Harm reduction

Harm reduction is a philosophy of public health intended to be a progressive alternative to the prohibition of certain lifestyle choices. The central idea of harm reduction is the recognition that some people always have and always will engage in behaviours which carry risks, such as casual sex and substance abuse. Harm reduction seeks to mitigate the potential harm associated with these behaviours without attempting to prohibit the behaviors. Harm reductionists contend that no one should be denied services such as healthcare and social security merely because they take risks. Further, harm reduction seeks a social justice response to substance abuse, as opposed to a criminalizing one.

Some critics of harm reduction contend that it appears to condone and even facilitate behaviors seen by some as immoral, dangerous, or socially destabilizing. For this reason, harm reduction has been very controversial in the United States, but less so in Europe, Australia and New Zealand.

Discussion about harm reduction in the United States is very polarized. Advocates are often characterized as "pro-drug" and critics are often characterized as responding from "moral panic". There is a third group that advocates an approach sometimes referred to as gradualism. Gradualism advocates are concerned that harm reduction programs are sometimes rooted in pessimism about the ability of addicts to recover and represent the "soft bigotry of low expectations." They are unlikely to categorize interventions as "good" or "bad". Rather, they tend to be more concerned that programs move clients toward abstinence when windows of opportunity open.

Harm reduction initiatives range from widely accepted designated driver campaigns, to more controversial initiatives like the provision of condoms in schools, safe injection rooms, drug legalization, and heroin maintenance programs.

Cannabis
Perhaps most commonly, harm reduction advocates view the prohibition of cannabis as outdated, ineffective and counter-productive. Among other arguments, they point out that health risks of cannabis use are relatively low, that cannabis is used anyway despite attempts to outlaw it, and that the prohibition might have the effect of criminalizing and marginalizing otherwise law-abiding cannabis users.

Some harm reductionists favor outright legalization of cannabis, allowing its sale e.g. through Dutch-style "coffee shops". Others think the best option would be some degree of decriminalization, such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, while concentrating law-enforcement resources on more serious crimes.

Cannabis decriminalization has been a hotly debated issue in many parts of the world, especially in many Western European countries such as Belgium, Germany, United Kingdom, Portugal, and Spain, where some measures have been taken towards lifting the ban on cannabis.

Related articles: Legal issues of cannabis, Health issues and the effects of cannabis, Cannabis rescheduling in the United States

Methadone
The neutrality of this section is disputed. Please see discussion on the talk page.

Some harm reductionists advocate the availability of the synthetic drug methadone (or, more recently, of buprenorphine) for users who are dependent on opiates (e.g. heroin, codeine). Methadone does not cause as strong a sense of euphoria in the user, but it does reduce or eliminate the cravings associated with withdrawal. Therefore, harm reductionists maintain, methadone should be made widely available to people, temporarily or permanently, to promote leading a fulfilling and healthy lifestyle. Critics of methadone treatment claim that this is merely a substitution of one addiction for another, or that methadone treatment does not work. There is an international literature to show that methadone programmes can help heroin users stabilise their lifestyles by obtaining a legal, regulated substitute drug. This could potentially help them look after themselves, their families, and re-enter the work force or pursue further education. These are the building blocks for regaining dignity and self esteem and are imperative for those who want to re-enter mainstream society. Harm reduction is a flexible philosophy that stresses understanding of the needs of the drug user, and responding to these needs in a flexible and realistic way, working at the pace and to achieve the goals that the person wants. However, for those drug users who want to change their life substitute medication should be complemented by psychological and practical support, enabling the person to reach their stated goals. In the UK methadone prescribing is seen as a way of reducing drug related crime &mdash; the provision of substitute medication removes the need to buy drugs through the underground street market.

Benefits of methadone treatment
These are benefits as stated by a Belgian Consensus Conference on Methadone Treatment, conducted by the Belgian Minister of Health. The following conclusions were sent to every Belgian doctor 1.
 * Methadone is an effective medication for the treatment of heroin addiction.
 * Methadone reduces heroin consumption and injection, reduces mortality related to heroin addiction, reduces the risk of infection with HIV as well as hepatitis B and C, improves therapeutic compliance of HIV-positive drug addicts, facilitates detection of illness and health education strategies and is associated with an improvement in socio-professional aptitude and a reduction in delinquency.
 * Prolonged treatment with proper doses of methadone is medically safe. At present, methadone has not been shown to be toxic for any organ.
 * There is no scientific reason to limit the overall number of heroin addicts admitted for methadone treatment.
 * Availability of methadone treatment should be increased to respond to the need for such treatment, including by private practitioners.
 * Psycho-social support is not compulsory and should be adapted to the individual needs of patients.

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 of syringes is limited users of heroin and other drugs frequently share the syringes. As a result, one user's infection, such as HIV or Hepatitis, can quickly spread to other users through the reuse of syringes contaminated with infected blood.

The principles of harm reduction propose that syringes should be made more easily available (i.e. without a prescription). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. Harm reductionists also argue that users should be supplied free of charge at clinics set up for this purpose: so-called needle exchange programs. Critics claim that these measures will encourage addiction by making it easier to inject illicit drugs, although this has never been shown to be the case in the many evaluations of needle exchange programs.

A closely related harm reduction based initiative is the "safe injection" site (see below).

DanceSafe and Related Programs
DanceSafe is a not-for-profit organization in the United States, wherein volunteers situated at raves and similar events perform free-of-charge tests on pills that participants bought on the assumption they were Ecstasy. These tests are viewed by proponents as a viable means of Harm Reduction because Ecstasy sold on the black market has gained somewhat of a reputation for being impure, containing unknown chemicals which can occasionally be harmful to the user. DanceSafe does not sell Ecstasy or other drugs; rather, they perform chemical tests after being provided with a sample of a pill by its owner. Harm reductionists support these programs as informing drug users of the purity of their drugs, thus decreasing the possibility of accidental overdoses and adverse drug reactions. Similar programs have been proposed and, in some cases, implemented to test the purity of other drugs. Critics of these policies claim that such programs encourage drug use by making it seem safer.

Drunk Driving and Alcohol-Related Programs
A high amount of media coverage exists informing users of the dangers of driving drunk. Most alcohol users are now aware of these dangers and safe ride techniques like 'designated drivers' and free taxicab programs are reducing the number of drunk-driving accidents. Many cities have free-ride-home programs during holidays involving high alcohol abuse, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In New South Wales [Australia] groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programs including designated driver, late night patron transport schemes. Many of the transport schemes are free of charge to patrons to encourage them to avoid drink-driving and reduce the impact of noisy patrons loitering around late night venues.

Moderation Management is a program which helps drinkers to cut back on their consumption of alcohol and which encourages safe drinking behavior.

Safer Sex Programs
Many schools now provide safer sex education to teen and pre-teen students, some of whom engage in sexual activity. Given the premise that some, if not most, kids are going to have sex, a harm-reductionist approach supports sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STDs. This runs contrary to the ideology of abstinence-only sex education, which holds that telling kids about sex can encourage them to engage in it.

Supporters of this approach cite statistics which they claim demonstrate that this approach is significantly more effective at preventing teenage pregnancy and STDs than abstinence-only programs; social conservatives disagree with these claims -- see the sex education article for more details on this controversy.

Legalized prostitution
There are many advocates of the legalization of prostitution in jurisdictions where it is illegal. Proponents state that there are several benefits:
 * legalization allows prostitutes to escape the influence of pimps and organized crime
 * legalization allows more effective public health measures against sexually transmitted diseases
 * legalization removes a victimless crime (although one could argue that the customers' families are victims, adultery is not considered a crime in most Western jurisdictions)

Other forms of harm reduction initiative
Other harm reduction programs to be expanded on:
 * Encouragement of the use of safer smoking practices such as vaporizers, as opposed to water pipes, cigarettes and straight pipes
 * Not notifying parents about their children receiving contraception
 * Not notifying parents for youth abortions
 * State regulated production and distribution of currently illegal drugs

Safer Injection Sites
"Safe injection rooms" are legally sanctioned, supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use.

Safe injection rooms provide sterile injection equipment, information about drugs and health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most prohibit the sale or purchase of illegal drugs. Many programs require identification cards. Some restrict access to local residents and apply other admission criteria.

Evaluations of safe injection rooms generally find them successful in reducing injection-related risks and harms, including vein damage, overdose and transmission of disease. They also appear to be successful in reducing public order problems associated with illicit drug use, including improper syringe disposal and public drug use.

The first and only safe injection site in North America opened in Vancouver, B.C. in September 2003. It is called Insite.

There are some 47 safer injection sites in cities in Europe. Generally in Europe they are referred to as "safer consumption rooms".

Some facts about safer injection sites can be found at Drug War Facts.Å

Heroin Maintenance Programs
Providing a medical prescription for pharmaceutical heroin (diamorphine) to heroin addicts has been seen in some countries as a way of solving the ‘heroin problem’ with potential benefits to the individual addict and to society.

In Switzerland Heroin Assisted Treatment is fully a part of the national health program. There as some 38 centers throughout the country at which dependent persons can receive heroin maintenance. The Swiss heroin maintenance program is generally regarded as a success and a valuable component of that country's overall approach to managing drug use in a harm decreasing manner. See the Reporton the Evaluation of the Swiss Scientific Studies of Medically Prescribed Narcotics to Drug Addicts.

The British have had system of heroin maintenance since the 1920's.  It was de-empahsized somewhat during the 1960s-1980s as a result of the U.S. led "war on drugs". However, in recent years the British are again moving toward heroin maintenance as a legitimate component of their National Health Service. This is because evidence is clear that methadone maintenance is not the answer for all opiate dependent addicts and that heroin is a viable maintenance drug which has shown equal or better rates of success in terms of assisting hardcore users establish stable, crime-free lives. Access a British report on heroin maintenance entitled Prescribing Heroin: what is the evidence?

The Netherlands in another country which has has several successful studies of medically supervised heroin mainentance. Results of two major clinical studies involving 547 heroin treatment patients is available from the CCBH (Central Committee on the Treatment of Heroin Addicts) website.

The first, and only, North American heroin maintenance project is in Vancouver, B.C.  Currently some 80+ long-term heroin addicts are taking part in the NAOMItrials. It is intended that this study will be extended to Toronto and Montreal.