Pompidou Group

Co-operation Group to Combat Drug Abuse and Illicit Trafficking in Drugs

Strasbourg, 29 September 2000                                                        P-PG/MIN/CONF (2000) 3

RISK REDUCTION AS A COMPONENT OF A COMPREHENSIVE,

MULTIDISCIPLINARY APPROACH TO DRUG ABUSE PROBLEMS

Discussion paper

prepared by Professor Helge WAAL

University of Oslo (Norway)

NB:   This paper contains a study drafted under the sole responsibility of its author. Its purpose is to stimulate the debate and it does not represent in any way an agreed position of the Pompidou Group.

Table of contents

       Summary............................................................................................................................. 3

I.              Concept.................................................................................................................... 4

II.            PROGRAMMEMES AND STRATEGIES.............................................................. 5

1.    Opioid maintenance............................................................................................ 5

2.    High risk drug use patterns............................................................................... 10

3.    Reduction of mortality and morbidity................................................................ 14

4.    Reduction of social harm.................................................................................. 16

III.           RELATIONSHIP TO OTHER DRUG POLICY STRATEGIES.......................... 17

IV.          PRACTICAL PROBLEMS IN IMPLEMENTATION............................................ 23

       References........................................................................................................................ 25

                                                                                                                                                                                                                                                                                                                  

Summary

I.          Risk reduction is in general a concept covering the reduction of any type of harm caused by the behaviour of individuals or by social and/or medical interventions. In the drug field it is particularly used to signify the reduction of risks for infections and other types of morbidity in drugs users who continue drug use. There is a considerable overlap with the concept of harm reduction that has, however, often an additional meaning of preference for reduction of harms connected to use over reduction of use, and sometimes to the stated belief that the harm is caused to a significant degree more by the attempts to prevent the use than by the use itself.

II.         It is difficult to make any principal division between risk reduction and harm reduction programmes. Four approaches can be distinguished. Opioid maintenance (by methadone, buprenorphine, LAAM – and sometimes codeine or prolonged effect morphine) intended to neutralise adaptations in the central nervous system so that the addict may then be able to live a life not dominated by dependency problems while staying opioid dependent. Controversial approaches such as medical prescription of heroin aim to reach groups not willing to accept usually used opioids. Prescription of injectable methadone is also controversial. This aims to reach addicts not willing to accept oral medication. High threshold projects put demands on the clients and aim at social rehabilitation. Low threshold projects aim to reduce harm and make less, if any, demands. Reduction of risky drug use patterns is achieved by dispensing of needles and syringes, teaching sterilisation by vaccination and by teaching less risky ways of use and by supplying on-the-spot testing and other means for users to ensure purity or specific content of illegal drugs. Prevention of morbidity and mortality in addition is approached through change of attitudes in social services and health institutions, by securing opioid coverage for those in need of treatment for diseases and by outreach health teams. There are specific projects to reach marginalised groups, and also projects to reduce risks in prisons. The most controversial approach is injections rooms or “gesundheitsräume” where the addicts can come to inject in safe surroundings. Reduction of social harm is a particular ambition of harm reduction strategies, which have approaches such as decriminalisation, separation of hard and soft drugs and attempts to create areas where the drug use lifestyle does not disturb the surrounding society.

III.        Risk reduction and harm reduction can for didactic reasons be seen as pragmatic positions between, the drug war at one extreme and legalisation at the other, harm reduction distinguished from risk reduction by acceptance of drug use as an ongoing phenomenon. Most of the strategies are accepted in at least some countries with drug use prevention as a high priority. The thrust of policies is moving in the direction of pragmatism, emphasising evaluation. The state of research does not justify extreme positions. The preferred course would seem to be to accept harm reduction and risk reduction measures within an emphasis both on supply and demand reduction approaches. Several – if possibly not all – programmes might be designed so as to combine these strategies. The aim should be to find the balance between different policy options. In general, risk reduction should be integrated in treatment and in demand and supply reduction activities rather than separate programmes.

IV.        Several of the programmes meet with practical problems. Most of these are solvable but conscious strategies are often necessary. In particular, it is important to develop adequate funding regulations.

I           THE CONCEPT

Risk reduction – sometimes expressed as risk minimisation - is a concept used in preventive and therapeutic medicine and in other social or biological interventions. The risks that are to be reduced may be connected to a behaviour or disease or to the interventions intended to prevent or cure the problem. The concept is not usually used in policy discussions, but in the choice between two interventions with the same effectiveness, the risks involved are obviously relevant for the choices. Risk reduction is also a goal for social policy and community planning meaning reduction of risks of possible harm to society.

Within the field of substance abuse and drug policy, a term frequently used is ”unsafe” – unsafe sex, unsafe drug consumption meaning behaviour with increased risk of getting infected with a disease such as HIV or infectious hepatitis. Another term is “high risk” often used as “high risk groups” meaning groups with increased incidence of the disease or other harms. “High risk behaviour” signifies behaviour with increased exposure to the risk.

Harm reduction – sometimes harm minimisation- is a more controversial concept, largely for historical reasons. In policy questions harm reduction is associated with opposition to the US policy of “war on drugs” and to the Nordic concept of a “drug free society”. In prevention and therapy the term is associated with measures aiming to reduce or prevent harm connected to the use of drugs rather than the use of the drug by itself. This might be seen as a controversy or division on the primary aim of policy.

The terms of risk reduction and harm reduction are often used interchangeably or at least with overlapping meaning. In particular, the concept of harm reduction has diverse meanings. Some would feel that the best way to reduce drug-related harm to society is to reduce the level of drug use. Others use the term specifically to signify a policy of acceptance of drug use in society, feeling that a “normalisation” of drugs is the best way to reduce the total level of harm. But as pointed out by Strang (1993) harm reduction per se is neither pro- nor anti-drug. Predetermined positions have no meaning, as the decisive element is the observed or anticipated harm. Neither has any measure taken to influence use any positive or negative value except through changes in harm consequent upon implementation. The main importance of the harm minimisation concept might according to Strang be to draw attention to the impact of treatment and policy decisions to individuals and to society as a whole.

A national working group on policy in the Canadian Centre on Substance Abuse (CSSA) underlines the need to clarify the concept of harm reduction as this is often used with different meanings. Their definition of harm reduction strategies is as follows: “A policy or programme directed towards decreasing the adverse health, social, and economic consequences of drug use without requiring abstinence from drug use”. A similar definition is given by Single (1996). “Harm reduction is a policy or programme directed towards decreasing adverse health, social and economic consequences of drug use while the user continues to use drugs.” “Harm reduction encompasses abstinence as a desirable goal, but recognises that when abstinence is not possible, it is not ethical to ignore the other available means of reducing human suffering” (Gunn, White & Srinivasan 1998). Legalisation is not an inherent part of harm reduction although a considerable number of those advocating it might be in favour.

Policies prioritising the reduction of drug use in society do not necessarily oppose endeavours to reduce risks connected to persistent use. Nevertheless, these types of policy obviously show a basic difference to harm reduction as in the meaning given by the CSSA.

Basically the view is that the total level of harm is most effectively reduced by reduction of drug use and not the risks connected to it. If a reduction in risks causes an increase in the level of use, the total result might be negative.

Obviously some of the risk reducing measures are more controversial than others. Below there follows an overview of programme and strategies aiming to reduce risks and/or harm. The overview attempts to point out which are most controversial and which most generally accepted.

II          PROGRAMMES AND STRATEGIES

The core approaches in risk reduction, as defined in this report, would be attempts to modify drug use behaviour in a less risky direction when it is not possible to prevent use or achieve abstinence. The education in safe or less risky use patterns also fall within the scope as do attempts to give care and support to addicts with illnesses or suffering and social deprivation. However, proposals on decriminalisation, legalisation of use in safe use areas and in particular the “normalisation of use” – attempts to integrate the patterns of use in mainstream society would fall outside the definition. While supporters of harm reduction might see these as important measures to reduce harm, they conflict basically with a view that increased acceptance and availability necessarily cause increase in use. Risk reduction programmes often encompass strategies to reduce unsafe sexual practice through education measures and the supply of condoms. As this report is structured to deal with risk reduction in drug use problems, these particular risk reduction aspects are left out.

Prevention efforts often contain elements of therapy to cure the disease or problems representing danger with the effect of overlapping concepts. Opioid maintenance – in particular methadone maintenance – is a cornerstone in the treatment system of most countries. Nevertheless, maintenance is also emphasised as a central element in all harm reduction approaches. Furthermore, there are very few maintenance programmes that do not have reduction of risk of HIV infection, hepatitis C infection, overdoses etc. as central goals and policy arguments. Finally, few programmes prevent therapy even if illegal drug use continues with the argument that continued maintenance reduces risks of morbidity, mortality and social nuisance. Maintenance is therefore considered to be an important risk reduction approach in this report.

Preventive efforts often contain elements of therapy to cure the disease or problems representing danger with the effect of overlapping concepts. Opioid maintenance – in particular methadone maintenance – is a cornerstone in the treatment system of most countries. Nevertheless, maintenance is also emphasised as a central element in all harm reduction approaches. Furthermore, there are very few maintenance programmes that do not have reduction of risks of HIV infection, hepatitis C infection, overdoses etc. as central goals and policy arguments. Finally few programmes stop therapy even if illegal drug use continues with the argument that continued maintenance reduces the risk of morbidity, mortality and social nuisance. Maintenance is therefore considered to be an important risk reduction approach in this report.

1          Opioid maintenance

In former British and Dutch colonies, opium use was a prevalent phenomenon and both countries had, as colonial powers, traditions for the supply of opium to dependent users (Berridge 1999, Wewer 1999). The British model has for several decades comprised medical prescription of opioids from codeine and morphine to heroin. The logic has been to treat the opiate addict as a patient with need of medication for his or her suffering. The present widely accepted type of maintenance is, however, of US origin. The model was developed by the researchers Dole and Nyswander in the mid 1960’s based on the observation that patients self administering methadone – a synthetic opioid – seemed to stabilise on a certain dose level that could be maintained through dosage once a day.

In the early stages, the model was pragmatically compared to the use of insulin for diabetics proposing that the heroin addict had acquired insufficient production of an unknown bodily compound to be replaced by methadone. Present knowledge points to the functions of the endorphins in the central nervous system. These are opioids produced in the body that influence specialised receptors, which in turn modulate functions of certain types of nervous cells. Heroin use (as use of other opioids) causes neuroadaptation and this distorts the regulatory system. The result is dysphoria and craving lasting also after the primary abstinence reactions have passed. The logic of the treatment is to use “suitable agonists” – drugs that have the same biologic effects without the same tendency to distort behaviour and cause intoxication. Three types of agonists are generally accepted based on medical research: methadone, buprenorphine (Subutex) and l-alpha-Acetylmethadol (LAAM). Codeine and morphine sulphate (prolonged action morphine) are also used to some extent. Heroine prescription is a more controversial approach. Whatever the agonist used, it is important to realise that the treatment goal is not the cure of dependency. What is attempted, is to neutralise disturbances in the central nervous system by a medication that primarily acts the same way as the culprit. The effect is present as long as the patient is getting the medication. He or she is basically retained in a dependent state but the treatment allows normalisation of lifestyle and protects against harm related to illegal drug use. If illegal drug use continues it is mostly in a better-controlled and less risky pattern.

Methadone maintenance

This drug has a slow metabolisation and a bodily “half life” of 24-36 hours. The patient with a sufficiently high dose will be able to avoid withdrawal by the intake of medication once a day. Drug craving is in this state markedly reduced and intake of heroin has little effect. Methadone is readily absorbed in the intestine and can be taken as a drinkable solution. This makes the administration practicable. Urine analyses will distinguish intake of heroin and other opioids from intake of methadone. The usual procedure is to give the patient increasing doses until “satiation” of the receptors and to control for intake of other drugs through analyses. Counselling is given to stimulate rehabilitation and social change.

Methadone maintenance has been controversial in most countries as the goal of abstinence is “given up”. Presently the treatment is regarded as a cornerstone in the treatment of heroin addiction almost everywhere. The US Institute of Medicine, in the homeland of “war on drugs”, places the approach as scientifically sound and a cornerstone in treatment systems. However, it should be noted that the demonstrable results are limited to maintenance. Time-limited use and the use of “methadone to abstinence approaches” are much less evidenced. As long as the patient uses methadone, use of heroin and injections are dramatically reduced, mortality and morbidity vastly diminished and the ability to make use of psychosocial treatment markedly increased. Criminality and social nuisance are reduced. What is less influenced is use of other drugs. Methadone does primarily work for opioid dependency such as heroin addiction. Drug users are often poly-drug dependent. Use of other types of drug will give the desired effects even though intensity of use might be reduced. It should also be remembered that while there is a general tendency in drug treatment evaluation to find that results improve with increasing time in treatment, the results in maintenance treatment are dependent upon continued drug administration. When the addicts leave maintenance, the problems return. Less than 10% seem to be able to end treatment without relapse (Eklund et al 1994).

Methadone treatment is currently little disputed. There are, however, disputes regarding the aims of treatment and the type of approach. Evaluation research demonstrating benefits generally concerns so-called “high dose, high threshold” programmes. The dose is adjusted to a dose level that “blocks” the tendency of craving and the euphoric effect of heroin use. The user has to accept a certain level of control and partakes in more or less developed psychosocial consultations. The aim is increased life quality and improved social functioning and living conditions. “Low threshold” programmes are programmes that put minimal or no demands on the patient, often supplying methadone by ambulatory services without attempts to control for intake of other drugs and often with moderate attempts to prevent diversion of methadone. Counselling is available only on demand if at all.

The aim in low threshold programmes is to establish rapport with the addict, to alleviate social harms and reduce risks of infections or make the addict available for medical treatment. Scientific evaluation here gives a much more diverse picture. What seems to be demonstrated is a reduction in criminality and social nuisance, but some reports judge even these reductions to be questionable. Reijneveld & Plomp (1993) did for instance find that clients who left a low threshold programme in Amsterdam fared better than those who continued. Van Ameijden et al 1999 judged that low threshold programmes do reduce mortality even though less than high threshold, and highly more so only when high dose approach was used.  A consistent finding might be that this approach seems to improve the relation between the addicts and the social and health services system.  Low threshold methadone programmes are a core element in the “Dutch model” and are judged by Dutch governmental papers to be central in keeping the harm of heroin use in Amsterdam and other cities at a low and acceptable level (Buning & van Brussel 1995, Ministry of Health, Welfare and Sports 1995, but see also Waal 1998). Low threshold programmes presently have central positions in drug programmes in Switzerland (Klingemann 1996), Britain (Franey et al 1993) and Germany (Fischer 1995). Marlatt (1996) analyses the development of harm reduction and points to low threshold as a core element. He states that this has emerged primarily as a “bottom-up” approach, more based on addicts advocacy than by addiction professionals.

Buprenorphine (Subutex)

Buprenorphine is a synthetic opioid acting as a so-called partial agonist. This means that it has a ceiling effect. Above a certain level a further increase in dose gives little or no increase in effect. It has been in use as an analgesic, particularly under the company name of Temgesic, for more than two decades. Reports of abuse have come from most parts of the world proving its abuse attractiveness and dependency- producing properties (Bachs, Bramness & Waal 1999).

Its use in the treatment of heroin addiction has been researched since the late 1970s in the US. Adequate dosage is 20-40 times the dosage usually given for pain treatment as Temgesic. In spite of relatively rapid metabolisation (half-life in average 2-3 hours) effects are prolonged and might, in adequate dosage, exceed 48 hours due to extremely tight binding to receptors. Buprenorphine might therefore be given once a day or even once every second day with adequate stabilising effects in heroin addicts. Several studies comparing buprenorphine and methadone with adequate research methodology conclude with comparable effects in comparable dosages. Side effects are also at the same level. However, buprenorphine is less toxic and abstinence reactions following cessation of use are less dramatic. On the other hand buprenorphine is made ineffective in the intestines and cannot be swallowed. The drug is usually given as sublingual solublets that are kept under the tongue. Supervised intake is therefore more difficult. The medication is readily solved in water and often used in injections.  

Subutex (high dose buprenorphine) is currently used in several countries as a supplement to or instead of methadone. In France, in particular, its use is widespread. It was registered there as an available medication in 1996 and by late 1998, there were an estimated 60,000 users (Bouchet & Vigneau 1998, Lert 1998). France has experienced a drop in the number of overdoses since 1994/95. As Subutex was introduced after the turning point, the use of Subutex can, at most be seen as a part of the explanation.  In 1994 France introduced a broader harm reduction approach. The totality of measures seems to have had effect. On the other hand a very high percentage of intravenous drug users in France currently inject Subutex.

The scientific status today is that high dose buprenorphine (Subutex) has a proven effect and should be introduced as an alternative drug for maintenance treatment. The role in relation to methadone is not decided. Some would recommend, as France does, Subutex as the first choice drug. Others, pointing to dispensing difficulties, abuse liability and somewhat less effect for hard-core addicts, would recommend buprenorphine for use primarily when methadone for some reason is inadvisable. Others would let the addict decide which drug to use.

LAAM (l-alpha-Acetylmethadol)

LAAM is a prodrug that is broken down in the body into two metabolites with agonist activity. The effect therefore initiates slowly 2-4 hours after intake and the effect is sustained for 72 hours. LAAM (or ORLAAM) is administered as a drinkable solution and can be taken every second – third day, usually three times a week.

Basically each of the metabolites has the same effects as methadone, and a patient can be changed from the one to the other drug without any severe difficulty. Most evaluation studies judge LAAM to have about the same effects, as methadone but patient satisfaction tends to be somewhat lower (Kosten 1990). There is a warning that patient with heart difficulties (prolonged Q-T period), should be careful. Further, the prolonged duration might prove a disadvantage in cases of intoxication.

Currently, LAAM is in use primarily in US but also in some European countries. It is usually recommended for stabilised patients who would prefer infrequent visits to the dispensary and for patients who have difficulty managing their weekend dosage.

Codeine and morphine sulphate

Both codeine and morphine sulphate can be taken orally 2-3 times a day with a relatively stable effect. Codeine has in particular some use in Germany while use of morphine sulphate has been more prevalent in France. The drugs are prescribed as tablets with take-home dosages as the effect does not last long enough to prevent withdrawal taken once a day.

There are papers describing acceptable patient satisfaction with these drugs, and one paper by Krausz et al (1998) indicates that codeine maintenance deserves more attention with considerable rehabilitative effects, at least in relatively well of patient groups. In general it is an uncontroversial statement that the effectiveness of these drugs in stabilising the addicts’ lives seems to fall short of that of methadone, buprenorphine and LAAM.

Prescribed codeine and morphine sulphate tablets are often crushed and dissolved into injectable solutions.

The medical prescription of heroin, injectable methadone and morphine chloride

Prescription of heroin and injectable opioids has a long tradition in the UK but mostly judged to have marginal importance. The basic view has been that the patient should have the type of medication that suited him or her best just as any patient with an illness. Evaluation projects do generally favour oral methadone. One controlled study found some increase in retention in treatment for heroin maintained addicts compared to oral methadone, but seen all together both treatment approaches had some advantages (Hartnoll et al 1980). The overall evaluation is that oral methadone is more easily administered and should usually be preferred, possibly with the competing alternatives of buprenorphine and LAAM.

In some countries, notably in Switzerland and the Netherlands, heroin projects have been proposed for those addicts who continue their addiction, causing social nuisance in spite of expansion of services. Particularly well known is the Swiss trial with heroin prescription (Uchtenhagen et al 1997, Uchtenhagen et al 1999), currently attracting interest in several countries (see for instance Kinnunen & Nilson 1999). The Swiss trial has demonstrated that it is feasible to supply addicts with heroin in projects where the addicts come three times a day to a centre to have their heroin injections. Some addicts not willing to accept oral methadone seem to accept this programme and to improve in social functioning. Other conclusions are more debatable, and it is still open to question whether this approach should have any place, at least any large place, within a sensible comprehensive treatment system. On the other hand, the intense opposition is also somewhat exaggerated overlooking the basic similarity across the board of agonist treatments.  To a relatively impartial observer, it seems that the projects raise unwarranted high hopes that are hard to understand. One reason might be that the projects catch the imagination of those who feel that anybody should have legal access to any drug of preference within a socially acceptable approach.  The vigorous opposition is also hard to understand except as an expression by those morally appalled by the use of heroin itself. Further research should be able to answer some questions, but some questions may be rooted in normative views. Others might not be researchable. For most countries a build up of treatment systems based on more easily managed uploads, should be the clear preference.

Agonist treatment for other drugs

The beneficial effect of opioid maintenance is primarily connected to the availability of opioids of long duration with stable levels in blood. For some other drugs this approach might also be feasible. Nicotine addicts might be stabilised with nicotine in less harmful administrations such as adhesives, chewing gum and so forth. Some benzodiazepine addicts might also stabilise with stable use patterns with drugs of prolonged metabolism.

Some adherents of harm reduction seem to hope that most types of abuse could be met with agonist maintenance. Some programmes have for instance tried out Ritalin for cocaine addicts and amphetamine addicts. Amphetamine has also been tried both in a Swedish programme and in UK. The Swedish experience is thirty years old and based on very poor research design (Lenke and Olsson 1998), but it is fair to sum up that the results are not promising. This is, as one would expect from a neurobiological point of view. The basic cellular dynamics of these drugs do not favour this approach, and to date there is no reliable report suggesting hopes in this direction.

Some tentative conclusions on maintenance approaches

Agonist maintenance - the use of long acting opioids in order to neutralise neuroadaptation in addicts – is a well-established and scientifically confirmed approach – but only for opioid dependence. Those addicted to or abusing other types of drugs are not improved. Suitable agonists for other types of illegal drugs of abuse are not in existence. The approaches best corroborated by research are high dose high level programmes using methadone, buprenorphine and LAAM. The treatment is not curative and the addict remains addicted. To a varying degree, addicts continue illegal drug use, but in a less risky way. The associated social improvements are either caused by the addict’s own ability to improve life with this support or through psychosocial interventions. In a harm reduction model maintenance should primarily aim to divert addicts from illegal and insecure supply.

Low threshold methadone is able to reach a broader range of addicts, but the benefits are less well established (concerning effects on HIV incidence, see for instance Langendam et al (1999)). This research area is not developed to the extent that definite conclusions can be drawn. The level of general criminality is low in restrictive countries such as Sweden and Norway and the level in general probably more dependent on general cultural factors and level of social welfare. Some programmes seem primarily to function as a means to furnish dependent addicts with a drug of choice within a legal and acceptable frame. This might be acceptable from a harm reduction point of view, but less well so from a position of supply and demand reduction. The overall benefit might be questioned, particularly in a long-term perspective.

2          High risk drug use patterns

The risks connected to drug use vary largely with mode of use, with purity of drugs and with knowledge on content of the used drug. The illegality might contribute to the harms through increased risk of infections, through varying and unknown content and purity of the drug and by skewed information on dangers of use. In addition, drug use life might be associated with unsafe sexual practice and unhygienic lifestyles or surroundings. These last aspects will not be dealt with.

Prevention of infections

The HIV epidemic brought several changes on the drug scene. The virus is spread through unprotected sex, and the use of condoms was often encouraged more vigorously than abstinence from sex with unsafe partners. As the virus is also spread through unclean equipment, the availability of clean syringes and needles is an important tool to fight the epidemic. Restrictions on sales became replaced by dispensing strategies in several countries. This met with opposition among some who thought it dangerous to “give the wrong message”. It was feared that the mental and practical barriers to drug use might decrease to the extent that a consequent increase in addiction would give a net sum of increased and not decreased harm. At present, this debate is closed in most countries with the conclusion that intravenous drug users should have access to sterile needles and syringes even though injecting is discouraged.

Another feature is that other types of viruses have made an impact. The sharing of syringes and needles also spreads Hepatitis B and C. As the body does not produce antibodies to the virus, hepatitis C very often causes chronic disease. This is prognosticated to cause a high number of liver failures and possibly increased prevalence of liver cancer. HTLV is also a concern because it might cause leukaemia.

The basic approaches to minimise risks are information on the risks, free and available, possibly anonymous testing, information on sterilisation procedures, possibly with supply of means to disinfect, and finally the dispensing of sterile equipment. Other types of approach are vaccination.

Information on risks

·         Several types of handouts

·         Information through campaigns

·         Information through treatment centres and outreach

·         Information through peer groups (the teaching of prostitutes/addicts as co-informants)

Free, voluntary and preferably anonymous testing

HIV, hepatitis and most other important infections can be traced by testing. In the beginning of the HIV epidemic there were heated discussion on whether testing should be involuntary. In some countries it was even suggested that positive results be followed by involuntary treatment, restrictions on movement, information to next of kin and so forth.

Testing is currently regarded as one of the most important tools to influence the behaviour of addicts, both those infected and those not. It is generally agreed that the best results, highest frequency of testing and best compliance occur when the testing is completely voluntary and might be done anonymously.

Sterilisation procedures

Water and ordinary soaps

·         Bleach

Approaches in dispensing

·         Sterile needles and syringes sold over the counter in pharmacies.

·         Slot machines, sometimes constructed to the effect that new equipment can be exchanged for used either free of charge or at a reduced price.

·         Outreach centres delivering sterile equipment free of charge or on an exchange basis.

·         Ambulatory or mobile dispensing buses or teams

·         Equipment sold in injection rooms

Generally there have been few negative reports of consequences (Paone et al 1999). Reactions from neighbours (NIMG-reactions) are often reported as are, more consequently, reports on used needles carelessly thrown around and of vandalism on machines. There have been rumours of children and by-passers accidentally pricking their skin. Verified reports on infections are very few. The dangers are probably somewhat larger connected to hepatitis B and C as HIV tends to become inactivated. Some recent projects have, however, demonstrated that in a worst case scenario viable proliferating HIV might be recovered from syringes stored in room temperature for in excess of 4 weeks Abdala et al 1999. This is both a strong argument for needle exchange programmes and a warning that used needles and syringes lying around can represent a danger.

The evaluation of effectiveness generally emphasises reduction in HIV incidence and prevalence. A status report to the Surgeon General in the US (Surgeon General 1998) recently gave the following summary points:

• Laboratory studies show prolonged viability of HIV in used needles (> 4 weeks), providing strong biological rationale for removal of used drug injection equipment from circulation.
• Syringe exchange programmes (SEPs) consistently attract persons with highest risk profiles for HIV infection and severe drug use, and are successful in referring SEP clients into detoxification and substance abuse treatment programmes.
• SEP-referred clients have similar rates of retention in substance abuse treatment to individuals from standard referral sources, despite more severe baseline drug use and high-risk lifestyles.
• Clients participating in SEPs have decreased re-use of contaminated syringes and reduced sharing of injection equipment.
• The data indicate that the presence of a syringe exchange programme does not increase the use of illegal drugs among participants, and in many cases, a decrease in injection frequency has been observed among those attending these programmes.
• Provision of sterile injection equipment through SEPs and pharmacy access is cost-effective; one HIV infection can be prevented for one third the cost of medical care for an infected person.
• The scientific evidence accumulated to date provides a basis on which municipalities that are heavily affected by an HIV epidemic driven by injection drug use should consider syringe exchange programmes as a tool for the identification of active users of injection drugs and their referral and retention into these services, as part of a comprehensive HIV prevention plan.

However, some warnings should be considered. In spite of years of information and high availability of syringes, high-risk behaviour is consistently found going on in interview research, particularly in high-risk groups. Further, the evidence that the incidence of hepatitis C is reduced is meagre. Some authors such as Hagan (et al 1999) conclude that such an effect is not demonstrable. Further, epidemiological data tells that the prevalence is consistently high everywhere, also in harm reduction. Some countries like Sweden, which, particularly in the Stockholm area, do not distribute needles, have a very low prevalence of HIV. Oslo, which only recently started large-scale methadone maintenance, has a very low level of HIV. It might seem that the most important factor is the addict’s behaviour (Waal 1998). If the addicts know their immunological status and consider infections as serious enough, most seem to be able to behave responsibly. Hepatitis C has not come through as a threat as serious as HIV. In that case, the most important measure would be information that makes the addicts take hepatitis C as serious as most of them take the danger of HIV.

Vaccination

Vaccinations are available for hepatitis A and B. Several outreach and treatment facilities offer these vaccinations free of charge. There is no vaccination for hepatitis C or for HIV. There are some reports on progress as to HIV but no convincing evidence.

An active vaccination programme with available vaccines should obviously be a high priority, non-controversial aspect.

Mode of use

To a large extent oral administration is less risky that intravenous. The risk of overdose is higher when used in places where one is not found. Risks increase when the use is intoxicated with alcohol, with different types of legal drugs or by other substances. It is therefore suggested that it is important to inform on less risky modes of use. The message of the “Just Say No” type is exchanged with graded messages built up to increase the ability to decrease risks experienced when the individual is not able or willing to abstain. The message is structured to example in this manner:

1.    The only safe choice is to abstain.

2.    If you do not manage to abstain, don’t inject. If you do inject, be sure that you use clean equipment.

3.    Be sure that you know the content of what you take.

4.    Don’t take drugs from a person you don’t trust.

5.    Be extra careful if not sober.

6.    Don’t take drugs in situations where nobody will care in case of accidents.

This type of information is used in several countries (for instance UK, Netherlands, Switzerland, and Spain). The arguments in favour are that drugs are used anyway. Increased knowledge reduces the harms. The contra argument is that the result is increased use, both because the use gets more accepted and because the self-confidence of the potential user in increased. Research to evaluate these questions is largely lacking.

“On-the-spot” testing –anonymous testing

Street heroin varies largely in purity and concentration. Some of the overdose mortality is connected to variations in strength making the user misjudge the amounts used. Content of infectious material has also sometimes caused diseases. These types of problems have both been used to argue legalisation and to argue availability of medical prescriptions. This type of problem has, however, become more focussed through the increase in use of “designer drugs” and “party drugs”. This problem has increased dramatically in most European countries. Drugs such as MDMA (“Ecstasy”, gammahydroxybutyrate (GHB) and ketamin are increasingly used in the youthful rave milieus and in the outgoing party type of milieus. The drugs are mostly technically easy to produce and often produced in simple illegal laboratories of low standard. The content is not only variable, but seems sometimes to have increased toxic properties.

To reduce the risks and increase responsible behaviour in discos, festivals and other occasions with rave-like parties, local authorities in several countries have arranged for “on-the spot” testing facilities. On delivering of drug sample, the customer can get information on content and sometimes on concentration of active drugs. Usually identification is not required from the customer.

The pro and contra arguments are the same as in the case of risk-reducing information. Research on the questions is also here insufficient.

3          Reduction of mortality and morbidity

Addicts in opioid maintenance are consistently found to have reduced mortality and morbidity, more so in high threshold than in low threshold programme while low threshold programmes reach farther into the addict population. Programmes reducing risks of infection also obviously decrease morbidity and might even succeed in engaging some addicts in therapy.

However, drug use and addiction cause drug-related deaths and health problems both in spite of and outside the scope of these types of projects. One type of problem is overdose deaths, suicides and violent deaths. Another type is infections and diseases such as abscesses, thrombosis, sepsis and endocarditis and other problems related to injections. Dispensing of needles does not seem to prevent such problems; in particular when the addict has developed inaccessible veins through repeated thrombosis.  Tuberculoses and other infections not related to the use of needles are also an increasing problem. Repeated wounds and traumas are frequent and malnutrition and/or neglected treatment of different types of diseases are not more.

In some countries the costs of health care itself creates barriers for addicts and other groups with scarce means. In others the attitudes in the health care system are unsympathetic to the addicts to the extent that access is hampered. Others again demand abstinence from drugs as a precondition for certain types of treatment. This is also, not uncommonly the case for psychiatric institutions and other mental health systems.

These types of problems can be alleviated through funding procedures, by change of attitudes in the health institutions, by introducing health services in maintenance programmes and in out reach projects, by creating special programmes for target groups. Funding procedures are country specific to a large extent and will not be specifically described.

Change of attitudes in health institutions

Attitudes are partly a social construct and partly a result of experiences and conflicting interest. Some problems can be alleviated through information and destigmatisation, but it is also important that the addict should not be an extra burden in stressed situations. This underlines the need for procedures and priorities. One specific problem is that it is not uncommon for an addiction to approach the health care more to secure a wanted drug than to get treatment for the somatic or psychiatric problem put forward.

A minimum requirement is service-oriented procedures and strategies for co-operation with other agencies and out-reach facilities to ensure follow up and treatment to those not able to adjust to hospital rules.

Short-term maintenance – further referral

Those seriously addicted should have their addiction maintained by agonists when in need of treatment for serious diseases. Hospitals and ambulatory should have recognised procedures to tackle this problem.  This is relevant also for psychiatric institutions. There should also be a possibility to refer for continued maintenance when appropriate.

Adequate health services in drug abuse treatment services

A variety of health services might be included in treatment services whether based on maintenance or not. Generally this is evaluated positively.

Out reach, low threshold services

Often addicts have a lifestyle and behavioural pattern that make health care inaccessible because of opening hours and location. This can be solved by outreach health care in drug scenes or in low threshold, walk in clinics. These clinics diagnose and treat irrespective of use of drugs.

Projects to reach specific groups

Some minorities might distrust the majority society or feel stigmatised by its representatives. In addition to the problems of addiction, this might be caused by ethnicity, social situation, gender problems or sexual orientation. The methadone low threshold-busing project in Amsterdam was originally designed to reach addicts belonging to marginalised Suriname groups (Buning et al 1990). Other projects might be designed to reach groups of prostitutes, socially deprived milieus, illegal immigrants, homeless psychiatric patients or groups recruited on a sexual basis. One main point would be that health care and other services are not made dependent upon abstinence.

Addicts in prison

Both in countries with a harm reduction orientation and in countries with restrictive drug policies, a high percentage of prisoners have drug problems. This has been met by high security prisons and restrictions on visitors. Nevertheless drugs are brought into prisons even though the qualities might be exaggerated. Drug use with sharing of equipment is consequently a problem, and several reports of seroconversion in prisons are published. A recent anonymous questionnaire survey in British prisons found half of the incarcerated intravenous drug users to have injected in prison during the last month prior to interview. It concludes that random mandatory testing seriously underestimates frequency of injections and argues that harm reduction measures such as hepatitis vaccination and sterilising tablets ought to be made available to inmates (Bird et al 1997). Uchtenhagen (1998) has given an overview of HIV prevention in prisons recommending access of syringes, bleach procedures and methadone in addition to drug free programmes in separate units and other treatment programmes.

Injection rooms – “Gesundheitsräume (Druckräume, Fixerstuben)”

This type of projects is particularly attributed to Frankfurt, which is known for a multifaceted harm reduction endeavour that seems to have reduced both social problems and health-related harms (Kemmesies 1995). The approach is also known from Switzerland, Netherlands and the UK. Basically this consists of supervised rooms where addicts can come to have their injections in safe and supervised surroundings – though more often than not on the condition that they are registered as customers. Often there are also age regulations and other limitations. Evaluations have established that a very high number of injections can be performed in such rooms without serious incidences. Injection rooms are also judged to alleviate social nuisance in areas strained by high drug use prevalence. Currently, there is debate over whether this approach is acceptable according to international regulations.

4          Reduction of social harm

Very few would debate that drug use causes social harm, but as described in part I, some would ascribe a substantial part of the harm to the restrictions and prohibitions. Others would point to the fact that legalised substances such as alcohol and nicotine produce more social harm, more health problems and deaths and even a substantial amount of violence and crime. The conclusion would be that the benefits of legalisation might easily be overstated (Waal 1999). It might also be contended that culturally dependent attitudes towards addicts are more important that law regulations (Ødegård 1995). Nevertheless prohibition and restrictions obviously also cause some of the harm. The social harms might be listed as follows:

·         Stigmatisation and marginalisation of users of illegal drugs contributes to the destructive behaviour of many addicts. The drug addict is view with suspicion both as chemically dependent and as a criminal. This prevents integration and therefore limits social regulation of behaviour.

·         Expulsion from the labour marked contributes to poverty and renders the addicts subject to choice between insufficient social benefits and property crimes.

·         Illegality of drugs causes drug crimes, criminal milieus and incarceration of addicts - at least of those involved in trafficking.

Some of these problems might be reduced through decriminalisation of use and possession for own use and by lowering a high level of drug sentences. These measures are outside the scope of this report and will have to be evaluated within the frames of general drug policy. Several of the problems might, however, be reduced through risk reduction measures.

Opioid maintenance

Whether when used as risk reduction or more specifically as therapeutic measures, a thoroughly evidenced aspect is reduction of criminality. In many studies on also finds increased social and vocational competence. This is both because this treatment as such reduces the problems of opioid dependence and because the costs of illegal drug use is high. The reduction of social stigmatisation varies more and is often dependent on conscious strategies to increase acceptance and socially acceptable types of behaviour.  The relative importance of high versus low-level programmes is open to debate.

The separation of drugs by dangerousness

Cannabis and sometimes “party drugs” are often judged to be more innocent than heroin and cocaine, perhaps also in the real world impossible to keep away from the social surroundings of adolescents.  When all types of drugs are met with the same concept of illegal drug and means of suppression, the users of the less problematic drugs might be unnecessarily exposed to problematic drugs and induced to combined use.  The logic would then be to separate “soft drugs” from hard drugs such as intended by the semi-official acceptance of cannabis dealing in the Dutch coffee shops.  Dutch governmental papers (Ministry of Health and Sports 1995) evaluate these measures positively. Nevertheless the approach is controversial.

Drug use accepting living quarters

Local authorities have some places created or accepted living quarters for drug users and heroin addicts without any precondition of abstinence. In the Frankfurt harm reduction approach (Kemmesies 1995) this is a prominent measure. To create living quarters acceptable to homeless addicts, some large empty buildings were built up with simple housing facilities, cafe, spare time areas and workshops. The building also contain injection room and methadone clinic. It is evaluated that this building keep several addicts off the street.

Open drug scenes

In some cities the authorities have tried out or accepted the development of areas where drug use and drug peddling are undisturbed by the police as long as kept within the district (For typology and description see Bless et al 1995).  Two well known examples are “Platzspitz” in Zürich and “Park-Anlage” in Frankfurt. Even though social workers and health personnel were involved, these areas attracted very high numbers of drug users and grew out of control. Social nuisance, criminality and health problems became increasingly intolerable until the authorities intervened with combinations of repression and harm reduction approaches. There are however, large variations in the scenes. When there is some active and constructive forces central in the development as has been the case in Christiania in Copenhagen or the areas are culturally incorporated as the Red Light districts for instance in Amsterdam, the difficulties might be less obvious.

Self help groups and interest organisations

Addicts’ lives bring more often than not development of social alienation and powerlessness. This might increase destructiveness of behaviour and social blind alleys. The views of the addicts are insufficiently heard and their possible positive contributions blocked. Both in Netherlands and in Denmark addicts’ organisations seem to play positive roles.  

III.        RELATIONSHIP TO OTHER DRUG POLICY STRATEGIES

Historically the origin of drug policies is often traced back to the first and second decades of the 20^th century. Alarmed by the increase in the use of drugs such as opiates but also of cocaine and to a lesser extent marihuana, both Europe and US developed basic structures such as legislation on medical drugs, laws on retail and wholesale trade of drugs and the authorisation of professions and societal organisations responsible for the prevention of use. One choice was to emphasise restrictions and to prioritise reduction of availability. In the US, the Harrison Act of 1914 and later supplements largely defined drug use within the penal code with all non-medical acquisition of drugs as illegal behaviour. In Great Britain, the Rollerstone Act of 1928, on the other hand, emphasised a medical point of view defining the addict within a health frame with a legal right to treatment – meaning opiates as medication. The Nordic attitude emphasised restrictions and reduction of availability on the one hand but defined the addict as a responsibility of the health care system on the other. The international conventions that define the nations’ duties to prevent all trade not allowed through the conventions and to regulate the legal trade through controlled channels, were largely but not solely due to influence of the US. A division in approach and aims in this way has long traditions. This is recognizable both in general drugs policy and in different areas of intervention.

General policy

The development has been analysed from different angles and theoretical frames. The drug policy positions are usually supposed to rest on a basis of science and concern for the welfare of people. From a historical point of view, the dominant belief systems, the professions and individuals in position and the cultural situations in the respective countries at the stages of decisions, might be more decisive (Berridge 1966, 1998, 1999). Within the traditions of social constructionism (see for instance Cohen 1990) the whole drug problem is seen as caused by the views and interests of the dominant actors influencing the policy choices.

The rise in use of illegal substances in the later decades of the 20^th century brought a sharpening of the policies. In the UK, the Brain committee concluded on a need for strengthened regulations and restrictions within the British health-oriented policy. In the US the restrictive policy was sharpened by President Nixon and later on by President Reagan coining the policy of “War on drugs”. The policy of drug free societies was adopted in the northern regions of Europe, particularly in the Scandinavian countries. These types of policies emphasise supply reduction as a preventive measure and are therefore associated with criminalisation of use, high level sentencing in drug cases, non traditional police methods as for instance undercover operations, international co-operation on police and customs level. Concerning demand reduction, the focus is on preserving and strengthening attitudes against use. This is usually believed to be enforced by keeping use illegal or at least socially not acceptable. The focus of therapy tends to be put on abstinence-oriented treatment.

At the extreme end, drug use is seen to be an evil causing problems and suffering to the extent that even harsh preventive measures are justified. Proponents sometimes voice the view that the life of the drug user should not be eased too much as this might increase tendencies to use, or prevent motivation for abstinence. It should be borne in mind, however, that these types of views are definitely not inherent in the policy model. The basic trait is not one of police methods and harsh life conditions for the addict. The basic trait is the view that drug use itself is a destructive phenomenon that should be prevented or reduced as far as possible. The harm is seen to be primarily caused by the drugs and by drug use, and the success of policy is a reduction of prevalence and incidence of drug use.

The tide has to a large extent turned against these types of policies during the last two decades. The opposition has built the case with a range of arguments, and Dutch drug policy has often been seen as setting a successful example (see for instance Buning & van Brussel 1995). The influential so-called Frankfurt declaration adopted by the “Konferenz Europãische Stãdte im Zentrum des illegalen Drogenhandels” in Frankfurt 1990, proclaimed that the elimination of drugs and drug use is a failure. Therefore “the priorities of drug-policy have to be changed dramatically”. Decriminalisation of use, free possession of small amounts of drugs, separation of some drugs such as cannabis from “hard drugs” such as heroin and a variety of measures aimed to alleviate problems for the user, should replace sanctions and policing.  

Currently, these types of views have considerable support although there is also considerable opposition as for example through a contrasting organisation of European cities (European Cities Against Drugs – ECAD).  In the extreme case, the problems of substance abuse are seen as primarily caused by the restrictions, not by the drugs. It is pointed out that some users can take drugs in a controlled way, and it is believed that most would be able to do so if not prevented or disturbed by criminalisation and stigmatisation. The destructive use patterns are seen as caused by the illegal status that creates criminal and harmful milieus. The drugs are made unsafe by the illegality that prevents knowledge on content, strength, purity and so forth. The solution is accordingly that one should make the drugs legally available and subjected to quality control. The use should be destigmatised or “normalised” and accordingly socially accepted (see for instance Nadelman 1990).

The liberal position that anybody should have the right to use drugs by their own choice is closely related to legalisation.  The arguments here are based on normative views on individual rights primacy in relation to the common good and often, but perhaps not necessarily, in contrast to a public health view. Proponents of this view are often also concerned with the consequences of criminalisation and non-traditional methods of investigation that are seen to infringe upon the civil rights in modern society (see for instance Husak 1992, Hamaide 1995. For an evaluation see: Waal 1999)

The proponents of harm reduction have founded an organisation, IHRA - International harm reduction association. This organisation publishes a scientific journal; the International Journal of Drug Policy. As can be read here, the concept of harm reduction covers a range of arguments and not all adhere to the more extreme positions. The core arguments are rather pragmatic. As drug use has been on the rise in all European countries and in the US, the fight against drugs is seen as a failure. While large resources are used in futile attempts to curb the use, insufficient are used to reduce the harm carried by use. The restrictive measures are further judged to cause harms both to society and to the user. Drug use prevention by legal sanctions, is judged to endanger goal-directed measures to reduce specific harms such as overdose deaths, deteriorating health of users and social problems. Prohibitions and restrictions cause higher drug prices increase the use of incarceration and the criminal activities to afford the drug supply. It is, however, contended by most that drug selling, particularly on a large scale and especially of drugs like heroin and cocaine, should be prohibited. Full-scale legalisation is therefore not in the centre of harm reduction even if proponents might be found within its adherents.

The controversies might for didactic reasons be sorted on a continuum from one ideological and political extreme to the other with the pragmatic positions in the middle as in table 1.

Table 1: DRUG POLICIES AS A CONTINUUM BETWEEN EXTREMES
War on drugs	The fight against drugs has absolute primacy. The dealer is an enemy. The addicts’ interests are subordinated to the needs of the fight. The ultimate aim is victory over the enemy forces (drugs, drug dealers, and drug producers).
Drug free society	The common good has primacy. The dealer is a threat to the weak and to the community. The addict is a problem and a victim. The ultimate aim is to create a society where drugs are hard to get and not of interest to the large majority. The weak should be protected.
Public health policy	Prevention and cure has primacy. Often prevention is seen as cost effective and should be prioritised when possible. Cure is costly and often difficult. The dealer is a contaminant and a risk to others but might also be a victim. The addict has a disease and should have treatment. The aim of policy is to reduce the prevalence and incidence of drug use. Restrictions and decrease in availability are important as means to reach the goals of reduced total consumption and thereby even more the problem consumption.
Risk reduction	This might be seen as a subgroup of public health policy. Reduction of use might have primacy but reduction of risks connected with no prevented use, is also a focus. The dealer is seen as a threat to the public good but also as an individual at risk. Information on less risky, unwanted behaviour and advocacy on safe procedures are accepted. The aim is to reduce prevalence and incidence both of drug use and of illnesses and harm connected to use.
Harm reduction	Reduction of harm associated with drugs in society has primacy. Drug use is seen as unwanted and problematic but nevertheless an unavoidable element in modern society. The prevention of use is unrealistic and when seriously attempted, an independent cause of harm. Such harm should be minimised by decriminalisation and by acceptance of the drug user as a person with rights and interests. Nevertheless drug use prevalence should be decreased and kept low if possible. The aim is a total level of harm that is as low as possible.
Legalisation	Reduction in use of the penal code and imprisonment has primacy. Drug use might be a problematic phenomenon to be reduced but should not be a punishable behaviour. The prohibitive laws are unwarranted and the real cause of destructive behaviour and problems. Drugs should be supplied in ways that do not presuppose illegal acts such as through public offices or monopolies, prescriptions and pharmacies or registered and controlled, privatised, authorised shops.
Liberalism and consumer orientation	The rights and interests of the individual have primacy. Restrictions are seen as an infringement on the right to consume wherever that does not threaten the interests of others. As consumers the users have the right to consumer control and quality information. Drugs should be available as other goods through stores with competition securing low prices and competent services.

To the extent that this didactic overview of policy positions is accepted, it can be seen that risk reduction and harm reduction constitute a sort of middle ground between two positions with opposite views on causes and measures. At the one end the drugs and their availability are seen as the ultimate problem. At the other the prohibitions, restrictions and the criminalisation are the real culprit. At the one extreme the addict is a criminal or at least a victim of criminals. At the other, the addict is a consumer hindered in voluntary activities through unjustified laws and persecution. At the one end, the goal is to prevent use and establish abstinence through therapy. At the other, the goal is to alleviate drug use lifestyles and ensure safe drug use through consumer information and quality control.

More pragmatic aspects dominate the middle ground. The reduction of risks and harm are not controversial. The problem arises if the goals and attempts are seen to endanger other and more important goals. In table 1, risk reduction and harm reduction have been defined as different positions as in the definitions of concepts in part I. Again, this is a didactic division. It is intended here to draw a line between positions where the reduction of drug use is seen as a prioritised goal and those where the reduction of harm connected to non-preventable use, has the highest priority. Obviously these positions have considerable overlap. Some measures would therefore be acceptable for both types of views. Others would be important to one and less acceptable to the other.

Basically Europe has developed in a pragmatic direction. The strong views and ideologies are less prominent. Goals are more often expressed as integration of services, and as documentation and evaluation with results as guidelines. There is an increasing emphasis on biological models, diagnostics and differentiation of approaches. Drug use is accepted as a lasting if regrettable phenomenon, and harm reduction has become an important goal in most countries. Risk reduction is almost universally accepted.

Is this a “trend, movement or change of paradigm” as formulated in an editorial in European Addiction Research by Fuchs and Degwitz (1995)? These authors, as most others, point to the influence of the HIV epidemic that brought prevention of an epidemic into primacy from the mid 1980’s. Abstinence could no longer be held as a precondition for treatment availability as the prevention and treatment of a potentially life threatening disease came into focus. Later on, drug deaths and other emergencies have become focus of intervention. Fuchs and Degwitz see this as basic changes and conclude that harm reduction is not only a change of emphasis but also a basic change of attitudes. “Society needs to accept limits to what can be changed and has to learn how to best live with what cannot be achieved”. They see the need to give up the goal of solving the drug problem as inherent in the harm reduction position. The need is to find ways to live with it as a problem of modern society.

The contra argument would be that we do live with several types of problems without giving up the continual fight to reduce them. Pollution, traffic accidents, discrimination are examples of unavoidable problems that it is nevertheless judged worthwhile to fight.

This means that even though there may seem to be an unbridgeable controversy at the bottom, much of the practical controversies seem more caused by the “rhetoric of war” than by principal disagreement on policies and programmes (Waal 1998). Opioid maintenance, needle dispensing and exchange, vaccination, most of the outreach health projects and measures to minimise stigmatisation are accepted in most if not all countries with restrictive policies. Risk reduction and opioid maintenance in prisons and by outreach to high risk groups are also found, as are non-traditional approaches in information and projects to approach marginalised groups. On the other hand, no countries have today based their policy on legalisation, and no countries seem to escape significant harm and social problems

through drug use. A harm reduction oriented country such as The Netherlands has specified the need to fight “social nuisance” through use of forced treatment and allow police investigation methods deemed an infringement on civil rights in Norway and Sweden.

Those programmes most controversial are those aiming at “normalisation” of drug use and those that seem to increase acceptance of drug use in society as a whole and to increase availability of drugs. Examples are low threshold maintenance, particularly projects that seem to give out illegal substances without measures to influence behaviour. Dispensing of heroin is often heatedly opposed as are projects that are suspected to build on drug users principal right to have drugs on their own demand and by their own choice. Projects to ensure quality and safety control for drugs whether in red light areas or in youthful rave milieus are also controversial.

According to a thoughtful paper by Farrel et al 1999, the problems of consumption and dependence – both of legal and illegal drugs are, and should be, a major concern of all modern societies. Consumption is a more important phenomenon than dependence, at least for drugs sufficiently researched such as alcohol and nicotine. The major elements influencing consumption are drug supply and drug demand. Harm reduction is a third element that might influence both level of supply and level of demand and the different measures taken should be judged not solely on the basis of changes in the level of harm but also through impact on the level of supply and demand.

Specific types of intervention – separation or integration

One important consideration is whether prevalence reduction (by discouragement of use) and reduction of quantity or harmful consequences are mutually exclusive.  MacCoun, from the Rand Corporation (1998), offers a framework for integration of these approaches and strategies for the successful integration of prevalence reduction, quantity reduction and harm reduction.

These are important considerations. In several countries treatment systems have been sharply divided between drug free/abstinence oriented programmes and maintenance and harm reduction programmes. This might both create futile disagreements and fights and deprive each type of programme of inspirations and methodology of the supplementing programmes. In most countries one presently sees increasing mutual acceptance between the approaches, but distrust is harder to overcome if the programmes have reason to feel insecure because of competition in funding.   

Repressive systems such as prisons also might show resistance and scepticism towards risk reduction. This is both because the aims might be seen as mutually in exclusive and because of attitudes in prison authorities and officers.  Again, the primary aim of the respective programmes should be respected, but the systems seem to profit on integration within this limitation.

Another sensitive area is prevention and information. Information programmes often intend to build negative attitudes towards drug use if not against the users. The question is whether information on modes of safe use might decrease resistance towards use and increase incidence and prevalence. Research in the area are insufficient, but the general trust seem to be that one might integrate risk reduction information with information intending to discourage use. In general information and campaigns seem to have limited effects and improvement both in evaluation and methodology is important. (See for instance White & Pitt 1998). Some have judged that concrete information experienced useful might increase the confidence of the receiver. Obviously however, one here would expect that it is important to find a fruitful balance of wording and content to avoid the message that drug use is both acceptable and safe enough for experimenting.  

IV.        PRACTICAL PROBLEMS IN IMPLEMENTATION

As should be obvious, risk reduction and even more harm reduction cover a wide spectre of projects and programmes. The practical problems in implementation vary accordingly. Here only a few of the more prevalent types of problems will be mentioned.

NIMBY – Not in my backyard

Several programmes have difficulties with protesting neighbours, particularly in the planning stage. This is well known not only for risk/harm reduction programmes but also for mental health programmes generally and for abstinence oriented programmes. In particular, opioid maintenance programmes and needle dispensing units have met with opposition, often making it difficult to find a localisation. Sometimes necessity has forced the choice of deprived areas where there are few vocal neighbours able to protest. Planners have to have active strategies to counteract such problems, sometimes even with the choice of mobile units to avoid powerful neighbours.

Clients in methadone maintenance outlets have a tendency to congregate in the centres or in the vicinity of the centres. This causes both real and imagined problems of social nuisance, criminality and peddling of drugs. Continual work with the customers, diversion to different outlets and dispensaries and other measures usually minimise the problems.

The same types of problems seem to be experienced in needle rooms, outreach facilities and so forth. The solutions are of the same type.

In needle distribution, vandalism of slot machines for needles and syringes is known but not unavoidable. The slot machines might have to be placed in areas where there is a heavy circulation of people.

Leakage of opioids

This is a problem, in particular, for maintenance approaches. Drugs are not only medication for the user/customer but also valuable goods. Some addicts do sell from the portions they have been given, unless supervised intakes are obligatory. Tightly controlled intakes reduce but do not prevent leakage or exchange with heroin and cocaine. If too much emphasis is put on preventing this, the level of control might both alienate clients and reduce the possibility of rehabilitation. Some would judge that leakage problems are overestimated, as methadone and in particular buprenorphine are less dangerous drugs than heroin and contribute to reduction of harms. Obviously, these types of attitudes are acceptable in some countries and offensive in others.

Negative attitudes in local authorities and in important personnel groups

Programmes are often dependent upon co-operation with local authorities, organisations and institutions. Both the addicts and the harm reduction programmes might meet sabotage or belated handling of applications and so forth. This type of problem should be met in the planning stages by the creation of alliances and by securing benefits for the parties in question.

Recruitment of personnel, particularly qualified personnel, is also sometimes difficult as the payroll might be insufficient and not only the addicts but also even the employees might have a negative stigma. This should be counteracted by positive publicity and benefits increasing job attractiveness.

Regulations, laws and legal unofficial and official practise

In some countries the regulation of certain opioids has made maintenance programmes difficult to implement. Central health authorities have for instance in Norway feared that the use of methadone might undermine the drug policy and decided particularly strict regulations on prescription. Some countries such as France have had regulations to the effect that the prescription of methadone should be confined to particular clinics. These types of approaches limit the availability. In others, it is the policies of the medical organisations or other professional bodies that create obstacles. Often general practitioners fear that addicts might represent a nuisance and/or disturb other categories of patients endangering their practice and income.

For other types of programmes such as needle dispension and injection (health) rooms, other regulations or fears have complicated implementation. It is for instance debated whether the rooms that represent official acceptance of intravenous heroin use might be contrary to international conventions.

Financing problems

Several risk reduction activities meet with funding problems. The activity can be seen both as a health related prevention activity and as reduction of social harms. Neither is usually covered by insurance whether social or private corporate. The addicts are not exactly wealthy citizens, and the public is often negative to the use of public sources if this endangers funding of other tasks. Quite often regulations are worded in ways that make risk reduction activities outside the defined scopes. Sometimes the public and populist political parties unilaterally demand repressive police actions and incarcerations regardless of evidence on limited effects of these types of approaches. It might be added that one also sometimes meet with simplified views that withdrawal of these types of measures would solve the problems

These type of problems quite often make risk reduction dependent on social initiatives and vulnerable in situations of financial shortage. Each country should develop regulations enabling risk reduction activities according to the logic of national traditions in funding of health and social interventions.

References

Abdala,N., P. C. Stephens, B.P. Griffith and R. Heimer. (1999). Survival of HIV-1 in Syringes. J Acquir Immune Defic Syndr Hum Retrovirol 20:73-80

Ameijden, E.J van., M.W. Langedam and R.A.Coutinho (1999), Dose-effect relationship between overdose mortality and prescribed methadone dosage in low-threshold maintenance programmemes. Addictive Behavior 24:559-563.

Bachs. L., Bramness. J.G. and Waal. H. (1999) “Buprenorfin – en litteraturgjennomgang,” Oslo, National centre of methadone assisted rehabilitation and National Institute of forensic toxicology.

Berridge, V. (1996), “European Drug Policy: the need for historical perspectives,” European Addiction Research 2:219-225.

Berridge, V. (1998), “Exploring the differences: Contributions to research on drug policies,” In Waal, H. (ed.), Patterns on the European drug scene. Report based on COST A6 project; Evaluation of Action Against Drugs in Europe. Oslo, National Institute of Alcohol and Drug Research, pp. 86-93.

Berridge, V. (1999), “Histories of harm reduction: Illicit drugs, tobacco and nicotine,” Substance Use and Misuse 34:1, 35-47.

Bird, A.G., S.M. Gore, S.J. Hutchinson, S.C. Lewis, S. Cameron and S. Burns (1997), “Harm reduction measures and injecting inside prison versus mandatory drugs testing: results of a cross sectional anonymous questionnaire survey. The European Commission Network on HIV infection and Hepatitis in Prison,” British Medical Journal 315:7099, 21-24.

Bless, R., D.J Korf and M. Freeman (1995) “Open Drug Scenes: A Cross National Comparison of Concepts and Urban Strategies.” European Addiction Research 1:128-138.

Bouchet, J. and J. Vigneau (1998), “The French Experience – the Pharmacist, General Practitioner and Patient Perspective,” European Addiction Research 4:19-23.

Buning, E.C., G.h.a.van Brussel and G. van Sandon (1990) “The ‘methadone by bus’ project in Amsterdam”, Br J Addict 85:1247-1250.

Buning, E. and G. van Brussel (1995), “The Effects of Harm Reduction in Amsterdam.” European Addiction Research, 1:92-98.

Canadian Centre on Substance Abuse National Working Group on Poolicy (1999) “Harm Reduction. Concepts and Practice. A Policy Discussion Paper. Ottawa: CCSA. http://www.ccsa.ca.

Cohen, P. (1990), “Drugs as Social Construct”. Dissertation, University of Amsterdam. Cedro. Centrum voer Drusgsonterzoek.

Eklund,C., L.Melin, A.Hiltunen and S.Borg (1994), “Detoxification from methadone maintenance treatment in Sweden: long-term outcome and effects on quality of life and life situation,” International Journal Addiction 29:627-45.

Farrel, M., P. Griffiths and J. Strang (1999), “Finding the Balance for different Policy Options,” in Derks. J., A. van Kalmthout and H.-J. Albrecht, Current and future Drug Policy Studies in Europe Freiburg i. Br., Max-Planck-Insitut für ausländisches und internationales Strafrecht pp 89-108.

Fischer, B. (1995), “Drugs, communities, and “harm reduction” in Germany: the relevance of “public health” principles in local responses.” Public Health Policy 16:389-411.

Franey, C., R. Power and B. Wells (1993), “Treatment and services for drug users in Britain.” J Substance Abuse 10:561-567.

Fuchs, W.J. and P. Degkwitz (1995), “Harm Reduction in Europe – Trend, Movement or Change of paradigma? European Addiction Research, 1:81-85.

Gunn, N., White, C., Srinivasan, R. (1998), “Primary Care as Harm Reduction for Injection Drug Users.” JAMA 280:1191-1195.

Hagan, H., J.P. McGough, H.Thiede, N. Weiss, S. Hopkins and A. Russell. (1999) “Syringe exchange and risk of infection with hepatitis B and C viruses.” American Journal of Epidemiology, 149:203-213.

Hamaide, J. (1995), “Repression of Illicit Drugs in Western Europe: Aspects of Legal Perspectice,” in Estievenart G (ed.), Policies and Strategies to Combat Drugs in Europe. The Treaty on European Union: Framework for a New European Strategy to Combat Drugs? Dordrecht, Martinius Nijhoff pp 147-158.

Hartnoll, R.L., M.C.Mitcheson, A. Battersby, G. Brown, M. Ellis, P. Fleming, N. Hedley (1980), “Evaluation of heroin maintenance in controlled trial,” Archives of General Psychiatry 37:877-884.

Husak, D.N. (1992), Drugs and Rights, New York, Cambridge University Press.

Kinnunen, A., and M. Nilson (1999), “Recent Trends in Drug Treatment in Europe,” European Addiction Research 5:145-152.

Kemmesies, U.E. (1995), “Szenebefragung Frankfurt/aM 1995,” Frankfurt am Main/Wiesbaden, INDRO e.V/Münster.

Klingemann, H.K. (1996), “Drug treatment in Switzerland: harm reduction, decentralization and community response.” Addiction 91:723-736.

Krausz, M., U. Verthein, P. Degkwitz, C. Haasen and P. Raschke (1998), “Maintenance treatment of opiate addicts in Germany with medications containing codeine – results of a follow-up study.” Addiction 93:1161-1167.

Langendam, M.W., G.H. van Brussel, R.A. Coutinho and E.J. van Ameijden (1999) “Methadone maintenance treatment modalities in relation to incidence of HIV: results of the Amsterdam cohort study”, AIDS 13:1711-1716.

Lert, F. (Rapporteur group de travail) (1998), “Evaluuer la mise á disposition de Subutex pour la prise an charge des usagers de drogue.” Paris, Ministère de la Santé.

Lenke, L. and B. Olsson (1998) “Drugs on Prescription – The Swedish Experiment of 1965.67 in Retrospect.” European Addiction Research 4:183-189.

Marlatt, G.A. (1996), Harm reduction: come as you are. Addictive Behaviour 21:779-788.

MacCoun, R.J. (1999), “Toward a Psychology of Harm Reduction,” American Psychologist, 53:

Ministry of Health, Welfare and Sports (1995), “Drugs Policy in the Netherlands. Continuity and change.” Zoetermeer, Hageman.

Nadelman, E.A (1991), “The case for legalisation,” in Inciardi, J.A (ed.), The Drug Legalisation Debate, Newbury Park, CA, Sage, pp. 17-44.

Nadelman, E.A., P.Cohen, E.Drucker, U.Locher, G.Stimson and A. Wodak (1994), “The Harm Redction Approach to Drug Control: International Progress,” http://www.paranoia.cin.drugs/war.on.drugs/debate/harm-reduction.html.

Paone, D., J. Clark, Q. Shi, D. Purchase and D.C Des Jarlais (1999) “Syringe exchange in the United States, 1996: A national profile. Am J Public Health 89:43-46.

Reijneveld S.A. and H.N.Plomp (1993), Methadone maintenance clients in Amsterdam after five years. Int J Addiction 28:63-72.

Single E (1996), “The Concept of Harm Reduction and its Application to Alcohol” 6th Dorothy Black Lecture, University of London, October 1996. Ottawa, CCSA.

Strang, J. (1993), “Drug Use and Harm Reduction: Responding to the Challenge,”

In Heather, N., A. Wodak, E. Nadelman and P. O’Hare (Eds), Psychoactive Drugs and Harm Reduction From Faith to Science. London, Whurr Publishers pp. 3-20.

Surgeon General. “Evidence-based findings on the efficacy of syringe exchange programmemes: an analysis from the assistant secretary for health and surgeon general of the scientific research completed since april 1998,” http://www.harmreduction.org/surgreview.html

Uchtenhagen, A., F.Gutzwiller, A.Dobler-Mikola, T.Steffen, (1997), “Programmemes for a Medical Prescription of Narcotics, A Synthesis of Results,” European Addiction Research 3:160-163.

Uchtenhagen, A. (1998), “HIV Prevention in Prisons,” in Waal,H. (ed) Patterns of the European drug Scene. An exploration of differences. Oslo, National Institute of Alcohol and Drugs Research, pp 219-224.

Uchtenhagen, A., A. Dobler-Mikola, T. Steffen, F. Gutwiller, R. Blättler and S. Pfeifer (1999) “Prescription of Narcotics for Heroin Addicts. Main Results of Swiss National Cohort Study.” Basel, Karger.

Wewer, L.J.S. (1999), “Review of Dutch Drug Policy”, in Derks, J., A. v Kalmthout, H-J Albrecht, Current and future Drug Policy Studies in Europe. Freiburg i. Br., Max-Planck-Institut für ausländisches und internationales Strafrecht, pp 263-288.

Waal, H. (1997), “Overstating the case. Methodological Comments on "The Effects of Harm Reduction in Amsterdam by Buning and van Brussel,” European Addiction Research 3:199-204.

Waal, H. (1998), Similarities and Differences Behind the Smoke Screen of War Rhetoric,” in Waal,H. (ed) Patterns on the European drug Scene. An exploration differences. Oslo, National Institute of Alcohol and Drugs Research pp 73-79.

Waal, H. (1998), “Drug Use Policies and HIV Prevention – Unhappy Bedfellows?”, in pp 211-218.

Waal, H. (1999), “To Legalize or Not to Legalize: Is that the Question,” In Elster J & Skog O-J (eds), Getting Hooked. Rationality and Addiction, New York, Cambridge University Press, pp 137-172.

Ødegård, E. (1995) “Legality and Legitimacy. On Attitudes to Drugs and Social Sanctions.” British Journal of Criminology 35 (4): 525-541.