What’s the deal with Harm Reduction & Drug Law Reform?
Another in the essay series, this article discusses the question: ‘Is it necessary to support drug law reform as a harm reductionist?’
On the 11th of November 2004, the then Executive Director of the United Nations Office on Drugs and Crime, Antonio Maria Costa famously stated:
‘Under the guise of “harm reduction”, there are people working disingenuously to alter the world’s opposition to drugs. These people use our well-intentioned statements for their own agenda …’
(Antonio Maria Costa, Executive Director, United Nations Office on Drugs and Crime to Robert Charles, Assistant Secretary, International Narcotics and Law Enforcement Affairs, USA, 11 Nov 2004)
The assertion made by Mr. Costa presupposes that there is no direct relationship between harm reduction and drug law reform and suggests that supporters of drug law reform are in some way subverting the concepts of harm reduction to further the drug law reform agenda. In this essay the writer will test Mr. Costa’s assertions by examining the relationship between harm reduction and drug law reform and respond to the question: Does supporting harm reduction necessarily mean supporting decriminalisation of illicit drugs?
Definition of Harm Reduction
Before exploring the relationship between harm reduction and drug law reform, it is important to first arrive upon a definition of harm reduction. The term ‘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)
Narrowing down this very broad definition, 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)
This definition of harm reduction never explicitly states a position on drug law reform. So what is the position of harm reduction advocates regarding drug law reform?
Consensus of harm reduction advocates regarding the decriminalisation of illicit drugs
Supporters of harm reduction are not a homogenous group and as such positions on drug law reform will vary from advocate to advocate:
“Finally, some people consider that harm reduction’s underlying intention is to achieve drug law reform and promote the legalization of drugs. It is an undeniable fact that some advocates of harm reduction are also advocates of drug law reform and the creation of some form of legal, regulated market, for some or all drugs that are currently proscribed and, effectively, unregulated. Equally, many harm reductionists would oppose such developments. Yet others would reject dealing with drugs within the criminal law but retain civil penalties for drug use. There is no consensus on this issue among harm reductionists.”
This lack of consensus seemingly indicates that it is not necessary to support decriminalisation of illicit drugs in order to support harm reduction, however if we examine more closely the characteristics of harm reduction identified by Ritter & Cameron (2005) we can see that while not all harm reduction strategies require drug law reform, drug law reform is congruent with harm reduction.
The lack of consensus amongst advocates of harm reduction is totally understandable when we consider that the two drugs that are commonly legally available in Western societies, alcohol and tobacco cause the greater share of drug related harms when compared to illicit drugs. It might be suggested that the very availability of these two substances contributes to their potential to cause harms to individuals and the community. If this premise is accepted it is intuitive to assume that decriminalising other substances could potentially contribute to greater harm.
“Some harm reductionists would, and do, argue that public policy regarding drugs – including the prevailing system of drug prohibition – should be subject to a utilitarian appraisal that evaluates the costs and benefits of prohibition and bases policy upon the evidence of what works best.”
Hunt observed there were considerable difficulties obtaining evidence in this area with only a small body of evidence existing at the time, mainly isolated to the depenalisation of cannabis in certain jurisdictions. Later findings published by Greenwald (2009) found however, that there has been some measurably positive harm reduction outcomes associated with Portugal’s decriminalisation of all illicit drugs in 2001. Greenwald asserts that since Portugal decriminalised drugs:
- drug user engagement with treatment services such as pharmacotherapy programs, withdrawal services, therapeutic communities has increased,
- Rates of reported new HIV infections amongst drug users has decreased,
- The rate of drug related deaths has decreased.
The relationship between decriminalisation and prevalence of drug use is less clear cut with prevalence of drug use falling among younger cohorts (13 – 18 years of age), while other age cohorts demonstrating an increased prevalence of illicit drug use since decriminalisation.
This phenomena may be due to the obvious success that decriminalising drugs in Portugal has had in reducing drug related harms. 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) purports 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 decriminalisation and resulting reduction in risks may result in a small increase in drug use in regards to frequency of use, however also in a decrease in related harms. It is also important to note that while such initiatives may result in an increased frequency of use there is little evidence to suggest that they are responsible for initiating previous non users to drug use as has been demonstrated in the decrease in prevalence of drug use amongst Portugal’s young people.
The primary goal of harm reduction is to reduce harm
The primary goal of harm reduction is to reduce drug related harm. This position does not necessitate a reduction of drug use (although this can also be viewed as a form of harm reduction). Harm Reduction is therefore value neutral regarding the use of drugs and harm reduction advocates take no position upon supply reduction policies, strategies and Interventions unless they result in harms to individuals or the community.
In a comprehensive review of the existing research regarding the links between drug law enforcement and the harms experienced by drug users, conducted by the International Centre for Science in Drug Policy (2010) it was found that:
“… law enforcement interventions are unlikely to reduce drug-related violence. Instead, and contrary to the conventional wisdom that increasing drug law enforcement will reduce violence, the existing scientific evidence strongly suggests that drug prohibition likely contributes to drug market violence and higher homicide rates. “
This harmful impact upon our communities is related to the violence that the prohibition of illicit trade engenders and does not take into account the range of other harms that can be associated with a war on drugs. According to the preface of the 2009 World Drug Report
“Global drug control efforts have had a dramatic unintended consequence: a criminal black market of staggering proportions. Organized crime is a threat to security. Criminal organizations have the power to destabilize society and governments. The illicit drug business is worth billions of dollars a year, part of which is used to corrupt government officials and to poison economies.”
(United Nations Office on Drugs and Crime website)
The financial cost of policing such criminal enterprise places additional strain upon national economies; monies that could be better spent on the provision of adequate healthcare and shelter for out communities.
In a study conducted by Collins and Lapsley in 2008 estimating the financial and social costs it was found that in the 2004/05 period that the cost attributable to illicit drugs in Australia cost $4.0 billion. Crime attributable jointly to both alcohol and illicit drugs cost a further $1.4 billion. These costs included the financial burdens carried by police, courts and corrections systems in regards to drug attributable crime. All of these harms are discussed at the macro level but the harms experienced by individuals should not be ignored.
Hunt (2003) cited research conducted by Lenton et al. (2000) that demonstrated that individuals who were convicted with a minor cannabis offence experienced a range of negative impacts including adverse implications regarding employability, further troubles with the law and negative impacts upon relationships, and accommodation, even 10 years post conviction. From this evidence it is not difficult to draw a conclusion that current drug laws contribute to drug related harms.
Evidence based approaches
A key element to a harm reduction approach is the use of strategies built upon an evidence based analysis. Current drug laws are not grounded in evidence. In fact the structure of our drug laws, deeming some drugs to be acceptable, others necessarily regulated and yet other drugs requiring total prohibition, is grounded in a history of political, economic, social and religious considerations rather than in any basis of evidence regarding comparative risk (Manderson 1993). It is not surprising therefore to find that despite more than 100 years of international effort to prohibit drug use, that drug use and related harms still exisits in nearly any pocket of the world that we care to think of.
The lack of evidence supporting criminal sanctions as a deterrent is noted by Hunt (2003) who concluded that penalty severity made very little impact upon behaviours such as drug use.
“Overall, the evidence suggests that depenalisation schemes are no worse than strict prohibition at deterring drug use, and the adverse social costs on individuals are significantly reduced.”
Another point to note is that drug laws and drug regulation often result in posing significant barriers in the implementation of effective harm reduction strategies as noted in this example:
“A consequence of the legal regulation of tobacco and nicotine is that the least harmful products are the hardest to obtain or most highly regulated. Snus is a Swedish ground tobacco, available loose or in a small pouch, and placed inside the upper lip. Swedish men have the lowest lung cancer mortality in Europe. Epidemiological modelling suggests that health gains from switching to Snus type products are nearly as large as from quitting all tobacco use.”
It can therefore be argued that not only do current drug laws contribute directly to drug related harms, but that they also obstruct alternative options for the implementation of evidence based harm reduction strategies. The history of harm reduction is littered with stories regarding the need to challenge existing laws in order to implement effective harm reduction interventions:
“Australia’s first NSP was an illegal program established at the Alcohol and Drug Service, St. Vincent’s Hospital in Darlinghurst, Sydney in November 1986 as an act of civil disobedience. The impetus to initiate this first NSP came about through the frustration of many failed attempts to obtain government approval for a legal needle syringe pilot program throughout the year 1986.”
(Australian Injecting and Illicit Drug Users League 2010)
One of the key rationales informing the move to decriminalise all drugs in Portugal was that by removing criminal sanctions, a corresponding reduction in stigma would result, increasing access to treatment services and thereby reducing drug related harms (Greenwald 2010). This rationale appears to have been proven correct with Portugese drug users accessing drug treatment and harm reduction services in record numbers despite no substantial changes in the prevalence of drug use in the general community. The impact of this is aptly described in the quote below:
“…decriminalization has resulted in earlier intervention and the provision of more therapeutic and targeted responses to both drug and drug-related problems. Through providing problematic drug users with a better system of detection and referral to treatment, the [Dissuasion Commissions] increase the ability to address the causes of and harms from problematic drug use.”
The relationship between harm reduction and drug law reform is complex. As has been established not all harm reduction advocates support the notion of drug law reform, or if they do, there appears to be a wide variance in opinion about what subsequent changes to drug law should be made. The range of harm reduction strategies and interventions that are implemented on a daily basis operate in parallel with current supply control measures creating somewhat of a social paradox. While this uneasy marriage of assistance and sanctions has existed for some time in many Western societies it cannot be denied that this has also been the cause of some tension, with many harm reduction advocates championing drug law reform as a logical extension of harm reduction. Is this the act of malcontents asserting a hidden agenda, as Anthony Maria Costa seemingly contended? The writer would argue that this is not the case and that supporting drug law reform is totally congruent with the aims and characteristics of harm reduction predicated on two key considerations:
- That any support of drug law reform is founded on an analysis of the evidence base
- That the evidence supports a net reduction in harms
Australian Injecting and Illicit Drug Users League (2010) ‘Legislative and policy barriers to needle & syringe programs and injecting equipment access for people who inject drugs’ Australian Injecting and Illicit Drug Users League Canberra, Australia http://www.aivl.org.au/files/29057-AIVL-book-text_FA.pdf accessed 7th November 2011
Caulkins , J., Feichtinger, G., Tragler, G. and Dagmar Wallner D. (2010) ‘When in a drug epidemic should the policy objective switch from use reduction to harm reduction?’ , European Journal of Operational Research, Vol. 201, no.1 pp. 308 – 315
Collins, D.J. & Lapsley, H.M. (2008) ‘The Costs of Tobacco, Alcohol and Illicit Drug Abuse to Australian Society in 2004/05.’ Commonwealth of Australia, Canberra ACT
Greenwald, G. (2010) ‘Drug decriminalization in Portugal: lessons for creating fair and successful drug policies.’ CATO Institute Washington D.C. U.S.A
Hunt N. 2003. ‘A review of the evidence-base for harm reduction approaches to drug use. Forward thinking on drugs.’ http://www.ihra.net/files/2010/05/31/HIVTop50Documents11.pdf accessed 4th November 2011
International Centre for Science in Drug Policy (2010) ‘Effect of drug law enforcement on drug-related violence: Evidence from a scientific review.’ International Centre for Science in Drug Policy , Vancouver Canada http://www.icsdp.org/docs/ICSDP-1%20-%20FINAL.pdf accessed 7th November 2011
Manderson, D. (1993) ‘From Mr Sin to Mr Big : a history of Australian drug laws.’ Oxford University Press, Melbourne Australia.
Ministerial Council on Drug Strategy, 2011. ‘The National Drug Strategy 2010–2015 A framework for action on alcohol, tobacco, and other drugs.’ Commonwealth of Australia
Ritter, A. & Cameron, J. (2005). ‘Monograph No. 06: A systematic review of harm reduction.’ DPMP Monograph Series. Fitzroy: Turning Point Alcohol and Drug Centre.
Stimson, G. (2010) ‘Harm reduction: the advocacy of science and the science of advocacy’ 1st Alison Chesney and Eddie Killoran Memorial Lecture, London School of Hygiene and Tropical Medicine, 17th November 2010 http://www.vandu.org/documents/harm_reduction__the_advocacy_of_science_and_the_science_of_advocacy.pdf accessed 5th November 2011
United Nations Office on Drugs and Crime ‘World Drugs Campaign website’ http://www.unodc.org/drugs/en/security-and-justice/index.html accessed 7th November 2011