Harm Reduction: A Public Health Strategy

Introduction

A public health approach to the problem of illicit drug use and addiction views the problem not as a phenomenon caused by individual psychological (or moral) factors but rather as one causing extensive social problems and threatening public health. Harm reduction theory reflects this attitude and goes a step further, holding that many of the most destructive consequences and refractory problems of illicit drug use are not the results of the drugs per se, but rather of drug policies, i.e., the prohibition of drug use and the criminalization of the drug user. A wide range of individual, social, and cultural factors determine patterns of drug use (from personal curiosity and peer pressure to social and economic deprivation, psychopathology and, possibly, genetic factors). But because of the continued availability and use of increasingly potent drugs, the harm reduction approach addresses the drug problem by altering drug control policies, not the drugs themselves--and certainly not human nature. New and m ore pragmatic drug policies can be powerful tools for minimizing the increasingly adverse consequences associated with the worldwide availability of psychoactive drugs. (1-4)

Current harm reduction practice is a response to two fundamental observations about drug use. First, it has been well documented that individuals in existing addiction treatment programs rarely achieve total abstinence. (5) Second, for most users of most drugs, controlled use without treatment is the norm. (6-9) The harm reduction approach holds that, over time, controlled use of all drugs is an achievable goal -- even for those people who have become chemically dependent.

Two basic principles of the harm reduction approach are that safer drug use is possible and that the likelihood of such use is a function of drug policies that affect drug markets, public perception, and education about psychoactive drugs. The application of these harm reduction principles has particular significance for public health in three distinct areas roughly analogous to those in preventive medicine: addiction treatment (tertiary prevention), preventive interventions and education aimed at safe r drug use (secondary prevention), and public policy and law reform (primary prevention). Each of these efforts must, for now, operate within the context of prohibitionary drug control regimes dictated, in large part, by international conventions.

I. Addiction Treatment

Methadone maintenance is the preeminent harm reduction approach to addiction treatment. Although the safe and effective use of methadone maintenance antedates the AIDS epidemic (10,11), the appearance of this new disease in 1981, and its link to injecting drug use (12) gave new importance to drug maintenance treatment. The provision of maintenance or substitute drugs to chronic dependent users who were deemed incapable of stopping their drug use on their own characterized the first period of addiction medicine in the United States, from 1900 to 1925 (13). This approach was adopted and expanded in Great Britain (where the influential Rolleston Report (14,15) of 1926 legitimized maintenance prescribing by physicians), but it was discredited in America by the militant temperance movement and shut down by the powerful and ambitious apparatus set up to enforce alcohol prohibition. By 1925 organized medicine and the US courts had rejected the maintenance approach in this country, silenced its proponents, and led American medicine to all but abandon the field to law enforcement officials and moral rhetoricians (16). It was not until the early 1960s (10) and the pioneering work of Dole and Nyswander that the concept of addiction treatment using prescribed maintenance drugs was reintroduced in the United States. Methadone was developed as a "medication" for the treatment of a long-lasting neurometabolic imbalance associated with sustained opiate use. Although speculative at the time, this idea has been validate d by contemporary brain research on the effects of compulsive drug use, i.e., addiction, tolerance, withdrawal, and drug craving. (17)

When properly prescribed, methadone provides relief from acute withdrawal symptoms and markedly reduces chronic narcotic craving by stabilizing blood levels of the drug and its metabolites, thereby permitting "normal" functioning. (15,18,19) The goal o f methadone maintenance therapy is not to achieve total abstinence, but rather to allow the individual to live with a specific chemical dependency (to opiates) by minimizing its disruptive effects on psychological and social well-being and (especially since the rise of AIDS) the risk to individual and public health. Today, methadone maintenance treatment has been adopted world-wide and in a wide range of new approaches. (19-23)

No method of treatment for addiction to opiates is so universally associated with success as is long-term, high-dose methadone maintenance treatment. (5,18,19,24-27) Positive outcomes include decreases in heroin use and injecting (28), reduction in criminal behavior and arrests (29), increased employment, and participation in family support. Most significantly for public health, methadone treatment is associated with reduced risk of AIDS and HIV infection: the rate of HIV infection among persons in methadone treatment is generally inversely proportional to the time in treatment.(30-33) For individuals in New York City entering methadone treatment before 1978, it is virtually zero. (34) Remaining in methadone maintenance treatment is associated with imp roved access to and utilization of other health and social services. Even for HIV-infected opiate addicts, the risk of infecting others is substantially reduced, e.g., the rate of injecting and sharing of needles is reduced as a function of time in methadone maintenance treatment. In addition, the many collateral health problems of addicts infected with HIV can be addressed through medical care services offered in conjunction with methadone programs; e.g., infectious diseases such as multiple drug-resistant tuberculosis can be effectively controlled within the context of primary care offered in methadone treatment programs (35), and for pregnant women vertical transmission of HIV to the fetus can be dramatically reduced by the use of zidovudine in a program of prenatal care based in the methadone maintenance treatment program.

Despite these overwhelmingly positive findings for methadone's impact on clinical and public health and social outcomes (many of them from American studies), the United States has fallen far behind in implementing this approach. There has been no expansion of the availability of methadone maintenance treatment in the United States since the beginning of the AIDS epidemic 13 years ago! Indeed, in New York City, several methadone clinics have been closed and their patients jammed into already over-crowded facilities, predictably increasing community hostility and the likelihood of loitering and drug transactions occurring around clinic sites.

Furthermore, the therapeutic efficacy of many methadone programs in the United States has declined and the standards of clinical practice deteriorated. There is widespread ignorance (even hostility) about the proper use of this treatment among many people administering it. Problems include administration of inadequate doses (36,37), imposition of arbitrary time limits on public treatment (38), and a misguided orientation toward abstinence as a treatment goal. (39) The continued failure to relax counter productive constraints on methadone treatment by US government regulatory agencies ill-equipped to oversee either clinical care or public health, and the continued punitive role of drug enforcement authorities in the field, have driven a once successful addiction treatment to the margins of medical practice and public health. (27,40,41)

Thus despite its proven clinical capabilities and over 3 million patient years of positive experience with methadone treatment, the attitudes and policies of prohibition have had a hugely adverse impact on public health by restricting access to this treatment world-wide, such that until 1994 France had only 52 patients in methadone treatment, and even in the late 1980s, Germany imprisoned doctors for dispensing methadone. With the growing international awareness of AIDS risks and the potential role of methadone in limiting its spread by reducing addicts' risky injecting behavior and needle sharing (42,43), these countries and most others in the developed world are now initiating or expanding methadone treatment. Australia increased its methadone treatment 10-fold between 1985 and 1994 and Germany 10-fold between 1990 and 1994. Even France has begun to open methadone clinics and will reach 1600 patients this year. Other countries, long accustomed to operating methadone treatment through specialized drug -dependency clinics, have now moved to expand methadone treatment through integrating it into mainstream medical practice. In the United Kingdom, the Netherlands, and Australia, for example, over 50% of methadone is now dispensed through general physician s in community-based private practices and, in New York, a "medical maintenance" program has successfully operated from a physician's office, prescribing methadone through pharmacies on a monthly basis. (44) Other innovations include "low-threshold" methadone programs, which make treatment more readily accessible to the less highly motivated addicts in the community. (45-47) In the Netherlands methadone buses carry prescribed doses for a list of 100 or more patients who may meet the bus at any one of the several designated locations daily. (33,48) In these programs no urine tests or counseling contacts are required, but these services are available through both specialized clinics and the public medical and social care system. (49-51)

II. Other Drug Substitution Initiatives

With the growing awareness abroad of oral methadone's efficacy, the medically supervised prescribing of other substitution drugs in Europe and Australia is now entering a phase of new clinical experimentation--including the use of injectable and smokeable drugs. In Great Britain, physicians have always retained the ability to prescribe injectable drugs (including heroin, cocaine, and amphetamines) (52) and they have increased this practice in response to the AIDS epidemic. (53-59) In the Netherlands, several pilot projects of morphine maintenance and other injectable opiates have been tried (60); and in Australia a small pilot program of injectable methadone has operated for 20 years. (61) Elsewhere, the prescription of nonopiates for people dependent on those drugs is gaining popularity. Amphetamines and benzodiazepines are being used in England to shift these dependencies to safer forms of drugs administered under medical supervision in more controlled conditions. (62)

Most impressively, in a series of recent initiatives in Switzerland, 200 patients are prescribed daily doses of injectable heroin, and this program will expand to 1000 patients in six to eight sites in 1995. In Berne users come to clinic up to three times a day and, for 10 francs (US$7.50), are dispensed up to a total of 1000 mg of pharmaceutical heroin and sterile injecting equipment. Another program in Zurich combines low-dose methadone with heroin both to stabilize users and to permit them to respond to continued craving for injectable drugs. These new Swiss programs offer substantial social and health services on-site and are quite costly ($10,000/year), but not nearly as much as untreated addiction, with its associated crime and negative social impact. Initial findings are quite positive regarding both the conduct of the programs and their outcomes. Retention is over 75% for 6 months among quite "hardened" addicts who had rejected methadone or done poorly in prior treatment. (63-65) Australia, the Netherlands, and Germany are all now considering similar approaches to prescribing injectable heroin.

III. Preventive Interventions for Safer Drug Use

Early in the AIDS epidemic the role of injecting equipment, specifically the sharing of needles and syringes contaminated with HIV, was clearly linked to AIDS transmission. And this pattern of spread among injecting drug users was extended to sexual partners and to the fetus during pregnancy and delivery. Thus by 1994, most new cases of AIDS in the large northeastern cities of the United States were associated directly or indirectly with drug use. (66) Yet although many countries and in the United States most states permit over-the-counter sales of needles and syringes (e.g., to diabetics), the possession and sale of such equipment for the purpose of illicit drug injecting is widely proscribed and vigorously prosecuted. Indeed, the possession of injecting equipment without a valid prescription is one of the quickest routes to a prison cell or to the revelation of one's drug habit to family members.

Accordingly the institution of needle exchange programs in the early years of the AIDS epidemic represented the first explicit harm reduction intervention aiming to reduce AIDS risk without necessarily reducing illicit drug use per se. Not surprisingly , needle exchange programs soon encountered the conflict between drug prohibition policies and public health (67) By directly addressing the most obvious linkage of intravenous drug. use and AIDS, needle exchange programs offered a way to control new transmission of HIV, but they also provoked the wrath of those people committed to total abstinence and "zero tolerance." Thus, whereas Europeans and Australians rapidly established and expanded such programs in the 1980s (often in response to the all-too-apparent American catastrophe), the United States itself resisted and continues to resist needle exchange programs, arguing that distributing needles sanctions illicit drug use and sends "the wrong message." (68)

While some community and political leaders complained that research on the efficacy and safety of needle exchange programs was lacking (it wasn't-- see references cited earlier (66-68)) the use of federal research funds for the evaluation of needle exchange programs was not permitted until 1992, the 11th year of the AIDS epidemic. And federal funds are still barred from use for operating needle exchange programs. Largely the private sector, charitable foundations, and community volunteers (with some modest local support in a few states) have provided the funds and personnel for those needle exchange programs that do exist. The United States still lags far behind other nations in this area and fewer than 5% of US injectors have access to needle exchange programs. (66-69) In a society so zealously (and quixotically) dedicated to being "drug free," there has been little room for compromise and the ideological dispute over needle exchange programs still rages, often taking on religious and racial overtones. (67) Such bitter confrontations effectively froze public and governmental action during the crucial early phase of the AIDS epidemic. So, today an estimated, 10,000 to 20,000 intravenous drug users are still newly infected with HIV in the United States each year. (70,71)

The positive effects of needle exchange programs on needle sharing and a wide range of other behaviors linked to AIDS risk are well documented in the United States, Great Britain, the Netherlands, and Australia. (43,68,71-78) But the most significant impact of needle exchange programs on public health may well flow from the ways in which they decrease the marginalization of the highest-risk drug users. Active users in needle exchange programs are more likely to get proper medical care (e.g., for tuberculosis and HIV) and many use these programs to access social and legal services and to enter drug treatment. (43,78-80) In New York City a modest 1 year pilot needle exchange program served 425 users, of whom 67% were successfully referred to treatment (8 1); in the United Kingdom, where 25% of new needle exchange program clients had never seen a general practitioner (75), many were then successfully referred to medical care. Yet despite very favorable reports on the public health impact of needle and syringe exchange programs in the United States by the Centers for Disease Control and Prevention, the Congressional General Accounting Office, and the Institute of Medicine of the National Academy of Sciences, these programs are still marginalized and fighting g to survive funding reductions while facing continued police harassment and criminal prosecution for those activists caught distributing needles (Grove et al., Unpublished data). Elsewhere in the world needle exchange programs are expanding under public health authorities' sponsorship and are the centerpiece of outreach efforts to the community that often involve active drug users and their organizations to promote the programs.

IV. Drug Policy Reform as Primary Prevention

Although addiction treatment and preventive interventions such as needle exchange programs play a crucial role in reducing the harms associated with drug use under prohibitionary regimes (82,83), changes in drug policy per se offer the best chance for primary prevention. By reducing the association of drug use with criminal prosecution--a system that drives drug use and the drug user to the most dangerous margins of society--the reform of punitive legal policies can produce clear benefits in the realm of public health and social order. Significant drug law reform is now underway in several European countries and Australia directly in response to perceived public health needs and humanitarian concerns. These reforms often start with decriminalization of marijuana. The Dutch regulation of cannabis is the most impressive example of this approach, both for its longevity (20 years) and its apparent success.

V. Dutch Cannabis Policy

Although legal prohibition of cannabis remains in the Dutch criminal code, personal use has not been prosecuted since 1976. Following the report of a National Commission (the Worlsing group on Narcotic Substances), an innovative regulatory system was devised to protect both drug users and the larger society. This plan drew a clear-cut distinction between drug users and traffickers, and between illegal drugs with so-called "unacceptable" health risks (e.g., heroin and cocaine) and cannabis products. The philosophy informing this approach was called the "separation of drug markets." It aimed to avoid contacts by young recreational users of cannabis with the "hard drug scene" and the criminal association and health risk that often accompanied it. The Netherlands permitted the retail trade of cannabis products in about 1500 local "koffeeshops" under very specific conditions, i.e., no advertising, no hard drugs, no disturbance of public order, no sale to minors (under 18). and no sale of quantities larger than 30 mg (e.g., 1 oz) per customer. Enforcement of these guidelines fell to local Triangle "Committees," composed of the Mayor, Chief of Police, and District Attorney of each city. Today the domestic Dutch market (which includes some foreign "drug tourists") is a well-established commercial structure operating in a "gray economy" with legal tolerance and even some taxation. It is supplied by many small to mid-sized local producers plus a number of larger importers. So far there has been little evidence o f organized crime in the koffeeshops and even less of violence associated with the domestic trade of cannabis in the Netherlands, with an estimated half-million regular customers. (84,85)

This tolerant policy toward the retail trade and use of cannabis for recreational purposes has, without question, had a positive influence in the Netherlands. For many years, the number of regular users of cannabis products in the Netherlands was relatively stable (at about 3%, i.e., less than 50% of the US level) but has climbed in recent years as a new wave of users try the drug. (86) In this period the number of problem hard drug users in the Netherlands has declined steadily, and the soft and hard drug markets are separated to a considerable extent--a clear confirmation of the strategy's efficacy. Furthermore, the Dutch public at large view cannabis use in a tolerant way, without stigma. Problem users (who are very rare) have ready access to divers e and comprehensive treatment facilities based in the public health sector (as is true for all Dutch users). In contrast, in the United States, several hundred thousand people are still arrested for cannabis use each year and over 50,000 are currently behind bars. (87)

VI. Municipal Policies for Informal Zoning

A large part of public objection to certain forms of drug use relates to their visible presence in the community, i.e., to public appearance of intoxicated individuals and to open-air drug dealing, which involves loitering, violence, and disorderly con duct. Such scenes are deeply embarrassing to city officials--especially in Europe, where public order is highly prized. With alcohol, the most widely used psychoactive drug in western society, use is generally accepted in private spaces (i.e., bars, restaurants, and homes) and public intoxication is tolerated under a wide range of circumstances (from the office Christmas party to public sporting events). But the use of illicit drugs is viewed quite differently. In the United States, with the exception of a few specific venues (e.g., Grateful Dead concerts or Rave dances), public use of illicit substances is often seen as a sharp challenge to authority, evidence of a breakdown of order and social control that attracts political attention and creates pressure for change. Hence, there is a constant tug-of-war between "cops and druggies," as the former attempt to uncover what the latter fail to fully conceal.

This tension, in the context of prohibition and its enforcement, spawned the "shooting gallery," a place where drug users could buy drugs and rent injecting equipment in a locale somewhat insulated from the view of the law. (88) But this accommodation to prohibition occurred at a huge cost in public health, and we are only now appreciating that these locations fostered the massive sharing of injecting equipment among inner-city populations most at risk for HIV. Shooting galleries became the chief vector for HIV transmission among drug users in the cities of the East Coast. (89)

European and Australian police and public health officials became aware of this relationship early in the AIDS epidemic and sought some balance of places where drug use could be contained, health risks reduced, and the social requirements of drug law enforcement met. In 1990 the disproportionate impact of uncontrolled drug use on large municipalities (as in the United States) led to the development of a European Cities Movement for Drug Policy--an attempt to shape drug policies in ways appropriate to cities, which inevitably are magnets for drug-using populations. Innovations include the tolerance of some limited open-air drug dealing scenes in a few restricted locations, often the more anonymous urban areas (e.g., near the central railroad station). These early experiences were sometimes negative (e.g., in Zurich's Platspitz). (91-93) But these experiences became instructive for later attempts at steering the use of drugs to less publicly offensive locations and for the need to establish many small scenes rather than one huge supermarket, especially in the context of widely divergent drug control policies in adjacent nations. The containment of open-air drug scenes and efforts at bringing a variety of outreach services to the world of active users is now underway as an explicit harm reduction program in over 20 jurisdictions in Europe and Australia. An essential part of this process is that drug users and their advocates be integrated into the process of finding feasible solutions to local drug problems.

VII. Conclusions

The clinical, social, and public policy adjustments to drug prohibition discussed here still leave major areas of public health risk unaddressed. Indeed, the limit of harm reduction's efficacy as a public health strategy is determined in large part by the vigor of prohibition's enforcement. Nowhere is this more true or more significant than in the United States. For although other countries (e.g., Malaysia, Singapore, and China) may have more frankly brutal and cruel penal structures (such as death penalties for possessing even small quantities of drugs), the United States has responded to its drug problem with the massive incarceration of its drug users, especially those from the poorest minority communities. Over 1 million young Americans are jailed each year for drug offenses. In a repetitive cycle of arrest, release, reoffense, and rearrest, American drug users are systematically driven to desperation and to the destruction of their personal health and social prospects while their communities are shattered by the violence of the drug wars. These statistics should be understood as data on human rights, perhaps even as "war crimes."

The prescription, "first do no harm," the cornerstone of medicine's Hippocratic oath, should also be adopted as a first principal of drug control policy. Our current policies do immense harm to large numbers of our citizens and appear to worsen our drug problems even as they damage the democratic institutions of civil society. Ultimately these practices must be modified by law reform. Drug policy is an issue of the most pragmatic sort (because of its public health impact), but it is also a matter of global geopolitics affecting the social destiny of entire nations. Indeed, if we are unable to find a way to address the realities of the huge illicit global drug economy in a way that reduces the harms associated with drug use, both public health and inter national peace will deteriorate even further. The recent experience of explosive growth of HIV/AIDS in Southeast Asia and India (94) and the deterioration of many urban centers in the United States and Europe, all attest to the powerful attraction of psychoactive drugs in a world full of pain and injustice. Ultimately, it is the solution to these social and economic problems that offers the best hope for ameliorating drug problems at their root cause. In the meantime, harm reduction may be all that stands between the dismal status quo and the exacerbation of public health catastrophe on a global scale.

Drucker, Ernest. "Harm Reduction: A Public Health Strategy." Current Issues in Public Health. 1(1995): 64-70.

Ernest Drucker, PhD, Director, Division of Community Health, and
Professor in the Department of Epidemiology and Social Medicine,
Montefiore Medical Center, Albert Einstein College of Medicine, 111 East
210th Street, Bronx, NY 10467-2490, USA.

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