This week some further reflections on the links between drug and tobacco harm reduction.
There are many interventions from a public health or health and safety perspective that could be called harm reduction – seat belts, crash helmets, speed limits, safer drinking levels, smoking bans. But as Ethan Nadelmann was at pains to point out at the GFN conference, harm reduction is not just another name for public health or health and safety. It sits at the intersection between public health on the one hand – and human rights and civil liberties on the other.
Harm reduction as applied to the world of illegal/controlled drugs refers to specific policies, programmes and practices that aim to reduce the harms associated with the use of these drugs in people unable or unwilling to stop. Te defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs.
Harm reduction can be defined by a range of principles in which policies and programmes are grounded. In 1996, the Canadian Centre on Substance Abuse offered the following:
Harm reduction accepts that some use of mind-altering substances is a common feature of human experience. It acknowledges that, while carrying risks, drug use also provides the user with benefits that must be taken into account if drug-using behaviour is to be understood. From a community perspective, containment and amelioration of drug-related harms may be a more pragmatic or feasible option than efforts to eliminate drug use entirely.
2. Humanistic Values:
The drug user’s decision to use drugs is accepted as fact. This doesn’t mean that one approves of drug use. No moralistic judgment is made either to condemn or to support use of drugs, regardless of level of use or mode of intake. The dignity and rights of the drug user are respected.
3. Focus on Harms:
The fact or extent of a person’s drug use per se is of secondary importance to the risk of harms consequent to use. The harms addressed can be related to health, social, economic or a multitude of other factors, affecting the individual, the community and society as a whole. Therefore, the first priority is to decrease the negative consequences of drug use to the user and to others, as opposed to focusing on decreasing the drug use itself. Harm reduction neither excludes nor presumes the long-term treatment goal of abstinence. In some cases, reduction of level of use may be one of the most effective forms of harm reduction. In others, alteration to the mode of use may be more effective.
4. Balancing Costs and Benefits:
Some pragmatic process of identifying, measuring, and assessing the relative importance of drug-related problems, their associated harms, and costs/benefits of intervention is carried out in order to focus resources on priority issues. The framework of analysis extends beyond the immediate interests of users to include broader community and societal interests. Because of this rational approach, harm reduction approaches theoretically lend themselves to evaluation of impacts in comparison to some other, or no, intervention. In practice, however, such evaluations are complicated because of the number of variables to be examined in both the short and long term.
5. Priority of Immediate Goals:
Most harm-reduction programs have a hierarchy of goals, with the immediate focus on proactively engaging individuals, target groups, and communities to address their most pressing needs. Achieving the most immediate and realistic goals is usually viewed as first steps toward risk-free use, or, if appropriate, abstinence.
Harm reduction interventions need not be delivered by formal treatment systems. Most of the people who use drugs do not need treatment but they do need options in the form of evidence-based, non-judgemental help and advice to assist them in the minimisation of risks from continuing to use drugs, and the risks of harming themselves or others.
Although it was not originally called harm reduction, the basic principle behind it took root in the 1980s within the American gay community once it was established that the AIDS virus was transmitted through bodily fluids. With their friends and partners dying around them, they mobilised to spread the message to adopt safer sex routines primarily the use of condoms. Although eventually endorsed by official health agencies, given the stigma and discrimination faced by this community (AIDS is God’s vengeance was commonly heard from religious leaders) this was largely a health movement built from the ground up.
The same message was picked up by more radical and pioneering UK drug workers, plus a handful of user activists. They also took their cue both from the example of the gay community, but also from some work done by my organisation at the time, the Institute for the Study of Drug Dependence (ISDD). This was the early 1980s, when glue sniffing became something of an epidemic among young people especially from economically and socially deprived areas. Kids were dying every week, often because they poured glue into large plastic bags, and then suffocated in the course of inhaling the fumes. The research team at ISDD came up with the notion that if you couldn’t stop kids from sniffing at least get the message out to inhale from small crisp packets instead. Also, the team advised that police and others not chase glue sniffers around as this could trigger a heart attack because of the toxicity of the substance.
This caused a huge stink (and not from glue fumes). The press dubbed it ‘the glue sniffers charter’; our Director took a lot of stick during a TV interview and we almost lost our government grant – just for trying to save some lives.
Drug workers, activists and health officials in Liverpool and other areas saw that within the world of injecting drug use, it was the sharing of needles, syringes and all the paraphernalia of injecting use that posed a significant risk of spreading blood borne viruses such as HIV and Hepatitis. On the basis that it would be next to impossible just to tell people to stop heroin use, it was decided to pilot some schemes around the UK whereby users could obtain clean works and/or be encouraged to smoke heroin rather than inject it. At the same time, within the treatment system, as a means of encouraging more people into treatment - there was a change of policy regarding the provision of opiate substitute prescribing allowing more long-term prescribing of drugs such as methadone. And this became government policy – harm reduction became a central plank in government drug strategy from the mid-1990s. It paid off: the UK had some of the lowest rates of HIV among injecting drug users in Europe while people came forward for treatment in large numbers, attracted by the option of opiate substitution therapy which in turn reduced levels of acquisitive crime.
Over time, the idea of harm reduction was extended to other forms of drug use. For example, from the earliest days of MDMA (ecstasy) use in the UK, young people were dying from symptoms closely related to heatstroke because the drug interferes with the body’s natural thermostat. The risk was compounded by the fact that most use was taking place in overheated clubs and dance venues with no proper ventilation and no access to free drinking water. Again, concerned front line drugs workers in collaboration with users, produced advice about staying hydrated, wearing loose clothes, taking time out from dancing – and more recently as the strength of the drugs has increased, about breaking pills up or only taking a dab of powder rather than the whole dose.
There are many other examples including the growth around the world in the number of drug consumption rooms where users can inject under medically supervised conditions to reduce the rising number of drug related deaths and the provision of on-site drug testing at festivals and other music venues.
Obviously, the whole notion of drug harm reduction has been controversial: critics say this is just enabling or condoning drug use and that harm reduction advocates are just looking for a back door to drug legalisation. It has taken a long time for the idea to become more acceptable at an international level, but harm reduction interventions are endorsed by the United Nations agencies covering drugs, HIV/AIDS and human rights.
However, despite endorsement and funding from many countries around the world, the notion of harm reduction remains controversial and subject to the ebb and flow of politics. The International Drug Policy Consortium cite the example of Brazil where the election of a new conservative government has seen many harm reduction services close down together with funding cuts and crackdowns on people who use drugs. The most visible example is ‘Bracos Abertos’, the harm reduction programme targeting homeless people using crack in ‘cracolandia’ in Sao Paulo. The programme was providing housing, access to work, skills building, and paraphernalia, and benefited from the direct support and funding from the local government. With the new conservative government, the programme has now been replaced by a programme called ‘redemption’, focusing on abstinence and religion.
There is, in my view, an underlying objection which baulks at the idea that drug users are even entitled to enjoy human rights or civil liberties. And this isn’t just because their form of drug use is illegal – it is a deep-seated hatred of people who use drugs as somehow sub-human, evil drug fiends. They should not be helped in any way concerning their drug use – unless they want to quit. Otherwise they can just die – who cares?
And for decades, drug users, especially those with the worst problems, mainly injecting drug users, bought into this narrative of shame, guilt and worthlessness, taking on the identity of addict or junkie because their lack of self-esteem robbed them of any other sense of self-worth.
But then groups of drug users began to form action groups and campaign for access to treatment and for those interventions that might help save lives because if your long-term goal was to quit drug use (as most intend to do) – you can’t recover if you are dead. And so there is now a drug harm reduction social movement reaching across the world.
And this entirely maps over to the world of tobacco harm reduction. The WHO through the FCTC is in effect saying the same thing – quit or die. Yet the FCTC defines tobacco control as “a range of supply, demand and harm reduction strategies that aim to improve the health of a population by eliminating or reducing their consumption of tobacco products and exposure to tobacco smoke” It also says the signature Parties are “Determined to promote measures of tobacco control based on current and relevant scientific, technical and economic considerations”.
At best, the FCTC is simply out of date and its Guidelines need updating because it was drafted before reduced risk nicotine products became available and whose life-saving value is now underwritten by current scientific evidence from eminent clinical researchers and academics worldwide.
At worst, the current evidence is being wilfully ignored and instead being trumped by demands from tobacco control advocates that e-cigarettes and the other new devices are banned altogether putting millions of lives needlessly at risk, the lives of the people who cannot or who are unwilling to quit smoking.
Tobacco Harm Reduction is no less a human rights issue than it is for drugs. The history of vaping shows a similar timeline of consumer led, grass roots action to take health matters into their own hands. The fact that people enjoy nicotine, but are concerned about their health and actively seek a safer option, for some a pathway to quitting altogether, seems to be anathema to some elements within the public health community.
The FCTC is all about ‘tobacco’ control, not ‘nicotine’ control. If nicotine is such an evil drug, how come it is perfectly acceptable to provide NRT as part of smoking cessation programmes?
So ‘vapers’ face increasing intransigence from health officials and regulators and a general hostility from the wider public who have been consistently misled through government and NGO campaigns which major on the essential lie that vaping is at least as dangerous as smoking, dubbed by one official from Public Health England as “the lie that kills”.
The WHO estimate that smoking will kill one billion people by 2100. There is huge role for new technology-related harm reduction to play in helping to ensure this doesn’t happen.