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Harm reduction is a new direction for health education which has been developing in in Western Europe and Australia. Instead of trying to prevent drug use, this new direction focuses on trying to prevent the harms associated with drug use. One of the most familiar example of harm reduction is needle exchange which has been effective in preventing AIDS among IV drug users.
Over the past two decades, drug abuse prevention in Western Europe and Australia has taken a new direction which has major implications for the future of drug education and drug abuse prevention here in the United States. This new direction was given the name "harm reduction" in a report of the British Home Office (1984) which described two alternate goals for drug abuse prevention programs - either reducing drug use or reducing the harms associated with drug use.
Since that time the International Conferences on the Reduction of Drug-Related Harm, held in Liverpool, England in 1990, Barcelona, Spain in 1991, Melbourne, Australia in 1992, and Rotterdam, the Netherlands in 1993 have illustrated the rapid growth of this strategy in Western Europe and Australia while the 1994 conference in Toronto showed its recent encroachment in North America.
Earlier proposals for such an approach included the "casualty-reduction" approach to glue sniffing adopted by the Institute for the Study of Drug Dependence in 1980 and the proposal for "cultivating drug use" suggested by Duncan and Gold in 1983 - using the word cultivation in the sense of promoting healthy and productive development, while "weeding out" tendencies toward abuse. Harm reduction has also been called damage limitation or harm minimization.
Whatever it is called, this new direction consists of a policy of preventing the potential harms related to drug use rather than focusing on preventing the drug use itself It recognizes that as Moore and Saunders (1991, p. 29) state, 44 given the universality of drug use in human societies and the very real benefits that accrue from drug use, the usual prevention goal of abstinence from drug use for young people is unthinking, unobtainable and unacceptable."
Mugford (1991) says that a harm reduction approach accepts the fact that people will continue to use drugs no matter what the laws may dictate and asks how they can do so most safety. Such a strategy is consistent with human experience. Historically, all human cultures, except the so-called "Eskimos" have accepted some form of recreational drug use and all attempts at prohibition of a drug once its use has been established have resulted in failure ...
Watson (1991, p. 14) defines harm reduction as, the philosophical and practical development of strategies so that the outcomes of drug use are as safe as is situationally possible. It involves the provision of factual information, resources, education, skills and the development of attitude change, in order, that the consequences of drug use for the users, the community and the culture have minimal negative impact.
Furthermore, harm reduction recognizes that measures intended to prevent drug use have often had the unintended effect of increasing the harms associated with drug use. Outlawing drugs results in the creation of black markets with associated corruption of law enforcers, violence between competing drug dealers, erosion of civil rights inevitable in policing a "victimless crime", and the seduction of youth into lucrative careers in drug dealing. A black market will sell illicit drugs to anyone re their age or mental state. The strength, purity and even the identity of drugs on the black market is uncertain leading to adverse reactions and overdoses.
In one sense, harm reduction may be seen as a form of tertiary prevention (Duncan, 1988, pp. 50-51) - preventing the long-term harms which may result from drug abuse. Such harm reduction measures as methadone maintenance and needle exchanges constitute harm reduction in this sense.
Needle exchanges, for instance, have gained increasing support as the epidemic of HIV infection associated with intravenous drug use has motivated many public health and drug abuse authorities to rethink their priorities in dealing with IV drug use, moving them toward harm reduction. Mugford (1991), for instance, reports that Australian efforts combining needle exchange, education of drug users on proper syringe hygiene, and establishment of safe disposal points for used syringes in public restrooms have resulted in keeping the seroprevalence of HIV among IV drug users in Australia down to only 2 percent. This compares with the 50-70 percent HIV seroprevalence among IV drug users in large U.S. cities. In Switzerland, where HIV seroprevalence among IV drug users had reached nearly 50 percent, it has dropped to less than 5 percent since the Swiss adopted a harm-reduction policy (Rihs-Middel).
In another sense, however, harm reduction can be primary prevention. The essence of harm reduction in this sense is the recognition of the distinction between drug use and drug abuse. Just as it is a truth that any drug can be abused, it is a truth that any drug can be used without abuse. No drug is inherently abusive. Tobacco would appear to be the only drug for which it cannot be said that users outnumber abusers. The Epidemiologic Catchment Area Study (Anthony and Helzer, 1991, p. 124) has demonstrated that 20.3 percent of all users of illicit drugs have experienced a period of abuse at some time during their drug use history. Only 4.2 percent of current illicit drug users were dependent or abusers. The first symptoms of drug abuse typically occurred within two to three years after beginning illicit drug use and the median duration of a case of drug abuse/dependence was four to five years (pp. 133-135).
Harm reduction recognizes that preventing drug abuse is a different task from preventing drug use and may be both a more justifiable and a more achievable goal. Harm reduction can mean educating drug users on how to use drugs safely and responsibly. Duncan and Gold (1985, ch. 18) describe the types of responsibilities which drug users might be taught in harm reduction-oriented drug education. These include responsibilities regarding the situations under which drugs are used, health responsibilities, and safety-related responsibilities.
Situational responsibilities would include the responsibility for only using a drug in environments conducive to pleasant and rewarding experiences - avoiding use in hazardous or threatening environments. Another situational responsibility would be only using recreational drugs in social settings. A third would be to make provision in advance for anyone who should become severely intoxicated. Always having someone present who can assist knowledgeably in the event of untoward reactions to the drugs being used is another responsibility.
Health responsibilities would include not using recreational drugs when under severe stress or emotionally distraught. Another would be to avoid exacerbating any health problems through drug use. Drug use during pregnancy should be restricted to those drugs which will not place the unborn child at risk. Avoiding the use of drug combinations which can have dangerous interactions is another health responsibility. Another would be to avoid continued use of drugs for long periods of time.
Safety-related responsibilities would include avoiding the performance of complex tasks, such as driving or operating machinery, while using recreational drugs. Another would be to take the smallest possible dose to produce the desired effects. Altered consciousness is inappropriate in potentially dangerous or unknown settings.
Many health educators will be uncomfortable with this direction. They may see it as a surrender in the war on drugs. Others will see it as a refocusing of our efforts on what really matters for health education - the prevention of health problems. It is the proper role of health educators to help people live healthier lives not to act as moral police.
For further information contact Dr. David F. Duncan at Brown University, School of Medicine, Box G-BH, Providence, R102912, or call 4Ol-863-2959.
The Catalyst - Page 9
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