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Reducing Harm
Needle exchange programs — in which drug users can exchange used syringes for new ones in order to stop the spread of disease — are probably the most well-known example of a "harm reduction" program.
The basic idea is that instead of trying to prevent problems like drug use, harm reduction aims at reducing the negative impacts of a behavior. These programs have become more and more widespread in the last few decades, but they remain controversial. Seattle, for example, is considering a measure that would stagger the times local bars would be forced to stop serving alcohol. Proponents feel this would help avoid a 2 AM rush on taxis (which potentially leads to drunk drivers), as well as limit noise pollution and binge drinking from those trying to fill up before a 2 AM cut-off.
One of the most controversial programs in North America is Vancouver, BC's "supervised injection" site Insite. The facility allows addicts to inject drugs under the supervision of medical staff. Supporters say the facility has greatly reduced the risk of death by overdose for the drug-injecting community of Vancouver, and has done so without affecting the broader community. But opponents say that the facility helps to normalize drug use and encourages drug use by making it less dangerous.
What are the ethics of "harm reduction" programs? What are the values that should underlie our public health policies?
GUESTS:
- Kathy Mulady: Public information officer for the Seattle City Attorney's Office
- David Duncan: Clinical associate professor at Brown University
- Ron Joe: Coordinator for addiction services in inner city Vancouver
- Bertha Madras: Professor of Psychobiology at Harvard Medical School
Tagged as: alcohol · drugs · public health
Photo credit: nicasaurusrex / Creative Commons
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Why is it cynical? What is your objection, or why do you oppose the idea, exactly, or ethically? You seem to say until we can treat people at the root, curing their addiction, then anything in the meantime is just a needless crutch or an enabler? What is the rationale for that view? Perhaps, it seems odd to me, coming from a Mental Health Association---isn't that what many mental health treatments attempt to do? Aren't antidepressants a cynical crutch, that chemically and artificially, allow the mind to heal? They help you along---perhaps, until you have the strength on your own. Doesn't a needle exchange, while not a treatment, help you along? Helps to prevent additional headache and disease? Or am I missing something?
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Jason,
How many of those people trying to get into Hooper are there for the 3rd or 4th time? I know the answer to this question and so do you.
The truth is that current treatment methods are only effective for a relativly small group of addicts. I don't have the percentages but the highest rates I've seen were presented by Hazelden, 56%, and the methodology used was so flawed as to render the results useless. In my opinion the report was biased by the need of the CEO to show high recovery rates.
Abstinence is, in my opinion, the best outcome and the outcome I would wish for all addicts.However, if it does not work for everyone, and it doesn't should we really leave no other option for the health and welfare of these people who suffer from addiction? That's not a very compasionate position. I would expect better from you.
I was excited when you entered the race for City Council. Several statements I read from you recently have caused me to no longer support your campaign. -
The only counry that has succeeded in stamping out rampant addiction were the Chinese Commies right after they came to power on the mainland, in 1949. The used their neighborhood cadres of community leaders to identify every addict in their blocks of authority and report their names to the next level of provincial commie authority. Addicts were rounded up and placed in concentration camps where they underwent treatment for a period of time, then released.
Routine examination of the these treated and presumably recovered addicts were carried out periodically and those found to have returned to the use of opium were simply dragged into the street and shot in front of their family and neigfhbors. This pretty much reduced substance addiction to a very minior public health issue in China for many yrs. Not sure how they handle it now.
The point is..until the US is prepared to blow the heads off convicted suppliers and dope smugglers and pot growers, we are only pretending to deal seriously with the problem. If we are not prepared to execute the people responsible for this epidemic, we will never stop it All the programs in the world and tens of billions spent on these are wasted resources.
I do not think we have the gumption to carry out this kind of draconian effort and nothing short of these extreme measures will end it.
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Reducing addiction harm? Reducing bad behavior caused by addiction? What about at work? Being the "victimized" employee of an abusive alcoholic and unable to find at my age and skills another job in this economy and unable to quit because in Oregon no matter how bad the job or abusive the boss a quit automatically means no unemployment benefits, I simply have to endure at the risk of my own health and sanity the addictive behaviors of my substance-abusing boss. I would like to see some protection in the workplace for those who as employees have to deal with chemically compromised supervisors. BTW I can't go over my boss' head because my boss is head of a one-person company. The boss' family members have either (a) moved as far away from the situation as they can or (b) enable - that would be the spouse along with the boss' social circle, so there is no intervention in the offing any time soon.
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Staggering bar closing seems a lot different from other harm reduction programs. Drinking is legal. This type of program doesn't really have any of the controversy that needle exchanges do, the only controversy it has, is that it is annoying. Closing bars at any hour is arbitrary nonsense---so changing those hours is just as arbitrary.
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Get real, this is really all about increasing profits for any corporation, business, or other entity that makes money from people using mood altering substances and the other purchases that go along with "partying". I am actually in favor of legalizing most mood-altering substances but don't try and package this as caring about the public good.
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I would be curious to hear people's thoughts on 'drunk cycling.' In my mind, the risk of hurting either the yourself or a bystander is much greater if you drive drunk, rather than if you ride drunk. This seems to be a respectable, and potentially responsible, form of harm reduction, but it is still illegal. In a bike-centric city like Portland, could we use this perspecitve to reduce rates of drunk driving?
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Many people think of harm reduction as a 'giving up' or an 'either/or.' It is really a backup, an interim plan, to reduce risk, to buy some time. It is like parachuting with a reserve parachute. Parachuting is perhaps a dangerous, stupid, and generally unnecessary risk, but if you take the risk, you might as well have some added protection, a second chute and any available safety equipment.
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teens & drinking - I can understand, and even support, letting your own kids drink at home in a controlled environment. Growing up, my parents occasionally let us try the wine or beer they were drinking but never to excess or without supervision, although it was never presented as a big deal. I cannot vouch for my siblings but, for me, this approach meant that I trusted my parents more than my peers on the subject of alchohol and/or drugs.
However, I have never understood the leap from that to letting someone ELSE'S kids drink at your house without their parent's explicit permission, and even then: They Are Not Your Kids!
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The blend of approaches (harm reduction and illegal drug suppression and interdiction) makes sense.
US society's unregulated drug of choice is alcohol. USe of alcohol is supported and encouraged, even with the demonstrable damage it causes to some of us.
Isn't our approach to addressing alcohol abuse a good model for abuse of illegal drugs: regulated serving centers (bars ), retail sales with heavy tax burdens on products to fund abuse programs, and non-profit and government abuse programs to help people who cannot control their use levels?
It seems that the "use and harm reduction" approach addresses the human element of the addicition problem.
Very interesting show today.
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I find it facinating that by "joining 'em" instead of "beating 'em" some organizations are actually able to help adicts. Perhaps this is because there is a non-adversarial relationship?
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Emily, I would strongly caution that you cease talking about parents who allow children to party at their house as a legitimate and common method of harm reduction. Parents who do this can be held criminally liable for anything that the children may do after consuming alcohol (not to mention issues of furnishing alcohol to a minor). This includes being liable for any deaths caused by the children. It is a VERY serious matter, and the way in which you are speaking about it makes it sound as though it's an accepted practice. Particularly in Oregon, this is not a behavior that parents should engage in. I would suggest that if you continue to refer to this activity on the show today that you counsel parents of the immense potential ramifications.
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That's a great point. Thanks. Our guest did clarify that responsibility to some degree when the example first came up but you're right about the serious level of legal and other liabilities. I don't know if it's a widely accepted practice but it does happen.
Thank you very much for flagging this up.
Emily -
Someone wrote an article a number of years ago about a study saying that Prohibition had actually worked and that the gangster and smuggling problems were actually fairly minor across the US.
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Diabetes is a physical disease. Addiction, although perhaps biological, is a mental disorder. This is not a fair comparison. Treatment for addiction doesn't always work, and is generally a form of therapy. Addiction treatment is rarely presented in a pill form, that would be a quick cure, in the way a potential cure for diabetes would be.
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If someone comes in to the Vancouver BC drug facility who has never used heroin, but wants to try it out in a safe environment, would he be allowed to do it. Would he be instructed how to do it "safely"?
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hi,
I was a heroin addict, and for a year, I injected 5 times per day. I've now been clean 15 years, thanks to methadone.
Shortly after I began using heroin, I relied on a needle-exchange program in Boulder, Colorado.
The needle exchange program was great -- not only did it provide me with clean needles (which helped me to avoid HIV & Hepatitis C), the program also gave me someone to talk with, however briefly, about what I was doing.
And it was my needle-exchange connection who first pointed out to me that I had become an addict. And later, he also served as an inspiring role model for me, since he had been an addict himself, but had been clean for 10 years.
Years later, after I'd become clean, I worked at two harm reduction programs, and I served as a role model myself for at least two people who were impressed to know that I had become clean and was leading a good life with the help of methadone.
By the way, I think harm reduction is great. But the quality of the programs depend greatly upon the staff and the administration of each program.
Sincerely,
Steve, SE Portland
PS: Heroin addicts speak of "getting straight" when they use heroin. Heroin is necessary for an addict to function normally and safely in society. I even had to use when I went on a day-long driving trip -- or I would not have been able to drive my car safely. -
In some ways it seems like harm reduction help addicts with their addictions. However, to determine it is all bad--like your guest from Harvard seems ridiculous. How about helping stop or slow public health dangers -- like HIV, hepatitis, etc. And also, people against these programs drive me crazy because there is often no access to treatment centers. So what is an addict to do? Harm reduction is an appropriate way to help addicts, to gain their trust, a potential first step to more intervention, and helps with other public health issues. I think it is a vital part of any intervention strategy.
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I believe these harm reduction clinics make a lot of sense. I've seen it to be true with non-drug and alcohol cases but I believe the idea is the same - that when you address or allow addictions to have a voice, in many cases the weight that addiction takes is lessened. These clinics allow addicts to meet the behaviors head on.
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What about people who don't want to go into treatment? Is it not better that they administer their drugs in the safest way possible?
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"harm reduction"
How about considering the other side of it, reducing harm and cost to the public? Some people are going to use no matter what so what if we set up a program of classes that a user could take to learn all about their chosen drug, upside and downside, and then get a license to use, and then the government give them their drugs at government cost at a clinic each day? Don't legalize and commercialize them because corporations would then have the incentive to create more users.
That would take the profit out and close down the drug smugglers, with the result that the police could turn to other crimes. The taxpayers would benefit from far less cost for drug enforcement at the borders, police, courts, jails, and drug related crimes.
Then the only people harmed would be the people who want to harm themselves by using.
And that would be "harm reduction" for the public.
Add in that Vancouver, BC program, to "reduce harm" to the users and you get the most effective overall "harm reduction" for all concerned.
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Howdy--
Once more, a drug crusader is whipping out the scare tactics, completely ignoring the evidence. You guest probably expects no one will challenge blanket statements such as "you've got more people driving on marijuana than aclohol."
Whether that's true or not, the fact is those drivers aren't causing the accidents. A recent report by Dr. Andrew Sewell reveals that while drunk drivers are unaware of their impairment, leading them to drive irresponsibly, marijuana users have an opposite effect--they believe they are more impaired than they are, so they compensate with exceedingly safe driving behavior.
However, your guest, realizing that this sort of thing is counterintuitive, knows that she can play on unjustified fears to demonize marijuana users. Harm reduction has to begin with verifiable information.
Happy Trails,
Ron
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As someone who is struggling to overcome a 47-year addiction to one of the truly harmful drugs - tobacco - I find it both ironic and disturbing that the US has a long history of picking and choosing which drugs - and drug users - it demonizes and which ones it supports through public subsidy.
Comments like those I'm hearing on this program from Professor Madras and others remind me that what this country is waging is a War On Some Drugs, and it has a lousy record of success. Given that, I applaud services like the supervised "harm reduction" facility in Vancouver BC.
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Mothers Against Misuse and Abuse (MAMA) has been working to reduce the harm from drug use and drug policy since 1982. Our approach is based on personal responsibility and informed decision, making with respect for human dignity.
We think it is realistic to acknowledge that a person is going to make their own decisions about drugs regardless of what the police, their mother, their friend or their doctors say. The more knowledge a person has about the drugs they might choose to use, the more likely they will make decisions that will reduce the harm.
If they use clean needles, they will reduce the chance of getting disease. If they know how many drinks per hour their body can process to prevent dieing from binge drinking, they are less likely to use in excess.
Prescription drugs taken properly, not in overdose, kill over 100,000 people a year.
With illegal drugs, people are often afraid to seek help due to the illegal nature of the drugs.
Letters we get from people who have lost family members who had an adverse effect from aspirin, are tragic. The statement I hear most often is we had no idea you could die from taking aspirin.
Other over the counter drugs cause many death and physical problems are not safe. The use of drugs in combination present even more problems.
With the story of tobacco we have seen that education works, as so many have quit using.
Treatment on demand for all drugs would be another important component to reducing the harm.
Empower the individual through education.
Sandee Burbank, Executive Director Mothers Against Misuse and Abuse mama@mamas.org www.mamas.org541-298-1031
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As a nurse who volunteered for many years with the IDU community in Eugene, OR I think that it is important to recognize that putting people in recovery programs will be ineffective if those people are not yet ready to change their behaviors. The philosophy of harm reduction is to protect the community from disease transmission and even to lessen the financial burden on local hospitals due to wounds from injecting-needle exchange programs do this effectively.
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I'm a recovering addict, 16 years sober, I used the 12 step model and think it is ONE good path to recovery. I have worked as a case manager in a residential program and am a certified addiction counselor.
Bertha Madras is part of the problem. Her rigid thinking around addiction denies that FACT that less than 50% of addicts recover from addiction. A study by the institution I worked for suggested that 56% of patients recovered but the methodology was flawed in that people who were unable to be contacted were not included. That number was a large percentage of patients and any one with half a brain knows which patients would refuse follow up care.
Her statement that no drug can be used safely is absurd and renders the remainder of her argument moot.
I believe that abstinence is the best outcome but for those whom abstinence treatment fails, harm reduction can be valuable.
Was there any talk of drugs used to treat this diseas? I didn't cath the whole program.
I ain't proofing this so accept my appologies on spelling mistakes.
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The elephant in the room is the corporations who make their money from selling drugs.
I am always reminded of the British Opium Wars against China to push opium in China and get the Chinese addicted. Why not Regulate the hell out of the drug and alcohol Corporations?
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I am a biology teacher at Portland Community College. One of the things I really want my non-majors biology students to learn is to use data and critical thinking. I am disappointed that I am only hearing about actual data with regard to reducing harm programs from the scientist David Duncan, while the scientist from Harvard, Bertha Madras cites no studies. The discussion leaves me thinking that Bertha Madras has an opinion but no data for me to evaluate. I am just suppose to take her word for it that harm reduction programs are bad. Very frustrating to me. I would like to know what the science is, not what she thinks personally.
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I wanted to comment in responce to Berthas statement that only alcohol could be used safely in small amounts, other drugs could not. I am an RN and just about everyone I care for gets IV morphine, dilaudid, numorphan or fentanyl, all opiods like heroin. My patients often do get a euphoric sensation while on the drugs. They are being used safely by just about everyone who enters a hospital. These patients do not go on to be addicts or criminals.
What about people with prescriptions for medical marijuana? Often they have issues with chronic pain, spinal injuries or are in treatment for cancer. They do not go on to cause car accidents or become criminals.
These drugs can be and are being used safely by many many people.
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I think you opted for sensationalism versus relevancy (big surprise) by posturing Duncan versus Madras. I would have valued hearing more from the local community.
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How about asking that great old lawyers question, Cui Bono, Who Benefits?
Thinking about it from a businessmans point of view, how to profit from peoples addictions? The alcohol and tobacco Corporations are obvious, but how to profit from the illegal drugs? Well, the police and military equipment manufacturers make huge money. The helicopter companies. The privatized jail Corporations. Police and military weapon suppliers. The people who take bribes, the people who run the growing and smuggling ops. Etc!
So, there are vested business interests in keeping drugs illegal and preventing "harm reduction", in keeping addicts addicted and hurting themselves and keeping the taxpaying public paying the price too.
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I think there is a huge misconception around the overall approach of the Harm Reduction model. Having worked in a needle exchange program in Portland, operated by the county health department and its partner at the time, the non-profit, Danzine, I would like people to understand that harm reduction is not about condoning behaviors. In fact, walking into an HR facility, it is quite apparent that every participant there (from the clients to the administrators) is operating from a very clear understanding that the behavior being addressed is potentially lethal at worst, and unhealthy, harmful, and a barrier to a more functional, healthy life at best. This is, in part, why the programs exist--to bring the users into contact with those who can help them to make healthier choices. The first choice might be to use a clean needle so that, as one commenter put it, the person might be alive another day to get clean. If you don't believe that, then you have to face the alternative which is to say that if you contract HIV, or have severe complications due to an abscess acquired from improper injection, or die that day due to an overdose, well, then that's what you get for being a drug addict. Harm reduction is simply stating you don't deserve to die for being a drug addict. Addicts should have the opportunity to get clean, and are more likely to do so by having access to experts who will help them in that struggle, instead of judging or condemning them. It is far more difficult to get clean when the majority of your interactions are with other users. Harm reduction and those who participate in it do not condone drug use; instead, they acknowledge the reality of the struggle users face.
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Harm reduction is designed to reduce the negative consequences of drug use for the person injecting drugs and the community.
Syringe exchange is a public health program for people who inject drugs. It is designed to reduce the spread of HIV, hepatitis C and other blood-borne infections to other injection drug users, their families and the larger community.
Exchange programs provide tools, resources, and education to enable people who inject drugs to protect themselves and their communities through safer injection practices and harm reduction methods. Exchange programs provide new, sterile syringes on a one-for-one exchange basis together with other health-related supplies, prevention counseling and referrals to other social services including drug treatment, housing and mental health counseling.
Syringe exchange services have been available in Multnomah County for 12 years. Rates of HIV among people who inject drugs in Multnomah County are lower than in other areas that do not provide these services. Multiple studies have found that the cities with low rates of HIV infectioin started syringe exchange and prevention efforts early in the AIDS epidemic before AIDS could get a foothold among people who inject drugs.
The National Institute of Health issued a report stating that exchange services do not increase needle injecting behavior nor encourage people to start injecting drugs. Studies have found that users of syringe exchange were 5 times more likely to seek drug treatment than those who had never been to syringe exchange. They also found that injectors who had attended a syringe exchange were more likely to remain in drug treatment.
Syringe exchange and other harm reduction and prevention programming are part of the solution to the complex issues of drug use in our community.
On December 16, 2009, the Federal Government removed the ban on the use of Center for Disease Control funding for Syringe Exchange Programs based on the strong evidence that they are effective in reducing the spread of HIV and hepatitis and other drug related harm.
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The comments by "evek" are an excellent summary of the intent of harm reduction initiatives. Thank you for your clarity, your compassion, and your realism. -
Harm reduction is designed to reduce the negative consequences of drug use for the individual injecting drugs and the community.
Syringe exchange is a public health program for people who inject drugs. It is designed to reduce the spread of HIV, hepatitis C and other blood-borne infections to other injection drug users, their families and the larger community. Exchange programs provide tools, resources, and education to enable people who inject drugs to protect themselves and their communities through safer injection practices and harm reduction methods. They provide new, sterile syringes on a one-for-one exchange basis together with other health-related supplies, prevention counseling and referrals to other social services including drug treatment, housing and mental health counseling.
Syringe exchange services have been available in Multnomah County for 12 years. Rates of HIV among people who inject drugs in Multnomah County are lower than in other areas that do not provide these services. Multiple studies have found that the cities with low rates of HIV infectioin started syringe exchange and prevention efforts early in the AIDS epidemic before AIDS could get a foothold among people who inject drugs.
The National Institute of Health issued a report stating that exchange services do not increase needle injecting behavior nor encourage people to start injecting drugs. Studies have found that users of syringe exchange were 5 times more likely to seek drug treatment than those who had never been to syringe exchange. They also found that injectors who had attended a syringe exchange were more likely to remain in drug treatment.
Syringe exchange and other harm reduction and prevention programming are part of the solution to the complex issues of drug use in our community. On December 16, 2009, the Federal Government removed the ban on the use of Center for Disease Control funding for Syringe Exchange Programs based on the strong evidence that they are effective in reducing the spread of HIV and hepatitis and other drug related harm.
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I love these solutions to illegal behavior. So typically American, soft headed and plainly silly.
Why not also start programs in Oregon's prisons teaching the violent morons that it isn't necessary to pound an 80 yr old lady through the pavement to steal her purse; nor shoot someone for the Timex watch on his wrist.
If we want our ciminal class (shooting up drugs is a criminal act) to do "less harm". Lets simply expand the idea from self harm to saving the rest of us from unnecessary violence from criminals who are too stupid to even be competent muggers. So lets teach prisoners how to be less violent in their mugging, home invasions, rapes. etc. the courses taught can be applied to college degree programs.
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The fact remains that the only program that has been successful over time in every country in the world is AA. And it succeeds only if one has the desire to quit drinking (doing drugs), not quiting for anyone or anything else: The addict must have the desire to get sober and clean and believe that he/she has a problem. The support provided by the AA program has saved countless lives, but you will never read or hear about them: The program is strictly anonymous and while not perfect, it is the only successful way to a new and better life. It has nothing to do with celebrity "going iinto treatment" stories so often in the news.
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Not true, Gabbyll. The AA's own figures for recovery and failure show almost precisely the same rates as for alcoholics who do nothing other than try to stop boozing on their own. In any case alcoholism or as the epidemiologists prefer 'problem drinkers' are not considered chemically addicted in the same way as those who use tobacco or heroin.
Plus the practice in some counties of compelling DUI convicts to attend a religiously oriented program such as the AA's run is considered by many legal authorities unconstitutional.
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I just listened to Friday’s Podcast on Harm Reduction and was disappointed to hear one of your guests share false information without being challenged or corrected. When Emily asked David Duncan about parents who let their kids drink at home to reduce harm, Duncan stated that in countries where parents do allow their kids to drink at home there are fewer problems with alcohol. Although this is a common myth in the U.S., it is simply not true. The U.S. has lower rates of alcoholism, youth binge drinking and health problems caused by alcohol than most European and Central and South American countries where drinking at younger ages with family is more common than in the U.S. The lowest rates of alcohol problems are in countries where national religions make drinking strictly prohibited or culturally unpopular. See this map from WHO: http://www.who.int/substance_abuse/facts/alcohol/en/index.html . A more extensive report from the U.S. Department of Justice addresses this misconception: http://www.dontletminorsdrink.com/downloads/Compareyouthdrinkrate_europe%20&%20us%202005%20ojjdp.pdf
I am not suggesting that strict prohibition is the answer (I don’t think it is). Harm reduction has its place in public health. But please get the facts right!!!!!!
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The data that shows early family approval of drinking at table has been around for some time and I think the connection between problem drinking and early introduction via the dinner table is accepted as correct.
Once upon a time in France some new President (Mendez France?) discovered than 25% of hospital beds in France were occupied by people suffering from alcohol related illness. He began a campaign to send the kiddies off to school with a bottle of milk rather than watered down wine. He was rather quickly voted out of office.
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Comments are now closed.
This bad idea has been floated in Portland at least two times before, in the mid-1970s and in about 1995.
Both prior proposals were fronted as medical intervention but come from a set of libertarian notions; that addiction is a lifestyle choice; that "we" can reduce the harm addicts cause by containing their environment; that treatment for addiction is religious or ineffective or expensive or unavailable; or that addicts must hit "rock bottom" prior to quitting. All nonsense.
Just in the past couple of weeks two other media organization have started on this story. Makes me think OPB listened to a persuasive individual who sold them a story.
The truth is Vancouver had a spike of access to heroin in the early 1980s caused by political troubles in Afghanistan and Mexico, coupled with a lack of willingness to understand addiction as a public health
issue by the BC government. Rather than providing evidence-based, outcome-driven treatment on demand, BC aped a Swiss pilot-project, and Insite, and others I think, were launched. The Swiss project ended after several addicts overdosed. The BC project limped along, often needing sympathetic political allies such as naive journalists to carry their message. Heroin addiction in BC increased - now tour guides take visitors to gawk at the decadence of dope fiends laying out on the street.
We'd oppose this idea for Portland.
When I drove by Hooper Detox yesterday morning there was a line out the door. I know from experience inside are twenty to thirty addicts ready to get clean. Most will be turned away. Funds are only available for only a few slots each day. Over a year the County turns away thousands of requests for help from dozens of clinics across the county. By turning away folks seeking treatment, we perpetuate addiction and all its ancillary ills.
Until we provide addiction treatment for those asking to quit, it's cynical and inhumane to enable sick addicts to stay sick and get sicker.
Jason Renaud
Mental Health Association of Portland
www.mentalhealthportland.org