelessness and drug use often overlap and the harms of substance use are exacerbated by homelessness. Responding to the twin problems of homelessness and substance use is an important aspect of strategies to end homelessness. The introduction and development of ten year plans to end homelessness in North America heralds a new era of systemic responses to homelessness. Central to many of these plans is the adoption of ‘Housing First’ as a policy response. Housing First focuses directly on housing people regardless of current patterns of substance use. As such, harm reduction is a key principle of Housing First. In this paper, we examine Housing First as an example of the integration of housing and harm reduction and then put forth a community level policy framework to further promote the integration of harm reduction as part of a response to homelessness. Drawing on Rhodes’ risk environment framework and current evidence of Housing First and harm reduction, we describe four key policy areas for action: (1) social inclusion policies; (2) adequate and appropriate supply of housing; (3) on demand harm reduction services and supports and (4) systemic and organizational infrastructure. We conclude by identifying areas for future research.     

Harm reduction in Australia: has it worked? A review

The literature is reviewed with a view to determining what evidence exists for the success of Australia's policy of harm minimization in relation to drug use. While there are relatively few examples of strategies which can unequivocally be said to have succeeded, there are many more for which the evidence is suggestive. While there has been a considerable mushrooming of research since the advent of the National Campaign on Drug Abuse, it would appear that little of this has measured the extent to which harm has been reduced. The National Drug Strategy would benefit from more policy-orientated research which measures drug-related harm if it is to be, as claimed, research driven.     

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

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

What is the transport-limiting barrier in iontophoresis?

We document evidence that the major rate-limiting step in iontophoretic drug delivery of low molecular weight charged solutes can be dermal perfusion at the site of application; for high molecular weight solutes, on the other hand, transport to the site of microcirculation uptake may, in some circumstances, become the slowest step.     

What is the role of harm reduction when drug users say they want abstinence?

Quantitative survey data indicate that most drug users starting treatment want abstinence rather than harm reduction (McKeganey et al., 2004). This finding has been seized upon by those seeking ‘evidence’ that abstinence is the bedrock of recovery and harm reduction is a negative and oppositional philosophy. However, all research involves questions of meaning, definition and value and an alternative research paradigm and different study design can provide important additional insights into treatment aspirations, including the desire for abstinence. Qualitative interviews conducted with 30 recovering heroin users (15 males and 15 females) in Southern England in 2009 confirm that those starting treatment often report a desire for abstinence. Nonetheless, drug users are frequently uncertain about their ability to achieve this and can have very different and inconsistent understandings of what being abstinent means. We suggest that the work of the critical theorist [Habermas, 1970] and [Habermas, 1991] could improve our understanding of abstinence and is consistent with recent efforts to achieve a working definition of recovery. Importantly, our qualitative data also reveal that drug users have treatment aspirations that extend far beyond their drug consumption. They additionally want to improve relationships, engage in meaningful activities, acquire material possessions, and achieve better mental and physical health. Moreover, these broader life goals are often inextricably linked to their drug taking. From this, we conclude that both abstinence and harm reduction discourses should more routinely prioritise the many diverse ‘wellness’ goals that so clearly motivate treatment clients. The harm reduction field will then likely find that it has more in common with abstinence-oriented services and the broader recovery agenda than it might otherwise have imagined.     

What is the role of NSAIDs in pre-emptive analgesia?

NSAIDs inhibit the cyclo-oxygenase enzymes, and decrease peripheral and central prostaglandin production. In addition to reducing the inflammation that accompanies tissue injury, decreasing prostaglandin production attenuates the response of the peripheral and central components of the nervous system to noxious stimuli. Such a reduction in the response to pain can reduce the peripheral and central sensitisation induced by noxious stimuli, and reduce the pain experienced in response to subsequent noxious stimuli. These properties would seem to make NSAIDs ideal drugs to use in a pre-emptive fashion, where analgesics are administered prior to a noxious stimulus, such as surgery, with the expectation that reduction in peripheral and central sensitisation will lead to a decrease of pain.However, the available perioperative trials of pre-emptive NSAID use have yielded modest or equivocal results, and these may be due, in part, to controversy associated with the definition of pre-emptive analgesia and how to conduct the corresponding clinical trials. Although NSAIDs may have a limited ability by themselves to induce a pre-emptive analgesic effect, the available trials suggest how the perioperative use of these drugs may be made more effective. It is expected that NSAIDs will play an increasing role in multimodal analgesia and pain relief in general.     

Systemic antifungal agents. What is in the pipeline?

With the increase in serious and often life-threatening fungal infections over the last 2 decades, there has been an enhanced effort to bring new antifungal agents into the therapeutic armamentarium. The introduction of new agents into the clinical setting has been slow, in part because several drugs which appeared promising in vitro and in short term animal studies later proved to be toxic. Toxicity has been a major hurdle in the development of antifungal agents because mammalian cells, in contrast to bacterial cells, share with fungal cells many structures and metabolic pathways. For example, the 2 most common classes of antifungal agents, polyenes and azoles, target the synthesis of the cell membrane, a structure shared by both mammalian and fungal cells, and thus these drugs have inherent toxicity. Antifungal agents that act on protein synthesis are also inherently toxic to mammalian as well as fungal cells. New agents that target the fungal cell wall, a structure with no homology in mammalian cells, may prove to be less toxic and are currently of great interest.