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Addiction Research Foundation
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HARM REDUCTION: A NEW APPROACH TO ALCOHOL AND DRUG PROBLEMS
Alcohol and Drug-related Harm
Alcohol and other drug use can harm individuals and society in various ways.
Drug-related harm may include damage to the user's health such as alcohol-related liver disease or death by drug overdose. Negative health consequences can also extend beyond the drug's direct effects. Some injection drug users (IDUs), for example, increase their risk of infectious diseases such as AIDS and hepatitis-B and C by sharing unsterilized needles.
Drug and alcohol use can affect the user's friends and family members. Substance use is often a factor in family problems including domestic violence and child abuse. Victims of family or sexual violence may use drugs or alcohol as a way to deal with their pain, to calm down or to sleep. In a recent ARF survey, 43 per cent of Toronto street youth said alcohol and drug problems played a role in their decision to leave home.
There are also significant social costs related to substance use. The increased health care and law enforcement and lost productivity resulting from alcohol and drug use in Ontario is estimated to have cost approximately $9 billion in 1986.
Through most of this century, Canada and other western societies have combined two approaches to illicit drug problems. On the one hand, there has been an effort to reduce the demand for illicit drugs through prevention programs — usually aimed at young people — and through treatment intended to help current users stop. On the other hand, considerable resources have been devoted to policing and the justice system in an attempt to limit the drug supply. Both types of strategy have the goal of reducing the overall level of illicit drug use.
In recent years, however, there has been growing concern that concentrating only on reducing consumption ignores other ways to reduce the immediate harm associated with continued drug use. As a result, there has been increased interest in approaches that focus on reducing the negative consequences of drug use rather than on drug use itself.
The starting point for such harm-reduction strategies is the attempt to identify and deal with the risks associated with alcohol and drug use in a concrete, pragmatic way. Harm reduction means focussing on the most immediate and achievable changes that can reduce the threat to the health and well-being of the user and of society. While helping users abstain from alcohol or drugs is one appropriate long-term goal, harm reduction strategies place the emphasis on practical, short-term improvements, whether or not they can be shown to reduce consumption.
Harm-reduction approaches are already well accepted for many legal and prescription drug problems. Measures to reduce the damage from drinking and driving, for example, include strategies that separate drinking from driving or that limit the damage from crashes through seat belts or air bags. Chewing gum and skin patches containing nicotine can reduce the risk of respiratory diseases by helping people stop smoking tobacco without going through nicotine withdrawal. Warning labels on prescription drug containers are another strategy to reduce the risk of accidents or other harm that could result from the use of certain drugs, either individually or in combination.
Since the 1980s, strategies for reducing harm associated with illicit drugs have had the greatest impact in the area of injection drug use and the prevention of infectious diseases. It is now widely accepted that clean needles and syringes and information about safer injection practices are important in preventing the spread of hepatitis-B and C and AIDS among injection drug users.
Harm reduction policies have been adopted and implemented in a number of jurisdictions. The reduction of "the harm caused by alcohol and other drugs to individuals, families and communities" has been a part of Canada's Drug Strategy since 1987. Both the British Advisory Council on the Misuse of Drugs and the World Health Organization (WHO) have stated that the spread of HIV is a greater public health threat than injection drug use. In its policy the WHO has advised that measures aimed at reducing drug use should not interfere with strategies to limit the spread of AIDS.
While much of the recent interest in harm reduction has been a response to the AIDS crisis of the last twelve years, strategies aimed at the reduction of drug-related harm have a much longer history.
In the 1920s, an influential group of British physicians, the Rolleston Committee, stated that prescribing drugs for users who were unable to break their dependence was "justifiable in certain cases ... in order to avoid serious withdrawal symptoms, or to keep the patient in a condition in which he can lead a useful life." In the 1960s, this approach led Britain to set up addiction clinics where opiates were prescribed to dependent users as a way of undercutting the illegal market.
Injection Drug Use and AIDS
It was recognized in the early 1980s that people who inject illicit drugs run a high risk of HIV infection. One of the principal ways the virus is spread within this group is through the sharing of unsterilized needles and syringes. This elevated risk of HIV transmission can be compounded by high-risk sexual contacts among IDUs and between IDUs and others.
In the U.S. and Britain, as many as 60 per cent of heterosexually acquired HIV cases are directly or indirectly related to injection drug use. In the U.S., injection drug users account for 20 per cent of reported AIDS cases. In Canada, there are an estimated 50,000 to 100,000 IDUs who are potentially at risk of contracting HIV from contaminated needles.
Needle Exchange Programs
Providing IDUs with clean needles and syringes has been recognized as an important way to limit the spread of HIV. As a strategy for harm reduction, needle exchanges recognize that while many injection drug users are unwilling or unable to stop taking drugs, they can be helped to reduce the risk of serious health consequences.
One of the first needle exchange programs was established in Amsterdam in 1984 by a drug users' organization called the "Junkie Union." Today needle exchanges are operating in Australia, North America, the United Kingdom, and several European countries. In Canada, there are over 30 needle exchange programs — including 10 in Ontario — many of which have received federal or provincial funding.
Studies among clients of Canadian needle exchanges have found these programs successfully reduce needle sharing and other high-risk behavior. It is more difficult to prove directly that needle exchanges reduce rates of infection. Nonetheless, in cities where needle exchanges were established relatively early in the AIDS epidemic, including Toronto and Vancouver, rates of HIV infection among IDUs have remained in the range of two to five per cent. By contrast, the rate of seroprevalence among IDUs in New York City, where needle exchanges are illegal, has been estimated to be as high as 60 per cent.
One concern regarding needle exchanges has been that while they can reduce the spread of AIDS, they may also encourage current and future drug use. There is, however, no evidence of increased drug use in any community as a result of such programs. On the contrary, studies in Amsterdam have recorded a drop the frequency of drug use and injecting among people using that city's needle exchange program.
Needle exchanges can also play an important role in giving drug users access to other health services. Exchanges are more effective when they reinforce AIDS prevention by providing condoms and safer sex and drug use information. They can also support the drug user in seeking other health or social services, including treatment for drug dependency.
As well as supporting safer drug-taking techniques, harm reduction strategies can also include encouraging users to switch to less dangerous drugs. One example of this approach is methadone replacement therapy.
Methadone is a synthetic opiate-like drug that has been used as a substitute for morphine since the 1940s and for heroin since the 1960s. Because it has many of the same properties as these opiates, it can be used to prevent withdrawal symptoms. And while it is true that maintaining the opiate user on methadone is replacing one drug of dependence with another, methadone offers a number of important advantages.
Methadone maintenance can be effective in preventing hepatitis and AIDS since methadone is usually taken orally. By providing controlled doses of the drug in a supervised setting, methadone programs can eliminate the risk of overdose. And since methadone is available by prescription and its effects last longer than heroin, methadone replacement can help the user break out of the cycle of criminal behavior that often goes along with opiate dependence and establish a more stable and productive way of life.
While research has shown methadone maintenance to be effective in reducing harm associated with opiate dependence, programs in Canada do not have adequate resources to meet the current need. In Ontario, the Addiction Research Foundation's methadone program has provided treatment services for more than 20 years. The province will soon open its first methadone clinic based in a community health centre, located in Toronto. In addition, a small number of Ontario physicians provide methadone to patients across the province.
A Comprehensive Approach
A unique application of harm reduction principles in the area of illicit drugs has taken place in the Mersey region of northwestern England. Here a number of individual strategies have been integrated into a comprehensive approach to reducing harm.
One important component of the Mersey model is the prescription of methadone and other drugs of dependence as part of a strategy aimed at helping users stabilize their lives. To reduce the risk of AIDS, Merseyside has pioneered the distribution of non-injectable drugs in the form of "reefers" — herbal or regular cigarettes containing heroin, methadone, cocaine or amphetamine. Pharmacists play a central role in the Merseyside system by dispensing drugs in the form of reefers, liquid, ampoules and aerosols and by providing clean needles as necessary.
The Merseyside system also recognizes that other areas of people's lives can both influence and be affected by drug use. As part of the region's harm reduction strategy, drug users are encouraged to make use of health, housing and employment services. The police play an important role in supporting harm reduction strategies. By cautioning possession offenders, providing them with information and referring them to treatment and needle exchange programs, police help steer drug users away from further involvement in criminal activity.
By all reports, Merseyside's comprehensive approach to harm reduction has contributed to slowing the spread of HIV. In 1991, the rate of HIV infection among IDUs in the Mersey Region was less than one quarter of the national rate for England as a whole. At the same time Merseyside was the only region in England to experience a drop in crime rates in 1990 and 1991.
Harm Reduction and Alcohol
Harm reduction strategies have long played an important role in the prevention and treatment of alcohol-related problems.
In Canada, alcohol is used much more widely than illicit drugs. In 1989, approximately 78 per cent of Canadians reported using alcohol at least once in the past year, while 6.5 per cent had used cannabis and 1.4 per cent had used crack or cocaine over the same period.
Alcohol plays a role in health and social problems from cancers, heart and liver disease, to traffic crashes and other injuries, to family and work-related problems. Each year in Canada, approximately 19,000 deaths are directly or indirectly related to alcohol use. In Ontario, more than one in 10 drinkers are at risk of alcohol problems. At the same time, the risks associated with alcohol use are not solely the result of heavy drinking. It is clear that even low levels of use can impair the ability to operate motor vehicles or heavy equipment, increase the risk of certain cancers and, during pregnancy, effect the development of the fetus.
Price and availability: One approach to the prevention of alcohol problems has been to control the way in which alcohol is distributed. Research has shown that regulating the price and physical availability of alcohol can influence both the level of overall consumption and the rates of related problems such as liver cirrhosis and traffic crashes.
In particular, through taxation and minimum pricing policies, governments can influence demand and reduce consumption by both low- and high-risk drinkers. Restricting the number of retail outlets, and their days and hours of operation has also been shown to reduce consumption and related problems.
In recent years, however, there has been a growing threat to the government's ability to regulate the alcohol market as a public health measure. At one level, there has been an increasing tendency to view the purchase of alcohol simply as an individual lifestyle decision. At another level commercial pressures and trade liberalization threaten to erode alcohol market controls. Nonetheless, policies aimed at regulating price and availability remain important tools for limiting alcohol problems.
Server intervention: Another strategy for reducing the risk of alcohol-related problems has been the development of training programs to help servers limit impairment and manage intoxicated patrons. These programs train the staff and management of licensed establishments to understand the physical effects of alcohol, to recognize and prevent intoxication, to deal with intoxicated patrons and to set house policies that will reduce alcohol-related problems.
Server training responds to the hospitality industry's legal responsibility for accidents and injuries involving patrons served to the point of intoxication. At the same time, such programs reflect society's interest in reducing drinking and driving and other alcohol-related problems. In Oregon, the implementation of a mandatory server training program in the late 1980s was linked with significant reductions in alcohol-related traffic crashes.
In Ontario, the Addiction Research Foundation has developed the Server Intervention Program (SIP). SIP has been endorsed by the Liquor Licence Board of Ontario and has trained more than 35,000 managers and staff of licensed establishments since 1986.
Reduced drinking: Harm reduction strategies can also play an important role in helping people deal with existing alcohol problems.
It is often assumed, for example, that alcoholism is progressive and that those who experience alcohol problems will develop severe alcohol dependence unless they stop drinking entirely. But while it is true severely dependent drinkers at one point drank less heavily, it is not the case that all those who experience alcohol problems will go on to be severely dependent.
Research indicates that most people who experience problems with their drinking do not develop severe dependence. More typical is a pattern in which periods of problem drinking alternate with periods of abstinence or drinking that does not create problems. On the basis of this evidence, researchers and treatment providers have questioned the assumption that total abstinence is the only appropriate goal for everyone with alcohol problems. Instead, they have proposed more flexible and pragmatic approaches that aim at reducing the harm associated with alcohol use, without prescribing a universal treatment goal.
One alternative has been to develop programs for people with alcohol problems who are not severely dependent. The aim of these programs is to help such "problem drinkers" deal with their drinking by setting their own objectives. Research has shown that these drinkers often recognize that alcohol causes problems in their lives and that they could benefit from changing their drinking behavior. On the other hand they are often wary of being labelled "alcoholics" and many are unwilling to enter formal treatment or accept abstinence as their only alternative.
The Addiction Research Foundation has developed a program to help problem drinkers set and work toward their own goals, whether that means achieving a pattern of low-risk drinking or abstaining entirely. The program is designed to help people identify situations in which they drink too much, set personal objectives for changing their drinking and develop appropriate strategies to deal with problem situations. The ARF has recently published a self-help book based on this approach and is studying the effectiveness of the self-help format when supported by a telephone assessment and follow-up.
A second issue is the acceptability of reduced drinking as a way of limiting the alcohol-related harm experienced by severely dependent drinkers. People who are severely dependent on alcohol have typically developed serious health, personal, financial, legal or work-related problems as a result of their drinking. They are often physically dependent on alcohol and experience withdrawal when they stop drinking.
For these drinkers, abstinence is clearly the appropriate treatment goal. However, in cases where the client is unwilling to accept abstinence as their treatment objective, reduced drinking may be an acceptable interim approach. By negotiating a clear treatment schedule and by closely monitoring the client's drinking, it may be possible to limit the negative consequences. At the same time, keeping the client in treatment may lay the basis for progressing to the goal of abstinence at a later date. While not ideal, this kind of pragmatic approach is preferable to withholding treatment.
An important aspect of contemporary harm reduction strategies is the assumption that the individual drug user should be treated not as a moral outcast but as a legitimate member of society who may need help. Unlike approaches that have the effect of marginalizing drug users, harm reduction recognizes that punishing and ostracizing the user may not be effective in reducing either the level of drug use or of related harm to individuals and society.
Indeed, as the example of injection drug use and AIDS illustrates, policies that criminalize drug taking behaviors can interfere with public health measures such as needle exchange programs. In such cases, reliance on traditional approaches to law enforcement can actually increase the risk of drug-related harm while decreasing the likelihood that individual users will seek out treatment or other health services.
Harm reduction, on the other hand, approaches drug-taking and the associated risks in a pragmatic and humane way. It attempts to provide a framework within which to evaluate current policies and practices in terms of their impact on the real and immediate problems facing both individual users and society.
To date, contemporary harm reduction approaches have made greater headway in Europe and Australia than in North America. There is, however, a growing interest in both Canada and the United States in developing harm reduction strategies to address a range of alcohol- and drug- related problems.
As an important part of this process, the Fifth International Conference on the Reduction of Drug Related Harm will be held in Toronto, Canada, March 6-10, 1994. The conference, which is being held in North America for the first time, will bring together hundreds of scientists, educators, policy-makers and health care professionals to discuss current applications and future opportunities for harm reduction. Conference sponsors include the Addiction Research Foundation; The Canadian Centre on Substance Abuse; Alcohol and Drug Programs, British Columbia; the Government of Quebec and the Mersey Drug Training and Information Centre.
For information about this conference, contact:
Conference Administrator 5th International Conference on the Reduction of Drug Related Harm
Addiction Research Foundation
33 Russell Street