Adiction Harm Rdd

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Given the immediacy of the threat posed by human

immunodeficiency virus/acquired immune deficincy

virus (HIV/AIDS) in the mid-1980s, it was probably

important to be explicit about harm reduction not neces-

sarily addressing drug consumption per se when first

describingthis approach [4]. However, as this paper notes,

harm reduction remains anathema to some who see it as

the thin endof thedrug legalization wedge, despite efforts

to dissociate these explicitly [5]. Some detractors even

accuse those who support harm reduction of having

vested interests in maintaining the drug problem [6].

As Hall suggests [7], those of us who fought for harm

reduction two decades ago would probably find it hard to

let go of this term, especially given the weight of evidence

of its success now amassed. Indeed, from a pragmatic

perspective its retention at this point in time is question-

able, given how polarizing and occasionally divisive it can

be. In particular, the more narrow ‘pure’ definition,

which states that harm reduction necessarily doesn’taddress drug consumption, could be perceived as protest-

ing too much. This definition certainly has little utility in

day-to-day clinical practice, as injecting and sexual risk

behaviour and drug-related harms are often also affected

by level of AOD use, drug users’ needs in this regard fluc-

tuating widely in both the short and long term.

While other taxonomies could replace harm minimi-

zation, including harm reduction (for example primary,

secondary and tertiary prevention), it might be too late

for this, as the World Health Organization, other United

Nations organizations and many countries in the

world have now embraced this terminology [8].Perhaps, at this point in time, it should be

re-emphasized that the harm reduction approach is the

first step in a continuum of care that extends to

abstinence-based AOD strategies. In this sense, harm

reduction is both a cure and a care-based approach [4]

consistent with acceptinga duty of care as a compassion-

ate and caring community, and while harm reduction

encompasses abstinence as a desirable goal, it recognizes

that when abstinence is not possible, it is not ethical to

ignore the other available means of reducing human suf-

fering [9].

Declarations of interest

None.

Keywords Abstinence, drug policy, harm minimiza-

tion, harm reduction, zero tolerance.

I NGRI D VAN BEEK

Kirketon Road Centre, South Eastern Sydney and Illawarra

Area Health Service, Sydney, NSW, Australia.

E-mail: [email protected]

References

1. Weatherburn D. Dilemmas in harm minimization. Addiction

2009; 104: 335–9.

2. Ministerial Councilon DrugStrategy.TheNationalDrug Strat-

egy: Australia’s Integrated Framework, 2004–2009. Canberra:

Commonwealth of Australia; 2004.

3. Zinberg N. E. Drug, Set, and Setting. New Haven: Yale Univer-

sity Press; 1984.4. Buning E. The role of harm reduction programmes in

curbing the spread of HIV by drug injectors. In: Strang J.,

Stimson G.V., editors. AIDS and Drug Misuse. London: Rout-

ledge; 1990, p. 153–61.

5. Single E. Defining harm reduction. Drug Alcohol Rev 1995;

14: 287–90.

6. House of Representatives, Standing Committee on Family

and Human Services. The Winnable War Against Drugs:

The Impact of Illicit drug Use on Families. Parliament of Aus-

tralia. 2007. Available at: http://www.aph.gov.au/house/

committee/fhs/illicitdrugs/report/fullreport.pdf (accessed 9

September 2008).

7. Hall W. What’s in a name? Addiction 2007; 102: 691–2.

8. Ball A. L. HIV, injecting drug use and harm reduction: apublic health response. Addiction 2007; 102: 640–90.

9. Gunn N., White C., Srinivasan R. Primary care as harm

reduction for injection drug users. JAMA 1998; 280:

1191–5.

HAR M R EDU CT ION IS NOW T HE

MAINSTREAM GLOBAL DRUG POLICY

For almost a century, the paramount objective of global

drug policy has been reducing drug consumption. In

1989 the US government argued [1]: ‘we must come to

terms with the drug problem in its essence: use itself.Worthy efforts to alleviate the symptoms of epidemic

drug abuse-crime and disease for example—must con-

tinue unabated. But a largely ad-hoc attack on the holes

in the dike can have only an indirect and minimal effect

on the flood itself’. Governments allocated relevant

resources overwhelmingly to supply control [2] for what

has been perceived as an essentially criminal justice

problem.

However, support has been growing recentlyfor focus-

ing on reducing the adverse consequences of drugs. An

influential World Health Organization (WHO) Committee

[3] expressed ‘concern for preventing and reducingproblems rather than just drug use’. Although harm

reduction type approaches existed long before thehuman

immunodeficiency virus (HIV), the recognition of an

acquired immune deficiency syndrome (AIDS) pandemic

in 1981 andthe subsequent realization of the substantial

costs of HIV spread among and from injecting drug users

stimulated support for the concept of harm reduction;

that is, policies and programmes aimed primarily at

reducing the health, social and economic costs of psy-

chotropic drugs without necessarily reducing drug

consumption.

Commentaries 343

© 2009 The Authors. Journal compilation © 2009 Society for the Study of Addiction Addiction, 104, 340–346

mailto:[email protected]://www.aph.gov.au/househttp://www.aph.gov.au/housemailto:[email protected]


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AIDS is now the fourth major cause of death in the

world [4], while needle sharing accounts for 30% of all

new HIV infections outside sub-Saharan Africa or one in

every 10 new global HIV infections. Since the early

1990s,it has been evident that a harm reductionpackage

(including needle syringe programmes [5] and substitu-

tion treatment [6] for heroin dependence) reduces HIV

spread without increasing illicit drug use. Although

harm reduction is among the most effective interventions

in the HIV prevention and treatment repertoire, Weath-

erburn [7] mentions HIV/AIDS only once.

Harm reduction has become accepted so widely

because of the severity of the global threat from HIV, the

strength of scientific evidencesupporting[8] the effective-

ness andsafety of harm reductionand therelative ineffec-

tiveness [9], high cost and serious collateral damage [10]

resulting from supply control. Harm reduction is now

supported by virtually all major relevant United Nations

organizations, including WHO, Joint United Nations Pro-gramme on HIV/AIDS (UNAIDS), United Nations Office

on Drugs and Crime (UNODC), United Nations Children’s

Fund (UNICEF) and the World Bank. Major international

organizations strongly supporting harm reduction

include the Red Cross and the Global Fund for AIDS,

Tuberculosis and Malaria. Although Weatherburn [7]

recommends dispensing with the term and concept of

harm reduction because the United States remains vehe-

mently opposed, global drug policy should not be held

hostage because some are in denial any more than is the

case with HIV control, evolution or global warming. Sci-

entific evidence must trump ideology.Evidence supporting supply and demand reduction is

scant. In the United States between 1981 and 2003 the

retail price of cocaine dropped [11] from $550/g to

$100/g while purity at the retail level increased from

40% to 70%. During this period similar changes [11] in

cocaine price andpurity occurred in Europeand theretail

price of heroin also declined by 50–80% in the United

States and Europe. In the decade after UNODC declared

[12] ‘a drug free world, we can do it!’, global heroin pro-

duction more than doubled and global cocaine produc-

tion increased 20% [13]. The estimated [14] benefit from

a $1.00 investment to reducethe societal costs of cocainein the United States brought returns of 15 cents for coca

plant eradication in South America, 32 cents from

attempts to interdict refined cocaine between South and

North America, 52 cents from investment in US customs

and police and $7.46 from drug treatment for US cocaine

users. Nevertheless, the US government allocated [15]

93% of available resources to drug law enforcement and

only 7% to drug treatment. A prospectiveevaluation [16]

of more restrictive drug legislation in the Czech Republic

found that three of five objectives were not achieved (with

data inadequate to assess the remaining objectives).

Many assert that illicit drug use will inevitably

increase with more liberal drug laws; yet life-time preva-

lence of smoking cannabis more than 25 times [17] was

32% among residents in more restrictive San Francisco

compared to 12% in more liberal Amsterdam using iden-

tical recruitment and survey methodology. Ever smoking

cannabis and use of all other illicit drugs were also more

prevalent in San Francisco.

A confidential report on drug policy commissioned by

the UK Cabinet in 2003 noted [18]: ‘a sustained seizure

rate of over 60% is required to put a successful trafficker

out of business—anecdotal evidence suggests that

seizure rates ashighas 80% may beneededin somecases.

Sustained successful interventions on this scale have

never been achieved’. The report [18] concluded: ‘The

drugs supply market is highly sophisticated, and attempts

to intervene have not resulted in sustainable disruption

to the market at any level’. A UK parliamentary commit-

tee concluded [19] recently: ‘if there is any single lessonfrom the experience of the last 30 years, it is that policies

based wholly or mainly on enforcement are destined to

fail’.

Any sensible drug policy will always combine ele-

ments of supply reduction, demand reduction and harm

reduction. The critical question is the relative allocation

of resources to supply, demand and harm reduction

required to minimize harms to the community. Drugs are

primarily commodities subject to the inexorable law of

supply and demand. The fall of communism showed that

ignoring powerful market forces carries heavy penalties.

Drugs should be regarded primarily as health and socialproblems, with harm reduction accepted as the guiding

principle.

Declarations of interest

None.

Keywords Abstinence, drug law enforcement, effec-

tiveness, harm reduction, HIV/AIDS, prohibition.

ALEX WODAK

Director, Alcohol and Drug Service, St. Vincent’s Hospital,

Darlinghurst, NSW 2010, Australia.

E-mail: [email protected]

References

1. Office of NationalDrug ControlPolicy. National Drug Control

Strategy. Washington, DC: US Government Printing Office;

1989.

2. Wood E., Tyndall M. W.,SpittalP. M., Li K., Anis A. H., Hogg

R. S. et al. Impact of supply-side policies for control of illicit

drugs in the faceof the AIDS and overdose epidemics: inves-

tigation of a massive heroin seizure. CMAJ 2003; 168:

165–9.

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3. World Health Organization Expert Committee on Drug

Dependence. Twentieth Report. Geneva: World Health Orga-

nization; 1974. Available at: http://whqlibdoc.who.int/trs/

WHO_TRS_551.pdf (accessed 9 September 2008).

4. Joint United Nations Programme on HIV/AIDS (UNAIDS)

and World Health Organization. AIDS Epidemic Update.

Geneva: UNAIDS; 2007. Available at: http://data.

unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf

(accessed 9 September 2008).

5. Wodak A., Cooney A. Do Needle syringe programs reduce

HIV infection among injecting drug users: a comprehensive

review of the international evidence. Subst Use Misuse

2006; 41: 777–816.

6. World Health Organization, United Nations Office on Drugs

and Crime & UNAIDS. Substitution Maintenance Therapy in

the Management of Opioid Dependence and HIV/AIDS Preven-

tion: Position Paper of the WHO, UN Office on Drugs and Crime

and UNAIDS . Geneva: WHO; 2004. Available at: http://

www.who.int/substance_abuse/publications/en/

PositionPaper_English.pdf. (accessed 9 September 2008).

7. Weatherburn D. Dilemmas in harm minimization. Addiction

2009; 104: 335–9.

8. Committee on the Prevention of HIV Infection AmongInjecting DrugUsers in High-Risk Countries.Preventing HIV

Infection among Injecting Drug Users in High-Risk Countries:

An Assessment of the Evidence. Washington, DC: Institute of

Medicine of the National Academies (The National Acad-

emies Press); 2006. Available at: http://books.nap.edu/

openbook.php?record_id=11731&page=R1 (accessed 9

September 2008).

9. McSweeney T., Turnbull P. J., Hough M. Tackling Drug

Markets and Distribution Networks in the UK; A Review of the

Recent Literature. London: Institute for Criminal Policy

Research; 2008.

10. Friedman S. R., Cooper H. L. F., Tempalski B., Keem M.,

Friedman R., Flom P. L. et al. Relationships of deterrence

and law enforcement to drug-related harms among druginjectors in US metropolitan areas. AIDS 2006; 20: 93–9.

11. Executive Office of the President, Office of National Drug

Control Policy. Technical Report for the Price and Purity of

Illicit Drugs, 1981 Through the Second Quarter of 2003.

Washington, DC: Rand Corporation; 2004. Available at:

http://www.whitehousedrugpolicy.gov/publications/price_

purity_tech_rpt/price_purity_tech_rpt.pdf (accessed 9 Sep-

tember 2008).

12. Storti C. C., De Grauwe P. Globalization and thePrice Decline of

Illicit Drug: CESifo Working Paper No. 1990. Munich: Ifo

Institute for Economic Research; 2007. Available at: http://

www.cesifogroup.de/pls/guestci/download/CESifo%20

Working%20Papers%202007/CESifo%20Working%20

Papers%20May%202007/cesifo1_wp1990.pdf (accessed 9September 2008).

13. United Nations International Drug Control Programme

(UNDCP). General Assembly Twentieth SpecialSession: A Drug-

Free World, We Can Do It. Geneva: UNDCP; 1998. Avail-

able at: http://www.un.org/ga/20special/presskit/pubinfo/

gassbro.htm (accessed 9 September 2008).

14. United Nations Office on Drugs and Crime (UNODC) 2008.

World Drug Report. Vienna: UNODC; 2008. Available at:

http://www.unodc.org/documents/wdr/WDR_2008/

WDR_2008_eng_web.pdf (accessed 9 September 2008).

15. RydellC. P.,Everingham S.S. Controlling cocaine.Supplyversus

Demand Programs. Prepared for the Office of National Drug

Control PolicyUnited States Army. Santa Monica:RAND Cor-

poration; 1994. http://www.rand.org/pubs/monograph_

reports/MR331/ (accessed 9 September 2008).

16. Zábranský T., Mravcík V., Gajdošíková H., Miovský, M. PAD:

Impact Analysis Project of New Drugs Legislation (Summary

Final Report). Prague: Office of the Czech Government, Sec-

retariat of the National Drug Commission; 2001. Available

at: http://www.ak-ps.cz/client/files/PAD_en.pdf (accessed 9

September 2008).

17. Reinarman C., Cohen P. D. A., Kaal H. L. The limited rel-

evance of drug policy: cannabis in Amsterdam and in San

Francisco. Am J Public Health 2004; 94: 836–42.

18. Cabinet Office Strategy Unit. Strategy Unit Drugs Project.

Phase 1 Report: Understanding the Issues. London: Cabinet

Office; 2003. Available at: http://www.cabinetoffice.gov.uk/

Sites/www.cabinetoffice.gov.uk/strategy/work_areas/%7E/

media/assets/www.cabinetoffice.gov.uk/strategy/

drugs_report%20pdf.ashx (accessed 9 September 2008).

19. Select Committee on Home Affairs. The Government’s Drugs

Policy: Is It Working? London: House of Commons; 2002.

Available at: http://www.publications.parliament.uk/pa/

cm200102/cmselect/cmhaff/318/31803.htm (accessed 9

September 2008).

DILEMMAS IN HARM MINIMIZATION:

A RESPONSE TO MY CRITICS

Let me begin by emphasizing a couple of points: I did not

(as Wodak says) [1,2] recommendthat weabandon harm

reduction because the United States is vehemently

opposed to it. Nor did I (as Strathdee & Patterson [3]

allege) fail to mention the benefits of treatment. These

commentators were so eager to slay the dragon that they

ended up tilting at windmills.

My concern was with harm minimization (namely,

macro harm reduction), not micro harm reduction. Theproblem I raised was this. If commitment to harm mini-

mization helps to improve our policies and programmes

then it ought to be possible to determine which policies/

programmes best minimize harm. This is impossible,

because (a) there is no common metric in which drug-

related harms can be compared; (b) many drug-related

harms are difficult, if not impossible, to measure; and (c)

reducing one type of drug-related harm often increases

others.

Wodak [2] and Strathdee & Patterson [3] respond by

defending needle and syringe exchange programmes

(NSPs) and attacking supply control, but I acknowledgedthe benefits of NSPs and the harms caused by supply

control. There is no argument here.

If supply control policy produced nothing but harm

one of the major dilemmas in harm minimization would

certainly disappear. Supply control policy in the United

States does not seem to have been very effective, but there

are three points to note about this. First, it is generally

accepted that prohibition makes illegal drugs more

expensive than they would otherwise be. This is impor-

tant, because higher illegal drug prices mean lower

demand for illegal drugs [4] and lower drug-related harm

Commentaries 345


http://whqlibdoc.who.int/trshttp://data/http://www.who.int/substance_abuse/publications/enhttp://www.who.int/substance_abuse/publications/enhttp://books.nap.edu/http://www.whitehousedrugpolicy.gov/publications/price_http://www.cesifogroup.de/pls/guestci/download/CESifo%20http://www.cesifogroup.de/pls/guestci/download/CESifo%20http://www.un.org/ga/20special/presskit/pubinfohttp://www.unodc.org/documents/wdr/WDR_2008http://www.rand.org/pubs/monograph_http://www.ak-ps.cz/client/files/PAD_en.pdfhttp://www.cabinetoffice.gov.uk/http://www.cabinetoffice.gov.uk/strategy/work_areas/~http://www.cabinetoffice.gov.uk/strategyhttp://www.publications.parliament.uk/pahttp://www.publications.parliament.uk/pahttp://www.cabinetoffice.gov.uk/strategyhttp://www.cabinetoffice.gov.uk/strategy/work_areas/~http://www.cabinetoffice.gov.uk/http://www.ak-ps.cz/client/files/PAD_en.pdfhttp://www.rand.org/pubs/monograph_http://www.unodc.org/documents/wdr/WDR_2008http://www.un.org/ga/20special/presskit/pubinfohttp://www.cesifogroup.de/pls/guestci/download/CESifo%20http://www.cesifogroup.de/pls/guestci/download/CESifo%20http://www.whitehousedrugpolicy.gov/publications/price_http://books.nap.edu/http://www.who.int/substance_abuse/publications/enhttp://www.who.int/substance_abuse/publications/enhttp://data/http://whqlibdoc.who.int/trs


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