Harm Reduction including HIV (Papers)

A small but vocal contingent of drug policy interpreters is attempting again to further the fallacious meme that ‘prohibition’ and ‘supply reduction’ are driving drug deaths in Australia, not poor policy interpretation and use which foster a permission model for the vulnerable and pop-culture informed community – particularly the young, Dalgarno Institute writes.


The National Drug Strategy

The latest National Drug Strategy 2017-26, now puts Demand Reduction as the priority! The strategy states that “Harm Minimisation includes a range of approaches to help prevent and reduce drug related problems…including a focus on abstinence-oriented strategies… [Harm minimisation] policy approach does not condone drug use.” (page 6)“Prevention of uptake reduces personal, family and community harms, allow better use of health and law enforcement resources, generates substantial social and economic benefits and produces a healthier workforce. Demand Reduction strategies that prevent drug use are more cost effective than treating established drug-related problems…Strategies that delay the onset of use prevent longer term harms and costs to the community.” (page 8)

The National Drug Strategy segments the drug issue into three main categories:

Tobacco – Alcohol – Illicit drugs

A quick summary of the policy focus/emphasis on each drug can be encapsulated as follows:


QUIT! Cessation, and exit from tobacco use is the ONLY goal for this drug. There is no illusion about the journey to that destination being difficult, and the reality of failure clear, but the goal posts don’t move QUIT is the ONE message ONE focus and ONE voice in all sectors of the media, community, education and legislation arenas. (Remember this is a legal drug, and until about 20 years ago, utterly socially acceptable) We have reduced smoking rates of 75% of Australian Males (not including females) after World War II down to around 14% of total population. According to health data, approximately 100,000 people give up tobacco each year, but about the same take it up. No prizes for guessing that cohort make up? The 16-24-year-old demographic usually engage (research shows us) in tobacco use mostly when drinking alcohol. Of course, learning ‘smoking’ as a delivery mechanism also equips the tobacco user for ‘smoking’ of other drugs.


‘Moderate! Drink Responsibility!’ However, a growing educative and legislative push (due to the rising costs of alcohol harms to community) is seeing attitudes change, with now approx. 21 per cent of Australians of drinking age now abstinent! (Remember this is a legal and completely socially acceptable drug.)

Illicit drugs

The mantra? ‘Use is likely, so use carefully and don’t die!’ And we are perpetually informed by certain vested interests that for the 3.5 – 4% of illicit drug users in this country (Cannabis use excised from stats here) that cessation of, or exiting from, drug use is virtually impossible – well so the mantra educates, and that ‘learned behaviour’ of powerlessness and choice stripped victimhood is now parroted as reason enough to ‘validate’ the notion of intractability.

So, then it is touted, the only answer for this demographic is either legalisation or a suite of policies or policy interpretations that enables, empowers, endorses or equips on going drug use, because, it is believed any ‘prohibition’ messaging will not only fail, but be counterproductive. But apparently NOT so with Tobacco, where such prohibition messaging has worked brilliantly!!The cognitive dissonance in this space continues to be breathtaking!

So, what of Harm Reduction ONLY policy implementation of our three pillar National Drug Strategy?

Harm Reduction.

Let’s be clear – what we have now in Australia’s drug taking public psyche (learned/taught behaviour), is well educated and fully self-aware, (and product aware) young adults determining that any drug use risk is manageable. Why? These purported intelligent, sophisticated ‘buzz’ seeking and cashed up adult party goers, willingly and deliberately seek out illicit drugs, purchase them with disposable income, not because of the tyranny of addiction, but to ‘enhance the party experience’. They then take these substances to public events and consume these psychotropic toxins.

Of course, they are fully aware of the mantra they have been taught, as early as secondary school, that if something happens all you should do is call the ambulance. Not only will these remarkable and brave tax-payer funded public servants attend to your self-inflicted illegally induced harm, but will ferry you, at cost to the public purse, to an already overcrowded and strained public health facility. There they will be treated by caring professionals, who have more regard for their well-being than the hapless drug user does. Once they are discharged from the hospital, there (for the most part) is no cost to them, and complete impunity from the law. Little, if no legal action or facilitated diversion is taken and the illicit drug user goes on their way until next drug taking episode.

Whilst no one wants to see injury, let alone death from these reckless behaviours, the mechanisms to ‘save lives’ are already well in play and consequently risk/responsibility factors are disregarded. What must not happen, but clearly is happening, is this utter carelessness for wellbeing of self and others cannot, must not be endorsed or worse, enabled/empowered by poor policy or policy interpretation/use.

There is little or absolutely no accountability for this costly, dangerous, self-indulgent and illegal behaviour. And the cry from the pro-drug lobby is not to call for best practice demand reduction, prevention and/or recovery/exit from this activity/behaviour – No, it’s to declare ‘inevitability’ of behaviour and then, the careless equipping, enabling or empowering of mechanisms to assist the educated self-harmer to continue to use!

Again, it is this permission, NOT prohibition that is continuing to put young lives (and more of them) at risk. The no-longer tacit, but now abundantly clear message in the cultural market place, is that ‘you can take drugs anytime and anywhere and nothing will be done, other than assistance for you if things go pear shaped!’

It’s this message, and not demand and supply reduction vehicles which is empowering ongoing drug use.

It’s time to change the narrative around this ever-permissive drug culture – if not for the sake of people’s lives, then for the emerging generation who are watching this model set them up for engagement, not avoidance of illegal drug use.

Genuine compassion driven anti-drug Harm Reduction must always be about the cessation and/or exiting from drug use and any policy or policy interpretation that fosters a contrary outcome is not good drug policy. The drug policy/strategy interpretation narrative has meant that the term ‘harm reduction’ and ‘harm minimisation’ are now interchangeable terms. Essentially this ensures that Harm Reduction becomes the only pillar of the three-pillar strategy is in play.

This has worked marvellously at convincing even anti-drug citizens, that there is only one option available. Time will not permit to table every encounter we’ve had, but the following statement reflects numbers we have heard…

“Pity we can’t use your harm prevention education program, because it’s illegal. We are only allowed to teach harm reduction in schools!” Head of a State Government Regional Education group, Victoria.

Of course, this is patently false, as Demand Reduction and prevention are not only best practice models, but mandated in the NDS, particularly for the demographic with the developing brain – 12-28-year-old! The Key questions that must be asked about illicit drug policy, are the following;

* Does the policy (or interpretation – harm reduction only) lead to an exit from or cessation of drug use, or does it enable, endorse, empower or equip on going drug use?

* Does the policy (or interpretation) increase or reduce demand for illicit drugs?

* Does the policy (or interpretation) undermine or support the other two pillars? (i.e. increase or reduce Demand or Supply for drugs)

If the policy use/interpretation is creating cognitive dissonance in implementation and leads to a conflagration, rather than collaboration of all three pillars, then the strategy is going to have difficulty in effectively moving a culture away from drug use.

Well, perhaps that is exactly the agenda of the pro-drug lobbyists who have inordinate and disproportionate influence in drug policy implementation? I hear even genuine and compassionate harm reductionists, who actually want to stop drug use and see people recover, railing against supply reduction pillar as ‘waste of resources’. And staggeringly many of these same good people are silent on Demand Reduction, the key to seeing change. These two modes of thinking are the key elements of ensuring only one ‘pillar’ of the NDS is focused on, for genuine or disingenuous purposes. Again, one must ask, does the drug policy interpretation facilitate:

Reducing – Remediating – Recovery from drug use?

Or does the policy instead facilitate the:

Enabling – Empowering – Equipping of drug use?

This interpretative matrix needs to be applied to all drug categories and types – for example, do the following strategies lend themselves more to Enabling or Reducing on going drug use?

* Injecting rooms

* Needle Syringe Programs

* Pill Testing

* 12 Step Programs

* Therapeutic Communities


People who inject drugs in Australia can appear to be well provided for with regard to sterile needles and syringes. Across the country there are 3500 needle and syringe programs (NSPs) which distribute almost 50 million pieces of equipment a year. But the international best practice for injecting drugs of a fresh needle for every injection is far from reality. People who inject drugs reuse syringes, share equipment like spoons, water and tourniquets, and a small proportion continue to share injecting equipment with others

. A 20-year survey by the Australian NSP Survey showed that…. Since 2011 the reuse had hovered around 21-25 per cent. The percentage of people who inject drugs who reported they shared syringes with others was also steady at 15-16 per cent from 2011-2015. And the sharing of equipment other than needles remained stable at 28-31 per cent.

This article in a recent ANEX update – notice the nonchalant manner that ‘best practice’ is used and the blithely mentioned MILLIONS of tax-payers funded syringes being unaccountably handed out, yet having 30% of injecting drug users STILL sharing equipment with 16% still sharing needles!

Of course, this proliferation of unaccountable injecting gear has been a key element in the rabid rise in street use and syringe/needle discarding. So, what may be the answer? Will we need to have 3500 injecting rooms open 24/7 for convenience of use and ease of access? Facilities too, with absolute zero accountability as there is absolutely NO potential ‘stigma bestowing’ process permitted that might challenge the behaviour of the self-harming drug taker!

If every injecting episode for every Intravenous drug user was to take place in an injecting room and a sunset clause on such behaviour, ensuring a transitioning to drug use exiting measures, then this might have some merit, as catastrophically expensive and unmanageable as that would be. However, the data tells us that for every single injecting episode that occurs ‘under supervision’, there are over 90 that happen elsewhere!

The appalling ‘health care’ logic, or lack of, is very concerning! It becomes even more so when policy caveats of ‘non-judgemental’ attitudes (whatever that this subjective descriptor can mean) are foisted upon, even the NSP staff – However, NO SUCH MORAL COMMENTARY can be levelled, what-so-ever, at the person who is the self-harming, law breaking, body destroying, and no doubt, family grieving drug taker! This at best is

‘moral’ hypocrisy – at worst unconsumable! (Of course, that last sentence itself is viewed as counterproductive and stigmatizing and thus not permitted in the discourse!)

“The perpetual permission of harm reduction only policies, NOT prohibition is putting lives at risk!” Dalgarno Institute.

Injecting Rooms

Gary Christian, Secretary for Drug Free Australia, has pointed to the lack of success by the Kings Cross Injecting Centre (MSIC) in reducing overdose deaths in the Kings Cross area. He said, “Tracking of overdose deaths in the Kings Cross area from 5 years before the injecting room opened compared with the 9 years after the injecting room was opened showed no change whatsoever in the percentage of deaths in the area as compared to the rest of NSW. The KPMG review showed that Kings Cross had 12% of NSW opiate deaths before the commencement of the MSIC, and in the 9 years after it remained at 12%, such has been its failure to make any difference.”

Evidence given to the NSW Parliament indicates that overdoses in the Kings Cross injecting room are 32 times higher than the overdose histories of those entering the injecting room, indicating that clients are experimenting with higher doses of opiates and cocktails of drugs knowing that if they should overdose in their experimentation, someone will bring them around. NSW Hansard records testimony from ex-clients of the injecting room who were rehabilitating from drugs that experimentation with higher doses of drugs is the reason for the inordinately high overdose rate in the room.

The question now appears to not be about ‘best practice’, but simply what emotive or socio-political drivers dictate when it comes to drug policy – So, where do you land? If you’re all for drug use, then another conversation and investigation in to the why of that is your priority. However, the disturbing reality for the tens of thousands of ex-users who already know the ultimate outcome of illicit drug use is. The reality is, those conversations and investigations are near impossible for a person using the substance in a culture that passively, no, actively permits it!

Any enterprise that inadvertently enables, empowers or equips ongoing illicit drug use has already breached best health care practice. Harm Reduction can never be about the support of on-going, health diminishing substance use. Caring, responsible and civic minded clinicians and policy makers will always be focused on movement toward exit from, and cessation of drug use. Mechanisms that enable any government agency to send a message to the community that we are not only supporting, but enabling tax payer funded illicit drug use, not only breaches care for the illegal drug user, but breaches international conventions. It also demonstrates a lack of concern for most of the non-drug using community.

I trust a thorough ‘best practice’ consideration of any drug policy ‘strategy’ will always seek to reduce demand for and use of any illicit drug, if not for the sake of the drug user, then for the wider community, who the vast majority of are illicit drug free. Our emerging generation need proactive and protective mechanisms to give them best chance to live drug free lives.

Let us be very clear, we are not conducting a ‘war against drugs’. We are however fighting for the brains, potentials, and in many instances, the very future of an entire emerging generation. (Dr Bertha Madras – Harvard) That for any caring civic minded human being is a fight worth having, and one worth joining!

Source: dbrecoveryresources.com/2018/04/permission-empowered-drug-policy-interpretations-drive-demand-for-drug-use/ Dalgarno Institute

Ontario opted not to follow B.C.’s lead on harm reduction, rejecting the idea of creating safe injection sites similar to the one in Vancouver. Postmedia News files

In December, the Liberal government introduced Bill C-37 in response to an epidemic of illicit drug use. The bill facilitates the creation of additional supervised injection sites by reducing previously established restrictions.

The decision to promote supervised injection sites is in line with the latest philosophy guiding addiction management — that of harm reduction. Proponents claim harm-reduction institutions will save lives while averting hundreds of thousands in medical and criminal-legal expenses.

Much in the harm-reduction philosophy is laudable — the desire to destigmatize and protect those with severe illnesses for one — but the field is slipping into dangerous, almost Brave-New-World territory.

In Toronto and Ottawa, supposedly inveterate alcoholics receive calculated amounts of alcohol hourly throughout the day at designated wet shelters and managed alcohol programs. Residents line up on the hour to receive just enough house-made wine to keep withdrawal symptoms at bay. Some drink almost three bottles of wine daily with little to do in between scheduled drinks.

Vancouver, which was Canada’s first city to establish a safe injection site in 2003, has now progressed to experimenting with “heroin-assisted treatment” as a means of further protecting addicts from the harms of tainted street drugs. Participants receive pharmaceutical-grade heroin injections two to three times daily. Recently, in place of heroin, the more innocuous-sounding but no less potent opiate, hydromorphone, is being administered instead.

Is their drug use no longer a problem because they’re off the street? And where exactly do the patients go from here?

Most lay supporters of harm-reduction policy assume a gradual attempt is made to wean the addict off the substance of abuse. Proponents claim that harm reduction isn’t about “giving up” on the addict but is actually a temporary stepping stone towards the ultimate goal of recovery.

But the reality is different.

Dr. Jeffrey Turnbull, who established Ottawa’s managed alcohol program, offers a more sober portrayal of the goals of harm reduction. In a Fifth Estate documentary, he compares his program for those with chronic and severe addictions to palliative care. He agrees his facility is a place for alcoholics to “die with dignity” as opposed to dying on the streets. One resident featured in the episode had been using the program’s services for four years; he was only 24 when he first entered the managed alcohol program.

No doubt, the medical community is frustrated by the high failure rates associated with abstinence-based treatment programs but the criteria for determining when an addict now warrants a harm-reduction approach is unclear. Addiction does not follow a linear natural history akin to metastatic cancer; rather, there exists a variable trajectory and the possibility for recovery is always there.

However, Turnbull’s admission points to an uncomfortable belief underlying the harm-reduction philosophy — the view that some addicts are without hope of ever leading a full, productive life free of drug use.

It may be true that, for some, the best we can do is safe, controlled sedation. But the medical community and society should not be so quick to condemn many others to the compromised mental prison that is the life of the addict.

Proponents argue that harm reduction and abstinence are not mutually exclusive, and some even suggest that harm-reduction institutions actually improve recovery rates. But this is a fiction and is without evidence.

Harm-reduction researchers have conveniently neglected to investigate any potentially negative findings of their policies. Their studies focus exclusively on the obvious benefits such as decreased overdose deaths, cost savings, and so-called “treatment retention.” That addicts will remain “in treatment” longer when freely administered their drug of choice is not surprising, but that this is in their best interests is highly questionable.

Politicians insist supervised injection sites and managed substance programs are effective “evidence-based” interventions, but these assertions are problematic when the evidence only tells half the story.

Canada is quickly moving towards an addiction defeatist infrastructure. Toronto, Montreal, Ottawa and Victoria are all following Vancouver’s lead in constructing further supervised injection sites. Widespread creation of managed substance programs is the next logical step of the harm-reduction approach. Unless vigilance is exercised, we risk relegating addicts to a half-conscious state whereby life is maintained but not really lived.

It is both tragic and ironic that the activist responsible for implementing widespread harm reduction policies in Toronto, Raffi Balian, recently died from an accidental overdose while attending a harm-reduction conference in Vancouver. His death highlights the inadequacy of half measures when dealing with the insidious and powerful disease that is addiction.

Jeremy Devine is a medical student at the University of Toronto’s Faculty of Medicine and a CREMS research scholar in the medical humanities and social sciences

Source: http://www.nationalpost.com/m/search/blog.     2nd March 2017

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

SEPTEMBER 20, 2004







(i) The New Haven Study

NEP activists frequently cite the results of a New Haven, Conn., study, published in the American Journal of Medicine, which reported a one-third reduction of HIV among NEP participants. However, the New Haven researchers tested needles from anonymous users, rather than the addicts themselves, for HIV.  They never measured “seroconversion rates,” which determine the portion of participants who become HIV positive during the study.  Also, sixty percent of the New Haven study participants dropped out; those who remained were presumably more motivated to protect themselves, while the dropouts likely continued their high risk behavior.

 Essentially, the New Haven study merely reported a one-third decrease in HIV-infected needles themselves, which, considering the fact that the NEP flooded the sampling pool with a huge number of new needles, is hardly surprising.  Even Peter Lurie, a University of Michigan researcher and avid NEP advocate, admits that “the validity of testing syringes is limited.”

Furthermore, the New Haven study was based on a mathematical model of anonymous needles using six independent variables to predict the rate of infection. The unreliability of any of the variables invalidates the result. The New Haven study also assumed that any needle returned by a participant other than the one to whom it had been given had been shared, and that any needle returned by the original recipient had not been shared. Both assumptions are suspect.   Also, the role of HIV transmission through sexual activity is downplayed. Prostitution often finances a drug habit. Non-needle using crack addicts have high incidence of HIV. Recent studies reveal that the greatest HIV threat among heterosexuals is from sexual conduct, not from dirty needles.   Less than one-third of the New Haven subjects practiced safe sex. In the New Haven study, sampling error alone could account for the 30 percent decline.
(ii) The HHS / NAS Study

In 1992, Congress directed the U.S. Department of Health and Human Services (HHS) to study NEPs. HHS in turn commissioned the National Academy of Sciences (NAS), an independent, congressionally chartered, non-government research center, to conduct the study.  According to the Congressional directive, if the NAS could show that NEPs worked and did not increase drug use, the Surgeon General could lift the ban on federal funding. The study was completed in 1995, and it concluded that well run NEPs could be effective in preventing the spread of HIV, and do not increase the use of illegal drugs. The NAS panel further recommended lifting the ban on federal funding for NEPs and legalization of injection paraphernalia. Now, seven years after the NAS study, Congress has yet to lift the NEP funding ban, clearly indicating that Congress maintains serious doubts as to the validity of the NAS/HHS conclusions regarding NEPs.  Of note is that study chairman Dr. Lincoln E. Moses cites the dubious New Haven study as a basis for the NAS findings.   The NAS panel admitted that its conclusions were not based on reviews of well-designed studies, and the authors admitted that no such studies exist.  Incredibly, the panel reported that “the limitations of individual studies do not necessarily preclude us from being able to reach scientifically valid conclusions.”

Two of the physicians on the NAS panel, Herbert D. Kleber, M.D. and Lawrence S. Brown, M.D., say the news media exaggerated the NAS’s findings. “NEPs are not the panacea their supporters hope for…We personally believe that the spread of HIV is better combated by the expansion and improvement of drug abuse treatment rather than NEPs, and any government funds should be used instead for that purpose.”   Dr. Kleber, executive vice president for medical research at Columbia University, added: “The existing data is flawed.  NEPs may, in theory, be effective, but the data doesn’t prove that they are.”  

This questionable NAS study represents the cornerstone research data used by the notoriously-politicized U.S. Department of Health and Human Services.  The pro-NEP advocacy of HHS, and its supporting data, has yet to convince Congress that NEPs are scientifically proven to reduce HIV infection while not increasing drug usage.

6 Id.
7  See Loconte, Joe, Policy Review, supra, note 2.
8  See New Jersey Family Policy Council, ANeedle Exchange Programs – Panacea or Peril, supra, note 1 
9    See Loconte, Joe, Policy Review, supra, note 2.
   (iii) The CDC Study

The Centers for Disease Control (CDC) conducted a study whose chief architect, Dr. Peter Lurie, recommended NEPs.  The CDC report calls for federal funds for NEPs and the repeal of drug paraphernalia laws
However, although the CDC study endorses NEPs, Dr. Lurie, the study’s author, acknowledges numerous problems:  None of the studies were randomized, and self reported behavior was often the basis for outcomes. Poor follow up and rough measurement of risk behavior also present problems, and he notes that syringe studies have limited validity. The report concludes: “Studies of needle exchange programs on HIV infection rates do not, and in part due to the need for large sample sizes and the multiple impediments to randomization, probably cannot provide clear evidence that needle exchange programs decrease HIV infection rates.”

(iv) The Montreal Study

A 1995 Montreal study, published in the American Journal of epidemiology, showed that IDUs who used the NEP were more than twice as likely to become infected with HIV as IDUs who did not use the NEP. Thirty three percent of NEP users and 13 percent of nonuser became infected.  There was an HIV seroconversion rate of 7.9 per 100 person years among NEP participants, and a rate of 3.1 per 100 person years among non-participants. 

A high percentage of both groups shared intravenous equipment in the last six months: 78 percent of NEP users and 72 percent of non-NEP users. Risk factors identified as predictors of HIV infection included previous imprisonment, needle sharing and attending an exchange in the last six months. The study authors stated: “We caution against trying to prove directly the causal relation between NEP use and reduction in HIV incidence. Evaluating the effect of NEPs per se without accounting for other interventions and changes over time in the dynamics of the epidemic may prove to be a perilous exercise.”  The study concluded:  “Observational epidemiological studies…are yet to provide unequivocal evidence of benefit for NEPs.” 
(v) The Vancouver Study
Vancouver has the largest NEP in North America, and was praised in the 1993 CDC report. It is financed by public funds, and by 1996 was distributing over 2 million needles per year.  A 1997 evaluation of the needle exchange program in Vancouver showed that since the program began in 1988, AIDS prevalence in intravenous users rose from approximately 2% to 27%.  This occurred despite the fact that 92% of the intravenous addicts in that jurisdiction participated in the needle exchange program.
The Vancouver study also found that 40% of the HIV-positive addicts who participated in the program had lent a used syringe in the previous six months, and that 60% of HIV-negative addicts had borrowed a used syringe in the previous six months.  Despite the enormous number of clean needles provided free of charge, active needle sharing continued at an alarming rate.  After only eight months, 18.6 percent of those initially HIV negative became HIV positive. 

The Vancouver study corroborates a previous Chicago study which also demonstrated that its NEP did not reduce needle-sharing and other risky injecting behavior among participants. The Chicago study found that 39% of program participants shared syringes, compared to 38% of non-participants; 39% of program participants, and 38% of  non-participants “handed off” dirty needles; and 68% of program participants displayed injecting risks vs. 66% of non-participants.
The Vancouver report noted that “it is particularly striking that 23 of the 24 seroconverters reported NEP as their most frequent source of sterile syringes, and only five reported having any difficulty accessing sterile syringes.”
The authors continue: “Our data are particularly disturbing in light of two facts:  first, Vancouver has the highest volume NEP in North America; second, HIV prevalence among this city’s IDU population was relatively low until recent years.  The fact that sharing of
injection equipment is normative, and HIV prevalence and incidence are high in a community where there is an established and remarkably active NEP is alarming.”  

What should be obvious from all of the studies above is that there is no conclusive scientific evidence that NEP’s arrest HIV infection.  Indeed, there is evidence that NEP’s breed HIV infection.

Some claim that the federal government supports NEPs. While the previous administration’s Department of Health and Human Services actively favored NEPs, those who were actually in charge of our national drug policy do not. General Barry McCaffrey, then director of the Office of National Drug Control Policy (ONDCP), when addressing the issue of NEPS stated “we have a responsibility to protect our children from ever falling victim to the false allure of drugs. We do this, first and foremost, by making sure that we send them one clear, straightforward message about drugs: They are wrong and they can kill you.” McCaffrey’s strong views influenced President Clinton not to approve federal aid money for NEPs.
A further elaboration of the ONDCP’s policy was provided by James R. McDonough, Director of Strategic Planning for ONDCP, who wrote:

       ‘  The science is uncertain. Supporters of needle exchange frequently gloss over gaping holes in the data — holes which leave significant doubt regarding whether needle exchanges exacerbate drug use and whether they uniformly lead to decreases in HIV transmission. It would be imprudent to take a key policy step on the basis of yet uncertain and insufficient evidence.

     The public health risks may outweigh potential benefits. Each day, over 8,000 young people will try an illegal drug for the first time. Heroin use rates are up among youth. While perhaps eight persons contract HIV directly or indirectly from dirty needles, 352 start using heroin each day, and more than 4,000 die each
     year from heroin/morphine-related causes (the number one drug-related cause of death).Even assuming that NEWS can further accelerate the already declining rate

  of  HIV transmission, the risk that such programs might encourage a higher rate of heroin use clearly outweighs any potential benefit.

    Treatment should be our priority. Treatment has a documented record of reducing drug use as well as HIV transmission. Our fundamental obligation is to provide treatment for those addicted to drugs. NEPS should not be funded at the expense of treatment.

Supporting NEPS will send the wrong message to our children. Government provision of needles to addicts may encourage drug use. The message sent by such government action would be inconsistent with the goals of our national youth-oriented anti-drug campaign.

NEPS do nothing to ameliorate the impact of drug use on disadvantaged neighborhoods. NEPS are normally located in impoverished neighborhoods. These programs attract addicts from surrounding areas and concentrate the negative consequences of drug use, including of criminal activity. 

 (vi) Among IV drug users, HIV is transmitted primarily through high-risk sexual      contact
Another reason why NEPs may not retard the spread of HIV is that HIV is transmitted primarily through high-risk sexual contact, even among IV drug users.  Contrary to prior assumptions, recent studies on the efficacy of NEPs have discovered that it is not needle exchange, but instead, high-risk sexual behavior which is the main factor in HIV infection for men and women who inject drugs, and for NEP participants. A recently released 10-year study has found that the biggest predictor of HIV infection for both male and female injecting drug users (IDUs) is high-risk sexual behavior and not sharing needles. High-risk homosexual activity was the most significant factor in HIV transmission for men and high-risk heterosexual activity the most
significant for women.  The study noted that in the past the assumption was that IDUs who were HIV positive had been infected with the virus through needle sharing.

The researchers collected data every 6 months from 1,800 IDUs in Baltimore from 1988 to 1998. Study participants were at least 18 years of age when they entered the study, had a history of injection drug use within the previous 10 years, and did not have HIV infection or AIDS. More than 90 percent of them said they had injected drugs in the 6 months prior to enrolling in the study. In their interviews, the participants reported their recent drug use and sexual behavior and submitted blood samples to determine if they had become HIV POSITIVE since their last visit. The study showed that sexual behaviors, which were thought to be less important among IDUs, are the major risk for HIV seroconversion for  both men and women. 

If the above conclusions are correct, the very presumption of NEP efficacy becomes suspect.  Indeed, the use of needle exchange programs to address a problem which is caused primarily by high-risk sexual behavior would seem to be highly misguided.

Another reason that Needle Exchange Programs do not effectively address the issue of “saving lives” is that HIV (regardless of how it is contracted) is not the primary cause of death for IVUs.  A study conducted at the University of Pennsylvania followed 415 IV drug users in Philadelphia over four years.  Twenty eight died during the study.  Only five died from causes associated with HIV.  Most died of overdose, homicide, suicide, heart or liver disease, or kidney failure.

Clean needles, even if they in fact prevent HIV, will do nothing to protect the addict from numerous more imminent fatal consequences of his addiction.  It is both misleading and unethical to give addicts the idea that they can live safely as IV drug abusers.  Only treatment
and recovery will save the addict.  The myth of “safe IV drug use” is a lie which is perpetuated by NEPs, and it is a lie which will tend to kill the addict, although his corpse may be free of HIV, for whatever consolation that will provide to the NEP proponent.  

The rise of NEPs, with their inherent facilitation of drug use (coupled with the provision of needles in large quantities), may also explain the rapid rise in binge cocaine injection which may be injected up to 40 times a day. Some NEPs encourage cocaine and crack injection by providing “safe crack kits” with instructions on how to inject crack intravenously.  Crack cocaine can be, and generally had been, ingested through smoking.  But the easy and plentiful availability of needles facilitates crack injection, creating a new segment of IV drug users, subject to health dangers they would otherwise have been spared exposure to.  In some NEPS, needles are provided in huge batches of 1000, and although there is supposed to be a one-for-one exchange, the reality is that more needles are put out on the street than are taken in.

NEPs also facilitate drug use through lax law enforcement policies.  Police are instructed not to harass addicts in areas surrounding NEPs. Addicts are exempted from arrest because they are given an anonymous identification code number. Since police in these areas must ignore drug use, and obvious and formidable disincentive to drug use disappears.  As the presence of law enforcement declines in these areas, the supply of drugs rises, with increased purity and lower prices, attracting new and younger consumers. 

Many drug prevention experts have warned that the proliferation of NEPS would result in a rise in heroin use, and indeed, this has come to pass. (However, the increase in drug use was ignored by the federally-funded studies which recommended federally funding NEPS). The National Center on Addiction and Substance Abuse at Columbia University reported August 14, 1997 that heroin use by American teens doubled from 1991 to 1996.  In the past decade, experts
estimate that the number of US heroin addicts has risen from 550,000 to 700,000. 
In 1994, a San Francisco study regarding a local NEP falsely concluded that there was no increase in community heroin use because there was no increase in young users frequenting the NEP.  The actual rate of heroin use in the community was not measured, and the lead author, needle provider John Watters, was found dead of an IV heroin overdose in November 1995. According to the Public Statistics Institute, hospital admissions for heroin in San Francisco increased 66% from 1986 to 1995.

In Vancouver, site of the largest NEP in North America, heroin use has risen sharply.  In 1988 when the NEP started, 18 deaths were attributed to drugs.  In 1993, 200 deaths were attributed to drugs. A 1998 report notes that drug deaths were averaging 10 per week.  Now Vancouver has the highest heroin death rate in North America, and is referred to as Canada’s “drug and crime capital.”

The 1997 National Institutes of Health Consensus Panel Report on HIV Prevention praised the NEP in Glasgow, Scotland, but the report failed to note Glasgow=s massive resultant heroin epidemic. Subsequently, as revealed in an article entitled “Rethinking Harm Reduction for Glasgow Addicts,” Glasgow took the lead in the United Kingdom in deaths from heroin overdose, and its incidence of AIDS continues to rise. 

Boston’s NEP opened in July 1993, and the city became a magnet for heroin. Logan Airport has been branded the country’s “heroin port.”  Boston soon led the nation in heroin purity (average 81%), and heroin samples of 99.9% are found on Boston streets. Subsequently, Boston developed the cheapest, purest heroin in the world and a serious heroin epidemic among the youth.  The Boston NEP was supposed to be a “pilot study,” but there was no evaluation of seroconversion rates in the addicts nor of the rising level of heroin use in the Boston area.

Similarly, the Baltimore NEP is praised by those who run it, but the massive drug epidemic in the city is overlooked.  The National Institute of Health reports that heroin treatment and ER admission rates in Baltimore have increased steadily from 1991 to 1995. At one open-air drug supermarket (open 9 a.m. to 9 p.m.) customers were herded into lines  sometimes 20 or 30 people deep. Guarded by persons armed with guns and baseball bats, customers are frisked for weapons, and then allowed to purchase $10 capsules of heroin.
One thing should be clear from the foregoing: since the implementation of NEPs, heroin use in our country has boomed.  It is obvious:  a public policy of giving needles to heroin addicts facilitates and encourages heroin use. 

Most citizens oppose NEPs in their communities, and are concerned about the prospect of dirty needles being discarded in public places.  These fears are not without merit.  NEPs distribute millions of needles every year, and there is little or no accountability for needles once they have been distributed.  A survey conducted in 1998 revealed that in that year 19,397,527 needles handed out, and at best 62% were exchanged, leaving 7-8 million needles unaccounted for.   Carelessly discarded needles create a well-documented public hazard:

* On February 11, 2001, a six-year old from Glade View, Florida, stabbed five children with a discarded syringe. (Kellie Patrick/Scott Davis, “Playground Attack Raises Health Worries,” Sun Sentinal, 2/9/00, p 1B).

* On February 2, 2001, a nine year old from the Bronx stabbed four children with a discarded needle. (Diane Cardwell, “Boy Accused of Needle Attack,” The New York Times, 2/2/01, p. A17.)

* On February 13, 2001, a syringe left at a bus station stuck a four year old boy. (Mike Hast, “Big Fines for Syringe Litterers,” Frankson & Hastings Independent, February 13, 2001,www.mapinc.org/drugnews/v01/n304/ a08.html.)

Besides the physical hazard created by discarded needles, there is a commonsense perception that NEPs bring an air of decay to the communities that host them.  After several years of operation, 343 Massachusetts towns and cities (out of a total of 347) continue to decline the option of approving a local NEP, although of the 10 available slots, only 4 are taken.
31  Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, HHS,       Washington, DC 2001;50:384-388. 
32  Maginnis, Robert L., 2001 Update On The Drug Needle Debate, Insight, Number 235, July 16, 2001, Family Research Council, 801 G. St. NW, Washington, DC 2001.
In March 1997, accompanied by a New York Times reporter, a member of the Coalition for a Better Community, a New York City group opposed to NEPs, visited the Lower East Side Needle Exchange. She was not asked for identification and was promptly given 40 syringes (without having to produce any to exchange).  She was also given alcohol wipes and “cookers” for mixing the drugs, and she was given an exchange ID card that would exempt her from arrest for possession of drug paraphernalia. She was then shown how to inject herself. 

Community opposition to the Lower East Side Needle Exchange arose soon after implementation of the local NEP due to an increase in dirty syringes on neighborhood streets, in school yards and in parks. There was observed to be a dramatic increase in the public display of injecting drugs.  NEP users were seen selling their syringes to buy more drugs. Exchange workers themselves were photographed selling needles offsite.  Neighbors perceived the Lower East Side NEP as little more than a wholesale distribution center for clean needles and a social club for addicts. 

Pro-needle activist Donald Grove concurred: “Most needle exchange programs actually provide a valuable service to users beyond sterile injection equipment. They serve as sites of informal organizing and coming together. A user might be able to do the networking to find good drugs in the half an hour he spends at the street based needle exchange site networking that might otherwise have taken half a day. [Grove, D. The Harm Reduction Coalition, N.Y.C., Harm Reduction Communication, Spring 1996].

In 1998, a U.S. Government official was sent to Vancouver, site of the largest NEP in North America, to assess the high incidence of HIV among NEP participants, and the skyrocketing death rate due to drug overdose.  He reported that the highest rates of property crime in Vancouver were within two blocks of the needle exchange.  He also observed, pursuant to a tour with the Vancouver Police, that there was a 24 hour drug market and plain view injection activity in the area immediately adjacent to the needle exchange.  Most poignantly, he was told, in a private interview with an elementary school teacher, that the children at area schools are not allowed outside at recess for fear of needles. 

There is ample evidence to suggest that very fundamental premises used to justify and support NEPs are seriously flawed.  First, NEP participants routinely continue to share needles and large percentages of the NEP participants are HIV positive, meaning that NEPs do nothing more than continue the spread of HIV (and HCV).  Significantly, no one has been able to explain satisfactorily why enhanced needle availability in and of itself would discourage needle sharing: needle sharing is an intrinsic aspect of IV drug use, and a NEP-issued needle will transmit HIV as well as any other needle.

Second, NEP studies have discovered (inadvertently) that needle sharing is not even the primary cause of HIV infection for IVUs.  It is primarily through high-risk sexual behavior that IVUs contract HIV; free needles do nothing to prevent sexually transmitted disease.  Furthermore, HIV (regardless of how it is contracted) is not even the primary cause of death for IVUs.  Most die of overdose, homicide, suicide, heart or liver disease, or kidney failure.  Clean needles may protect an addict from HIV, but they do nothing to protect him from the more numerous, and more imminent fatal threats of his addiction.  Several key NEP proponents have died of heroin overdose; no doubt their needles were very clean.

Third, the science is inconclusive.  Although the proponents of NEPs uniformly aver that the scientific debate regarding the efficacy of NEPs is over, in truth, even the reports favoring NEPs are burdened with imprecise methodology, and many of the authors of those reports caution that their results should not be deemed conclusive. Today, there is still no conclusive scientific evidence: (1) that NEPs reduce the spread of HIV and HCV, or (2) that NEPs do not encourage IV drug use.  Indeed, the correlation between the rise of NEPs and the explosion of IV drug use, if it is a coincidence, is a remarkable one.  Dispassionate observers will look at the current epidemic of heroin and IV cocaine use as a tragedy which might have been averted, or mitigated, but for the misguided mercies of the NEP concept.
Fourth, while the benefits of NEPs may be in doubt, the costs to the surrounding communities are very real.  The overwhelming majority of communities dread the prospect of a local NEP, for self-evident and well-documented reasons.

 34  D.B. Des Roches, Information, Memorandum for the Director, Through: the Deputy Director, Subject: Vancouver Needle Exchange Trip Report, Executive Office of the President, Office of National Drug Control Policy, Washington, D.C. 20503, April 6, 1998.

In good faith, the Substance Misuse Management in General Practice issued guidance now proven to be based on unfounded figures – they were taken at face value from the National Treatment Agency for Substance Misuse. Peter O’Loughlin puts the record straight.
Many – perhaps most of us – have become accustomed, even weary, of the plethora of self-congratulatory announcements issued by the National Treatment Agency for Substance Misuse. Most of the spin aims to persuade us that protocols and implementations of the current drug treatment strategy are succcessful. Indeed, such is the glut of these proclamations of success, that there is a temptation, at least by this writer, to skip them in favour of more factual and unbiased reading.
On the other hand, when a responsible and professional network such as the Substance Misuse Management In General Practice chooses to re-issue verbatim one of the more misleading documents emanating from the NTA, and endorse it as an “important report”, this writer sits up and pays attention.
The document in question is Good Practice in Harm Reduction (NTA report, October 2008).
While acknowledging that government targets for reducing drug-related deaths have not been met, it makes the following claim: “Drug related deaths have gone down in recent years”.
It then purports to show how harm reduction “combines work aimed directly at reducing the number of drug-related deaths and blood-borne virus infections, with wider goals of preventing drug misuse and of encouraging stabilisation in treatment and support for abstinence”.
It is the intention of this article, with the aid of statistical evidence from the National Audit Office and the Health Protection Agency, to show that the claim relating to drug deaths is palpably misleading – and that the current emphasis on harm reduction is failing not only in reducing drug deaths, but that they are actually increasing. This is alongside the abysmal failure of inappropriately named “harm reduction” methods to contain the escalation of blood-borne diseases.
The following facts for drug deaths arising from misuse were published by the NAO in its April 2007 and autumn 2008 reports.
• Drug deaths from heroin and morphine are increasing year on year
• In 2003-4 there was a marked increase in drug-related deaths which were largely attributed to heroin, methadone and morphine.
• Drug-related deaths are the highest in five years.
• The total number of drug-poisoning deaths arising from drug misuse in 2007 increased by 16% from 2006, to 2,640.
• In 2007, 196 deaths involving cocaine occurred, the highest number of deaths involving cocaine since records by the Office of National Statistics began in 1993.

Deaths attributed to methadone are at their highest since 1999. In 2007, methadone-related deaths increased by 35% over 2006 to 325.
The following facts were published by the Health Protection Agency.
• The level of HIV infection among injecting drug users (IDUs) in England and Wales is higher now than at the start of the decade.
• In London, where the prevalence of HIV in IDUs is higher than elsewhere in England and Wales, one in 20 IDUs is infected.
• In the remainder of England and Wales, HIV among IDUs has risen from about one in 400 in 2002 to about one in 150 in 2006.
• The prevalence of hepatitis C among IDUs has risen from 33% in 2000 to 42% in 2006.
• About one in five IDUs has hepatitis B infection, which extrapolates as an increase approaching 200% since 1997.
It is self evident from the facts that the disproportionate emphasis on harm reduction is failing to achieve that which the NTA document would have us believe.
The author(s) of the document contents have – knowingly or unknowingly – resorted to a technique known as ‘perception management’. This process could be regarded as more sinister than spin, since it seeks to bury the truth under a garbage of rhetoric in order to manufacture a ‘truth’ designed to influence or change the perceptions of a targeted audience.
Via email, I expressed my disappointment to the SMMGP for publishing as a “policy update” the NTA document, together with the endorsement the SMMGP gave. I now place on record my appreciation to Dr Chris Ford for the courtesy and promptness of her response.
In an age where avoidance of responsibility is so common, I also take this opportunity of expressing my admiration and respect for the forthrightness of her “mea culpa”, together with the integrity and that rare quality of humility which she displayed in our subsequent correspondence.
PETER O’LOUGHLIN is certificated in substance misuse and dependency by the Department of Addictive Behaviours, St George’s Medical School and Addaction, is an associate member of the Medical Council on Alcohol, a registered psychotherapist and clinical hypnotherapist. His 25 years’ experience spans detox, street work, rehabilitation,1:1 and group counselling.
Source: Addiction Today Feb.22nd 2009

By Evelyn Yang,M.A.Part of the nature of community-based health initiatives, such as community anti-drug coalitions, is the importance of community participation. It is standard practice to create community collaborative groups that direct planning, implementation and evaluation of community-based prevention efforts. However, research has not yet demonstrated that collaboration and interventions targeting community participation can effectively move the needle on behavioral/health outcomes. Why has this been the case?

• Researchers and community members do not agree in their “goals and priorities.”

• Difficulty in reaching agreement on program objectives.

• Confusion around stakeholders’ roles and responsibilities.

• Externally driven time constraints may not allow communities enough time to gather a group of stakeholders together that can collaboratively drive a process resulting in population level change.

• Lack of sufficient funding, technical assistance and resources to sustain community initiatives.

• Community consensus-based models may not address the power differences and conflicts that exist in the community.

• Researchers may be using inappropriate methods/tools to adequately evaluate the complex interconnectedness of the various programs,policies and practices implemented by a coalition.

While community-based health initiatives have become popular vehicles to support health promotion and disease prevention, evaluations of many of these efforts have shown only a limited impact in changing behaviors at the population level. Outcomes have not lived up to the promise of these comprehensive, community-change oriented models. However, while other health prevention initiatives show little to no effects, HIV prevention initiatives have demonstrated greater success. What are the lessons to be learned from the HIV prevention field?

Lessons from HIV Prevention Initiatives

• Emphasis on Modifying Social Norms – Programs, practices and policies target modifying the social norms around risky behaviors, focusing on increasing the social desirability of avoiding risky behavior.

• Use of Formative Research – Research was conducted to specifically tailor interventions to a targeted population.

• Use of Trusted Community Peer Volunteers – Community member volunteers help ensure that interventions/programs are provided in ways that are appropriate to the context of the environment and the people they are reaching.

• Understanding the Nature of Risk and Communities – Since HIV is easily communicable through relatively few engagements in risky behavior, successful interventions target changing just a few risky behaviors. Also, the target population is easily identified and relatively homogeneous, which helps in program adaptation. This is very different from coalitions that engage in multi-level/multi-strategic efforts targeted at the general community.

Implications for Community Anti-Drug Coalitions

From the current body of research on coalition effectiveness and from the lessons learned from the HIV prevention field, there are new directions for community anti-drug coalitions to move towards as they work on addressing their local substance abuse issues:

• Need to better understand how to best evaluate community-based health initiatives, including the scale and time frame needed to have a detectable impact on health outcomes.

• Need to be concrete and think through what are realistic and valid outcomes. If a coalition’s focus is on changing individual behavior, then expecting population level change may be unrealistic.

• Need for new evaluation tools and methods to fully understand the rich, synergistic coalition process.

• Need to focus on community-level change, including policies and norms, and energizing community members and organizations.

• Critical to use programs, policies and practices that specifically target high-risk behaviors and also have strategies focused on the population as a whole. Use a mix of universal, selected and indicated approaches.

• Community readiness and capacity issues must be addressed – need a thorough understanding of the community before programs, policies and practices can be tailored and implemented.

For more information, please read: Merzel, C. & D’Affitti, J. (2003). Reconsidering Community-based Health Promotion: Promise, Performance, and Potential. American Journal of Public Health, 93, 557-574.

Evelyn Yang is the Manager of Evaluation and Research for CADCA’s National Coalition Institute. You may contact her at eyang@cadca.org.

Visby, Sweden – May 3rd to 6th, 2001

‘The History of Harm Reduction’
Paper by Peter Stoker: Director, National Drug Prevention Alliance (UK).

1. Introduction

With a title like ‘the history of …’ you might reasonably expect a historian to be standing here, but I’m not one. Nevertheless I can apply my experience to analysing this situation, and much of that experience, until I moved into the drugs field 15 years ago, was as a construction engineer. Part of my training then was to explore when things collapse, and find out why. Our society has not yet totally collapsed, but it is showing signs of severe stress. Cracks are appearing, and we need to shore the whole structure up quickly, if we are not to be crushed. What is causing this? Basically, our foundations are being undermined.

In this paper I will try to give you my ‘structural analysis’ of the Harm Reduction movement, and some indications for avoiding future collapse.

When Torgny Peterson first asked me to deliver this paper, I misheard him. I thought he asked me to write not about the History, but about the Mystery of Harm Reduction. It seemed a sensible request, but in checking my dictionary I found that a more appropriate word than “Mystery” would be “Mysticism” – which the dictionary defines as:

‘A belief characterised by self-delusion or dreamy confusion of thought, especially when based on mysterious agencies’.

How true that is! And some of the agencies are more mysterious than others.

2. Historical Perspective

Harm Reduction has always been around. In the Garden of Eden, when Eve ignored the advice to “Just Say No to Snakes” and then peer-pressured Adam into biting that apple, it dawned on them that they were naked and they cried out “What shall we do?”. Well, Walmarts hadn’t been invented at that time, so the best they could come up with by way of Harm Reduction was a fig-leaf.

And ever since then, we have been using the “fig-leaf” approach to society’s drug problems.

John Stuart Mill, considered by many to be the father of Liberty, was born in London in 1806. A prodigiously intelligent man, the culmination of his career came in the celebrated essays he published between 1859 and 1865; in particular his classic work “On Liberty”1. Many of those who wish to legalise or liberalise drugs employ philosophic arguments, quoting from this treatise to justify their position. But in doing so they are making a fundamental strategic error. Their favourite quote is:

‘Over himself, and over his own mind and body, the individual is sovereign’

However this is but one sentence in thousands which speak quite the opposite, which emphasise that the individual has an obligation to society, and that the rights of society outweigh those of the individual. On my copy of Mills classic text ‘On Liberty’, the dust jacket gives a more apposite quote:

‘the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others…’

And therein lies the key phrase. Harm to others. For the driving force in the thinking of a drug aficionado is that the individual is sovereign, and the only harm that is significant is harm to that individual – harm to others can be dismissed as the deluded invention of prohibitionists. Mill rejects this, taking direct issue with those who abuse substances and making it clear that, because of the harm caused to others by this individual action, such abuse should be repressed by law. This was particularly far-sighted, given that he wrote it in l859, when drug availability was low and its abuse was virtually non-existent in enlightened democratic nations.

In the context of morality, law and punishment, Mill says ‘Whenever , in short there is definite damage, or definite risk of damage, either to an individual or to the public, the case is taken out of the province of Liberty and placed in that of morality or law’. Punishment is seen to be right ….’for such actions as are prejudicial to the interests of others …the individual is accountable [to society] and may be subjected either to social or legal punishment if society is of the opinion that the one or the other is requisite for its protection.’

False reliance on Mill is not the only example of drug liberalisers wishing to live in another time. One of the studies frequently cited as ‘evidence’ of the innocuous nature of cannabis is the 1896 Indian Hemp Commission report. A premier libertarian in my country, Dr. Colin Brewer, who is a senior member of the International Anti-Prohibition League, frequently eulogises Victorian times as an example of how we might have ‘drug peace’ instead of ‘drug war’.

Those who are more familiar with Mill’s work can take a more objective view. Gertrude Himmelfarb, editor of ‘On Liberty’ makes the point that ‘Mill’s principle of liberty is less applicable than before, given that our social reality today is infinitely more complicated.’ For those of us who are familiar with the drug culture, Himmelfarb might be accused of missing the point. The main purpose of ingesting drugs is precisely to depart from ‘our social reality today’. It follows that anything which facilitates or excuses this departure, including ‘cherry picking’ useful phrases from 150 year-old documents, is fair game.

3. America in the Seventies and later

Although the Office of Substance Abuse Prevention now rejects the term ‘responsible use’, back in the Seventies many people were more gullible. A rash of deaths from huffing (solvent sniffing abuse) produced a proposal to give guidance on less risky methods of sniffing. This followed on recommendations drafted in the early 1970s for education on ‘responsible use’ of alcohol, including recommendations for drinking and driving (as distinct from ‘not drinking and driving’). David Duncan (et al), writing in 1994 in the Journal of Drug Education2, identified this as the start of a paradigm shift; and he remarked that such shifts can often be huge but equally are often incremental, and so creep up on society unawares. Given that Duncan and colleagues were offering an unabashed argument in favour of harm reduction, he would presumably have wished for society to stay unawares – at least of the moves by his school of thought.

Society may have been unawares but some people certainly were not. One of those who read ‘Harm Reduction – a New Paradigm for Drug Education’ was Dr. Robert DuPont, a drug specialist who had earlier publicly recanted his support for permissive approaches to drugs – especially cannabis. DuPont sent a stiff letter to the editor of the Journal, saying that Duncan’s article was a regurgitation of the failed ‘ responsible use initiative of 20 years ago’ , and commenting that whilst there might be a place for harm reduction in tertiary prevention, to mitigate the effects on hard core users, harm reduction was a disastrous idea in primary prevention in schools., in that it would undercut the important goal of non-use. Typical of the ‘pearls of wisdom’ in the article was the proposition that ‘Harm reduction is consistent with the human experience …’ and ‘Prevention often increases harm’. Particularly fascinating were the ‘findings’ that moderate users of drugs were healthier psychologically and enjoyed higher life satisfaction than either abusers or non-users. You may also be intrigued to learn that marijuana users enjoy better social skills, a broader range of interests and more concern for the feelings of others than non-users. DuPont reacted emphatically. He was in a strong position to make criticism, since up to that point he had been a member of the Journal’s board of directors – but not any more; he resigned so that his name could ‘no longer be associated with this dangerous message’.

Others have – perhaps wishfully – perceived a paradigm shift in drug policy. In a retrospective paper entitled ‘A Kinder War’ the high priest of drug liberalisation, Arnold Trebach3 spoke of a change being in the air. There was, he perceived, greater understanding of ‘…[the] enduring reality of drug use, the absurdity of even attempting to create a drug-free society, and the need to treat drug users and abusers as basically decent human beings’. In l980 an organisation called the Drug Abuse Council spent $10 million , most of it from the Ford Foundation, to produce a 300 page report entitled ‘Facts About Drugs’. It included such gems as the statement that users are no threat to society, only abusers are; it supported the idea of giving heroin to heroin addicts and – not surprisingly – it proposed, as a Harm Reduction expedient, the decriminalisation of cannabis. It suggested that there should be a distinction between what it called ‘recreational use’ and ‘misuse that harms society’. It went on to say that ‘by adhering to an unrealistic goal of total abstinence from the use of illicit drugs, opportunities to encourage responsible drug using behaviour are missed’. The Drug Abuse Council comforted itself in the supposed validity of its recommendations by predicting that ‘…heavy use would prevail for the next few years….’. In fact from the year of their report’s publication and for the succeeding 11 years, America brought about an astonishing public health success which yielded an overall reduction in the use of all substances by all ages of 60%, removing 13 million drug-users from the slate. In this as in everything else the Drug Abuse Council had got it wrong.

Unfortunately, expression of Harm Reduction philosophy was not confined to the private sector. In 1996 at Emory College in Atlanta, Georgia, the first South Eastern Harm Reduction Conference4 was – appallingly – co-hosted by America’s prestigious Centre for Disease Control. Some of the very well known libertarian groups with which CDC rubbed shoulders included the Drug Policy Foundation, the Lindesmith Foundation and Eric Sterling’s Criminal Justice Policy Foundation. A specimen statement from this bizarre grouping was ‘In allowing users access to the tools needed to become healthier, we recognise the competency of their efforts to protect themselves, their loved ones, and their communities’. The notion that one way of becoming healthier might be to stop or indeed never start being drug users would presumably have been lost on this gathering.

At about the same time a much more negative assessment of Harm Reduction came from body called the Family Research Council. In the council’s magazine ‘Insight’ writer Rob Maginnis5 produced an exemplary analysis of Harm Reduction; he noted the support from William F Buckley and the ACLU (American Civil Liberties Union) which he cited as ‘a leading promoter of Harm Reduction’. ( I have been advised by one of my gurus – the marvellous Otto Moulton – to constantly watch out for the ACLU; they have always been a major player in drug liberalisation, yet they are rarely seen or mentioned in this context. A possible explanation for this protected position may be the high percentage of ACLU members or supporters amongst the media). Maginnis gives an early example of Harm Reduction in Holland in the l970s, when they were handing out needles in an attempt to limit the spread of hepatitis – this was before the AIDS epidemic had become apparent.

ACLU are quoted as asserting that ‘Harm Reduction assumes drug-users civil rights and individual autonomy should be respected, it treats drug users as important participants in the process of gaining and maintaining control over their drug use, and makes no moral judgement based solely upon an individuals’ use of drugs’.

American drug policy experts, Sue Rusche and Stephanie Haynes, whose assistance with this paper I gratefully acknowledge, both define the Seventies as a period in which responsible use was the lubricant that allowed a whole generation to slide down the slope into drug abuse. Rusche cites use prevalence figures which are stark and inescapable. In 1962, less than two per cent of the American population had had any encounter with any illegal drug. But by 1979, 34 per cent of adolescents, 65 per cent of high-school seniors and 70 per cent of young adults had tried drugs. It was responsible use policies which fuelled this escalation. Between 1973 and 1978, 11 American states decriminalised marijuana. Some 30,000 ‘head shops’ sprang up to supply a curious population with drug paraphernalia. At the same time schools drug education materials taught children how to ‘use drugs responsibly’.

At first, parents were unwitting collaborators in this unfortunate process, in that they were blind to what was going on. But when their eyes were opened, they reacted strongly and assertively. Parent groups, such as Sue Rusche’s National Families in Action, PRIDE – the Parents Resource Institute for Drug Education, and the National Federation of Parents for Drug-Free Youth sprang up all over America, until at one time there were more than 8000 such groups. The parent movement hammered the professionals who had swallowed the Harm Reduction notion, and the parents were extremely successful in producing a paradigm shift of their own, back to prevention. The parent movement defined ‘Drugs’ as any and all illegal drugs, plus any legal drugs (such as alcohol and tobacco) used illegally – for example by those who were under age. Simple strategy goals were defined:

– Prevent use before it starts.
– Persuade users to stop.
– Help those who can’t stop to find treatment so that they can.

Parent campaigns closed the Head shops and put a stop to any decriminalisation. Several states have more recently succumbed to expensive PR campaigns and have swallowed the notion of using raw cannabis as ‘snake oil’ medicine, which just goes to show that you can fool the people some of the time, if your advertising budget is big enough. But in terms of non-medical use, no state has decriminalised marijuana since 1978, and several have actually re-criminalised it. Under the sterling work of the Parent movement in the Seventies and later, the “responsible use” message went into the garbage can, to be replaced by the “no use” message.

Would that it were that straight forward today! How was it that the American parent and family movement, consisting almost entirely of volunteers, managed to intercept and prevent this collapse? I plan to give you an explanation later.

4. Britain in the Eighties and early Nineties

When my wife and I first became workers in the drugs field, for the first seven or eight years we worked in “Street agencies” – face-to-face with addicts, alcoholics, and others at various points along the continuum of substance abuse. We also worked to assist the families and significant others around the user, and we worked as specialist advisers to the teachers in more than 100 schools. We were blissfully ignorant of the storm clouds gathering in the Liverpool area, and we pursued our duties on exactly the same strategic basis as the American parent movement had eventually developed, that is:

Stop it starting. If it’s started, stop it.
If it’s still not stopped then help it to stop. Full stop!
The first signs of trouble came when we, in concert with other Drug Education Advisers across England and Wales started attending National drug education conferences. We might have expected a few radical statements in an arena populated by teachers, but we were unprepared for the virulence of what we heard. It quickly became apparent to us (but sadly not to enough of our contemporaries) that the Drug Education Advisers were being hijacked by a small but well-organised bunch of libertarians. The radicals all sounded like the Beatles, with their nasal Merseyside accents. Liverpool was COOL, so you listened to anyone who came from there – whether they were carrying a guitar or not.
One of these exponents of Scouse charisma was former teacher and Sociology/Criminology graduate Pat O’Hare, now better known as the Director of the International Harm Reduction Association. O’Hare and colleagues were well enough resourced to be able to run a glossy magazine – “the Mersey Drugs Journal” which in due course became the even more glossy “International Journal of Drug Policy” (IJDP). The list of contributing editors to in the IJDP read like a “Who’s Who” of drug libertarianism.

Liverpool in the eighties was a swirling pool of powerful undercurrents. Anger at its social and economic situation compared to the affluent south-east had flared up into serious riots in the Toxteth area of the city, in 1981. Although these eventually subsided, a sharp antagonism remained. Dislike for the Establishment as a species translated into identification with subculture – including drugs. Whether jealous comparison of economies was at the root of the next factor or not, the fact is that there was also antipathy towards all things American amongst the so-called ‘caring professions’ – not reflected in the general population – and out of this came a striving for new directions. The up-swelling of libertarian philosophies at this same time seemed to fuse naturally into the process. One specific outcome was a vigorous seeding of the idea of Harm Reduction; a seeding which took root not just in Liverpool but also – through energetic propagation – across the rest of Britain and internationally.

Whilst other British cities with a high incidence of drug use were obvious places for the Harm Reduction gospel to be spread, it was by no means limited to these centres. Obviously the onset of AIDS, at the start of the Eighties, was a catalyst in the development of Harm Reduction; as a drug agency worker at that time I can vividly remember that we were all deeply concerned at this new major health hazard, and we were invited to regard AIDS as a greater threat to society than drug abuse, a notion which helped to undermine the significance of drug abuse as something to be arrested or prevented. With hindsight it is clear that though AIDS is a terrible disease it is also preventable – as is drug use, and that of the two, widespread drug use is in fact a much bigger threat to society at large. Prevent drug use and you are well on the way to preventing AIDS.

Liverpool was one of the areas where AIDS was a particular threat, largely due to the already high prevalence of drug abuse. But what is not widely known is that this drug use, and in particular heroin use, did not generally involve injecting; ‘chasing the dragon’ (‘smoking’) was the preferred method. It was then that the Liverpool Harm Reduction activists entered the arena. . What happened next was related to me by the mother of two heroin addicts, who later became one of our leading Parent campaigners. In the words of one of the Harm Reduction crusaders, International Journal editor Peter McDermott6:

‘As a member of the Liverpool cabal who hijacked the term Harm Reduction and used it aggressively to advocate change during the late 1980s, 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…’

McDermot goes on to talk about the importance of the ‘availability of a legal supply of clean drugs and good supplies of sterile injecting equipment’. Note that he incorporates legalisation and needles as part of the Harm Reduction package; note too that he talks about ‘supply’ – not ‘exchange’ of injecting equipment.

What McDermott and his colleagues meant by good supplies was more than just a rejection of the idea of needle exchange, a process which was supposed to be associated with dialogue between the drug worker and the user, with the aim of encouraging transition to a healthier lifestyle. McDermott & Co. had much more in mind than handing out a pack of needles without dialogue. The reality was, as the Liverpool mother told me, giving out needles by the bag full, and even giving out needles to known drug dealers, whom the police had agreed they would overlook if they found them carrying bagfuls of injecting equipment, to be given out with the drugs they sold. The net effect of this policy was that over a period, Liverpool moved from being an area with a low incidence of injecting drug users to one of a high incidence of injecting.

What the ‘Liverpool cabal’ had as their driving force may be judged from McDermott’s editorial of the time, that said:

‘…we must continue to guard Harm Reduction’s original radical kernel, without which it loses almost all of its political power.’

This movement, piously promoted in the name of treating drug users with respect, was in fact an exercise in radical politics. At least one of the ‘cabal’ was known to be a Stalinist.

The political angle was generally masked by rhetoric around the prevention of disease (and in particular AIDS) and the dignity of the user, but their preaching across Britain was both energetic and rapid. The message was promoted to drug workers, teachers, health workers and – not least – to police forces. In 1988 I sat in on a presentation to a regional health authority given by Alan Parry, another leading light in the Liverpool cabal. Parry outlined their policy: money would be moved from Abstinence and Detoxification into Harm Reduction. Prevention was dismissed as ineffective and they would therefore block any drug education scheme unless it could be proved to be innovative and with evaluation built in. When a questioner from the floor asked Parry what evaluation they were doing on their Harm Reduction work, he answered that there was very little funding available and so they would not be evaluating what they were doing – but they did feel it was ‘working well’.

[In this context, it is enlightening to hear the comment made a decade later to one of our member groups by Anna Bradley, at that time Director of Britain’s Institute for the Study of Drug Dependence. Pushed back from her opening gambit, which was to allege a lack of evidence for Prevention, Bradley was forced to concede that ‘… there is no research base for harm reduction’. She has now left ISDD.]

At the time that I took on additional work as an education advisor, assisting our local schools with their drug education work – if any – the whole of England and Wales, a population of some 50 million people, had its drug education coordinated by just over 100 people like myself. Most of these were teachers who had moved sideways into becoming Drug Education Coordinators. They had little or no knowledge of drugs and they were therefore eagerly looking for guidance from those they considered to be more experienced. One hundred is a very small number for a group of determined radicals to penetrate and persuade, and I saw this taking place at drug education conferences and training sessions at the time, without realising how wide-reaching and profound it was to become.

The British Harm Reduction movement did not content itself with staying in Britain – it soon established links elsewhere. We knew that those involved were using electronic means of communication globally long before e-mails were common. One of the ‘travelling salesmen’ was Julian Cohen, co-author of the ambiguously-titled ‘Taking Drugs Seriously’. Cohen7 argues for the ‘plusses of drug taking’; a typical item in Julian’s carpetbag is:

‘The primary prevention approach ignores the fun, the pleasure, the benefits of drug use … drug use is purposeful, drug use is fun for young people and drug use brings benefits to them.’

The European Movement for the Normalisation of Drug Policy (EMNDP) had its first meeting in Swindon, England in 1989. The Merseyside campaigners soon found themselves off to America [1988] where they were feted by libertarians, ‘in the street and on the Hill’. Amongst those on this promotional trip was Pat O’Hare, now Director of the International Harm Reduction Association. O’Hare and colleagues presented a paper8 with the innocuous title of ‘Drug Education, a Basis for Reform’ to a Maryland conference, convened by a relatively new organisation called the Drug Policy Foundation, about which we now know a little more! Thanks to Otto Moulton I have a tape of what was actually said by O’Hare and his companion Ian Clements at that conference; it bears little relationship to the written paper. O’Hare told his largely American audience that ‘England has absolutely nothing to learn from America’ and added that ‘…this 12-step rubbish is absolute cr*p’. One member of the audience made so bold as to ask O’Hare ‘What are the 12-steps ?’ . ‘I don’t know’ he responded. (but he did know they were ‘cr*p’). He then invited his audience to consider the notion that:

‘If kid’s can’t have fun with drugs when they’re kids when can they have fun with them?’

O’Hare was demonstrating that when it comes to radicalism, we Brits can show the former colonies a thing or two.

One milestone on the Harm Reduction road was the establishment of European Cities on Drug Policy (ECDP). Their first International Conference, held in 1990, in the German city of Frankfurt, produced the so-called Frankfurt Resolution, calling for heroin distribution to addicts, decriminalisation of cannabis and the provision of shooting galleries. It initiated a recruiting drive, and one of its first disciples was Scotland, much to the disgust of our Scottish prevention colleagues. According to Glasgow’s Families For Change organiser Maxie Richards “…harm reduction has become a vested interest of the Social Service industry, and with only one purpose: keeping social peace at the cost of dispensing drugs”.

5. Taking stock. Where are we now?

We’re in big trouble, that’s where we are. Through a combination of strong adversaries and weak friends we can see the Harm Reduction Movement approaching critical mass in several countries. In England we have many, perhaps most schools adopting a Harm Reduction approach to their education, and the libertarian elite are well entrenched in the Education ministry’s corridors. A self-appointed and exclusive pressure group of educationists and related disciplines, the Drug Education Forum, seems curiously able to protagonise – with impunity – a philosophy which effectively neuters prevention in our schools. We do our best to alert and galvanise those in control, and we have had several meetings with Keith Hellawell, whom you heard earlier. But even a senior advisor like Keith, with all the experience of being a Chief Constable to stiffen him, is likely to find that changing the direction of our government officials is like boxing with cotton wool. It is small comfort – in fact no comfort at all – for colleagues in Australia to tell me that the situation is even worse there, and has been for at least a decade, with Harm Reduction education being the mandatory norm, and cannabis decriminalisation a fact of life in some areas.

I don’t think I need to take time in this gathering by telling you about Switzerland, since I am reasonably sure that you are familiar with that disaster area. An avalanche of Harm Reduction. When looking for the reasons why Switzerland has gone downhill, one explanation may lie in the fact that the director of the so-called ‘Swiss Experiment’ also happened to be the President of the Swiss branch of the International Anti-prohibition League!

Similarly, I believe you will know a good deal about the Netherlands. Their particular brand of Harm Reduction was visible for many years before drugs became the issue, and cannabis cafes opened. As a young man in the late Fifties, I can remember walking in astonishment along Canal Street in Amsterdam, looking at brightly lit and decorated shop-windows in which the ‘Item for Sale’ was not a washing machine; it was a human being.

6. How did we get into this mess?

In reflecting on the development of Harm Reduction, one stark contrast emerges. How was it that there are two virtually identical philosophies; one from only 20 years ago, operating under the title of ‘Responsible Use’ – was quickly identified as ‘The Emperor’s New Clothes’ and kicked out, and yet here we are now, faced with Harm Reduction deeply embedded, with its tentacles reaching everywhere – even into government ? What caused the difference ?

If I asked all of you here today to come up with one word as an explanation, that word would probably be ‘Soros’. In one sense you would be right; the money that George has injected into the libertarian movement, compared to that which we can marshal, is like us attacking their artillery with our cavalry. We British tried that once, it was heroic but futile.

I would like to offer you the deeper explanation of why Harm Reduction flourished where Responsible Use failed, in the push for liberalisation.

It was in the 1960s both in the UK and in the USA that a sea change in educational approaches really took hold; morals-based education gave way to individual rights. Apparently disparate subjects such as reading, mathematics, history, geography and religious education fell victim to the excesses of an overheated individual rights approach in which some pupils could even decide whether to participate in classes or not. It goes without saying that lifestyles subjects such as sex education, drugs education and personal/social education would be swept along at the front of this wave.

One book you might care to read, if you want to get into this in more depth, called ‘The Great Disruption’ – is by Francis Fukuyama9. Fukuyma concludes that there has been a major paradigm shift. Who created that shift ?

I believe the answer lies in a process known as Values Clarification, also associated with Outcome-Based Education. This originated in Wisconsin, USA in the 1970’s under the leadership of a man whom we regard as one of the fathers of psychotherapy – Carl Rogers, together with Professor Sidney Simon and psychologist William Coulson. Rogers started with a very laudable concept i.e. that pupils should be facilitated to discover, and thus reach consensus on values which are beneficial to society. Sadly, within a short time the concept was diverted into one in which pupils were facilitated to discover values which were beneficial to them as individuals. External constraints were to be viewed as obstacles to the individual’s ‘Self-Actualisation’ – as Abraham Maslow, another contemporary of Rogers termed it. Thus, the notion was advanced that ‘… children should be left to create their own autonomous world, and that adults would be anti-democratic if they tried to pass their values to their children’. This was echoed by co-author Sidney Simon in the statement ‘..the school must not be allowed to continue fostering the immorality of morality. An entirely different set of values must be nourished’.

Similar approaches were observed in Gestalt-based education practices in Switzerland. A typical guiding assertion was that ‘Morals are regarded as obstacles which hinder the development of ‘my authentic self’ and the teacher has no right to impose his sense of values about what is right or wrong’. In Australia, classroom techniques resembling group therapy were deployed to produce changes in children’s attitudes and behaviour and challenge their previously held values.

Carl Rogers eventually expressed his own concern about the monster he had created, referring to it as ‘this damned thing’ and wondering ‘did I start something that is in some fundamental way mistaken, and will lead us off into paths that we will regret?’. But by then the wave had swept things beyond his reach. Britain now has a Journal of Values Education which invites school classes to discuss such questions as ‘Are drugs really bad for you?’, ‘What are the benefits and risks of drug taking?’ and ‘If adults drink alcohol why should I not take Ecstasy ?’

I believe that study10 of the Values Clarification process and related movements helps explain how we have reached where we are today. This is why Harm reduction has taken root, when Responsible Use died off quickly after a first flourish of growth, having fallen on stony ground.

But we cannot blame Rogers for everything that has happened in the last 20 to 30 years, anymore than we can blame George Soros. One is an idealist and the other an opportunist, but they both sowed seeds in grounds which we ourselves have made fertile.

External factors across and within society have, by their confluence, brought about enormous changes. Emancipation of the young, their greater disposable income, disempowerment of traditional authority – including parents and teachers, a more materialistic society and a ‘me first’ outlook, dismantling of ‘community’, the highlighting of ‘personal rights’ at the same time as the downplaying of ‘responsibilities’, effects of structural unemployment and the need for a more mobile workforce – this last factor adding to the breakdown of the nuclear family. The ‘contribution’ of the professions in being part of the problem rather than part of the solution is a major influence, as Professor Norman Dennis11 makes clear. I could say more, but you get the picture …

And the results of this we can now see in our undisciplined classrooms; in a police force which is perceived as sometimes more ready to arrest victims than criminals in order to reduce the harm to the latter; in drug workers campaigning to free colleagues who have apparently allowed drug dealing to be pursued on their premises, and in Education Authorities that will not allow school nurses to issue Aspirin or Paracetamol for fear of a negative reaction, but are receptive to the idea of issuing ‘morning after pills’ to young girls without their parents’ knowledge.

Harm Reduction is no more than an extension of this much deeper and wider paradigm shift. Addressing only Harm Reduction in seeking to strengthen our society against structural collapse is an over-simplification that could prove fatal.

7. What should be our rational response?

This paper is about the history rather than the solution, but I don’t feel I can leave you without at least trying to offer some provocation. Here are a few possibilities:

Option 1 – find another George

Option 2 – react less, act more. Define the ‘Harm’

Option 3 – identify and study the processes that brought us to today, and from this
develop promising corrective strategies

Option 4 – carry on doing what you are doing, but better

Option 5 – save the world, and in doing so

Option 6 – take heart from good news such as this12 .


1. Mill. J.S. ‘On Liberty’ (1985 Penguin Classics)

2. Duncan et al ‘Harm Reduction’ – an emerging new paradigm for Drug Education (1994 Journal of Drug Education)

3. Trebach A. ‘A Kinder War’ (1993 Scientific American)

4. Drug Policy Foundation/Center for Disease Control ‘Southeastern Harm Reduction Conference (1996 Conference Advisory)

5. Maginnis R. ‘Harm Reduction’ – an Alternative to the Drug War ?’ (1996 Family Research Council)

6. McDermott P. ‘Editorial’ (1992 International Journal on Drug Policy)

7. Cohen J. Clements I. Kay L. ‘Taking Drugs Seriously’
(1991 Healthwise)

8. O’Hare P, Cohen J, Clements I. ‘Drug Education – a Basis for Reform’ (1988 Drug Policy Foundation Conference)

9. Fukuyama F. ‘The Great Disruption’ (1999 The Free Press)

10. Stoker P. ‘Moralising….Demoralising: The Fight over Personal and Social Education’ (2000 pre-publication edition)

11. Dennis Prof. N. ‘Social Irresponsibility – How the Social Affairs Intelligentsia have Undermined Morality’ (1997 The Christian Institute)

12. Sullivan Dr. L ‘Drug Policy – a Tale of Two Countries’ (1999 News Weekly)



by Peter Stoker – Director, National Drug Prevention Alliance
Update of paper originally written for ECOD conference 1994, from conversation between Peter Stoker and David Partington, then Director of Yeldall Christian Centres.

Harm Reduction, Decriminalisation, Legalisation, Cannabis the Peaceful Cure all these contentious issues are deeply interlinked. One must therefore consider them in combination

Thousands of years before Christ, advice was already being given as to moderation in drinking alcohol. One might say this was one of the earliest examples of Harm Reduction. It stemmed from the philosophy that if someone is irrevocably set on ingesting a substance they had best do it with the least risk.. But the only sure way to avoid risk was, and still is, not to partake. For example, “Eve, leave that apple alone or you’ll be sorry”. Abstinence can in some ways be regarded as the ultimate Harm Reduction, not just for alcohol and other drugs but also in other health-risk areas such as sexual behaviour. The Harm Reduction guidance for tobacco is, in fact, “Just Say No”. This raises an instructive point of comparison between Harm Reduction for alcohol and for tobacco. Both have been around for thousands of years. Neither has been prohibited for most of this time. Both have very slick and highly-financed PR and sales promotion. And yet in recent years there has been a crusade against tobacco, i.e. abstinence is best, compared with moderation as the rule for alcohol. A cynic might say the difference is in the manufacturer’s PR. But this is not borne out by observation. What has tipped the balance against tobacco has been acceptance by society of what they see as the hard facts, of which the death toll (100,000 per year) is only one. Even though alcohol is no slouch in this context, accounting for any where up to 50,000 deaths per year and is the Number One drug of abuse by youth, (cannabis comes second), there are no signs of people Just Saying No to a tipple. Alcoholism still continues to occur, in priests and paupers, but drink is here to stay, it seems. Why?

Perhaps the answer lies in the Harm Reduction aspect of alcohol. In contrast with most if not all other drugs you can take just a little alcohol as a beverage, i.e. for thirst, or taste, or social/religious rituals. Or you can use it as a drug, by taking higher volumes, and risk the consequences – health, social, legal, and of course spiritual. We say to ourselves that controlled beverage drinking is what we do. Uncontrolled excess is what other people do. But because we can handle it, it should remain legal and those others need to learn their Harm Reduction lessons better. This is a more tenable position with legal drugs, including pharmaceuticals, than with street drugs, precisely because more is known. (Though the professionals still let us in for unexpected Harm with these from time to time; witness Thalidomide, Valium, Ativan, and so on.) Strengths, or to put it another way, toxicities, are marked on the bottle or packet, and there may even be a sober little message from the government. Research into the negative effects of alcohol or tobacco has been produced over long years by many august bodies. Not a little of this research is funded by tobacco or alcohol manufacturers, which makes for a fair degree of scepticism in the reader.

Street drugs are another matter entirely. There are no Quality Controllers in the back-street labs, or in the fields of the Golden Crescent, the Golden Triangle, the hinterlands of Medellin and Cali. What you buy is a lottery; that powder might be worthless talc or something that boosts you so high that you never wake up; not in this world, anyway. The more severe consequences are more likely to happen to the inexperienced or to the recently relapsed, therefore Harm Reduction advice must take account of where the user is in what some euphemistically entitle “their drug-using career”. (For ‘Harm Reduction’ read ‘Career Guidance’ !) That amazing new dance drug you’ve just paid £15 for could be a caffeine tablet dyed blue. Your £5 ‘trip’ could have nothing more hallucinogenic than the picture of the Pink Panther on the top. Even the grass you buy could be freshly mown. Things change rapidly too. The Mexican grass which Haight-Ashbury hippies smoked to get high often rated little stronger than 0.5% THC (Tetra-hydra-cannabinol, the bio-active molecule that stones you). Today you can buy ‘Skunk’ and other genetically modified varieties of “Nederweed” which can go as high as 25-30% THC. And who is around to advise you on this? The man who is selling it, that’s who.

That astonishing growth in strength is equivalent to being advised to take one aspirin a day “for a healthier heart”, and the day after being told to take 50 aspirins a day for the same reason. Would you do it? With aspirin? Well, young people do it every day with street drugs. And that certainly includes the spuriously-entitled “soft” drugs. Harm reduction with street drugs and related behaviour needs to happen, because harm is happening. We may, some of us anyway, still be working to encourage people to choose a lifestyle free of drug abuse but meanwhile we must strive to minimise the harm that is happening now, albeit to a minority. Today’s minority will become tomorrow’s majority if we get this wrong. But we need to recognise that in offering Harm Reduction advice (which itself may not be welcomed by the user) we are addressing the use of dynamically variable substances by dynamically variable people in dynamically variable social settings. Responsible behaviour may be no more than accidental in people doing irresponsible things, like abusing drugs. Harm Reduction can help, but if you are delivering it you need to approach the process with a certain humility as to the outcome you are likely to achieve.

Empowerment can come from Harm Reduction. Empowerment for the individual user to feel more in control of their life, less fearful of the damage they may be causing themselves or others. Perhaps, in this more stable setting, they can become better able to look at the longer term and make some positive decisions.

That is the good side of Harm Reduction. The side that says, in all moral conscience, one cannot withhold damage-limiting information from people just because their current behaviour is outside your norms. Deliver a message for life free of drug abuse by all means, but also give them what they need to stay as healthy as they can; to stay alive, in extreme cases. Where a darker side of Harm Reduction occurs is when it is hijacked by unscrupulous groups for their own purposes. The seemingly solid rock of logic which, when you pick it up, crumbles to dust in your hand, but not before revealing some nasty things underneath. This should hardly be surprising; many a good idea in history has been perverted to serve aims radically different to those which gave birth to the idea in the first place. In this case the hijackers are an alliance of drug-legalisers, libertarians and radical educationists. (Other forces including politics, commerce and organised crime are also in play). Their broad strategy is something like this:

Spread the (false) idea that you can’t prevent drug abuse. Spread the thought that it is morally wrong and “value-laden” to try to do so.
Argue for the removal of values in teaching. (In fact a “value vacuum” philosophy is an extremely value-laden concept, leaving children prey to “someone else’s” values sooner or later).
Allege that ‘everyone’ is doing it, or ‘millions’ are. (Truth is 8 out of 10 youth either never try or else give up after two or less tries. As for ‘millions’ – even if 5 million in Britain are, which is very doubtful, this means 51 million are not).
Spread the (tendentious) idea that as all youth might use drugs (but teaching them not to is “wrong”) what is needed is Harm Reduction teaching for all children in schools, with no guidance as to use or no use. (The inference the young people will draw is self evident).
Tell parents to “switch off”, it’s just youth rites of passage, you were young once, you smoke, so lay off preaching, the kids are alright, etc .etc.
Spread the (false) idea that cannabis is harmless. (Therefore needing no Harm Reduction limits).
This last one, the “Harmless Cannabis” myth, is strategically very important to the legalisers. They see it as the crucial first domino which could topple the drug array. And if it doesn’t, well at least it’ll be nice to get stoned legally at last. This is why they fight so hard to keep you believing there is ‘no Harm’, ‘no problem’. A library of over 12,000 worldwide accredited research papers (held at Mississippi University), testifying to its harmfulness, is studiously ignored. Hard evidence shows brain cells damaged or even killed; heart, lungs and endocrine impaired, immune system broken down, faster lung cancer than tobacco, paranoid psychoses, schizophrenia precipitated, addiction in physical as well as psychological terms, etc., etc. The list goes on, but is steadfastly shunned by the pot lobby, whose rallying cry seems to be, “Don’t confuse me with the facts!”. Blind faith and epidemic denial are the rule. Obviously no one has told these lobbyists that the toxicity of substances is not decided by debate.
An especially significant point concerns the areas of Health (and therefore of Harm) other than the physical, i.e. intellectual, emotional, spiritual, environmental and social. These areas are totally blanked out by the drug apologists – mainly because they have no answer; this is harm they cannot reduce. Speculative and extravagant claims as to pot’s medicinal value are made, all of them discredited years ago but still exhumed regularly and reverently. In fact, the medicinal value of cannabis is limited, more than overshadowed by the negative side-effects, and other drugs do the jobs better.

Within the last few years the BMA, the Lords Science & Technology Committee, and the prestigious Institute of Medicine in the USA have all come down against the use of raw (unprocessed) cannabis as medicine, and certainly not when smoked. Every relevant medical institution in the USA has tested and rejected it as medicine for any ailment, from glaucoma to MS, from cancer to HIV/AIDS. Faced with the 8-parameter approval schedule the Food and Drug Administration apply to every drug, cannabis could not even pass one. The French Government have also concluded that cannabis can no longer be defined as a ‘soft’ drug; in fact they believe it should be termed ‘hard’. The media persists in promoting ‘debates’ in which the prevention worker is faced with the user(s) in wheelchairs; the former is then harangued by the interviewer for ‘denying’ this useful medicine to the sick.

Medical use is a hostage to legalisation. Don’t take my word for it; as long ago as 1980 Keith Stroup, the then director of NORML, the oldest pro-pot campaign in the world, was publicly quoted as saying “We will use the medical marijuana issue as a red herring to give pot a good name”. And they did. Even so, were medical use of extracts to be proved valid in future (and it’s nowhere in sight yet) this would only be a basis for medical prescription, and certainly not a basis for relaxing laws on use for non-medical purposes. So, there is much to be rejected in the pleadings of legalisers. And yet we, the public, see through the tobacco propaganda, so what is different about cannabis? What is different is where the media stand. And they mainly stand, apart from some exemplary exceptions, shoulder-to-shoulder with the cannabis lobby, refusing to let evidence impede their ‘journalistic privilege’. This compulsion to romanticise pot can only partly be explained by the search for newsworthy copy. Quite what the whole truth is, it would be fascinating to find out.

The combined thrust of the above-listed radical ploys is to gradually shift public attitudes, to convince us that drug abuse is no more than the equivalent of a little scrumping “when you were a lad”, youth should be empowered without “adult-imposed” value systems, their drug taking (now or in the future) should be facilitated with teachings of D-I-Y Harm Reduction. And of course they would be at less risk of “legal harm” (i.e. arrest and penalty) if the stuff were legalised… …decriminalisation is quite definitely only the first step.

Legalisation (and its half sister, Decriminalisation) is not a very bright idea, owing more to pipe dreams than reality, as you might expect. Everywhere it has been tried things have got worse and drug use has increased. Sweden, China, Spain, Italy; there are just a few of the many examples of countries who painfully discovered what are the real costs of relaxing drug laws. The ‘Mecca’ for the drugs pilgrims is of course Amsterdam.

Protagonists allege that drug use there has not been increased by decriminalisation, but this is based on a survey known to be flawed, and other surveys which give more breakdown show youth use – the critical parameter – increasing by between two and four times. The evidence on the streets is that pot-purveying ‘coffee’ shops have soared from less than 200 before law change to more than 8000 now. Are we really supposed to believe that all these retail outlets are flourishing on the trade that 200 once made do with? Incidentally Holland is also the most crime-prone country in Europe, hardly a coincidence. But perhaps the most irrefutable evidence (which is why the legalisers try to studiously ignore it) comes from Alaska, a modern state with a population of millions. Decriminalisation of cannabis was introduced, with the support of the police, nearly 20 years ago, after hearing all the arguments now being peddled over here, such as: general use won’t go up; problem use won’t go up; use of other drugs won’t go up, and crime will of course come down. Reviewed in the early 90s, this policy was found to have produced enormous increases in general use, and in problem use, and in use of all other drugs, and – shockingly for many – crime went up. Faced with this incontrovertible proof, the police and other authorities enacted a repeal, returning drug possession to the illegal status it deserves as a negative influence on society.


At least in part Harm Reduction is a response to a feeling of being overwhelmed by drugs, a feeling which the media do much to foster. There is no need to surrender, nor even to encourage self fulfilling prophecies. Several countries have marked reduced usage levels – the US by 60% in the 1980–92 period; Sweden, from critical levels down to a few percent in recent years; Eastern Belgium, by 20-30% compared to neighbouring provinces… the list goes on. What characterises these achievements is that they have all been pro-active, actively facilitating prevention whilst at the same time providing intervention and treatment. Harm Reduction is seen as just one aspect of intervention i.e. it has a place, but it should be kept in its place.

These and other countries have painfully learnt an important lesson; that the pursuit of Liberty is valid but the pursuit of Licence is not – and that Liberty which harms or jeopardises other is not worthy of the name. A sense of proportion about all aspects of drug services is needed. When addressing this vexed subject it may be helpful to remember a few simple guidelines, based on some essential truths:

Most people do not want a drug-addled society.
Legalisation is Fool’s Gold; don’t you be the fool.
Drug Prevention works well if you do it well, and empowers young people more than drug use ever will.
“Liberation” is not achieved by ingesting toxic substances.
Be alive to the distinction between “Liberty” and “Licence”.
It is healthier in every respect to rely not on substances but on strengthening one’s own resources. In this context, the search for one’s own spirituality can never be other than impeded in a consciousness which has been artificially distorted.
Harm Reduction is appropriate for those that use and not for those who don’t; (you’ll make your own sensible judgements about those on the fringe).
And, as ever, the most effective and balanced answer is a sensitive mix of Prevention (even for users), Harm Reduction for users, and the other safety nets of Treatment and Rehabilitation beneath these initial strategies.
Let us, on this basis, therefore all strive to promote Health more than just reduce Harm, remembering that in all the great religions, and in secular bodies such as the World Health Organisation, Health is defined not just as physical competency, but also intellectual, social health, emotional, and environmental, and, especially in the light of this conference, spiritual health.


Norwegian intravenous drug abuse has increased dramatically. At the beginning of the 1990s, there were between 4 000 and 5 000 intravenous drug abusers, in the year 2001 the number was estimated to be between 10 000 and 14 000. Notwithstanding close to 40 years of contacts with injecting drug abusers, I have never understood the details of the injecting per se. I have been in drug dens, seen injecting drug abusers, but never observed the injections being performed. Only when I visited Norway, I had the opportunity of closely studying the various phases constituting the injecting of heroin.

In the public debate and in research it has been overlooked that many drug abusers, when preparing the drugs, thrust their syringes into the same solution, that the solution is filtered through cotton swabs or cigarette filters, that addicts often have ulcerated skin chaps, that the intravenous abuse of drugs most often is a collective activity performed in a contagious environment.

At the “Plata” in Oslo, an open square close to the Railway Station, I could follow the drugs trade and the injecting during two weekends. At Christmas time 2003 and in March 2004, I took approximately 300 photographs. The pictures show e.g. how the drug addicts manage “patients difficult to inject”, i.e. themselves. The injection technique is occasionally highly sophisticated, which is seen in the pictures. Puncturing the vena jugulars interna seemed to be ordinary business.

In Norway a distribution of syringes and needles through the “needle bus” started already in 1988. Today, the distribution is performed at special clinics all over the country. Approximately 2 million syringes are distributed only in Oslo. Norway has – just as Sweden – the goal of a “drug-free society”, but the actual development is in the opposite direction. In February 2005 the first injection room was opened.

The main drug in Oslo is the brown heroin, which – depending on quality – requires citric acid to be prepared. Rohypnol is appreciated as a supplement.

The Rohypnol tablets had a blue protective cover. In order to dissolve the active substance, the drug abusers sucked off the coloured cover, thus the turquoise colour of their teeth.

The drug trade went on day and night, however mostly during daytime. During the night it moved further up into the adjacent street Tollbugata, where syringes and needles and can be picked up anonymously in a kiosk-like operation, commonly called “the street kitchen”, open from 11 AM to 11 PM. In spite of hundreds of drug addicts moving around the area, the atmosphere was peaceful.

Most of them were fairly “drowsy” from opiates and tranquil, except when they experience a withdrawal or a difficult business transaction. The age of those present, I estimated to vary between 18 and 50 years, and most of them had progressed far into their drug careers. During the weekend, the clientele became younger, when youngsters from other parts of the country took the train to Oslo in order to buy illegal drugs.

Staff at the needle exchange station experienced a conflict upon turning away people under the age of 18, which is the age limit for receiving free needles. I think that when a youngster lingers in a clearly unsuitable environment such as the “Plata”, he or she is to be helped out of it. Young girls, and also young men, are sought after in drug abusing coteries. When they have become dependent upon a drug dealer, they turn into a real treasure chest. The girl and the boy are sent out to make money as prostitutes or to act as middlemen in drug selling or fencing. It is easier for a young, healthy person to hide his or her criminal intentions than it is for an addict scarred by drug abuse.

When it was time for injecting, a camp was set up at the Plata. Some addicts retreated into a parking garage or sat down under lorries down by the harbour a few hundred meters away. Most of the people of whom I took photos were injecting together with one or more partners, with whom the heroin was prepared and shared. The syringe and the needle were clean when they were taken out of the package. That was, however, not the case with the spoon or the cup, where the heroin was mixed; neither were the water, the citric acid, nor the Rohypnol, which was added to the heroin.

Practice makes perfect: when necessary one drug abuser helped another to locate veins hard to find. They would inject into the head, the neck, into arms and legs, everywhere blood could be drawn from a vein. When the veins would no longer serve, the injections were taken intramuscularly.

What conclusion?

Intravenous drug abusers after a while develop skin wounds and injection scars, and they are not particularly prim and proper. If they were to protect themselves against blood borne infections, the same way as we do in the medical services, they would need not only clean syringes and needles, but also clean mixing bowls, sodium chloride and protective gloves. Of course they would then neither dip the needles into the same solution, nor have unprotected sex.

The risk of infections spreading through paraphernalia was recently addressed in a study of injecting drug addicts. Even though the syringes and needles were handed out and collected by specially trained staff and most of the addicts never shared syringes, the frequency of hepatitis C increased in the group. The scientists’ conclusion was that the needle exchange program did not curb the hepatitis infection. Instead they called for “a culturally, sensitive behavioural intervention” in order to protect addicts from the infection (Sarkar K et al., The Lancet, vol. 361, 2003).

Their conclusions are well in agreement with my observations in Oslo.

The needle exchange programme is evidently not effective in stopping the spread of either HIV not hepatitis. If anything, the needle exchange programme is likely to be treacherous in creating a false sense of security.

There are probably only two effective methods of protecting the spread of infection. The most effective method is that the individual drug abuser becomes drug-free. The best effort by society in the short run is to support regular testing and counselling among active drug abusers.

Source: SFAI Tidningen, the Official Journal of the Swedish Association for Anaesthesia and Intensive Care, vol. 11, no. 2, May 2005. Tr. J.H.

“ Effective Alternatives to Harm Reduction”

by Peter Stoker, C.Eng., Director, National Drug Prevention Alliance


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.


1.1 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!


2.1. 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).


3.1 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.


4.1 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.


5.1 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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