Harm Reduction

Harm Reduction: A New Direction for Drug Policies and Programs

PATRICIA G. ERICKSON
DIANE M. RILEY
YUET W. CHEUNG
PATRICK A. O’HARE
Copyright Date: 1997
Pages: 476
https://www.jstor.org/stable/10.3138/j.ctt1287zhr
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  • Book Info
    Harm Reduction
    Book Description:

    This edited collection provides the latest in research and critical thinking on public health alternatives to conventional criminal approaches aimed at limiting the harms of both legal and illegal drugs for users and society.

    eISBN: 978-1-4426-5753-3
    Subjects: Political Science, Law, Health Sciences, Sociology

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-viii)
  3. Foreword
    (pp. ix-x)
    ERNEST DRUCKER

    In the few years since the First International Conference on the Reduction of Drug-Related Harm (held in Liverpool in 1990), the term ‘harm reduction’ has gained wide currency in both public-health and drug policy. Perhaps this is because of the vacuum that existed before that time, when an often acrimonious struggle between prohibition and ‘legalization’ occupied the field. This dichotomy tended to exclude more pragmatic approaches such as those the Dutch began to explore in the late 1970s, with diminished criminalization and greater involvement of drug users themselves in the formation of policy and design of new programs. But, without...

  4. Acknowledgments
    (pp. xi-2)
  5. Introduction: The Search for Harm Reduction
    (pp. 3-14)

    This volume is a collection of selected, revised papers originally presented at the fifth International Conference on the Reduction of Drug-Related Harm held in Toronto, Canada, 6–10 March 1994. The series of international conferences began in Liverpool in 1990, and was triggered by two major factors. The first was the gradual recognition, by a growing number of countries, of the need for more pragmatic strategies for minimizing the risk of HIV transmission among injection drug users. The second factor was the success of certain pragmatic and innovative risk reduction programs that had been introduced in the Netherlands, Australia, and...

  6. Part I: HISTORY, POLICY, AND SOCIAL THEORY
    • 1 The Case of the Two Dutch Drug-Policy Commissions: An Exercise in Harm Reduction, 1968–1976
      (pp. 17-31)
      PETER D.A. COHEN

      In the unruly times of the sixties, when a series of different political movements had unsettled the classic paternalistic ruling style in the Netherlands, youth had suddenly started to dance to strange music on strange intoxications. Sons and daughters of doctors, bricklayers, judges, and bank employees smoked a strange-smelling weed called marijuana. According to the law this was forbidden, and according to mostly American sources, marijuana provoked all kinds of psychic disturbance. Even worse, marijuana hunger was unsatisfiable and led to addiction, not only to the weed itself but also to other illicit drugs like cocaine and morphine.

      At the...

    • 2 Legalization of Drugs: Responsible Action towards Health Promotion and Effective Harm Reduction Strategies
      (pp. 32-46)
      LINE BEAUCHESNE

      Canada, with its orientation towards a health-promotion policy, has distanced itself somewhat from repressive American drug policies. Health and Welfare Canada, in its 1986 publicationA Framework for Health Promotion, adopted the definition of health promotion endorsed by the World Health Organization: ‘health promotion is the process of enabling people to increase control over, and to improve, their health’ (Health and Welfare Canada, 1986: 6). In other words, health cannot merely be defined as the absence of illness; health policy cannot simply be defined as investment in finding cures. Health promotion implies increasing a person’s autonomy over the management of...

    • 3 The Battle for a New Canadian Drug Law: A Legal Basis for Harm Reduction or a New Rhetoric for Prohibition? A Chronology
      (pp. 47-68)
      BENEDIKT FISCHER

      In the late 1980s, Canadian drug policy seemed to be heading towards a paradigmatic change. In similar fashion to the United States, or even more vigorously at times, the country over decades had chosen a system of legal repression as its primary answer to ‘illicit’ drugs (Giffen et al. 1991; Solomon and Green 1988; Erickson 1992a). ‘Illicit’ drugs in the Canadian context are those substances that made their way onto the schedules of Canada’s successively emerging prohibition laws, starting shortly after the turn of the century. This lengthy ideological crusade started in 1908 with the mobilization of police and justice...

    • 4 The De-Medicalization of Methadone Maintenance
      (pp. 69-79)
      MARSHA ROSENBAUM

      The institution of methadone maintenance treatment in the United States represented a culmination of increased medicalization of American society during the first half of the twentieth century. Drug technologies had been developed that would alleviate all forms of pain that had been defined by Americans as uniformly intolerable (Illich 1976). During the 1950s deviant behaviour was redefined not as ‘badness’ but as disease, and addiction as an illness that could be treated with advancing medical technologies (Conrad and Schneider 1980). Therehabilitative idealbecame the dominating solution to the crime problem, as thousands of offenders were reformed in a myriad...

    • 5 Readiness for Harm Reduction: Coming to Grips with the ‘Temperance Mentality’
      (pp. 80-98)
      BRUCE K. ALEXANDER and GOVERT F. VAN DE WIJNGAART

      The stringent anti-drug policy that has prevailed in North America for the last few decades has proved ineffective, costly, and cruel (Alexander 1990; Boaz 1990; Nadelmann 1989; Peele 1993; Trebach 1993; van de Wijngaart 1991; Wisotsky 1986). Fortunately, there are promising new directions, of which harm reduction appears the most realistic (New-combe 1989; Watson 1991; Heather et al. 1993). However, it is not yet clear that society will tolerate any substantial deviation from the familiar policy.

      We believe that Canadian society is very nearly ready for changes in the direction of harm reduction, but that the immediate prospects are less...

    • 6 Harm Reduction at the Supply Side of the Drug War: The Case of Bolivia
      (pp. 99-116)
      FERNANDO GARCÍA ARGAÑARÁS

      Harm reduction is usually defined as a benign approach to drug use, one that rejects its criminalization and questions the punitive policies associated with it. In this paper, harm reduction is redefined so as to include the set of problems and characteristics that prevail at the supply side of the drug war. The perception that certain drugs – and not others – are an evil that must be eradicated at all costs, together with geopolitical considerations about the ‘security’ of the Andean region, have made ‘fighting supply’ the cornerstone of U.S. policy in the hemisphere since 1985. This work focuses...

  7. PART II: HUMAN RIGHTS
    • 7 Harm Reduction, Human Rights, and the WHO Expert Committee on Drug Dependence
      (pp. 119-130)
      ROBIN ROOM

      Under the various international conventions on psychoactive drugs, the World Health Organization (WHO) has specific treaty responsibility to act as the source of scientific and medical advice to the international drug-control system. WHO’s task, when it is asked for advice on a drug, is to evaluate a drug’s dependence potential, its abuse liability, and its medical usefulness, and to recommend whether and in which schedule a drug should be placed under the control of the international drug-control machinery (Bruun et al. 1975).

      The main WHO mechanism for accomplishing this task has been a series of expert committees, which used to...

    • 8 Harm Reduction, Doping, and the Clashing Values of Athletic Sports
      (pp. 131-150)
      TRUDO LEMMENS

      A harm reduction approach to the problems created by drug use should imply more than an assessment of the direct physical and psychological harms and benefits of drug use. This is recognized by a growing attention for human rights in the analysis and critique of current drug policies. Human rights indeed have their place in a harm reduction approach. They are not only a legal expression of values we share, but also shape our human identity. Oppressing human rights harms individuals directly in their roots. Nevertheless, human rights only reflect some of the core values of the specific social and...

    • 9 Will Prisons Fail the AIDS Test?
      (pp. 151-173)
      RALF JÜRGENS

      What has gone wrong with HIV/AIDS policies in prisons? As stated by Harding and Schaller (1992a: 761–2), ‘despite clear recommendations made by international bodies in 1987/88 … and the substantive policy change in some countries, the overall picture is bleak. Discrimination, breaches of medical confidentiality, and segregation remain wide-spread. Treatment programs for HIV-infected prisoners are inadequate. Tuberculosis is increasing in prison populations … No effective measures for preventing HIV transmission through injection drug use are applied in most countries.’

      This situation persists although international and national recommendations on HIV/AIDS and drug use in prisons are all consistent in favouring...

    • 10 Is Prenatal Drug Use Child Abuse?: Reporting Practices and Coerced Treatment in California
      (pp. 174-192)
      AMANDA NOBLE

      A number of women in the United States have been prosecuted for their drug use during pregnancy; there have been approximately 150 such cases reported nationwide. This chapter discusses a different form of punishment, one that is far more common. In California, poor women and women of colour are often tested for illicit drugs when they arrive at hospitals to deliver their babies. Sometimes the infant’s urine is tested, sometimes the mother’s urine is tested and sometimes both are tested. If they test positive for drugs, hospital workers frequently call child-welfare workers, who begin an investigation of child abuse that...

  8. PART III: ALCOHOL AND PUBLIC HEALTH
    • 11 Towards a Harm Reduction Approach to Alcohol-Problem Prevention
      (pp. 195-202)
      ERIC SINGLE

      Harm reduction was developed as an approach to deal with problems associated with illicit drug use, and we tend to think of it in this context. The basic thesis of this paper, however, is that the trend towards harm reduction in illicit drugs is closely paralleled by a similar trend in measures aimed at reducing the consequences of heavy-drinking occasions.

      A variety of prevention measures have developed in the recent past that focus not so much on restricting drinking occasions, but rather on reducing the harm that may arise when drinking takes place. In the following discussion several examples will...

    • 12 Reducing Alcohol-Related Harm: A Balanced and Disaggregated Perspective
      (pp. 203-212)
      MARTIN PLANT

      This paper reviews some evidence related to the minimization of alcohol-related problems. Two types of data are considered. The first of these is an impressive array of evidence suggesting that abstainers share with ‘heavy drinkers’ a high rate of premature mortality from coronary heart disease and other causes. This evidence, from a variety of different countries, suggests that there are tangible health benefits derived from moderate, and even not-so-moderate, levels of alcohol consumption. One possible explanation for this is that drinking stimulates the production of high-density lipoprotein cholesterol. It is recommended that evidence on this protective effect should be integrated...

    • 13 Harm Reduction and Licensed Drinking Settings
      (pp. 213-227)
      TIM STOCKWELL

      In relation to illicit drugs, law enforcement and harm reduction strategies are usually viewed as being mutually incompatible. In this chapter it will be argued, however, that once a drug becomes legally available, law-enforcement efforts can shift from the stereotype of ‘zero tolerance’ to being a powerful tool for reducing harm.

      To understand this point it is helpful to imagine an alternative universe in which heroin is legally available and in which it is necessary to devise a set of laws regarding its sale and distribution. In order to promote low-risk use this legislation would need to include some of...

    • 14 Reducing Alcohol-Related Harm in Communities: A Policy Paradigm
      (pp. 228-244)
      CLAIRE NARBONNE-FORTIN, RENÉ LAUZON and RONALD R. DOUGLAS

      Alcohol, an accessible and legal drug, is sometimes underestimated as a potentially harmful substance. As a result, a greater emphasis is often placed on the harmful consequences of illicit drug use. The Addiction Research Foundation, a provincial drug agency in Canada, reported that in 1994, 82 per cent of adults and 56 per cent of students between the ages of twelve and nineteen reported having used alcohol in the previous year. This compares to 0.7% and 1.5% respectively having used cocaine during the same period. The same report indicated that approximately 10% of Ontario deaths in 1991 were associated with...

    • 15 Harm Reduction and Alcohol Abuse: A Brief Intervention for College-Student Binge Drinking
      (pp. 245-262)
      G. ALAN MARLATT and JOHN S. BAER

      How many college students drink, and what are the problems they experience with alcohol? A recent random survey conducted with 1595 students at the University of Washington (Lowell 1993) provides illustrative data from a large public West Coast university with a total population of over 35,000 students. More than half the students were light or non-drinkers, but undergraduates tended to be more extreme in their drinking patterns than graduate/professional students. Although there were more abstainers (28.6%) among undergraduates than graduate students (19%), among undergraduates there was a higher proportion (31%) ofbinge drinkers(defined as drinking five or more drinks...

  9. PART IV: LABORATORY, CLINICAL, AND FIELD STUDIES
    • 16 Animal Self-Administration of Cocaine: Misinterpretation, Misrepresentation, and Invalid Extrapolation to Humans
      (pp. 265-289)
      JOHN P. MORGAN and LYNN ZIMMER

      The increase in cocaine use in North America during the 1970s and early 1980s provoked a series of cautionary tales regarding its dangers, particularly its addictive powers. In the medical, clinical, and popular literatures, evidence of cocaine’s addictiveness took two forms: (1) personal accounts of people who claimed to have lost control of the drug and (2) reports of laboratory experiments in which animals consumed enough cocaine to cause their own deaths. The second narrative was particularly important, given that cocaine was known to cause neither physical dependence nor withdrawal symptoms of the sort associated with opiates (Gawin and Kleber...

    • 17 Harm Reduction Interventions with Women Who Are Heavy Drinkers
      (pp. 290-302)
      GERARD J. CONNORS and KIMBERLY S. WALITZER

      Alcohol consumption and associated negative consequences among women are significant public-health concerns that may be alleviated in part through the use of harm reduction interventions. In this regard, one harm reduction intervention holding particular promise for heavily drinking women experiencing alcohol-related problems is drinking-moderation training.

      This chapter accordingly will focus on several topics. The first section includes background information on alcohol consumption and related problems among women. There follows a discussion of drinking-moderation interventions as a harm reduction strategy. An example of such an intervention for heavily drinking women, the Women and Health Program, is described. The description of this...

    • 18 Two Steps Forward, One Step Back: Anti-User Bias in New York State’s Approach to Needle Exchange
      (pp. 303-323)
      ROD SORGE and RUTH E. HARLOW

      Harm reduction – when this term is used at all in the United States – has largely been and largely remains a synonym for needle exchange despite its much broader, more nuanced meanings. While needle exchanges have grown in number and visibility since the first such program was established in the United States in 1988, the concepts and definitions of harm reduction as an underlying philosophy have been much less extensively debated and formulated in the public realm. Some U.S. needle-exchange programs have developed sophisticated harm reduction analyses and approaches, but the public-health authorities and other government bodies that have...

    • 19 Shopping, Baking, and Using: The Manufacture, Use, and Problems Associated with Heroin Made in the Home from Codeine-Based Pharmaceuticals
      (pp. 324-339)
      JULIA REYNOLDS, SIMON LENTON, MIKE CHARLTON and JANE CAPORN

      Prohibition can only be expected to be successful in reducing harm when there is little demand for the proscribed drug, controls are difficult to subvert, and similar drugs are unavailable or less harmful (Wodak 1993). This chapter provides an example of drug prohibition where these conditions have not been met. It describes the unintended negative consequences of heroin supply reduction and strategies employed in an attempt to reduce the harms associated with this situation. In parts of Australia and New Zealand the unmet demand for a preferred drug, white-powder heroin, has led heroin users to resort to manufacturing a much...

    • 20 ‘Really Useful Knowledge’: The Boundaries, Customs, and Folklore Governing Recreational Drug Use in a Sample of Young People
      (pp. 340-362)
      LAURA GAMBLE and MICHAEL GEORGE

      Research into the recreational use of illegal drugs has never, arguably, achieved the prominence it deserves. ‘Successful’ recreational drug users may teach us more about treating problematic drug use than studying casualties whose drug use has become problematic or studying abstainers. Recent surveys of drug use amongst young people (Baldwin 1991) suggest that the prevalence of recreational or dance drug use as well as the use of cannabis and hallucinogenic drugs has increased substantially. Research that focuses on problematic or dependent drug use, therefore, fails to take account of the far larger cohort of drug users who maintain control over...

  10. PART V: COMMUNITIES AND SPECIAL POPULATIONS
    • 21 Alcohol and Other Drug Use in the Punjabi Community in Peel, Ontario: Experiences in Ethnocultural Harm Reduction
      (pp. 365-382)
      YUET W. CHEUNG, TIMOTHY R. WEBER and PURVI BIRING

      Over the past four or five years, the harm reduction approach has been broadened from one that deals more specifically with the prevention of HIV infection among intravenous drug addicts to one that is meant to be applicable to a wide range of illicit and licit drugs and different modes of substance use (Cheung 1994). While this search for a new ‘paradigm’ (Erickson 1992; Erickson and Ottaway 1994) has stimulated a great variety of new efforts in drug-abuse prevention, intervention, treatment, policy, and research (O’Hare et al. 1992; Heather et al. 1993), very few of such efforts have focused on...

    • 22 Female Drug Injectors and Parenting
      (pp. 383-392)
      AVRIL TAYLOR

      Drug-using mothers are generally regarded in negative terms (Perry 1987). Injecting drug use by mothers, in particular, is, at the very least, seen as putting children at risk (Mondanaro 1989) and can be regarded as a sign of outright unfitness in a mother (Densen-Gerber et al. 1972). Indeed, the unfitness to be a parent is one of the strongest stereotypical images of female drug injectors and can be the basis upon which policies relating to the care of their children are based.

      But this image is to a large extent stereotypical rather than based on empirical evidence. Very little research...

    • 23 The Harm Reduction Model: An Alternative Approach to AIDS Outreach and Prevention for Street Youth in New York City
      (pp. 393-409)
      MICHAEL C. CLATTS, EDITH SPRINGER, W. REES DAVIS, GLENN BACKES, CHRISTOPHER LINWOOD, MARIE BRESNAHAN and STACEY RUBIN

      Studies indicate that as many as two million adolescents in the United States are homeless, and that as many as 200,000 youth live as permanent residents of the streets (United States 1986). Although the size of the homeless and runaway youth population in New York City is not known with any degree of precision, available data suggest it may number as many as 20,000 (Gunn 1988; Schafer and Caton 1984). Many of these youth have lived for periods of time in shelters and welfare hotels, but many have spent at least some amount of time in which they were abjectly...

    • 24 Working with Prostitutes: Reducing Risks, Developing Services
      (pp. 410-428)
      SARAH CROSBY

      This chapter is based upon the experience and work of Manchester Action on Street Health (MASH), a voluntary organization providing an innovative, sexual-health service for street prostitutes in Manchester, north-west England.

      The principle of harm reduction is central to the work of the MASH project. Harm reduction within the context of MASH focuses on the health risks associated with unsafe and/or injecting drug use. From this perspective, harm reduction can be conceptualized as a variety of interventions designed to reduce the potential harm to street prostitutes generated by their patterns of drug use and sexual activity. MASH recognizes that clients...

    • 25 A Harm Reduction Approach to Treating Older Adults: The Clients Speak
      (pp. 429-452)
      KATHRYN GRAHAM, PAMELA J. BRETT and JANE BARON

      Only a small proportion of persons who attend conventional addictions treatment programs are older adults (Ellis and Rush 1993; Moos et al. 1993). While this may partly be attributable to older people having a lower rate of alcohol problems compared to younger adults, it is also true that many people (both old and young) experience serious alcohol-related problems but are unwilling to participate in conventional addictions treatment programs. Although there has been increasing focus in the addictions field on early identification and on recruitment into treatment through workplace programs and the courts, there have been relatively few attempts to make...

    • 26 Harm Reduction Efforts inside Canadian Prisons: The Example of Education
      (pp. 453-472)
      ANDRÉA RIESCH TOEPELL

      In general, education is guided by several goals, including the intent to inform, raise awareness, or cause an effect (i.e., learn something new, revise previously learned information, change beliefs, attitudes, or behaviours, etc.). Education is inherently a beneficial facet of everyday life, and the dissemination of information through it is recognized as constructive.

      Within the harm reduction model, education plays a critical role: it is the cornerstone of the model’s many components. In risk prevention efforts (such as syringe-cleaning/exchange, safer sex, and substance-use alternatives), education is a vital component to successful risk reduction through behaviour change. In the promotion of...

  11. Contributors
    (pp. 473-476)