Harm Reduction is concerned with minimising the negative impact of drugs and alcohol on individuals and communities. The need to help prevent harm to the health and lifestyle of the individual user as well as to the people around him or her is seen to be paramount.

Harm reduction means that no matter how people feel about their drug use then there are practical services that can be offered to them.

• advice about how to use drugs more safely will be provided
• they may be offered some drug using equipment
• for some there may be prescribable alternatives to illegal sources of supply.

Rationale behind harm reduction

'HIV is a greater threat to public and individual health than drug misuse. The first goal of work with drug users must therefore be to prevent them from acquiring or transmitting the virus. In some cases this will be achieved through abstinence. In others, abstinence will not be achievable for the time being and efforts will have to focus on risk reduction. Abstinence remains the ultimate goal but efforts to bring it about in individual cases must not jeopardise any reduction in HIV risk behaviour which has already been achieved.' [1]

The AMCD recognised that people would not stop taking drugs because they were being told not to do it – that ‘Just Say Mo’ strategies may deter some people from taking drugs that they would have minimal impact on the community of people who were injecting.

Accepting this – the question then became one of how people could be engaged with by services so that lives could be saved – that people could be kept alive long enough to get into treatment.

For this to happen, clean injecting equipment had to be made widely available and people had to be taught how to use it – hence the first needle exchanges

Although the spread of HIV has to a certain extent been contained amongst injecting drug users, the need for needle exchanges continues – this has been emphasised by the emergence of a new and potentially devastating blood borne virus – Hepatitis C.

Achievements of the model

Professor Gary Stimson in a speech to the Methadone Alliance Conference in 2000[2] argued for three major achievements of harm reduction

• We were ahead of many countries in the prescribing of substitute opiate drugs to people who are dependent on them - a history which goes back to the 1920s, to a time when the UK and the US started on very different drugs policy paths.
• HIV prevention has been a remarkable success story in the UK. We were looked to in admiration by many others around the world. It is a success that has the potential to be repeated, with respect to HCV and HBV.
• We also managed to develop effective harm reduction measures associated with the consumption of other drugs.

The question of collusion

There are many opponents of harm reduction strategies who argue that they simply collude with harmful drug use and make it harder for people to give up. The National Drug Prevention Alliance is one organisation that believes that harm reduction initiatives are wrong headed. Their website is http://www.drugprevent.demon.co.uk/.

Melanie Phillips is perhaps the best known opponent of harm reduction in Britain – she argues that it is ‘actually a euphemism for throwing in the towel altogether against drug abuse’[3].

It works

In 1997, in Connecticut, a needle exchanges caused a great deal of hostility in the surrounding community due to discarded syringes and so on. The exchange was closed down forcing people to use more risky methods of using but the levels of drug related debris did not decrease.[4]

One 2001 literature review reported that “Despite variations between programs, a recent international comparison showed that in 29 cities with established NEPs, [needle exchange programmes] HIV prevalence decreased on average by 5.8% per year, but it increased on average by 5.9% per year in 51 cities without NEPs’[5]

Neil Hunt[6] in his review of the evidence bases argues that there is evidence for harm reduction interventions that:-

• definitely work – such as methadone and other replacement therapies, or needle and syringe programmes. These should be considered for adoption in regions where they are currently unavailable;
• show promise and require cautious expansion with evaluation in ways that are adapted to local settings e.g. heroin prescribing, depenalisation, the use of drug consumption rooms and pill testing;
• are widely used yet under-researched - notably information, education and communication programmes and motivational interviewing approaches to conventional harm reduction targets such as the prevention of HIV, hepatitis C, hepatitis B and overdose.

Care Planning and Relapse Prevention This course will enable clients to design client centred care plans and look at strategies to help prevent clients relapsing.