Harm reduction: the least worst treatment of all
Charlotte Allan and Nat Wright
explore the controversial option of harm
reduction
Harm
reduction" is the theory and practice of reducing the negative
consequences of drug use for the individual and for society as a
whole.1
It covers a range of initiatives from government polices and programmes
to providing services, such as needle exchanges and safer injecting
advice. Those who advocate harm reduction do so because overcoming an
addiction is extremely difficult, and it helps minimise damage in the
meantime. For others, harm reduction where adverse consequences of
drugs are reduced without necessarily reducing their consumption poses
an ethical
dilemma.2
How can health professionals be seen to advocate anything other than
cessation when patients are taking illegal substances to the detriment
of their own health?
A policy of
harm reduction may be applicable to many aspects of health-for
example, the promotion of drinking in moderation rather than becoming
teetotal or promoting safer sex rather than abstinence. Debates around
the ethics of harm reduction initiatives are not new. In the 1920s,
barrier contraception was denied to conscripts of the US army on
"ethical" grounds of promoting sexual
promiscuity.3
What was the result? A large increase in the prevalence of sexually
transmitted diseases.
A
valuable interim measure
The
premise behind approaches designed to reduce harm is that many people
who start taking drugs become trapped in a cycle of addiction, and
resuming control of their lives can be a difficult and lengthy
process-it would be futile for a doctor to refuse to treat a
patient until they had stopped taking drugs. There are safer ways of
using drugs and harm reduction for patients is a valuable interim
measure to help them make informed choices and improve their overall
health.
Harm reduction advice takes
many forms and initiatives have been shown to reduce the number of drug
related
deaths.4
Encouraging a patient to smoke heroin rather than inject it will reduce
their risk of viral infections (hepatitis B, hepatitis C, or HIV), deep
vein thrombosis, cellulitis, and other bacterial infections. The
provision of schemes for exchanging needles is one of a number of
initiatives which has maintained low prevalence of HIV transmission
among drug users and has reduced rates ofhepatitis
C.5
6
Not only do harm reduction initiatives have important
health benefits for the person with the addiction, but they benefit
society too. Substituting heroin use with methadone prescribed by a
doctor has been shown to reduce illegal heroin use and reduce the
amount of criminal
activity.
MATT SUMNER/THE IMAGE WORKS/TOPFOTO
Needle exchanges: one method of harm reduction
Prevention not cure
However,
critics of policies of harm reduction think that the policies condone
or promote drug use, encouraging people either to continue using drugs
or to start using drugs, without recognising the dangers of their
addiction. Drug users do need to be aware of the risks of their
actions, but people with an addiction will be unable to stop
suddenly.
Some people argue that
instead of putting resources into services to reduce harm, they should
be used to tackle drug traffickers, to prevent people becoming addicted
in the first place. In fact, in many countries this is what happens.
About a quarter of the total budget for drugs in the United States is
spent on treatment, the rest is spent on law
enforcement.7
However, drug raids tend to lead only to a temporary disruption in
supply before new markets establish-optimal
control of illicit drugs requires a balance between treatment for drug
users and law enforcement to disrupt the supply
lines.
Since drug users may resort
to crime to fund their habit, misuse of drugs affects the whole of
society. Some people think that although harm reduction has benefits,
its effectiveness is limited and there should be expansion of drug
detoxification and rehabilitation services instead. This is certainly
the ideal and the best treatment for those who are able to undergo
detoxification and achieve abstinence. However, we all meet large
numbers of patients who, despite trying to lose weight or stop smoking,
are simply unable to achieve their goal.
For certain drugs, such as heroin and cocaine, which
have a much higher addictive potential than food or nicotine, the
difficulties are magnified. Harm reduction is therefore a pragmatic
approach that takes treatment to where the user is, rather than waiting
until the drug user is ready to achieve lasting abstinence. Methadone
not only reduces use of heroine, amount of injecting, sharing
equipment, and crime but also improves psychological and physical
health.8
Society
has an underlying disapproval of drug use and drug users. This seems to
extend to harm reduction advice, which may be disapproved of because it
is seen as condoning such practice and sets a poor example to young
people making lifestyle choices for the first time. However, advice and
provision of services need to be carefully targeted to those who are
already addicted, and facts about drugs and assertiveness training
should be provided to young people to enable them to make their own
choices about drug use. As overcoming addiction is so difficult, harm
reduction is a feasible policy, especially if combined with other
interventions such as legislation, police crack down on drug imports,
and widening access to treatment services-including
detoxification or maintenance
options.
What
is the situation in your country? Post a rapid response
on
www.studentbmj.com
Practising harm reduction accepts that eradicating drug
use is not possible and seeks to remain morally neutral towards an
individual's illegal drug use. In the United Kingdom, the General
Medical Council recommends doctors not to allow one's
"personal views about patients' race, culture, gender,
sexuality, or age" to prejudice the care they
receive.9
This means we should not judge a drug user's lifestyle in the
same way that we would not judge a middle class professional who came
in with a "self inflicted" broken leg from a skiing
accident. Harm reduction accepts that many people who have a problem
with drugs have been deprived of opportunities in
life-problematic drug use is much more common in deprived
communities where unemployment, family breakdown, crime, and disorder
are
high.10
It acknowledges that blaming individuals for their drug using problem
is too simplistic.
No quick fix solutions
Tackling drugs issues has no quick
solutions and a multi-layered approach is necessary including
legislation, policing policies, and education. For those who are
already hooked within a cycle of addiction, interventions to reduce
harm have important health benefits. It can take years and several
attempts at detoxification to come off drugs, and some will perhaps
never achieve this goal. Meanwhile, services to reduce harm are
essential for individuals and society. Just as Churchill pragmatically
stated that democracy was the worst form of government apart from the
rest, harm reduction is the worst treatment intervention for drug
users, apart from all the
rest.
Charlotte Allanintercalating medical student University of Leeds
Email: charlotteallan@yahoo.co.uk
Nat Wrightgeneral practitioner consultant in substance misuse Leeds
studentBMJ 2004;12:89-132 March ISSN 0966-6494
- Harm reduction, accessed online http://www.shesinrecovery.com/relapse/harmreduction.html, on 14/01/04
- Wodak, A. Harm reduction: Australia as a case study, Bull NY Acad Med, 1995 Winter; 72(2):339-47
- Glantz L and Mariner W. Annotation: Needle exchange programs and the Law - Time for a Change. American Journal of Public Health 1996; 86(8): 1077-1078
- Sporer, KA. Strategies for preventing heroin overdose, BMJ 2003;326:442-444
- Des Jarlais D. Structural interventions to reduce HIV transmission among injecting drug users, AIDS 2000; 14:suppl_6
- Goldberg D, Cameron S and McMenamin J. Hepatitis C virus antibody prevalence among injecting drug users in Glasgow has fallen but remains high. Communicable Disease and Public Health 1998; 1(2): 95-97
- Drug Control Funding Tables, accessed on the Office of National Drug Control policy Website at http://www.whitehousedrugpolicy.gov/publications/policy/04budget/fund_tables.pdf on 14/01/01
- Gossop M, Marsden J, Stewart D. NTORS after five year: changes in substance use, health and criminal behaviour during fivr years after intake, London: Department of Health, 2001
- General Medical Council. Good Medical Practice. 2001
- Drug Misuse and the Environment: A report by the Advisory Council on the Misuse of Drugs. Her Majesty's Stationery Office: London, 1998.
