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Commentaries 343 Given the immediacy of the threat posed by human immunodeficiency virus/acquired immune deficincy

Commentaries

343

Given the immediacy of the threat posed by human immunodeficiency virus/acquired immune deficincy virus (HIV/AIDS) in the mid-1980s, it was probably important to be explicit about harm reduction not neces- sarily addressing drug consumption per se when first describing this approach [4]. However, as this paper notes, harm reduction remains anathema to some who see it as the thin end of the drug legalization wedge, despite efforts to dissociate these explicitly [5]. Some detractors even accuse those who support harm reduction of having vested interests in maintaining the drug problem [6]. As Hall suggests [7], those of us who fought for harm reduction two decades ago would probably find it hard to let go of this term, especially given the weight of evidence of its success now amassed. Indeed, from a pragmatic perspective its retention at this point in time is question- able, given how polarizing and occasionally divisive it can be. In particular, the more narrow ‘pure’ definition, which states that harm reduction necessarily doesn’t address drug consumption, could be perceived as protest- ing too much. This definition certainly has little utility in day-to-day clinical practice, as injecting and sexual risk behaviour and drug-related harms are often also affected by level of AOD use, drug users’ needs in this regard fluc- tuating widely in both the short and long term. While other taxonomies could replace harm minimi- zation, including harm reduction (for example primary, secondary and tertiary prevention), it might be too late for this, as the World Health Organization, other United Nations organizations and many countries in the world have now embraced this terminology [8]. Perhaps, at this point in time, it should be re-emphasized that the harm reduction approach is the first step in a continuum of care that extends to abstinence-based AOD strategies. In this sense, harm reduction is both a cure and a care-based approach [4] consistent with accepting a duty of care as a compassion- ate and caring community, and while harm reduction encompasses abstinence as a desirable goal, it recognizes that when abstinence is not possible, it is not ethical to ignore the other available means of reducing human suf- fering [9].

Declarations of interest

None.

Keywords

Abstinence, drug policy, harm minimiza-

tion, harm reduction, zero tolerance.

INGRID VAN BEEK

Kirketon Road Centre, South Eastern Sydney and Illawarra Area Health Service, Sydney, NSW, Australia. E-mail: ingrid.vanbeek@sesiahs.health.nsw.gov.au

References

1. Weatherburn D. Dilemmas in harm minimization. Addiction 2009; 104: 335–9.

2. Ministerial Council on Drug Strategy. The National Drug Strat- egy: Australia’s Integrated Framework, 2004–2009. Canberra:

Commonwealth of Australia; 2004.

3. Zinberg N. E. Drug, Set, and Setting. New Haven: Yale Univer- sity Press; 1984.

4. Buning E. The role of harm reduction programmes in curbing the spread of HIV by drug injectors. In: Strang J., Stimson G.V., editors. AIDS and Drug Misuse. London: Rout- ledge; 1990, p. 153–61.

5. Single E. Defining harm reduction. Drug Alcohol Rev 1995;

14 : 287–90.

6. House of Representatives, Standing Committee on Family and Human Services. The Winnable War Against Drugs:

The Impact of Illicit drug Use on Families. Parliament of Aus- tralia. 2007. Available at: http://www.aph.gov.au/house/ committee/fhs/illicitdrugs/report/fullreport.pdf (accessed 9 September 2008).

7. Hall W. What’s in a name? Addiction 2007; 102 : 691–2.

8. Ball A. L. HIV, injecting drug use and harm reduction: a public health response. Addiction 2007; 102: 640–90.

9. Gunn N., White C., Srinivasan R. Primary care as harm reduction for injection drug users. JAMA 1998; 280 :

1191–5.

HARM REDUCTION IS NOW THE MAINSTREAM GLOBAL DRUG POLICY

For almost a century, the paramount objective of global drug policy has been reducing drug consumption. In 1989 the US government argued [1]: ‘we must come to terms with the drug problem in its essence: use itself. Worthy efforts to alleviate the symptoms of epidemic drug abuse-crime and disease for example—must con- tinue unabated. But a largely ad-hoc attack on the holes in the dike can have only an indirect and minimal effect on the flood itself ’. Governments allocated relevant resources overwhelmingly to supply control [2] for what has been perceived as an essentially criminal justice problem. However, support has been growing recently for focus- ing on reducing the adverse consequences of drugs. An influential World Health Organization (WHO) Committee [3] expressed ‘concern for preventing and reducing problems rather than just drug use’. Although harm reduction type approaches existed long before the human immunodeficiency virus (HIV), the recognition of an acquired immune deficiency syndrome (AIDS) pandemic in 1981 and the subsequent realization of the substantial costs of HIV spread among and from injecting drug users stimulated support for the concept of harm reduction; that is, policies and programmes aimed primarily at reducing the health, social and economic costs of psy- chotropic drugs without necessarily reducing drug consumption.

© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction

Addiction, 104 , 340–346

344

Commentaries

AIDS is now the fourth major cause of death in the world [4], while needle sharing accounts for 30% of all new HIV infections outside sub-Saharan Africa or one in every 10 new global HIV infections. Since the early 1990s, it has been evident that a harm reduction package (including needle syringe programmes [5] and substitu- tion treatment [6] for heroin dependence) reduces HIV spread without increasing illicit drug use. Although harm reduction is among the most effective interventions in the HIV prevention and treatment repertoire, Weath- erburn [7] mentions HIV/AIDS only once. Harm reduction has become accepted so widely because of the severity of the global threat from HIV, the strength of scientific evidence supporting [8] the effective- ness and safety of harm reduction and the relative ineffec- tiveness [9], high cost and serious collateral damage [10] resulting from supply control. Harm reduction is now supported by virtually all major relevant United Nations organizations, including WHO, Joint United Nations Pro- gramme on HIV/AIDS (UNAIDS), United Nations Office on Drugs and Crime (UNODC), United Nations Children’s Fund (UNICEF) and the World Bank. Major international organizations strongly supporting harm reduction include the Red Cross and the Global Fund for AIDS, Tuberculosis and Malaria. Although Weatherburn [7] recommends dispensing with the term and concept of harm reduction because the United States remains vehe- mently opposed, global drug policy should not be held hostage because some are in denial any more than is the case with HIV control, evolution or global warming. Sci- entific evidence must trump ideology. Evidence supporting supply and demand reduction is scant. In the United States between 1981 and 2003 the retail price of cocaine dropped [11] from $550/g to $100/g while purity at the retail level increased from 40% to 70%. During this period similar changes [11] in cocaine price and purity occurred in Europe and the retail price of heroin also declined by 50–80% in the United States and Europe. In the decade after UNODC declared [12] ‘a drug free world, we can do it!’, global heroin pro- duction more than doubled and global cocaine produc- tion increased 20% [13]. The estimated [14] benefit from a $1.00 investment to reduce the societal costs of cocaine in the United States brought returns of 15 cents for coca plant eradication in South America, 32 cents from attempts to interdict refined cocaine between South and North America, 52 cents from investment in US customs and police and $7.46 from drug treatment for US cocaine users. Nevertheless, the US government allocated [15] 93% of available resources to drug law enforcement and only 7% to drug treatment. A prospective evaluation [16] of more restrictive drug legislation in the Czech Republic found that three of five objectives were not achieved (with data inadequate to assess the remaining objectives).

Many assert that illicit drug use will inevitably increase with more liberal drug laws; yet life-time preva- lence of smoking cannabis more than 25 times [17] was 32% among residents in more restrictive San Francisco compared to 12% in more liberal Amsterdam using iden- tical recruitment and survey methodology. Ever smoking cannabis and use of all other illicit drugs were also more prevalent in San Francisco. A confidential report on drug policy commissioned by the UK Cabinet in 2003 noted [18]: ‘a sustained seizure rate of over 60% is required to put a successful trafficker out of business—anecdotal evidence suggests that seizure rates as high as 80% may be needed in some cases. Sustained successful interventions on this scale have never been achieved’. The report [18] concluded: ‘The drugs supply market is highly sophisticated, and attempts to intervene have not resulted in sustainable disruption to the market at any level’. A UK parliamentary commit- tee concluded [19] recently: ‘if there is any single lesson from the experience of the last 30 years, it is that policies based wholly or mainly on enforcement are destined to fail’. Any sensible drug policy will always combine ele- ments of supply reduction, demand reduction and harm reduction. The critical question is the relative allocation of resources to supply, demand and harm reduction required to minimize harms to the community. Drugs are primarily commodities subject to the inexorable law of supply and demand. The fall of communism showed that ignoring powerful market forces carries heavy penalties. Drugs should be regarded primarily as health and social problems, with harm reduction accepted as the guiding principle.

Declarations of interest

None.

Keywords Abstinence, drug law enforcement, effec- tiveness, harm reduction, HIV/AIDS, prohibition.

ALEX WODAK

Director, Alcohol and Drug Service, St. Vincent’s Hospital, Darlinghurst, NSW 2010, Australia. E-mail: awodak@stvincents.com.au

References

1. Office of National Drug Control Policy. National Drug Control Strategy. Washington, DC: US Government Printing Office;

1989.

2. Wood E., Tyndall M. W., Spittal P. M., Li K., Anis A. H., Hogg R. S. et al. Impact of supply-side policies for control of illicit drugs in the face of the AIDS and overdose epidemics: inves-

tigation of a massive heroin seizure. CMAJ 2003; 168 :

165–9.

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3.

World Health Organization Expert Committee on Drug Dependence. Twentieth Report. Geneva: World Health Orga- nization; 1974. Available at: http://whqlibdoc.who.int/trs/ WHO_TRS_551.pdf (accessed 9 September 2008).

4.

Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization. AIDS Epidemic Update. Geneva: UNAIDS; 2007. Available at: http://data.

unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf

(accessed 9 September 2008).

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Wodak A., Cooney A. Do Needle syringe programs reduce HIV infection among injecting drug users: a comprehensive review of the international evidence. Subst Use Misuse 2006; 41 : 777–816.

6.

World Health Organization, United Nations Office on Drugs and Crime & UNAIDS. Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Preven- tion: Position Paper of the WHO, UN Office on Drugs and Crime and UNAIDS. Geneva: WHO; 2004. Available at: http:// www.who.int/substance_abuse/publications/en/ PositionPaper_English.pdf. (accessed 9 September 2008).

7.

Weatherburn D. Dilemmas in harm minimization. Addiction 2009; 104 : 335–9.

8.

Committee on the Prevention of HIV Infection Among Injecting Drug Users in High-Risk Countries. Preventing HIV Infection among Injecting Drug Users in High-Risk Countries:

An Assessment of the Evidence. Washington, DC: Institute of Medicine of the National Academies (The National Acad- emies Press); 2006. Available at: http://books.nap.edu/ openbook.php?record_id=11731&page=R1 (accessed 9 September 2008).

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McSweeney T., Turnbull P. J., Hough M. Tackling Drug Markets and Distribution Networks in the UK; A Review of the Recent Literature. London: Institute for Criminal Policy Research; 2008.

10.

Friedman S. R., Cooper H. L. F., Tempalski B., Keem M., Friedman R., Flom P. L. et al. Relationships of deterrence and law enforcement to drug-related harms among drug injectors in US metropolitan areas. AIDS 2006; 20 : 93–9.

11.

Executive Office of the President, Office of National Drug Control Policy. Technical Report for the Price and Purity of Illicit Drugs, 1981 Through the Second Quarter of 2003. Washington, DC: Rand Corporation; 2004. Available at:

http://www.whitehousedrugpolicy.gov/publications/price_ purity_tech_rpt/price_purity_tech_rpt.pdf (accessed 9 Sep- tember 2008).

12.

Storti C. C., De Grauwe P. Globalization and the Price Decline of Illicit Drug: CESifo Working Paper No. 1990. Munich: Ifo Institute for Economic Research; 2007. Available at: http://

Working%20Papers%202007/CESifo%20Working%20

Papers%20May%202007/cesifo1_wp1990.pdf (accessed 9 September 2008).

13.

United Nations International Drug Control Programme (UNDCP). General Assembly Twentieth Special Session: A Drug- Free World, We Can Do It. Geneva: UNDCP; 1998. Avail- able at: http://www.un.org/ga/20special/presskit/pubinfo/ gassbro.htm (accessed 9 September 2008).

14.

United Nations Office on Drugs and Crime (UNODC) 2008. World Drug Report. Vienna: UNODC; 2008. Available at:

WDR_2008_eng_web.pdf (accessed 9 September 2008).

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Rydell C. P., Everingham S. S. Controlling cocaine. Supply versus Demand Programs. Prepared for the Office of National Drug Control Policy United States Army. Santa Monica: RAND Cor-

poration; 1994. http://www.rand.org/pubs/monograph_ reports/MR331/ (accessed 9 September 2008).

16. Zábranský T., Mravcík V., Gajdošíková H., Miovský, M. PAD:

Impact Analysis Project of New Drugs Legislation (Summary Final Report). Prague: Office of the Czech Government, Sec- retariat of the National Drug Commission; 2001. Available at: http://www.ak-ps.cz/client/files/PAD_en.pdf (accessed 9 September 2008).

17. Reinarman C., Cohen P. D. A., Kaal H. L. The limited rel- evance of drug policy: cannabis in Amsterdam and in San Francisco. Am J Public Health 2004; 94: 836–42.

18. Cabinet Office Strategy Unit. Strategy Unit Drugs Project. Phase 1 Report: Understanding the Issues. London: Cabinet Office; 2003. Available at: http://www.cabinetoffice.gov.uk/

media/assets/www.cabinetoffice.gov.uk/strategy/ drugs_report%20pdf.ashx (accessed 9 September 2008).

19. Select Committee on Home Affairs. The Government’s Drugs Policy: Is It Working? London: House of Commons; 2002. Available at: http://www.publications.parliament.uk/pa/ cm200102/cmselect/cmhaff/318/31803.htm (accessed 9 September 2008).

DILEMMAS IN HARM MINIMIZATION:

A RESPONSE TO MY CRITICS

Let me begin by emphasizing a couple of points: I did not (as Wodak says) [1,2] recommend that we abandon harm reduction because the United States is vehemently opposed to it. Nor did I (as Strathdee & Patterson [3] allege) fail to mention the benefits of treatment. These commentators were so eager to slay the dragon that they ended up tilting at windmills. My concern was with harm minimization (namely, macro harm reduction), not micro harm reduction. The problem I raised was this. If commitment to harm mini- mization helps to improve our policies and programmes then it ought to be possible to determine which policies/ programmes best minimize harm. This is impossible, because (a) there is no common metric in which drug- related harms can be compared; (b) many drug-related harms are difficult, if not impossible, to measure; and (c) reducing one type of drug-related harm often increases others. Wodak [2] and Strathdee & Patterson [3] respond by defending needle and syringe exchange programmes (NSPs) and attacking supply control, but I acknowledged the benefits of NSPs and the harms caused by supply control. There is no argument here. If supply control policy produced nothing but harm one of the major dilemmas in harm minimization would certainly disappear. Supply control policy in the United States does not seem to have been very effective, but there are three points to note about this. First, it is generally accepted that prohibition makes illegal drugs more expensive than they would otherwise be. This is impor- tant, because higher illegal drug prices mean lower demand for illegal drugs [4] and lower drug-related harm

© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction

Addiction, 104 , 340–346