Drugs Harm reduction

1 drugs

1.1 needle exchange programmes
1.2 targeted , low-threshold primary health care outlet
1.3 supervised injection sites

1.3.1 united states


1.4 opioid replacement therapy (ort)
1.5 heroin maintenance programmes
1.6 naloxone distribution

1.6.1 united states
1.6.2 australia


1.7 cannabis
1.8 alcohol
1.9 alcohol-related programmes
1.10 tobacco
1.11 psychedelics

drugs

in case of recreational drug use, harm reduction put forward useful perspective alongside more conventional approaches of demand , supply reduction. many advocates argue prohibitionist laws criminalise people suffering disease , cause harm; example, obliging drug addicts obtain drugs of unknown purity unreliable criminal sources @ high prices, thereby increasing risk of overdose , death. website erowid.org collects , publishes information , first-hand experience reports kinds of drugs educate (potential) drug users.

while vast majority of harm reduction initiatives educational campaigns or facilities aim reduce drug-related harm, unique social enterprise launched in denmark in september 2013 reduce financial burden of illicit drug use people drug dependence. michael lodberg olsen, involved establishment of drug consumption facility in denmark, announced founding of illegal magazine sold drug users in copenhagen , district of vesterbro, able direct profits sales towards drug procurement. olsen explained: no 1 has solved problem of drug addiction, not better people find money buy drugs way through crime , prostitution?

needle exchange programmes

a bin allowing safe disposal of needles in public toilet in caernarfon, wales.

the use of illicit drugs can involve hypodermic needles. in areas (notably in many parts of us), these available solely prescription. availability limited, users of heroin , other drugs share syringes , use them more once. result, infections such hiv or hepatitis c can spread user user through reuse of syringes contaminated infected blood. principles of harm reduction propose syringes should available or @ least available through needle , syringe programmes (nsp). syringes provided in sufficient quantities, rates of hiv lower in places supply restricted. in many countries users supplied equipment free of charge, others require payment or exchange of dirty needles clean ones, hence name.

a 2010 review found insufficient evidence nsp prevents transmission of hepatitis c virus, tentative evidence prevents transmission of hiv , sufficient evidence reduces self-reported injecting risk behaviour. has been shown in many evaluations of needle-exchange programmes in areas clean syringes more available, illegal drug use no higher in other areas. needle exchange programmes have reduced hiv incidence 33% in new haven , 70% in new york city.

the melbourne, australia inner-city suburbs of richmond , abbotsford locations in use , dealing of heroin has been concentrated protracted time period. research organisation burnet institute completed 2013 north richmond public injecting impact study in collaboration yarra drug , health forum, city of yarra , north richmond community health centre , recommended 24-hour access sterile injecting equipment due ongoing widespread, frequent , highly visible nature of illicit drug use in areas. during period between 2010 , 2012 four-fold increase in levels of inappropriately discarded injecting equipment documented 2 suburbs. in local government area city of yarra, of richmond , abbotsford parts of, 1550 syringes collected each month public syringe disposal bins in 2012. furthermore, ambulance callouts heroin overdoses 1.5 times higher other melbourne areas in period between 2011 , 2012 (a total of 336 overdoses), , drug-related arrests in north richmond 3 times higher state average. burnet institute s researchers interviewed health workers, residents , local traders, in addition observing drug scene in frequented north richmond public injecting locations.

on 28 may 2013, burnet institute stated in media recommends 24-hour access sterile injecting equipment in melbourne suburb of footscray after area s drug culture continues grow after more ten years of intense law enforcement efforts. institute s research concluded public injecting behaviour frequent in area , inappropriately discarding injecting paraphernalia has been found in carparks, parks, footpaths , drives. furthermore, people inject drugs have broken open syringe disposal bins reuse discarded injecting equipment.

the british public body, national institute health , care excellence (nice), introduced new recommendation in april 2014 due increase in presentation of number of young people inject steroids @ uk needle exchanges. nice published needle exchange guidelines in 2009, in needle , syringe services not advised people under age of 18 years, organisation s director professor mike kelly explained different group of people presenting @ programs. in updated guidance, nice recommended provision of specialist services rapidly increasing numbers of steroid users , , needles should provided people under age of 18—a first nice—following reports of 15-year-old steroid injectors seeking develop muscles.

targeted , low-threshold primary health care outlet

nsp , opioid substitution therapy (ost) outlets in settings offer basic primary health care. these known targeted primary health care outlet - these outlets target people inject drugs and/or low-threshold health care outlet - these reduce common barriers clients face when try access health care conventional health care outlets. accessing sterile injecting equipment clients visit nsp outlets, , receiving pharmacotherapy (e.g. methadone, buprenorphine)they visit ost clinics; these frequent visits used opportunistically offer needed health care. these targeted outlets have potential mitigate clients perceived barriers access healthcare delivered in traditional settings. provision of accessible, acceptable , opportunistic services responsive needs of population valuable, facilitating reduced reliance on inappropriate , cost-ineffective emergency department care.

supervised injection sites

a clandestine kit containing materials inject illicit drugs (or legitimate ones illegitimately).



injection kit obtained needle-exchange programme.

supervised injection sites (sis), or drug consumption rooms (dcr), legally sanctioned, medically supervised facilities designed address public nuisance associated drug use , provide hygienic , stress-free environment drug consumers.

the facilities provide sterile injection equipment, information drugs , basic health care, treatment referrals, , access medical staff. offer counseling, hygienic , other services of use itinerant , impoverished individuals. programmes prohibit sale or purchase of illegal drugs. many require identification cards. restrict access local residents , apply other admission criteria, such have injection drug users, in europe don t exclude addicts consume other means.

the netherlands had first staffed injection room, although did not operate under explicit legal support until 1996. instead, first center legal inject drug in berne, switzerland, opened 1986. in 1994, germany opened first site. although, in netherlands operated in gray area , supported local authorities , consent police until bundestag provided legal exemption in 2000.

in europe, luxembourg, spain , norway have opened facilities after year 2000. did 2 existing facilities outside europe, sydney s medically supervised injecting center (msic) established in may 2001 trial , vancouver s insite, opened in september 2003. in 2010, after nine-year trial, sydney site confirmed permanent public health facility. of late 2009 there total of 92 professionally supervised injection facilities in 61 cities.

the european monitoring centre drugs , drug addiction s latest systematic review april 2010 did not find evidence support concerns dcr might encourage drug use, delay treatment entry or aggravate problems of local drug markets. jürgen rehm , benedikt fischer explained while evidence show dcr successful, interpretation limited weak designs applied in many evaluations, represented lack of adequate control groups. concluding leaves door open alternative interpretations of data produced , subsequent ideological debate.

the emcdda review noted research effects of facilities faces methodological challenges in taking account of effects of broader local policy or ecological changes , still concluded facilities reach target population , provide immediate improvements through better hygiene , safety conditions injectors. further facilitates not increase levels of drug use or risky patterns of consumption, nor result in higher rates of local drug acquisition crime. while usage associated self-reported reductions in injecting risk behaviour such syringe sharing, , in public drug use , increased uptake of detoxification , treatment services. however, lack of studies, methodological problems such isolating effect other interventions or low coverage of risk population, evidence regarding dcrs — while encouraging — insufficient drawing conclusions regard effectiveness in reducing hiv or hepatitis c virus (hcv) incidence. concluding there suggestive evidence modelling studies may contribute reducing drug-related deaths @ city level coverage adequate, review-level evidence of effect still insufficient.

critics of intervention, such drug prevention advocacy organisations, drug free australia , real women of canada point rigorous evaluations, of sydney , vancouver. 2 of centers, in sydney, australia , vancouver, british columbia, canada cost $2.7 million , $3 million per annum operate respectively, yet canadian mathematical modeling, there caution validity, indicated 1 life saved fatal overdose per annum vancouver, while drug free australia analysis demonstrates sydney facility statistically takes more year save 1 life. expert advisory committee of canadian government studied claims journal studies reduced hiv transmission insite not convinced these assumptions entirely valid. sydney facility showed no improvement in public injecting , discarded needles beyond improvements caused coinciding heroin drought, while vancouver facility had observable impact. drug dealing , loitering around facilities evident in sydney evaluation, not evident vancouver facility.

united states

in united states, efforts open supervised injection sites (sis, called safe injection sites) underway, although legality of sis still questionable , controversial. currently, federal law not explicitly define whether sis legal or not, leaves issue of legality open interpretation.  although still gray area, clauses of federal controlled substances act (csa) may threaten core of existence.  section 856 of csa states that:

“it shall unlawful to… manage or control place… , knowingly , intentionally… make available use… place purpose of unlawfully manufacturing, storing, distributing, or using controlled substance”.

currently, there no official, state-sanctioned supervised injection sites operating in united states, many cities working on gaining approval. in january 2017, bill introduced in favor of legalizing safe injection sites in california. in bill, assemblywoman susan eggman sought authorization of these facilities, otherwise known drug consumption programs , in various cities/ counties across california, including los angeles , san francisco. although bill passed through assembly , various committees, failed 2 votes on senate floor. in washington, similar efforts made open these facilities in seattle , king county, met strong opposition. in january 2017, senator mark miloscia proposed bill ban supervised injection sites in washington. despite political resistance through failed legislation, there still persists strong movement across major u.s. cities legalize these sites.

existing laws , vagueness hinder efforts toward legalizing sis in united states. instance, csa deems drug possession , management of areas utilized drug consumption illegal. legality of sis in question, facilities offering similar and/or underground services operate in united states. in boston, supportive place observation , treatment (spot) program not allow drug use on site, practices harm reduction strategies. spot provides space intoxicated individuals seek medical care, education, , support. in september 2014, social service agency developed underground sis evaluate impact , feasibility of implementing sis in united states. drug injection room , adjacent room post-injection monitoring, underground sis closely follows models of sis in european countries. though there no legally sanctioned sis in united states, underground sis , harm reduction programs provide services prevent health consequences associated injection drug use.

while legislative efforts have been made legalize , implement sis harm reduction, remains controversial issue , has been met protests , petitions opposition.  in washington, critics pushed passage of initiative-27 ban public funding of sis in king county, subsequently ruled in king county superior court infringement on authority of king county board of health. opponents of facilities argued implementation of sis contradict goal of preventing substance abuse. other opposition groups in california took issue liability involved if overdose occur, unsure if patient or healthcare staff responsible. in both san francisco , seattle, residents concerned location of sis, afraid facility increase crime rates in surrounding area. due these , other opposing viewpoints, legislative efforts implement sis in united states have been slow progression. 

in response movement in united states supporting opening of sis, states such new mexico , cities including seattle, san francisco, ithaca, new york city, , philadelphia have convened task forces study feasibility , impact of these sites , make recommendations. many of these efforts have been part of larger harm reduction programs focused on reducing prescription opiate , heroin abuse. part of evaluation, san francisco considered healthcare impact on citizens, such lives saved, hospital stays, , cases of hiv , hepatitis c. concluded sis potentially decrease these factors annually. city conducted surveys , focus groups gather opinion residents , business owners on these facilities. on half of survey respondents , focus group participants supported sis. benefits such reductions in drug usage, drug overdoses, , spread of disease identified, in addition concerns including non-usage of sis , increased crime in neighborhood. cost-benefit analysis of supervised injection site there has been completed , suggests 1 sis result in savings of $3.5 million u.s. dollars annually, due lower medical costs. elsewhere, harm reduction coalitions, academic public health researchers, nonprofit organizations, , professional medical societies have made contributions understanding roles of these facilities in harm reduction. in baltimore researchers @ johns hopkins university published report commissioned abell foundation recommendations opening 2 facilities in city. in boston massachusetts medical society adopted resolution supporting pilot program led state examine impact of these sites on lives saved.

opioid replacement therapy (ort)

number of yearly u.s. deaths involving prescription opioid pain relievers. non-methadone synthetics category dominated illicit fentanyl, , has been excluded more accurately reflect deaths prescription opioids.

opioid replacement therapy (ort), or opioid substitution therapy (ost), medical procedure of replacing illegal opioid, such heroin, longer acting less euphoric opioid; methadone or buprenorphine typically used , drug taken under medical supervision. formulations of buprenorphine incorporate opiate antagonist naloxone during production of pill form prevent people crushing tablets , injecting them, instead of using sublingual (under tongue) route of administration.

in countries, such switzerland, austria, , slovenia, patients may treated slow-release morphine when methadone deemed inappropriate due individual s circumstances. in germany, dihydrocodeine has been used off-label in ort many years, no longer prescribed purpose. extended-release dihydrocodeine again in current use in austria reason. research usefulness of piritramide, extended-release hydromorphone (including polymer implants lasting 90 days), dihydroetorphine , other drugs ort @ various stages in number of countries.

the driving principle behind ort program s capacity facilitate resumption of stability in user s life, while experience reduced symptoms of withdrawal symptoms , less intense drug cravings; however, strong euphoric effect not experienced result of treatment drug. in countries (not usa, uk, canada, or australia), regulations enforce limited time period people on ort programs conclude when stable economic , psychosocial situation achieved. (patients suffering hiv/aids or hepatitis c excluded requirement.) in practice, 40-65% of patients maintain complete abstinence opioids while receiving opioid replacement therapy, , 70-95% able reduce use significantly, while experiencing concurrent elimination or reduction in medical (improper diluents, non-sterile injecting equipment), psychosocial (mental health, relationships), , legal (arrest , imprisonment) issues can arise use of illicit opioids.

heroin maintenance programmes


timeline of total number of u.s. overdose deaths involving heroin.

providing medical prescriptions pharmaceutical heroin (diacetylmorphine) heroin-dependent people has been employed in countries address problems associated illicit use of drug, potential benefits exist individual , broader society. evidence has indicated form of treatment can improve health , social circumstances of participants, while reducing costs incurred criminalisation, incarceration , health interventions.

in switzerland, heroin assisted treatment established programme of national health system. several dozen centres exist throughout country , heroin-dependent people can administer heroin in controlled environment @ these locations. swiss heroin maintenance programme regarded successful , valuable component of country s overall approach minimising harms caused illicit drug use. in 2008 national referendum, majority of 68 per cent voted in favour of continuing swiss programme.

the netherlands has studied medically supervised heroin maintenance. german study of long-term heroin addicts demonstrated diamorphine more effective methadone in keeping patients in treatment , in improving health , social situation. many participants able find employment, started family after years of homelessness , delinquency. since then, treatment had continued in cities participated in pilot study, until heroin maintenance permanently included national health system in may 2009.

a heroin maintenance programme has existed in united kingdom (uk) since 1920s, drug addiction seen individual health problem. addiction opiates rare in 1920s , limited either middle-class people had easy access due profession, or people had become addicted side effect of medical treatment. in 1950s , 1960s small number of doctors contributed alarming increase in number of drug-addicted people in u.k. through excessive prescribing—the u.k. switched more restrictive drug legislation result. however, british government again moving towards consideration of heroin prescription legitimate component of national health service (nhs). evidence has shown methadone maintenance not appropriate opioid-dependent people , heroin viable maintenance drug has shown equal or better rates of success.

a committee appointed norwegian government completed evaluation of research reports on heroin maintenance treatment available internationally. in 2011 committee concluded presence of numerous uncertainties , knowledge gaps regarding effects of heroin treatment meant not recommend introduction of heroin maintenance treatment in norway.

the first, , only, north american heroin maintenance project being run in vancouver, b.c. , montreal, quebec. currently, on 80 long-term heroin addicts have not been helped available treatment options taking part in north american opiate medication initiative (naomi) trials. however, critics have alleged control group gets unsustainably low doses of methadone, making them prone fail , rigging results in favor of heroin maintenance.

critics of heroin maintenance programmes object high costs of providing heroin users. british heroin study cost british government £15,000 per participant per year, equivalent average heroin user s expense of £15,600 per year. drug free australia contrast these ongoing maintenance costs sweden s investment in, , commitment to, drug-free society policy of compulsory rehabilitation of drug addicts integral, has yielded 1 of lowest reported illicit drug use levels in developed world, model in rehabilitated users present no further maintenance costs community, reduced ongoing health care costs.

a substantial part of money buying heroin obtained through criminal activities, such robbery or drug dealing. king s health partners notes cost of providing free heroin year one-third of cost of placing user in prison year.

naloxone distribution

naloxone drug used counter overdose effect of opioids; example, heroin or morphine overdose. put, naloxone displaces opioid molecules brain s receptors , reverses respiratory depression caused overdose within 2 8 minutes. world health organization (who) includes naloxone on list of essential medicines , , recommends availability , utilization reversal of opioid overdoses.

formal programs in opioid inverse agonist drug naloxone distributed have been trialled , implemented. established programs distribute naloxone, per s minimum standards, drug users , peers, family members, police, prisons, , others. these treatment programs , harm reduction centres operate in afghanistan, australia, canada, china, germany, georgia, kazakhstan, norway, russia, spain, tajikistan, united kingdom (uk), united states (us), vietnam, india, thailand, kyrgyzstan, denmark , estonia.

united states

officers in quincy, massachusetts, began carrying nasal spray form of drug in october 2010, following completion of department of public health pilot program, in naloxone distributed friends , families of opiate users, in 2007. quincy officers have administered drug 221 times , reversed 211 overdoses since commencement of initiative. espanola valley, new mexico , ocean county, new jersey police officers followed quincy example in 2013. quincy mayor thomas koch explained in 2014: s easy cynical person say, oh, re druggies, re junkies, let them die. when put name , face , family that, s different story. people go down road never come back, if can bring them back, there s hope.

following use of nasal spray device police officers on staten island in new york, additional 20,000 police officers begin carrying naloxone in mid-2014. state s office of attorney general provide us$1.2 million supply 20,000 kits , police commissioner william bratton said: naloxone gives individuals second chance .

some harm reduction programs distribute naloxone kits people use opioids , friends , families prevent overdose deaths. distribution of naloxone , public education harm reduction programs has been shown increase survival rate opioid users experience overdose.

australia

in march 2013, trial programs commenced in australian states of new south wales (nsw) , australian capital territory (act). following publication of position statement on peer-based distribution , administration of naloxone in august 2013, harm reduction victoria, based in australian state of victoria, commenced training workshops drug users on administration of naloxone in event of opiate overdose. during week beginning march 3, 2014, 19 workshops had been completed hrv , 156 drug users had been provided naloxone, paid community health agencies.

cannabis

specific harms associated cannabis include increased accident-rate while driving under intoxication, dependence, psychosis, detrimental psychosocial outcomes adolescent users , respiratory disease. safer cannabis usage campaigns including ukcia (united kingdom cannabis internet activists) encourage methods of consumption shown cause less physical damage users body, including oral (eating) consumption, vaporization, usage of bongs cool , extent filters smoke, , smoking cannabis without mixing tobacco.

the fact cannabis possession carries prison sentences in developed countries pointed out problem european monitoring centre drugs , drug addiction (emcdda), consequences of conviction otherwise law-abiding users arguably more harmful harm drug itself. example, adversely affecting employment opportunities, impacting civil rights, , straining personal relationships. people ethan nadelmann of drug policy alliance have suggested organized marijuana legalization encourage safe use , reveal factual adverse effects exposure herb s individual chemicals.

the way laws concerning cannabis enforced selective, discriminatory. statistics show socially disadvantaged, immigrants , ethnic minorities have higher arrest rates. drug decriminalisation, such allowing possession of small amounts of cannabis , possibly cultivation personal use, alleviate these harms. decriminalisation has been implemented, such in several states in australia , united states, in portugal , netherlands no, or small adverse effects have been shown on population cannabis usage rate. lack of evidence of increased use indicates such policy shift not have adverse effects on cannabis-related harm while, @ same time, decreasing enforcement costs.

in last few years strains of cannabis plant higher concentrations of thc , drug tourism have challenged former policy in netherlands , led more restrictive approach; example, ban on selling cannabis tourists in coffeeshops suggested start late 2011. sale , possession of cannabis still illegal in portugal , possession of cannabis federal crime in united states.

alcohol

traditionally, homeless shelters ban alcohol. in 1997, result of inquest deaths of 2 homeless alcoholics 2 years earlier, toronto s seaton house became first homeless shelter in canada operate wet shelter on managed alcohol principle in clients served glass of wine once hour unless staff determine inebriated continue. previously, homeless alcoholics opted stay on streets seeking alcohol unsafe sources such mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities. programme has been duplicated in other canadian cities, , study of ottawa s wet shelter found emergency room visit , police encounters clients cut half. study, published in canadian medical association journal in 2006, found serving chronic street alcoholics controlled doses of alcohol reduced overall alcohol consumption. researchers found programme participants cut alcohol use average of 46 drinks day when entered programme average of 8 drinks , visits emergency rooms dropped 13.5 average of 8 per month, while encounters police fall 18.1 average of 8.8.

downtown emergency service center (desc), in seattle, washington, operates several housing first programmes utilize harm reduction model. university of washington researchers, partnering desc, found providing housing , support services homeless alcoholics costs taxpayers less leaving them on street, taxpayer money goes towards police , emergency health care. results of study funded substance abuse policy research program (saprp) of robert wood johnson foundation appeared in journal of american medical association in april 2009. first controlled assessment in u.s. of effectiveness of housing first, targeting chronically-homeless alcoholics, showed programme saved taxpayers more $4 million on first year of operation. during first 6 months, study reported average cost-savings of 53 percent (even after considering cost of administering housing s 95 residents) — $2,500 per month per person in health , social services, compared per month costs of wait-list control group of 39 homeless people. further, despite fact residents not required abstinent or in treatment alcohol use, stable housing results in reduced drinking among homeless alcoholics.

alcohol-related programmes

a high amount of media coverage exists informing users of dangers of driving drunk. alcohol users aware of these dangers , safe ride techniques designated drivers , free taxicab programmes reducing number of drunk-driving accidents. many cities have free-ride-home programmes during holidays involving high alcohol abuse, , bars , clubs provide visibly drunk patron free cab ride.

in new south wales groups of licensees have formed local liquor accords , collectively developed, implemented , promoted range of harm minimisation programmes including aforementioned designated driver , late night patron transport schemes. many of transport schemes free of charge patrons, encourage them avoid drink-driving , @ same time reduce impact of noisy patrons loitering around late night venues.

moderation management programme helps drinkers cut on consumption of alcohol encouraging safe drinking behaviour.

the hams harm reduction network programme encourages positive change regard use of alcohol or other mood altering substances. hams encourages goals of safer drinking, reduced drinking, moderate drinking, or abstinence. choice of goal individual.

harm reduction in alcohol dependency instituted use of naltrexone.

tobacco

tobacco harm reduction describes actions taken lower health risks associated using tobacco, combustible forms, without abstaining tobacco , nicotine. of these measures include switching safer (lower tar) cigarettes, switching snus or dipping tobacco, or using non-tobacco nicotine delivery systems. in recent years, growing use of electronic cigarettes smoking cessation, long-term safety remains uncertain, has sparked ongoing controversy among medical , public health between seek restrict , discourage use until more known , see them useful approach harm reduction, risks unlikely equal of smoking tobacco. usefulness in tobacco harm reduction substitute tobacco products unclear, in effort decrease tobacco related death , disease, have potential part of strategy.

it acknowledged discontinuation of tobacco products confers greatest lowering of risk. however, there considerable population of inveterate smokers unable or unwilling achieve abstinence. harm reduction may of substantial benefit these individuals.

psychedelics

the zendo project conducted multidisciplinary association psychedelic studies uses principles psychedelic therapy provide safe places , emotional support people having difficult experiences on psychedelic drugs @ select festivals such burning man, boom festival, , lightning in bottle without medical or law enforcement intervention.

also, mdma commonly sold slang names ecstasy , molly adulterated. nonprofit organization dancesafe offers on-site testing of contents of pills , powders @ various electronic music events around us. sell kits users test contents of drugs themselves. pillreports.com invites ectasy users send samples of drugs laboratory testing , publishes results online.