What are drug users looking for when they contact drug services: abstinence or harm reduction?

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying 'abstinence' as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited 'reduced drug use', and 7.4% cited 'stabilization' only. Less than 1% of respondents identified 'safer drug use' or 'another goal', whilst just over 4% reported having 'no goals'. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.     

Strengthening drug policy and practice through ethics engagement: an old challenge for a new harm reduction

Harm reduction proponents aim to identify and support policies and programmes that moderate or decrease the deleterious consequences of illicit drug use. While harm reduction is clearly a value-based response to drugs, for many, 'ethics' merely represent institutional research and professional practice regulations to be satisfied, subjective moral claims, or philosophy that is too abstract to offer tangible benefits in keeping with the pragmatism of harm reduction. In this paper we revisit the relationship between harm reduction and ethics, reframe ethics as a pragmatic concern for all of harm reduction, and argue that greater attention to the actual values and beliefs underpinning harm reduction can help to enhance policy, practice and research outcomes. Examples are given of early progress in this area to illustrate possible features of ethics engagement in harm reduction, and existing ethics materials are highlighted as suitable supporting resources for applied ethical decision-making in this field.     

Will modifying inhalants reduce volatile substance misuse? A review

Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying ‘abstinence’ as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited ‘reduced drug use’, and 7.4% cited ‘stabilization’ only. Less than 1% of respondents identified ‘safer drug use’ or ‘another goal’, whilst just over 4% reported having ‘no goals’. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.     

KEYNOTE ADDRESS FROM THE 7TH INTERNATIONAL CONFERENCE ON THE REDUCTION OF DRUG-RELATED HARM:Harm reduction and social policy: should addicts be paid?

Harm reduction principles have not been applied to social policy programs that affect drug users. This paper considers whether income supports for the drug-dependent poor might be harm reducing, given that a principal harm related to drug dependence is crime committed to finance drug use. We examine the political fate of the principal income support program in the United States that targeted the drug dependent. Revelations that the money was being used in part for the purchase of drugs has led to a scaling back and tightening of the program. We suggest that the program might have been more effectively defended if attention had been paid to community harms rather than only to drug consumption by recipients. European and Australian governments provide income support which is no doubt also used for drug consumption, but in the context of universalist income support programs they do not require a harm reduction defense. We conclude that great potential for reducing drug-related harm may fall well outside the domain of targeted drug policy, whether of the supply reduction, demand reduction or harm reduction variety.     

CROSS-CULTURAL APPROACHES TO HARM REDUCTION RESEARCH: SOME CONSIDERATIONS ON THE BRAZIL EXPERIENCE

Harm reduction initiatives for drug users comprise a range of approaches, including drug-user treatment, advocacy for changes in drug policy, needle exchange programs, bleach distribution, and broad-based interventions that focus on both safer drug use and less risky sexual behaviors. In many developing nations, harm reduction is a relatively new strategy, which focuses almost exclusively on the connections between drug use and the spread of HIV infection. In Brazil, harm reduction programs are few, and little has been documented about their scope, experience, and effectiveness. This paper reviews the status of Brazilian harm reduction initiatives in general, with a specific focus on lessons learned from the conduct of cross-national research in Rio de Janeiro. The study demonstrated the feasibility of implementing a community-based prevention program among an at-risk population of cocaine users in Brazil, and in other countries where there is little tradition of research with out-of-treatment drug users. Finally, the paper addresses aspects of the harm reduction movement that tend to hamper its progress in both developed and developing nations. [Translations are provided in the International Abstracts Section of this issue.]     

Assembling the dominant accounts of youth drug use in Australian harm reduction drug education

Education programs are a central element of Australian harm reduction drug policy. Considered less judgmental and more effective than the punitive policies of Australia's past, harm reduction drug education is premised on the goal of reducing ‘risks’ and harms associated with illicit drug use rather than an elimination of use per se. In this article I analyse two sets of key texts designed to reduce drug related harm in Australia: harm reduction teaching resources designed for classroom use and social marketing campaigns that are targeted to a more general audience. I identify two significant accounts of young people's drug use present in Australian harm reduction drug education: ‘damaged mental health’ and ‘distress’. I then draw on some of Deleuze and Guattari's key concepts to consider the harm reducing potential these accounts may have for young people's drug using experiences. To demonstrate the potential limitations of current drug education, I refer to an established body of work examining young people's experiences of chroming. From here, I argue that the accounts of ‘damaged mental health’ and ‘distress’ may work to limit the capacity of young drug users to practice safer drug use. In sum, current Australian harm reduction drug education and social marketing may be producing rather than reducing drug related harm.     

Cross-cultural approaches to harm reduction research: some considerations on the Brazil experience

Harm reduction initiatives for drug users comprise a range of approaches, including drug-user treatment, advocacy for changes in drug policy, needle exchange programs, bleach distribution, and broad-based interventions that focus on both safer drug use and less risky sexual behaviors. In many developing nations, harm reduction is a relatively new strategy, which focuses almost exclusively on the connections between drug use and the spread of HIV infection. In Brazil, harm reduction programs are few, and little has been documented about their scope, experience, and effectiveness. This paper reviews the status of Brazilian harm reduction initiatives in general, with a specific focus on lessons learned from the conduct of cross-national research in Rio de Janeiro. The study demonstrated the feasibility of implementing a community-based prevention program among an at-risk population of cocaine users in Brazil, and in other countries where there is little tradition of research with out-of-treatment drug users. Finally, the paper addresses aspects of the harm reduction movement that tend to hamper its progress in both developed and developing nations.     

Contested space in the pharmacy: Public attitudes to pharmacy harm reduction services in the West of Scotland

BackgroundInternationally, community pharmacies have become increasingly involved in providing harm reduction services and health advice to people who use illicit drugs.ObjectiveThis paper considers public opinion of community pharmacy services. It discusses attitudes to harm reduction services in the context of stigmatization of addiction and people who use drugs.MethodsThis exploratory study involved twenty-six purposively sampled members of the public, from the West of Scotland, participating in one of 5 focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, none of whom were problem drug users.ResultsThree thematic categories were identified: methadone service users in community pharmacies; attitudes to harm reduction policies; contested space. Harm reduction service expansion has resulted in a high volume of drug users in and around some Scottish pharmacies. Even if harm reduction services are provided discretely users' behavior can differentiate them from other pharmacy users. Drug users' behavior in this setting is commonly perceived to be unacceptable and can deter other consumers from using pharmacy services. The results of this study infer that negative public opinion is highly suggestive of stereotyping and stigmatization of people who use drugs. Participants considered that (1) community pharmacies were unsuitable environments for harm reduction service provision, as they are used by older people and those with children; (2) current drug policy is perceived as ineffective, as abstinence is seldom achieved and methadone was reported to be re-sold; (3) people who use drugs were avoided where possible in community pharmacies.ConclusionsCommunity pharmacy harm reduction services increasingly bring together the public and drug users. Study participants were reluctant to share pharmacy facilities with drug users. This paper concludes by suggesting mechanisms to minimize stigmatization.     

Harm reduction: Come as you are

The purpose of this paper is to describe what harm reduction is, how it developed, how it works, and why it is becoming a major approach in the addictive behaviors field. Based on principles of public health, harm reduction offers a pragmatic yet compassionate set of strategies designed to reduce the harmful consequences of addictive behavior for both drug consumers and the communities in which they live. To illustrate how harm reduction has been applied to both the prevention and treatment of addiction problems, highlights of a national conference on harm reduction are presented. The historical roots of harm reduction programs in Europe (Netherlands and the United Kingdom) are described. The paper concludes with a discussion of four basic assumptions central to harm reduction: (a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addiction; (b) it recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm; (c) it has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “topdown” policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches.     

Security trumps drug control: How securitization explains drug policy paradoxes in Thailand and Vietnam

This paper investigates the paradoxes inherent in Thai and Vietnamese drug policies. The two countries have much in common. Both are ultra-prohibitionist states which employ repressive policies to contain drug markets. Their policies have, however, diverged in two key areas: opium suppression and harm reduction. Thailand implemented an effective intervention to suppress opium farming centred upon alternative development, whereas Vietnam suppressed opium production through coercive negotiation with nominal alternative development. Vietnam has embraced elements of harm reduction, whereas Thailand has been slow to implement harm reduction policies. This paper hypothesises that these two differences are largely a product of their perceived relationship to security. The two cases demonstrate how once an issue is securitized the ultra-prohibitionist rules of the game can be broken to allow for more humane and pragmatic policies.     

Exploring the existence of drug policy ‘ideologies’ in Australia

Aims: Knowledge of public opinion towards drug policy is often limited to analyses of individual survey questions. There has been less thought given to the underlying structure of public opinion, and how attitudes towards different facets of drug policy, for example, law enforcement and harm reduction, might align into ideological positions. This paper aims to assess the extent to which distinct ideologies are present among the general public in Australia in relation to drug policy.

Method: The study involved a Latent Class Analysis of data taken from the 2010 National Drug Strategy Household Survey. The analysis categorized individuals into mutually exclusive groups (classes), according to their responses to 15 attitudinal items.

Findings: Six classes of individuals were identified, and were labelled as: uninformed, ambivalent, detached prohibitionists, committed prohibitionists, harm reductionists and legalizers.

Conclusions: The unique analysis presented in this paper demonstrates the existence of six distinct classes of opinions towards drug policy in an Australian sample. Whilst there were a large proportion of respondents in support of both drug legalization and harm reduction, there were also many who opposed drug legalization, yet supported harm reduction. Any assumption that supporting harm reduction automatically equates with support for legalization, is erroneous.     

Revisioning women and drug use: gender sensitivity, embodiment and reducing harm

The purpose of this paper is ‘to revision’ our approach to women's use of drugs – which means to let go of how we have seen in order to construct new perceptions. Women use a variety of substances for a range of reasons, including pleasure. Yet, women who experience problems are left feeling stigmatised, marginalised and demoralised. The paper includes three inter-related discussions. First, two co-existing approaches to drug use, the classical and the postmodern, are explained. Second, after demonstrating how the postmodern approach is more valuable for the development of a gender-sensitive perspective, I will, with special reference to drug use, explain the complexities of two contemporary concepts, gender and embodiment. Here, I attempt to generate a deeper appreciation of these concepts in the postmodern approach. Third, I ask, ‘How can we develop a gender-sensitive, harm reduction approach’? The contention is that while harm reduction philosophies are admirable, these need to be gender-sensitive in order to be effective. A multi-levelled, ‘gender-sensitive’ view of harm reduction is put forward, as harm reduction is examined at the subjective, treatment, relationship, occupational and leisure levels.     

Gradualism, identity, reinforcements, and change

This paper reflects the ongoing development of gradualism, a drug treatment perspective that seeks to make use of the full array of effective, creative, and innovative harm reduction and abstinence-oriented treatments available to help addicted individuals move along a continuum from active/chaotic use to abstinence or moderation, as appropriate. The essence of gradualism is an emphasis on positive change and transformation as therapeutic goals. The paper first looks at manifestations of gradualism in harm reduction treatment facilities. Following this is a discussion of the role of identity transformation in the change process. The final section explores how contingency management or motivational incentive interventions could be used in harm reduction settings to facilitate this kind of therapeutic movement.     

Living with addiction: The perspectives of drug using and non-using individuals about sharing space in a hospital setting

Hospitals seem to be places where harm reduction approaches could have great benefit but few have responded to the needs of people who use drugs. Drawing on recent theoretical contributions to harm reduction from health geography, we examine how the implementation of harm reduction is shaped by space and contested understandings of place and health. We examine how drug use and harm reduction approaches pose challenges and offer opportunities in hospital-based care using interview data from people living with HIV and who were or had recently been admitted to a hospital with an innovative harm reduction policy. Our data reveal the contested spatial arrangements (and the related practices and corporeal relations) that occur due to the discordance between harm reduction and hospital regulatory policy. Rather than de-stigmatising drug use at Casey House Hospital, the adoption of the harm reduction policy sparked inter-client conflict, reproduced dominant discourses about health and drug users, and highlights the challenges of sharing space when drug use is involved. The hospital setting produces particular ways of being for people who use and those who do not use drugs and the demarcation of space in a drug using context. Moving forward, harm reduction practice and research needs to consider more than just interactions between drug users and healthcare providers, or the role of administrative policies; it needs to position ethics at the forefront of understanding the collisions between people, drug use, place, and space. We raise questions about the relationship between subjectivity and spatial arrangements in mediating the success of harm reduction.     

Secondary harm mitigation: A more humanitarian framework for international drug law enforcement

This article introduces the concept of ‘secondary harm mitigation’ as a framework for improving the humanitarian credentials of international drug law enforcement agencies. The concept is rooted in a critical analysis of the compatibility of the harm reduction philosophy with Australia’s international drug law enforcement practices. On a utilitarian level, the net benefits of international drug law enforcement are determined to be, at best inconclusive, arguably counterproductive and in most cases, incalculable. On a humanitarian level, international drug law enforcement is also determined to be problematic from a criminological standpoint because it generates secondary harms and it is indifferent to the vulnerability of individuals who participate in illicit drug trafficking. Accordingly, the article concludes that a philosophy of harm reduction grounded in the public health perspective is inadequate for mitigating secondary harms arising from Australia’s efforts to combat international illicit drug trafficking. A tentative list of secondary harm mitigation principles is presented and the article argues that secondary harm mitigation should replace supply reduction as a core tenet of Australia’s National Drug Strategy. The article also concludes that secondary harm mitigation may provide a viable framework for stimulating a productive dialogue between those who advocate prohibition and those who call for decriminalisation at the global level.     

Advocacy for harm reduction in China: A new era dawns

BackgroundChina's initial response to drug use and HIV was largely ineffective but has improved with recent government endorsement of harm reduction interventions. This paper examines the views of senior key informants inside China who articulated core needs and objectives for the development of a harm reduction advocacy strategy.MethodsThirty-nine key informants (KI) were interviewed, representing 19 stakeholder bodies selected from the Chinese government public health sector, public security sector, international agencies such as WHO, UNODC and UNAIDS, and international non-government organisations.ResultsThe concept of harm reduction is widely understood and considered valid. Support for harm reduction is increasing, but KIs perceived an imbalance between the rapid expansion of methadone maintenance treatment programs over needle and syringe programs and other interventions. Challenges for harm reduction identified by KIs included: policy inconsistencies; lack of skilled resources, training programs and technical capacity; poor coverage of interventions; and gaps in the sharing of information. KIs suggested numerous ways to strengthen the capacity of the government and communities to reduce drug related harm.DiscussionIncreased acceptance of harm reduction in China, particularly among public security, implies a new level of optimism towards addressing the HIV epidemic among drug users, and parallels an impressive expansion of harm reduction interventions. Nevertheless, scaling up a response to the ongoing dual epidemic of drug use and HIV remains an enormous challenge. With appropriate technical education and training, ongoing advocacy, and a cohesive, coordinated multi-sectoral effort, the capacity of the government and community to adopt, support and promote measures to reduce HIV and other drug related harm would be markedly strengthened.     

Factors associated with attitudes toward harm reduction among judges in Ontario,Canada

Responses from a questionnaire on knowledge and attitudes toward drugs were received from 89 criminal court judges in Ontario, Canada. Younger judges and females were significantly more likely (P<0.05) to be sympathetic toward harm reduction policies than males or older judges. In addition, judges who were more knowledgeable about the effects of drugs were significantly more likely to favor harm reduction approaches. Increased knowledge of cocaine and marijuana was significantly related to an increased likelihood of favoring harm reduction approaches toward each drug. More research is required on the observed relationship between knowledge and harm reduction attitudes. Depending on the direction of this relationship and whether causal inferences may be drawn, social change that is congruent with harm reduction approaches might be promoted through targeted educational campaigns. As well, a better understanding is needed as to whether attitudes change with age or remain relatively stable within age cohorts. Finally, the sentences that judges give may influence societal attitudes and ultimately affect drug policies.     

The Global Fund's leadership on harm reduction: 2002–2009

Injecting drug use is a major driver of the HIV epidemic globally. Whilst robust evidence points to the effectiveness of harm reduction programmes to halt and reverse injecting drug use driven epidemics, uptake of these programmes in developing and transitional countries has been slow. In part, this slow uptake stems from inadequate financial resources for harm reduction; legal, socio-cultural and medical barriers leading to stigmatisation; and weak health systems unequipped to manage marginalized groups.The Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2002, has become the major multilateral source of external funding for harm reduction programmes in countries experiencing concentrated HIV epidemics driven by injecting drug use. Between 2004 to end of 2008, the Global Fund invested around US$180 million in harm reduction programmes in 42 countries. This funding has helped to initiate and scale up harm reduction programmes in settings where domestic funding was lacking.In addition to financing harm reduction programmes globally, the Global Fund has stimulated a strong dialogue between vulnerable groups and governments. Furthermore, the Global Fund has engaged in a dialogue with countries to encourage an evidence-based approach to policy-making that recognizes the immense value of harm reduction in HIV prevention and control.     

Discipline or contain?: The struggle over the concept of harm reduction in the 1997 Drug Policy Committee in Finland

Based on archive sources and interviews with the people involved, this case study revisits the 1997 Drug Policy Committee in Finland and the struggles that were fought out within that committee over the definition of drug issues: the two main rival camps were the police authorities that were advocating for a drug-free society and insisting on policies of strict control and, on the other hand, the social welfare, health and criminal policy alliance that was in favour of harm reduction. The committee's efforts produced the first national drug strategy. Applying a social constructionist approach to social problems, the analysis concludes that the general objective of harm reduction, in the drug strategy was based not only on public health concerns: the ideological roots of the concept can be traced back to the tradition of a rational and humane criminal policy that was first adopted in the 1960s and 1970s. According to this tradition, criminal and social policy were primarily aimed at minimising overall social harm and at protecting the minorities that were the targets of control. The article describes the argumentation of different administrative and professional groups and their positions on harm reduction and the goals of a drug-free society. The end results, the aims and measures of the drug strategy, was a compromise between two logics, which has since paved the way to the further elaboration of the policy of harm reduction but also stricter criminal controls on drug users.     

‘An Irish solution to an Irish problem’: Harm reduction and ambiguity in the drug policy of the Republic of Ireland

While policy makers in the Republic of Ireland had been concerned with illicit drug use since the late-1960s, it was only from 1980 onwards that the emergence of a culture of intravenous heroin use in areas of generalised social deprivation in Dublin gave urgency to this policy process. This paper traces the gradual introduction, on public health grounds, of harm reduction practices and services – such as methadone maintenance, needle exchange and the creation of outreach and locally-based services – following the identification in the mid-1980s of needle-sharing amongst injecting drug users as one of the key routes for the transmission of HIV in this country. It is argued that harm reduction in the Republic of Ireland has been largely implicit, in the sense that political leaders have generally not encouraged or participated in explicit public debate on this topic, nor have they ever publicly announced that this concept now underpins much of the healthcare system's responses to illicit drug use. It is also argued that this covert style of policy making has persisted, despite the more recent proliferation of formal policy-making structures and the dominance of a rhetoric which emphasises strategic management and the allegedly transparent and evidence-based nature of drug policy. This tactic of shrouding drug policy in ambiguity is discussed in the context of the wider tendency within Irish political culture to manage sensitive and potentially divisive social issues in such a manner. It is concluded that the ambiguity which surrounds harm reduction in Ireland has been functional in that it has confused and frustrated ideological opponents of this concept, but dysfunctional in that it has not facilitated the emergence of more tolerant or respectful attitudes towards drug users and may have delayed the introduction of a wider range of harm reduction practices.