19 June, 2008

To harm or not to harm...

There is a great need in Australia and around the world to respond to the devastation caused by drug addiction, and yet, there is some ambivalence as to the parameters of the method of help. The harm reduction response appears to have a great deal of merit for both reducing the additional health burdens associated with addiction, as well as a positive way to connect with and support users who are not yet ready to move toward abstinence. However the methods of the harm reduction movement at times appear to, at the very least condone and as a general rule support and facilitate illicit drug consumption. This can be seen as problematic, and a hard sell to the general public. Benefits would have to be substantial to receive continued government support.

Harm reduction can be defined as ‘any policy or program designed to reduce drug-related harm without requiring the cessation of drug use’. Harm reduction is about reducing harm so that the illicit drug user (IDU) can continue to use drugs, whilst also staying safe. Many believe a compromise of harm reduction and abstinence would be more palatable, and in fact this is often the approach of government. However there is a notable difference between offering services that encourage harm reduction as well as services that encourage abstinence, and creating one service that does both. The difference is that at its core, harm reduction does not aim for abstinence. Why? Because it is deemed a fundamental right as a citizen to be able to involve oneself in a pleasure seeking activity, and remain a supported member of society without compromising further rights. A similar though limited example could be nicotine addiction, or even obesity. The individual brings poor health upon themselves for the sake of their own pleasure and the state intervenes to provide health care. The fact that the drug is illicit of course means there are an array of penalties attached to drug use, however health care must remain the right of the citizen, without an expectation that the individual will cease their drug taking. There must be no strings attached. This can be hard to get your head around. After all, why should the government support something that is illegal? Answer; because not supporting, whilst maintaining a semblance of morality, will prove to be more irresponsible than noble.

Let’s take a safe injecting facility (SIF) as an example of harm reduction. A SIF is a “legally sanctioned supervised injecting centre with trained staff, including nurses, who supervise all injecting at the facility and revive clients who have overdosed. Clients are required to bring their own drugs to the centres and are provided with clean injecting equipment and information on safer injecting practices.” The benefits of such a scheme are as any could deduce; the IDU stays alive and uninfected. The primary aim of SIFs is to reduce the morbidity and mortality associated with drug overdoses by ensure that adequate emergency health care support is on site. Injecting centres also aim to reduce the transmission of blood borne viruses such as HIV/AIDS and hepatitis B and C through safe needle use and a clean environment. There are obvious objections to these centres. Notably the two most common objections are that of condoning illicit drug use as well as an absence of incentive to cease drug use. It is hard to deny that a rubber stamp of approval could be inferred by the IDU. However, before dismissing the facility and its aims, it is important to assess its current outcomes. The following results include statistics from needle exchange programs (centers or mobile units that provide clean needles to IDUs).

In 2002, the National Centre in HIV Epidemiology and Clinical Research estimated that 450 new HIV infections occur in Australia each year with 3.4% of newly acquired infections being attributed to a history of injecting drug use (ADCA, 2003:3). This statistic is incredibly low. In America (where harm reduction methods have not been strongly embraced) HIV prevalence among injecting drug users has been documented at well over 40% (ADCA, 2003:3). Or a little cost benefit analysis; a 2002 study of the return on investment in Australian NSPs over the past 10 years showed that an outlay of almost $150 million on NSP initiatives had resulted in savings in the range of $2.4 and $7.7 billion and that 25 000 cases of HIV have been avoided among injecting drug users between 1988 (when NSPs were introduced) and 2000.

Why should the harm reduction model be pursued? Well perhaps the best reason is because it works, and has repeatedly been proven to improve the lives of addicts. There are many who eat themselves into massive health issues, or smoke till their lungs become useful in the construction of freeways, and yet we treat their health. We pump them with legal drugs and cut them up while they continue to attack their bodies in the name of pleasure. They get the healthcare they need, not the health care they deserve. And yet IDUs don’t because the government declared their pleasure seeking behaviour illegal? Punish their illegal behaviour that affects others, for sure! But to punish the behaviour that causes damage to them? Go down that road and we will be locking up a lot of people. Assuming harm reduction is the most effective way to support the IDU in relation to health outcomes, it is important that the method is supported to ensure its sustainability as policy.

Why should the harm reduction model be demolished? Well perhaps the best reason is because it fails to protect the individual longer than a single visit. It does nothing to change the dangerous culture of obtaining illegal drugs prior to ‘safely’ injecting, nor does it assist with the social and financial burdens post injecting. It presents illicit drug use as a legitimate pleasure seeking activity, and condones further illicit activity. It’s like shaking your head at a baby playing with a huge knife, taking the knife away, placing giant gloves on their hands and then giving the knife back. Government funded assistance of illegal activity? Are we for real? End it now before we start handing out little old ladies hand bags to thieves or baseball bats to abusive husbands!

Well I hope you are superbly confused! I will not tell you where I stand on the issue and have only sought to give you some information to think about. Social policy is complex and there is not always a moral and immoral way to help people. Have fun thinking up your own solutions!

And as always, have a great week!

1 comment:

Liam said...

Gen, thanks for a very thorough overview of the dilemma of harm reduction. It is, as you state, a very complex and difficult area both ethically and practically.

I just wanted to highlight that there are three strands to harm minimisation policy, which is the overarching way that governments deal with illicit drugs.

The three strands are:
harm reduction, supply reduction and demand reduction.

Supply reduction is the policing end of the policy. Prevent drugs from entering the country and then prosecute anyone who does the wrong thing.

Demand reduction is programs aimed at reducing drug use. This is where education programs on abstinence and treatment for drug use come into play.

The third area of harm reduction is as you have outlined. If after the first two areas of policy have failed, then let us make sure that those people who continue to use drugs will do so in the safest manner.

The largest amount of government funding is for the area of supply reduction. Harm reduction is the least funded, but as you stated perhaps the most cost effective.

Every clean syringe distributed by a Needle Syringe Program is one less chance for a person to contract a blood borne infectious disease (Hepatitis, HIV, etc.) It is also one less chance that I, a non injecting drug user, will contract a blood borne infectious disease from an injecting drug user.

It is scary to see countries that at a federal level push abstinence as a policy. This leads to a lack of education about the spread of disease, let alone safe usage practices. One only needs to look at the US to see that pushing abstinence as government policy does not work in stopping individuals from illicit drug use.

I must point out that as a soldier I am a strong advocate for the abstinence of enslaving substances. I must also highlight that over the last 12 months I have witnessed 3 people who I am closely involved with pursue a total abstinence model of overcoming alcohol addiction.

Thanks again for tackling some of the tougher issues out there. Thanks especially for not 'dumbing down' the discussion and for highlighting the challenges and grey areas rather than trying to convince us what is right and wrong.
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