Harm reduction

Harm reduction, or harm minimization, is a range of public health policies designed to lessen the negative social and/or physical consequences associated with various human behaviors, both legal and illegal. Harm reduction policies are used to manage behaviors such as recreational drug use and sexual activity in numerous settings that range from services through to geographical regions. Critics of harm reduction typically believe that tolerating risky or illegal behaviour sends a message to the community that such behaviours are acceptable and that some of the actions proposed by proponents of harm reduction do not reduce harm over the long term.[1][2]

Needle-exchange programmes reduce the likelihood of users of heroin and other drugs sharing the syringes and using them more than once. Syringe-sharing can lead to infections such as HIV or hepatitis C, which can spread from user to user through the reuse of syringes contaminated with infected blood. Needle and syringe programme (NSP) and Opioid Substitution Therapy (OST) outlets in some settings offer basic primary health care. Supervised injection sites are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers. The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff.

Opioid replacement therapy (ORT), or opioid substitution therapy (OST), is the medical procedure of replacing an illegal opioid, such as heroin, with a longer acting but less euphoric opioid; methadone or buprenorphine are typically used and the drug is taken under medical supervision. Another approach is Heroin assisted treatment, in which medical prescriptions for pharmaceutical heroin (diacetylmorphine) are provided to heroin-dependent people. Toronto's Seaton House became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, homeless alcoholics opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities. To reduce the likelihood that street users will consume adulterated or misidentified drugs, such as MDMA, some agencies offer drug checking to reduce overdose risks.

Media campaigns inform drivers of the dangers of driving drunk. Most alcohol users are now aware of these dangers and safe ride techniques like 'designated drivers' and free taxicab programmes are reducing the number of drunk-driving accidents. Many schools now provide safer sex education to teen and pre-teen students, who may engage in sexual activity. Since some adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STIs. Since 1999 some countries have legalized prostitution, such as Germany (2002) and New Zealand (2003).

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in injecting drug users and sex-workers.[3] HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease.[3]


In the case of recreational drug use, harm reduction is put forward as a useful perspective alongside the more conventional approaches of demand and supply reduction.[5] Many advocates argue that prohibitionist laws criminalise people for suffering from a disease and cause harm; for example, by obliging drug addicts to obtain drugs of unknown purity from unreliable criminal sources at high prices, thereby increasing the risk of overdose and death.[6] The website Erowid.org collects and publishes information and first-hand experience reports about all kinds of drugs to educate (potential) drug users.

While the vast majority of harm reduction initiatives are educational campaigns or facilities that aim to reduce drug-related harm, a unique social enterprise was launched in Denmark in September 2013 to reduce the financial burden of illicit drug use for people with a drug dependence. Michael Lodberg Olsen, who was previously involved with the establishment of a drug consumption facility in Denmark, announced the founding of the Illegal magazine that will be sold by drug users in Copenhagen and the district of Vesterbro, who will be able to direct the profits from sales towards drug procurement. Olsen explained: "No one has solved the problem of drug addiction, so is it not better that people find the money to buy their drugs this way than through crime and prostitution?"[7]

Needle exchange programmes

The use of some illicit drugs can involve hypodermic needles. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, users of heroin and other drugs frequently share the syringes and use them more than once. As a result, infections such as HIV or hepatitis C can spread from user to user through the reuse of syringes contaminated with infected blood. The principles of harm reduction propose that syringes should be easily available or at least available through a needle and syringe programmes (NSP). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries users are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name.

A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour.[8] It has been shown in the many evaluations of needle-exchange programmes that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programmes have reduced HIV incidence by 33% in New Haven and 70% in New York City.[9]

The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated for a protracted time period. Research organisation the Burnet Institute completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum, City of Yarra and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. During the period between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the local government area the City of Yarra, of which Richmond and Abbotsford are parts of, 1550 syringes were collected each month from public syringe disposal bins in 2012. Furthermore, ambulance callouts for heroin overdoses were 1.5 times higher than for other Melbourne areas in the period between 2011 and 2012 (a total of 336 overdoses), and drug-related arrests in North Richmond were also three times higher than the state average. The Burnet Institute's researchers interviewed health workers, residents and local traders, in addition to observing the drug scene in the most frequented North Richmond public injecting locations.[10]

On 28 May 2013, the Burnet Institute stated in the media that it recommends 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area's drug culture continues to grow after more than ten years of intense law enforcement efforts. The Institute's research concluded that public injecting behaviour is frequent in the area and inappropriately discarding injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken open syringe disposal bins to reuse discarded injecting equipment.[11]

The British public body, the National Institute for Health and Care Excellence (NICE), introduced a new recommendation in early April 2014 due to an increase in the presentation of the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services are not advised for people under the age of 18 years, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programs. In the updated guidance, NICE recommended the provision of specialist services for "rapidly increasing numbers of steroid users", and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.[12]

Opioid substitution with a primary health care outlet

NSP and Opioid Substitution Therapy (OST) outlets in some settings also offer basic primary health care. These are known as 'targeted primary health care outlet'- as these outlets primarily target people who inject drugs and/or 'low-threshold health care outlet'- as these reduce common barriers clients often face when they try to access health care from the conventional health care outlets.[13][14] For accessing sterile injecting equipment clients frequently visit NSP outlets, and for receiving pharmacotherapy (e.g. methadone, buprenorphine) they visit OST clinics; these frequent visits are used opportunistically to offer much needed health care.[15][16] These targeted outlets have the potential to mitigate clients' perceived barriers to access to healthcare delivered in traditional settings. The provision of accessible, acceptable and opportunistic services which are responsive to the needs of this population is valuable, facilitating a reduced reliance on inappropriate and cost-ineffective emergency department care.[17][18]

Supervised injection sites

Supervised injection sites (SIS), or Drug consumption rooms (DCR), are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers.

The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programmes prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be injection drug users, but generally in Europe they don't exclude addicts who consume by other means.

The Netherlands had the first staffed injection room, although they did not operate under explicit legal support until 1996. Instead, the first center where it was legal to inject drug was in Berne, Switzerland, opened 1986. In 1994, Germany opened its first site. Although, as in the Netherlands they operated in a "gray area", supported by the local authorities and with consent from the police until the Bundestag provided a legal exemption in 2000.[19]

In Europe, Luxembourg, Spain and Norway have opened facilities after year 2000.[20] As did the two existing facilities outside Europe, with Sydney's Medically Supervised Injecting Center (MSIC) established in May 2001 as a trial and Vancouver's Insite, opened in September 2003.[21][22][23] In 2010, after a nine-year trial, the Sydney site was confirmed as a permanent public health facility.[24][25] As of late 2009 there were a total of 92 professionally supervised injection facilities in 61 cities.[20]

The European Monitoring Centre for Drugs and Drug Addiction's latest systematic review from April 2010 did not find any evidence to support concerns that DCR might "encourage drug use, delay treatment entry or aggravate problems of local drug markets."[20] Jürgen Rehm and Benedikt Fischer explained that while evidence show that DCR are successful, that "interpretation is limited by the weak designs applied in many evaluations, often represented by the lack of adequate control groups." Concluding that this "leaves the door open for alternative interpretations of data produced and subsequent ideological debate."[26]

The EMCDDA review noted that research into the effects of the facilities "faces methodological challenges in taking account of the effects of broader local policy or ecological changes", still they concluded "that the facilities reach their target population and provide immediate improvements through better hygiene and safety conditions for injectors." Further that "the availability of safer injecting facilities does not increase levels of drug use or risky patterns of consumption, nor does it result in higher rates of local drug acquisition crime." While its usage is "associated with self-reported reductions in injecting risk behaviour such as syringe sharing, and in public drug use" and "with increased uptake of detoxification and treatment services."[20] However, "a lack of studies, as well as methodological problems such as isolating the effect from other interventions or low coverage of the risk population, evidence regarding DCRs—while encouraging—is insufficient for drawing conclusions with regard to their effectiveness in reducing HIV or hepatitis C virus (HCV) incidence." Concluding with that "there is suggestive evidence from modelling studies that they may contribute to reducing drug-related deaths at a city level where coverage is adequate, the review-level evidence of this effect is still insufficient."[20]

Critics of this intervention, such as drug prevention advocacy organisations, Drug Free Australia and Real Women of Canada[25][27][28] point to the most rigorous evaluations,[29] those of Sydney and Vancouver. Two of the centers, in Sydney, Australia and Vancouver, British Columbia, Canada cost $2.7 million[30] and $3 million per annum to operate respectively,[31] yet Canadian mathematical modeling, where there was caution about validity, indicated just one life saved from fatal overdose per annum for Vancouver,[32][33] while the Drug Free Australia analysis demonstrates the Sydney facility statistically takes more than a year to save one life.[34] The Expert Advisory Committee of the Canadian Government studied claims by journal studies for reduced HIV transmission by Insite but "were not convinced that these assumptions were entirely valid."[32] The Sydney facility showed no improvement in public injecting and discarded needles beyond improvements caused by a coinciding heroin drought,[35] while the Vancouver facility had an observable impact.[32] Drug dealing and loitering around the facilities were evident in the Sydney evaluation,[36] but not evident for the Vancouver facility.[32]

United States

In the United States, efforts to open up Supervised Injection Sites (SIS, also called Safe Injection Sites) are now underway, although the legality of SIS is still questionable and very controversial. Currently, federal law does not explicitly define whether SIS are legal or not, which leaves the issue of legality open to interpretation.[37] Although still a gray area, some clauses of the federal Controlled Substances Act (CSA) may threaten the very core of its existence. Section 856 of the CSA states that:

“It shall be unlawful to… manage or control any place… and knowingly and intentionally… make available for use… the place for the purpose of unlawfully manufacturing, storing, distributing, or using a controlled substance”.[38]

Currently, there are no official, state-sanctioned Supervised Injection Sites operating in the United States, but many cities are working on gaining approval.[39] In January 2017, a bill was introduced in favor of legalizing Safe Injection Sites in California. In the bill, Assemblywoman Susan Eggman sought for the authorization of these facilities, otherwise known as "drug consumption programs", in various cities/ counties across California, including Los Angeles and San Francisco. Although the bill passed through the Assembly and various committees, it failed by 2 votes on the Senate Floor.[40] In Washington, similar efforts were made to open up these facilities in Seattle and King County,[41] but were also met with strong opposition. In January 2017, Senator Mark Miloscia proposed a bill to essentially ban Supervised Injection Sites in Washington.[42] Despite political resistance through failed legislation, there still persists a strong movement across major U.S. cities to legalize these sites.

Existing laws and their vagueness hinder efforts toward legalizing SIS in the United States. For instance, the CSA deems drug possession and management of areas utilized for drug consumption illegal.[37] With the legality of SIS in question, facilities offering similar and/or underground services operate in the United States.[43][44] In Boston, the Supportive Place for Observation and Treatment (SPOT) program does not allow drug use on site, but practices harm reduction strategies. SPOT provides a space for intoxicated individuals to seek medical care, education, and support.[45] In September 2014, a social service agency developed an underground SIS to evaluate the impact and feasibility of implementing SIS in the United States. With a drug injection room and an adjacent room for post-injection monitoring, this underground SIS closely follows the models of SIS in European countries.[46] Though there are no legally sanctioned SIS in the United States, underground SIS and harm reduction programs currently provide services to prevent health consequences associated with injection drug use.[43]

While legislative efforts have been made to legalize and implement SIS for harm reduction, it remains a controversial issue and has been met with protests and petitions from the opposition. In Washington, critics pushed for the passage of Initiative-27 which would ban the public funding of SIS in King County, but was subsequently ruled in the King County Superior Court as an infringement on the authority of the King County Board of Health.[47] Opponents of the facilities argued that implementation of SIS would contradict the goal of preventing substance abuse.[48] Other opposition groups in California took issue with the liability involved if an overdose were to occur, unsure if the patient or the healthcare staff would be responsible.[49] In both San Francisco and Seattle, residents were most concerned about the location of SIS, afraid that the facility would increase crime rates in the surrounding area.[50] Due to these and other opposing viewpoints, legislative efforts to implement SIS in the United States have been a slow progression.

In response to a movement in the United States supporting the opening of SIS, states such as New Mexico[51] and cities including Seattle,[52] San Francisco,[53] Ithaca,[54] New York City,[55] and Philadelphia[56] have convened task forces to study the feasibility and impact of these sites and to make recommendations. Many of these efforts have been part of larger harm reduction programs focused on reducing prescription opiate and heroin abuse. As part of their evaluation, San Francisco considered the healthcare impact on its citizens, such as lives saved, hospital stays, and cases of HIV and hepatitis C. They concluded that SIS would potentially decrease these factors annually. The city also conducted surveys and focus groups to gather opinion from residents and business owners on these facilities. Over half of survey respondents and focus group participants supported SIS. Benefits such as reductions in drug usage, drug overdoses, and spread of disease were identified, in addition to concerns including non-usage of SIS and increased crime in the neighborhood. A cost-benefit analysis of a supervised injection site there has been completed and suggests that one SIS could result in savings of $3.5 million U.S. dollars annually, primarily due to lower medical costs.[57] Elsewhere, harm reduction coalitions, academic public health researchers, nonprofit organizations, and professional medical societies have made contributions to understanding the roles of these facilities in harm reduction. In Baltimore researchers at Johns Hopkins University published a report commissioned by the Abell Foundation with their recommendations for opening two facilities in the city.[58] In Boston the Massachusetts Medical Society adopted a resolution supporting a pilot program led by the state to examine the impact of these sites on lives saved.[59]

Opioid replacement therapy (ORT)

Opioid replacement therapy (ORT), or opioid substitution therapy (OST), is the medical procedure of replacing an illegal opioid, such as heroin, with a longer acting but less euphoric opioid; methadone or buprenorphine are typically used and the drug is taken under medical supervision.[60] Some formulations of buprenorphine incorporate the opiate antagonist naloxone during the production of the pill form to prevent people from crushing the tablets and injecting them, instead of using the sublingual (under the tongue) route of administration.[60]

In some countries, such as Switzerland, Austria, and Slovenia, patients may be treated with slow-release morphine when methadone is deemed inappropriate due to the individual's circumstances. In Germany, dihydrocodeine has been used off-label in ORT for many years, however it is no longer frequently prescribed for this purpose. Extended-release dihydrocodeine is again in current use in Austria for this reason. Research into the usefulness of piritramide, extended-release hydromorphone (including polymer implants lasting up to 90 days), dihydroetorphine and other drugs for ORT is at various stages in a number of countries.[60]

The driving principle behind ORT is the program's capacity to facilitate a resumption of stability in the user's life, while they experience reduced symptoms of withdrawal symptoms and less intense drug cravings; however, a strong euphoric effect is not experienced as a result of the treatment drug.[60] In some countries (not the US, UK, Canada, or Australia),[60] regulations enforce a limited time period for people on ORT programs that conclude when a stable economic and psychosocial situation is achieved. (Patients suffering from HIV/AIDS or Hepatitis C are usually excluded from this requirement.) In practice, 40–65% of patients maintain complete abstinence from opioids while receiving opioid replacement therapy, and 70–95% are able to reduce their use significantly, while experiencing a concurrent elimination or reduction in medical (improper diluents, non-sterile injecting equipment), psychosocial (mental health, relationships), and legal (arrest and imprisonment) issues that can arise from the use of illicit opioids.[60]

Heroin maintenance programmes

Providing medical prescriptions for pharmaceutical heroin (diacetylmorphine) to heroin-dependent people has been employed in some countries to address problems associated with the illicit use of the drug, as potential benefits exist for the individual and broader society. Evidence has indicated that this form of treatment can greatly improve the health and social circumstances of participants, while also reducing costs incurred by criminalisation, incarceration and health interventions.[61][62]

In Switzerland, heroin assisted treatment is an established programme of the national health system. Several dozen centres exist throughout the country and heroin-dependent people can administer heroin in a controlled environment at these locations. The Swiss heroin maintenance programme is generally regarded as a successful and valuable component of the country's overall approach to minimising the harms caused by illicit drug use.[63] In a 2008 national referendum, a majority of 68 per cent voted in favour of continuing the Swiss programme.[64]

The Netherlands has studied medically supervised heroin maintenance.[65] A German study of long-term heroin addicts demonstrated that diamorphine was significantly more effective than methadone in keeping patients in treatment and in improving their health and social situation.[66] Many participants were able to find employment, some even started a family after years of homelessness and delinquency.[67][68] Since then, treatment had continued in the cities that participated in the pilot study, until heroin maintenance was permanently included into the national health system in May 2009.[69]

A heroin maintenance programme has existed in the United Kingdom (UK) since the 1920s, as drug addiction was seen as an individual health problem. Addiction to opiates was rare in the 1920s and was mostly limited to either middle-class people who had easy access due to their profession, or people who had become addicted as a side effect of medical treatment. In the 1950s and 1960s a small number of doctors contributed to an alarming increase in the number of drug-addicted people in the U.K. through excessive prescribing—the U.K. switched to more restrictive drug legislation as a result.[70] However, the British government is again moving towards a consideration of heroin prescription as a legitimate component of the National Health Service (NHS). Evidence has clearly shown that methadone maintenance is not appropriate for all opioid-dependent people and that heroin is a viable maintenance drug that has shown equal or better rates of success.[71]

A committee appointed by the Norwegian government completed an evaluation of research reports on heroin maintenance treatment that were available internationally. In 2011 the committee concluded that the presence of numerous uncertainties and knowledge gaps regarding the effects of heroin treatment meant that it could not recommend the introduction of heroin maintenance treatment in Norway.[72]

The first, and only, North American heroin maintenance project is being run in Vancouver, B.C. and Montreal, Quebec. Currently, over 80 long-term heroin addicts who have not been helped by available treatment options are taking part in the North American Opiate Medication Initiative (NAOMI) trials. However, critics have alleged that the control group gets unsustainably low doses of methadone, making them prone to fail and thus rigging the results in favor of heroin maintenance.[73]

Critics of heroin maintenance programmes object to the high costs of providing heroin to users. The British heroin study cost the British government £15,000 per participant per year, roughly equivalent to average heroin user's expense of £15,600 per year.[74] Drug Free Australia[75] contrast these ongoing maintenance costs with Sweden's investment in, and commitment to, a drug-free society where a policy of compulsory rehabilitation of drug addicts is integral, which has yielded the one of the lowest reported illicit drug use levels in the developed world,[76] a model in which successfully rehabilitated users present no further maintenance costs to their community, as well as reduced ongoing health care costs.[75]

A substantial part of the money for buying heroin is obtained through criminal activities, such as robbery or drug dealing. King's Health Partners notes that the cost of providing free heroin for a year is about one-third of the cost of placing the user in prison for a year.[77][78]

Naloxone distribution

Naloxone is a drug used to counter an overdose from the effect of opioids; for example, a heroin or morphine overdose. Naloxone displaces the opioid molecules from the brain's receptors and reverses the respiratory depression caused by an overdose within two to eight minutes.[79] The World Health Organization (WHO) includes naloxone on their "List of Essential Medicines", and recommends its availability and utilization for the reversal of opioid overdoses.[80][81]

Formal programs in which the opioid inverse agonist drug naloxone is distributed have been trialled and implemented. Established programs distribute naloxone, as per WHO's minimum standards, to drug users and their peers, family members, police, prisons, and others. These treatment programs and harm reduction centres operate in Afghanistan, Australia, Canada, China, Germany, Georgia, Kazakhstan, Norway, Russia, Spain, Tajikistan, the United Kingdom (UK), the United States (US), Vietnam,[82] India, Thailand, Kyrgyzstan,[83] Denmark and Estonia.[84]

United States

Officers in Quincy, Massachusetts, US began carrying the nasal spray form of the drug in October 2010, following the completion of a Department of Public Health pilot program, in which naloxone was distributed to friends and families of opiate users, in 2007. Quincy officers have administered the drug 221 times and reversed 211 overdoses since the commencement of the initiative. Espanola Valley, New Mexico and Ocean County, New Jersey police officers then followed the Quincy example in 2013. Quincy mayor Thomas Koch explained in early 2014: "It's easy for the cynical person to say, 'Oh, they're druggies, they're junkies, let them die. But when you put a name and a face and a family to that, then it's a different story. Some people who go down this road will never come back, but if we can bring them back, there's always hope."[85]

Following the use of the nasal spray device by police officers on Staten Island in New York, an additional 20,000 police officers will begin carrying naloxone in mid-2014. The state's Office of the Attorney General will provide US$1.2 million to supply nearly 20,000 kits and Police Commissioner William Bratton said: "Naloxone gives individuals a second chance to get help".[86]

Some harm reduction programs distribute Naloxone kits to people who use opioids and their friends and families to prevent overdose deaths. The distribution of Naloxone and public education by harm reduction programs has been shown to increase the survival rate for opioid users that experience an overdose.[87]


In March 2013, trial programs commenced in the Australian states of New South Wales (NSW) and the Australian Capital Territory (ACT).[88] Following the publication of its position statement on the peer-based distribution and administration of naloxone in August 2013,[89] Harm Reduction Victoria, based in the Australian state of Victoria, commenced training workshops with drug users on the administration of naloxone in the event of an opiate overdose. During the week beginning March 3, 2014, 19 workshops had been completed by HRV and 156 drug users had been provided with naloxone, paid for by community health agencies.[90]


Specific harms associated with cannabis include increased accident-rate while driving under intoxication, dependence, psychosis, detrimental psychosocial outcomes for adolescent users and respiratory disease.[91] Some safer cannabis usage campaigns including the UKCIA (United Kingdom Cannabis Internet Activists) encourage methods of consumption shown to cause less physical damage to a users body, including oral (eating) consumption, vaporization, the usage of bongs which cool and to some extent filters the smoke, and smoking the cannabis without mixing it with tobacco.

The fact that cannabis possession carries prison sentences in most developed countries is also pointed out as a problem by European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), as the consequences of a conviction for otherwise law-abiding users arguably is more harmful than any harm from the drug itself. For example, by adversely affecting employment opportunities, impacting civil rights,[92] and straining personal relationships.[93] Some people like Ethan Nadelmann of the Drug Policy Alliance have suggested that organized marijuana legalization would encourage safe use and reveal the factual adverse effects from exposure to this herb's individual chemicals.[94]

The way the laws concerning cannabis are enforced is also very selective, even discriminatory. Statistics show that the socially disadvantaged, immigrants and ethnic minorities have significantly higher arrest rates.[93] Drug decriminalisation, such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, would alleviate these harms.[93] Where decriminalisation has been implemented, such as in several states in Australia and United States, as well as in Portugal and the Netherlands no, or only very small adverse effects have been shown on population cannabis usage rate.[93] The lack of evidence of increased use indicates that such a policy shift does not have adverse effects on cannabis-related harm while, at the same time, decreasing enforcement costs.[93]

In the last few years certain strains of the cannabis plant with higher concentrations of THC and drug tourism have challenged the former policy in the Netherlands and led to a more restrictive approach; for example, a ban on selling cannabis to tourists in coffeeshops suggested to start late 2011.[95] Sale and possession of cannabis is still illegal in Portugal[96] and possession of cannabis is a federal crime in the United States.


Traditionally, homeless shelters ban alcohol. In 1997, as the result of an inquest into the deaths of two homeless alcoholics two years earlier, Toronto's Seaton House became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, homeless alcoholics opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities. The programme has been duplicated in other Canadian cities, and a study of Ottawa's "wet shelter" found that emergency room visit and police encounters by clients were cut by half.[97] The study, published in the Canadian Medical Association Journal in 2006, found that serving chronic street alcoholics controlled doses of alcohol also reduced their overall alcohol consumption. Researchers found that programme participants cut their alcohol use from an average of 46 drinks a day when they entered the programme to an average of 8 drinks and that their visits to emergency rooms dropped from 13.5 to an average of 8 per month, while encounters with the police fall from 18.1 to an average of 8.8.[98][99]

Downtown Emergency Service Center (DESC), in Seattle, Washington, operates several Housing First programmes which utilize the harm reduction model. University of Washington researchers, partnering with DESC, found that providing housing and support services for homeless alcoholics costs taxpayers less than leaving them on the street, where taxpayer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation[100] appeared in the Journal of the American Medical Association in April 2009.[101] This first controlled assessment in the U.S. of the effectiveness of Housing First, specifically targeting chronically-homeless alcoholics, showed that the programme saved taxpayers more than $4 million over the first year of operation. During the first six months, the study reported an average cost-savings of 53 percent (even after considering the cost of administering the housing's 95 residents)—nearly $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among homeless alcoholics.

A high amount of media coverage exists informing users of the dangers of driving drunk. Most alcohol users are now aware of these dangers and safe ride techniques like 'designated drivers' and free taxicab programmes are reducing the number of drunk-driving accidents. Many cities have free-ride-home programmes during holidays involving high alcohol abuse, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In New South Wales groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programmes including the aforementioned 'designated driver' and 'late night patron transport' schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.

Moderation Management is a programme which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behaviour.

The HAMS Harm Reduction Network is a programme which encourages any positive change with regard to the use of alcohol or other mood altering substances. HAMS encourages goals of safer drinking, reduced drinking, moderate drinking, or abstinence. The choice of the goal is up to the individual.

Harm reduction in alcohol dependency could be instituted by use of naltrexone.[102]


Tobacco harm reduction describes actions taken to lower the health risks associated with using tobacco, especially combustible forms, without abstaining completely from tobacco and nicotine. Some of these measures include switching to safer (lower tar) cigarettes, switching to snus or dipping tobacco, or using a non-tobacco nicotine delivery systems. In recent years, the growing use of electronic cigarettes for smoking cessation, whose long-term safety remains uncertain, has sparked an ongoing controversy among medical and public health between those who seek to restrict and discourage all use until more is known and those who see them as a useful approach for harm reduction, whose risks are most unlikely to equal those of smoking tobacco.[103] "Their usefulness in tobacco harm reduction as a substitute for tobacco products is unclear,[104] but in an effort to decrease tobacco related death and disease, they have a potential to be part of the strategy.[105]

It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, there is a considerable population of inveterate smokers who are unable or unwilling to achieve abstinence. Harm reduction may be of substantial benefit to these individuals.


The Zendo Project conducted by the Multidisciplinary Association for Psychedelic Studies uses principles from psychedelic therapy to provide safe places and emotional support for people having difficult experiences on psychedelic drugs at select festivals such as Burning Man, Boom Festival, and Lightning in a Bottle without medical or law enforcement intervention.[106]

Drugs such as MDMA (commonly sold by the slang names "ecstasy" and "molly") are often adulterated. One harm reduction approach is drug checking, where people intending to use drugs can have their substances tested for content and purity so that they can then make more informed decisions about safer consumption. European organisations have offered drug checking services since 1992 and these services now operate in over twenty countries. As an example, the nonprofit organization DanceSafe offers on-site testing of the contents of pills and powders at various electronic music events around the US. They also sell kits for users to test the contents of drugs themselves. PillReports.com invites ecstasy users to send samples of drugs for laboratory testing and publishes the results online.


Safer sex programmes

Many schools now provide safer sex education to teen and pre-teen students, who may engage in sexual activity. Since some adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STIs. This runs contrary to abstinence-only sex education, which teaches that educating children about sex can encourage them to engage in it.

These programmes have been found to decrease risky sexual behaviour and prevent sexually transmitted diseases.[107] They also reduce rates of unwanted pregnancies.[108] Abstinence only programmes do not appear to affect HIV risks in developed countries with no evidence available for other areas.[109]

Legalized prostitution

Since 1999 some countries have legalized prostitution, such as Germany (2002) and New Zealand (2003). However, in most countries the practice is prohibited. Gathering accurate statistics on prostitution and human trafficking is extremely difficult. This has resulted in proponents of legalization claiming that it reduces organized crime rates while opponents claim exactly the converse. The Dutch prostitution policy, which is one of the most liberal in the world, has gone back and forth on the issue several times. In the period leading up to 2015 up to a third of officially sanctioned work places had been closed down again after reports of human trafficking. Prostitutes themselves are generally opposed to what they see as "theft of their livelihood"[110]

Sex work and HIV

Despite the depth of knowledge of HIV/AIDS, rapid transmission has occurred globally in sex workers.[9] The relationship between these two variables greatly increases the risk of transmission among these populations, and also to anyone associated with them, such as their sexual partners, their children, and eventually the population at large.[9]

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in injecting drug users and sex-workers.[3] HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease.[3] Peer education as a harm reduction strategy has especially reduced the risk of HIV infection, such as in Chad, where this method was the most cost-effective per infection prevented.[3]


The threat of criminal repercussions drives sex-workers and injecting drug users to the margins of society, often resulting in high-risk behaviour, increasing the rate of overdose, infectious disease transmission, and violence.[111] Decriminalisation as a harm-reduction strategy gives the ability to treat drug abuse solely as a public health issue rather than a criminal activity. This enables other harm-reduction strategies to be employed, which results in a lower incidence of HIV infection.[3]

Psychiatric medications

With the growing concern about psychiatric medication adverse effects and long-term dependency, peer-run mental health groups Freedom Center and The Icarus Project published the Harm Reduction Guide to Coming Off Psychiatric Drugs. The self-help guide provides patients with information to help assess risks and benefits, and to prepare to come off, reduce, or continue medications when their physicians are unfamiliar with or unable to provide this guidance. The guide is in circulation among mental health consumer groups and has been translated into ten languages.[112]


Critics, such as Drug Free America Foundation and other members of network International Task Force on Strategic Drug Policy, state that a risk posed by harm reduction is by creating the perception that certain behaviours can be partaken of safely, such as illicit drug use, that it may lead to an increase in that behaviour by people who would otherwise be deterred. The signatories of the drug prohibitionist network International Task Force on Strategic Drug Policy stated that they oppose drug use harm reduction "...strategies as endpoints that promote the false notion that there are safe or responsible ways to use drugs. That is, strategies in which the primary goal is to enable drug users to maintain addictive, destructive, and compulsive behavior by misleading users about some drug risks while ignoring others."[113]

In 2008, the World Federation Against Drugs stated that while "...some organizations and local governments actively advocate the legalization of drugs and promote policies such as "harm reduction" that accept drug use and do not help drug users to become free from drug abuse. This undermines the international efforts to limit the supply of and demand for drugs." The Federation states that harm reduction efforts often end up being "drug legalization or other inappropriate relaxation efforts, a policy approach that violates the UN Conventions."[114]}}

Critics furthermore reject harm reduction measures for allegedly trying to establish certain forms of drug use as acceptable in society. The Drug Prevention Network of Canada states that harm reduction has "...come to represent a philosophy in which illicit substance use is seen as largely unpreventable, and increasingly, as a feasible and acceptable lifestyle as long as use is not 'problematic'", an approach which can increase "acceptance of drug use into the mainstream of society". They say harm reduction "...sends the wrong message to...children and youth" about drug use.[115] In 2008, the Declaration of World Forum Against Drugs criticized harm reduction policies that "...accept drug use and do not help drug users to become free from drug abuse", which the group say undermines "...efforts to limit the supply of and demand for drugs." They state that harm reduction should not lead to less efforts to reduce drug demand.[116]

Pope Benedict XVI criticised harm reduction policies with regards to HIV/AIDS, saying that it was "a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems".[117] This position was in turn widely criticised for misrepresenting and oversimplifying the role of condoms in preventing infections.[118][119]

Neil Hunt's article entitled "A review of the evidence-base for harm reduction approaches to drug use" examines the criticisms of harm reduction, which include claims that it is not effective; that it prevents addicts from "hitting a rock bottom" thus trapping them in addiction; that it encourages drug use; that harm reduction is a Trojan horse strategy for "drug law reform" such as drug legalization.[120]

See also


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