This report offers an overview of the evidence-based for the reduction of drug-related health harms that existed at the moment of its publication. The document is a testament to the Beckley Foundation’s pioneering work on drug policy to the extent it assessed the emerging evidence underpinning harm reduction approaches that have now been incorporated to the mainstream: heroin prescription, drug consumption rooms, needle exchange programmes and substitute prescribing. Furthermore, the publication dispelled the myths that suggested harm reduction initiatives fostered an environment encouraging higher levels of injecting drug use, instead highlighting the potential of these interventions to reduce drug-related deaths and the transmission of bloodborne diseases.
This is the fourth report in our current series analysing the effectiveness of drug policies in reducing drug use and related problems. The first report articulated our concern that the current international policy framework is not meeting its objective of significantly reducing the scale of the illicit drug market, and that the number of drug users is expanding in most regions of the world. In our second report, we argued that the way to resolve the consequent disagreements on the future direction of policy should be through an objective review of the effectiveness of current policies and programmes, and suggested a broad methodology and approach for such a review to be conducted. This report proposed six fundamental aims for drug policies, the achievement of which could be measured over time to judge whether progress was being made. We have now moved on to consider the current global evidence base for the effectiveness of specific policies and activities that are designed to impact on drug-related problems. We started this review in our third report, published in December 2004, which assessed the impact of efforts to reduce the overall scale of drug markets and drug use through supply reduction and law enforcement programmes. Having found very little evidence that these approaches can achieve significant and sustained reductions in drug use, with this report we are starting to look at policies and programmes that target specific drug-related harms, starting with efforts to reduce the health damage associated with drug use – primarily blood borne infections and overdose deaths. This report, therefore, attempts to review the current evidence for attempts to tackle these harms. Some of these activities – needle and syringe programmes, low threshold access to treatment and general health services for drug users – have become known collectively as ‘Harm Reduction’. The defining feature of harm reduction programmes is their focus on the prevention of drug-related harm rather than the prevention of drug use itself. This is not to deny that, theoretically, a reduction in use will lead to reduced harm; but it reflects a view that, while they have laudable aspirations, policies primarily intended to prevent drug use have rarely produced tangible results and have proven unable to reduce the harms with which we are concerned. However, as the Executive Director of the UN Office on Drugs and Crime, Antonio Costa, has himself pointed out, all drug policy activities aim to reduce harm. The crucial question is which of these activities are effective in achieving that aim. We need to understand whether the harms we are concerned about are most effectively tackled by attempts to reduce overall levels of use, by targeted action on the specific harmful behaviours, or by a mixture of both approaches.
CONCLUSION While the evidence base for the reduction of drug-related health harms continues to emerge – particularly on the more experimental approaches such as Heroin Prescribing or Consumption Rooms, and delivery in developing countries – there is now ample evidence that the core ‘Harm Reduction’ activities, when implemented in a timely and professional manner, have proved their worth in averting large-scale transmission of infections, and reducing death rates amongst drug users. There are also encouraging indications that the accessible provision of services such as needle exchange and substitute prescribing is an effective way to make contact with a ‘hidden’ population of drug users, stabilise their behaviour, and encourage them to take steps towards giving up their risky lifestyle. However, concerns remain that the existence, and public promotion, of these approaches create an atmosphere and environment that encourages higher levels of injecting drug use. We were not able to locate any evidence where such a link has been identified – indeed, the consensus statement issued by the WHO, UNAIDS and UNODC (2004a, 2004c) acknowledges this point specifically. We are therefore concerned that the resistance to these measures, at community and policy level, is more due to ideological unease at being ‘soft’ on drug users, rather than any objective appraisal of the evidence. The resolution of these concerns is a matter for urgent attention in those countries and regions currently facing widespread injecting drug use – national governments and international agencies need to agree effective responses to potential HIV epidemics in Central and Eastern Europe, across Asia, the Middle East and Latin America. Western European and North American countries need to develop more effective responses to HIV/AIDS, Hepatitis infection and overdose deaths. The temptation to avoid difficult policy choices now will, according to our currently accumulated knowledge, lead directly to significant avoidable loss of life, and treatment and healthcare expenditures, in the future.
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