“ Effective Alternatives to Harm Reduction”
by Peter Stoker, C.Eng., Director, National Drug Prevention Alliance
ABSTRACT:
An orchestrated effort to radically change drug policy from prevention to acquiescence operates under an alias of ‘Harm Reduction’. This paper explains how this so-called harm reduction differs from the traditional ‘real’ harm reduction, and evaluates the various techniques advanced by harm reductionists which – in effect – facilitate drug use. A comparison is drawn with prevention in its modern form, and recommendations are given for a more positive orientation to drug strategy Conclusions are offered.
1. WHAT IS THE BACKGROUND?
1.1 What is ‘real’ harm reduction? What is pseudo ‘harm reduction’?
Terms like Risk Reduction, Damage Limitation, Risk Minimisation, and so on have been around for decades, but it is only in the last 25 years that their meaning has been cynically subverted.
Traditionally, it has always been the practice of drug workers, when working with drug users, to find out in detail, the answers to ‘The Five Ws’ – (What? Which? Where? When? and With whom?) … what substances being used; by which method, in what quantity, how often, and in what circumstances (such as used on own or used in groups, and in what type of place). All these questions are in addition to the simple but crucial Sixth Question ‘Why are you using’ ? – but from the answers to the Five Questions the drug worker will consider what might be done to reduce the risk of damage in the period before the user actually commits to giving up his or her use. The overall goal is cessation of use, and this transitory intervention to reduce risk has always been seen as part of the process of stabilising, of ‘straightening out’ the drug user in preparation for a healthier life style.
This is what you might call ‘Real harm reduction’ – but since that term – ‘ Harm Reduction’ has been so deeply discredited in recent years, it would be better to use some entirely different name for the traditional process.
Let’s turn now to the term ‘Harm Reduction’ as it is generally used today. This is what I term ‘so-called harm reduction’.
The present process which masquerades under the name Harm Reduction was born sometime in the 1980s, in the north-west of England. As a small number of radical activists in the Liverpool and Manchester area were considering how they could undermine the legal system around drugs and legitimise their use. Exactly why they would want to do this we will probably never know, but we do know that some of them were drug-users themselves, and we also know that some were political activists, for example Stalinists. Tomas Hallberg will be giving you much more detail on this, in his paper “100 Years of Harm Reduction” – and I can also refer you to a paper I presented in Visby, Gotland, at the 2001 Hassela World Drug Conference – the paper is entitled “The History of Harm Reduction” and you can access it for our website.
1.2 Why were ‘real’ and ‘so-called’ harm reduction invented?
It should be self-evident, but just to spell it out, ‘real’ harm reduction was invented simply to reduce harm; ‘so-called’ or ‘pseudo’ harm reduction was invented to advance libertarianist radical agendas.
When you look at the quality of so-called harm Reduction, it is pretty pathetic anyway. It trots out a few limp recommendations which anyone who has come near a drug would know anyway. This exposes the dishonesty of the process; it has been dressed up to look like a ‘medical assistance’ programme, when its real purpose is to (a) send the public to sleep and (b) to suggest that drug use can be ‘managed’ safely.
You don’t have to take my word for this – listen to what the architects of Harm Reduction actually said. These are the words of Peter McDermott, one of the original Liverpool radicals:
“As a member of the Liverpool cabal who hijacked the term Harm Reduction and used it aggressively to advocate change during the late l980’s, I am able to say what we meant when we used the term. Its real value lay in its ability to signify a break with the style and substance of existing policies and practice. Harm Reduction implied a break with the old unworkable dogmas – the philosophy that placed a premium on seeking to achieve abstinence”
and McDermott went on to say
“…we must continue to guard harm reduction’s original radical kernel, without which it loses almost all of its political power”.
The tactics deployed by those activists, and adopted by many more since, were carefully thought out. They sought to soothe public alarm about drug misuse, they tried to make drug use seem as a normal as possible, indeed they even tried to persuade people that there were benefits to drug use which everyone should recognise – and of course they argued that one of the greatest harms of drug use flowed from its illegality, therefore – they claimed – great benefit to society would result from drug legalisation. ‘Harm’ would be a thing of the past.
In studying the changes in drug use across America, and applauding the enormous achievement of reduction of use between 1980 and 1992, the question must be asked ‘What happened after 1992? Why did things go wrong?’ There are a number of contributory factors; for example, both the government and the parents took their eye off the ball, believing that the problem was solved for all time. Probably some of the material produced in the 80s was starting to look a little tired, and quite possibly the campaigners against drugs who had started their battles in the late 70s were starting to look a little tired too!
But there was one factor that separated the 90s from the 70s. Money. Lots of it. When the original pro-cannabis campaigners in the 70s started their efforts, they had to rely on a relatively small bankroll from a man already known for his interest in libertarianism – Hugh Hefner, the inventor of ‘Playboy’. Hefner donated around $10 million , but over a lengthy period. One other man in the 1990s made that figure look ridiculous. The banker for legalisation in the 90s was George Soros, the man who has made $billions from currency speculation, and now applies his fortune to trying to run the world his way. The most notable example of this came last year, when he pledged some $10 million to ‘America Coming Together’ – an organisation dedicated to preventing George Bush from getting back into the White House. He has also invested large sums in the promotion of euthanasia – but shows no signs of wishing to try it for himself.
But it is in the field of drug law reform that George really gets his cheque book out. In an interview with the Press Association, published in ‘Time’ magazine in 1997, Soros said the had ‘spent more than $90 million in recent years to weaken drug laws’. Byron Wein, a friend of Soros, told Time ‘You must understand. He thinks he’s been anointed by God to solve insoluble problems’. Soros’ method of ‘solving’ problems was to instruct drug campaigners to ‘… target a few winnable issues, such as medical marijuana …’. Campaigns funded by Soros have included paying students a bonus for every name they added to petitions for referenda … not very different from ‘buying votes’.
Soros has continued to be the Godfather of the legalisation movement. A few other rich libertarians have put their money into the pot (in both senses of the word) – but nobody comes close to George when it comes to money for old dope …
1.3 But what ‘harm’ are they talking about?
It is when we start to examine the actual Harms that the so-called harm Reductionists say should be reduced that the real truths start to emerge. The ‘Harm Reductionists’ are preoccupied with actual or perceived harms to the user; they are totally user-focused. Their aim is not prevention of use, but facilitation of use. And when it comes to considerations of harm, their focus is extremely narrow; of the seven possible elements of total health they are only concerned with one or two who at most – that is, with physical harm – and with one very particular aspect of social harm.
Their gospel is that if you limit physical harm, and if you remove the social harm to users which comes from being on the wrong side of the law, then you have done all you need to do to create an acceptable situation for society.
1.4 What ‘harms’ are they are ignoring?
There are many harms which are being ignored, and I would suggest that these can be considered under three headings:
– Harm to the users themselves
– Harm to other people, and
– Harm (to users or others) during ‘pre-addiction’ stages
As I have already said, legalisers and libertarians narrowly focus on physical harm and what they might term “Harm from illegality”. You may well have heard them say that drug users are “otherwise law-abiding” – meaning that apart from this one ‘different’ behaviour, they are a good citizens. Would we be prepared to accept the argument that paedophiles, or burglars, or murderers are “otherwise law-abiding” – and that apart from this one ‘minor lapse’, they are good citizens?
Let’s examine the three areas of neglect in measuring total harm:
Harm to the users themselves
For centuries now there has been a definition of what health comprises. You will find broadly similar definitions in most of the ancient religions, but you’ll also find a very similar definition from bodies such as the World Health Organisation. Health is deemed to include not just physical aspects, but also mental aspects, intellectual, social, emotional, spiritual and environmental aspects. You may be healthy in some of these but not in others – and I have found from my work with clients that you can subjectively assess the health of a drug-using client against each of these parameters.
Sadly, far too many people take the narrow view, which is the view closest to the medical profession’s mainstream interest in physical health and in mental health – the latter defined in terms of how stable your brain is, rather than how much you can do with the brain cells you have. Nevertheless, it is undeniably the case that harm to a user can accrue in each of the health elements, and even if we don’t yet have the tools to quantify these harms in the intellectual, social, emotional, spiritual and environmental areas, it is obvious that they are additive to the physical and mental harms. The important conclusion to be kept at the forefront of any discussions of harm reduction is that there is more harm than is being talked about so far.
Harm to others
I remember, about 20 years ago, when I first entered this field of work, listening to the mother of a chronic drug user. Her family had suffered years of runaways, stealing from home, violence upon her, the father and the other kids … so, when she found that he had run away once more and was sleeping in the fields, she went to church, knelt down, and prayed that it would snow. This is how much harm other people suffer, so much that they would even accept losing a son as preferable to another year of misery for everyone else.
Of course the harm that is described in this family is by no means the whole of the story. Drug-users like to think of themselves as committing a ‘victimless crime’; in fact the consequences of their crime ripple across society. When they get ill, doctors and nurses and paramedics and ambulance drivers get involved. When they disrupt school classes or run away from school, then teachers and educational welfare officers and the school administrations get involved. And when they commit crimes police or probation officers become involved. The crimes may either in order to get money to buy drugs or – as is frequently overlooked – because their moral structure has been unravelled by their drug use and replaced with a ‘self-centred, rapid-gratification compulsion’; this is an effect both in their social interactions and in their bio-chemistry. The outcome is a fertile soil in which crime can grow.
The user may be in employment, and British statistics suggest that more than half of all drug users do have a job. Their drug use can impact their workmates, their managers, and the profit line of the whole company. Churches and other religious centres may be involved in seeking to support the family, or even the users themselves. And when their crimes against society come to the attention of the authorities then there are costs incurred by police, lawyers, judges, probation officers, prison facilities and so on. Consider also traffic accidents, time taken in A&E Departments, family problems up to and including divorce and child abuse can often be related to a drug user in the family.
So if anybody tries to tell you that their drug use of does not affect anyone else, show them this list – and tell them they are living in a dream world – even if at that moment they are not stoned.
Harm (to users and others) in pre-addiction stages
It seems to be almost a convention in journalistic circles, or in the so-called intellectual discourse about drugs, to refer to all drug users as “drug addicts”. In fact the addicts are a minority percentage of the total drug users, and initiatives that are developed for addicts are often inappropriate for the pre-addiction stages. But the main danger of talking about addiction as the problem which needs to be addressed is the implicit assumption that any drug use prior to this stage is insignificant. This is a gross error. Significant harm can accrue to drug users, to the people around them, and to society, from the first day of their use. The stoned young man who crashes his car – killing other people and maybe himself – can do so on first time he uses. The girl who becomes a victim to date rape, or succumbs to sexual advances because she has drunk too much, can suffer this fate the first time she drinks. It may take you years to develop lung cancer from tobacco – or head and neck cancers from cannabis, but not all drug consequences are so slow to arrive!
2. WHAT TECHNIQUES DO THEY PROPOSE – AND WHAT’S WRONG WITH THESE TECHNIQUES ?
2.1. Needles and works. Probably the best-known technique is so-called ‘needle exchanges’. One of the earliest applications of this was in the same part of England where the psycho-political, pseudo Harm Reduction was born, that is to say the Liverpool – Manchester area. The same people who invented pseudo Harm Reduction also persuaded the police not to take action against possessors of drugs and – even more extraordinary – not to take action against drug dealers, provided these drug dealers handed out needles and syringes at the same time as selling their drugs. Dealers were of course not interested in dialoguing with their clients and encouraging them to stop buying their stuff – they wanted to sell the drugs, give them a bag of syringes and needles, and move on to the next client. This policy certainly had an effect, but not the one that its architects had suggested. The effect was to turn Liverpool, which had been an area where heroin was mostly smoked and injecting was a rarity, into an area with an extremely high level of injecting use. The reason was simple economics – if you inject heroin you can use less to get the same hit, compared to smoking it (‘chasing the dragon’).
Needle exchanges can now be seen in many countries and one thing that unites all them – they are based more on faith than on science.
2.2 Issuing condoms – in the context of harm reduction associated with drug use was rapidly introduced in European countries in the late 1980s, when HIV and Aids was just beginning to be an issue. But more frequent issue of condoms had been a practice for some time before this, as part of a general liberalisation of sexual behaviour, especially amongst the young.
2.3. Methadone is only the latest in a long line of attempts to find a non-addictive substitute for Opiates. It started with a morphine which was developed as a supposedly non-addictive alternative to a opium; quite soon it was realised that morphine was just as addictive, so the chemists went back to their laboratories. Their next product was heroin, which was supposed to be a non-addictive alternative to morphine; again it was soon found to addictive. And so we come to today’s brave new world in which Methadone was first promoted to the medical profession on the basis that it would the non-addictive alternative to heroin – what a crass error that has turned out to be. Not only is Methadone, if anything, more addictive than heroin, it is very tough drug to withdraw from – and, because it is so powerful, it has caused many deaths – indeed, a few years ago in Scotland, there were more deaths in one year from Methadone than their were from heroin.
2.4. Heroin on demand Somewhere, in a back room, one day, someone came up with the mind-numbing idea that heroin addicts would lead to more stable lives if they were given free heroin. What do you suppose would be the reaction if you proposed today that alcoholics would lead more stable lives if they were given free alcohol? The stupidity of both ideas is equal. The most obvious example of this notion was in Switzerland, where the introduction of heroin distribution was disguised by calling it ‘an experiment’. It was nothing of the sort – any more than bringing the Trojan horse into Troy was an experiment in the study of carpentry. Why would the Swiss believe what they were being told about this ‘experiment’? – Perhaps the answer lies in the fact that the man in charge of it was also the president of the Swiss branch of the IAL – the International Anti-prohibition League, a radical group dedicated to the legalisation of drugs.
2.5. Just a little for me, thanks. Harm Reductionists suggest that encouraging moderation in consumption is a sound approach. But to them, suggesting abstaining from drug use is heresy, therefore they are talking less about moderating use and more about maintaining use. Unfortunately for this theory, all the mechanisms of tolerance and addiction are working against it.
2.6. Short breaks from use come in the same category as moderation; they are just trying to apply a sticking plaster to a festering wound. They falsely reassure and validate drug-using behaviour. Whilst moderation of use and short breaks from use can be stepping stones to abstinence, they simply do not work as long as the user intends to return to their use.
2.7. Quality Control. In England a few years ago a new notion came out; that was the idea of having a mobile laboratory outside a rave club, where drug users could have their pills tested for purity – lack of dangerous adulterants – and strength. Even if these mobile laboratories were capable of meaningful test results, the simple fact is that if you buy three of four pills there is no guarantee that what is in the one you have tested is in the other three. And there is another overriding criterion anyway; the first major media coverage in the UK of a young person’s death from ecstasy concerned Leah Betts – she took one ecstasy tablet, at her 18th birthday party, collapsed and died. I can tell you with absolute certainty, having spoken to the professor of medicine who analysed the substance in her body that it was pure ecstasy – there were no adulterants. I can also tell you, because Leah’s parents are friends of mine, that this was not the first time she had used ecstasy – she had tried it a few times before, with no ill effects – and yet this time her body reacted violently, just as it would from a bullet in Russian Roulette.
2.8. Crack Kits. Despite the considerable concern expressed – even by the most dedicated legalisers – some people seem to think that you can even smoke crack ‘safely’. A typical attempt occurred in Connecticut, USA in 1997. A kit included antiseptic swabs, alcohol preparation swabs, antibiotic ointment, some vitamin C tablets, some condoms (of course) and some elastic bands and a rubber mouthpiece for your crack pipe. Amongst the wonderful recommendations in this pack were the following examples:
– “If you smoke indoors, make sure it is ventilated. Poorly aired rooms can be risky for tuberculosis (TB). Cover your mouth when coughing.”
“If you have problems breathing, OR ARE COUGHING UP DARK STUFF, slow down or stop smoking for a while. See a doctor if it continues.”
2.9. Dump the law. And finally we come to the Harm Reductionists’ trump card, law relaxation. What does this have to do with Harm Reduction? Simply that liberalisers see the greatest harm to drug users coming from the illegality of their chosen substances. The harm is that they get arrested, or they get in other trouble with the police; they may have to pay fines, or even go to prison …. all of this is grossly unfair, they would say, when all you are engaging in is a little harmless pastime. It follows that Harm Reductionists end up as pressure groups for legalisation … (or maybe they started that way; you choose).
3. DO THEIR APPROACHES WORK?
3.1 Harm reduction – research and observation
For a complete analysis of the failures of the so-called harm reduction , you can do no better than read the paper submitted by Eric Voth MD, President of the International Drug Strategy Institute, at the conference held in the European Parliament on March 1st and 2nd this year. Eric has used his medical expertise and experience in clinically analysing the various processes attempted by the harm reductionists; the results they have published – and the results they would rather forget.
The claim is made that needle exchange programmes reduce the transfer of HIV and Hepatitis C. Three studies – in Montreal (1997), Seattle (l999) and Vancouver (ongoing) show that the reverse is the case. In another, comparative assessment of thirteen studies focusing on needle exchange programmes and HIV spread, seven of the thirteen reported no significant effect and two actually found higher HIV spread in the needle exchange group. One study found other factors – such as HIV testing and counselling for example – may be more effective in reducing HIV incidence. The studies often have serious shortcomings: there are inadequate outcome tallies – few actually measure NIV incidence, and most often the studies rely on self-reporting of change of behaviour. Often systematic control for co-variates is lacking, and there are poor definitions of degrees of use or non-use. ~Eric Voth concludes that the collected evidence for needle exchanges and their effects on HIV spread is at best inconclusive . They also do not seem to reduce the spread of either drug addiction or injecting use. Voth finishes by suggesting that the early great hopes that many people had for needle exchanges as a ‘silver bullet’ to fight HIV may have impeded the introduction of other potentially more effective strategies.
The term ‘needle exchange’ is optimistic, to say the least. The average needle requirement for a heroin user is around 3,000 needles per year – and three times this for injecting cocaine users. Of 131 needle exchange programmes identified by the Center for Disease Control, l07 programmes reported that almost 40% of needles were not returned; the total handed out by these l07 programmes was almost 20 million needles which means that 8 million needles were discarded somewhere else.
Needle sharing was supposed to be reduced by generous distribution of needles; the fallacy of this was exposed in several studies, including Chicago (1995) which showed almost 40% of clients continued to share needles. Interestingly this figure was identical to the level of sharing amongst users who did not access the needle exchange; this shows that there was no educational benefit from participation in needle exchanges.
In Seattle it was found that the highest incidence of infection occurred amongst current clients of the needle exchange – the goal of elimination or even reduction of risky behaviour had self-evidently not been achieved. Baltimore was one of the first American cities to introduce needle exchanges; within a few years it was found that Baltimore had one of the most severe drug problems in the nation, with 10% of the population addicted. The percentage of opiate use amongst male and female arrestees was found to be higher than even Washington DC, Philadelphia or New York.
Looking at other countries, Puerto Rico needle exchanges were studied in 1998. They found no significant change in injection habits; only 40% of needles were returned and there was no evaluation process in place. In India a study in 2003 showed that prevalence of HIV before needle exchanges was 1% and after was 2%. In the same period (1996-2002) Hepatitis B rose from 8% to 18% and Hepatitis C rose from 17% to 66%.
Harm reduction has been the ‘Trojan Horse’ carrying liberal policies into other countries as well as those mentioned above. Decriminalisation of cannabis in Holland prefaced an increase in use of 142% between 1990 and 1995. For those who suggest that it is prohibition which encourages organised crime to grow, the fact is that organised crime groups in Holland rose from three in 1988 to ninety three in l993, prompting the Minister of Justice to announce that Holland had become ‘the crime capital of Europe’. Holland has also become the leading exporter of Ecstasy – much to the disgust of the Dutch population, 73% of which feel that their drug laws are too lax. England would claim that it has not decriminalised cannabis, it has merely de-penalised it – but this is just playing with words. The evidence on the street, as reported by such authorities as the Police Federation, shows a drastic increase in use and also shows many young people falsely believing that cannabis in England is now legal and that they can ignore the police. Injecting rooms in Australia fare no better; in a shooting gallery in the Kings Cross area of Sydney, there were 36 times greater overdoses than in the rest of the district.
A telling comparison of harm reduction versus prevention was produced by Dr. Lucy Sullivan and published in 1999 in the ‘News Weekly’ magazine. She compared the preventive approach of Sweden with the harm reduction approach of Australia. She found that lifetime use in Sweden was only 9% compared to 52% in Australia, and that use in the previous year was only 2% in Sweden compared to 33% in Australia. Under 20 year-old dependent users were five times more frequent in Australia and drug related deaths were twice as frequent. Most tellingly given the promotion of needle exchanges, the number of Aids cases per million population in Australia was twice that of Sweden.
3.2 Harm Reduction on the street – ‘Outreach’
The principle of outreach work is an honourable one, and has been practised for many decades. Since people beset by social exclusion may not come to agencies and seek help, then the agencies may choose to go out and find these people in their own habitat. Where this principle becomes unworkable is in the subversion of the goals of the outreach workers. Traditionally they have worked to bring their clients to a point of reasoned judgement when they will elect to discontinue their harmful behaviours, including drug misuse. In 1987 at a PRIDE conference in America I heard a Norwegian drug worker describe how the outreach workers they had recruited, who started with the goal of abstinence, over a period became activists campaigning for legalisation of drugs. One possibility is that some of that group of drug workers may themselves have been drug users and – and therefore they saw legalisation as something that would validate their own use and therefore protect their employment. But there is another mechanism in play. This has to do with a drug worker striving to gain the trust of the client, trying to get inside their thinking and understand them better, but only being able to do this after the client has accepted them. Unfortunately, too many outreach workers – or youth workers – make the mistake of ‘buying’ acceptance from a client in exchange for accepting all of that client’s behaviour without question. They have forgotten that their attitude should be “I love you – but I don’t love your behaviour”. Having thus over identified with the client, it becomes a simple step of self justification for these workers to campaign for law relaxation, to underpin their own subverted position.
3.3 The workplace
Drug misuse in the workplace costs industry dear; an estimate of the cost to British industry is in excess of £3 billion per year. This affects everybody in and around the workplace – the managers, employers, and any shareholders. But despite this harm to everyone, there is often a practice of misguided loyalty. I well remember one of my female clients who was an alcoholic; when the supervisor was seen to be heading for the area where she was working, her colleagues would hide her in a broom cupboard until the supervisor had gone away. It was not until the supervisor confronted this woman and gave her the simple option of counselling or dismissal that she at last faced her condition honestly, and set herself on road to recovery.
I also recall an astonishing statement by a trade union representative for London’s underground railways, reported in the national press. This ‘Brain of Britain’ announced that since underground train drivers were within their rights to consume drugs over the weekend, they should be given Mondays off to ‘straighten out’ before taking their control in the train on Tuesdays. For a long time after that, I worried every time I got into an underground train. I also recalled one crash on the underground in London, some years ago, which killed two people and injured many others, and the driver later tested positive for cannabis.
Some of the harms from drug misuse can be much less dramatic, but can add up to a major cost. Here’s a simple example you can apply to your own country: Just for example, given that there are nearly 60 million people in Britain, if we ignore the old and the young, we are probably left with a workforce of around 30 million people. Taking an average of the highest and lowest wages in Britain, a conservative figure for payment would be around £10 per hour. If we assume that on average every worker loses just one hour in a year from the some consequence of drug use, including alcohol of course … consequences as small as arriving to work late the following day, or even just a late return from lunch – whatever the cause, that lost hour adds up to a cost to the nation of £300 million.
3.4 Education – formal and informal
It is in the Education sector that Harm Reduction can be at its most insidious. We are dealing here with young, impressionable minds – and lest you should think that impressionable minds only come inside the heads of 15 year-olds or younger, bear in mind that current research now shows that maturation of the occurs last in the pre-frontal lobe – the area which processes analysis, decision-making, imagination and planning – and also bear in mind that this maturation is now thought to be not complete until a person is in their early twenties.
Traditional ‘Harm Reduction’, as I have already described it, is conducted with known users on a one to-one basis in order to mitigate their drug-using behaviour whilst seeking to end it. Such a process is impossible in a classroom that has a wide variety of pupils in it, with of wide variety of experiences. The fact is that most of them have either never used at all or will have given up after one or two tentative attempts. In other words, the great majority have not bought into the drug culture. Perhaps the main reason why so many do not use is the culture of society around them – a culture of disapproval by parents, teachers, other authorities – and, most importantly, by their friends; a culture of Health Promotion; a culture of Responsible Behaviour – having regard for others. If one now introduces into the classroom a suggestion that drug use is inevitable, that any one may get involved in it, and that the school will therefore give out instruction in preferable methods of use (these will be described as ‘less risky methods’ but will be rapidly misconstrued by young people as meaning ‘safe methods’) then what thought pattern will they develop in their minds? I suggest to you that it is likely to include the following:
– drug use is inevitable
– the school must be accepting it because there are telling me how to do it
– it can’t be that dangerous otherwise they would forbid it
– they’re saying that everybody’s doing it, so I don’t want to be left out
and the result? More schoolchildren use drugs. And how is that interpreted? It is interpreted as an argument for more harm reduction. In other presentations by Ann Stoker we will explore just how far reaching this psycho-political initiative has become, and also the look at some of the people behind it.
4. THE ALTERNATIVES
4.1 Selective use of real harm reduction
There is a place for advising on the reduction of harm, but it is certainly not in the socio-political arena, as a ‘Trojan Horse’ for legalisation. And it does not belong in the classroom – or in any other places where you are communicating with a wide variety of people, many of them non-users, and some of them on the edge of deciding whether or not to use.
The correct place for reduction of harm is as part of the response to known use, and it is conducted on a one-to-one basis, and always with the goal of abstinence made explicit to them. The user needs to know that it is your wish that they give up using, even if they are not willing to stop right now. (You may also decide that some individuals, who are currently denying that they are using, should be advised as if they are users). Don’t protest that there are too many users out there for you to work with on a one-to-one basis; the fact is that if your advice is valid and presented in a non-patriarchal. non-patronising way, the word will get round on the street to others anyway.
The other important aspect of harm reduction is that you must stay abreast of the research and observation, across the international scene. There are many question marks over practices such as needle exchange, and in time it may become clear that some practices should be modified – or even abandoned altogether. Equally, some new practices will be developed, which can improve the situation. So the lesson is to keep aware, monitor your procedures, and continuously test them against the international body of knowledge.
4.2 Outreach work with an abstinence goal
Outreach is an honourable pursuit, with a strong moral base – but it can be diverted (as it was in Norway). Your outreach workers need to have strong and constantly renewed links with your main office base, and their goals and practices need to be regularly tested and renewed. Remember that they are in a vulnerable position – by the nature of their job, they are presenting themselves to their clients as ‘something different from the official structure, someone you can trust and to whom you can relate’. And of course they have to deliver on a promise of confidentiality – what they hear from an individual has to stay between that outreach worker and his/her client. (This does not mean that general information about what drugs are on the street, drug prices, trends in use and practice, etc cannot be extracted anonymously; such an information analysis will assist and inform the whole agency, including the cadre of outreach workers themselves). Outreach workers need to be given flexibility in order to achieve their job specification, to develop a trusting relationship with the client – but this cannot extend to them re-writing your drug strategy!
4.3 Assertive treatment and rehabilitation
It used to be said – and I confess that I was one of those who absorbed this idea as ‘gospel’ – that a treatment process will not succeed unless the client has committed to it of their own free will. There is a joke amongst psychotherapists, which asks ‘How many psychotherapists does it take to change a light bulb?’ The answer is ‘Only one, but the light bulb has to really want to change’.
Experience has now shown that this is not the case. In Sweden there has been many years of ‘mandatory’ treatment, and comparative research studies have shown that the mandatory schemes have outcomes as good as the voluntary ones. The conclusion is that there is a place for both – and some people will respond better to a process of they have personally volunteered for it, whilst others need a little push.
The use of ‘a little push’ does not have to be confined to treatment centres; I have sometimes received new clients who have been sent to me by their employers, with the condition that they either commit to counselling about their drug problem – or they are dismissed from their job. Of course you can imagine that often such people arrived in my office in a very bad temper, not wanting to be there, and very sceptical of the value of counselling. But I can say that over a quite short period, when they realised that I would not report back to their employer anything they said to me, and that my mission was simply to help them, then they relaxed and started to address their problem, with good results.
4. 4 What is prevention?
The word ‘prevention’ is to come extent problematic, because it means different things to different people. If you look in the Oxford English Dictionary you will find the word PREVENT is defined as ‘to obstruct or to hinder’. this modern usage of the word is unhelpful in drugs prevention because if you’re going to or obstruct or hinder something, this must mean that the activity has already started. In the case of drug abuse we cannot wait until the activity has already started, we need to do something sooner. This means we have to go back to the original, Latin root meaning of the word prevention; it comes from the Latin verb praevenire – meaning to come before the, to act before the event. This shows that if you wish to prevent, you must work pre-event.
Here is another elegant definition of what ‘prevention’ means, written by CSAP – The Center for Substance Abuse Prevention (USA) in 1993. It said:
‘Prevention is the sum of our actions to ensure healthy, safe and productive lives for all our children and families’.
Another very powerful definition comes from the one of the original American gurus of drug prevention, Bill Lofquist, from Associates for Youth Development, Tucson, Arizona. Bill says:
‘ If we can get beyond the notion that prevention is only “stopping something from happening”, to a more positive approach, that creates conditions which promote the well being of people, we can begin to view human services quite differently. This, in turn, can transform and enrich our approaches to helping people and building communities that are relatively free of the symptoms we have designed the services around.’
So that is what prevention means. But isn’t that a very wide definition? The answer is, it is as wide as society itself. And it means much, much more than just giving out information – which are too many people consider is all you need to do.
It is because of this confusion between the just information-based-giving and prevention, that many people think that education is the whole of prevention. It is not. Education is an important part of prevention, but the nature of every-day education in our schools and colleges today, and the pressures on teaching staff, are such that formal education does not properly address prevention – even if it wanted to.
A simple acronym of which will help you to remember what comprehensive prevention means, is ‘KAB’. This stands for Knowledge plus Attitudes plus Behaviour. All these three need to be addressed if you are going to significantly influence behaviour. I will get into this in more detail later in this section.
One of the attacks on Drug Prevention by our opponents is that you cannot prevent everyone from using drugs, and therefore you should not try to prevent use of drugs. This is a false premise; if you look at other areas of life of, there are many examples where we seek to prevent undesirable behaviour; for example, obesity, unwanted sexual behaviour, crime, and – closer to our professional subject area – smoking. In none of these cases do we say that we expect to succeed with 100 per cent of the people, and in fact the success rate is much lower than this, nevertheless we can see that society benefits generally, from the effect on those people with whom we are successful, and so we continue making the prevention effort. Drug prevention should be no different to this, and the only reason that it is not applied as extensively as it should be, is the cynical and unjustified attacks by libertarians who – quite correctly – see it as an obstacle to their goals.
4.2 Does it work?
Yes, it certainly does. But as I said above, it does not work for everybody – and it is also true to say that what works for one person will not work for another. Let’s look at some proof of the Effectiveness have prevention:
One of the world’s leading researchers in drug prevention is Nancy Tobler; she published a major paper summarising her work so far. She identified more than 240 prevention programmes which were proved successful. 240 – and yet our opponents say there is no evidence that Prevention Works! from these 240 programmes she selected 140 which could be categorised into groups with similar characteristics in their techniques, and from this tree conducted a meta-analysis; this allowed her to produce recommendations for the characteristics of successful programmes.
Another senior researcher is Bonnie Benard; when I first encountered her she was working with Project Snowball in Illinois, a very successful programme, and one which Ann Stoker has visited and studied. Bonnie works these days at NIDA – the National Institute on Drug Abuse in Washington DC, but the list of ‘Characteristics of Effective Prevention’ which she reproduced in her Illinois days is still today, for me, one of the best short summaries of what produces good prevention.
Here is another specific example of what prevention can achieve. Every two years in America, a survey is taken across thousands of households, and is also correlated with surveys at schools. Amongst the subjects it addresses, drug abuse features highly, and a chart can be plotted to show what has been happening since the 1950s.
On this chart one can see that drug abuse started to escalate in the 1960s, under the noses of a largely apathetic Parent and Schools body, until by 1980 total of 24 per million people were drug users – and that included high-school pupils who were getting stoned before they went to college, if they went at all.
A few years before this appalling peak figure was reached, parents started to wake up to what was happening and they found that the academics and the drug workers were suggesting that the best approach was something they called “Responsible Use” – that is what today we would term ‘So-called Harm Reduction’. Parents, who set up more than 8,000 representative group, pressured the academics into taking a more responsible attitude towards use, and pushed them into developing effective prevention programmes. The effect of this was dramatic; from the peak 1980 level of 24 million over the next 12 years use dropped by 60 per cent, down to 13 million. For this was a tremendous public health campaign success by any standards, and yet throughout this period the pro drug factions, strongly supported by the sympathetic media, were announcing the that the “the war on drugs is failing” – and of course they are still telling the same lie today.
There are many other examples of successful prevention – some large and some small. You will hear soon about the Teenex programme which Ann Stoker wrote, and which has operated without a break over the last 17 years in Britain, as well as being established in Germany, Holland, Portugal, and Bulgaria.
As further proof of what a preventive approach can achieve, I can also tell you that during the eight-years that Ann Stoker was the director of a drugs agency in a London Borough, analysis showed the levels of drug use in that borough to be 20% below the national average.
4.3 What does prevention involve? the detailed techniques.
A core consideration, which I mentioned before, is the acronym ‘KAB’ – by this I mean that for prevention to be effective it must address not only the delivery of knowledge, and the shaping of attitudes, but also explicitly engage with behaviour – by encouraging good behaviour, more so than discouraging bad behaviour.
Prevention techniques need to vary according to the setting in which they are delivered, the culture of the people to whom you are delivering – and obviously the age group. Another factor will be to what extent there are any users in the grouper, and what their level of use is.
Prevention used to be traditionally defined in terms of primary, secondary and tertiary prevention. Primary meant prevention of use, Secondary meant prevention of harm from use and tertiary meant prevention of relapse back into use, that is, after treatment. These terms seem to have fallen out of favour in the profession and now a new set of terms replace them:
Universal prevention means prevention delivered to the general population, to promote overall health, and – in this context – to prevent the onset of drug use.
Selective prevention means prevention delivered to those thought to be at risk of using.
Indicated prevention means prevention for users in the early stages of use.
The goal of all these types of prevention is abstinence, and to that extent the new terms are less equivocal than the old. If we consider the these types of prevention as filters, each of which tries to prevent anyone falling through to the next level below, then a hypothetical arrangement might show the Universal Prevention filter addressing 100% of the population. The Selective Prevention filter addresses much fewer people – perhaps only 20% of the population, whilst the Indicated Prevention filter addresses even less – perhaps under 5% of the population. As these smaller percentages are reached, other services start to come into play; these would include Intervention – either in an agency or by Outreach (and – where appropriate – the application of Real Harm Reduction techniques). As the user becomes more deeply involved in drug use – regular user, or chronic user, or even an addict (and the percentage of this would be very small, perhaps one or two percent) then Treatment, Rehabilitation and After-care for relapse prevention would all need to come into play.
Now lets look at some specific prevention techniques, addressing these by different sectors of the community:
Government – their prevention work should mainly consist of a specifying and resourcing the achievement of those goals through top level management and evaluation leading to upgrading the system. They also initiate major public health promotion campaigns, including advertising campaigns. They ought to fund only those agencies who are complying with the National Strategy – sadly, in England this is not the case.
Health service – the problem with the British health service is that it is not a health service, it is a sickness service. it is dominated by physical and mental health considerations, and it does very little about the other elements of Health I have described earlier. Health Promotion needs to take a much more significant role. When it comes to resource in the promotion of emotional social spiritual health and the like, much more advantage could be taken of the voluntary sector, provided this was given the sound background resourcing from government.
Home Affairs – this is a key department, dealing with policing, justice system, and the laws which are in force at any given time. At present it is obsessed with crime figures and how to reduce them – sometimes by expedients such as reducing penalties Or not imposing imprisonment. This obsession with statistics needs to be replaced by a health- promoting approach. This should include rational laws which the public can understand and support; rational sentencing which has, as its focus, the encouragement of people back into law-abiding and constructive citizens; and a judiciary which is more in touch with real life. In Britain the Home Office has funded significant drug prevention projects in the past, but some of these have been penetrated and diverted by libertarian interests. A case in point is the ‘Blueprint’ project, which had the massive sum of £7 million allocated to developing and testing a so-called prevention project in schools. When such a project is put under the management of a person who is known to advocate Harm Reduction as their preferred strategy, one has to wonder exactly what the government is playing at.
Schools – in primary or junior schools there is great scope for universal prevention, and there are some excellent examples of this in – amongst others – America, Britain and Australia. These courses do not get into the gritty detail of what drugs look like, or what they do to people who use them – this needs to be left for the older age groups. Prevention that you deliver in primary schools consists of teaching young people how their bodies work; what happens when they put different substances into their bodies; how to respect themselves and other people . It also addresses subjects like anger, how do you deal with anger towards another pupil or to an older person. Core messages are “you are a special and unique person. You have been given the wonderful gift which is life. You are not alone, you are part of a large community. You need to take care of yourself, take care of where you live, and take care of each other”.
Three good examples of this approach are DARE ( Drug Abuse Resistance Education), Life Education Centres, and the Kangaroo Creek Gang. The first one comes from America, the second from Eastern Australia and the third one from Western Australia. As with all successful prevention programmes, attempts have been made by the opposition to jeopardise them – this is too long a story to include here.
Secondary schools – again, there are many good example of effective prevention in secondary schools. NIDA (The National Institute on Drug Abuse) in America has produced a very valuable booklet which summarises these within the American experience.A series of attainment targets for each age through secondary schools has been developed in America, and in Britain we in the NDPA have reworked this ( with the permission of the US Department of Education) to suit the British educational curriculum. NDPA is also continuously developing model drug prevention policy for schools. As well as lessons in the classroom, extra-mural programmes can be very useful. One of these, Teenex, you will hear about as part of this presentation.
Another relatively new technique which is being applied in America, Australia and some British schools is random drug testing. Attempts in the past to introduce drug-testing have not been very successful, because they depended on teachers identifying pupils that they wanted to have tested – and sometimes this system was open to abuse, or at the very least was suspected of being so. The new system uses a computer-based randomised selection of pupils (and the more enlightened schools will extend it to the teaching staff as well). The tests are administered by a school nurse or by external specialist staff who visit the school for this purpose. Another change from the past is that instead of automatically expelling someone who is found to have drugs in their system, the more usual response these days is to refer them for Counselling , and either suspend them for a short period or make a contract with them which says that they will be permitted to continue in school on the understanding that they may be tested again for drugs at any time. NDPA is the British representative for an international specialist committee on drug testing, and we can provide detailed information and research/observation reports about drug testing.
The medical profession – doctors and nurses are no better informed during their training than teachers; most of them will acknowledge that they received little or no information about street drugs or other drugs of abuse. And most of them, sadly, take the attitude that they do not want drug abusers in their surgeries. Furthermore, very few of them are seriously committed to health promotion or drug prevention – their focus is to wait until somebody becomes sick – and then treat them. So, the medical profession is actually unhealthy, and the symptoms are clear. ‘ The treatment’ is to improve and widen the training that all doctors receive in respect of abuse of drugs – whether this relates to illegal street drugs, to legal drugs such as alcohol and tobacco, or to pharmaceuticals such as tranquillisers and anti-depressants and substances like Ritalin. Not only is the profession unhealthy, but too many of the professionals are also unhealthy – there is a high percentage of alcohol and drug abuse in the medical profession, and this needs to be tackled more assertively. Another related profession is the pharmacists; they often come into direct contact with drug users, and they are in a very good position to help not only drug users, but ordinary members of the community who may be at risk from the unwitting abuse of pharmaceuticals.
The workplace – this is one of the best settings in which to promote prevention with older adolescents and adults. Some companies run comprehensive health promotion programme, some categorised as “employee assistance programmes”. one reason why the work place is a good setting is that the workforce is accustomed to taking instruction and training from the company; drug prevention can be incorporated into other existing subjects, such as health and safety, productivity, supervision, and company profitability. Where companies are too small to run their own comprehensive schemes, there are good examples of resource sharing between companies.
The media – some realism is needed here. Whether one is talking about television, or radio, or newspapers or magazines , the media does not exist to be a propaganda arm for drug prevention, or even to be an information service to the community; the purpose is to make the largest possible profit for the people who own the media – they achieve this by selling advertising, and they need to attract as many people as possible, so that the advertisers will place their products with them. We, the public, are the consumers of media products and we indicate by what we purchase those media subjects which interest at, so one might observe that we get the media we deserve. Of course it is also true that there are people in the media who are promoting their own agendas, and this complicates the situation, nevertheless the reality is that the media will only cover a limited amount of positive material about prevention of problems. Problems are much more likely to sell that newspaper or that TV programme. Having said all this, there is scope for the media to become more informed about the positive options, and to weave these into their existing coverage.
Leisure and entertainment – some of the comments about the media apply equally here but there is still significant scope for the leisure and entertainment industry to promote healthy behaviour without damaging their profit line. One example is the style of non-alcoholic drinks which if anything have bigger profit margins than alcohol. Another example is the management of dance clubs; instead of providing drug testing kits at the door, they can operate a strict ‘no drugs policy’ and they can promote this policy inside the club – the message is “come in, you can have a great time, and you don’t need drugs to do it”.
Sports – traditionally, the sporting sector has been treated very patriarchally by its administrators; they seem to treat sportsmen and women like naughty children who need to be watched closely and punished if they transgress. There is very little sign of any positive preventive education within this sector – this is the great potential for improvement. Additionally, there is a group of excellent programmes which have come out of Texas, which utilise a sporting environment to achieve personal development, conflict resolution, citizenship and other personal growth areas – in this is a much more constructive way of using sport than merely suggesting that it can be an alternative to drug use.
The voluntary sector – there is an enormous amount that can be done using the voluntary services. One of the first steps is to get better links between the groups which have some shared interest; an example of this in Britain is the link that now exist between our ‘Coalition on Cannabis’ and ‘Rethink’, the mental health charity – they have joined together to press the government for better responses to “dual diagnosis” – the situation in which a person is involved with drugs and also has mental health problems.
Drug workers – the main shortcoming in at least my own country – and from my observation I would say in other countries too – is that too much of the total is concentrated on sorting out the problem and not enough to prevent them in the first place. The situation is made worse by too many drug workers having lost sight of the basic goal, which is to produce a healthy society; they have become trapped by the rhetoric of Harm Reductionists and legalisers, falsely believing that in doing so they are giving their drug using clients a good service. The truth is they are giving them a very bad service – indeed, a disservice by allowing them to remain involved with drugs.
Further Education, Universities and Colleges – these establishments have particular problems with drug abuse, and this may be because this is the first time for many young people that they have moved away from home, away from the eyes of their parents. There is a culture of excess in many of these establishments – conspicuous consumption of alcohol and reckless involvement with drugs is seen as necessary to gain acceptance by one’s peer group. Another factor which worsens the situation seems to be the academics, who often demonstrate indulgence when they should be demonstrating leadership.
Teacher training – teachers we have spoken to say that almost no drug training has been given to trainee teachers , and to make things worse there is a large contingent of libertarian trainers in these Teaching colleges. Clearly, these establishment need to be ‘cleaned out and straightened up’.
Young people – research demonstrates that young people are one of the most effective prevention resources for other young people. The value of ‘peer education and peer prevention’ is well demonstrated in the literature and in practice. The Teenex programme is only one of many examples of this.
Parents – together with young people, parents are one of the strongest agents for prevention. (This may be why liberal groups have eroded the position of parents, along with other authority figures, to move the axis of power from ‘parent-child’ to ‘advisory agency-child’. Again, there is a good deal of literature to describe this area.
Faith groups – there is an important place for these groups, and what they say can be influential even with people who are not members of a given faith group, or any group at all.
Clear leadership on moral issues and values needs to be provided, in terms which are meaningful in today’s society. Faith leaders in some cases seem to be too relaxed about negative behaviours and seem to think that they will gather more support for their cause if they justify transgressions rather than pointing out what is wrong. No one is suggesting that ‘fire and brimstone’ sermons are called for, but what is needed is clear spiritual leadership and guidance. In this context, a relatively new technology is developing under the name of “Bio-ethics”. The Institute of Bio-Ethics in Sydney, Australia, is a good example of a resource which can be accessed.
4.4 Is it cost-effective?
There are a number of ways in which the cost-effectiveness of prevention can be measured, but it is fair to say that much more evaluation is needed. Prevention suffers from being the ‘Cinderella service’ in the drugs field. reward. The relatively short supply of evaluation stems from the smallness of most prevention budgets – and the short-sightedness of funders. They demand $1 of prevention activity for every $1 they give, so they do not allocate any money for evaluation. Hopefully the currently renewed interest in prevention will allow this to be rectified.
Of course the libertarians claim that there is ‘no evidence that prevention works’. This is not true, but one could more easily argue that that there is no evidence that Harm Reduction works. The extracts that I gave earlier, from Dr. Eric Voth’s analyses, emphasise this point.
5. CONCLUSIONS
5.1 Create and sustain a Positive, Preventive Culture throughout your society
5.2 Build a prevention-oriented strategy involving the whole community
5.3 Apply early intervention, by agencies cross-referral and by outreach
5.4 Limit the use of ‘real’ Harm Reduction to part of the Treatment process (and use another name for it!)
5.5 Deliver assertive treatment services with an abstinence goal, some of them linked to the Justice system, and
5.6 Balance the rights of the individual with the rights of society.
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