Wither Harm Reduction?

There can be few ideas that have been more immediately appealing than reducing the harm associated with the use of illegal drugs. When it was first articulated in 1988 by the Advisory Council on the Misuse of Drugs harm reduction offered those in the drugs field a way of engaging with clients in which there were more gains, more easily achieved, than the often slow progress of the long road to recovery from dependent drug use.

It is impossible to calculate the amount of money that has been directed at harm reduction within the UK over even the last fifteen years but that figure must be in the tens of billions of pounds. Methadone maintenance, a cornerstone of harm reduction influenced drug treatment, has consistently absorbed the lion’s share of what is now an £800 million a year treatment budget. Hundreds of millions of needles and syringes have been given out to injecting drug users and thousands upon thousands of drug users have been counselled in the practices of safer drug use.

The position of harm reduction at the very forefront of UK drug treatment policy is looking much less assured today than at any time in the recent past. The current drug strategy contains only a single, passing reference to the term (and even that is only a footnote to the alcohol harm reduction strategy for England). The pre-eminent focus of the UK drug strategy is on the recovery rather than simply reducing the harms associated with individual’s drug use (HM Government 2010). So why has harm reduction fallen so far from its favoured position?

First, harm reduction may have suffered as a result of the sheer success it has enjoyed in attracting massive government support set against the evidence of continuing and in some respects escalating drug harm. Hepatitis C is now so widespread amongst injecting drug users that it is difficult to see how, in the absence of harm reduction measures, it could be any more prevalent. In some cities 60% of injecting drug users are Hepatitis C positive. Drug related deaths have continued at an intolerably high level (around 2000 a year) despite a government commitment to reduce the numbers of addict deaths. In some cities, most notably Edinburgh, there have been more deaths associated with methadone than with heroin. There are signs that the level of HIV infection amongst injecting drug users long championed as a success of harm reduction is starting to increase. Between 60% to 70% of crime is connected to the drugs trade and there are clear indications of children using drugs at an increasingly young age. We are now seeing a cocaine problem that has already overtaken our heroin problem. We estimate that there are around 400,000 children growing up with one or both parents dependent upon illegal drugs. None of these are the statistics of a drug problem whose harms have been effectively reduced. The persistence of those harms has given rise to a growing feeling that it may only be by reducing the overall level of drug use that it will truly be possible to reduce the extent of the drug harms we are seeing.

Second, political support for harm reduction may have waned in the face of the evidence that most drug users entering treatment are looking not for advice on how to use their drugs with lower levels of harm but for support in how to become drug free. The first research paper reporting that finding came from Scotland showing that approaching sixty percent of drug users starting a new episode of drug treatment were looking for help in achieving a single goal – to become drug free (McKeganey et al 2004). Those findings were initially rejected by many in the drugs field although a large, National Treatment Agency survey in 2007 reported that 80% of drug users in treatment who were those using heroin, 73% of those using crack cocaine, and 50% of those on methadone were seeking to become drug free (National Treatment Agency, 2008). The emphasis on abstinence in these studies ought not really to have threatened the harm reduction lobby since abstinence was very much at the heart of the earliest formulations of the harm reduction approach. The Advisory Council on the Misuse of Drugs “Act AIDS and Drug Misuse Report”, for example, set out a hierarchy of goals which combined the aim of reducing the shared use of injecting equipment with the aims of reducing the use of prescribed drugs, and increasing abstinence from all drug use. Over time however, harm reductionists steadily diluted their commitment to reducing all forms of drug use (McKeganey 2011).

Third, political support from harm reduction may have waned as a result of the increasingly strident tone of some harm reductionists lobbying in support of the drug using lifestyle and calling for some form of relaxation in the drug laws. Levine has written that “harm reduction is a movement within drug prohibition that shifts drug polices from the criminalized and punitive end to the more decriminalized and openly regulated end of the drug policy continuum. Harm reduction is the name of the movement within drug prohibition that in effect (though not always in intent) moves drug policies away from punishment, coercion, and repression, and toward tolerance, regulation and public health”. (Levine 2001). Craig Reinarman, a U.S. academic supportive of harm reduction has identified the dangers of an increasingly strident tone on the part of some harm reductionists in calling for drug law reform. “The (harm reduction) movement has succeeded”, Reinarman writes, “partly because it blended human right and public health, not because it chose one as superordinate.…The public health principles that under gird harm reduction practices have afforded much needed political legitimacy to controversial policies. This legitimacy is a precious resource, some of which might be jeopardized if the movement were to give loud primacy to the right to use whatever drugs one desires and to make legalization its principle policy objective” (Reinarman 2004:240)

UK drug policy is now at an intersection in which one of the key questions that needs to be addressed has to do with whether it will be possible to combine the current focus on recovery with a commitment to continue to support services aimed at reducing drug related harm. Those who have benefited from the allocation of substantial public funding for harm reduction initiatives may well see their budgets reduced as resources are targeted on the recovery focussed services. If the reaction to any such rebalancing of the drugs treatment budget is an increasingly belligerent tone on the part of those who support harm reduction, it is questionable whether such a combination will be able to develop (Stimson 2010). However, successful interlinking of these approaches may also require harm reductionists to temper their support for drug law reform, emphasising less the rights of the individual to use illegal drugs, and concentrating rather more on individual and public health protection.
Neil McKeganey, Professor of Drug Misuse Research University of Glasgow

Source: Wither Harm Reduction? : UK Drink & Drug News February 2011

Advisory Council on the Misuse of Drugs (1988) AIDS and Drug Misuse: part 1. London: HMSO, 1988.

HM Government (2010) Drug Strategy Reducing Demand Restricting Supply Building Recovery: Supporting people to live a Drug Free life

Levine, Harry G. (2001), The secret of world-wide drug prohibition: The varieties and uses of drug prohibition. Hereinstead , October 2001 On-line: .

McKeganey, N., Morris, Z., Neale, J., Robertson, M. (2004) What are drug users looking for when the contact drug services Abstinence or harm reduction Drugs Education Prevention and Policy 11 (5) 423-435

McKeganey, N (2011) Controversies in Drugs Policy and Practice. Palgrave

National Treatment Agency (2008) 2007 User Satisfaction Survey of Tier 2 and 3 Service Users in England.

Reinarman, C. (2004) Public Health and Human Rights: The virtues of ambiguity International Journal of Drug Policy 15 pp 239-241.

Stimson, G, (2010) Harm reduction: the advocacy of science and the science of advocacy The 1st Alison Chesney and Eddie Killoran Memorial Lecture. London School of Hygiene and Tropical Medicine 17th November 2010

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