Harm reduction as the basis for Hepatitis C policy and programming

Transcription

1 Harm reductin as the basis fr Hepatitis C plicy and prgramming First Canadian Cnference n Hepatitis C Mntreal, May 4, 2001 Eric Single Prfessr f Public Health Sciences, University f Trnt. Parts f the discussin in this presentatin are derived frm E. Single, "A Harm Reductin Framewrk fr Drug Plicy in British Clumbia," a backgrund paper prepared fr the British Clumbia Federal/Prvincial Harm Reductin Wrking Grup, December The authr wuld als like t acknwledge the cntributin f Dr. Diane Riley t this presentatin. The descriptin f harm reductin measures wes much t Dr. Riley, wh cllabrated n earlier papers and was the principal authr f a plicy discussin paper n harm reductin prepared by the CCSA Natinal Wrking Grup n Addictins Plicy (Riley et al., 1999; als available at the CCSA website: Cmmunicatins regarding this presentatin shuld be directed t Dr. Single at 6 Mervyn Avenue, Etbicke, Ontari M9B 1M6 ( e.single@utrnt.ca). Abstract Harm reductin measures have helped drug users reduce the risk and severity f adverse cnsequences withut leading t increases in verall levels f drug use in the general ppulatin. Indeed, in many cases harm reductin has been a vital first step twards recvery frm addictin. This presentatin explres different cnceptualizatins f harm reductin, presents a framewrk fr drug plicy based n an empirical cncept f harm reductin and discusses the implicatins t Hepatitis C plicy and preventin prgramming. 1. Intrductin Illicit drug use is a serius public health and scial prblem in Canada, accunting fr hundreds f deaths and thusands f hspitalisatins attributable t illicit drug use in Canada annually (Single, Rbsn et al., 1999). The ecnmic csts f illicit drug use in Canada have been cnservatively estimated at ver $1.4 billin annually (Single et al., 1998). The prblems f drug use nt nly cncern individual drug users, they als negatively affect many cmmunities, making neighbrhds unsafe, diminishing prperty values and diverting limited criminal justice resurces frm ther pressing needs. The purpse f this presentatin is t discuss the cncept f harm reductin and its applicability t prgramming fr the preventin f Hepatitis C. The fcus f my remarks will be n harm reductin plicy and preventin prgramming aimed at injectin drug use such as syringe exchange, drug substitutin r maintenance prgrammes and ther use-tlerant interventins. Such plicies have been termed "harm reductin" because they placed first pririty n the reductin f drug-related

2 harm, rather than the preventin f drug use per se. The presentatin begins with an histrical verview f harm reductin plicies and practices. Evidence f the effectiveness f harm reductin prgramming will be summarized and I will present an verview f a harm reductin framewrk that is currently being cnsidered in British Clumbia. The presentatin cncludes with a discussin f the implicatins f this new apprach t Hep C plicy. 2. Harm Reductin Cncepts and Practices 2.1. Histrical verview Beginning in the late 1980s, a new type f health prmtin prgram develped t reduce the spread f bld-brne disease, particularly HIV infectin, amng intravenus drug users. These measures include syringe r needle exchange prgrams, bleach kits, prvisin f smkable drugs and methadne maintenance (Riley, 1993; Riley, 1994). Because they emphasize the minimizatin f adverse cnsequences f drug use rather than the preventin f drug use per se, these preventin prgrams have cme t be knwn as "harm reductin" r "harm minimizatin". The genesis f these harm reductin prgrams actually began prir t the AIDS pandemic. The s-called British system fr prviding herin t addicts in the U.K. is ne f the earliest examples. In general, harm reductin prgrams have been mst thrughly develped in the U.K., the Netherlands, and ther parts f Eurpe, and mre recently in Australia (Riley et al., 1999). Harm reductin is less cmmn but increasing in Nrth America. Harm reductin has generally prved t be effective and it has gained increasing fficial acceptance. Fr example, it is nw the fficial basis f Australia's Natinal Drug Strategy and Canada's Drug Strategy. There are several reasns underlying the emergence f harm reductin prgramming, discussed belw. The majr impetus, hwever, is undubtedly the threat f HIV and ther bld brne disease. The verwhelming imprtance f the AIDS pandemic vershadws ther cncerns abut the adverse cnsequences f illicit drug use, thus prviding plitical supprt fr needle exchange prgrams and ther effrts t prevent HIV infectin t the general ppulatin (Riley et al., 1999). Harm reductin was initially clsely identified with syringe exchange, but harm reductin has expanded t include a wide variety f prgrams and practices. These include the prvisin f bleach kits t intravenus drug users (IDUs), prvisin f smkable drugs such as herin-laced cigarettes and methadne maintenance. Such prgrams are als a way f establishing cntact with drug users, prviding educatin, cunseling and access t treatment and ther services (Riley et al., 1999). Harm reductin has als expanded t preventin prgramming fr licit drugs such as alchl and even tbacc. Syringe exchanges pened unfficially in Canada in 1987, with the first fficial exchange pening in Vancuver in March f Services were initially prvided thrugh fixed sites and street utreach, as well as limited representatin at ther agencies prviding services t drug users in dwntwn areas. Over time, mbile vans have been added t services in several cities. Kits cntaining needles, bleach and cndms are distributed thrugh these agencies. Between 1989 and 1993, the

3 Federal gvernment cst-shared pilt utreach prgrams based n a multifaceted services mdel in five prvinces (Riley, 1994). Over this time there has als been a rapid grwth in ther utreach prgrams that include syringe exchange. Prgrams are nw perating in the Yukn, the Nrth West Territries, Calgary, Edmntn, and Halifax as well as in a number f cmmunities in Quebec, BC and Ontari. At the current time, there are mre than 200 syringe exchanges in rural and urban areas in Canada, with mre under develpment. In additin, there are nw numerus pharmacies that prvide syringe exchange services. Methadne treatment is nw available thrughut Canada. While there are still waiting lists in many jurisdictins, the number f methadne placements has increased in the recent past. Fr example, in British Clumbia there are currently 480 physicians authrized t prescribe methadne and 190 pharmacies authrized t dispense methadne, with apprximately 4,800 active clients enrlled in the prvincial methadne prgram in 1999 (Andersn, persnal cmmunicatin). Harm reductin emerged in large part as a respnse t the dire threat that HIV psed t IDUs. Mre recently, the threat f hepatitis and ther bld brne infectins has been a further impetus. Other factrs that have supprted the develpment f harm reductin include the psitive results f evaluatins and the limited effectiveness f "supply-side" strategies in reducing the spread f HIV infectin and ther adverse cnsequences f drug use. 2.2 Harm reductin and legal drugs Harm reductin was develped as an apprach t deal with prblems assciated with illicit drug use, particularly the spread f bld-brne disease frm the sharing f needles by IDUs. Therefre we tend t think f harm reductin in the cntext f illicit drug use. Hwever, the cncept f harm reductin has als been applied t legal drugs such as alchl and tbacc. Harm reductin as it is applied t nictine refers t thse plicies and prgrams aimed at reducing tbacc-related harm amng persns wh cntinue t smke.(1) Tbacc addictin is caused and sustained by nictine, but the majr adverse cnsequences f smking are caused by ther agents in tbacc. A variety f ways have been devised r prpsed t reduce the harm assciated with smking withut ending the dependence n nictine. Examples include lw-tar, medium r high nictine cigarettes; putting a marker n cigarettes t remind smkers nt t smke t the end where tars cncentrate; placing mst f the nictine in the frnt part f the cigarette s that the smker receives the dse f nictine desired withut mst f the carcingens; nictine gum and patches when used by smkers t reduce intake (rather than fr smking cessatin); smkeless tbacc; taxing cigarettes accrding t tar cntent; nn-tbacc cigarettes with lwer levels f carcingens; and educating smkers t decrease the number f puffs per cigarette, and/r puff duratin and puff vlume. Hwever, tw majr factrs limit the applicability f harm reductin measures t smking. First, the prblems f tbacc use are mainly thse arising frm chrnic disease (Single, Rbsn et al., 1999), thus placing severe limits n the utility f harm reductin measures. Secnd, unlike alchl r illicit drug users, the vast majrity f smkers are dependent users. Effrts t find a safer way f smking have nt received much attentin because it is generally held that there is n safe

4 level f smking. The fcus f preventin has therefre been n preventive educatin, treatment and cessatin prgrams aimed at cnvincing smkers t stp smking altgether rather than t cut their intake r smke in safer ways. Nnetheless, harm reductin measures may still be used as an additinal strategy that is cmplementary t ther, abstinence-based tbacc preventin measures. Unlike tbacc, harm reductin is playing an increasingly imprtant rle in the preventin f alchl prblems. Indeed, the trend tward harm reductin in illicit drugs is clsely paralleled by a similar trend in alchl preventin tward measures aimed at reducing the cnsequences f drinking. Until recently, the fcus in preventive educatin regarding alchl has generally been n the adverse effects f alchl cnsumptin and the message fr all drinkers was generally unequivcal: drinking less is better. The message in harm reductin appraches is smewhat different: avid prblems when yu drink. This is cmplementary rather than cntradictry t the message that drinking less is better. Indeed, sme harm reductin appraches (e.g., the prmtin f lw-alchl cntent beverages) invlve drinking less. But harm reductin differs frm prir alchl preventin appraches in that it fcuses n decreasing the risk and severity f adverse cnsequences arising frm alchl cnsumptin withut necessarily decreasing the level f cnsumptin. The defining feature f harm reductin appraches t alchl is the attempt t reduce the harmful cnsequences f alchl cnsumptin in a situatin where peple will be drinking. That drinking will take place is accepted as a fact, implying neither apprval nr disapprval. The drinker is nt seen as abnrmal in any way, and he r she is respnsible fr his r her actins. Harm appraches t alchl preventin are neutral regarding the lng-term gals f interventin, which may r may nt include abstentin. Examples f harm reductin measures fr alchl include: the intrductin f earlier pening hurs fr a liqur utlet in dwntwn Edmntn t reduce the use f nn-beverage alchl by Skid-rw inebriates; cmpartmentalizatin f space and padding f furniture in licensed establishments t minimize the harm that may result if a fight breaks ut; the intrductin f new impaired driving cuntermeasures, such as graduated licensing systems and/r zer tlerance laws fr new drivers; measures t reduce alchl prblems at special events, such as a B.C. prgram addressing drinking issues at secndary schl graduatin celebratins; the intrductin f special glassware in Scttish pubs which crystallizes rather than shards when brken, thus reducing the number and severity f injuries frm pub fights (Plant, et al., 1994); the prmtin f lw-alchl beverages; server training prgrams; and cntrlled drinking prgrams (Wilk et al., 1997; Flemming et al., 1999). Mst f these examples f harm reductin measures are relatively new, as there is a distinct trend tward preventin measures t reduce the harmful cnsequences f drinking rather than drinking per se. There are several reasns fr this shift in alchl preventin twards a harm reductin apprach. Mst ntably, there is reasnably cnclusive evidence that mderate drinking cnveys significant health benefits, particularly in reducing crnary heart disease (see, e.g., English et al.,

5 1995; Maclure, 1993; Piklainen, 1995; Single, Ashley et al., 1999). There is als declining plitical supprt fr cntrls ver the availability f alchl in light f declining cnsumptin in many cuntries and the ersin f internatinal trade barriers. The mst recent estimates f alchl-attributable mrtality and mrbidity indicate that the relative cntributin f accidents t verall alchl-related mrtality and mrbidity is much greater than previusly thught (Single, Rbsn et al., 1999). Finally, there is increasing recgnitin f the rle that pattern f drinking play in the develpment f alchl prblems. In particular, the setting where drinking takes place ften has a significant influence n the develpment f acute prblems arising frm intxicatin. Thus, hw ne drinks can be as imprtant as hw much ne drinks in determining the likelihd that a prblem will ccur as a result f ne's alchl cnsumptin. Fr all f these reasns, increased attentin is likely t be given t preventin measures that fcus n preventing prblems assciated with drinking rather than restricting access t alchl r reducing the amunt f drinking per se. Thus, the trend tward harm reductin in illicit drugs is clsely paralleled by a similar trend in alchl preventin, albeit fr different reasns. With declining plitical supprt fr alchl cntrl measures and the emergence f new evidence abut ptential health benefits assciated with lw-level alchl cnsumptin, it may be expected that alchl preventin will increasingly fcus n the reductin f harmful cnsequences f alchl rather than mnitring individual levels f cnsumptin t avid dependence. 3. Effectiveness f harm reductin practices and prgrams Several reviews have been published assessing the effectiveness f harm reductin measures (see, e.g., MacPhersn, 1999; Ericksn et al., 1997; Dlan, 1997; Heather et al., 1993; Strang and Farrell, 1992). While there are clearly gaps in ur infrmatin base, these reviews have generally shwn that harm reductin prgrams have had a psitive impact in reducing the spread f HIV and ther infectins, and in helping many dependent users t lead nrmal lives as prductive members f sciety, withut leading t increases in levels f drug use. Syringe Exchange: Needle and syringe exchange prgrams are, t many peple, the epitme f the harm reductin apprach. They were first established in a few Eurpean cuntries in the mid-1980s and, by the end f the decade, were perating in numerus cities arund the wrld. Sme exchange prgrams prvide utreach services in the frm f mbile vans r street wrkers t deliver services t drug scenes r t user's hmes. In Amsterdam, plice statins prvide clean syringes n an exchange basis. Autmated syringe exchange machines are nw being used in many Eurpean and Australian cities. These vending machines release a clean syringe when a used ne is depsited. Such machines are fairly inexpensive and accessible n a twenty-fur hur basis. The machines, hwever, decrease the imprtant persnal cntact between drug users and health-care wrkers. Bleach kits (cntaining bleach and instructins fr cleaning equipment) can be distributed as anther way t make drug injectin less dangerus. While bleach is nt ttally effective in eliminating HIV and it des nt kill the pathgen which causes hepatitis, such kits d help t reduce the likelihd f infectin being passed thrugh sharing f dirty equipment.

6 There is nw clear evidence that attendance at syringe exchanges and increased syringe availability is assciated with a decrease in risk (e.g., decreased sharing) as well as a decrease in harm (e.g., lwer levels f HIV and Hep C infectin). Methadne Prgrams: Numerus studies have shwn that methadne maintenance reduces mrbidity and mrtality, diminishes the users' invlvement in crime, curbs the spread f bld-brne disease and helps drug users t gain cntrl f their lives. One f the key factrs underlying the success f methadne as a harm reductin measure is that it brings the user back int the cmmunity rather than treating them like an utsider r a criminal. Methadne prgrams wrk best if they are numerus, accessible and flexible. In particular, the recent expansin f methadne prgrams in British Clumbia appears t have had a psitive impact. Andersn (1999) makes a strng argument that methadne maintenance has been an imprtant reasn why rates f HIV infectin have nt been greater amng IDUs in British Clumbia. The number f new HIV infectins amng IDUs has steadily declined by 60% ver the past 2.5 years (Andersn, 1999). Cnsequently, the prprtin f new HIV infectins accunted fr by injectin drug use (IDU) declined frm ne-half in 1996 t ne-third in Cntrary t earlier predictins when the HIV infectin rate was increasing amng IDUs, the peak prevalence f HIV infectin amng IDUs in British Clumbia never exceeded per cent, and it is nw decreasing (Andersn, 1999). It is reasnable t expect similarly gd results regarding reductins in the spread f Hep C. Educatin and Outreach Prgrams: Drug educatin materials with a harm reductin fcus aimed at high-risk ppulatins are readily available in a number f cuntries, including the United Kingdm, Hlland and Australia. In many cuntries, utreach wrkers cntact persns such as drug injectrs and prstitutes at risk f becming infected with HIV. These wrkers distribute educatinal material, syringes, cndms and bleach kits, and help users cntact ther services. Hwever, such educatinal materials remain cntrversial. While nt prmting drug use, such materials tell the user hw t reduce the risks assciated with using drugs, teaching such things as safer injecting practices. There is little research t date regarding the net impact f these prgrams n drug-related harm. Law Enfrcement and Criminal Justice Plicies: Harm reductin appraches have been adpted by law enfrcement agencies in England, Australia and many Western Eurpean cuntries. In these lcatins, there are cllabrative prgrams between law enfrcement and health authrities aimed at imprving the preventin and treatment f drug prblems. Fr example, in Amsterdam, plice statins will prvide clean syringes n an exchange basis. In Hamburg, Germany, plice wrk with health fficials and drug users grups wrking tgether t help drug users access scial services. Yet anther example is the Merseyside "Respnsible Demand Enfrcement" prject in the U.K, where plice have agreed nt t cnduct surveillance n drug prgram clients, instead referring arrested drug ffenders t health services fr treatment. There are at least tw significant develpments in Canada in this regard. First, there has been a shift in plice pririties twards the enfrcement f laws against drug trafficking rather than drug pssessin. This has been reflected in criminal justice statistics, which shw a distinct trend tward greater number f arrests fr

7 trafficking and decreases in the number f drug pssessin charges as a percentage f all drug ffences. Secnd, a special "drug curt" has been established in Trnt and ther drug curts are planned in ther Canadian cities. Mdelled after American drug curts but with sme significant variatins, the drug curts ffer an alternative t incarceratin t addicted drug ffenders. Offenders are required t receive treatment and are clsely mnitred in regular curt appearances. T my knwledge there has been n systematic assessment f the impact f changing plice pririties twards the enfrcement f trafficking ffences in Canada. Hwever, the Trnt drug curt is being subject t a systematic evaluatin and the (unpublished) preliminary results are very prmising. Offenders in drug curts cmpare favurably with cntrls regarding indicatrs f drug use and drug-related harm. Prescribing drugs: The best example f this type f harm reductin measure is the herin maintenance system in the U.K. Drug users are ffered flexible prescribing regimes ranging frm shrt-term detxificatin t lng-term maintenance. The majrity f clients receive ral methadne, but sme receive injectable methadne, thers injectable herin, and a small number receive amphetamines, ccaine r ther drugs. These drugs are dispensed thrugh lcal pharmacists. In the Mersey Regin f England, users may als be prescribed smkable drugs. Anecdtal evidence suggests that drug-related health prblems seen by services and acquisitive crime have decreased as a result f these services. The level f HIV infectin amngst drug injectrs in the Mersey Regin is very lw. There are n Canadian data n the effectiveness f drug maintenance prgrams ther than methadne prgrams. A multi-site herin maintenance trial has been prpsed fr Canada and is currently under develpment by a team f researchers headed by Prf. Benedikt Fischer at the University f Trnt. Switzerland has carried ut a large-scale natinal experiment with prescribing f herin and ther drugs t users. Operating in eight cities, the prgram ffers accmmdatin, emplyment assistance, treatment fr disease and psychlgical prblems, clean syringes and cunselling. Users are in regular cntact with health wrkers and they are prvided links t drug-free treatment. Mst users n drug maintenance prefer herin, which is prvided up t three times a day fr a small daily fee. Preliminary results indicate that herin maintenance is efficacius but there were insufficient data t draw the same cnclusin fr ccaine. The prgram has nt resulted in a black market f diverted herin and the health f the addicts in the prgrams has clearly imprved. The authrities have cncluded frm these preliminary data that herin causes very few prblems when used in a cntrlled manner and administered in hygienic cnditins. Based n these findings, the Swiss gvernment has expanded the prgram. Injectin rms: Several Eurpean cities have develped facilities knwn as "injectin rms", "health rms", "cntact centres", where drug users can take drugs in a cmparatively clean and safe envirnment. Injectin rms have been prpsed fr Vancuver. This is regarded as better than the pen injectin f illicit drugs in public places r the cnsumptin f drugs in "shting galleries" that are usually unhygienic and cntrlled by drug dealers. Evidence f impact is limited, but an evaluatin f three Swiss drug rms fund that they are effective in reducing the transmissin f HIV and the risk f drug verdse.

8 "Tlerance Areas": Open drug scenes emerged in many Eurpean cities during the late 1980s. These are areas supervised by the plice where pen drug use is tlerated and services prvided such as syringe exchange and mbile methadne units. Examples include "Platfrm Zer" is lcated at the Rtterdam railrad statin, "Needle Park in Zurich, and tw tlerance areas established in parks in Frankfrt, Germany. Cntrary t the success f ther harm reductin measures, pen tlerance znes have nt had psitive results. Their impact n drug-related harm is nt clear because they tend t be unstable and they are ften shrt-lived. "Needle Park" in Zurich grew unmanageable and was clsed in A secnd attempt als became uncntrllable, and was clsed in March f In Frankfrt, the tlerance znes in parks were shut dwn in 1992, nt fr lack f cntrl but rather because it was felt that mst drug users had been successfully mved t accmmdatins and treatment centres utside the city centre. In sum, the available evidence generally supprts a psitive assessment f harm reductin measures, particularly with regard t syringe exchange, drug maintenance and drug curts. Hwever, the weight f evidence is that tlerance znes have nt been successful and the jury is still ut with regard t ther harm reductin measures. 4. The current cnceptual cnfusin surrunding the term "harm reductin" Althugh the available evidence indicates that harm reductin has generally been successful in reducing the spread f AIDS and amelirating ther drug-related harm, there is still a lack f cnsensus regarding the meaning f the term. At least three different cncepts f harm reductin have emerged in the recent past: 1. Harm reductin restricted t measures aimed at cntinuing users: Harm reductin riginally referred nly t thse plicies and prgrams that attempt t reduce the risk f harm amng persns wh cntinue t use drugs. This cncept f harm reductin excludes abstinenceriented appraches. A key aspect f this cnceptualizatin is that the user's decisin t take drugs is accepted as a fact, at least fr the time being. This des nt mean apprval f the user's decisin t cntinue using drugs. Rather, use-tlerant measures such as syringe exchange presume that fr the present the user is ging t cntinue his r her drug use, and that interventins must necessarily take that fact int accunt. Anther imprtant aspect is that the user is treated as a nrmal persn rather than as sick r deviant. There is an expectatin that the user will behave "nrmally", i.e. as a citizen with rights and bligatins under the law. Thus, the drug user is respnsible fr his r her behaviur. This cncept is embdied in the phrase ften used by the Dutch when they describe their drug users as "Dutch citizens wh use drugs." 2. The all-encmpassing cncept f harm reductin: Thus, in its riginal sense, harm reductin referred t nly thse plicies and prgrams aimed at reducing the harm caused by drug use amng

9 persns wh culd nt be expected t cease using drugs at the present time. But t many, harm reductin refers t any prgram and plicy aimed at reducing drug-related harm. Abstinence-riented treatment prgrams see their wrk as cntributing t the reductin f drug-related harm, and with gd reasn. Law enfrcement representatives clearly view supply restrictins as reducing drugrelated harm. Thus, the secnd cnceptualizatin f harm reductin is an all-encmpassing ne, reflected in general definitins which refer t any prgram and plicy aimed at reducing drug-related harm as harm reductin. Harm reductin is fficially the basis f Canada's Drug Strategy, nt in the restricted sense but in this all-encmpassing meaning f the term. Unfrtunately, this cnceptualizatin des nt discriminate well between harm reductin and ther prgrams, as virtually every alchl and drug plicy and prgram attempts t reduce harm. Fr example, althugh they wuld nt cnsidered t be harm reductin prgrams in the riginal sense f the term, the reductin f drug-related harm is the ultimate gal f supply restrictins and abstinence riented treatment prgrams. Thus, the tw mst cmmn understandings f the cncept f harm reductin are quite different frm ne anther. The riginal, mre restrictive ntin f harm reductin has the advantage f being mre cnceptually clear-- it distinguishes "harm reductin" frm ther substance abuse prgrams and plicies. As the basis fr a drug strategy, hwever, it has the disadvantage that it excludes sme plicies and prgrams that clearly represent an imprtant aspect t drug plicy, namely, abstinence-riented treatment and supply restrictin strategies. The secnd, all-inclusive cnceptualizatin f harm reductin has the advantage f including abstinence-riented prgrams and plicies. Hwever, this meaning f harm reductin is nt useful fr prviding strategic directin. If harm reductin refers t any plicy r prgram aimed at reducing drug-related harm, then any alchl, tbacc and drug plicy r prgram can justifiably be included in a drug strategy because all substance abuse strategies seek t reduce drug-related harm in sme fashin. 3. Harm reductin as an empirical test: In part as a respnse t the all-inclusive cnceptualizatin f harm reductin, sme harm reductin advcates have attempted t dissciate the plicy f criminalizatin f drug users frm harm reductin by applying an empirical test as the defining criterin f harm reductin. Accrding t this line f argument, the criminalizatin f drug use is nt harm reductin because it creates mre harm than it avids. Regardless f whether ne views the criminalizatin f illicit drug users as creating mre harm than gd, the plicy debate has led t a third cnceptualizatin f harm reductin in which a plicy r prgram is deemed t be harm reductin based n an empirical assessment f the evidence. That is, a plicy r prgram is cnsidered t be harm reductin, nt if it is intended t reduce harm, but nly if it actually des reduce harm (Lentn and Single, 1998).(2)

10 This empirical definitin incrprates a cst benefit equatin at its very cre. It presumes a calculatin f the net gain r lss fr a given plicy r prgram. It is the effectiveness f the plicy r prgram that determines whether it shuld be deemed t be harm reductin. The empirical definitin f harm reductin entails certain disadvantages. First, defining harm reductin in terms f its net effectiveness in reducing harm may nt be cnsistent with the way that many peple think f the term. Plicies and prgrams that might pass the empirical test f net effectiveness are nt necessarily thse which sme persns wuld cnsider t be harm reductin. Fr example, the mney-laundering laws in Canada have succeeded in prducing substantial revenue at relatively little cst. While ne might questin whether this has had a significant impact n the supply f illicit drugs, it culd reasnably be argued that the diversin f illicit drug prfits int gvernment cffers and gvernment funded preventin prgrams represents a net gain and that the new laws against mney laundering are therefre a harm reductin plicy. Whether r nt ne agrees with this assessment, the pint is that many persns wh subscribe t harm reductin in its riginal sense wuld nt view any supply side strategy as harm reductin. T redefine harm reductin in terms f empirical evidence f effectiveness culd therefre lead t cnfusin. Thse supply strategies and abstinence-riented interventins that demnstrably reduce drug-related harm wuld nw be cnsidered t be harm reductin measures, and use-tlerant measures that d nt reduce harm wuld nt be cnsidered harm reductin. It wuld require a cmmunicatins strategy that recgnizes the riginal meaning f harm reductin and clearly explains the prpsed new cnceptualizatin. A secnd drawback t the "effectiveness" definitin is that it generally des nt include a ntin f cst effectiveness. A very expensive interventin wuld be cnsidered t be harm reductin as lng as it can be demnstrated that there is a net gain in reducing drug-related harm. If the ultimate gal is t distinguish plicies and prgrams that shuld be given pririty, cnsideratin must be given nt nly t their effectiveness, but als t their csts. Third, as a practical matter is it very difficult t determine whether specific plicies invlve a net reductin in drug-related harm. Many f the benefits and undesirable side effects (such as the adverse scial cnsequences f marginalizing drug users) are intangible and thus difficult t include in the calculus. Such a definitin leaves pen the questin f whether many, if nt mst, drug plicies and prgrams are "harm reductin." Furth, an empirical definitin f harm reductin culd create an bstacle fr new and innvative interventins. If supprt were limited t thse prgrams that have demnstrated effectiveness, it wuld be ptentially mre difficult t prmte and develp new prgrams, which must necessarily g thrugh preliminary develpment and pilting withut empirical evidence f effectiveness. Last but nt least, the empirical cnceptualizatin f harm reductin is value-free. While this has clear advantages in defusing drug plicy debates by referring t evidence rather than persnal beliefs, it shuld als be recgnized that there are limits t what are acceptable ptins that have nthing t d with empirical evidence r effectiveness. The chice f which drug plicies and prgrammes t supprt necessarily invlves sme value judgments. There are drug enfrcement practices

11 which may be effective but wuld still be unacceptable t mst Canadians because f civil rights and scial justice implicatins. Fr example, it was nrmative cnsideratins, nt cncern with a lack f effectiveness, which led the gvernment t end the "writs f assistance". These were virtually lifetime search warrants fr drug enfrcement fficers, which, nce issued, did nt require judicial apprval fr searching private prperty in drug cases. While undubtedly effective in facilitating drug enfrcement, writs f assistance were ended due t cncerns that they vilated rights t privacy that had evlved in law ver a thusand years. Anther example is the debate ver apprpriate penalties fr drug ffences. One argument in favur f less severe penalties fr ffences such as cannabis pssessin has been that the punishment desn't fit the crime. This is nt based n cnsideratin f effectiveness s much as a value judgment cncerning the severity f punishment in relatin t the nature f the crime. Thus there are limits regarding what is scially and plitically acceptable in interventins--ne can minimize value judgments in drug plicy issues by cnsidering empirical evidence f effectiveness but value judgments regarding what is acceptable plicy can never be eliminated. Nr shuld they be. We can and shuld give greater cnsideratin t evidence f effectiveness when priritizing interventins, but nly amng thse ptins which are legally, mrally and plitically acceptable in the Canadian cntext. 5. A ptential slutin: plicy based n an empirical cnceptualizatin f harm reductin Thus, thrughut Canada and elsewhere, plicies directed at prblems arising frm injectin use f illicit drugs, such as Hep C strategies, are faced with a prblem f strategic directin. The cncept f harm reductin has been the underlying basis f many prgrams and measures in the recent past. It has prvided the initial ratinale and strategic directin fr the develpment f a wide variety f new and ften innvative appraches t IDU prblems such as the widespread develpment f syringe exchange prgrams, methadne maintenance and utreach prgramming aimed at injectin drug users. These mre recently develped harm reductin measures c-exist with traditinal, abstinence-based appraches such as abstinence-riented treatment prgrams and supply side strategies aimed at preventing the initiatin f drug use. The place f these mre traditinal, abstinence-based appraches in a harm reductin-based plicy is unclear. While few wuld dispute the desirability f reducing drug-related harm, there is a need fr clarificatin f the cncept f harm reductin and the develpment f greater cnsensus regarding its implicatins t plicy and prgramming. I am cnvinced that ultimately, the mst suitable cnceptualizatin f harm reductin is the empirical definitin despite its drawbacks. The prblems created by requiring evidence f effectiveness are cnsiderable but nt insurmuntable.

12 5.1 Key features f a plicy framewrk based n an empirical cnceptualizatin f harm reductin In a plicy based n an empirical cncept f harm reductin, a plicy r prgram is cnsidered t be harm reductin nt merely if its aim is t reduce drug-related harm, but nly t the extent that evidence indicates that it actually des reduce harm. This requires a reasnable evidentiary basis fr decisin-making. A cnceptualizatin f harm reductin based n empirical criteria wuld nt autmatically assume that prgrams such as needle exchange are harm-reducing. Only by determining whether an interventin actually achieves its gals in terms f reducing measurable perfrmance indicatrs such as Hep C infectin rates can we really determine if it shuld be cnsidered harm reductin. By the same tken, the empirical definitin als has the advantage f nt excluding abstinence-based appraches n a priri grunds. If such prgrams reduce drug-related harm, they shuld be cnsidered harm reductin. T maintain harm reductin as a primary cnceptual basis f plicy in the absense f cmplete infrmatin n the effectiveness f interventins, it is recmmended that there a cnsensus be develped cncerning strategic perating principles until better infrmatin becmes available. The unfrtunately fact f the matter is that the empirical evidence f the effectiveness f plicies r prgrams is currently inadequate. Until this situatin is redressed by enhanced research, any harm reductin-based plicy will require a set f strategic principles in rder t prvide a reasnable sense f pririties and fcus. Fremst amng these wuld be the principle: "first, d n harm". This des nt exclude abstinence-riented appraches, yet it gives a clear sense f strategic directin, with pririty given t immediate steps t prevent harm in situatins where injectin drug users cannt be reasnably expected t cease use at the present time. Other strategic principles include: Respect the basic human dignity f injectin drug users. Fcus n the harms caused by injectin drug use, rather than drug use per se. Maximize interventin ptins. Chse apprpriate utcme gals, giving pririty t effective prgrams with practical, realizable gals. 5.2 A harm reductin framewrk fr injectin drug use plicy The fllwing cnceptual framewrk has been prpsed fr plicies directed at reducing the harms (such as Hep C infectin) resulting frm illicit drug use. As seen in Figure 1, the framewrk cmpnents cnsist f the primary gal f the plicy, strategies t achieve this gal, agencies respnsible fr interventins, strategic planning t develp prgram pririties and perfrmance indicatrs, research underpinning planning and evaluatin, and funding. There is a feedback lp whereby perfrmance indicatrs are mnitred and the results used t infrm strategic planning fr the next phase f the strategy. The gal f a harm reductin-based plicy is t reduce the harms assciated with drug use as much as pssible within the limits f available resurces. The strategies t achieve this gal fall int three general categries: demand reductin, supply interdictin and interventins directed at drug users. The three majr strategies are

13 nt entirely mutually exclusive-imprving treatment effectiveness reduces drug demand, and reducing drug demand is likely t result in a decrease in the supply f drugs. Nnetheless, these three strategies represent a reasnable classificatin f the majr ways in which reductins in drug-related harm can be achieved. Interventins t achieve these bjectives cnsist f demand reductin preventin prgramming, the enfrcement f drug laws and interventins directed at drug users. The first tw sets f interventins-supply and demand reductin-crrespnd t primary preventin, while the third set f inventins directed at drug users crrespnds t secndary and tertiary preventin. Interventins aimed at drug users cnsist f risk reductin measures (i.e., harm reductin in the riginal sense f the term), treatment and rehabilitatin f drug users, and scial welfare plicies that supprt treatment and rehabilitatin. Law enfrcement is primarily respnsible fr supply interdictin and health agencies are generally respnsible fr demand reductin, while interventins aimed at drug users are the respnsibility f bth health and scial welfare agencies. Again, there is necessarily sme verlap with regard t respnsible agencies. Fr example, law enfrcement cntributes t preventin prgramming thrugh schlbased educatinal prgrams, and scial welfare agencies cntribute t the reductin f drug demand. The use f new drug curts t divert users frm jail t treatment represents anther example where law enfrcement cntributes t mre than just supply interdictin. Ideally, the three majr types f interventins shuld be well planned and crdinated with ne anther. In practice, this is made difficult by the multiplicity f gvernment and nn-gvernmental rganizatins invlved. T ensure effective strategic

14 Figure 1: A cnceptual framewrk fr drug plicy Surce: E. Single, A Harm Reductin Framewrk fr Drug Plicy in British Clumbia, backgrund paper prepared fr the British Clumbia Federal/Prvincial Harm Reductin Wrking Grup, December planning, gals shuld be agreed upn, as well as strategic bjectives and guiding principles. Decisins must be made cncerning prgram pririties and funding, and perfrmance indicatrs must be specified and mnitred. The basis f gd strategic planning is sund research. Infrmed decisins n prgram pririties requires scientifically credible basic research n the basic bilgical mechanisms f dependence, the psych-scial risk factrs, and the interplay f individual characteristics, pharmaclgical prperties f psychactive substances and the envirnment in which cnsumptin ccurs. Applied research n the effectiveness f specific interventins is als vital. Research plays a key rle in the evaluatin f perfrmance indicatrs, which in turn prvides infrmatin needed t strategically plan interventins in the future. Last but nt least, gvernment cmmitment t the drug strategy is the final and perhaps mst essential cmpnent t the framewrk. The degree f cmmitment

15 determines funding levels, which dictates the limits f what can be accmplished. The framewrk is a dynamic mdel in that it includes a feedback lp whereby perfrmance indicatrs are mnitred and this infrmatin is used t adjust prgramming and strategically plan the next phase f the drug strategy. The results f evaluatin als have an impact n the level f gvernment cmmitment-a strategy that is achieving its gals is mre likely t receive cntinued supprt. A strategy that is unable t demnstrate its effectiveness is less likely t receive cntinued funding. 5.3 Distinguishing features f a harm reductin drug plicy The cmpnents f the framewrk presented in Figure 1 wuld generally apply t any drug plicy, whether r nt it is based n harm reductin principles. There are several aspects f the prpsed framewrk that characterize it as a harm reductin framewrk: First, the verriding gal is harm reductin. The chice f this gal has significant impacts n prgram pririties and perfrmance indicatrs, fcusing n specific drug-related health and safety prblems. An alternative gal, e.g., t create a drug-free sciety, wuld fcus instead n reducing the number f citizens wh use any drugs and lead t different prgram pririties. Secnd, in a harm reductin-based strategy, ne f the mst imprtant types f interventins is the set f measures that attempt t reduce the risk f adverse cnsequences amng cntinuing drug users. This refers t harm reductin measures in the riginal sense f the term such as drug substitutin r syringe exchange prgrams. A drug strategy nt based n harm reductin wuld place less emphasis r even exclude such strategies. Anther way in which this represents a harm reductin framewrk cncerns the key rle that research plays in the dynamic aspect f the framewrk. If ne adpts the empirical definitin f harm reductin, research is essential t establish which prgrams are truly harm reducing and whether the strategy is meeting its gals. A zer-tlerance drug plicy wuld entail less research t mnitr success, basically requiring infrmatin nly the prprtin f the ppulatin wh use any drugs in any amunt, rather than mre detailed infrmatin n specific patterns f use and specific drug-related harms. Finally, a distinguishing feature f a harm reductin framewrk is the greater cnsideratin that is given t unintended adverse cnsequences that might arise frm interventins. The verriding criteria in evaluating impact is net harm-the extent t which a plicy r prgram reduces adverse cnsequences, taking int accunt all the cnsequences that result frm the interventin. As nted earlier, the first and fremst guiding principle f a harm reductin plicy is: first, d n harm. 5.3 Issues in the use f an empirically based cncept f harm reductin It was nted earlier that there are certain disadvantages t using an empirically based definitin f harm reductin. First, it might well result in sme plicies and prgrams being labeled as harm reductin even thugh many peple wuld nt rdinarily think f them in that way. Fr example, sme frms f abstinence-riented treatment r the enfrcement f prceeds f crime legislatin are nt typically thught f as harm reductin prgrams. If such measures prduce a demnstrable

16 net reductin in harm, hwever, perhaps they shuld be cnsidered harm reductin. By the same tken, a plicy r prgram that has been traditinally thught f harm reductin shuld perhaps nt be carry that label if it fails t reduce harm. A secnd difficulty with the empirical definitin is that it des nt include a ntin f cst effectiveness. While this wuld nt necessarily be part f the definitin f harm reductin, the verall gal f drug plicy shuld be framed t include cst effectiveness. Fr example, the gal might be expressed as fllws: t reduce drugrelated harm as much as pssible within the limits impsed by available resurces. When framed in this manner, the cst effectiveness f alternative plicies and prgrams must necessarily be a prime cnsideratin in determining pririties. Perhaps the majr difficulty with the empirical definitin f harm reductin is the burden it impses n data systems and research. As nted earlier, we simply dn't knw the net impact f many interventins. If plicies and prgrams that are harm reductin are t be given pririty, then all interventins under a drug plicy shuld be subject t systematic evaluatin in rder t determine whether they are in fact harm reducing. This will require the develpment f apprpriate, reliable and valid perfrmance indicatrs fr prgram impacts, and cnsiderable research. It may lead t sme resistance by health care wrkers and law enfrcement specialists already verburdened by dealing with drug prblems. But the empirical justificatin that a prgram is harm-reducing need nt necessarily be based n cmpelling evidence. Fr many interventins, standards culd be set such that effectiveness is assessed n weight f evidence rather than mre rigrus, expensive and ptentially disruptive evaluatin studies. One f the first steps in develping a drug plicy based n an empirical cnceptualizatin f harm reductin wuld be t develp a cnsensus amng health care wrkers, law enfrcement and thers invlved in the plicy cncerning the evidentiary framewrk that wuld be emplyed. Despite these prblems, the empirical cnceptualizatin f harm reductin has cmpelling advantages. While we can never eliminate nrmative aspects f drug plicy, evidence-based decisin-making is the nly realistic ptin fr priritizing interventin ptins. Plicies and prgrams cannt expect t cntinue t receive supprt indefinitely withut evidence f effectiveness. The requirement that an interventin demnstrate a net psitive impact in reducing drug-related harm befre it can be deemed t be harm reductin wuld prmte evidence-based decisinmaking and mre cst effective prgramming. Only by determining whether an interventin actually achieves its can we really determine if it shuld be cnsidered harm reductin. There wuld nt be a priri classificatin f plicies and prgrams int harm reductin vs. ther strategies. Measures that have been traditinally assciated with the term harm reductin, such as syringe exchange prgrams, wuld have t demnstrate effectiveness if they are t be cnsidered harm reductin. Further, this cncept f harm reductin wuld nt exclude abstinence-based appraches n a priri grunds. If such prgrams reduce drug-related harm, they wuld be cnsidered harm reductin. Fr bth abstinence-riented interventins and use-tlerant harm reductin measures, cntinued supprt wuld depend n evidence f effectiveness.

17 6. Implicatins f a harm reductin strategy 6.1 Relatinship f harm reductin t ther appraches Harm reductin and abstinence-riented appraches: The empirical definitin entails n a priri judgment cncerning harm reductin. It wuld apply the same criteria t abstinence-riented interventins that wuld be applied t any drug plicy r prgram t determine whether it is harm reductin. That is, if the weight f evidence indicates that there is a net psitive impact n drug-related harm, it wuld be cnsidered harm reductin. Sme abstinence-riented interventins wuld likely be cnsidered harm reductin n this basis, while thers wuld nt. By the same tken, sme measures that have been thught f as harm reductin wuld n lnger be cnsidered as such if they fail t prduce a net reductin in drug-related harm. Harm reductin and supply reductin: As with use-tlerant interventins, an empirical definitin f harm reductin wuld include thse supply side strategies that have a net psitive impact n drug-related harm and exclude thse which d nt. Harm reductin and drug refrm (such as decriminalizatin r legalizatin f particular drugs r all drugs): Hwever it is defined, harm reductin shuld nt be cnfused with supprt fr drug refrm. Rather, it shuld be viewed as the middle grund where persns with widely differing views n drug plicy can agree with ne anther regarding practical, immediate ways t reduce drug-related harm amng users. A harm reductin cncept that is clearly defined and based n evidence f cst effectiveness wuld fster the building f meaningful alliances and supprt fr prgrams such as needle exchange frm all persns wh share the same gal f reducing the harm assciated with drug use, even thugh there may be strng disagreements (largely nrmative) regarding the preventin f use per se in the general ppulatin. 6.2 Implicatins t Hep C prgram pririties The prpsed harm reductin framewrk fr drug plicy wuld have imprtant implicatins t Hep C prgramming and prgram pririties. These implicatins flw nt nly frm the suggested guiding principles fr harm reductin, but als frm ther cnsideratins that wuld apply t any Hep C plicy. The harm reductin principles wuld suggest giving a relatively high pririty t the fllwing types f prgramming: Preventin, treatment and law enfrcement plicies and prgrams that d nt exacerbate the Hep C infectin and ther prblems caused by injectin drug use; Plicies and prgrams which maximize interventin ptins fr health care wrkers, law enfrcement persnnel and thers dealing with injectin drug users at high risk f incurring r spreading Hep C infectin; Plicies and prgrams with practical, realistic gals; and Plicies and prgrams that treat injectin drug users as members f the cmmunity and minimize the marginalizatin f users. In additin t the guiding principles, cnsideratin f cst effectiveness wuld indicate that the fllwing interventins shuld be given high pririty: Prgrams that are supprted by evidence f effectiveness;

18 Prgrams targeted t high-risk grups; Preventin and early interventin prgrams; Prgrams that are cmprehensive in scpe, addressing a wide f range f issues bearing upn the spread f Hep C by injectin drug use; and Prgrams that make maximal use f existing netwrks f specialists and rganizatins dealing with injectin drug users. There are yet ther cnsideratins in setting prgram pririties that wuld necessarily have t be taken int accunt, even thugh they may nt be specific t a harm reductin strategy. Fr example, any Hep C strategy shuld be sensitive t the cultural needs f the cmmunity it serves and the cntext in which it is implemented. It shuld be balanced with regard t gegraphic distributin f resurces. It shuld als ensure that it addresses all aspects f the cntinuum f risk, including health enhancement fr thse with little r n risk, risk avidance measures fr thse with mderate risk, and early interventin and treatment fr thse at highest risk. 6.3 Implicatins t research and evaluatin A plicy based n harm reductin als has significant implicatins t evaluatin and research. First, the chice f plicies and prgrams used t achieve strategic bjectives must be evidence-based. Only thse interventins that have a net impact f reducing drug-related harm wuld be supprted. This in turn implies that all plicies and prgrams wuld subject t systematic evaluatin. Secnd, all aspects f a plicy shuld be subject t same standards regarding the need t demnstrate effectiveness. This implies that in additin t preventin and treatment prgramming, supply side interventins shuld als be subject t systematic research n its net impact n drug-related harm such as Hep C infectin rates. As with preventin and treatment interventins, the effrts t restrict illicit drug supplies shuld be assessed in terms f the immediate and lng-term impacts, including impact n drug prices and availability as well as unintended cnsequences, such as the difficulties that drug enfrcement may create fr treatment r the inadvertent prmtin f unsafe methds f drug administratin. Althugh drug enfrcement csts Canada mre than $400 millin annually (Single et al., 1998), there is virtually n research regarding its impact in reducing Hep C infectin r ther drug-related harm. A harm reductin strategy clearly wuld entail cnsiderable demands n research. It wuld require regular natinal and prvincial surveys n the extent and crrelates f injectin drug use as well as specialized studies n particular issues. Currently, hwever, there is paucity f funding fr research required t underpin evidencebased strategies.(3) Withut a lng-term investment in research t evaluate prgramming and mnitr perfrmance indicatrs, a drug strategy can be called harm reductin nly with regard t its intent. T be harm reductin in mre than name nly, research and mnitring systems are required t ensure that interventins actually reduce drug-related harm.