Drugs and Society: Public Health and Harm Reduction

CJ Trowbridge

HED 315

2020-06-04

Reaction Paper: Unit 2

Reducing Drug Related Harm (Powerpoint)
- Course goal: To give participants the opportunity to examine drug-related harm, and help participants gain a basic understanding of how harm reduction principles, policy and practice work together to address that harm.
- Harm reduction is an approach that aims to reduce drug-related harm experienced by individuals and communities, without necessarily reducing the consumption of drugs.
- Racial disparities in enforcement
  - 1992: 92.6% of federal crack arrests were black.
  - 1991: 52% of those reporting crack use were white.
  - 1993: 88% of federal crack distribution convictions were black; 4.1% were white.
- Racial disparities in sentencing
  - 5 grams of crack cocaine = 5 years in prison
  - 500 grams of powder cocaine = 5 years in prison
- Drug, set, and setting
  - Drug: pharmacology
  - Set: individual drug user
  - Setting: contexts of drug us
- Continuum of drug use: Low risk -> ? -> high risk
  - Abstinence
  - Experimental
  - Occasional
  - Regular
  - Heavy
  - Chaotic
- Structural factors impact harm
  - Race
  - Class
  - Sex
  - Gender
  - Sexuality
- Types of harm
  - Physical
  - Psychological
  - Social
  - Economic
  - Legal
  - Political
- European context of harm reduction
  - Universal healthcare
  - Political pragmatism
  - Activism and inclusion
- Merseyside Model of Harm Reduction
  - HIV is a greater thread than drug use
  - Abstinence should not be the only goal
  - Reach out to users
  - Innovate with services
  - Multi-disciplinary approach
- US context for harm reduction
  - No universal healthcare
  - Cutbacks in welfare
  - Politics not science
  - Punishment instead of treatment
  - Institutional racism
- Effects of the US war on drugs
  - Lack of information
  - High opportunity costs
  - Increase in drug related harm
  - Growth of prison industrial complex
    - 5 million people incarcerated
    - 25% are for drug charges
    - 95% of the 1985-1995 prison population increase was drug related
  - Principles of Harm Reduction in the US context
    - Decision to use drugs is accepted
    - Drug users treated with dignity
    - User expected to take responsibility for their own behavior
    - Reducing harm, not consumption
    - No pre-defined outcomes
  - Growing support for harm reduction
    - Scientific evidence
    - New political leadership
    - Waning support for war on drugs
    - Frustration with the abstinence model
  - Harm reduction program elements
    - User involvement
    - Any positive change is good
    - Supportive agency policy
    - Collaborations with other providers on the continuum
  - Harm reduction in practice
    - Making contact
    - Meeting survival needs
    - Engaging
    - Holistic needs assessment
    - Focus on consumer’s own needs and goals
    - Meeting needs to reduce harm
    - Maximizing health and potential
  - Collaborative model
  - Harm Reduction Theory (pdf)
    - Abstract: This paper discusses the user side of harm reduction, focusing to some extent on the early responses to the HIV/AIDS epidemic in each of four sets of localities—New York City, Rotterdam, Buenos Aires, and sites in Central Asia. Using available qualitative and quantitative information, we present a series of vignettes about user activities in four different localities in behalf of reducing drug-related harm. Some of these activities have been micro-social (small group) activities; others have been conducted by formal organizations of users that the users organized at their own initiative. In spite of the limitations of the methodology, the data suggest that users’ activities have helped limit HIV spread. These activities are shaped by broader social contexts, such as the extent to which drug scenes are integrated with broader social networks and the way the political and economic systems impinge on drug users’ lives. Drug users are active agents in their own individual and collective behalf, and in helping to protect wider communities. Harm reduction activities and research should take note of and draw upon both the micro-social and formal organizations of users. Finally, both researchers and policy makers should help develop ways to enable and support both micro-social and formally organized action by users.
      - Drug users are active agents in their own individual and collective behalf, and in helping to protect wider communities.
      - both researchers and policy makers should help develop ways to enable and support both micro-social and formally organized action by users.
    - IHRA recommends that the term harm reduction should be understood to mean, ‘policies and programmes which attempt primarily to reduce the adverse health, social and economic consequences of mood altering substances to individuals drug users, their families and their communities.
    - We have seen users themselves as the ones with primary agency in harm reduction. It is their actions that do or do not transmit infections, do or do not result in overdoses, do or do not create problems for their neighbours.
      - Agencies like syringe exchanges can provide risk-reduction supplies, information and counselling, but users themselves – individually and in groups – take the decisive actions.
    - The authors focus on case studies of four areas and the way the presence or lack of the afore-mentioned principles of harm reduction impacted the spread of HIV and the public health response to HIV.
    - New York
      - In 1975 New York, “IDUs were living in a particularly hostile legal and sociopolitical environment… New York City government’s fiscal crisis led to the closing of many social services. Partly because of this, massive waves of arson-induced and other fires ravaged impoverished and minority areas of the city, leaving behind considerable community demoralization, overcrowding and many half-destroyed structures that became the sites of shooting galleries in which HIV spread rapidly among IDUs… During the 1980s, New York IDUs also faced increased stigmatization, incarceration rates, community hostility, and police pressure due to an enhanced Federal government “War on Drugs” and then to an emerging large-scale “crack epidemic” among poor minority youth.”
      - The public health response to the epidemic among IDUs was long-delayed and limited because: (1) New York was the “first city” to confront epidemic HIV among IDUs; (2) the massive demonization of drug users made both officials and communities slow to react, and led to opposition from higher authorities that slowed the beginning of syringe exchange for years. Opposition to syringe exchange included sections of the African-American community. Even outreach and treatment-based educational efforts for IDUs began to emerge only in 1986, and they were slow to develop.
      - A massive city-wide, semi-public illegal street market in sterile syringes began in the late 1970s and rapidly expanded in the early 1980s.
      - Had HIV incidence rates continued at the 10+ percent rates of the last years of the 1970s, HIV prevalence among IDUs would have reached levels of 70 percent or more by the time large-scale outreach began in 1987 and even higher rates by the time syringe exchange began. Luckily, this tragedy was mitigated to a degree by the grass-roots, micro-social actions of many IDUs themselves, so HIV prevalence never reached above 50 percent or, in some local areas of New York, perhaps 60 percent.
      - Starting in 1990, a group of activists that contained both current and former IDUs, members of ACT UP, and NDRI researchers on their “free time,” organized themselves and set up a number of underground syringe exchanges in several locations in the City. This created circumstances that facilitated New York State’s making them legal and then funding them later on.
    - Rotterdam
      - In 1986, the first HIV study among Rotterdam IDUs found 12 percent HIV-positive. This rate never got any higher. In Amsterdam, one hour’s drive from Rotterdam, HIV-prevalence among IDUs was already 30 percent in 1986, a figure which gradually declined to 26 percent in the second half of the nineties.
      - In the early 1980s, before HIV was known to be prevalent in the Netherlands, the Dutch government had changed its drug policy from a psycho-therapeutic and detoxification-oriented approach towards harm reduction, including large-scale methadone maintenance programmes. Absolute priority was given to keeping IDUs from penury, malnutrition, homelessness and bad health. This context was relatively supportive for self-organization of drug users. Most drug users had homes.
      - Grassroots groups rose up to meet the need for sterile needles and dissemination of information, without having to face a hostile domestic political and sociocultural landscape like that of the US.
      - By the end of the 1980s needle exchange programmes were operational in 60 Dutch cities.
    - Buenos Aires
      - The first AIDS case from injecting drug use in Argentina was diagnosed in 1985.
      - Injecting use has become a more hidden and individual practice. In many cases the IDUs do not talk about their injecting practice even with their partners. Their silence is related to the stigma that associates drug injecting with AIDS and death.
        
        In contrast to the New York “shooting galleries” where large groups used together, sharing needles.
      - Friendship groups of drug injectors in Buenos Aires reacted to HIV infections and AIDS deaths in their social networks by reducing their risk behaviours beginning in the late 1980s when they began to develop an understanding of the disease. This was well before harm reduction programmes began there in the late 1990s.
      - Harm reduction programmes began in the late 1990s in the Buenos Aires Metropolitan Area conducted by NGOs. It took several years more to involve governmental agencies in the acceptance and development of harm reduction strategies.
    - Central Asia
      - The injection-driven HIV epidemics in countries of the former Soviet Union constitute the fastest growing HIV epidemics in the world.
      - Use of homemade opiates in medicinal teas, a practice indigenous to Uzbekistan’s villages, has, since the collapse of the Soviet Union, been largely overtaken by injection of opiate preparations including heroin trafficked from Afghanistan and bound for markets in Russia and the west.
      - Unlike some other countries, Uzbekistan appeared to embrace the implementation of syringe exchange… Unfortunately government support has neither meant access to syringes nor widespread use of these trust points by injection drug users, since the creation of needle exchange was accompanied by government decree that state “narcological” (drug treatment) centers were the only ones authorized to implement the HIV prevention strategy.
      - A legacy of Soviet era psychiatry, the psychiatrist/ narcologists and the narcological dispensaries in which they work are more linked to government drug control than to health services… Paid staff are largely untrained in harm reduction, much less counselling
      - Non-governmental contributions to harm reduction are blocked by the Uzbek government’s aggressive campaign to block NGO access to bank funds, subject them to tax audits, and require foreign NGOs to prove in court that they have not exceeded the mandates of their missions. This crackdown is part of a broader government effort to prevent engagement of civil society in the public sphere with particular restrictions applied to those activities that try to fill the vacuum left by government.
      - The American notion of addiction and the moral character of abstinence, assumed to be universal and stable, do not migrate well across Central Asian borders. There is no recovery culture, nor even a stable notion of drug users, and often, no stable drug supply.
    - Perhaps most evident in this review is the fact that grassroots drug users have often acted for themselves to find ways to protect themselves and each other from HIV and other harms.
  - marlatt: come as you are (pdf)
    - The purpose of this paper is to describe what harm reduction is, how it developed, how it works, and why it is becoming a major revolutionary force in the way we respond to human problems ranging from addiction to AIDS.
    - Although, as we shall see, harm reduction has its origins in Europe, it is quickly taking hold as a middle-road alternative to the two established traditional approaches favored in this country: the moral model (War on Drugs) and the disease model of addiction.
    - The principal goal for drug policy should instead be to reduce the harms to society arising from the production, consumption, and control of drugs. Total harm (to users and the rest of society) can be expressed as the product of total use and the average harm per unit of use and thus can be lowered by reducing either component. Attention has been focused on the first; greater attention to the second would be beneficial
    - harm reduction is much more attractive. Each policy or programmatic decision is assessed for its expected impact on society. If a policy or program is expected to reduce aggregate harm it should be accepted; it is expected to increase aggregate harm, it should be rejected.
    - shifting a drug injector to a less dangerous form of drug use may be more important than persuading an occasional user of marijuana to cease consumption.
    - the purpose of the Santa Cruz program is not to “help” young people — rather, young people want to learn how to do it for them
    - much of U.S. drug policy is racist in its consequences, particularly in terms of the number of African-Americans in prison for drug offenses.
      - The minimum sentence for possession of five grams of crack cocaine (favored by African-Americans) is 5 years imprisonment-yet possession of cocaine in powder form (favored by whites) does not carry the same 5-year sentence unless possession is 500 grams (100 times as much of the same drug, cocaine).
    - Foreign visitors to Amsterdam and other major cities in the Netherlands are often struck with what appears to be a liberal and permissive approach to drugs and sex. Special “coffee shops” sell marijuana and hashish, which can be consumed in the shop or taken home. In the red light district, prostitutes can be viewed sitting in their parlor rooms along many streets, beckoning to prospective “window-shopping” clients. Prices for sexual services are fixed and condom use is mandatory. Pornography shops and “live sex” shows are predominant throughout the district, where police on bicycles patrol the streets, providing protection for both prostitutes and their customers. In another part of the city, one of several mobile vans known as the Methadone Bus is parked on a side street, servicing addicts who fine up for oral methadone, condoms, and clean hypodermic syringes (given in exchange for their “dirty” needles).
      - The Dutch being sober and pragmatic people, they opt rather for a realistic and practical approach to the drug problem than for a moralistic or over-dramatized one. The drug abuse problem should not be primarily seen as a problem of police and justice. It is essentially a matter of health and social well-being.
    - The United Kingdom pioneered the “medicalization” approach in which drug abusers can be prescribed drugs such as heroin and cocaine on a maintenance basis.
      - Although prescribing drugs for addicts fell into disfavor over the ensuing years, this policy continues to be practiced in Merseyside, England, serving the population around the city of Liverpool
    - Australia has planned a trial of providing heroin and other opiates to injecting drug users
    - American views of drug use and addiction have been based on two competing and sometimes conflicting models: the moral model and disease model. In terms of the moral model, American drug-control policy has determined that illegal drug use and/ or distribution of such drugs is a crime deserving of punishment.
      - the criminal justice system has collaborated with national drug policy makers in pursuing the “War on Drugs,” the ultimate aim of which is to foster the development of a drug-free society. The majority of federal funding for drug controls has been based on a “supply reduction” approach. Federal enforcement agencies are funded primarily to promote interdiction programs designed to reduce the supply of drugs coming into this. National, state, and city police are funded to arrest drug dealers and users alike in an attempt to further reduce the supply of drugs. As we have already noted, American courts and prisons are overcrowded with inmates convicted of drug offenses.
      - The second approach is to define addiction (e.g., alcoholism or heroin addiction) as a biological/genetic disease that requires treatment and rehabilitation. Here the emphasis is on prevention and treatment programs that focus on remediation of the individual’s desire or demand for drugs, a “demand reduction” approach. Despite the apparent contradiction between viewing the drug user as either a criminal deserving of punishment or as a sick person in need of treatment, both the supply reduction and the demand reduction models are in agreement that the ultimate aim of both approaches is to reduce and eventually eliminate the prevalence of drug use by focusing primarily on the drug user (“use reduction”).
    - Harm reduction, with its philosophical roots in pragmatism and its compatibility with a public health approach, offers a practical alternative to either the moral or disease models. Unlike proponents of the moral model, who view drug use as bad or illegal and who advocate supply reduction (via prohibition and punishment), harm reduction shifts the focus away from drug use itself to the consequences or effects of addictive behavior. Such effects are evaluated primarily in terms of whether they are harmful or helpful to the drug user and to the larger society, and not on the basis of whether the behavior itself is considered morally right or wrong. Unlike supporters of the disease model, who view addiction as a biological/genetic pathology and promote demand reduction as the primary goal of prevention and abstinence as the only acceptable goal of treatment, harm reduction offers a wide range of policies and procedures designed to reduce the harmful consequences of addictive behavior. Harm reduction accepts the practical fact that many people use drugs and engage in other high-risk behaviors and that idealistic visions of a drug-free society are unlikely to become reality.
      - Harm reduction recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm
      - Harm reduction is not anti-abstinence. Harmful effects of unsafe drug use or sexual activity can be placed along a continuum
    - Harm reduction has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “top-down “policy
      - Addiction and AIDS are problems that are so plagued with stigma and tainted with moral condemnation that individuals who suffer from these problems are often marginalized by society. Unlike other disorders such as cancer or heart disease, in which those who are afflicted or affected have formed powerful lobbying groups and “patient advocacy” societies, it is rare to find parallel advocacy groups in the addictions field.
    - Harm reduction promotes low-threshold access to services as an alternative to traditional high-threshold approaches
      - Street-outreach programs provide an example of the low-threshold approach to harm reduction.
  - We waged a war on drugs for a century: who won?
    - While Rodrigo Duterte was campaigning to be elected president of the Philippines last year, he said on many occasions that he would arrange, if elected, for people who sold or used drugs to be killed.
      - Extrajudicial killings began even before his inauguration, with victims usually shot and then drugs and guns planted to make it look like the assailants had acted in self-defence.
      - at least 9,400 people have already been killed by police and vigilantes
      - So far, with the exception of praise from the US president, Donald Trump, there has been strong international condemnation of the extrajudicial killings in the Philippines, including from Amnesty International and Human Rights Watch. The United Nations human rights council voted 45-1 to urge the Philippines to desist.
    - The unpalatable fact for policymakers everywhere is that extrajudicial killings of people who use drugs would never occur without the sanction of a global drug prohibition
    - Global drug prohibition was expected to reduce the international drug market and make it less dangerous. But this is the opposite of what happened.
      - their price fell by 80% over a quarter of a century
      - More than 100 new psychoactive drugs are identified within the EU every year
      - drug-related deaths, disease, violence and corruption have in many places increased rather than decreased
      - property crime – taking money or property without threat – has skyrocketed from the 1960s to the present day
    - In the past few years, former world leaders – and even some in office – have started calling for drug law reform
      - In the past few years, former world leaders – and even some in office – have started calling for drug law reform
      - improve treatment
      - start reducing and, where possible, eliminating sanctions for drug use and drug possession
      - regulate as much of the drug market as possible, starting with recreational cannabis
      - shrink extreme poverty, which exacerbates drug problems
    - Countries implementing at least some of these measures have seen a decrease in deaths, disease, crime and violence
    - It should not take extrajudicial killings in the Philippines in 2017 to make the world realise that global drug prohibition has turned out to be an expensive way of making a bad problem much worse.
  - Edith Springer
    - Work with street-based crack-using sex workers in New York City in aids prevention
    - Religious organizations had trouble doing outreach to these people
    - They invited Edith to develop a project to conduct this kind of outreach and harm prevention
    - Recruited six kids to be aids educators
      - Mostly volunteer, plus a small weekly stipend and a metro card
    - Discovered patterns of crack use
    - Explored positive changes that could happen
    - Expanded education
      - HIV
      - Safer drug use
      - Money management
      - Anger management
    - 30% of them quit crack, even though no one told them to
    - Instead of saying, we’re not going to provide you a meal until you stop smoking crack, they just said we’re going to provide you a meal, and the people decided to quit on their own.
    - Work is extremely important
    - 7/10 active drug users employed full-time
    - Most people who can’t handle drugs are alcohol users
    - We teach people not to use drugs but we don’t teach people how not to use drugs
    - Cultures where people don’t learn how to drink are cultures that have alcohol problems
  - staying alive
    - Insite is a place where people can go to inject safely
    - Reactionary politicians don’t like it
      - They feel that it enables addiction
    - Building relationships with drug users is key to getting them into services that can help them recover
    - Almost everyone with chaotic drug use was sexually abused as a child
    - This was a really complicated piece with a lot of examples and anecdotes that reinforced the major points.
    - There are major political forces in opposition to harm reduction
    - Success comes in small steps
  - Carl Hart: Drug Use is not the Problem
    - Goal is a nationwide shift towards liberalizing drug laws
    - Drugs aren’t the problem
      - Poverty, drug policy, lack of jobs are the problem
    - 80-90% of people who use drugs do not get addicted
    - If you provide alternatives to people, then they don’t overindulge in drugs
    - The majority of drug users maintain normal lives and don’t have a problem
    - The same 10-15% of people who use alcohol have a problem
    - People get addicted because of trauma
    - All schedule 1 drugs are defined as “no current medical use” and yet all schedule 1 drugs are currently sold by doctors for medical purposes.
    - Discussions of rat park and human replications
    - There is no absolute, abject addict, and there is no drug that reliably does that to people at large. Addiction is always a small percent of the users of any drug.
  - illegal drug classifications are based on politics, not science (pdf)
    - Illegal drugs including cocaine, heroin and cannabis should be reclassified to reflect a scientific assessment of harm, according to a report by the Global Commission on Drug Policy.
    - “The international system to classify drugs is at the core of the drug control regime – and unfortunately the core is rotten,” said Ruth Dreifuss, former president of Switzerland and chair of the commission.
    - Restrictions on milder, less harmful drugs should also be loosened, the commission said, to include “other legitimate uses”, including traditional, religious or social use. Some illegal drugs, including cocaine, heroin, cannabis and cannabis resin, were evaluated up to 30 years ago or have never been evaluated, Dreifuss said, which seriously undermines their international control.
    - “It was a political decision. According to the studies we’ve seen over past years, substances like cannabis are less harmful than alcohol,”
    - After 50 years, the war on drugs has not been won, Santos said. It had caused “more damage, more harm” to the world than a practical approach that would regulate the sale and consumption of drugs in a “good way”.