A case against the argument that harm reduction strategies are costly and encourage people to use drugs.
A little background…
Well this is the first post in a couple of months and I should probably offer some kind of explanation. I started study this year undertaking a postgraduate course in Alcohol and other Drugs studies. This combined with full time employment and fulfilling my obligations to Mrs Stonetree and the Stonetree juniors have conspired to keep me away from the blog for a while, but now I am back with something a little different.
The following article is actually an essay I wrote about some of the arguments proposed by opponents to harm reduction, hence the article is a bit longer than I would normally write. I have to say that writing the essay involved 2 parts fun and 1 part utter revulsion (my partner had to remind me several times that my children were in the room while I was reading some of the opposition research as I tend to utter my thoughts out loud when particularly aggravated). Anyway on with the show!
Since it’s emergence in the early 1980’s, harm reduction has remained a contentious issue, attracting many critics from within our communities. In this essay the writer will explore the ideas that harm reduction is both costly and encourages drug use and provide evidence to demonstrate that both arguments are contrary to current evidence.
Harm Reduction: A definition
The definition of harm reduction has been subject to a variety of interpretations. Even the language applied to harm reduction is muddied and interchangeable with a variety of terms used to describe those strategies and policies that focus upon the harms associated with drug use. Such terms include ‘harm minimisation’ and ‘harm prevention’. According to Australia’s National Drug Strategy (2011):
“Harm reduction works to reduce the adverse health, social and economic impacts of drug use on communities, families and individuals.” (pg. 27)
Harm reduction is one of three pillars that support the overarching philosophy of Australia’s drug policy of harm minimisation. The remaining two pillars focus on the reduction of both the supply and demand for drugs within our communities.
Narrowing down this very broad definition of harm reduction, Ritter and Cameron (2005) synthesized the works of a number of writers who had sought to define harm reduction. They identified the following common characteristics:
- that the primary goal is reducing harm rather than drug use per se;
- that it is built on evidence-based analysis (strategies need to demonstrate, on balance of probabilities, a net reduction in harm);
- that there is acceptance that drugs are a part of society and will never be eliminated;
- that harm reduction should provide a comprehensive public health framework;
- that priority is placed on immediate (and achievable) goals; and that
- pragmatism and humanistic values underpin harm reduction
(pp. 5-6 Ritter & Cameron 2005)
While a number of countries including Australia have adopted harm reduction as an integral component of national drug policy, the prevalence and type of harm reduction programs and practice varies widely from nation to nation. Within Australia harm reduction interventions are delivered at both a programmatic level through the provision of pharmacotherapy, needle and syringe programs, peer education programs and the Medically Supervised Injecting Centre (MSIC) in Sydney. Behavioural interventions aimed at reducing drug related harms are also utilised in alcohol and other drug treatment programs such as counselling, consultancy and continuing care (CCCC’s).
Opposition to Harm Reduction
Despite its adoption as a key strategy underpinning Australian drug policy since 1985, harm reduction continues to face opposition from many quarters. A number of writers (Donoghue 2006, Fry 2010), have asserted that this opposition is founded in moral and legal objections requiring adherence to the law and abstinence from drugs. Examples of the legal and moral concerns of those who oppose harm reduction are succinctly summarised by the following quote taken from a submission made to the Australian House of Representatives Standing Committee on Family and Human Services (2007):
‘Needle exchange programs provide health benefits, but what is the real message being conveyed? That it is okay to use illegal substances? That it is okay to harm or kill yourself? That it is okay to continue treating the closest people to you like the scum of the earth? That it is okay to steal, rob and mug? ‘
(ToughLove submission to the Australian House of Representatives Standing Committee on Family and Human Services cited in The Winnable War on Drugs pg 111)
These concerns with legality and morality provide a backdrop for the arguments asserted by opponents to harm reduction. Opponents such as Christian (2011), O’Loughlin (2007) and Kall et. al (2007) have contended that a range of harm reduction strategies are not cost efficient and that they promote drug use. These contentions are voiced, despite a growing body of evidence that demonstrates the efficacy of harm reduction strategies and programs in not only protecting individuals who use drugs from harm, but in also providing both social and economic benefits for our communities.
Harm Reduction and the promotion of drug use
The arguments supporting the notion that harm reduction encourages drug use is grounded in the moral position that drug use is ‘bad’ and cannot be countenanced in our society. Some opponents to harm reduction (Coalition against Drugs 2007, Drug Free Australia 2007), have expressed concerns that harm reduction is nothing more than a ‘Trojan horse’ for drug legalisation. While a central contention of harm reduction is that drug use in our society is inevitable (as evidenced by over 100 years of attempted international control and prohibition), harm reduction is actually value neutral in regard to the morality of drug use, focussing instead upon the harms associated with the use of drugs. While some supporters of harm reduction may indeed support decriminalisation or regulation of illicit drugs with the aim of reducing the legal and social harms associated with unregulated black markets, there is according to Hunt (2003) no consensus amongst harm reductionists in regards to drug law reform.
Another argument asserted by critics of harm reduction is that by reducing the harms associated with drug use, more people would be prepared to consume drugs. In a paper examining the policy implications of changing drug policy focus from use reduction to harm reduction Caulkin et. al. citing Macoun pg.315 (2010) purport that:
“…people do often decide to participate in an activity more frequently when it is safer, but the increases are smaller, proportionately, than the reductions in harm, so total harm is generally reduced when an activity is made less harmful.”
So it may well be true that harm reduction may result in a small increase in drug use in regards to frequency of use, however also in a decrease in related harms. While harm reduction initiatives may result in an increased frequency of use there is no evidence to suggest that they are responsible for initiating previous non users to drug use. In a study of European medically supervised injecting centres Hedrich pg. 41 (2004) found:
“Consumption rooms reach a population of often older, long-term users some of whom have had no previous treatment contact. Services appear particularly successful in attracting groups that are difficult to reach. No evidence was found to suggest that naive users are initiated into injecting as a result of the presence of consumption rooms.”
In fact this lack of capacity to reach relatively new drug users may pose a problem for harm reduction programs in reducing the harms experienced by a significantly vulnerable group.
Harm Reduction and cost effectiveness
Another criticism levelled against harm reduction by its opponents is that it is not cost effective. Perhaps the most compelling argument against this position is the two national evaluations of Australian needle and syringe programs (National Centre in HIV Epidemiology and Clinical Research 2002 and 2009) measuring the economic viability of Needle Syringe Programs. Spanning nearly two decades of provision of needle syringe programs in Australia, the findings of both reports demonstrated an overwhelming cost saving in regards to both health and social costs saved due to the prevention of transmission of blood borne viruses. In the latter of the two reports it was found that:
“For every one dollar invested in NSPs, more than four dollars were returned (additional to the investment) in healthcare cost-savings in the short-term (ten years) if only direct costs are included; greater returns are expected over longer time horizons.” (pg.8)
Shifting to another widely used harm reduction strategy, methadone utilised as an opiate substitution therapy has a wealth of evidence to support it’s efficacy in reducing drug related harms for people who use opiates. According to a review of the effectiveness of alcohol and other drug treatments conducted by the Australian National Council on Drugs (2001) the demonstrated benefits of methadone included a reduction in criminal activity, reduction in rates of imprisonment and an increase in engagement education and employment when compared to those people not engaged in treatment. It was also found that methadone held much higher retention rates when compared with other (non harm reduction focussed ) treatments such as counselling or therapeutic communities. These findings again suggest that a harm reduction initiative of national scope can result in significant cost savings relating to the costs incurred through criminal proceedings, incarceration and the overall costs of crime for the community.
Summary – The opposition to harm reduction and unintended consequences
It could be argued that one of the consequences of a continuing resistance to harm reduction strategies and programmes is that such strategies have come under far greater scrutiny than other forms of alcohol and other drug intervention. Needle and syringe programs in Australia have undergone two major economic evaluations nationally in the past decade, testing their economic viability, methadone as an opiate substitution therapy is one of the most well researched and evidenced pharmacotherapies utilised in drug treatment and the medically supervised injecting centre in Sydney has operated under a trial status for over a decade. Overwhelmingly in all instances, the balance of research has demonstrated not only the effectiveness of these initiatives in reducing drug related harms, but that that they can, and do benefit the whole of the community through financial savings.