Harm reduction or harm minimisation refers to a range of public health policies designed to reduce the harmful consequences associated with recreational drug use and other high risk activities. Harm reduction is put forward as a useful perspective alongside the more conventional approaches of demand and supply reduction.
Many advocates argue that prohibitionist laws criminalize people for suffering from a disease and cause harm, for example by obliging drug addicts to obtain drugs of unknown purity from unreliable criminal sources at high prices, increasing the risk of overdose and death.
Its critics are concerned that tolerating risky or illegal behaviour sends a message to the community that these behaviours are acceptable.
Responsible drug use
Responsible drug use is a harm reduction strategy based on a belief that illegal recreational drug use can be responsible in terms of reduced or eliminated risk of negative impact on the lives of both the user and others.
Some critics believe that all illegal recreational use is inherently irresponsible, due to the unpredictable, unregulated nature of the drugs and the risks of addiction, infection, and other side effects. Nevertheless, harm reduction advocates claim that the user can be responsible by employing the same general principles applicable to the use of alcohol: avoiding hazardous situations, excessive doses, hazardous combinations of drugs, using the smallest dose necessary, avoiding injection, and not using drugs at the same time as activities that may be unsafe without a sober state.
Needle and syringe exchange and related programs
The use of heroin and certain other illicit drugs can involve hypodermic syringes. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, users of heroin and other drugs frequently share the syringes and use them more than once. As a result, one user's infection (such as HIV or Hepatitis C) can spread to other users through the reuse of syringes contaminated with infected blood.
The principles of harm reduction propose that syringes should be easily available (i.e. without a prescription) or at least available through a Needle and Syringe Exchange (NSE) program. Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries users are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name. It has been shown in the many evaluations of needle-exchange programs that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programs have reduced HIV incidence by 33% in New Haven and 70% in New York City.
Critics of this harm reduction intervention, such as Drug Free Australia,point to the US Institute of Medicine's 2006 review of needle exchange programmes, even though this study concludes almost the exact opposite of what Drug Free Australia claims.
IOM describes a limitation of the design of studies into the efficiency of needle exchange programs, which "generally do not allow separate examination of program elements, so the independent contribution of improving access to sterile needles and syringes cannot be assessed",they nevertheless recommend that, "[g]iven consistent evidence that multi-component HIV prevention programs that include sterile needle and syringe is associated with reductions in drug-related HIV risk behavior, such programs should be implemented where feasible". However they concluded that the evidence for NSEs having an effect on the incidence of HIV was "limited and inconclusive" and noted the need for further research.They also state that "multiple studies show that NSEs do not reduce transmission of [Hepatitis C]," which they note, "has been attributed to the apparent failure of NSEs to provide enough ancillary injecting equipment such as sterile cotton, water, and alcohol wipes."
Cannabis
Further information: Legal issues of cannabis, Health issues and the effects of cannabis, Removal of cannabis from Schedule I of the Controlled Substances Act, and Drug policy of the Netherlands
Specific harms associated with cannabis include increased accident-rate while driving under intoxication, dependence, psychosis, detrimental psychosocial outcomes for adolescent users and respiratory disease. Strategies recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) to deal with those include roadside drug-testing to deter intoxicated driving and education about patterns of use that increases the risk for dependence, mental health and respiratory problems.
The fact that cannabis possession carries prison sentences in most developed countries - although rarely imposed - is also pointed out as a problem by EMCDDA, as the consequences of a conviction for otherwise lawabiding users arguably is more harmful then any harm from the drug itself. For example by adversely effecting professional or travel opportunities and straining personal relationships.[40]
The way the laws concerning cannabis are enforced is also very selective - even discriminatory. Statistics show that the socially disadvantaged, immigrants and ethnic minorities have significantly higher arrest rates. Drug decriminalization, such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, would alleviate these harms. Where decriminalization has been implemented, such as in several states in Australia and United States, as well as in Portugal and the Netherlands no adverse effects have been shown on population cannabis usage rate. The lack of evidence of increased use indicates that such a policy shift does not have adverse effects on cannabis-related harm while, at the same time, decreasing enforcement costs.
Alcohol
Traditionally, homeless shelters ban alcohol. In 1997, as the result of an inquest into the deaths of two homeless alcoholics two years earlier, Toronto's Seaton House became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, homeless alcoholics opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities. The program has been duplicated in other Canadian cities and a study of Ottawa's "wet shelter" found that emergency room visit and police encounters by clients were cut by half. The study, published in the Canadian Medical Association Journal in 2006 found that serving chronic street alcoholics controlled doses of alcohol also reduced their overall alcohol consumption. Researchers found that program participants cut their alcohol use from an average of 46 drinks a day when they entered the program to an average of 8 drinks and that their visits to emergency rooms drop to an average of eight a month from 13.5 while encounters with the police fall to an average of 8.8 from 18.1.
Downtown Emergency Service Center(DESC), in Seattle Washington, operates several Housing First, harm reduction model, programs. University of Washington researchers, partnering with DESC, found that providing housing and support services for homeless alcoholics costs tax- payers less than leaving them on the street, where tax-payer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation appeared in the Journal of the American Medical Association April, 2009.[44] This first US controlled assessment of the effectiveness of Housing First specifically targeting chronically homeless alcoholics showed that the program saved tax-payers more than $4 million over the first year of operation. During the first six-months, even after considering the cost of administering the housing, 95 residents in a Housing First program in downtown Seattle, the study reported an average cost-savings of 53 percent—nearly US $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among homeless alcoholics.
Other forms of harm reduction initiative
Other harm reduction programs to be expanded on:
Encouragement of the use of safer cannabis smoking devices/cannabinoid delivery systems such as vaporizers, as opposed to water pipes, cigarettes and straight pipes
Encouragement of the use of smokeless systems of nicotine delivery, known as Tobacco harm reduction, as opposed to the much riskier method of burning and inhaling tobacco.
Promote the use of safer modes of use such as safer crack pipes (as opposed to use of a pipe which may burn or cut the users mouth, increasing risk of transmittable diseases) Use of screens which are safer than the use of a brillo pad which may embed metal particles into the lungs.
Promote various safer use strategies such as having a chronic alcoholic have a chaser of water between drinks.
Advocate the use of a Substitute Decision Maker or Power of Attorney so a person's rent is paid before the drug of choice, ensuring the person always has housing.
Provide vitamins to ensure a person's physical needs are somewhat met
Lessen the use of mouthwash, Gravol, isopropanol etc. in poverty-stricken chronic alcoholics as a source of an alcohol, and replace with something less destructive, such as ethanol without toxic additives, and eliminate the use of isopropanol.
Allowing young people decision making power and access to contraceptives
Allowing young people decision making power to terminate a pregnancy.
State regulated production and distribution of formerly illegal drugs (legalization)
See also