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Speed Limits. Harm Reduction for People who use Stimulants
Abstract and Figures
This report presents an overview on harm reduction interventions for problematic stimulant use. In it, we focus predominantly on interventions for people who smoke methamphetamine and freebase cocaine. While we initially aimed at addressing other
amphetamine-type substances (ATS), cathinones and cocaine hydrochloride, as well as other non-injection routes of administration, most of the available harm reduction literature and interventions turned out to address smoked methampetamine and crack cocaine. The main contributions of the present study are twofold. First, it provides a worldwide literature review of harm reduction interventions for PWUS. Second, it documents, describes and analyses seven cases of good harm reduction practices for PWUS in different world regions.
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... Harm reduction services were originally focused on reducing adverse health outcomes for people injecting heroin [24]. Smoking drugs also carry health risks, including pulmonary distress [13,25], COVID-19 [15], overdose (OD) [26], burns and lacerations on the lips [27,28], tuberculosis [29], HIV, and HCV [3][4][5]. ...
... Despite the increasing availability of safer smoking services internationally, harm reduction efforts targeting noninjection drug use have received comparatively less attention than those for IDU [15,24,27,31,32], even as health and social consequences associated with smoking substances are becoming better understood. People who smoke drugs are often characterized as a hard-to-reach population for social service programs [27] because these programs have traditionally been focused on the provision of supplies (e.g., syringes, naloxone) to people who inject drugs [33]. ...
... People who smoke drugs are often characterized as a hard-to-reach population for social service programs [27] because these programs have traditionally been focused on the provision of supplies (e.g., syringes, naloxone) to people who inject drugs [33]. The distribution of safer smoking supplies (e.g., sterile pipes, stems, filters) by harm reduction organizations creates an opportunity to engage people who smoke drugs who may not otherwise access harm reduction programming [24,30,34]. Further, in 2019, the United Nations Office on Drugs and Crime called for the expansion of programs for people who use stimulants, particularly those providing safer smoking education and supplies [28]. ...
Background
Providing sterile drug smoking materials to people who use drugs can prevent the acquisition of infectious diseases and reduce overdose risk. However, there is a lack of understanding of how these practices are being implemented and received by people who use drugs globally.
Methods
A systematic review of safer smoking practices was conducted by searching PubMed, PsycInfo, Embase for relevant peer-reviewed, English-language publications from inception or the availability of online manuscripts through December 2022.
Results
Overall, 32 peer-reviewed papers from six countries were included. 30 studies exclusively included people who use drugs as participants ( n = 11 people who use drugs; generally, n = 17 people who smoke drugs, n = 2 people who inject drugs). One study included program staff serving people who use drugs, and one study included staff and people who use drugs. Sharing smoking equipment (e.g., pipes) was reported in 25 studies. People who use drugs in several studies reported that pipe sharing occurred for multiple reasons, including wanting to accumulate crack resin and protect themselves from social harms, such as police harassment. Across studies, smoking drugs, as opposed to injecting drugs, were described as a crucial method to reduce the risk of overdose, disease acquisition, and societal harms such as police violence. Ten studies found that when people who use drugs were provided with safer smoking materials, they engaged in fewer risky drug use behaviors (e.g., pipe sharing, using broken pipes) and showed improved health outcomes. However, participants across 11 studies reported barriers to accessing safer smoking services. Solutions to overcoming safer smoking access barriers were described in 17 studies and included utilizing peer workers and providing safer smoking materials to those who asked.
Conclusion
This global review found that safer smoking practices are essential forms of harm reduction. International policies must be amended to help increase access to these essential tools. Additional research is also needed to evaluate the efficacy of and access to safer smoking services, particularly in the U.S. and other similar countries, where such practices are being implemented but have not been empirically studied in the literature.
... Besides overdose deaths, people who use snorted cocaine can experience substance use disorders, intoxication, or withdrawal, as well as other stimulant-induced mental illnesses such as psychotic, bipolar, depressive, anxiety, obsessive-compulsive, and sleep disorders, as well as sexual dysfunction (American Psychiatric Association [APA], 2013). Furthermore, cocaine consumption can lead to various negative consequences on physical health, including damage to the brain, heart, lungs, liver, and kidneys (Riezzo et al., 2012), as well as an increased risk of accidents and blood-borne or sexually transmitted infections (Rigoni et al., 2018). ...
... Cocaine use may also exacerbate economic and social vulnerability, raising the risk of poverty or homelessness, encountering familial, academic, and occupational difficulties, involvement in accidents with third parties, neglecting or abandoning children, engaging in violent or criminal activities, and experiencing incarceration (Rigoni et al., 2018). ...
Introduction: cocaine use presents significant public health challenges. A promising approach to address this global health problem is to identify protective behaviors that can mitigate use, prevent risks, and minimize negative consequences for people who use snorted cocaine. Objective: this study aims to explore risk prevention and harm reduction behaviours among people who use snorted cocaine in order to contribute to the development and evaluation of harm reduction interventions in the future. Method: qualitative, exploratory study, based on in-depth interviews. Protective behavioral strategies were identified through in-depth semi-structured interviews from 10 cocaine users from Latin America. Results: we identified a range of strategies that people who use snorted cocaine employ in order to avoid cocaine use, prepare for its use, assess substance quality, minimize risks during consumption (including those related to poly-drug use), control dosage, protect routes of administration, mitigate potential adverse effects, reduce sexual risks, avoid legal problems, and recovering. Discussion and conclusions: this is the first study to explore protective behavioral strategies in experienced snorted cocaine users. Such insights into users' self-regulatory practices and care strategies can inform the development of future interventions.
... A partir de uma análise de estudos internacionais de chemsex, percebe-se que este fenômeno, até nos lugares onde já é considerado um problema de saúde pública, é extremamente difícil de ser mensurado. Isso ocorre por alguns motivos: o medo e o estigma em relação ao uso de drogas ilícitas, o estigma em relação às práticas sexuais envolvidas, o fato de muitos desses homens não identificarem suas práticas como arriscadas, o fato da maior parte das sessões de chemsex ocorrer em ambientes privados e também o fato da maioria dos profissionais não ter conhecimento do fenômeno, prejudicando a identificação do mesmo (Rigoni et al., 2018). ...
... Outro aspecto importante referente aos aplicativos é que eles podem funcionar como espaços privilegiados para a transmissão de mensagens sobre redução de riscos para a prática de sexo químico, assim como auxiliar na busca por serviços de saúde, se esse for o caso. Além disso, a segurança e privacidade proporcionadas por ser uma plataforma onde é possível trocar informações de forma anônima e confidencial pode ser muito atraente para pessoas que se sentem envergonhadas e estigmatizadas (Rigoni et al., 2018). ...
O fenômeno "chemsex" refere-se ao uso de substâncias psicoativas em contextos sexualizados com a intenção de sustentação, melhora, desinibição e/ou facilitação da experiência sexual, especialmente por gays e outros homens que fazem sexo com homens (HSH). Este artigo busca compreender e oferecer cuidado significativo para o fenômeno do chemsex no Brasil por meio da redução de danos. Utilizando a etnografia digital, foi criado um perfil de suporte no principal aplicativo de relacionamento voltado para essa população, o Grindr, oferecendo escuta livre de julgamentos e informações de redução de danos para a prática. Os resultados da experiência revelam convergências e discrepâncias em relação à literatura internacional, destacando a relevância do meio digital na disseminação de informações e possibilidades de cuidado para aqueles que enfrentam barreiras de acesso aos serviços de saúde.
... Moreover, safer smoking equipment delivered through syringe services programs (SSPs) may engage people who smoke drugs who might not otherwise use SSP-delivered harm reduction services. Safer smoking equipment can be specific for each type of drug used, but generally includes a heat resistant pipe or foil, protective mouthpiece, tamp, screen, and lip protectant, all of which reduce heat-related injuries and infection risk (Rigoni et al., 2018). In addition to reducing direct harm from improvised smoking devices, safer smoking equipment can reduce the sharing of supplies, which in turn is thought to lower risk of respiratory infections, a potential benefit that is particularly salient amid the COVID-19 pandemic (Prangnell et al., 2017;Harris, 2020). ...
Background:
Drug use route transition interventions promote safer consumption by facilitating a switch from injection to safer routes such as smoking or oral consumption.
Methods:
We performed a descriptive analysis using data from questions about "free, clean equipment for smoking" heroin, methamphetamine and/or crack from the Seattle 2018 National HIV Behavioral Surveillance survey of people who inject drugs (N = 555). We estimated the proportion of respondents with access to free safer smoking equipment, and among these participants, the proportion who reported that this access reduced their injection frequency. Among respondents without access to free safer smoking equipment, we described the proportion who were interested in getting access, and whether they thought this access would reduce their injection frequency.
Results:
Among participants who reported prior year heroin (n = 495), methamphetamine (n = 372), or crack (n = 88) injection, 11%, 11% and 12% reported access to free safer smoking equipment, respectively. Of those with access, the proportion that reported that access reduced their injection frequency ranged from 12% to 44%. Among participants without access, 28% who used heroin, 45% who used methamphetamine, and 49% who used crack were interested in access. Of interested participants, a majority reported that they thought this access would reduce their frequency of injection.
Conclusions:
Access to free safer smoking equipment was limited. Many participants were interested in getting free safer smoking equipment and reported that this access may reduce their injection frequency. Safer smoking equipment is a harm reduction strategy that should be available to reduce risks from opioid and stimulant injection.
... While participants' approach to MDMA appeared to be in uenced by effective safer drug use messaging, in contrast, participants demonstrated little knowledge about harm reduction for cocaine use in the interviews. Concerns about safer snorting, short or long-term health damage from overuse, nasal ushing, testing for adulterants were hardly discussed; yet can signi cantly help reduce the harms of snorting cocaine (35). Relatedly, concerns about mixing cocaine with alcohol was not discussed by participants, yet they were aware of the risks of mixing MDMA and other commonly used party drugs GHB and ketamine with alcohol. ...
Background: This paper examines the drug use and harm reduction practices of a subset of young adults in the Greater London area who engage in recreational poly-drug use. It traces their complex relationships with three popular party drugs – MDMA/ecstasy, cocaine, and alcohol – and explores the difficulties of balancing the harms and benefits within the context of situated poly-drug use practices.
Method: Longitudinal qualitative interviews with 31 young adults, aged 22 to 25. Three phases of thematic, semi-structured interviews were conducted from February 2018 to April 2019.
Results: This paper describes participants’ relationships to both MDMA and cocaine and the various ways they balance the risks and pleasures associated with these drugs. Participants appeared to succeed in balancing the two with MDMA, based largely on effective harm reduction messaging. With their cocaine use, however, we see a rise in challenges complicating this balancing act. Framed by ‘harm reduction from below,’ this paper shows that participants generally see cocaine’s adverse effects as less physically and mentally harmful than those of MDMA and this is reflected in their drug use choices. But the perception of cocaine’s relative safety has consequences, particularly when we consider the drug’s normalization and acceptability in spaces where it is frequently co-consumed with alcohol. In light of their consistent co-consumption of cocaine and alcohol, this pathway analysis suggests that participants’ efforts to reduce harm in one instance could create more harm and long-term negative effects in another. And as a result, participants struggle to bring the risk and pleasure of this co-consumption into balance.
Conclusion: Further exploration on both young peoples’ evolving motivations of drug choice and use and on how young people navigate the nuances of balancing acts within their poly-drug use would be a helpful contribution to advancing field of harm reduction. An emphasis on the psychological and physical risks of the prevalent practice of co-consuming cocaine and alcohol are also encouraged.
... Self-management of drug use can lead to less problematic patterns of use [54] and increases the chances of becoming and staying abstinent of drugs [55]. People who use stimulant drugs often create (informal) rules to self-manage their use according to perceived risk and triggers, such as only using when feeling well, using only with friends or during weekends and establishing a maximum amount or frequency of use [56]. While self-management can be learned, and supported by peers, it must build upon the person's ability, empowering the skills and competencies they already use to control their use and reduce their risks [57]. ...
Background
Amphetamine-type stimulants (ATS) are globally widely used. Scientific literature generally defines four phases of substance use (initiation, continuation, increase and decrease); however, there is limited understanding of what influences these different phases of ATS use. The ATTUNE study investigated which factors shape individual phases of use, or ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use.
Methods
Qualitative, semi-structured interviews ( n = 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily.
Results
Amphetamine and MDMA were the most commonly used ATS. Yet, types of ATS used differed between the countries. We found that people who use ATS have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation, decrease and sometimes dependence. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of ATS, phase or country.
Conclusions
These findings demonstrate that tailor-made interventions are needed for the diverse types of people who use ATS and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.
... Self-management of drug use can lead to less problematic patterns of use (Chavarria et al., 2012) and increases the chances of becoming and staying abstinent of drugs (Ferrari et al., 2009). Stimulant drugs users often create (informal) rules to self-manage their use according to perceived risk and triggers, such as only using when feeling well, using only with friends or during weekends, and establishing a maximum amount or frequency of use (Rigoni et al., 2018). While self-management can be learned, and supported by peers, it must build upon users' ability, empowering the skills and competencies they already use to control their use and reduce their risks (Zuffa & Ronconi, 2015). ...
Background: Amphetamine Type Stimulants (ATS) are globally widely used. However, there is limited understanding of what influences different phases of ATS use, as well as whether this varies by type of ATS user (groups). The ATTUNE study investigated which factors shape individual ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use.
Methods: Qualitative, semi-structured interviews (n= 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily.
Results: Most ATS users consumed amphetamine only (28%), followed by amphetamine and MDMA (17%). Yet, types of ATS used differed between the countries. We found that that ATS users have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation and decrease. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of user, phase or country.
Conclusions: These findings demonstrate that tailor-made interventions are needed for the diverse user types and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.
... These and other actions are highlighted in a global study on harm reduction by the Dutch institution Mainline 62 . These actions feature the need to fight poverty, violence against users, and precarious access to housing and the supply of counseling services and safe use 44,62 . ...
Os arcabouços teórico-práticos que compõem o paradigma psicossocial no campo das drogas, tais como a redução de danos e a promoção da saúde, trouxeram foco ao sujeito em sofrimento na relação com a realidade social. Eles valorizam a singularidade de usuários e profissionais para compreensão do processo saúde-doença e a construção das políticas de saúde. Conceito que embasa e agrega essas características é o de construção de autonomia. Entretanto existem acepções e ações distintas relativas à autonomia, pluralidade intrínseca ao desenvolvimento da política de saúde mental e drogas no país. O objetivo deste artigo é descrever as estratégias para construção de autonomia para pessoas que fazem uso abusivo de drogas. O método utilizado foi a revisão integrativa, buscando-se, nas bases PsycInfo, PubMed, Biblioteca Virtual de Saúde (BVS) e Web of Science, estudos que analisaram o processo de cuidado a usuários de drogas. Foram sistematizadas ações que constroem autonomia e as barreiras para o cuidado. Foram selecionados 22 estudos, sendo 18 pesquisas em Centros de Atenção Psicossocial Álcool e Drogas (CAPS AD) e quatro em serviços de atenção primária. Sobressaíram ações realizadas na dimensão do resgate de valor social, como planos terapêuticos singulares e oficinas de redução de danos. Representam barreiras a exigência da abstinência, a falta de ações intersetoriais, falta de reinserção social por vínculos de trabalho e não participação em instâncias comunitárias e políticas. Evidencia-se um conjunto de práticas contraditórias e difusas, havendo as que constroem autonomia e as que impõem o controle sobre o usuário. Ainda assim, as ações dos CAPS AD e atenção primária demonstram ser fundamentais para o resgate de autonomia frente à estigmatização e marginalização.
... In the quantitative approach, a cross-sectional epidemiological study was carried out in a representative sample of people who use crack assisted by a program called Atitude (Attitude) -Comprehensive Care Program for Drug Users and their Families -, a public social protection service that aims to respond to the vulnerability situation associated with drug use. The Program is recognized for the excellence of the care it provides for people who use crack and other drugs [25,26], prioritizing individuals who are in a situation of exposure to violence, face risk of death due to drug trafficking, and whose family bonds are weakened [27]. ...
Objective
To estimate the prevalence and factors associated with the effect of alcohol on crack cocaine use and to analyze experiences related to combined use. Materials and methods: sequential mixed methods (qualitative and quantitative) research, carried out between August 2014 and August 2015 with people who use crack. In the quantitative approach, a cross-sectional study was conducted with 1,062 participants. Factors associated with “alcohol use with the effect of increasing the effect of crack/crack craving” were estimated by multiple regression. In the qualitative approach, 39 interviews were conducted using Bardin’s content analysis technique.
Results
871 (82.0%) participants reported consuming alcohol, among them, 668 (76.7%) used alcohol combined with crack: 219 (32.8%) reported feeling an effect of reduction in paranoia and/or crack craving and 384 (57.5%) reported feeling an increase in the effect of crack and in the craving to consume the drug. This relationship was also observed in the narratives of the people who use crack, with the possibility of a cyclic effect of consumption of the two substances. Those who related alcohol use to the effect of increasing crack craving (384) were more likely to use alcohol before crack (OR: 1.81; 95%CI: 1.13–2.89); to consume more than 20 stones daily (OR: 1.48; 95%CI: 1.01–2.16); to remain in abstinence from crack for less than one month (OR: 3.20; 95%CI: 1.91–5.35); to use dependence treatment services (OR: 1.85; 95%CI: 1.26–2.71); and to commit physical violence (OR:1.67; 95%CI:1.08–2.56).
Conclusion
The findings of this study indicate that the modulation of the effect of alcohol use on crack cocaine depends on the moment when the drugs are consumed, and the use of alcohol before crack consumption is associated with characteristics that suggest a greater vulnerability to patterns of harmful crack use. Even though combined use is referred to as a way of reducing the negative effects of crack, the damage of this association may be greater than its possible benefits.
The report was published by Correlation Network and the European Harm Reduction Network. It provides an overview of the organisation and working methods of drug consumption rooms (DCRs) in Europe. It offers information about the functioning of DCRs and on the organisation and structure of such facilities
This Special Issue of Sexual Health examines research and healthcare practice relating to sexualised drug use among gay, bisexual and other men who have sex with men (GBMSM), colloquially known as 'chemsex' or 'party and play' (PnP). It draws together evidence relating to the epidemiology, sociology and psychology of chemsex, as well as the policy, community and clinical interventions that are required to ensure men have access to high-quality health care that meets their needs and reduces harm. Findings and discussions within the Issue emphasise the need to sensitively, non-judgementally and meaningfully engage with gay men about their engagement in chemsex in order to help improve their sexual health and wider wellbeing.
Rates of drug use remain substantially higher among gay and bisexual men (GBM) and people living with HIV (PLHIV) in Sydney, New South Wales, Australia. The use of drugs to enhance sexual pleasure within cultures of Party and Play creates opportunities to discuss sexual health, mental health, consent and wellbeing. Community organisations with a history of HIV prevention, care, treatment are well-placed to respond. ACON's (formerly the AIDS Council of New South Wales) multi-dimensional response to 'chemsex' includes: direct client services support for individuals seeking to manage or reduce their use; health promotion activities that support peer education; partnerships with research institutions to better understand cultures of chemsex; and policy submissions that call for drug use to be approached as a health, rather than a criminal, issue. The approach speaks the language of Party and Play subcultures; employs culturally relevant terminology and imagery; uses content designed, created and delivered by peers; and operates within a pleasure-positive, harm-reduction and community-led framework. These interventions have led to increased service uptake, strong community engagement, robust research partnerships and the recognition of GBM as a priority population in relevant strategies.
Chemsex is the colloquial term used for a specific pattern of drug use that is increasingly common among men who have sex with men (MSM) globally. The recreational substances employed are used specifically in a sexualized context. The reasons for chemsex among MSM are complex. The Anova Health Institute (Anova) provided harm-reduction services in Cape Town, South Africa in 2013 and 2014. This project, known as Tikking the Boxes had two objectives: first to provide direct harm-reduction services to drug-using MSM in Cape Town, South Africa, and second, to reduce HIV and hepatitis B and C transmission among this population. This was done by identifying drug-using behaviour among MSM and linking them to harm-reduction services. Employing people who were currently using drugs was a novel aspect of this program, and successfully facilitated access to MSM drug-using networks. At the launch of the project, the concept of harm reduction was easily misunderstood by MSM. Another challenge was that the harm-reduction service, encompassing needle exchange, excluded opioid substitution therapy. People who use drugs were employed as outreach workers, requiring the project to be very flexible and adaptable to sometimes complex lives and difficult-to-reach peers. JAB SMART is Anova's new harm-reduction initiative and started in May 2017, with support from the City of Johannesburg Health Department, and is the first project of its kind in the city to provide harm-reduction services to people who inject drugs (PWID) and their sexual partners.
Drug consumption rooms (DCRs) and supervised injecting facilities (SIFs) target the most vulnerable people who use drugs (PWUD) – particularly people who use opioids, people who inject drugs (PWID), people who use drugs heavily1 or high-risk drug users (HRDI)2. While decreases in risky injecting behaviours are an outcome of DCR use, HCV prevention and treatment in these settings haven’t been adequately described. There are no international DCR standards for HCV practice and surveys are yet to address HCV prevention, treatment or sero-prevalence status of DCR clients. This online survey provides a ‘snapshot’ of DCR clients’ HCV status; approaches to HCV in DCRs, and what DCRs need to expand these services.
This Overview of International Literature collates what we understand to be a full list of the relevant published papers and reports on drug consumption rooms (DCRs) and supervised injecting facilities (SIFs) internationally (for definitions, see next section). This Overview updates the overview provided by the Drug Policy Modelling Program, University of New South Wales (deVel-Palumbo, Matthew-Simmons, Shanahan & Ritter, 2013) ; and updates the categories that classify the main areas of evidence provided by the research to date. We included papers and reports where SIFs/DCRs were the main topic or where SIF/DCR clients were the population studied. The aim of this document is to provide an exhaustive, easy to read overview of scientific literature pertaining to SIFs/DCRs internationally that would facilitate scholars in summarizing main research areas, as well as identifying the key scientific contributions and in preparation of advocacy materials.
This Report is the final report about the Housing First Europe social experimentation project funded by the European Commission
Results:
Program evaluation demonstrated modest improvements in participant psychological distress, personal well-being and stage of change and reductions in methamphetamine use post intervention. Qualitative data revealed benefits of a specialised harm reduction intervention for this population through addressing fear of discrimination and stigma.
Conclusions:
The presented harm reduction program for MSM who use methamphetamine demonstrates the potential for a specialist peer-based approach to reduce harm in this vulnerable population. This approach may be suitable for adaptation with MSM populations in similar high-income settings.
In response to the apparent rise in chemsex in the Netherlands Mainline Foundation interviewed 27 MSM about their crystal meth use and/or experience with injecting in a sexual context. These men were interviewed about their motivation for methamphetamine use, their sexual risk-taking behaviour, methods and context of their drug use, and their information- and care needs. In 2015 this resulted in the status report Tina and Slamming: MSM, Crystal Meth Use and Intravenous Drug Use in a Sexual Context. Following the publication of this report Mainline foundation has been offering harm-reduction intervention for MSM and promoting the development of a continuum of care by building networks, training professionals and investing in advocacy. In our view, a continuum of care means the availability of a sufficient level of qualitative and effective preventive interventions, harm reduction services and treatment facilities that are connected, can track and intervene in the 'lifecycle' of individual drug use, and are easily accessible by the target group. This case study describes the various interventions of Mainline foundation, that make up their continuum of care approach concerning chemsex issues.