Harm Reduction in Substance Use and High-Risk Behaviour E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Addiction Press
• Sprache: Englisch

Seitenzahl: 1292

Veröffentlichungsjahr: 2012

Beschreibung

Harm Reduction is a philosophy of public health intended as a progressive alternative to the prohibition of certain potentially dangerous lifestyle choices. Recognising that certain people always have and always will engage in behaviours which carry risks, the aim of harm reduction is to mitigate the potential dangers and health risks associated with those behaviours.

Harm Reduction in Substance Use and High-Risk Behaviour offers a comprehensive exploration of the policy, practice and evidence base of harm reduction. Starting with a history of harm reduction, the book addresses key ethical and legal issues central to the debates and developments in the field. It discusses the full range of psychoactive substances, behaviours and communities with chapters on injecting, dance drugs, stimulant use, tobacco harm reduction, alcohol use and sex work.

Written by an international team of contributors, this text provides an essential panorama of harm reduction in the 21st century for educators and researchers in addiction and public health, postgraduate students and policy makers.

Leseprobe

Contents

Cover

Title Page

Copyright

Dedication

Foreword

List of Figures and Tables

Figures

Tables

List of Contributors

Editors

Contributors

Section I: Background

Chapter 1: Introduction

Chapter 2: A Brief History of Harm Reduction

The First Few Thousand Years

Historical Understandings of the Risks of Injecting

Alternatives to Prosecution for Offences Involving Alcohol and Other Drugs

Drug Treatment in Police Stations

Drug Referral Schemes

The History of Two Different Systems

The Twentieth Century

Liverpool, United Kingdom

The Netherlands

North America

Australia

IHRA, International Harm Reduction Association

References

Chapter 3: Drug Education or Drug Propaganda?

Provision of Information About Drugs

Exploration of Attitudes Towards Drug Use

Development of Skills Relevant to Decision-Making About Drug Use

The Methods Used

Who Should Lead Drug Education for Groups of Young People?

The Aims and Effectiveness of Drug Education

Reclaiming the Education in Drug Education

What can be Done?

References

Section II: Policy

Chapter 4: Harm Reduction and International Law: Drug Control vs. Human Rights

Introduction

International Drug Control Regime: Treaties and Bodies

Flexibility in the International Drug Control Regime

Why is Human Rights Law Important to Harm Reduction?

Harm Reduction and the Human Right to Health

Conclusion

References

Chapter 5: A Brief, Personal History of Harm Reduction Advocacy

Two Decades of Advocacy

Advocacy in Developing and Transitional Countries

Country by Country, City by City

Human Rights: the Way Forward?

References

Chapter 6: Harm Reduction and the Role of Police Services

The Role of Police Services in Supporting Harm Reduction

Police Services and Harm Reduction: Some Examples

Alternatives to Prosecution for Offences Involving Alcohol, Drugs and Prostitution

Drug Treatment in Police Stations

Referral from Police Stations to Drug Treatment Services

Police Services' Role in Multi-Agency Approaches to Drugs and Drug Related Crime

Needle Syringe Programmes

Drug Referral Schemes

Preventing Drug Overdose Deaths

Police support for drug consumption rooms

Conclusion

References

Chapter 7: Harm Reduction in Prisons and other Places of Detention

Two Epidemics: HIV and Incarceration

The HIV Epidemic in Prisons

The Epidemic of Incarceration

Risk Behaviours in Prisons

HIV Transmission Resulting from Risk Behaviours in Prisons

International Human Rights and the Responsibility of Prison Systems

Responding to HIV and Other Infections in Prisons: a Human Rights and Public Health Imperative

Prison Healthcare: the Need for Increased Funding and a New Model

Special Attention should be Given to Women Prisoners

Undertaking Broader Prison Reform

Conclusion

Note

References

Chapter 8: International Security and the Global War on Drugs: The Tragic Irony of Drug Securitisation

Introduction

Drugs and Security

A Comparison With the Legal Opiates Market

Unintended Consequences of the War on Drugs

Securitising Organised Crime

Maintaining the Status Quo

Shifts in Power Dynamics

A Three-Pillar Impact Assessment

Conclusion: the Global Drug Control System is in Crisis: the Time has Come to Explore Alternatives

Transform Drug Policy Foundation

Acknowledgement

References

Chapter 9: The Ethics of Harm Reduction

Introduction

What is Harm Reduction?

Is Harm Reduction a Value-Neutral Approach to Drug Use?

Liberalism and Ethical Presumptions of Harm Reduction

Ethical Theories and Frameworks for Assessing Harm Reduction Approaches

Principlism

Dignity and Human Rights

Virtue Ethics

Communitarian Ethics

A Pluralist Approach to Ethical Decision-Making Based on Dignity

Case Studies of Harm Reduction Ethics

Providing Information on ‘Safer’ Groin Injecting

Smokeless Tobacco and Harm Reduction

Conclusions

References

Chapter 10: Harm Reduction: Contribution to a Critical Appraisal from the Perspective of People Who Use Drugs

References

Section III: Specific Interventions

Chapter 11: Injecting

Introduction

Diseases Spread by Injection Equipment

Iatrogenic Spread of Infection by Injection

The UK Experience of Combined Heroin and Crack Cocaine Injection

Pharmacology and Neurobiology

‘Street Pharmacology’ and Speedballing Culture

Prevalence and Geographic Variation

Risks Associated with Speedballing

Blood-Borne Infections

Bacterial Infection and Venous Damage

Overdose

Sexual Risk

Cardiovascular Risk

Overdose and the Provision of Naloxone

Naloxone

Supervised Injecting Facilities (SIFs)

Conclusions

References

Chapter 12: Recovery and Harm Reduction: Time for a Shared, Development-Oriented, Programmatic Approach?

Introduction

Harm Reduction

Recovery

Recovery and Harm Reduction Compared

Conclusions

References

Chapter 13: Harm Reduction for Stimulants

Introduction

Risks and Harms

Physical Health Problems

Mental Health Problems

Harm reduction interventions

Conclusions

References

Chapter 14: Ecstasy and Related Drugs (ERDS) and Harm Reduction

Introduction

Ecstasy and Harm Reduction

Guidelines for Venue Safety

Peer Led Interventions

Pill Testing

Where to From Here?

References

Chapter 15: Alcohol: Harm Reduction

Alcohol Related Harm

Patterns and Trends in Consumption

Young People

Definitions of Alcohol Related Harm

Screening for Alcohol Related Harm

Harm Reduction Strategies

Reactive Interventions

Regulation and Licensing

Community Harm Reduction Interventions

Pricing

Labelling

Regulation of Marketing

Harm Reduction Interventions in Health Care and Other Settings

Harm Reduction Through Education

Educational Interventions in the School Setting

Strengthening Families Approaches

Young People Focused Approaches

Considerations

Higher Education Based Initiatives

Harm Reduction Interventions Aimed at Undergraduate Students

Promising Approaches

Social Normative Interventions

Media/Marketing Campaigns

Conclusion

References

Chapter 16: Tobacco Harm Reduction

Introduction

Nicotine Maintenance Strategies

Facilitating Periods of Temporary Abstinence with Pharmaceutical Products

Facilitating Long-Term Tobacco Abstinence with Long-Term Maintenance Pharmaceutical Products

Conclusions

Note

References

Chapter 17: Drugs and Harm Reduction: Cannabis And The Cannabinoids

Introduction

Uncontroversial ‘Indirect’ Harms of Cannabis and the Cannabinoids

Short-Term and Effects and Pharmacology

Neuroimaging the Acute Effects of Cannabis and the Cannabinoids

Long-Term Effects of Cannabis and the Cannabinoids

Association Between Cannabis Use and Development of Psychotic Illness

Modelling Studies of the Association Between Cannabis Use and Psychosis

Effect of Cannabis Use on Outcomes in Psychotic Disorder

Cannabis Dependence Syndrome

A Positive Role for Cannabidiol?

Summary and Conclusions

References

Chapter 18: The Resurrection of Psychedelic Research

A Recent History of Psychedelic Use in the West

The Resurrection of Psychedelic Research

The Beckley Foundation

Lifting the Veil on Conscious Experience

Minimising Harms Associated with Psychedelics

The Effects of Psychedelics

The Future of Psychedelics

References

Chapter 19: Harm Reduction and Sex Workers: a New Zealand Response: Taking the Harm Out of the Law

Introduction

Background

Reorienting the Law: A Harm Reduction Strategy

The Harm of Stigma and Discrimination

Harm Reduction for Sex Workers in Hostile Legal Environments

Conclusion

References

Chapter 20: Harm Minimisation: Gambling

Gambling in Society

Recognition of Gambling-Related Harms

Harm Minimisation and Responsible Gambling

Targets for Reducing Gambling-Related Harms

Empirical Evaluation

Demand Reduction Strategies

Supply Reduction Strategies

Harm-Minimisation Strategies

Conclusions

References

Chapter 21: Young People and Harm Reduction in the UK: A Community Perspective

Separate Needs of Young People

The Borough of Luton

The Luton Underground (Drug Service for Young People in Luton)

The Luton Underground's Harm Reduction Philosophy

The Promotion of Self-Care

Educating Our Stakeholders

Our Failure to Meet the Needs of Young People who Use Drugs

A Lost Generation

Politics and Young People's Services

What We are Working with Today and Moving Forward

A Broader Perspective on Harm Reduction within Service Delivery

An Example of the Work of Luton Underground

Embracing the Principles of Harm Reduction when Working with Young People

A New Perspective for Young People's Services

References

Chapter 22: Making Tools for Harm Reduction: The Story of Exchange Supplies

The Beginning

How Exchange Supplies Developed

Exchange Supplies: A Social Enterprise

Our Products and the Law

Citric Acid

Water for Injections

Aluminium Foil

The Nevershare Syringe

Harm Reduction Works: A National Campaign

The Future

References

Section IV: Regions

Chapter 23: Harm Reduction in Central and Eastern Europe

Central European Countries

Patterns of Drug Use in the Region and Specific Responses

Harm reduction in prisons

Key Challenges and Current Developments

Baltic Countries

Specifics of Drug Use in the Region and Specific Responses

HR in Prisons

Key Challenges and Current Developments

Moldova

Ukraine

Specifics of Drug Use and Specific Responses

References

Chapter 24: Harm Reduction in Western Europe

Introduction

Beginnings

How Common are Harm Reduction Measures Throughout Europe?

Decriminalisation of Drugs in Portugal

A Dual Track Approach in Finland

Switzerland

United Kingdom

France

The Netherlands

Conclusion

References

Chapter 25: Harm Reduction in Russia, South West and Central Asia

Russia

South West Asia: Southern Caucasus

Specifics of Drug use in the Region, and Specific Responses

Central Asia

Recent Developments and Key Challenges

References

Chapter 26: Harm Reduction in South, South East and East Asia

Introduction

Historical Perspective

Impact of Drug Control Laws and Polices

Traditional Responses to Drug Use

The Beginnings of Harm Reduction

The New Era: Harm Reduction in the Context of HIV

UN Initiatives in Support of Harm Reduction

Conclusion

References

Chapter 27: History and Context of Harm Reduction in the United States

Early Harm Reduction in the United States: Methadone, Acupuncture Detox and Drug Testing

Reagan, the Drug War and Harm Reduction

Other Drug-User Initiated Public Health

Anti-Prison Activism

International Solidarity

References

Chapter 28: Harm Reduction In Canada: The Many Faces of Regression

Historical Background to Harm Reduction in Canada

Harm Reduction Programmes

Recent Developments

A Brief Overview of Harm Reduction Across Canada

Conclusion

References

Chapter 29: Harm Reduction in Latin America and the Caribbean

Transformation of Drug Use Patterns

Impact of Different Theoretical Paradigms on the Current Concept of Harm Reduction

Drug Law Reform to Achieve Harm Reduction

Harm Reduction Debates Among Civil Society Organisations

Conclusion

Note

References

Chapter 30: Policy and Practice in Harm Reduction in Australasia

Thirty Years of Harm Reduction in Australia

Strategic Harm Reduction

Harm Reduction in Australia: A Tale of Two Decades

Internet, Digital Media and Newer Synthetic Drugs

Harm Reduction in Australian Prisons

Harm Reduction in Aotearoa, New Zealand

Conclusion: Harm Reduction and the Long Haul

References

Chapter 31: Harm Reduction in Sub-Saharan Africa

Background

Prevalence of Substance Use and Misuse

Prevalence of Injecting Drug Use (IDU)

HIV, Hepatitis C and Risk Behaviours

Service Provision

Drug Use, HIV and Treatment in Prisons

Legislation and Policy

Discussion

Conclusion

References

Chapter 32: Overview of the Harm Reduction Situation in the Middle East and North Africa

Context

History of Drug Use and Current Situation in the MENA Region

Current Policy and Practice

Outreach

Needle and Syringe Exchange Programmes (NSPs)

Opioid Substitution Therapy (OST)

HR in Prisons

Policy Developments

Civil Society and Advocacy for Harm Reduction

Gaps and Opportunities

Recommendations

References

Section V: Conclusions

Chapter 33: Conclusions

References

Index

This edition first published 2012

© 2012 by Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

Harm reduction in substance use and high-risk behaviour: international policy and practice / edited byRichard Pates, Diane Riley.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-4051-8297-3 (pbk.:alk. paper)

I. Pates, Richard. II. Riley, Diane M. (Diane Mary), 1953–

[DNLM: 1. Harm Reduction. 2. Substance-Related Disorders–therapy. 3. Risk Reduction Behavior. 4. Risk-Taking. WM 270]

362.19686—dc23

2012007474

A catalogue record for this book is available from the British Library.

Cover image: Gracey Stinson/Morguefile.com

Cover design by Steve Thompson

This book is dedicated to Dominic Pates, Helen Jamet and Suzanne Pates, and Gemma and Cleo Pates, all of whom have been my strength and support.

RP

Foreword

The prevention of the spread of the human immunodeficiency virus among and from whole communities of people who inject drugs is no less than a public health triumph – one of the public health triumphs of the 20th century, as far as I am concerned. There is much history in this volume, about harm reduction, its antecedents, and other aspects of humankind's relationship with drugs and other fancies; and very welcome it is, because much of the extraordinary history of the current movement is in danger of disappearing. In this historical spirit, my own small involvement in this public health triumph came about relatively accidentally, in a way which introduced me to the predominant feature of the field: prejudice and discrimination, based on man's inhumanity to man.

Those who use drugs (of any kind, legal, illegal, anodyne or exciting) participate in one of the most useful tools for defining who's in and who's out, who's in power and who is not...I learnt this again when I ran a harm reduction workshop with WHO in the mid-1990s, in Guizhou in the south of China, for Public Security and Public Health officials from 10 Chinese Provinces. The Public Security officials traveled to the workshop straight from organizing the public executions which marked National Drug Control Day, executions of low level heroin user dealers and small time heroin traders. Each evening was marked with copious quantities of the local Maotai, 55-plus% alcohol, a slower but reliable form of execution. The extreme irony of celebrating the death of those using a pharmacologically pretty harmless drug by drinking large amounts of a severely harmful one brought home to me the utility of labeling people by the drugs they use, and selectively dealing with them on that basis. Using the drugs as an excuse, a cover, a blind to draw away attention, to effectively silence and subjugate the people.

The more I look at drugs, the more I see people. The more I look at people, the more I see a propensity to dehumanize so as to control. The more I look at the harm reduction movement of the last three decades, the more I see hope. Harm reduction drives towards re-humanizing the dehumanized, de-demonizing the demonized, normalizing and welcoming back to the human fold the outcast person, and the outcast behaviour...and reclaiming them as part of our humanity, so we can confront and deal with them in properly human ways.

The accident that happened to me, that I referred to above, was when I worked in the AIDS Branch at the Centers for Disease Control in the late 1980s. I was very supernumerary, and reputations were being made; territory was strongly claimed and fiercely guarded. But there was a bit of turf no-one wanted, and it was the scrap thrown to me – HIV among injecting drug users. I remember at the time, around 1988, noting that in an epicentre of the epidemic in the US, in the northeast states of New York and New Jersey, the number of people diagnosed with AIDS with histories of injecting drug use outnumbered those diagnosed who had histories of male to male sex – and yet there was no-one in the AIDS Branch at CDC, the home of the discovery of AIDS, the world leading public health institution, specifically studying this massive and devastating part of the epidemic. A first exposure to the depth to which prejudice permeates our institutions...and a surprise to a youngish public health practitioner, whose aspiration was to get the science right, and had trouble seeing, let alone understanding, the basis on which some people with AIDS were worth more than others.

It has always seemed to me that there is a parallel between our drug policies and the practice of execution of deserters in war (who have always seemed to me far more heroic in their humanness than the adrenalin charged killer who wins the medal; perhaps only because I can completely identify with the former and do not for a moment understand the latter). The more dangerous we can make the use of a particular drug, by removing any possibility of quality control or regulation of access or informed use, the more likely are users likely to suffer harm from its use, so bolstering our initial proposal that its use is dangerous...if we do our job well enough, we might be fortunate in that a few will die, providing us with exactly what we need pour encourager les autres.

‘Harm reduction’ as a name may have started with HIV, but as we read in these pages as a concept it is co-contingent with humanity – it is in essence part of the definition of being human. Harm reduction is a normal human response to intractable, usually behaviourally-based, problems that allow no immediate solution – what could be more sensible than to ensure that the harm they cause is lessened to the extent possible? Is this not, indeed, simply good public health practice under a different guise? And again as we read within these pages, is not the best public health synonymous with human rights?

HIV is just the starting point, the entry into the world of systematic discrimination and dehumanization. Harm reduction takes us through the door that HIV opens, a door to ourselves; and we betray it and our selves if we do not follow up, and confront the beast within.

This current book is as good a guide to this journey as it is possible to produce – a guide through personal experiences, from activists to users to educators and policy makers and police; a global guide, spanning the world as do the phenomena, the problems, the philosophy and the response; and a guide that takes us into the many paths that harm reduction, branching out from its beginnings with injecting drug use and HIV, is beginning to explore. It will serve us for many years, as textbook and inspiration.

Professor Nick CroftsSenior Research FellowUN Interregional Crime and Justice Research InstituteTurin, Italy

List of Figures and Tables

Figures

11.1 Rapid expansion of HIV prevalence among people who inject drugs in a sample of cities worldwide

16.1 Pathways of male tobacco use in Sweden

16.2 Lung cancer risk by age and cigarette consumption in Cancer Prevention Study, II

16.3 Death rates for heavy smokers, smokers who reduced cigarette consumption by > 50% and other categories of smokers and ex-smokers

20.1 Strategies to reduce gambling-related harms

Tables

3.1 Approaches to drug education

6.1 Sub-sample of the 797 MPS simple caution cases recorded in 1984: adult simple cautions involving class A drugs

6.2 Number of adult offenders administered simple cautions for drug trafficking offences involving class A, B or C drugs in 2004: Metropolitan Police Service and City of London Police

6.3 Number of adult offenders administered simple cautions for drug trafficking offences involving class A, B, or C drugs in 2004: West Yorkshire Police

6.4 Number of adult offenders administered simple cautions for possession offences involving class A, B, or C drugs in 2004 in four police service areas

7.1 Elements of a comprehensive programme to prevent HIV transmission in prisons

7.2 Ensuring that prisoners are included in national scale-up efforts

8.1 How this applies to drug policy

8.2 Securitising the drugs threat

24.1 Harm reduction vs. punitive prohibition

24.2 Progression of the two-track drug policy in Finland

26.1 Drug control frameworks

26.2 Compulsory drug treatment in the region

30.1 Supply reduction measures in Australian prisons: coverage and evaluation

30.2 Demand reduction measures in Australian prisons: coverage and evaluation

30.3 Harm reduction measures in Australian prisons: coverage and evaluation

32.1 Harm reduction initiatives in the MENA region

32.2 Syringe distribution in four countries in the region in 2008

List of Contributors

Editors

Richard Pates

Consultant Clinical Psychologist/Independent Consultant, UK

Diane Riley

Canadian Foundation for Drug Policy; School of Public Health, University of Toronto; Founder, International Harm Reduction Association, Canada

Contributors

Eliot Ross Albert

International Network of People Who Use Drugs, Deputy Director/Programme Coordinator, UK

Tina Alwyn

Reader in Health Psychology, Cardiff Metropolitan University, UK

Monica J. Barratt

Research Fellow, National Drug Research Institute at Curtin University, Perth, Australia

Ingrid van Beek

Director, Kirketon Road Centre, Sydney, Australia

Calum Bennachie

Coordinator, Wellington, New Zealand

Alex Blaszczynski

School of Psychology, University of Sydney, Australia

Steven Branstetter

Assistant Professor, Department of Biobehavioral Health, Pennsylvania State University, USA

Stefan Brugger

Medical Student and Researcher, Neuropsychopharmacology Unit, Imperial College, London, UK

Dave Burrows

Director, AIDS Projects Management Group, Sydney, Australia

Adrian Carter

NHMRC Postdoctoral Research Fellow, UQ Centre for Clinical Research, University of Queensland, Australia

Walter Cavalierri

Canadian Harm Reduction Network, Canada

Allan Clear

Harm Reduction Coalition, New York, USA

Julian Cohen

Independent Consultant and Trainer, UK

Jan Copeland

National Drug and Alcohol Research Centre, University of New South Wales, Australia

Jon Derricott

Co-founder/Writer/Filmmaker, Exchange Supplies, UK

Paul Dillon

Manager, National Drug and Alcohol Research Centre, University of New South Wales, Australia

Kate Dolan

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia

Jimmy Dorabjee

Chairperson, Asian Network of People Who Use Drugs, Harm Reduction Advisor, Australia

Richard Elliott

Executive Director, Canadian HIV/AIDS Legal Network, Canada

Michael Farrell

Professor and Director, National Drug and Alcohol Research Centre, University of New South Wales, Australia

Amanda Fielding

Countess of Wemyss, Founder and Director, Beckley Foundation, Beckley, Oxford, UK

Jonathan Foulds

Professor of Public Health Sciences & Psychiatry, Pennsylvania State University, College of Medicine, USA

Sally Gainsbury

Centre for Gambling Studies, Southern Cross University, Australia

Patrick Griffiths

Communications and Research Officer, Anex, Victoria, Australia

Jean Paul Grund

Centrum voor Verslavingsonderzoek/Addiction Research Centre, Utrecht, The Netherlands; Centre for Addictology, First Faculty of Medicine, Charles University, Prague, Czech Republic; CVO – Research & Consultancy, The Netherlands

Wayne Hall

Professor and NHMRC Australia Fellow, Deputy Director (Policy), UQ Centre for Clinical Research, University of Queensland, Australia

Catherine Healy

National Coordinator, New Zealand

Robert Heimer

Professor of Epidemiology and Public Health, Yale School of Public Health, USA

Neil Hunt

Researcher and Trainer; Honorary Senior Research Associate at the School of Social Policy, Sociology and Social Research, University of Kent; Honorary Research Fellow with the Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, UK

Bev John

Reader and Head of Research in Psychology, School of Psychology, University of Glamorgan, UK

Ralf Jürgens

Consultant, HIVAIDS, Health Policy and Human Rights, Canada

Danny Kushlik

Head of External Affairs, Transform Drug Policy Foundation, UK

Simon Lenton

Deputy Director National Drug Research Institute, Curtin University, Perth, Australia

Alisher Latypov

Eurasian Harm Reduction Network, Vilnius, Lithuania; Columbia University Global Health Research Center of Central Asia, New York, USA

Mags Maher

Freelance Specialist Trainer and Consultant, Hertfordshire, UK

Raewyn Marshall

Community Liaison Worker, Wellington, New Zealand

Peter G. Miller

Senior Research Fellow, School of Psychology, Faculty of Health, Deakin University, Australia

Geoffrey Monaghan

HIV/AIDS Prevention and Care Expert, UNODC, Russia

Lisa Moore

Department of Community Health Education at San Francisco State University, USA

Neo K. Morojele

Deputy Director, Alcohol and Drug Abuse Research Unit, Medical Research Council, Pretoria, South Africa

Danny Morris

Freelance Trainer and Consultant, Hereford, UK

Geoffrey Noller

Research Fellow, Department of Psychological Medicine, University of Otago, Dunedin, New Zealand

David J. Nutt

Professor of Neuropsychopharmacology, Neuropsychopharmacology Unit, Imperial College London, UK

Patrick O'Hare

Independent Consultant; Former CEO of the International Harm Reduction Association, HIT, UK

David Otiashvili

Addiction Research Centre, Union Alternative Georgia, Tbilisi, Georgia Centre for Addictology, First Faculty of Medicine, Charles University, Prague, Czech Republic

Charles D.H. Parry

Director, Alcohol & Drug Abuse Research Unit, Medical Research Council, Pretoria, South Africa

Richard Pates

Consultant Clinical Psychologist/Independent Consultant, UK

Laurence J. Reed

Clinical Senior Lecturer, Neuropsychopharmacology Unit, Imperial College, London, UK

Diane Riley

Canadian Foundation for Drug Policy; School of Public Health, University of Toronto; Founder, International Harm Reduction Association, Canada

Ana Rodas

Research Officer, National Cannabis Prevention and Information Centre, Randwick, New South Wales, Australia

Diana Rossi

Professor and Researcher of the Faculty of Social Sciences at the University of Buenos Aires; Social Worker and Specialist in youngsters' social problems, Intercambios Asociacón Civil, Buenos Aires, Argentina

John Ryan

Chief Executive Officer, Anex, Victoria, Australia

Otilia Scutelniciuc

United Nations Joint Programme on AIDS (UNAIDS), Almaty, Kazakhstan

Edmund Silins

Senior Research Assistant, National Drug and Alcohol Research Centre, University of New South Wales, Australia

Pavlo Smyrnov

International HIV/AIDS Alliance in Ukraine, Kyiv, Ukraine

James Stone

Clinical Senior Lecturer, Neuropsychopharmacology Unit, Imperial College, London, UK

Raminta Stuikyte

European AIDS Treatment Group, Brussels, Belgium; Eurasian Harm Reduction Network, Vilnius, Lithuania

Jallal Toufiq

The National Centre for Drug Abuse Prevention, Treatment and Research, Morocco

Bruce Trathen

Consultant Addiction Psychiatrist; Sub-Saharan Harm Reduction Network Executive Committee, UK

Ivan Varentsov

Eurasian Harm Reduction Network, Vilnius, Lithuania; Andrey Rylkov Foundation for Health and Social Justice, Moscow, Russia

Alex Wodak

Director, Alcohol & Drug Service, St Vincent's Hospital, Darlinghurst, Australia

Tomas Zabransky

Centre for Addictology, First Faculty of Medicine, Charles University in Prague ResAd, LLC, Prague, Czech Republic

Section I

Background

Chapter 1

Introduction

Diane Riley and Richard Pates

Harm reduction for psychoactive substance has been practised for centuries (see chapter 2) but harm reduction as we now know it was first developed in the 1980s, mainly as a response to HIV and hepatitis transmission among people who use drugs. There is now an extensive literature on harm reduction in academic journals and books and there are numerous publications aimed at advising and informing on best practice in many areas. We have come a long way since the days when all attempt at limiting the harm from psychoactive substances and high-risk behaviours simply involved prohibition, bans, and telling people not to partake. We know that the use of alcohol and other psychoactive substances goes back many thousands of years, sex work is called ‘the oldest profession’, and gambling has a very long history too. All of these have attracted opprobrium from the establishment in almost all countries and at most times in history, and attempts to recognise their inevitability and render them safer have been scant.

That harm reduction around psychoactive substances has been controversial is of interest in itself. If we look at another major cause of death and injury throughout the world, that of the motor car, we see a very different situation. It has never been seriously suggested that cars should be banned because of the number of deaths caused through their use (far more than heroin overdoses), but we have put in numerous harm reduction measures in an attempt to ameliorate these accidents. In terms of cars themselves we have introduced safer cars that stop more efficiently, that have greater protection for the occupants through stronger construction and crumple zones, and so forth. We provide seat belts and airbags so that in the event of an accident the occupants have a lesser chance of being injured. We have laws to limit the amount of alcohol people may consume before driving; we impose speed limits and enact a considerable amount of legislation to make the roads safer. We also make the motoring environment safer by constructing crash barriers, traffic lights, roundabouts and other physical changes to the infrastructure. These are all harm reduction measures designed to reduce death and injury on the road, and apart from some people feeling it infringes their personal liberty to be made to wear a seat belt or crash helmet, nobody really objects. The situation regarding harm reduction for psychoactive substances and gambling has been very different indeed.

This book covers a number of areas pertaining to harm reduction. The first section is an introduction by way of a history of harm reduction (which deserves a book in itself and is thus brief) and a discussion about the role of education in primary prevention, an attempt to remove the harm before it occurs. The second section looks at policy, offers a critique of various policy matters, examines law and policing, and raises questions about ethics and legalisation. The third section is centred around harm reduction for individual substances and behaviours, offering expert views on current best practice and ideas. The chapter on opiate harm reduction has been written from the ‘recovery’ perspective. There is much discussion elsewhere in the book about opiate substitution therapy (OST), so this is not included in this chapter, but current thinking is that the use of substitute medication such as methadone is necessary in the treatment of opioid problems but not sufficient, it stabilises those dependent on opioids but is not a cure. In the UK and a number of other countries we have created a system for helping people stop using opiates but we have not really helped them become free of dependence (on both the drugs and the services that provide them). In some countries such as Canada, methadone is being given to users of Oxcycontin, many of the young people, to help them discontinue use of the pain killer; the result has been an increase in methadone users who are also buying Oxycontin on the street. This is not an example of best practice in harm reduction.

The fourth section is a global geographical review highlighting what services have been available in all the continents and where the deficiencies lie. Whereas we are well informed about Western Europe, North America and Australia we are less well informed about parts of the world with large populations, increasing problems, and a marked deficiency of services. This comprehensive survey has highlighted how far harm reduction has come since the 1980s, from being a mainly northern European and Australian concern to being truly global and reaching some of the most disadvantaged people in the world.

We have assembled a distinguished group of experts to write this book, some well known and some less well known, but all experts in their fields. There may appear to be some gaps in the content and this is not accidental; there are some subjects that deserve more space than this long book allows and it is our intention to include them in another book. There is, for example, discussion of gender issues in a number of the chapters, but no specific chapter on girls and women. This is one example of a subject which needs more space than allowed here.

The chapter on Australasia is different in format to the other regional chapters. The author who was to write this was unable to do so due to unforeseen circumstances and we therefore gathered, at short notice, a distinguished panel of Australian and New Zealand authors to write a number of perspectives on these two countries.

Any book on a subject like this is only as good as its current content and we are aware that this is only a snapshot of harm reduction a decade into the twenty-first century. It is hoped that this will provide a useful resource for students, academics, policy-makers, law enforcement officers and all those interested in the reduction of harm. An attempt has been made to be comprehensive, but even in a book of this length there will be gaps. The subject of performance and image enhancing drugs was to have been included but again the authors were unable to deliver the chapter (for reasons beyond their control and not because of performance deficit) and it is hoped to devote another book to this increasingly relevant area.

Harm reduction has become part of accepted practice in many parts of the world. It is inevitable that new challenges will arise, new drugs that will cause moral panics and new political systems that will reject the libertarian ideas of harm reduction. What is important is that in both policy and practice the foundations have been laid to continue this work, to develop it, and to try to reduce the harm that is associated with the inevitable use of psychoactive substances and the other behaviours associated with human beings such as gambling and sex work.

Chapter 2

A Brief History of Harm Reduction

Diane Riley, Richard Pates, Geoffrey Monaghan, and Patrick O'Hare

The First Few Thousand Years

Harm reduction has no doubt been part of the human behavioural repertoire since psychoactive substances were first used by our early ancestors. In most cultures which used such substances (and this appears to have been almost all), social rituals and religious codes often regulated consumption and associated behaviours. In many societies today these rites of passage, rituals and codes have all but eroded, leaving a void that risks and harms can fill. Until the industrial revolution, harms related to human-machine interaction (or collision) were, while still an occurrence (the arm caught in the grindstone, the leg in the plough), were not of such high risk to so many as to demand the regulations that we have today. In this chapter we give a brief overview of some of the historical underpinnings of harm reduction as we know it, including the role of police in reducing drug related harm.

Historical Understandings of the Risks of Injecting