Harm Reduction: Policies in Public Health

Elizabeth Nodine, M.D.

Case Western Reserve University

Public Health Online Textbook Chapter

April 25, 2006

I. Introduction

Harm reduction is a philosophy intended to be an alternative to prohibition of high-risk lifestyle choices. At the core of harm reduction philosophy is the acknowledgment that some people will always be engaged in behaviors that carry risks, like intravenous drug use (IVDU), unsafe sex, and smoking. A harm reduction approach attempts to lessen the consequences of such behavior when eliminating the behavior altogether is not realistic. Furthermore, instead of criminalizing these behaviors, harm reduction pursues a social justice response. Harm reduction philosophy supports the idea that people should not be denied health care and social services just because they take risks1.

Critics of harm reduction believe that this philosophy condones and may even encourage risky behavior. They feel these programs are socially destabilizing. Although many of these illegal activities are popularly known as “victimless crimes”, opponents argue that there are indeed victims, such as family members and society at large. Advocates of harm reduction counter that these initiatives are not incompatible with abstinence-based programs. They believe that since risk is a universal part of life, and since change and recovery are processes with many stages, harm reduction is a needed part of public health programs. Opinions regarding this debate are not divided neatly along party lines, as many Republicans as well as Democrats support harm reduction policies. Harm reduction remains a polarizing subject in the United States, with relatively more support in Europe, Canada, Australia and Africa2. The purpose of this chapter is to introduce the concept of harm reduction and to present a wide range of harm reduction initiatives currently in practice in public health.

II. Applications of Harm Reduction Policy

A. Illicit Drug Use

Needle Exchange Programs

Needle exchange programs are one of the oldest examples of harm reduction policy in the U.S. and involve supplying users of heroin and other injectable drugs with clean hypodermic needles. In areas of the country where syringes are only available by prescription, users frequently share syringes. As a result, any user whose blood is infected by HIV, Hepatitis C, or another blood borne infection, quickly spreads his disease. Needle exchange programs have perhaps the best-documented success rates of any harm reduction strategy. In 1998, the U.S. Surgeon General prepared a review of syringe exchange programs which concluded that, “there is conclusive scientific evidence that [these programs], as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces transmission of HIV and does not encourage the illicit use of drugs”3. The review also noted an actual decrease in injection frequency among those attending the programs. The study also identified these programs as a unique opportunity to identify, refer and retain these high-risk individuals in local treatment programs and other health services. For a more in-depth discussion on needle exchange programs, see Clare Grey’s chapter within in this textbook.

Methadone

Methadone is a synthetic drug used to reduce the harm caused by opiate addiction (usually heroin). It is not associated with the euphoria of opiates, but does reduce and may even eliminate the strong cravings that accompany opiate withdrawal. Methadone is a legal medication prescribed under a physician’s supervision within a carefully monitored program. In contrast to heroin use, it does not affect mental capabilities or employability. Methadone Maintenance Treatment (MMT) has been repeatedly shown to be cost effective, averaging about $13 a day. MMT has also been found to reduce criminal behavior and promote better health and productivity. Cost benefit analyses indicate that for every treatment dollar, $4 to $5 is saved in social and health costs. Additionally, because it can eliminate unsafe needle use, MMT significantly decreases the spread of HIV, Hepatitis B and C and other blood born diseases4. A relatively newer target of MMT intervention is the prison population. A recent survey in Puerto Rico found that 58% of inmates reported using heroin while incarcerated. The government has responded by piloting small MMT trials in prisons that have so far made significant gains in lessening more harmful drug use. Yet despite its proven benefits, only 20% of heroin addicts are in MMT programs5.

Legalization/Decriminalization of Drugs

Many harm reduction initiatives focus on legalization or decriminalization of certain illicit substances, particularly those drugs felt to cause relatively little harm compared with the costs of law enforcement (e.g. marijuana). Legalization refers to a system in which no aspect of the production and possession cycle is considered an offense. One model of legalization is known as regulation, which is used in the alcohol model of a control board. Decriminalization, by contrast, refers to prohibition with certain civil penalties but with no criminal charges for possession of small quantities of drugs. These strategies mandate that intervention be based on the relative harmfulness of a particular drug to society6. Harm reductionists feel that current drug policies overemphasize arrest, incarceration and military source control in other countries as a means of dealing with illicit substance abuse.

By many measures, incarceration does little to reduce the harm caused by illicit drug use, yet it is very costly. Of the nearly 700,000 drug-related arrests in 2002, 88% were for possession (as opposed to selling to others) and most of these were for marijuana7. Approximately 4 billion dollars is spent on minor marijuana offenses per year in the U.S. Similarly, emphasizing prohibition has been shown to increase risk of black market crime and black market sales to minors. The annual revenue generated by the illegal drug industry is approximately 400 billion dollars, which is roughly 8% of total international trade⁶. Harm reduction advocates believe that these law enforcement resources are not being effectively allocated and are diverting funds from fighting other types of crime, making it a questionable policy choice. They favor lessening harm through prevention, education and treatment.

Examples of legalization and decriminalization strategies abound in Europe. Perhaps the most extreme example is found in the Netherlands, where Dutch citizens over 18 years old are permitted to use cannabis in coffee shops that are government regulated. Since this policy was enacted more than 20 years ago, there has been no significant increase in cannabis use. In fact, rates of use are much lower than in the U.S., which criminalizes cannabis production and possession. Canadian drug policy endorses a decriminalization strategy in which law enforcement resources target large scale traffickers of hard drugs rather than prosecuting possession charges for small amounts of less harmful “soft” drugs (e.g. marijuana)⁶.

The current U.S. policy regarding illicit drug use, commonly referred to as the “war on drugs”, has enormous social consequences not only in the U.S. but also abroad. Those who oppose this policy often charge that it is a war against farmers, often the world’s poorest, who grow drugs or their precursors. For example, the U.S. initiative known as “Plan Columbia” attempts to reduce the supply of common illicit drugs (Colombia produces 90% of the world’s cocaine and is also a major supplier of heroin) by supplying billions of dollars of aid to fumigate crops. The local farmers claim that this destroys their food crops, contaminates the grass, and kills their livestock, all of which is leading to mass starvation8. Opponents also claim that this “war” has fueled organized crime, corrupted police and governments, and distorted economic markets around the world. The conservative economist Milton Friedman has long championed harm reduction strategies as an alternative to the “war on drugs”, stating, “As I predicted… on the basis primarily of our experience with Prohibition, drug prohibition has not reduced the number of addicts appreciably if at all, and has promoted crime and corruption” 9. He further criticizes the U.S. for spending scarce resources better used on health and education towards an ever more expensive supply-reduction effort.

B. Alcohol- Related Programs

Prohibition: America in the 1920s

Perhaps the best-known example of a U.S. public health policy related to alcohol was the national policy of Prohibition, which was passed in January 1920. World War I gave prohibition initiatives new ammunition, with an increasing distrust of immigrant populations and sensitivity to wastefulness. Prohibitionists claimed liquor was a menace to patriotism. The aftermath of this decision was a court system overwhelmed by liquor violation trials and the development of an elaborate system of illicit trafficking (made famous by Al Capone’s group). The law did not to diminish the demand for alcoholic products. In fact, during the early years of Prohibition, the age at which drinking began was lower and the number of women drinkers was higher. People of relative wealth continued to drink in large numbers and in small towns the law was simply ignored10.

The Depression brought a demand for increased employment and tax revenues and in 1933, after 13 years, Prohibition ended. By most accounts the policy of was a failure. Although Prohibition disrupted the manufacturing and distributive agencies through which alcohol had been legally supplied, the demand for it persisted. It can be said that the current system of alcohol regulation is a form of harm reduction policy replacing Prohibition. In the rest of the world, with the exception of some Muslim areas, no government has succeeded in eliminating alcohol use¹⁰.

Designated Drivers

A highly successful and widely accepted harm reduction initiative involves safe driving alternatives for intoxicated individuals. These programs are popularly known as designated driver campaigns. Most alcohol users are aware of these safe ride techniques and many cities offer free-ride-home programs (free taxicab rides), as well as free subway fare during holidays commonly involving over consumption of alcohol. According to the U.S. Department of Transportation, these initiatives have been very successful: since 1982, when these programs were first publicized, fatalities from drunk driving are down by 41%. A similar, although much less well accepted intervention known as “Contract for Life”, has also seen significant success. These agreements, originally promoted by Students Against Drunk Driving (SADD), have high school students sign a pledge to attempt to abstain from alcohol use, but to agree to call their parents if they are ever in a situation that threatens their safety. Their parents sign a pledge to provide transportation and defer discussion for a later, calmer time. However, many parents still express alarm about such contracts, claiming they send a message that underage drinking is acceptable11.

Moderation Management

Controlled drinking as an alternative to abstinence for certain problem drinkers is reported as a viable option by some researchers. Controlled drinking research from various studies has shown that a certain percentage (usually reported to be around 18-20%) of alcoholic patients can successfully reduce their level of consumption to non-problematic levels. Furthermore, these alcoholics seemed to be at no greater risk for relapse than abstainers. However, moderation management with respect to alcoholism continues to invoke hostilities within the field of addiction medicine12. As binge-drinking morbidity and mortality remains a prominent issue on college campuses, moderation initiatives will likely continue to spark debate.

C. Tobacco-Related Programs

Tobacco use remains the leading cause of preventable death and disease in the United States. According to the Centers for Disease control, most smokers have at least some interest in quitting. However, as with most highly addictive substances, abstinence from nicotine use remains an elusive goal for many smokers. Tobacco harm reduction strategies substitute traditional smoked tobacco products with alternative sources of tobacco thought to reduce risk of tobacco-related disease. Various kinds of Potential Reduced Exposure Products (PREPs) containing tobacco are currently on the market. Many of these products are actually produced by cigarette companies themselves in response to legal action against them in recent years. Most PREPs claim to reduce the level of certain toxins, usually by using different fermentation processes or by adding chemicals. There are also products that heat rather than burn the tobacco, thereby reducing toxic combustion (e.g. Accord, Eclipse)13. Lastly, oral, non-combustible products (smokeless tobacco) offer an alternative to smoking.

From a public health standpoint, many of these PREPs are problematic, primarily because most of these products are completely unregulated. Tobacco companies are free to make claims about these products without independent scientific scrutiny. In the past, “light” cigarettes were marketed as being safer than regular cigarettes. However, we now know that there were no meaningful reductions in nicotine intake due to subtle design features (the cigarettes were designed to allow the smoker to inhale more deeply and thus negate the effects of a lower level of nicotine). Most researchers of tobacco addiction strongly believe that a regulatory agency like the Food and Drug Administration must evaluate all products if harm reduction initiatives are to succeed¹³.

In the case of chewing tobacco, the health outcome differences are clearer. Although smokeless tobacco is not risk-free, it does pose significantly less risk than smoking. For example, while smokers live roughly 6-7 years less than non-smokers, smokeless tobacco users lose only .04 years (15 days) compared to nonsmokers. While smokeless tobacco increases the risk for oral cancer, most studies show that smoking has an even higher risk. Most importantly, smokeless tobacco caries no increased risk for lung cancer or heart disease. The best case study in support of smokeless tobacco is in Sweden, where in the last 40 years a large percentage of male smokers have switched from traditional smoking to smokeless snuff products. Since then Sweden’s cancer rates, oral cancers included, have decreased and are now the lowest in Europe. By contrast, women in Sweden have not changed to smokeless tobacco in high numbers and their cancer rates remain high accordingly. Despite such data, much of the public health community, including the U.S. Surgeon General, has not supported this type of harm reduction, fearing it will prevent people from quitting tobacco use altogether¹¹.

D. Sex-Related Programs

Sex Education and Condom Distribution in Schools

The 1995 Youth Risk Survey found that 20.9% of high school males and 14.4% of high school females had had sex with 4 or more partners, yet only 54.4 % reported using condoms. Accordingly, approximately 3 million adolescents are infected with sexually transmitted diseases (STDs) each year, constituting 25% of new cases annually. One fourth of new HIV infections in the U.S. occur in those under age 22. Adolescents face many obstacles to using condoms, including access, cost, confidentiality, embarrassment and their perception that risk of infection and pregnancy is low14.

Recent increases in sexually transmitted diseases (STDs), including HIV, among teenagers in the United States have prompted communities to institute harm reduction programs to protect their youth. Among these have been sex education programs in schools that provide condoms to sexually active students. School condom availability as a public health policy is supported by many national health organizations, including the Institute of Medicine and the American Academy of Pediatrics. Comparison studies of high schools show an increase in condom use when condoms are made available in schools (50% compared to 37%). Additionally, studies have consistently shown no increase in sexual activity with this rise in condom use. Specifically, the World Health Organization review of studies on sexual education found that access to counseling and contraceptive services did not lead to earlier or increased sexual activity. This may in part be due to the fact that approximately 98% of school condom programs provide students with counseling, which includes abstinence information as well as safe sex discussions. Despite this data, many social conservatives oppose these initiatives on the premise that they undermine abstinence-only programs¹⁴.

Confidentiality and Adolescent Abortion

Approximately one million adolescents become pregnant each year in the U.S. and roughly 40% of these teens will choose an abortion. Many states require that parents of pregnant minors be notified before an abortion is performed. These laws were put into place because many parents feel they have a right to know about any significant health issues of their underage teens. However, adolescent pregnancy brought to term is associated with clear physical and mental health risks15. Because of these risks, many professional societies, including the American Medical Association, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists, oppose compulsory parental notification of teen abortions. They argue that if one service at a health clinic mandates parental notification then teens will be less likely to seek other services such as family planning. They feel this would lead to an actual increase in abortions, especially “back-alley” abortions. Likewise, such laws might discourage treatment of STDs, including HIV, which could also threaten lives16.

Prostitution

Government policies toward prostitution vary greatly around the world. In some Muslim countries prostitutes are given the death penalty, whereas in the Netherlands prostitutes are tax paying, unionized professionals. Prostitution is also legal in Australia, Germany, Switzerland and New Zealand, although most areas require licensing. In the U.S., regulated brothels are permitted in some counties in Nevada, but in the rest of the country prostitutes are considered criminals. Because of their criminal status, prostitutes are less likely to seek legal or medical help if they are harmed, making them prime targets for predators. Street prostitutes, as opposed to those in brothels or escort services, are at greatest risk of violent crime. Because the average American prostitute has 868 partners a year, they are often significant vectors in the spread of sexually transmitted diseases, including HIV. Many harm reduction advocates therefore recommend either registering prostitutes for required health checks or providing education to encourage barrier contraception and greater interaction with health care. In Australia, education campaigns have been very successful, with non-IV drug-using sex workers being among the lower HIV-risk communities there17. Criminalizing prostitution can make addressing these issues much more difficult.

E. Other Harm Reduction Strategies

DanceSafe

There are many new applications of harm reduction philosophy related to public health that are just beginning to gain attention. DanceSafe is a national program aimed at reducing the health risks associated with adverse reactions to and overdoses of Ecstasy at so-called rave parties. This program provides free testing of pills purchased at these parties to ensure purity. Critics believe these programs only encourage drug use by making the drugs seem safer1. Unfortunately, data regarding effectiveness of this program is still lacking.

Weight Management

Another initiative that is gaining new popularity is harm reduction as an alternative to dieting. The current obesity epidemic, along with the dismal track record of standard diets, has made this approach more popular with many weight management counselors in recent years. Diet protocol often mandates severe changes in food quantity and content as well as stringent exercise programs. The vast majority of people are unable to adhere to this and end up gaining more weight in the long term. Harm reductionists believe in more realistic, attainable goals that focus on changing aspects of the patients’ lifestyle that they are most able to change. They feel this empowers the patient and therefore will result in better long-term outcomes. Similarly, to prevent the negative consequences of repeated weight loss and regain (yo-yo dieting), some advocates champion weight maintenance as opposed to weight losses as the goal of such weight management programs¹⁸.

III. Conclusion

Harm reduction focuses on what and how we provide information and support to those practicing risky behaviors in our community. Although currently associated predominantly with substance abuse, harm reduction strategies can be applied to many other public health matters, as detailed in this chapter. Because harm reduction policies avoid the huge barriers to public health associated with prohibition and abstinence, they may offer more effective and sustainable alternatives. Although they continue to spark debate, many harm reduction initiatives have clearly been successful at improving public health and we should expect them to continue to play an important role in shaping public health policy in the future.

Bibliography