EURAD examines Harm Reduction

Brief Claims and Replies

A EURAD Think Tank Production partially funded by the European Commission

This EURAD document about certain aspects of Harm Reduction is designed to teach. It reflects EURAD 's standpoint which is an extremely cautious approach to methadone programmes and EURAD 's scepticism towards needle distribution programmes.

This paper consists of two parts. Part one is a more general discussion regarding perspectives on harm reduction. Part two deals more specially with methadone and distribution of free needles/syringes.

Part ONE

Introduction

In this document we deal with "harm reduction" and two of its major components, namely methadone and free needles/syringes.
The concept "harm reduction" implies that it is desired to minimise the harmful effects of the drug abuse of an individual.
But it might also imply that there is such a thing as "safe drug taking" when the "harm" is reduced or eliminated.

EURAD states that it is the drug taking in itself and the behaviour drug abuse causes, that is the root of the "harm".

Therefore, by introducing "harm reduction" and leaving the drug taking unattended, the general public might be lulled into false hopes about the solution of the drug problem. In fact, EURAD queries whether this, in the long run, might not also mean harm production to individuals, families and communities.

Complications

There are several factors complicating the scene. EURAD is well aware of the fact that European countries are not all alike. They differ in history, tradition, religion, economic resources, languages, social welfare policies, etc. Therefore, their measures against drug abuse must differ. However, what all countries have in common is the need to reduce drug abuse. We must learn successful strategies from each other and adapt them to the conditions in our own countries. We learn from history that no country has ever decreased their drug problems by making it easier to use drugs. Distribution of methadone and free needles might make it easier to keep on using drugs. The habit is then untouched.

Another important factor to take into account is the goal of the drug policy in each country. We must constantly bear in mind that distribution of methadone and free needles are measures directed towards very advanced drug abusers, late in their career of drug abuse. EURAD puts focus on the pre-debut and early drug abuse stages before dependency has occurred. Prevention and early intervention are the major strategies on which communities should place priority for the future. If that is done, not so many will reach a point where they are considered hopeless cases and given methadone as "terminal treatment".

For humane reasons, we cannot abandon those individuals addicted to drugs TODAY. So what do we do? EURAD pleads for a combination of measures, mobilisation of economic and personal resources from communities, organisations and individuals. We will never be able to curb the drug abuse situation just by handling out strong addictive drug like methadone which also for example has no effect at all on other drugs like alcohol, cannabis, cocaine, amphetamines, etc.

Methadone can also be tempting to politicians to use as a cosmetic strategy just because it is cheap. Politicians - and taxpayers! - favour cheap "solutions". The drug problem has however reached such proportions that a mobilisation of an informed public is needed.

Not black and white

The picture is however not totally black and white. EURAD states that methadone might have a role for advanced opiate addicts even in a well-conducted, restrictive national drug policy/strategy.
The conditions for such programmes are presented later in this stage.

Legalisation - Harm Reduction - Background

The increasing demands for harm reduction have, of course, a background which has to be taken seriously.
Also, the demands for legalisation and decriminalisation can be said to have the same background, namely a continuously deteriorating drugs situation. International drugs criminality has in many cases developed into the fastest growing economic sector. Its economic and social force makes it a powerful enemy. It not only constitutes a threat to the judicial order, but also to the judicial social welfare structure and health and undermines the development and maintenance of society and democracy.

Many of those advocating legalisation, decriminalisation and/or harm reduction do so due to a feeling of fatigue, impotence, despair or capitulation. Their ambition then is not to solve the problem but to manage it. They say we must "learn to live with it". The further the boundaries of tolerance are gradually stretched, the greater the need to manage the problem rather than solve it.

EURAD does not accept that low level of ambition, simply because we believe that the price is too high. Drug abuse ruins too many lives to become complacent about it and accept it.

One of EURAD' s main tasks is therefore to inspire courage and hope into the drugs situation. We do that because we know that the drug problem can be substantially reduced with restrictive, humane and democratic measures.

EURAD Drug Policy

To clarify the EURAD standpoint on harm reduction, we need to review some of EURAD' s general standpoints on drug policies.

EURAD advocates a demand restrictive policy called "The Third Way". This concept means that we differ from present policies ("The Third Way") which mainly focuses on the supply side. But we also differ form "The Second Way" which wants to legalise drugs and make them freely available. This would be more disastrous the present shortcomings of the supply- control strategies.

To preserve democracy, ANY serious strategy presented must face the same question: Will this help to achieve a drug-free society?

EURAD fears that strategies like harm reduction might well increase and change the nature of the problem in the future. EURAD claims that a successful strategy against drugs must focus on the individual user. As long as the pattern of drug taking is untouched, the problem remains and increases since drug takers are left in a position where they can spread the habit to beginners.

Focusing on the individual user means that every person using drugs must be addressed. If discovered, users in the early stages can stop their drug taking quite easily since they are not yet addicted. Advanced drug abusers might need different forms of treatment. Our communities need to provide a great variety of measures, depending on the individual situation.

Part TWO

Methadone - Important to know

1. Methadone is a synthesised opiate replacement substance with effects which can be very similar to the opiates (opium, morphine, heroin). Methadone differs from the opiates mainly by having a very long-lasting effect in the body (24-36 hours compared to 3-4 hours for heroin). It is effective only on addiction of opiates and therefore not useful in the case of other chemical dependency states such as with alcohol or cocaine. It cannot be used against drug addiction in general.
   
2. Methadone, which is a strong drug, gives rise to dependency.
   
3. When methadone, likewise opiates, leave the body, disagreeable physical abstinence/withdrawal symptoms arise.
   
4. Methadone's long lasting effect constitutes the base on which the pharmacologist Dole developed his special methadone maintenance method for the treatment of opiate addicts.
   
5. When dosage is well assessed and adjusted, the heroin addicted who receives his daily dose of methadone finds his craving for heroin is eliminated. Large doses of methadone totally block all effects of opiates, lower doses only partially. Large adjustment is therefore very delicate.
   
6. Methadone has been utilised for the treatment of opiate addiction (primarily heroinists since the mid-1960s and so therefore a fairly well tested and well documented method. Methadone was originally intended for elder, well-motivated addicts of so called therapeutic 1 type. Using methadone to curb opiate addiction of epidemic2 nature is another matter. Contrary to original intentions, methadone programmes which are not properly administered can contribute to a deterioration of the narcotics situation by supplying methadone to the drug market.
   
7. Methadone removes the motivation of the addict to become drug free.

Therapeutic type of addiction occurring after medication with dependence-producing drugs. In some cases, the heavy medication is a consciously taken risk, sometimes it is result of overmedication or lack of medical skill.

Addicts suffering form therapeutic type of addiction are mostly older people who are not likely to spread their addiction to other. The willingness or unwillingness to spread the habit is important, differing therapeutic type of addiction from epidemic type. See Bejerot, N:Addiction and Society (Springfield, IL:Charles C. Thomas, 1970)

Epidemic type of addiction is 1.a. characterised by its spread among friends who have been close contact with each other. The spread is mostly done in the early stages of drug abuse. Bejerot (19700 named that period "honeymoon of drug abuse", since the drug taker in that stage has pleasurable effects. NO bad side effects have yet occurred.

Strict Programme

Let us look at some of the experiences of maintenance treatment with methadone in Sweden. Well-controlled Swedish studies3 show that herionists who were treated in a maintenance programme managed much better than a control group which continued with heroin in constant euphoric doses. All this sounds good, especially since many of the methadone patients can certify that the method helped them to leave their drug environments and enter into an orderly social life. It is necessary, however, to know that the Swedish model did not accept anyone for methadone treatment who

1. had not tried and failed at last three times in serious efforts to achieve drug-free rehabilitation and is not dependent on any intoxicating agent other than heroin.
   
2. was under 20 years of age.
   
3. had injected heroin for less than four years.

What can EURAD advise about methadone?

We can advise that methadone programmes have little or no place in communities that run efficient demand restrictive policies of prevention and early intervention with brakes all the way down the slope of drug abuse.

However, failing that and when communities introduce methadone programmes, we advise that some necessary conditions learnt from the above high threshold model must be placed at the outset.

• that the addict is selected according to strict criteria
• that the substance is, in principle, never given to the addict to take away, but must be consumed under the supervision of experienced personnel, to counteract methadone entering the illegal drugs market
• that measures (e.g. urine tests under control forms) are taken in order to counteract the temptation to manipulate and to continue with poly drug abuse
• that the programme is administered by experience and competent personnel
• that the possibility of reducing programme is offered as an option after a preliminary period of stabilisation
• that the programme should be operated under strict and scientifically tested forms
• that methadone maintenance must always be accompanied by social and other necessary support
• that methadone programmes can never replace measures taken to prevent or stop drug abuse at an early stage. Methadone is a substance, directed to chronic heroinists, NOT to teenagers or others in the early stages of drug abuse. Methadone is not and easy and cheap once for all solution. It is a measure that can even deteriorate the problem.
  Early intervention will decide the future size of the addict population in our societies.

Bejerot calls "psycho-social contagion" really means that a drug taker who likes the effects of the drug and sees no ill effects, wants his friend to share this experience. Therefore, he willingly "advertises" his drug and declare its advantages. The novice, who is curious and trusts his friend, is tempted to try. If there are many friends using the drug, the peer pressure can be considerable. Jesus worded clearly this phenomenon of "advertising good or bad feelings" almost 2000 years ago: "The mouth speaks that the heart is full of".

Needle / syringe distribution

The discussion about distribution of free needles has much in common with the discussion of methadone. Naturally, EURAD does not doubt the good intentions behind the demand for free needles and syringes. But good intentions are not always the same as good actions and good results.
Exactly as with methadone, many find it difficult to imagine that a theoretically attractive model, which may have certain beneficial effects in individual cases, can have the directly opposite effect when put into large-scale use.

Different methods of needle distribution are a newer phenomenon than the distribution of methadone. The measure is primarily intended to be a preventive measure against the spread of HIV/AIDS.

There are, however, different opinions about the value of free needles. It is almost impossible to prove in a short-term scientific study whether such programmes have an effect on the HIV/AIDS-epidemic or not. Scientific reports on the subject do not give any clear-cut picture of the value of these programmes. The contradictory reports from the various syringe exchange programmes should be cause for consideration.

Important to know about drug users and needles/syringes

1. Intoxicated and confused addicts are likely to be careless with needles.
2. Drug users cannot be expected to act responsible under the influence of their drugs.
3. Drug users become impatient for the next injection of drugs and will not necessarily wait for a clean needle.
4. Some drug users refuse to stop the common ritual of sharing the needles.
5. The intravenous drug addict is threatened by death from many angles and not only by AIDS: overdose, accidents, intoxicated violence, etc.
6. Heroinists are sexually low-active, cocaine and amphetamine users in many cases are high active. While methadone is directed only to opiate addicts, needle distribution affects also abusers of stimulants.
7. HIV/AIDS is spread more by sex that by sharing needles.

Objections

The objections which are usually directed against needle/syringe distribution programmes are:

A ). The programmes reduce the threshold against intravenous drug abuse and thus encourage injecting among those who still take drugs orally or by sniffing.

B ). Society is stimulating a destructive and dangerous practice

C ). Syringe exchange programmes often claim that they get a majority of the syringes in return. Even if that is the case, that means discarded needles/syringes left lying around in parks, beaches or other public places. They pose a health risk to the completely innocent children playing there and to the general public in all.

D ). Discard needles/syringes become desirable articles of trade for addicts outside the distribution programmes.

E ). Focusing on needles/syringes might make society forget that HIV/AIDS is spread to a greater extent by sex than by the sharing of needles/syringes. Drug taking impairs judgement, and heterosexual contacts between addicts and non-addicts is proving to be a major route for the spread of HIV/AIDS in the future. Addicts, in many cases, are only mildly interested in using free condoms. The intoxicating effects of the drugs might also simply make them forget to use condoms.

F ). A syringe exchange programme in Malmö/Lund, Sweden has shown some discouraging results. An example is that the spreading of hepatitis B (a blood borne virus) continued undiminished despite access to clean syringes. This indicates that free syringes by no means is guarantee for HIV/AIDS-free drug taking. It cannot be scientifically proven that this programme has had any effect on suppressing the HIV-epidemic.

What can EURAD advise about needles/syringes?

In view of the above, we maintain and emphasise that needle/syringe distribution programmes, as well as poorly controlled methadone programmes, have no place in communities that run efficient demand restrictive policies of early intervention what brakes all the way down the slope of drug abuse.

However, having failed that and faced with communities like Merseyside (England) who did not listen to the pleas of parents not to introduce needle distribution programmes in the first place, we hope that communities invest more resources into education and prevention leading through to drug free treatment. We understand it is unrealistic to abolish these needle programmes overnight but we do not advise any community to start up new programmes.

We also advise communities to remember that needle/syringe programmes promote a dangerous behaviour and life style which might increase the risk of spreading HIV/AIDS.

It is possible for communities to reduce the grave practice of drug abuse. It has been done in many different countries at different times- and it can be done again.

EURAD wishes to state clearly that it is drug abuse which is the source of the drugs epidemic.

The main question is how we can force drug abuse into retreat-not how we can make it safer. Free syringes to addicts can increase drug abuse by giving the impression that under these conditions abuse is safe.
What in the short-term appears to be "harm reduction" may in the long-term prove to be "harm production"