Harm Reduction -- A Framework for Incorporating Science into Drug Policy

GUEST COLUMN February 1995

by Don C. Des Jarlais, PhD

The articles on addictive substances in [the Jan. 1995] issue of the Journal* provide additional information on both the adverse health consequences of the nonmedical use of psychoactive drugs and the ways in which such consequences might be reduced. It is now abundantly clear that the nonmedical use of psychoactive drugs is one of the major causes of health problems in the United States, as reflected in the physiological effects of the drugs (overdoses and alcohol cirrhosis), behavior while under the influence of drugs (drunken driving and domestic violence), and consequences inherent in drug administration (carcinogens in tobacco smoke, human immunodeficiency virus [HIV] and other serious infections transmitted through shared injection equipment). Additional health problems arise when criminal laws are used to suppress psychoactive drug use. The recent increases in homicide among U.S. youth [1] may be a result of the increased availability of firearms associated with the illegal distribution of crack cocaine.

That the United States has enormous health problems associated with the nonmedical use of psychoactive drugs is not surprising. Over the centuries, and particularly during the first quarter of the 20th century, [2-4] our laws and social customs for regulating this practice incorporated many fundamental scientific errors, such as (1) bad pharmacology -- that marijuana is an addictive narcotic and that tobacco does not contain a drug; (2) bad psychology -- that repetitive drug use can always be controlled through intentional behaviors; (3) bad sociology -- that the drugs used by foreigners and minority groups are the bad drugs, and that criminal laws can effectively reduce psychoactive drug use at a low cost to society; and (4) bad economics -- that the increased "cost of business" for selling an illegal product will outweigh the increased profits to be made from selling through illegal markets.

The point is not to identify the scientific mistakes in our present system for regulating nonmedical psychoactive drug use, but to develop a new system that is consistent with present scientific knowledge and able to incorporate new scientific findings. If the United States is to reduce the adverse health consequences of such drug use, we will probably need an explicit public health perspective on it. Spurred by the urgency of the HIV epidemic among injection drug users, groups in Europe and Australia have been developing just such a perspective, using the terms "harm reduction" and "harm minimization" to describe it. [5-8]

It must be emphasized that the harm reduction perspective is still under active development, and there is as yet no consensus on its fundamentals. Nevertheless, the following may be considered a current working list of its basic components:

1. Nonmedical use of psychoactive drugs is inevitable in any society that has access to such drugs. Drug policies cannot be based on a utopian belief that nonmedical drug use will be eliminated.
   
   
2. Nonmedical drug use will inevitably produce important social and individual harm. Drug policies cannot be based on a utopian belief that all drug users will always use drugs safely.
   
   
3. Drug policies must be pragmatic. They must be assessed on their actual consequences, not on whether they symbolically send the right, the wrong, or mixed messages.
   
   
4. Drug users are an integral part of the larger community. Protecting the health of the community as a whole therefore requires protecting the health of drug users, and this requires integrating the drug users within the community rather than attempting to isolate them from it.
   
   
5. Drug use leads to individual and social harms through many different mechanisms, so a wide range of interventios is needed to address these harms. These interventions include providing health care (including drug abuse treatment) to current drug users; reducing the numbers of persons who are likely to begin using some drugs; and, particularly, enabling users to switch to safer forms of drug use. It is not always necessary to reduce nonmedical drug use in order to reduce harms.

The harm reduction perspective thus would be particularly amenable to using research findings. Indeed, within this perspective, failure to monitor the outcomes of nonmedical drug use and failure to use research findings would violate the core value of a realistic pragmatism. The harm reduction perspective emphasizes the need to base policy on research rather than on stereotypes of (legal and illegal) drug users.

One of the most common criticisms of harm reduction programs (such as syringe exchanges) is that they would be a first step on the slippery slope toward legalization of currently illegal drugs. It is critical to understand the differences between a public health harm reduction perspective and a libertarian "everyone has the right to take whatever drugs he or she desires" perspective. Within the harm reduction perspective, individual rights are important and their loss is a harm to be avoided. At the same time, government and public health authorities have a definite responsibility for formulating policies to reduce the health and social harm associated with the nonmedical use of psychoactive drugs, and civil and criminal laws are seen as potent tools toward this end. A harm reduction perspective does, however, call attention to the possible adverse health and social consequences of relying on criminal laws and stigmatizing drug users as methods for reducing nonmedical drug use.

The value of harm reduction policies should be assessed against their actual effects on drug-related harms rather than on their consistency with cultural traditions. Accordingly, there are three immediate tasks for harm reduction in the United States:

1. Providing adequate treatment for persons with psychoactive drug use problems. This should include problems with both legal and illegal drugs, and short- and long-term types of treatment. A combination of public funding and private health insurance may be needed to provide an adequate treatment system.
   
   
2. Reducing the transmission of HIV associated with illicit drug use. Recent estimates indicate that drug injection-related HIV transmission has become the most common type of new HIV infection in the country. [9] Harm reduction strategies, including treatment on demand and legal access to sterile injection equipment, [10] need to be implemented nationally. [11]
   
   
3. Developing new regulatory formats for distributing drugs for some nonmedical use. New formats are needed in which adults have inconvenient and expensive but noncriminal access to some drugs. The drug preparations should be formulated to reduce the likelihood of dependency and of immediate behavioral impairment. Commercial advertising for the drugs should be severely restricted and countered by realistic countercommercials.

The goal of such new regulatory formats can be stated in economic terms: to reduce the profit potential in selling products for nonmedical drug use. This economic goal is in sharp contrast to the present system, in which legal drugs are sold to tens of millions of persons at moderate profit margins and illegal drugs are sold to millions of persons at enormous profit margins. Tobacco/nicotine is an obvious example of nonmedical drug use where such a new regulatory approach is needed.

Success on any of these three tasks would greatly enhance the political credibility of the harm reduction perspective and provide legitimacy for trying other harm reduction programs.

On a longer term basis, it will also be important to create a health-oriented research and development program for nonmedical psychoactive drug use. If one accepts that people in the United States and elsewhere will continue using such drugs, it is obvious that current botanical, chemical, and neuroscience methods should be able to produce safer products than those currently available, both licit and illicit. Less harmful drug use could be based on new drugs, newmethods of administration for current drugs (such as nicotine inhalers, which would not produce carcinogenic smoke), and new social customs to reduce drug-related harm (such as designated driver programs and injection without sharing the injection equipment).

As better drug products and new social customs are developed, it will be important that the legal and regulatory restrictions placed upon them do not prevent them from replacing the more harmful products and customs.

Developing public support for a harm reduction public health perspective on nonmedical drug use will not be easy. There are strong emotional commitments to cultural traditions that demonize selected psychoactive drugs. There are multibillion-dollar vested economic interests in the status quo arrangements for selling both legal and illegal drugs. While the health and criminal justice problems associated with the present "unrestricted marketing of legal drugs/war on illegal drugs" policies are rather obvious, many political leaders have responded by calling for the intensification of present policies rather than for the development of new policies. Herbert Kleber has called this the "needing ever more king's horses and men to put Humpty together again" reaction (personal communication, Oct. 1994).

But there are also optimistic signs. There is a growing recognition that at least some of the adverse consequences of nonmedical drug use (e.g., HIV transmission) can be reduced without increasing drug use. There is also a growing recognition that current legal status is not commensurate with the addiction liability and health consequences of some drugs (e.g., nicotine in tobacco).

There are also developments -- the increased role of drug injection in HIV transmission, [9] the recent increase in marijuana and LSD use among youth, [12] the potential banning of tobacco by the Food and Drug Administration, the cost of incarcerating illicit drug users -- that may force a reexamination of policies toward nonmedical drug use. Public health officials need to articulate and promote harm reduction policies that can incorporate scientific research into programs to reduce the helath and social problems associated with nonmedical drug use.

[1] Centers for Disease Control and Prevention. Homicides among 15-19-year-old males -- United States, 1963-1991. Morbidity and Mortality Weekly Report. 1994; 43: 725-727.

[2] Musto DF. Opium, cocaine, and marijuana in American history. Scientific American. 1991; 265: 40-47.

[3] Musto DF. The American Disease: Origins of Narcotic Control. Expanded edition. New York, NY: Oxford University Press; 1987. Also see Yale University Press; 1973.

[4] Courtwright DT. Dark Paradise: Opiate Addiction in America Before 1940. Cambridge, Mass: Harvard University Press; 1982.

[5] Des Jarlais DC, Friedman SR, Ward TP. Harm reduction: a public health response to the AIDS epidemic among injecting drug users. Annual Review of Public Health. 1993; 14: 413-450.

[6] Brettle RP. HIV and harm reduction in injection drug users. AIDS. 1991; 5: 125-136.

[7] Berridge V. Harm reduction: an historical perspective. Presented at the Third International Conference in Reduction on Drug-Related Harm; March 1992; Melbourne, Australia.

[8] Heather N, Wodak A, Nadelmann E, O'Hare P, eds. Psychoactive Drugs and Harm Reduction: From Faith to Science. London, England: Whurr Publishers; 1993.

[9] Holmberg SD. Emerging epidemiological patterns in the USA. Presented at the Sixth Annual Meeting of the National Cooperative Vaccine Development Group for AIDS; October 30-November 4, 1993; Alexandria, Va.

[10] Kaplan, EH, Khoshnood K, Heimer R. A decline in HIV-infected needles returned to New Haven's needle exchange program: client shift or needle exchange? American Journal of Public Health. 1994; 84: 1991-1994.

[11] National Commission on AIDS. The Twin Epidemics of Substance Use and HIV. Washington, DC: National Commission on AIDS; 1991.

[12] Johnson LD, O'Malley PM, Bachman JG. National Survey Results on Drug Use from the Monitoring the Future Study, 1975-1993. Vol. 1. Secondary School Students. Rockvile, Md: National Institute on Drug Abuse; 1994.