Harm Reduction – the Idea and the Ideology
Professor Dr A. Hamid Ghodse, Member and Past President, INCB.

Abstract:

The role of harm reduction within drug treatment services, against a background of emerging HIV infection is considered, and augmented by detail description of component services – needle exchange, substitute prescribing, and outreach services. The author concludes by commenting on the positives and negatives of harm reduction philosophy and practice, the basic aim of limiting harm amongst users being subjugated in some quarters as a ‘front’ for liberalisation of drug policies. The author argues for a more positive approach by health care professionals, rather than a sense of fatalism that can be induced by the very term ‘harm reduction’.

Keywords: Harm reduction, needle exchange, substitute prescribing, outreach services.

Author’s note: This article is drawn from the author’s textbook “Drugs and Addictive Behaviour; a guide to Treatment” - 3rd Edition, 2002, Cambridge University Press. The cooperation of the publisher, Cambridge University Press, in allowing this article to appear in this Journal, is much appreciated by the Institute on Global Drug Policy and the International Scientific and Medical Forum on Drug Abuse.

Harm reduction
Although the over-riding aim of treatment is to bring about permanent change so that those who abuse drugs and/or are dependent upon them can cope without, it is acknowledged that this may not be achieved for all those who seek help and that, even when successful, it may take a considerable period of time. A consensus therefore emerged that a more pragmatic response was indicated with greater emphasis on the need to prevent or at least to reduce the harm associated with drug abuse and dependence. This approach gained impetus because of the particular threat posed to injecting drug users and the wider community by HIV infection, and harm reduction (or harm minimisation) became the main focus of attention of many agencies. In the midst of new enthusiasms it is worth noting that harm reduction is not a new response. For years, some professionals have advocated that opiate addicts should be prescribed injectable heroin, which they prefer, rather than theoretically safer oral methadone, to prevent them resorting to black market sources with all the attendant hazards. They pointed out that the harmful consequences of drug abuse are rarely due to the effect of the drug itself, but are more often due to the method of its administration and the presence of adulterants. However, since the late 1980s, harm reduction has been formally identified as an approach to treatment and encompasses a range of different goals including stopping (or reducing) injecting, sharing injection equipment, illicit drug use, prescribed drug use and offending behaviour. Other lifestyle goals may also be covered by the umbrella term of harm reduction, including, a healthy lifestyle, getting a job, avoiding criminal activity, safe sex etc.

Needle exchange schemes
Needle exchange schemes are probably the most visible components of harm reduction programmes and, ever since it became apparent that intravenous drug users are a high-risk group for contracting HIV and, latterly hepatitis C, there has been a body of opinion advocating the provision of sterile injection equipment to addicts who inject drugs. It is argued that this will be a genuine public-health measure and good preventive medicine because, theoretically, if sufficient syringes were provided, there would be no need to share injection equipment at all, and the transmission of the HIV virus between addicts and from them to the non-drug-using population would be reduced.

The simplicity of this approach is appealing, but it has certain unbolt disadvantages. There is a very real risk, for example, that the easy availability of sterile syringes and needles may make the transition to injecting easier and more acceptable and might encourage more young drug abusers to start injecting and to do so sooner; equally there may be less incentive for others to give up injecting. Such a policy could therefore lead to an increased number of injectors within the population and an increased number of severely dependent individuals. Furthermore, it would not completely eliminate the sharing of injection equipment, which is associated with socialising and communal feeling in the drug sub-culture and not just with the shortage of needles, so there are bound to be some individuals who would carry on sharing regardless of the hazards. In addition, there will always be occasions when the drug user forgets to carry his/her own syringe or has attempted to have a fix when he/she did not intend to. [1]

There are certain practical problems associated with the policy too, such as the number of syringes to be issued per day, and restrictions on those who may receive them. Should they, for example, be given to anyone who asks for them, even before they inject for the first time? Logically, to prevent AIDS and hepatitis they should be freely available, but many professionals caring for drug abusers feel very uncomfortable in a situation in which they seem to be condoning, if not positively encouraging self-injection, which inevitably leads on to a more severe dependent state. A common policy is to provide syringes on a 'new for old' basis only. This prevents the accumulation of large stocks of injection equipment outside the 'system' and ensures the safe, ultimate disposal of potentially contaminated syringes and needles. However, it cannot control, nor even estimate, how many times or by how many people a returned syringe and needle has been used. In practice, in some areas where syringe-exchange schemes have been introduced, local communities complain bitterly that used syringes and needles are left lying around and are a serious hazard to young children.

Although the provision of sterile injection equipment is less simple than it first appears, syringe-exchange schemes have proliferated rapidly. Research into their effectiveness is difficult because of the long-time lag between infection with HIV and seroconversion (presence of detectable antibody) and because HIV is not exclusively transmitted by sharing contaminated injection equipment. However, it appears that providing sterile injection equipment can contribute to the adoption of safer drug-use behaviour amongst injecting drug users and will therefore reduce the incidence of HIV among addicts. [2, 3] However, it should be noted that even without providing free syringes, fear of HIV infection may bring about beneficial changes in techniques of drug administration, with a reduction in all complications due to injection. [4]

Perhaps the best way forward is to judge each case on its merits, rather than to adopt a stereotyped response. Where it is clear that a stable addict does inject regularly and will continue to do so, and if one can be confident that the injection equipment will not be shared, it may be sensible to provide syringes and needles. On the other hand, it is foolish to pretend that the chaotic polydrug abuser, who is frequently intoxicated and for whom sharing injection equipment is an integral part of drug-taking behaviour, is a safe person to entrust with a supply of syringes and needles. On a more positive note, the provision of a "user-friendly" service, offering equipment that addicts want and need, is one way of attracting them into contact with health service professionals and thence, perhaps into treatment. Such programmes can offer holistic help and advice - for example on sexual risk behaviour - that also contribute to harm reduction in its widest sense.

Some countries have extended the concept of providing sterile injection equipment still further and have set up "shooting galleries" -specific facilities where drug addicts can self-inject with illicit drugs. The motivation for such developments may include a wish to remove addicts from the street and other places where self-injection offends many members of the public; concerns about the public health risks of needles and syringes that are disposed of in public places; and also a desire to minimise risk in the case of an overdose. Whatever the motivation, the provision of such "shooting galleries" contravenes International Conventions and, by providing a formal outlet for illicit drug trafficking, seems contrary to the concept of prevention in its more general context.

The provision of syringes and needles to addicts has been discussed in some detail because it is of considerable topical interest. It is not, however, the only aspect of harm reduction. Another similarly controversial question has risen about whether young solvent abusers, at risk of fatal accidents while intoxicated, should be instructed in safer techniques of solvent sniffing - such as not putting a plastic bag right over the head, not sniffing alone, not sniffing in dangerous places (e.g., roof tops, canal banks). Preventive education of this type, although potentially life saving, at best conveys a very ambivalent message about drug taking and at worst seems to encourage the practice.

These examples emphasise the unpalatable fact that the laudable aim of harm reduction may sometimes conflict with the much more important aim of preventing and reducing the underlying problems of drug abuse and dependence. It is worth noting that the harmful consequences of drug abuse were largely ignored by the general population until one of these consequences, AIDS, became a serious threat to themselves as well. The vociferous support for harm reduction since then suggests that it is motivated more in unthinking self-interest than in a genuine concern for the well-being of drug abusers. For the latter group, the best approach is undoubtedly to encourage them vigorously to become abstinent from drugs. This is achieved more easily if it is attempted early in a drug-taking career, and ideally it should be attempted before self-injection becomes established and causes severe physical and psychological dependence. Easy access to treatment facilities is therefore a very important factor in harm reduction. Only if treatment and persuasion fail should measures that may reinforce dependence be considered.

Substitute prescribing
The use of methadone for the stabilisation, detoxification or maintenance of opiate- dependent individuals has been described in some detail earlier in the chapter.. One of the reasons for adopting this type of substitute prescribing is to attract more drug users to services, so that treatment, in its broader sense, can be initiated as soon as possible. It may have very positive benefits in terms of harm reduction, in that the patient may cease to use illicit drugs, may stop injecting, or at least use a sterile injection technique. However, while substitute prescribing may be a helpful tool in helping the drug-dependent individual to move towards abstinence or towards intermediate goals, there is a very real risk that this progress may be unacceptably slow and that the patient may be maintained indefinitely in an opiate-dependent state, without any clear decision having been taken that this is the right course of action for this particular patient. It follows that if the potential benefits of substitute prescribing are to be fully realised, it is essential that treatment interventions should have a clearly defined aim, and that there are well-established routes into detoxification.

Outreach services
Despite general acknowledgement of the importance of easy access to treatment and the consequent growth in drug services in recent years, the majority of drug users are not in touch with these services. Indeed, there may be a period of several years between starting illicit drug use and making contact with a helping agency. Reducing this time lag early in a drug-taking career, when intervention is most likely to be successful, is essential for effective prevention. Because waiting for drug users to attend established services is clearly an inadequate response, outreach services have been developed that are proactive in making contact with drug users to offer them short-term help and to refer them on to appropriate helping agencies.

If outreach services are to be effective, some type of needs assessment is essential. For example, the reasons why existing services are not being used will have to be established and, if necessary, these services will be reviewed and modified so that they are acceptable and attractive to those who need them. In particular, outreach can aid the development of effective liaison and referral mechanisms between a wide range of agencies, including voluntary services and statutory health and social services.

However, outreach workers will never be able to achieve contact with all drug users, nor will they be able to achieve onward referral to an appropriate agency for all those with whom they do come into contact. Therefore, an important aspect of their work is to achieve change at community level and to achieve harm reduction by a cascading educational process. Thus, when working with a certain number of individuals, they also try to ensure that their message reaches other drug users with whom their client comes into contact. Because outreach developed as an attempt to reduce the spread of HIV and AIDS, much of the work is focused in this area, with an emphasis on advice on safer sexual practices and safer injecting practices and on practical measures such as the provision of condoms and sterile injection equipment. Effective harm reduction, however, encompasses far more than this, and outreach workers should not lose opportunities to discourage regular drug use among experimental users, to discourage injection by potential injectors, to encourage established injectors to switch to safer, oral administration of drugs and to encourage drug injectors and their sexual partners to be immunised against hepatitis.

Conclusion
It appears that, for some people, harm reduction has become an ideology and an end in its own right, rather than one component of a comprehensive and holistic approach to the treatment of substance dependence. While the concept has been embraced with enthusiasm in some countries, it remains controversial in others and this is perhaps because of some of the practices now subsumed under this heading. For example those who advocate the legalisation of drugs may do so, under a “harm reduction” umbrella. Furthermore, as indicated above, many harm reduction practices were introduced only in response to the threat of HIV/AIDS. In other words, they were public health measures, intended for the good of society as a whole, rather than focusing on what was best for the individual patient. The harm reduction measure “shooting galleries” can similarly be categorised as a method of social control and one which reduces the social visibility and inconvenience of drug injectors in public places. Focussing on the good of the individual patient permits greater clarity about what is genuinely harm reducing for them. Specifically, the over-riding aim should always be to reduce demand for drugs and to encourage abstinence. While some harm reduction practices may be expedient in particular sociocultural settings, anything that appears to encourage drug consumption should be treated with scepticism. On the other hand, harm reduction, in the sense of tertiary prevention, is a long-established and important component of medical treatment.

Finally, it is important to emphasise that the very term “harm reduction” risks conveying the gloomy and inaccurate message that substance dependence is not susceptible to effective treatment and that all that is possible is a reduction in the harm that it causes. Substance dependent individuals deserve a more positive and energetic response from health care professionals.

Biography
Professor Hamid Ghodse has been President of the International Narcotics Control Board since 2004. He is Professor of Psychiatry and International Drug Policy at the St. George's Medical School, University of London, and the Director of the International Centre for Drug Policy at the United Nations Office in Vienna.

References
1. Stimson GV (1995) AIDS and injecting drug use in the United Kingdom 1987-1993: the policy response and the prevention of the epidemic. Social Science Medicine, 5, 699-716

2. Klee H & Morris J (1995). The role of needle exchanges in modifying sharing behaviour: cross-study comparisons 1989—1993. Addiction, 90, 1635—1645

3. Crawford V (1997). Injecting drug use. Current Opinion in Psychiatry, 10, 215—19.

4. Ghodse AH, Tregenza G and Li M, (1987). Effect of fear of AIDS on sharing of injection equipment among drug abusers. British Medical Journal, 2, 698-
699.