DRUG-RELATED
RISK & HARM
RISK
(A) The probability that a type of drug
use will result in harm
(B) Drug use (consumption behaviour)
with a high probability of causing
harm
Drug consumption has 7 risk components,
and risk also arises from its causes & effects
HARM/BENEFIT
A negative/positive consequence (longterm
effect or outcome) of drug use
3 types: health damage, socio-legal
problems, & economic costs
3 levels: individual, community or society
RISK
Drug consumption has seven core risk
components, with 2 key indicators for each
PRODUCT Purity & Adulterants
ACCESS Sources & Availability
AMOUNTS per Dose & per Period
PATTERNS Frequency & Stages of use
MIXTURES Poly-use & Multi-use
METHODS Route of use & Care
CONTEXT Set & Setting
R. Newcombe (1992). The reduction of drug-related harm. IN P. O’Hare et
al. (eds), The Reduction of Drug-Related Harm. London: Routledge.
HARMS &
BENEFITS
Mental &
Physical SOCIOHEALTH
LEGAL ECONOMIC
DAMAGE PROBLEMS COSTS
INDIVIDUAL
COMMUNITY
SOCIETAL
RISK ESTIMATION
CALCULATING RATES OF
DRUG-RELATED HARM
EXPOSURE DRUG USE Example
PREVALENCE Number of people 1M users of E
FREQUENCY Mean no. of occasions 12 times a year
LEVEL Mean amount used 2 tablets per
occasion
NUMERATOR: number of cases of harm
(eg. death, heatstroke, psychosis)
DENOMINATOR: number of cases of exposure
to risk
(1) number of people, eg. one million users
(2) number of occasions, eg. 12 million occasions
(3) number of doses, eg. 24 million doses
WHAT IS BEING NEGLECTED
BY HARM REDUCTION
POLICY & SERVICES?
RISKS
DRUG PRODUCTS – variable purity (overdose)
- toxic adulterants (ecstasy)
- toxic additives (cannabis)
- bacterial contaminants (heroin)
ACCESS TO DRUGS – substitute prescribing
(99% methadone)
- cultivation of cannabis
(possible imprisonment)
- forensic data on seized drugs
(distribution to drug users)
HARMS
INDIVIDUAL HARM - TO DRUG DEALERS
- many/most users are user-dealers
- need dealers to cooperate on safer drug products
(since government will not provide quality supply)
- distinguish social supply from commercial supply
- end imprisonment for cannabis trafficking
CAUSES
DRUG LAWS - decriminalisation as first step
then legalisation
Effects
(1) reduction in criminalisation & discrimination
(2) users more willing to come forward for help
(3) talk to young experimenters directly
(4) clean hygienic measured controlled products
(5) point of sale information and advice
ENDPOINT
WOULD YOU WANT TO EAT IN A
RESTAURANT WHICH GAVE YOU:
(1) AN INFORMATIVE MENU – WITH ADVICE ON
INGREDIENTS, CALORIES, etc.
(2) A SUITABLE SETTING FOR DINERS ONLY
(3) CLEAN CROCKERY & CUTTLERY
BUT
SERVES BAD FOOD AT HIGH PRICES? – THAT IS,
* INGREDIENTS IN VARIABLE, UNKNOWN AMOUNTS
* FOOD ADULTERATED WITH TOXIC CHEMICALS
* FOOD CONTAMINATED WITH BACTERIA
BECAUSE THIS IS WHAT HARM REDUCTION
MAINLY OFFERS DRUG USERS. FOR EXAMPLE,
IDUs ARE GIVEN ADVICE ON SAFER INJECTING,
INJECTING ROOMS, AND CLEAN NEEDLES &
PARAPHERNALIA – BUT HAVE TO INJECT ILLICIT
DRUGS (HIGH PRICES, VARIABLEDOSES,
ADULTERATED, IMPURE & CONTAMINATED)
For harm reductionists, pressing for a legal supply of
drugs should neither be (a) irrelevant, nor (b) a hidden
agenda – it should be their explicit, formal agenda
MAIN 2 EXAMPLES OF HARM REDUCTION IN OTHER FIELDS
An intervention can be classed as harm reduction if its
objective is less risky behaviour (safer use/sex), instead of,
or as well as, prevention of the behaviour (abstinence)
ALCOHOL
Information/advice on unsafe, safe and beneficial
amounts of alcohol per week, by gender
Products with a range of potencies available, with
information on labels about %ABV
Quality-controlled production and delivery by breweries,
and sale by off-licenses and licensed bars
Most bars sell food and non-alcoholic drinks
Law permits sale to (a) adults only, (b) sober people only
Drink-driving is an offence, detected by breathalyser
Public drunkenness (with or without disorder) is an offence
Local by-laws prohibit alcohol use in public places
Giving alcohol to child under 5 years is an offence
Laws gradually introduce young people to alcohol
(enter bars at 14, drink with meal at 16, buy alcohol at 18)
Alcohol use is prohibited by many organisations in the
workplace and/or during working hours (eg. transport,
security, medical), and may be monitored by drug tests
Alcohol units and helping agencies for problem drinkers
SEXUAL BEHAVIOUR
Information/advice/education on safer sex – activities (esp.
non-penetrative), protection (esp. condoms), lifestyles (esp.
monogamy and fidelity), etc.
Free condoms provided from health agencies, and on sale
at pharmacies and in vending machines (eg. pub toilets)
Other contraception also available from health agencies
and pharmacies, eg. the pill, dam, coil, vasecectomy, etc.
Legalisation of prostitution (medical monitoring, etc.)
Chemical/physical castration of repeated serious sexual
offenders – esp. child abusers and rapists
STD clinics and HIV/hepatitis units for treatment
DRUG-RELATED RISK AND HARM
<- - - - - - - - - - - - R I S K - - - - - - - - - - - -> < - - - H A R M - - ->
CAUSES DRUG CON- SHORT-TERM LONGER-TERM
SUMPTION EFFECTS EFFECTS
(INGESTION) (INTOXICATION) (OUTCOMES)
laws/policy product, access, physical effects health damage
soc. exclusion amount, pattern, mental effects sociolegal problems
genes/traits method, context, economic costs
etc. mixtures
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- - R I S K R E D U C T I O N - - HARM REDUCTION
I N T E R V E N T I O N S
RISK-HARM RELATIONSHIPS
RISK HALLMARK HARMS Specific causes
PRODUCT POISONING/ODs Variable purity
INFECTIONS & additives etc.
ACCESS CRIMINALISATION Drug offences
DEALING, ACQ. CRIME Funding habit
PATTERNS DEPENDENCE Daily use
MENTAL DISORDERS Regular use
AMOUNTS POISONING/ODs/DEATHS High doses
METHODS INFECTIONS Sharing needles
MIXTURES POISONING/ODs/DEATHS Drug cocktails
CONTEXT ACCIDENTS/INJURIES Driving, work etc.
EXPOSURE & DISORDER Public places etc.
RISKS REDUCED BY MAIN TYPES OF
HARM REDUCTION INTERVENTION
MAIN TYPES OF H-R INTERVENTION
TYPE OF RISK INFO TEST | PRES EXCH ROOM LAWS
|
PRODUCT * * | * *
ACCESS * | * *
AMOUNT * | * *
PATTERN * | *
METHOD * | * * *
MIXTURE * |
SETTING * | * *
__________________________________________________________________________
INDIRECT INFO INFORMATION & ADVICE on all drugs and all risks/harms –leaflets, software, websites, etc.
TEST DRUG TESTING FACILITIES: mainly for ecstasy (on-site in clubs, and take-home kits)
DIRECT
PRES SUBSTITUTE PRESCRIBING: mainly oral methadone; also other opiates, stimulants, and injectables & reefers
EXCH NEEDLE EXCHANGE for IDUs, including new-for-old syringes, and injecting paraphernalia
DRUG CONSUMPTION ROOMS/AREAS: mainly for IDUs (also: tobacco smokers)
LAWS LEGALISING USE &/OR SUPPLY: mainly for cannabis use (Europe), but also cannabis supply (Holland, Switz.)
PRINCIPLES OF HARM REDUCTION
INTERVENTION STAGES KEY PRINCIPLES
MAKING & MAINTAINING USER-FRIENDLINESS (accessible, flexible,
CONTACT drop-in & outreach, suitable/friendly staff,
relevant client-led services, etc.)
DELIVERING SERVICES MULTI-LEVEL DELIVERY: direct & indirect
interventions into drug use and its causes/effects
CHANGING BEHAVIOUR HIERARCHY OF OBJECTIVES – based on
the 7 components of risk, and its key sub-types
ACHIEVING AIMS TARGET EVALUATION: 3 types of outcome
(REDUCING HARMS AND at 3 levels, with targets: performance indicators
INCREASING BENEFITS) with specified levels of change and deadlines