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The reduction of drug-related harm: a conceptual framework for theory, practice and research

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Abstract

Harm-reduction is a social policy which prioritizes the aim of decreasing the negative effects of drug use. This chapter provides the first conceptual framework for theory, practice and research into drug-related harm-reduction.
The reduction of drug-related harm A conceptual framework for
theory, practice and research
Russell Newcombe, IN P O’Hare et al. (1992). The reduction of drug-related harm. London: Routledge.
INTRODUCTION
Harm reduction — also called damage limitation, risk reduction, and harm minimization — is a social policy
which prioritizes the aim of decreasing the negative effects of drug use. Harm reduction is becoming the major
alternative drug policy to abstentionism, which prioritizes the aim of decreasing the prevalence or incidence of
drug use. Harm reduction has its main roots in the scientific public health model, with deeper roots in
humanitarianism and libertarianism. It therefore contrasts with abstentionism, which is rooted more in the punitive
law enforcement model, and in medical and religious paternalism.
Health care, criminal justice and educational services can specialize in either strategy (e.g. syringe exchange
compared with rehabilitation) or can combine elements of both approaches (e.g. flexible prescribing clinics which
offer detoxification and maintenance). However, in some fields (e.g. school drug education), abstentionism has an
almost total monopoly. Rather than use either strategy out of faith, policy makers and service providers should
monitor and evaluate how effective they are at achieving their aims and objectives. However, whereas abstentionist
interventions are relatively easy to evaluate (i.e. how many people are prevented from starting or continuing to use
drugs), harm reduction interventions require the selection of a subset of desired goals from a matrix of potential
harm reduction options.
Harm reduction goals are also hierarchical — that is, they vary in their propensity for decreasing negative effects
of drug use. The most well-known goal sequence is that endorsed by the British Government's Advisory Council
on the Misuse of Drugs (1988, 1989) as a strategy for reducing the transmission of HIV infection among and from
injecting drug users. Namely: the cessation of sharing of injection equipment; a move from injectable to oral drug
use; a reduction in the quantity of drugs consumed; and, finally, abstinence. Other sub-goals can also be added at
various points in the hierarchy: for example, cleaning injection equipment before sharing it, reducing the number
of people with whom equipment is shared, and switching from illicit to prescribed injectable drugs. An analogy can
be made with an acrobat's safety-net system: if one net fails, there is another net underneath.
However, before we can rank harm reduction goals and measure the effectiveness of interventions at achieving
them, it is necessary to decide which harms we want to reduce — a process which inevitably will be based on a
complex mixture of organizational goals, moral beliefs, and rational analysis. This chapter attempts to develop an
initial conceptual model for professionals theorizing about, practising, or evaluating harm reduction interventions
with drug users. Although this model may turn out to be somewhat limited in its validity or usefulness, it should
hopefully provide a springboard for others to develop more sophisticated conceptual frameworks (for earlier
developments, see Newcombe, 1987a, b, c; 1988, 1989; Parker et a1.,1988).
To unpack the concept of harm reduction, we first need to distinguish between the causes and effects of drug use,
or, more precisely, the classes of drug-taking behaviour which are known or are suspected to produce particular
classes of consequence (outcomes). Risk is a term used to describe the likelihood of a drug-taking behaviour
resulting in any of a number of consequences. Harm and benefit are complementary terms used to describe whether
a particular consequence is viewed as negative (undesirable) or positive (desirable). The next section will consider
the concepts of harmful and beneficial effects of drug use and related interventions. The following section will
examine the components of riskiness in drug-taking behaviour and the final section will go beyond measurement
issues to consider how we can interpret and respond to the outcomes of harm reduction interventions.
HARMS AND BENEFITS
Drug-taking behaviours known or believed to be risky (e.g. mixing alcohol with heroin) are more likely to have
harmful effects (e.g. overdose), whereas less risky behaviours (e.g. moderate consumption of alcohol alone) are
more likely to be associated with neutral or even beneficial effects (e.g. increased longevity). More often, drug-
taking behaviours may be said, from most perspectives, to result in a complex pattern of negative, positive and
neutral effects (e.g. smoking tobacco aids concentration but decreases lung efficiency). Furthermore, deciding\
whether particular consequences of drug use are harms, benefits, or of neutral value, depends on the morals and
values of the decision maker(s).
Broadly speaking, a change (e.g. increase) in the level of a harm can be reconstrued as the same as the opposite
change (e.g. decrease) in the level of benefit, suggesting that it may be more accurate to speak of optimizing
consequences, which incorporates both reducing harm and increasing benefits. Though a consensus could probably
be reached on the desirability of most consequences for most people, there are also several outcomes which would
divide people of different political and ideological persuasions œ for example: prescribed opiate use pacifying
unemployed youths in cities; use of psychedelic drugs contributing to new art forms; decriminalized cannabis use
leading to a reduction in youthful alcohol use or glue-sniffing. More generally, the very notion of beneficial effects
of illicit psychoactive drug use appears to be universally rejected by drug policy makers, with surprisingly few
having yet even made the conceptual leap from reducing the prevalence of drug use to reducing the prevalence of
drug-related harm.
The present moral starting-point can be assumed to be that consensually held by most social/health professionals
and authorities in the Western world, though space/time constraints preclude a more detailed analysis of this
perspective here. Developing precise concepts is important because it allows us to measure the effectiveness of
harm reduction interventions, and measurement is the basis of evaluation. Harms and benefits can be organized
according to many schemes, depending on the objectives of the classifier and tolerance for complexity. Figure 1.1
shows one useful two-dimensional scheme, which produces nine categories of drug-taking consequences from the
three-valued dimensions of type and level (the origins of this conceptual scheme can be found in Newcombe,
1987a, b, c, 1989; Working Party on Harm Minimization, 1989).
On the type dimension: health harm/benefit includes the extent and quality of disease, fitness, injury, medical
conditions, psychological health and psychiatric problems; social harm/benefit includes the extent and quality of
aggression/affiliation, public order/disorder, group conflict/cohesion and integration/marginalization; economic
harm/benefit refers to the extent and quality of financial variables, including debt, acquisitive crime and the
national economy.
On the level dimension: individual harm/benefit refers to outcomes for the drug user; community harm/benefit
refers to consequences for the drug user's family, friends, neighbours and/or colleagues; societal harm/benefit
refers to the effects on the structures and organizations of society (e.g. health services, criminal justice system, civil
liberties, - culture, the economy).
For instance, a case of cirrhosis of the liver from excessive alcohol use can be classified as an individual health
harm; stigmatization of the relatives of drug users can be classified as a community social harm; and the cost of
drug law enforcement can be classified as a societal economic harm. Similarly, a reduced level of social anxiety
engendered by drinking alcohol can be classified as an individual social benefit; a lower prevalence of HIV
infection produced by reduced equipment-sharing among drug injectors can be classified as a community health
benefit; and the substantial boost to the economy provided by taxes on permitted drugs is a societal economic
benefit. Clearly, the drug-taking behaviour of a single person can and usually does have consequences of each type
at each level, so why bother to separate them? The main function of the harms/benefits model is to help policy
makers and service providers decide which harms they are attempting to reduce, so that scientific evaluation is
possible.
A more accurate classification of harms and benefits could be achieved by a multi-dimensional scheme,
incorporating, for instance, a time dimension (e.g. short-, medium- and long-term effects), a duration dimension
(e.g. temporary, permanent) and/or a scale dimension (e.g. minor, moderate, major). Furthermore, quantification of
the various kinds of harms and benefits would also increase the scientific validity of evaluations of harm reduction
interventions, though this is an extremely difficult task. Indeed, unless policy makers and service deliverers have
enough resources for a comprehensive research programme extending over several years, it will not be possible to
evaluate the positive and negative consequences of particular harm-reduction strategies within a multi-dimensional,
quantifiable model — particularly those consequences which take a long time to show up (e.g. organ diseases,
increased longevity) or which are difficult to define and measure (e.g. distress to relatives, social cohesion).
Thus, an organization attempting to implement a harm reduction strategy with its client group must decide both
which types of outcome it would like to influence, and which outcomes it has the resources to measure. For
instance, a syringe exchange scheme prioritizes reducing the spread of HIV infection, and a scheme with limited
resources might evaluate this harm reduction goal by assessing the results of voluntary HIV tests every quarter
year. Similarly, the evaluators of a local antidrink/driving campaign could examine road accident statistics before,
immediately after and three months after the intervention.
RISKS
Perhaps the easiest (most practical and inexpensive) way of evaluating many harm reduction interventions is to
focus on risks rather than consequences (harms/benefits), because riskiness of drug-taking behaviour is usually
easier to assess by observational, interview and questionnaire methods. For instance, it is easier to ask drug
injectors if they are sharing injecting equipment (risk) than it is to discover how many are HIV-positive (harm).
Similarly, it is easier to measure the effects of an anti-smoking intervention on the community prevalence or
individual frequency of tobacco smoking, than it is to monitor the target group to see what individual health harms
(e.g. lung cancer, heart disease) they eventually incur. However, the reliability and validity of risk measurements is
typically lower than that for outcome measurements (particularly when we compare self-report data with
physiological data).. Therefore, ideally, evaluation of both risks and outcomes should be undertaken, though the
context of evaluation is usually far from ideal.
One scheme for understanding drug-taking risks is based on factoring out the conceptual components of drug-
taking behaviour into quantitative dimensions (dosage, potency and frequency) and qualitative dimensions (access,
preparation, route and style of administration, poly-use pattern, after-care, set and setting), which can also be
expressed as How? and Why? questions. Harm reduction interventions should be based on procedures which aim
to change the behaviour of drug users towards the optimum point on the chosen dimensions (which raises another
major issue for research). This analysis draws heavily on the work of Weil (1972), Weil and Rosen (1983) and
Zinberg (1984, 1987), and some of its origins can be found in Newcombe (1987a, b, c, 1989).
Dosage
This refers to the quantity (how much?) of drug taken at one time (i.e. as a single hit or within a specific time
period). It can be measured as quantity of pure drug taken (e.g. gram of cocaine), quantity of drug product taken
(e.g. a pint of beer) or cost of drug taken (e.g. a £5 wrap). The risk here relates to exceeding the dose level at which
negative effects start to outweigh positive effects, and thus risking (for example) overdose and significant
poisoning.
Potency/toxicity
This refers to the scale of the mental and physical effects caused by a size/weight unit of a drug. For example, high
nicotine cigarettes are more potent than low nicotine cigarettes, heroin is more potent than opium, and cocaine is
more potent than coca leaf. The less potent and more natural forms of a drug are usually less likely to have harmful
effects (Weil and Rosen, 1983). This argument could also be extended to different types of drug (e.g. caffeine is
less potent than amphetamine, LSD is less potent than DOM).
Frequency
This refers to the number of times a person uses a drug in a given time period, and thus to the number and duration
of periods of abstinence. A common distinction is between daily users, weekly users and occasional users. Though
riskiness generally increases with frequency, occasional users (especially novices) also face higher risks because of
their lack of knowledge of safer drug use techniques (Dom, 1987).
There are also several qualitative dimensions of riskiness, where levels of risk are more easily attached to nominal
categories rather than being measurable on a numerical scale. Seven qualitative categories of risk are examined
here.
Access
This refers to the method by which a person gains possession of a drug — for instance, by stealing money or
selling sex to get it, buying it on the black market, getting it on prescription, etc. One obvious consideration is that
illegal drugs are more likely to contain adulterants than prescribed drugs, and are thus more likely to cause harm to
the user.
Preparation
This refers to the relevant actions carried out before and during the administration of a drug, such as filtering
adulterants out of injectable drugs, cleaning injection equipment, eating a meal before drinking alcohol, using a
small plastic bag to inhale solvents, adding a filter to self-rolled cigarettes and chopping powdered drugs before
sniffing them.
Route and style of use
These refer to the method of administration of a drug and the way in which a particular method is implemented.
They are major determinants of the riskiness of drug use.
There are four main routes of drug use, involving the digestive, respiratory, membranal and circulatory systems of
the body. The digestive route (swallowing) is arguably the safest route, both because it produces the slowest onset
of intoxication (making effects more easy to handle) and because it has the advantage of ejecting remnants of the
drug from the body if poisoning or over-intoxication occurs (though some argue that it is practically easier to
swallow an overdose of a drug than it is to overdose by smoking or sniffing).
The second most popular route of drug use is respiratory, which can involve (a) inhaling the gaseous forms of
chemicals which vaporize at room temperature (e.g. solvents) or when heated (e.g. heroin), or (b) sucking in the
smoke of combusting substances from pipes, cigarettes or other devices (e.g. tobacco, cannabis). The long-term
harmful effects of smoking, especially the smoking of products containing carcinogens, are well documented.
The third route of drug use is membranal, which typically involves either (a) chewing plants (e.g. tobacco, coca,
khat) so that the active ingredients seep out and pass through the membranes of the mouth and throat, or (b)
vigorously sniffing (snorting) powdered drugs onto the nasal membranes through the nostrils (other usable
membranes include the anus and the genitals). Chewing some drugs can cause damage to the lining of the mouth
and throat, and sniffing some drugs (e.g. cocaine) can damage the septum.
The fourth and least common route of drug use involves using a syringe and needle to inject drugs directly into the
circulatory system, via a vein or muscle, or under the skin. Under ideal conditions, this method is potentially less
harmful than respiratory or membranal methods. However, injectors of illegal drugs face several harmful effects,
including overdose, physical damage and diseases such as hepatitis B and HIV/AIDS.
The style of drug administration also influences the riskiness of drug-taking. For instance, drinking alcohol spirits
slowly may be less risky than gulping them down; inhaling tobacco smoke deep into the lungs may be more risky
than drawing it into the mouth only; injecting drugs with the proper technique (e.g. angle and depth of penetration)
is less risky than injecting drugs with no knowledge of injecting technique.
Poly-use patterns
Another major determinant of riskiness is poly-drug use, since combinations of two or more drugs produce, in
physiological terms, a new drug, often far more potent than the sum of its parts. Combining depressant drugs such
as opiates and alcohol is known to be particularly dangerous, though less is known about the possible effects of
many other popular drug combinations (e.g. amphetamine and cannabis, cocaine and heroin).
After-care
This refers to individual risk-reducing activities taken after drugs have been administered, such as drinking plenty
of water after heavy alcohol consumption (to avoid a dehydration-related hangover), washing out the nose with
water after a session of drug-snorting, cleaning up skin penetration sites after injecting drugs, and disposing of used
paraphernalia safely (e.g. needles, matches).
Set
This refers to the reasons why people take drugs, and their personality, knowledge, attitudes and mood at that time.
For instance, if a neurotic person or someone in a bad mood took LSD, that person would face higher risk of a bad
trip than a stable person or someone in a good mood. Similarly, if a person drinks several units of alcohol, unaware
that this will cause a deterioration in driving performance, then he or she may be at more risk of an accident.
Setting
This can be expressed as the questions: where, when, who with, and what if..? In brief, this means that the riskiness
of drug-taking can be affected by the situation in which the drug is taken (e.g. glue-sniffing is safer in a park than
on a building site), the time of day the drug is taken (e.g. alcohol consumption may have more negative effects if
drunk earlier in the day), the people in whose company the drug is taken (e.g. being stoned on cannabis among
strangers can cause paranoia) and the occurrence of unexpected events (e.g. a necessity to drive arising when
drunk, visitors arriving when tripping on LSD). Set and setting risks can be substantially reduced with foresight
and planning.
Conclusion
In conclusion, it is possible to factor out the risk components of drug-taking behaviour, and measure them with
observation, interview and questionnaire methods. Some harms and benefits can also be measured in this way,
though the measurement of many positive and negative consequences of drug use requires an extensive range of
multidisciplinary research methods; hence the recommendation to harm reduction evaluators to focus on the
measurement of the risk components of drug-taking behaviour. Once it has been decided which risk behaviours the
intervention is designed to change, evaluation of effectiveness can begin with one or both of two options:
comparisons of risk behaviour across time within the target group, and/or comparisons of risk behaviour in the
target group compared with a control group (similar people who did not receive the intervention).
INTERPRETING AND RESPONDING TO THE OUTCOMES OF HARM REDUCTION
INTERVENTIONS: SOME HYPOTHETICAL SCENARIOS
By employing conceptual schemes like those described in the previous section, it becomes possible to measure the
outcomes of harm reduction interventions. But how do we then interpret these outcomes, and how do we respond
to their implications? A thorough analysis of these issues is outside the scope of this chapter, but examination of
some hypothetical outcomes of harm reduction interventions should highlight several problems inherent in these
tasks.
First, consider a national mass media campaign aimed at reducing the harm associated with the use of solvents by
11-15-year-olds. For a six-month period, the target group is informed through television, magazines, hoardings and
leaflets that inhaling solvents can cause death or serious health problems, but that if they are going to inhale
solvents, some of the risks can be reduced through particular procedures (e.g. using a small plastic bag, so that
accidental suffocation can be avoided). Before the campaign, a representative sample of 1,000 youths is surveyed,
and it is found that 10 per cent have experimented with solvents in the previous year. Official statistics also reveal
that 100 youths died from using solvents in the previous year, and that a further 500 suffered serious injuries/health
problems related to solvent use. Now, consider two possible outcomes of the intervention when a follow-up is
conducted a year after the campaign ended (Table 1.1)-:
In the first outcome scenario, 20 per cent of a representative sample stated that they had experimented with
solvents in the previous year, though the annual number of deaths is down to fifty and the annual number of
solvents-related health problems is down to 250. Harm reductionist would accept that a higher prevalence of
experimentation should be tolerated if deaths and health problems are being significantly reduced, whereas
abstentionists would find an increased prevalence of use conflicting with their priorities.
In the second outcome scenario, 60 per cent of a representative sample of youths stated that they had experimented
with solvents in the previous year, though the annual number of deaths and solvents-related health problems are
down to the same levels as in the first scenario (i.e. 50 and 250). Many harm reduction practitioners might have
difficulty accepting this outcome as a success, either because the much higher prevalence of use could lead to
unforeseen negative consequences in the long term, or because this scenario activates deep-rooted abstentionist
fears and desires.
The second example concerns the introduction of a syringe exchange scheme for injecting drug users (IDUs) in an
inner city area, the primary objective of which is to reduce the spread of HIV infection among and from IDUs.
Annual surveys in the three years before the intervention have revealed three reasonably stable rates: about 5 per
cent of the adult community injects drugs, 60 per cent of IDUs are sharing injecting equipment, and the annual
HIV incidence rate among IDUs is 10 per cent. Table 1.2 shows three possible outcome scenarios one year after
the intervention:
In the first hypothetical outcome, prevalence of injecting has doubled, though prevalence of equipment sharing
dropped from 60 to 40 per, cent and the annual HIV/IDU rate has dropped from 10 to 6 per cent. Do these
moderate reductions in risk and harm justify the increase in prevalence of injecting? Given the primary goal of the
intervention, the answer is positive only if the numerical incidence of syringe-sharing (risk behaviour) and/or HIV-
seroconversion (harmful effect) are reduced.
To illustrate this, assume that the population of IDUs numbered 1,000 before the intervention: this means that 600
were sharing syringes and 100 had become HIV-positive in a year. One year later 2,000 people are injecting drugs:
this means that 800 are sharing injecting equipment and the number of IDUs to become HIV-positive totals 120. In
short, the problem with Outcome 1 is that although the proportions of IDUs engaging in syringe-sharing and
becoming HIV-positive are reduced, the increased prevalence of injecting means that the numbers of people
engaging in syringe-sharing and becoming HIV-positive are increased.
By contrast, Outcome 2 is more acceptable in terms of the criteria of effectiveness, because, although community
prevalence of injecting has still doubled, syringe-sharing is down to 20 per cent and the HIV rate is down to 2 per
cent, resulting in reduced numbers of people sharing syringes (400) or becoming HIV-positive (40). Lastly,
Outcome 3 exhibits a quadrupling of prevalence to 20 per cent (4,000), though syringe-sharing is reduced to 1 per
cent (40) and the monthly HIV rate to zero. This outcome is clearly the most effective in terms of HIV prevention,
yet the correlate is 3,000 more people injecting. Even if these IDUs were receiving prescribed drugs and full
medical care, would all people charged with responding to this outcome be able to accept a fourfold increase in
drug injecting as the price for preventing the spread of HIV? What other harms might be invoked or increased by
this higher level of prevalence? Clearly, acceptable targets on prevalence, risk and harm variables need to be
decided before an intervention if policy makers and service providers are serious about evaluating the level of
efficacy.
The final example involves the random allocation of 300 new opiate-injecting clients to one of three methadone
conditions at a drug clinic: methadone detoxification, oral methadone maintenance, or injectable methadone
maintenance. Putting the primary harm of HIV to one side for the purpose of this example, assume that the dual
gals of treatment are reducing acquisitive crime (i.e. stealing money or property to buy drugs) and improving the
health of the client (e.g. weight, white blood cell count). Ninety per cent are in poor health and involved in drug-
related acquisitive crime on arrival at the clinic. Consider the two possible outcomes given in Table 1.3.
Without going into a detailed analysis of this example, a few minutes' consideration should reveal the difficulties
of interpreting and responding to both hypothetical outcomes. The main conflict is that each treatment option is
effective at reducing one type of harm, but relatively ineffective at reducing the other. Resolution could be found in
prioritizing either harm from the outset, or breaking each down into component harms (e.g. types of acquisitive
crime, types of ill-health) and quantifying or ranking them.
CONCLUSION
Defining and measuring drug-related risks and harms is a complex and difficult task, as is interpreting and
responding to the outcomes of harm reduction interventions. The main problems are likely to be conflicts between
changes in prevalence and level of harm, and conflicts between changes in different categories of harm. However,
evaluation of the effectiveness of harm reduction interventions is possible, if the aims of policy makers and the
objectives of practitioners are clearly stated at the outset, using a conceptual framework like the one described
here. Ideally, this means going beyond general goals such as a reduction in the 14vels of particular risks and harms,
to a specification of quantifiable reduction targets on these levels, and a specified top limit for acceptable
community prevalence of the relevant drug-taking behaviours.
Finally, it should be noted that the three hypothetical cases described above were simplified versions of real-world
situations, and assumed that high-quality information was available to evaluate clearly defined criteria of
effectiveness — which is rarely the case in practice. As in all new areas of endeavour, these problems will only be
resolved by applying harm reduction through a combination of practice, theory and research. Though many of the
risks and harms associated with drug use can undoubtedly be reduced by appropriate strategies, our incomplete
understanding of drug use and the complexities of human nature should also forewarn us that many interventions
will inexplicably fail, while others will succeed in ways that could not have been foreseen.
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Parker, H., Balm, K. and Newcombe, R. (1988) Living with Heroin: The impact of a drugs 'epidemic' on an
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Our valuable member Russell Newcombe has been with us since Sunday, 19 December 2010.
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Technical Report
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People who use illicit drugs (PWUD) experience a wide range of drug-related harms. The goal of harm reduction is to reduce these adverse effects of drug use, without necessarily reducing drug use itself. By providing a safe and hygienic environment to consume pre-obtained drugs under the supervision of trained staff, drug consumption rooms (DCRs) aim to reduce both individual-level and public-level harms associated with illicit drug use. A substantial body of evidence has accumulated over the past three decades to support the effectiveness of DCRs in achieving their primary health and public order objectives, and therefore supports their role within a continuum of services for PWUD. Despite the abundance of scientific evidence supporting DCRs, there continues to be social and structural barriers to the implementation of this public health intervention in communities across the globe. Yet, the debate about implementing new DCRs remains high on the political agenda in a number of countries worldwide. To date, Belgium does not offer a DCR to its drug using population. Against this background, the Belgian Science Policy Office (BELSPO) commissioned a first-ever study to assess the feasibility of DCRs in Belgium. The objective of the current feasibility study was to identify (legal) preconditions, design and operational considerations that would allow a DCR to be added within a continuum of policy initiatives for PWUD in five Belgian cities: Ghent, Antwerp, Brussels, Charleroi and Liège. The aims were threefold: (1) provide an up-to-date overview of the effectiveness, models, and barriers of DCRs worldwide, with particular attention to DCRs in Belgium’s four neighbouring countries; (2) conduct an in-depth analysis of the legal framework within a DCR could operate in Belgium; and (3) conduct a feasibility study with local stakeholders and PWUD from each of the five cities. Based on our findings, we formulate 18 recommendations specifically tailored to the Belgian context: essential preconditions (including legal options); main considerations when implementing a DCR; the implementation process; and monitoring and evaluation.
Article
Writing in the context of proposal to expand the decriminalisation of illicit drugs in the Australian Capital Territory, Australia's smallest and most progressive jurisdiction, this article explores the key question of the use of quantitative thresholds to determine the level of drug use distinguishing personal use from trafficking. Recent literature demonstrates the use of quantitative thresholds has yielded highly divergent approaches in jurisdictions around the world. The literature also points to the underlying challenges involved in evaluating whether it is appropriate to employ quantitative figures to make that distinction, and if so how and to what ends. Harris (2011) goes so far as to describe 'conviction by numbers' as a 'lazy shorthand' that may exact an 'immeasurable cost of injustice' (3). Yet practices which do not rely on quantitative measures are at real risk of exacerbating discretionary judgments by police and prosecutors that may well result in discriminatory application of the laws. The basis on which the balance between these two countervailing considerations is struck in these discussions is not always clear. The paper focuses first on the merits of adopting an approach based on quantitative thresholds and argues that the implications of applying legally mandated drug quantities is in fact not as cut and dried as many authors have assumed. There is an important 'middle way' between the rote application of quantitative measures and their abandonment. This middle way has previously been ignored. The article then addresses exactly how and on what basis quantitative thresholds should be determined if they are to reflect and advance harm reduction principles. Finally, the paper considers and critiques arguments that quantitative thresholds should be set not only by reference to the consumption patterns of users but also in relation to the relative harm of particular substances. As a whole, the essay aims to contribute to a broader international literature on thresholds, a vexed question which matters not only in Canberra, but around the world.
Article
Full-text available
A quantitative study (n=121) of service user experience of clients engaging with Irish methadone services.
Article
Background Many women who inject drugs are aware of the associated risks, however social influences play a part in their behavioral decisions. Incorporation of others in drug use behaviors may be common practice among women who use drugs. The aim of this study was to gain an in-depth understanding of women’s injection drug use experiences with a focus on interpersonal involvement. Methods: Venue-based recruitment was conducted in collaboration with a harm reduction program. A group of 30 women, ages 18 and older, who reported injecting drugs within the past 30 days took part in a demographic survey and semi-structured interview to gain an understanding of their injection practices. In vivo coding and thematic analysis were conducted. Results: Three main themes that relate to incorporating others into injection drug behaviors surfaced, including: (1) injection practices described as we and not I, (2) partnered purchase and drug preparation, and (3) assisted injection. This group of women most often incorporated sexual and/or romantic partners (same and other-gender), friends, or family members into their injection drug use behaviors. Some women described a lack of ability to inject themselves and require assistance every time they use. Women also reported helping other women during drug use behaviors. Conclusions: Our primary themes indicate that a variety of relationship partners are important conceptual links in theoretical frameworks explaining drug use behaviors among women. Findings suggest same gender assistance during drug use behaviors, including injection, that may reduce harm. The interpersonal nature of injection drug use among women may indicate the expansion of treatment options designed for couples or other relationship partners, such as family, together.
Research
Full-text available
Draft research report informed by peer to peer research data in MQI and Ana Liffey Dublin
Article
This article considers the effects of an educational intervention with young people designed to reduce the risk of child sexual exploitation (CSE). Drawing on findings from a qualitative study, we consider processes of engagement with the initiative, the relevance of the strategy adopted by the delivery team and the impacts on the perspectives of young people targeted. Focusing on mutually constitutive problems of context sensitivity, recognition of ambiguity and the silencing of alternative narratives, we raise several critical caveats that should be considered in the design and implementation of future CSE awareness raising initiatives. Overall, we aver that an unstinting focus on individual behaviour management unduly responsibilizes young people and draws inflexible demarcation lines between appropriate and inappropriate sexual conduct.
Chapter
The emergence and widespread use of e-cigarettes have generated a huge debate among scientists, public health personnel and policy makers. Drawing on interviews with a sample of Stop Smoking Advisors and e-cigarettes users in SE England, this chapter discusses some of the ethical issues linked to the contemporary views of nicotine addiction and the use of e-cigarettes as part of the Harm Reduction principle. In view of the principlism framework this chapter reflects on the anti-smoking regulations and discusses the development of e-cigarettes regulations in the United Kingdom (UK). E-cigarettes have established a new entity that might lead to a cultural redefinition of nicotine addiction; thus, challenging attempts to establish an ethical framework for the acceptable use of e-cigarettes.
Chapter
This chapter documents the rise of alternative strategies of drug control which aim to reduce drug related harm, rather than drug use per se. It explores the concept of harm reduction, its evolution over time, and its limitations, recommending that harm reduction strategies should also seek to address the harm that is caused by inequality and human rights abuses related harm. The final section address the extent to which harm reduction strategies have already become embedded in global drug policy practice, and suggests that it remains very much of secondary status.
Minimization of harm: a U-curve theory
  • N Dorn
Dorn, N. (1987) 'Minimization of harm: a U-curve theory', Druglink 2 (2), 14-15.
Willy Whizz: Harm reduction through drug education', Liverpool: Drug Education Project, South Scfton DHA (see also
  • R Newcombe
Newcombe, R. (1987a) 'High timc for harm reduction', Druglink 2 (1), 10-11. (1987b) 'Willy Whizz: Harm reduction through drug education', Liverpool: Drug Education Project, South Scfton DHA (see also Mersey Drugs Journal 1 (2), 11). (1987c) 'A framcwork for designing and evaluating drug cducation based on harm reduction', Report of the Drug Education Project to South Sefton DHA, Liverpool. -(1988) 'Serious fun: Drug education through popular culture', Druglink 3 (6),10-13.
Living with Heroin: The impact of a drugs 'epidemic' on an English community
  • H Parker
  • K Balm
  • R Newcombe
Parker, H., Balm, K. and Newcombe, R. (1988) Living with Heroin: The impact of a drugs 'epidemic' on an English community, Milton Keynes: Open University Books (Chapters 8 and 9).
The Natural Mind: A new way of looking at drugs and the higher consciousness, London: Jonathan Cape (rev. cdn, 1986). and Rosen, W. (1983) From Chocolate to Morphine: Understanding mind-active drugs
  • A Weil
Weil, A. (1972) The Natural Mind: A new way of looking at drugs and the higher consciousness, London: Jonathan Cape (rev. cdn, 1986). and Rosen, W. (1983) From Chocolate to Morphine: Understanding mind-active drugs, Boston: Houghton-Miffiin.
The Use and Misuse of Intoxicants: Factors in the development of controlled use
  • N Zinberg
Zinberg, N. (1984) Drug, Set and Setting: The basis for controlled intoxicant use, New Haven, USA: Yak University Press. (1987) The Use and Misuse of Intoxicants: Factors in the development of controlled use, Lexington, Mass.: Lexington Books.