Tuesday, December 29, 2009

Nasal Naloxone

Some more information on the potential nasal administration of naloxone. The site has a review of current literature on the topic, treatment protocol, recommendations and links to useful teaching materials.


Tuesday, December 8, 2009

Nasal Naloxone

See the below website for a summary of some recent evidence that indicates that naloxone administered through a nasal spray has the same effectivess in averting overdose death as compared to naloxone administered by needle (i.e. intramuscular injection).


PSI programs distributing naloxone should consider if switching to nasal sprays is a practical, affordable, acceptable option for their intervention sites.

Contact me (robgray@laopdr.com) or Petra (pstankard@psi.org) for more information.


Monday, November 30, 2009

How to use a tourniquet

The Blog "Injecting Advice" has a useful 1 page outline on how to properly use a tourniquet to inject more safely. See:


The BLOG itself is useful - you may want to consider signing up, or sharing it with your English-speaking team members.


New report on ATS use in Asia

UNODC has released a new report on ATS use in Asia - Patterns and Trends of Amphetamine-Type Stimulants and Other Drugs in East and South-East Asia, 2009.

With heroin use generally on the decline in Asia, increasingly our programs are (or will probably be) seeing ATS users. The tools to work with ATS users are often different. Methadone or other substitution therapry does not work with ATS users, for example. But ATS is, increasingly, injected - so NSP programs are likely to be part of the regional response to ATS use.

The report includes useful summaries of the ATS situation, country-by-country. Find the report at:


Wednesday, November 25, 2009

Global Fund Grants and Procurement of Harm Reduction Supplies in Eastern Europe and Central Asia - new report

Support from the Global Fund has been instrumental in increasing the availability of harm reduction services and supplies, such as clean needles and syringes. However, harm reduction organizations in the region are confronting an influx of poor quality supplies that threatens the success of their programs. Improving the quality of supplies is an important step toward an effective and sustainable HIV response. This report, by the Open Society Institute’s Public Health Program, evaluates Global Fund grants and procurement practices in Armenia, Georgia, Russia, and Tajikistan. In each country, needles and syringes have been procured that drug users do not find usable because, for example, they may be the wrong size or type.

The report is at:


Women, Harm Reduction and HIV. Report from Azerbaijan, Georgia, Kyrgyzstan, Russia, and Ukraine

Women who use drugs face a dual challenge: they are more vulnerable to both sexually and injection-transmitted HIV infection than male drug users, and they encounter greater obstacles to accessing the services they need. This report, by the Open Society Institute’s International Harm Reduction Development Program, summarizes the results of field assessments of women’s access to harm reduction, antiretroviral, and reproductive health services in five countries: Azerbaijan, Georgia, Kyrgyzstan, Russia, and Ukraine.

The report is at:


Global Fund Extension of HIV Prevention Programmes for People at High Risk for HIV in Russia

The International AIDS Society (IAS) and the International Harm Reduction Association (IHRA) today welcomed the announcement by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to extend by two years its funding of HIV prevention programmes (known as the GLOBUS grant) in the Russian Federation at a cost of US$24 million. “This two-year extension will save thousands of lives,” said Robin Gorna, IAS Executive Director. “While this decision is very welcome, it is nevertheless a band-aid measure, not a long-term solution. External funding cannot prop up Russia’s HIV response forever. The onus is still on the Russian Government to listen to the science and 20 years of proven practice and put in place long-term harm reduction prevention programmes that will save tens of thousands of young Russian lives”.

More info at:


Friday, November 20, 2009

Detachable Needles and HIV - Research and Program Implications

Recently published literature indicates a likely link between using syringes with detachable needles and transmission of HIV and HCV. (See: William Zule, High dead-space syringes and the risk of HIV and HCV infection among injecting drug users, Drug & Alcohol Dependence, 2009.)

Syringes with detachable needles have larger “dead space” in them, able to hold 40 (or more) times the amount of blood compared to non-detachable syringe/needles. This greater “dead space” leads to greater amounts of blood left over in the syringe, which (presumably) leads to greater HIV/HCV infection rates. The evidence is still not strong enough to prove causation, but is strong enough that researchers are calling for programs to make some practical adjustments.

I’m recommending that you consider 2 simple additions to your IDU program:

Add some simple questions to our IDU TRaC questionnaires to:

Ask IDUs what they are using the inject: detachable or not

On those TRaCs where we also track HIV/HCV, see if there’s an association between using detachable s and higher rates of disease

I have asked Gary Mundy (Reg’l Researcher, Asia) to work on the questions.


IDU programs should:-

Inform clients of the potential greater risk of using detachables-
Consider procuring non-detachables, or, at least, actively promoting non-detachables

At the very least, ask your IDU clients what kinds of syringes and needles they are using. If detachable are common, then share with them this new evidence indicating that detachables may be more risky to use. This is a new area of harm reduction, and the evidence is still coming in. But it’s possible that we could help reduce transmission by paying more attention to the types of injecting equipment we are providing/promoting, as in this case.

Sunday, November 15, 2009

Social Networking and Drugs Work

PSI IDU programs, globally, are under-utilizing social networking methodologies to help influence the behaviors of our target groups.

Obviously, these technologies are most useful in environments where our staff, outreach workers, or program beneficiaries are using cell phones or internet. In most of our IDU countries, staff and outreach workers own cell phones. Those programs should consider how to use social networking technologies in their "Marketing Mix." One obvious option - use Twitter to get information out to outreach teams in an efficient manner.

For more information on social networking technologies being used in drugs work, please see the presentation below.



Sunday, November 8, 2009

The "Sharing" Question

A useful post, below, on how to ask drug users if/when they share equipment:



Thursday, November 5, 2009

Syringe sharing cut by two-thirds after injecting room opens

Having shown that the safer injecting facility in Vancouver benefited residents by reducing public injecting and injection-related litter, researchers have now shown that it also safeguarded its users by cutting the number who shared syringes by two-thirds.

To read more, go to:



Tuesday, November 3, 2009

'Asian Network of People who Use Drugs' Launched

Drug users from across Asia met in Bangkok in October 2009 to formally create the ‘Asian Network of People who Use Drugs’ (ANPUD). This new network aims to advocate for the rights of people who use drugs and help unify their voices in a continent which has the largest number of drug users in the world, yet poor access to harm reduction services in many places.

Find out more at:


Experts Urge Russia to Expand HIV Programmes for People Who Inject Drugs

As Moscow prepares to host the 3rd Eastern Europe and Central Asia AIDS Conference (EECAAC) on 28–30 October, the Eurasian Harm Reduction Network, the International AIDS Society and the International Harm Reduction Association issued a joint call to the Russian Government to dramatically expand access to HIV prevention programmes for people who inject drugs.

To see the statement, go to:


Thursday, October 29, 2009

Submission to the UN Human Rights Council on Kazakhstan

The Canadian HIV/AIDS Legal Network (on behalf of a number of local and international durg policy organizations) made a recent submission to the UN Human Rights Council on the state of human rights and HIV in Kazakhstan.

The report "describes several key human rights priorities and provides recommendations for Kazakhstan’s Government to better respect, protect and fulfill human rights, consistent with its international obligations, in areas of particular relevance to an effective response to HIV."

This is an excellent read for anyone interested in the protection of human rights in the context of HIV public health activities. It is critical that project implementers be aware of potential and existing human rights violations and, where possible, advocate for policies that protect the human rights of people living with HIV and at high risk of HIV infection.


Friday, October 23, 2009

Wider distribution of Naloxone

Australian experts have called for the removal of barriers that prevent the drug naloxone from being easily available for peer administration after heroin overdose.

In a letter to the MJA, Professor Simon Lenton, Deputy Director of the National Drug Research Institute, along with colleagues from Melbourne’s Burnet Institute and the National Drug and Alcohol Research Centre, said that naloxone administration by peers has been shown to be a “remarkably safe” intervention to prevent deaths from heroin overdose. “We call on all Australian states and territories to immediately enact Good Samaritan legislation to legally protect laypeople using naloxone in emergency situations,” they said. They also called for the drug to be reclassified from a Schedule 4 (S4) to S3 or S2 to make it available over the counter. “Heroin overdose deaths are preventable. We need to take action now to enable peer-led intervention to reduce this serious outcome.” Nine years ago there had been a push to trial the distribution of naloxone to the peers of people at risk of a heroin overdose, but, as the heroin market was disrupted and use declined, the trials did not proceed, the authors said. However, they noted that overseas trials have shown that fears about naloxone, such as that it would be unsafe to administer or would encourage more risky drug use, had been proved to be unfounded. By December 2008 there were 52 programs in the United States that distributed naloxone to the peers of heroin users which had caused over 1000 documented overdose reversals, they said. MJA 2009; 191 (8): 469.

More at the site below:


Monday, October 19, 2009

Vending Machines for Safe Injection

An interesting AP article came out last week describing the efforts of a harm reduction organization operating in Puerto Rico. Because the needle and syringe exchanges in that area operate only during daylight, vending machines with safe injection equipment cater to IDUs who may need access to clean equipment in the evening hours. This is an interesting and innovative way of getting the clean equipment to IDUs, and one which may be particularly effective in certain settings.


Thursday, October 8, 2009

Calculate your needle coverage

Harm Reduction Works has created an on-line calculator to help you estimate the extent to which the number of syringes being distributed to illicit drug users within an area compares to an estimate of the potential need for sterile injecting equipment.

See: http://www.harmreductionworks.org.uk/5_web/coverage_calculator/index.php

This could hel you think through your "Universe of Need" for IDUs, regarding needles/syringes.


Wednesday, October 7, 2009

A cocaine vaccine?

Immunization with an experimental anti-cocaine vaccine resulted in a substantial reduction in cocaine use in 38 percent of vaccinated patients in a clinical trial supported by the National Institute on Drug Abuse (NIDA), a component of the National Institutes of Health. The study, published in the October issue of Archives of General Psychiatry, is the first successful, placebo-controlled demonstration of a vaccine against an illicit drug of abuse.

For more information on this ground-breaking finding, please see below.


The vaccine is not ready for widespread use yet. But this could become one way for PSI to do product-based drug demand reduction, wherever cocaine use is prevalent and widespread.


Tuesday, September 29, 2009

Harm Reduction - Defined

The International Harm Reduction Association has released a new detailed position statement defining "harm reduction". Although a term that many of us use daily, the term has been the subject of some debate. This definition encompasses both the public health and human rights dimensions of "harm reduction" and is a useful tool for even the most seasoned of IDU program implementers. The full statement can be found at http://www.ihra.net/Whatisharmreduction


‘Harm Reduction’ refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community.


The harm reduction approach to drugs is based on a strong commitment to public health and human rights.

Targeted at risks and harms

Harm reduction is a targeted approach that focuses on specific risks and harms. Politicians, policymakers, communities, researchers, frontline workers and people who use drugs should ascertain:

What are the specific risks and harms associated with the use of specific psychoactive drugs?
What causes those risks and harms?
What can be done to reduce these risks and harms?

Harm reduction targets the causes of risks and harms. The identification of specific harms, their causes, and decisions about appropriate interventions requires proper assessment of the problem and the actions needed. The tailoring of harm reduction interventions to address the specific risks and harms must also take into account factors which may render people who use drugs particularly vulnerable, such as age, gender and incarceration.

Evidence based and cost effective

Harm reduction approaches are practical, feasible, effective, safe and cost-effective. Harm reduction has a commitment to basing policy and practice on the strongest evidence available. Most harm reduction approaches are inexpensive, easy to implement and have a high impact on individual and community health. In a world where there will never be sufficient resources, benefit is maximised when low-cost/high-impact interventions are preferred over high-cost/low-impact interventions.


Harm reduction practitioners acknowledge the significance of any positive change that individuals make in their lives. Harm reduction interventions are facilitative rather than coercive, and are grounded in the needs of individuals. As such, harm reduction services are designed to meet people’s needs where they currently are in their lives. Small gains for many people have more benefit for a community than heroic gains achieved for a select few. People are much more likely to take multiple tiny steps rather than one or two huge steps. The objective of harm reduction in a specific context can often be arranged in a hierarchy with the more feasible options at one end (eg measures to keep people healthy) and less feasible but desirable options at the other end. Abstinence can be considered a difficult to achieve but desirable option for harm reduction in such a hierarchy. Keeping people who use drugs alive and preventing irreparable damage is regarded as the most urgent priority while it is acknowledged that there may be many other important priorities.

Dignity and compassion

Harm reduction practitioners accept people as they are and avoid being judgemental. People who use drugs are always somebody’s son or daughter, sister or brother or father or mother. This compassion extends to the families of people with drug problems and their communities. Harm reduction practitioners oppose the deliberate stigmatisation of people who use drugs. Describing people using language such as ‘drug abusers’, ‘a scourge’, ‘bingers’, ‘junkies’, ‘misusers’, or a ‘social evil’ perpetuates stereotypes, marginalises and creates barriers to helping people who use drugs. Terminology and language should always convey respect and tolerance.

Universality and interdependence of rights

Human rights apply to everyone. People who use drugs do not forfeit their human rights, including the right to the highest attainable standard of health, to social services, to work, to benefit from scientific progress, to freedom from arbitrary detention and freedom from cruel inhuman and degrading treatment. Harm reduction opposes the deliberate hurts and harms inflicted on people who use drugs in the name of drug control and drug prevention, and promotes responses to drug use that respect and protect fundamental human rights.

Challenging policies and practices that maximise harm

Many factors contribute to drug-related risks and harms including the behaviour and choices of individuals, the environment in which they use drugs, and the laws and policies designed to control drug use. Many policies and practices intentionally or unintentionally create and exacerbate risks and harms for drug users. These include: the criminalisation of drug use, discrimination, abusive and corrupt policing practices, restrictive and punitive laws and policies, the denial of life-saving medical care and harm reduction services, and social inequities. Harm reduction policies and practice must support individuals in changing their behaviour. But it is also essential to challenge the international and national laws and policies that create risky drug using environments and contribute to drug related harms.

Transparency, accountability and participation

Practitioners and decision makers are accountable for their interventions and decisions, and for their successes and failures. Harm reduction principles encourage open dialogue, consultation and debate. A wide range of stakeholders must be meaningfully involved in policy development and programme implementation, delivery and evaluation. In particular, people who use drugs and other affected communities should be involved in decisions that affect them.

Thursday, September 24, 2009

AIDS Vaccine Trial Shows Partial Protection

Extremely exciting news today. The results from an AIDS vaccine study in Thailand has shown the vaccine to be partially protective (31.2%) against the HIV virus. While this does not mean that a vaccine is around the corner, it is a huge step forward.

For First Time, AIDS Vaccine Shows Some Success (New York Time, Sept. 24,2009)

A new AIDS vaccine tested on more than 16,000 volunteers in Thailand has protected a significant minority against infection, the first time any vaccine against the disease has even partly succeeded in a clinical trial.

Scientists said they were delighted but puzzled by the result. The vaccine — a combination of two genetically engineered vaccines, neither of which had worked before in humans — protected too few people to be declared an unqualified success. And the researchers do not know why it worked.

“I don’t want to use a word like ‘breakthrough,’ but I don’t think there’s any doubt that this is a very important result,” said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, which is one of the trial’s backers.

“For more than 20 years now, vaccine trials have essentially been failures,” he went on. “Now it’s like we were groping down an unlit path, and a door has been opened. We can start asking some very important questions.”

Results of the trial of the vaccine, known as RV 144, were released at 2 a.m. Eastern time Thursday in Thailand by the partners that ran the trial, by far the largest of an AIDS vaccine: the United States Army, the Thai Ministry of Public Health, Dr. Fauci’s institute, and the patent-holders in the two parts of the vaccine, Sanofi-Pasteur and Global Solutions for Infectious Diseases.

Col. Jerome H. Kim, a physician who is manager of the army’s H.I.V. vaccine program, said half the 16,402 volunteers were given six doses of two vaccines in 2006 and half were given placebos. They then got regular tests for the AIDS virus for three years. Of those who got placebos, 74 became infected, while only 51 of those who got the vaccines did.
Although the difference was small, Dr. Kim said it was statistically significant and meant the vaccine was 31.2 percent effective.

Dr. Fauci said that scientists would seldom consider licensing a vaccine less than 70 or 80 percent effective, but he added, “If you have a product that’s even a little bit protective, you want to look at the blood samples and figure out what particular response was effective and direct research from there.”

The most confusing aspect of the trial, Dr. Kim said, was that everyone who did become infected developed roughly the same amount of virus in their blood whether they got the vaccine or a placebo.

Normally, any vaccine that gives only partial protection — a mismatched flu shot, for example — at least lowers the viral load.

That suggests that RV 144 does not produce neutralizing antibodies, as most vaccines do, Dr. Fauci said. Antibodies are long Y-shaped proteins formed by the body that clump onto invading viruses, blocking the surface spikes with which they attach to cells and flagging them for destruction.

Instead, he theorized, it might produce “binding antibodies,” which latch onto and empower effector cells, a type of white blood cell attacking the virus.

Whatever the vaccine does, he said, it does not seem to mimic the defenses of the rare individuals known to AIDS doctors as “long-term nonprogressors,” who do not get sick even though they are infected. They have low viral loads because they block reproduction in some way that is still mysterious.

“If we knew what immune response did it, we’d be able to be a lot more efficient in targeting it,” Dr. Kim said.

Also, the RV 144 tested in Thailand was designed to combat the most common strain of the virus circulating in Southeast Asia. Different strains circulate in Africa, the United States and elsewhere, and it is not clear that the vaccine would have similar results, even in modified form.
The thousands of Thais chosen were a cross-section of the Thai young adult population, not just high-risk groups like drug injectors or sex workers, Dr. Kim said.

One of the substances that were combined to make RV 144 is Alvac-HIV, from Sanofi-Pasteur, a canarypox virus with three AIDS virus genes grafted onto it. Variations of Alvac were tested in France, Thailand, Uganda and the United States; it was found safe but generated little immune response.

The other, Aidsvax, was originally made by Genentech and is an engineered version of a protein found on the surface of the AIDS virus; it is grown in a broth of hamster ovary cells.
It was tested in Thai drug users in 2003 and also in gay men in North America and Europe; it did not protect them against infection, and Genentech spun off the rights to develop the vaccine.
In 2007, two trials of a Merck vaccine in about 4,000 people were stopped early; it not only failed to work but for some men seemed to increase the risk of infection.

Combining Alvac and Aidsvax was a hunch by scientists: If one was designed to create antibodies and the other to alert white blood cells, might they work together even if neither worked alone?

Mitchell Warren, executive director of AVAC, the AIDS Vaccine Advocacy Coalition, which pushes for vaccines and other forms of prevention, was enthusiastic about the trial data.
“Wow,” he said. “This is a hugely exciting and, frankly, unexpected result. It changes our thinking in ways we hadn’t anticipated.”

“We often talk about whether a vaccine is even possible,” he added. “This is not the vaccine that ends the epidemic and says, ‘O.K., let’s move on to something else.’ But it’s a fabulous new step that takes us in a new direction.”

Mr. Warren said the finding showed the need for large human trials, expensive as they are. Studies in mice and monkeys have not been good at predicting what would work in people, and small human trials in which researchers test results by looking for antibodies in blood have limited value.

Dr. Fauci agreed.

“This is not the endgame,” he said. “This is the beginning.”

"Jury in on Heroin Ban"

Find below and excellent editorial on prescription heroin and the link between injecting drug use and inequality. An excellent piece!

Jury in on heroin ban (The Age, September 24, 2009)

In October 1987, while travelling overseas to learn about HIV and injecting drug use, I spent an evening in a ''shooting gallery'' in Brooklyn, New York City. I watched for hours as four Hispanic men and women injected ''speedballs'' of heroin mixed with cocaine. It was a life-changing experience. We were in the basement of a dilapidated, abandoned tenement building. There was no electricity. Cars parked in the street were propped up on bricks with smashed windscreens. This was urban squalor unimaginable in Australia.

Carrying injecting equipment in the streets was far too risky, especially for minorities. Renting a ''shooting gallery'' for a few hours reduced the risk of being bothered by the police. Needles and syringes were supplied, but the catch was they had already been used by many other people.

I watched as the four injected with little regard for hygiene. Thinking of comparable situations in Australia, I wondered why these American injectors had such little concern for their future. Then I realised that a decent education, proper housing or a reasonable job would have been impossible dreams. Hope for a better life for their children or grandchildren? Forget it. By contrast, the revolving door of prison would have been an all too familiar reality. That was when I first became interested in inequality and illicit drug use.

Inequality has been a constant theme in illicit drugs. Australia's first laws on drugs in the late 19th century banned the smoking of opium in South Australia, Victoria and NSW. The only opium smokers then were the Chinese working in the goldfields.

American missionaries in the 19th century witnessed the appalling misery resulting from the British forcing opium on to the Chinese. China tried to stop the then more powerful British but lost both opium wars. The experience helped prompt the US to convene the International Opium Commission in Shanghai in 1909, setting the scene for global drug prohibition.

Sixty years later, then US president Richard Nixon declared a war against drugs. As Nixon aide John Ehrlichman said: ''Look, we understood we couldn't make it illegal to be young or poor or black in the United States, but we could criminalise their common pleasure. We understood that drugs were not the health problem we were making them out to be, but it was such a perfect issue for the Nixon White House that we couldn't resist it.''

Effective political strategy turned out to be a public policy disaster. While politicians in many countries competed to have the toughest policies, drug production and consumption soared and deaths, disease, crime and corruption steadily increased. The six deaths from drug overdose in Australia in 1964 rose to more than 1100 in 1999.

Multiple scientific studies suggest that prescribing heroin to the most severely dependent heroin injectors, who have not benefited from all other treatments and punishments, has real benefits for the individuals and the community.

In 1997, a large Swiss study concluded that for this minority of entrenched heroin users who had never benefited from repeated episodes of diverse treatments or prison, giving them heroin as part of their treatment provided huge benefits, with few side effects. Their physical and mental health improved considerably. Consumption of street drugs decreased. Crime, measured three different ways, decreased substantially. The treatment was much more expensive than the standard methadone treatment, but for every Swiss franc the program cost, there were gains of two Swiss francs.

Rigorous scientific studies were then also conducted in the Netherlands, Spain, Germany and Canada. All showed similar results. All were published in reputable journals. This month, the results of a British study were released. Again, the results were similar to the previous studies. In each, heroin was self-administered under stringent supervision. Abundant, high-quality psychological and social support was provided.

After a decade of heroin-assisted treatment in Switzerland, the treatment is still only provided to a steady 5 per cent of those seeking help. This small minority of severely dependent drug users is so important because they account for a disproportionate share of the drug-related crime.

In a national referendum last year in Switzerland, 68 per cent supported retaining heroin-assisted treatment as a last resort. The Netherlands now also provides the treatment. Earlier this year, 63 per cent of members of the German parliament voted to allow heroin-assisted treatment. All major political parties in Denmark recently supported the treatment.

Australian researchers in the 1990s investigated heroin-assisted treatment for more than five years. In July 1997, health and police ministers voted six to three to support a trial but prime minister John Howard aborted the process, arguing that it would ''send the wrong message''.

Twelve years later, the message from the scientific evidence is clear: if we want to help drug users, their families and communities, then prescribing heroin should be part of the package we provide.

But we should also try to reduce the extent of inequality in our community. There is increasing evidence that more unequal communities have worse public health outcomes, with higher rates of illicit drug use, mental illness, obesity and crime. At a time when our taxation system is under review, reducing inequality is the debate that Australia has to have.

We don't need a debate about heroin-assisted treatment. We should be providing this now to the small minority with very severe problems who have not benefited from repeated episodes of other treatments.

Alex Wodak is director of the Alcohol and Drug Service at St Vincent's Hospital, Sydney. He is speaking at the ''Drugs in Hard Times'' conference on October 1 in Melbourne. Link to story: http://www.theage.com.au/opinion/jury-in-on-heroin-ban-20090923-g2m5.html

Sunday, September 13, 2009

Calls for wider distribution of Naloxone in the UK


Plea to ease curbs on 'miracle' heroin drug Naxalone, used to revive users who have overdoses

Some fear proposals could encourage riskier habits

Denis Campbell, health correspondent guardian.co.uk

Sunday 13 September 2009 22.05 BST

The government's advisers on illegal substances want curbs eased on a controversial "Lazarus" drug that reverses heroin overdoses, in an effort to cut the rising death toll among addicts.

When a heroin user has an overdose, one injection of naloxone revives them from unconsciousness and gives them enough time for medical help to arrive. It is already used by ambulance crews, casualty staff and out of hours GPs faced with someone who has taken a potentially fatal dose of heroin or another opiate.

The Advisory Council on the Misuse of Drugs, the body that advises the Home Office, is pushing for naloxone to be made much more widely available so that people working with the UK's estimated 300,000 heroin addicts can stock it.

The ACMD has asked the Medicines and Healthcare Products Regulatory Agency, the government's medicines watchdog, to allow frontline drugs workers, managers of hostels for the homeless and other staff who may witness an overdose to retain and inject the drug.

In a letter to the MHRA, Prof Les Iversen, chair of the ACMD's technical committee, said the National Treatment Agency for Substance Misuse (NTA)'s decision to let 950 relatives and carers of heroin addicts be trained in using naloxone "represents a step forward in tackling the high number of fatal opiate overdoses".

He adds: "We consider that provisions should be extended to cover others who may be in contact with drug users through their work."

Iversen, a professor of pharmacology at Oxford University, has hailed naloxone as "a miracle drug in terms of opiate overdoses" that could save 500 heroin users from dying every year. It might have saved singer Michael Jackson's life if it had been administered after his overdose, he believes.

However, doctors and drugs experts are divided about proposals to make naloxone more readily available.

Some fear that it could encourage users to indulge in even riskier drug-taking. Others have warned that up to 3% of those receiving naloxone suffer potentially life-threatening side-effects ‑ and even that it can be used as a weapon in fights between users.

But interest in naloxone as an antidote and potential lifesaver is growing, especially following the most recent annual statistics for deaths from all types of drugs that showed they rose by 11% to 2,928 in 2008 – the highest figure since 2001.

The Medical Research Council hopes to give the drug to 58,000 heroin users who have recently been released from prison as a way of examining its advantages and disadvantages, and a £1m pilot project research project involving 5,800 ex-inmates is due to start soon.

Prof John Strang, one of those behind the MRC's move, said: "The downsides of naloxone are very little. It's not pleasant, because it induces almost instantaneous cold turkey, but it saves lives."

The NTA's director of delivery, Rosanna O'Connor, said: "Naloxone forms part of the government's harm reduction and overdose prevention strategy. The government recognises the life-saving potential of naloxone and supports its use in a number of settings."

Thursday, September 10, 2009

New study on overdose and Naloxone project in UK

As concern mounts about Britain's failure to reverse the recent growth in drug-related deaths, the first large-scale UK follow-up study has assessed the impact of training in overdose recognition and management featuring the opiate blocking drug naloxone. See brief report below.


Overdose video

Go to the link below to see a new, amusing video on overdose (worth watching, and circulating). The video offers a good summary of the main risk factors for opiate overdose.

You might consider putting the video on computers in your drop in centers, if you have them, or just circulating it among your staff, to build their understanding of the issue.



Monday, August 31, 2009

Opium cultivation in India

An interesting article below (from the blog "Talking Drugs") on increases in opium cultivation in India.


Opium cultivation increasing in India

An increase in illegal opium cultivation has brought new prosperity to parts of the Arunachal Pradesh region in eastern India. However this source of new wealth has also left a trail of addiction in its wake.

The Lohit valley in eastern Arunachal Pradesh on the border with China and Myanmar currently has about 10,000 hectares of opium fields. India is a big legal producer of opium, which is used to make such medicinal products such as Codeine and Morphine. However the opium fields in the valley are not licensed and it is roughly estimate that they produce around 100 tons of opium a year, some of it is consumed locally in the region while the rest is sold on the illegal market. India is said to be a major transit route for illicit heroin, opium, morphine base and hashish from Afghanistan, Pakistan, Myanmar and to a lesser extent Nepal. A lot of the drugs trafficked through India end up on the European market.

Myanmar which after Afghanistan is the second biggest illegal opium producer in the world accounts for 5 percent of global production. Although opium production has increased in the last two years, due to international pressure the 1990s saw the Myanmar military government carry out a major crackdown on illegal opium cultivation. This caused cultivation to shift across the border into India. Rising poverty in the region is seen as the reason that more people are choosing to grow the crop instead of legal alternatives that bring in less income.

The local government seems to have turned a blind eye not only on the increasing opium addiction but also on the lack of infrastructure and addiction treatment clinics in the area. Financial support packages that are designated to the region are often siphoned off by corrupt local government officials and have little effect on alleviating poverty.

Like most people in developing or third world countries who chose to cultivate drugs for the illegal market, the opium growers in eastern India seem to be doing it more out of economic necessity than a desire to be the next Pablo Escobar. If the governed improved the local infrastructure and looked for legal alternative crops, villagers would find opium cultivation less appealing.

The profits from opium cultivation has meant now in rural villages in the Lohit valley it is not uncommon to see expensive solar panels on the houses, as well as well dressed girls with polished nails. However in most villages in the valley at least a quarter of the adult population are addicted to opium. This has a toll on society far greater than the economic benefits brought by this lucrative crop.

Alcohol Harm Reduction?


In the harm reduction movement, there's an effort to develop strategies to reduce the harms realted to alcohol. The WHO is active in this effort, and has released a draft strategy, viewable at the website below:


Many PSI countries are considering how to get more involved in lifestyle diseases or health problems more common in developing economies - alcohol certainly falls in that category. There are many ways PSI could get involved. Here's one section from the report, below, showing some possible interventions:

Possible policies and interventions

(1) regulating the drinking context to minimize violence and disruptive behaviour
(2) serving alcohol in plastic containers or shatter-proof glass
(3) enforcing laws against serving to intoxication
(4) legal liability for consequences of harm resulting from intoxication caused by the serving of alcohol
(5) management policies relating to responsible serving of beverage on premises
(6) training staff in relevant sectors how better to manage intoxicated and aggressive drinkers
(7) reducing the alcoholic strength of different beverage categories
(8) social welfare care and support programmes
(9) providing necessary care or shelter for severely intoxicated people
(10) providing consumer information and labelling alcoholic beverages on the harm related to alcohol
(11) fortifying alcoholic beverages or food products with vitamins in order to prevent nutritional deficits among heavy drinkers

Sunday, August 30, 2009

Overdose Awareness Day - Aug 31st

Dear subscribers,

Today (Aug 31) is Overdose Awareness Day.

Please find below a link to a new website (put together by the Int'l Harm Reduction Association) bringing together some some critical documents (from research to advocacy) on overdose.

Opiod overdose continues to be one of the main causes of mortality among our drug user clients in virtually every country where we work with IDUs. Our flagship program on this issue is PSI Russia, implementing an Innovations Fund-funded project to reduce overdose deaths through outreach and distribution of Naloxone.



Drugs and west Africa

Please find below a link to a new UNODC report on drugs and crime in west Africa, with a special focus on the issue of the trafficking of cocaine and other drugs from S. America via west Africa to Europe.

The link also brings you to a superb photo essay on Guinea Bissau, now widely regarded as having become a 'narco-state.'

While the report is illuminating (just skim the exec summary), it mentions HIV only in passing and includes no recommendations for how to deal with growing rates of drug use among west Africans, due to their increasing exposure to these trafficked drugs. In that respect, the report is yet another disappointing publication from UNODC, the lead agency on IDU within the UN, but still ill-at-ease with this role, it seems.

We continue to look more to UNAIDS and WHO for leadership on strongly advocating for harm reduction for people already involved in drug use, in Africa and the rest of the world.


Thursday, August 27, 2009

Editorial on drug reform

Alex Wodak, one of the most respected figures in the harm reduction movement, wrote an enlightening piece on drug reform, below, summarizing some of the major developments in drug reform, globally, in recent months. Worth reading.



Tide turns in favour of drug reform
Alex Wodak
August 27, 2009

One hundred years ago, the US convened the International Opium Conference. This meeting of 13 nations in Shanghai was the beginning of global drug prohibition.

Prohibition slowly became one of the most universally applied policies in the world. But a century on, international support for this blanket drug policy is slowly but inexorably unravelling.

In January, Barack Obama became the third US president in a row to admit to consumption of cannabis. Bill Clinton had admitted using cannabis but denied ever inhaling it. George Bush was taped saying in private he would never admit in public to having used cannabis. When Obama was asked whether he had inhaled cannabis, he said: ''Of course. That was the whole point.''

Obama has candidly discussed his drug use. ''Pot had helped, and booze; maybe a little blow [cocaine] when you could afford it.'' He has also admitted the ''war on drugs is an utter failure'' and called for more focus on a public health approach.

In February, a Latin American drug policy commission similarly concluded that the ''drug war is a failure''. It recommended breaking the ''taboo on open debate including about cannabis decriminalisation''. The same month, an American diplomat said the US supported needle-exchange programs to help reduce the transmission of HIV and other blood-borne diseases, and supported using medication to treat those addicted to opiates.

In March, the United Nations Commission on Narcotic Drugs met in Vienna as the culmination of a 10-year review of global drug policy. A ''political declaration'' was issued which, at the urging of the US, excluded the phrase ''harm reduction''. This omission caused a split in the fragile international consensus on drug policy and resulted in 26 countries, including Australia, demanding explicit support for harm reduction in a footnote.

In April, Michel Kazatchkine, of the Global Fund to Fight Aids, Tuberculosis and Malaria, argued in favour of decriminalising illicit drugs to allow efforts to halt the spread of HIV to succeed. The same month, a national Zogby poll in the US provided evidence of changing opinion on the legalisation of cannabis: 52 per cent supported cannabis becoming legal, taxed and regulated.

In May there was movement on several fronts. The Governor of California, Arnold Schwarzenegger, said: ''I think it's not time for [legalisation], but I think it's time for a debate.'' He was supported by a number of other American politicians, while Vicente Fox, a former Mexican president, said he was not yet convinced it was the solution but asked: ''Why not discuss it?'' The Colombian Vice-President, Francisco Santos Calderon, is already convinced. ''The only way you can really solve the problem [is] if you legalise it totally.''

Obama's drug czar, Gil Kerlikowske, the director of the Office of National Drug Control Policy, said he wanted to banish the idea of fighting a ''war on drugs'', while the United Nations Secretary-General, Ban Ki-moon, said criminal sanctions on same-sex sex, commercial sex and drug injections were barriers for HIV treatment services. ''Those behaviours should be decriminalised, and people addicted to drugs should receive health services for the treatment of their addiction,'' he said.

In Germany, the federal parliament voted 63 per cent in favour to allow heroin prescription treatment.

In July, the Economic and Social Council, a UN body more senior than the Commission on Narcotic Drugs, approved a resolution requiring national governments to provide ''services for injecting drug users in all settings, including prisons'' and harm reduction programs such as needle syringe programs and substitution treatment for heroin users. This month, Mexico removed criminal sanctions for possessing any illicit drug in small quantities while Argentina is making similar changes for cannabis.

Portugal, Spain and Italy had earlier dropped criminal sanctions for possessing small amounts of any illicit drug, while the Netherlands and Germany have achieved the same effect by changing policing policy.

It is now clear that support for a drug policy heavily reliant on law enforcement is dwindling in Western Europe, the US and South America, while support for harm reduction and drug law reform is growing. Sooner or later this debate will start again in Australia.

Alex Wodak is director of the Alcohol and Drug Service at St Vincent's Hospital.

IDU issues from the 9th International Congress on AIDS in Asia and the Pacific

The link below will take you to the Int'l Drug Policy Consortium site.

Scroll down to the section "9th International Congress on AIDS in Asia and the Pacific" to see a short collection of links to stories from this year's ICAAP conference related to IDU. For those of us who couldn't be at ICAAP, this is a good summary of the main IDU-related issue that came up at the conference.



Tuesday, August 25, 2009

Evidence supporting increased distribution on injecting equipment

The below abstract from a new article shows how NSP in Australia is reducing HIV but not being as effective at reducing HCV (Hep C).

HCV is much harder to control, but it is predicted that increasing needle distribution rates would have a positive impact on reducing HCV.

The article provides more evidence for why a "free" needle distribution policy (rather than one-for-one needle "exchange") is the right thing to do, from a public health perspective.


The Impact of Needle and Syringe Programs on HIV and HCV Transmissions in Injecting Drug Users in Australia: A Model-Based Analysis, Kwon, Jisoo A BSc; Iversen, Jenny; Maher, Lisa; Law, Matthew G; Wilson, David P, Journal of Acquired Immune Deficiency Syndromes: August 2009 - Volume 51 - Issue 4 - pp 462-469

Objectives: We aim to estimate how changes in sterile syringe distribution through needle-syringe programs (NSPs) may affect HIV and hepatitis C virus (HCV) incidence among injecting drug users (IDUs) in Australia.

Methods: We develop a novel mathematical model of HIV and HCV transmission among IDUs who share syringes. It is calibrated using biological and Australian epidemiological and behavioral data. Assuming NSP syringe distribution affects the number of times each syringe is used before disposal, we use the model to estimate the relationship between incidence and syringe distribution.

Results: HIV is effectively controlled through NSP distribution of sterile syringes {with the effective reproduction ratio below 1 [0.66 median, interquartile range (0.63-0.70)] under current syringe distribution}. In contrast, HCV incidence is expected to remain high and its control is not feasible in the foreseeable future. The proportion of injections that are shared and the number of times each syringe is used before disposal are the driving factors of HCV incidence. The frequency in which each syringe is used can potentially be influenced by changes in syringe distribution. We estimate that if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%. However, if it was decreased to one third of the current level, then ∼3 times the incidence could be expected.

Conclusions: This research highlights the large benefits of NSPs, puts forward a quantitative relationship between incidence and syringe distribution, and indicates that increased coverage could result in significant reductions in viral transmissions among IDUs.

Monday, August 24, 2009

Overdose Videos

In honor of the upcoming Overdose Awareness Day (Aug 31), there are some high quality videos on YouTube about overdose, for example:



Traces of cocaine found on up to 90% of dollar bills in American cities

Ed Pilkington
New York
Monday 17 August 2009

It's an image much beloved of Hollywood directors: the head lowered over a mirror, a crisp greenback tightly rolled and inserted in a nostril, then applied at the other end to a line of white powder.

Researchers from the American Chemical Society in Washington have discovered that the practice of consuming cocaine through rolled up paper money is far more than just a cinematic cliché. They found that in big cities in the US, up to 90% of the notes tested positive for traces of the drug.

In Washington itself, the percentage of notes with cocaine residue reached 93%, a prevalence almost matched by other urban areas such as Boston, Detroit and Baltimore.

Though some of the contamination can be blamed on cocaine crystals being rubbed from one note onto others in bundles of currency, the researchers did find an apparent growth in the phenomenon. Similar tests conducted two years ago found that only 67% of US banknotes had cocaine traces.

The study put that growth down to a probably increase in cocaine consumption in America, where there are thought to be as many as 6 million regular users of the drug.

For the first time, the researchers compared the results with tests on banknotes from other parts of the world. After the US and Canada, Brazil recorded almost as high a frequency of cocaine residue, at 80% of its paper money.

China (20%) and Japan (16%) were notably lower on the scale.

Any film directors hoping to be authentic in their portrayal of cocaine snorting should note that the researchers found that in the US the bills of choice of cocaine consumers were $5, $10, $20 and $50. Both the modest dollar note, and the more elusive $100 note appear to be rarely deployed as an aid to nasal intoxication.

Hep C treatment access

Please see brief report from ICAAP on the issue of Hep C (HCV) treatment access, a critical issue for our drug user clients in most of the countries where we work.

In many of our countries, upwards of 50% of our clients have Hep C, with little access to treatment. Wherever possible, we should be advocating for getting treatment for our clients.

Story below.



The 9th International Conference on AIDS in Asia and the Pacific (ICAAP) that took place on the 9th – 13th of August this year was interrupted by a small group of campaigners demanding access to drugs that treat HIV patients who also have been affected by Hepatitis C. The campaigners were from a broad coalition of Asia Pacific regional networks concerned with HIV/Aids and drug use. Seven Sisters, one of the main networks that participated brings together seven smaller networks that each provide a representative to form a committee that campaigns on behalf of drug users and people infected with HIV.

It is estimated that one-third of individuals with HIV also are infected with Hepatitis C and it has become an increasing cause of death amongst HIV sufferers. Drugs exist that have had success treating the virus however campaigners argue that the drugs are too expensive and people are dying because they cannot afford the medication, which can cost up to 1500 USD a month.

Protesters anger was aimed at the pharmaceutical giant Roche which they blame for keeping the prices high and they chanted “shame on you Roche, shame on you!”

Hepatitis C is an infection that affects the liver and can lead to liver fibrosis or cirrhosis, if sufferers do not receive treatment means that they will eventually need a liver transplant or die. Most individuals coinfected with HIV and Hepatitis are injecting drug users (IDU’s). However according to the WHO many countries still discriminate against injecting drug users and they are excluded from treatment.

Nanao Haobam a former IDU and now an HIV/AIDS activist in Bangkok who works with the Asia Pacific Network of People living with HIV (APN+) gave an insight to his own tragic personal situation "Almost every month my friends are dying and just in the last two months, five of them have lost their battle with Hepatitis C. Now, my doctor wants me to start on the treatment but it will cost me 1500 USD per month. Where do I get that money?"

The HIV treatment activist movement played a huge role in lowering the price of antiretroviral drugs by putting pressure on governments, bi-laterals and pharmaceutical giants. These efforts resulted in a dramatic fall in the cost of antiretroviral treatment to only a dollar a day. This is an inspirational example to the IDU community who want to reduce the price of these drugs in order to prevent people dying who otherwise could be saved.

Anne Bergenstrom from the UN Task Force on Harm Reduction in Asia Pacific has presented statistics on how IDU’s are being increasingly neglected by harm reduction policies and that they receive only two percent of the budget allocated to Aids policy in the region. Drug users in Asia and Pacific regions on average face greater discrimination than in Europe and would benefit from policies that allow drug users to obtain needed medications and treatments. Dean Lewis a member of the Asian Network for People who Use Drugs (ANPUD) told recent forum on Injecting Drug Users that "Such a policy is still unavailable in many Asian and Pacific countries."

Annie Maiden from the Australian Injecting and Illicit Drug Users League (AIVL) supported Mr. Lewis’s point stating that even in Australia the policies in place to protect the rights of drug users are not adequate. According to the WHO there are about 13 million estimated IDUs in the world out of which 43% of them belong to the Asia Pacific region. In some Asian countries 50-70% of HIV infections are due to injecting drug use.

An accomplishment would be the removal of the patent from the drug that treats Hepatitis C, known as Pegasys. This would allow low-cost generic versions on to the market allowing more infected individuals access to the drug.

More UN endorsement for Harm Reduction

See below article which describes how another UN body (ECOSOC) has endorsed harm reduction.

While this is good news, the story highlights the sad reality that the UN still does not speak with one voice on this issue. Even though all the main UN health bodies (i.e. WHO, UNAIDS) fully endorse harm reduction, as have the most recent General Secretaries, some UN bodies (i.e. UNODC and the notorious Commission on Narcotic Drugs), still prevaricate on the issue. UNODC is the lead agency on IDU within the UN, but its director still often speaks of NSP programs with only moderate support.

In our IDU countries, we look primarily to WHO and UNAIDS to support our harm reduction programs. It's important to keep UNODC colleagues well informed, but we usually don't rely on them for strong, vocal support for harm reduction. We hope UNODC will continue to be more and more comfortable supporting harm reduction in the future.

Details below.


18th August 2009

UN Economic and Social Council Endorses Harm Reduction


In July 2009, the United Nation’s Economic and Social Council (ECOSOC) adopted a resolution related to the work of the Joint United Nations Programme on AIDS (UNAIDS). The resolution was agreed at an ECOSOC meeting in Geneva focusing on the social determinants of health. It contains an explicit supportive reference to harm reduction – the first official mention of harm reduction by this senior UN body.

The resolution “[r]ecognizes the need for UNAIDS to significantly expand and strengthen its work... to support increased capacity and resources for the provision of a comprehensive package of services for injecting drug users including harm reduction programmes”. The resolution was supported by 31 Member States (and was not opposed during the meeting), and follows on from another recent endorsement of harm reduction by the UNAIDS Programme Coordinating Board. This resolution is further evidence of the expanding acceptance and credibility of harm reduction approaches at the international level.

ECOSOC was one of the original UN bodies established under the United Nations Charter in 1945. It co-ordinates the work of a number of specialised UN agencies, programmes and commissions – including UNAIDS. The ECOSOC meetings serve as the central forum for discussing a broad range of issues such as standards of living, employment, economic and social progress, and health problems. Crucially, however, ECOSOC is also the ‘parent’ body of the central drug policy forum in the UN – the Commission on Narcotic Drugs. Unlike ECOSOC, CND which has yet to make an official, explicit endorsement of harm reduction, due in no small part to an over-reliance on consensus which has allowed a minority of Member States (including Japan, Russia and the USA) to actively oppose harm reduction during discussions and in the wording of resolutions. It will be interesting to see whether the ambiguous and incongruous position of CND changes now that harm reduction has been formally endorsed by ECOSOC as well as the UN General Assembly (the chief organ of the United Nations comprising all 192 Member States), and the Office of the High Commissioner for Human Rights.

Using heroin to treat addiction

The story below presents results from a new study showing the efficacy of using controlled prescription of heroin to reduce health and social harms among drug users, which proved to be more effective than prescribing methadone.


New York Times, 19 August 2009, journalist Benedict Carey

Study Backs Heroin to Treat Addiction

Top of Form

For years, European countries like Switzerland and the Netherlands have allowed doctors to provide some addicts with prescription heroin as an alternative to buying drugs on the street. The treatment is safe and keeps addicts out of trouble, studies have found, but it is controversial — not only because the drug is illegal but also because policy makers worry that treating with heroin may exacerbate the habit.

The study, appearing in the current issue of the New England Journal of Medicine, may put some of those concerns to rest.

“It showed that heroin works better than methadone in this population of users, and patients will be more willing to take it,” said Dr. Joshua Boverman, a psychiatrist at Oregon Health and Science University in Portland. Perhaps the biggest weakness of methadone treatment, Dr. Boverman said, is that “many patients don’t want to take it; they just don’t like it.”

In the study, researchers in Canada enrolled 226 addicts with longstanding habits who had failed to improve using other methods, including methadone maintenance therapy. Doctors consider methadone, a chemical cousin to heroin that prevents withdrawal but does not induce the same high, to be the best treatment for narcotic addiction. A newer drug, buprenorphine, is also effective.

The Canadian researchers randomly assigned about half of the addicts to receive methadone and the other half to receive daily injections of diacetylmorphine, the active ingredient in heroin. After a year, 88 percent of those receiving the heroin compound were still in the study, and two-thirds of them had significantly curtailed their illicit activities, including the use of street drugs. In the methadone group, 54 percent were still in the study and 48 percent had curbed illicit activities.

“The main finding is that, for this group that is generally written off, both methadone and prescription heroin can provide real benefits,” said the senior author, Martin T. Schechter, a professor in the School of Population and Public Health at the University of British Columbia.

Those taking the heroin injections did suffer more side effects; there were 10 overdoses and six seizures. But Dr. Schechter said there was no evidence of abuse. The average dosage the subjects took was 450 milligrams, well below the 1,000-milligram maximum level.

About 663,000 Americans are regular users of heroin, according to government estimates. The researchers said 15 percent to 25 percent of them were heavy users and could benefit from prescription heroin. That is, if they ever were to get the chance. Heroin is an illegal, Schedule 1 substance, meaning it has a high potential for abuse and serves no legitimate medical purpose. That designation is unlikely to change soon, researchers suspect.

In an editorial with the article, Virginia Berridge of the London School of Hygiene and Tropical Medicine concluded, “The rise and fall of methods of treatment in this controversial area owe their rationale to evidence, but they also often owe more to the politics of the situation.”

Link to story: http://www.nytimes.com/2009/08/20/health/research/20heroin.html?_r=1&ref=health

Mexico legalizes drug possession

See story from NYT below.

From a public health perspective, what's most encouraging about this is the stipulation that: "Anyone caught with drug amounts under the personal-use limit will be encouraged to seek treatment..."


August 21, 2009
Mexico Legalizes Drug Possession

MEXICO CITY (AP) — Mexico enacted a controversial law on Thursday decriminalizing possession of small amounts of marijuana, cocaine, heroin and other drugs while encouraging government-financed treatment for drug dependency free of charge.

The law sets out maximum “personal use” amounts for drugs, also including LSD and methamphetamine. People detained with those quantities will no longer face criminal prosecution; the law goes into effect on Friday.

Anyone caught with drug amounts under the personal-use limit will be encouraged to seek treatment, and for those caught a third time treatment is mandatory — although no penalties for noncompliance are specified.

Mexican authorities said the change only recognized the longstanding practice here of not prosecuting people caught with small amounts of drugs.

The maximum amount of marijuana considered to be for “personal use” under the new law is 5 grams — the equivalent of about four marijuana cigarettes. Other limits are half a gram of cocaine, 50 milligrams of heroin, 40 milligrams for methamphetamine and 0.015 milligrams of LSD.

President Felipe Calderón waited months before approving the law.


Thursday, August 20, 2009

Exchange Supplies

A few weeks ago, Rob posted a link to the Harm Reduction Works website to draw everyone's attention to some of the great materials available. If you haven't taken a look at them, I highly suggest it. Again, the website is http://www.harmreductionworks.org.uk/.

Harm Reduction Works is the product of Exchange Supplies and the National Treatment Agency. Check out some of the work of Exchange Supplies at http://www.exchangesupplies.org/. They are an innovative organization of drug workers that seek to improve injecting supplies, education tools, etc. to better serve people who use drugs. Their injection supplies include small changes - i.e. different colored plungers to reduce the risk of sharing - that make a big difference. Their campaigns on this site and on Harm Reduction Works are innovative and exciting - definitely worth a few minutes to check out their work.

Wednesday, August 12, 2009

2010 Int'l Harm Reduction Conference - Liverpool, England

The abstract submission system for ‘Harm Reduction 2010’ - next year's Int'l Harm Reduction Conference in Liverpool, England - is now open and will close on November 1st 2009.

All delegates who wish to present at the conference – either orally or with a poster – are encouraged to make submissions about innovative harm reduction services, new or ground-breaking research, effective or successful advocacy campaigns, or key policy discussions or debates.

In addition, the Executive Programme Committee is particularly keen to receive abstract submissions related to the conference theme – ‘Harm Reduction: The Next Generation’, and have produced a ‘Guide for Developing and Submitting an Abstract’ to further assist delegates.

For more information about the conference, please go to:


Friday, August 7, 2009

Harm Reduction Works

The website below, from a UK organization called Harm Reduction Works, provides links to a long list of superb materials (including short videos and other highly creative items) on various topics related to harm reduction.


Check it out; you won't be disappointed.




Wednesday, August 5, 2009

Helping America's Least Wanted

See below an opinion piece published in the Washington Post arguing in favor of needle and syringe programs, notable mainly because it was written by a conservative commentator closely alligned with George Bush.

NSP is not a conservative or liberal issue. Iran (both the government and highest religious authorities) support NSP. So does the Chinese Communist Party. So too the governments of Malaysia, Uzbekistan, and Indonesia. Israel and Afghanistan are aligned on this issue. Every government of western Europe explicitly supports needle and syringe programs.

As of March 2009, harm reduction policies or programmes have been adopted in more than half of the 158 countries and territories where injecting drug use is reported.

For a complete list of the countries that support harm reduction, go to: http://www.ihra.net/Assets/1556/1/HarmReductionPoliciesandPractiveWorldwide5.pdf


Helping America's Least Wanted

By Michael Gerson
Wednesday, August 5, 2009

The RV arrived at a corner near D.C.'s Marvin Gaye Park, also known to locals as "Needle Park." A steady procession of addicts came to the door, mounted a few steps and sat down. One by one, they dropped used needles into a container and received new needles in return, along with alcohol wipes and the small, bottle-cap-like "cookers" in which heroin is heated.

Reggie Jackson, Teefari Mallory and Hazel Smith -- staff members at PreventionWorks, Washington's largest needle-exchange program -- are at the park twice a week, offering clean needles to prevent disease transmission, condoms, drug treatment referrals, HIV/AIDS testing and a few kind words. "You still play the guitar?" "You'll have a swollen hand if you keep going there." "Love you, baby."

It is the eyes and arms of addicts that draw your attention. Eyes that are glassy, or unnaturally bright, or tired beyond exhaustion. Arms that are ulcerated sticks or purpled parchment; with repeated use, needles become blunt and tear the skin. Some addicts adopt a defensive politeness -- "yes, sir" -- and quickly leave. Others want to talk -- "I love plants, and I love kids" -- trying to provide hints of their humanity. They are America's least wanted.

They are also at the center of a controversy. Needle-exchange programs have always been politically controversial, with opponents arguing that they send a mixed moral message about drug use. The House of Representatives recently passed an amendment banning exchanges in the District within 1,000 feet of places where children gather -- which, if approved by the Senate, would effectively put programs like PreventionWorks out of business. Staffers joke that they could work only in graveyards and the middle of the Potomac.

This restriction might make sense if needle-exchange programs increased the number of addicts. But they don't. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, has comprehensively reviewed the scientific studies on needle exchange. "It does not," he says, "result in an increase in drug abuse, and it does decrease the incidence of HIV. . . . The idea that kids are going to walk out of school and start using drugs because clean needles are available is ridiculous."

My experience in Washington was consistent with Fauci's view. Addicts who came for needles were generally in their 40s and 50s. The availability of clean needles no more caused their addiction than the provision of clean shot glasses would cause alcoholism.

The main purpose of needle exchange, according to Jackson, the supervisor of the mobile unit, is to keep people alive until they can get clean -- a process that can take years, if it happens at all. Needle-sharing is the third-leading cause of HIV infection in our nation's capital. It is also a major contributor to the spread of hepatitis C, the main cause of liver transplants in the United States. Jackson is well acquainted with these facts because, while an addict, he contracted both diseases. "If they had a truck like this in the '60s, '70s and '80s," he told me, "maybe I wouldn't have gotten infected."

The staff members of PreventionWorks build long-term relationships with people no one else knows by name. Because of this, they have a good feel for when addicts are ready for treatment. While I was in the RV, Jackson signed up two addicts for detox. Mallory used her own car to drive one addict, with whom she had been working for eight years, to treatment. "He's ready, ready to go," she said, fighting tears.

Critics claim that needle-exchange programs create a moral hazard by legitimizing drug abuse. But it does not legitimate drug abuse to help people with the clinical disease of addiction avoid other deadly diseases until they are ready for help. Sacrificing the lives of addicts to send an "unmixed" moral message actually sends a troubling moral message: that the unwanted have no worth.

As each addict leaves the RV, Smith -- who was an addict on the street herself four years ago -- tells them, "I love you." When I asked her why, she said: "If someone years ago had told me they loved me, it might not have been so long."

Street addicts are connected to the rest of us by only a few invisible strands -- people such as Smith, Jackson and Mallory -- and those strands should not be severed.


Effectiveness of NSP to reduce HIV / HEP

The below article provides some fresh evidence linking NSP with reduced HIV transmission, from Australia. The authors also estimate that "if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%." More evidence that getting needles into the drug user networks in generous quanitities reduces HIV.

Having these sources, published in the most respected journals in our field, provides us with strong evidence to help in our advocacy efforts to launch and scale up harm reduction services for IDUs.

The full article is not yet available pulically for free - just this abstract.


JAIDS Journal of Acquired Immune Deficiency Syndromes:

August 2009 - Volume 51 - Issue 4 - pp 462-469

doi: 10.1097/QAI.0b013e3181a2539a

The Impact of Needle and Syringe Programs on HIV and HCV Transmissions in Injecting Drug Users in Australia: A Model-Based Analysis

Kwon, Jisoo A BSc; Iversen, Jenny; Maher, Lisa; Law, Matthew G; Wilson, David P


Objectives: We aim to estimate how changes in sterile syringe distribution through needle-syringe programs (NSPs) may affect HIV and hepatitis C virus (HCV) incidence among injecting drug users (IDUs) in Australia.

Methods: We develop a novel mathematical model of HIV and HCV transmission among IDUs who share syringes. It is calibrated using biological and Australian epidemiological and behavioral data. Assuming NSP syringe distribution affects the number of times each syringe is used before disposal, we use the model to estimate the relationship between incidence and syringe distribution.

Results: HIV is effectively controlled through NSP distribution of sterile syringes {with the effective reproduction ratio below 1 [0.66 median, interquartile range (0.63-0.70)] under current syringe distribution}. In contrast, HCV incidence is expected to remain high and its control is not feasible in the foreseeable future. The proportion of injections that are shared and the number of times each syringe is used before disposal are the driving factors of HCV incidence. The frequency in which each syringe is used can potentially be influenced by changes in syringe distribution. We estimate that if syringe distribution or coverage doubled, then annual incidence is likely to reduce by 50%. However, if it was decreased to one third of the current level, then ∼3 times the incidence could be expected.

Conclusions: This research highlights the large benefits of NSPs, puts forward a quantitative relationship between incidence and syringe distribution, and indicates that increased coverage could result in significant reductions in viral transmissions among IDUs.

Thursday, July 30, 2009

Does Hep C treatment work for IDUs?

Programs working with IDUs should be providing clients with treatment for Hep C (and possibly vaccination for Hep A and B. There is no Hep C vaccine yet.)

But there is some resistance to this goal from those who question the efficacy of treatment for active drug users. The vast majority of new Hep C cases in the world are among IDUs, so understanding Hep treatment options for IDUs is critically important.

The article below presents data showing that Hep C treatment works for active drug users - important information for our advocacy and implementation, to improve the health of our IDU clients.


Clinical Infectious Diseases 2009;49:561?573

C 2009 by the Infectious Diseases Society of America.

DOI: 10.1086/600304


Hepatitis C Treatment for Injection Drug Users: A Review of the Available Evidence

Margaret Hellard, Rachel Sacks-Davis, and Judy Gold

Centre for Population Health, Burnet Institute, Melbourne, Australia

Globally, 90% of new hepatitis C infections are attributed to injection drug use, but there is a continuing reluctance to treat injection drug users (IDUs). There is evidence that a sizeable proportion of IDUs who begin hepatitis C treatment achieve a sustained virological response (SVR). In chronic hepatitis C treatment trials, the SVR rate among IDUs appears to be comparable to rates among non-IDUs; in trials prescribing pegylated interferon plus ribavirin, the median rate of SVR among IDUs was 54.3% (range, 18.1%-94.1%), compared with 54%?63% in the large treatment trials.
Few trials of acute hepatitis C treatment report on outcomes in IDUs; however, among these trials, the SVR among IDUs was 68.5%, compared with 81.5% among non-IDUs. Additional studies are required to determine the optimal circumstances for treatment (e.g., enrollment in drug treatment, the requirement of a period of abstinence from injection drug use, or the establishment of multidisciplinary treatment programs).

Received 30 October 2008; accepted 18 March 2009; electronically published 9 July 2009.

Reprints or correspondence: A/Prof M. Hellard, Centre for Population Health, Burnet Institute, 85 Commercial Rd., Melbourne, VIC 3004, Australia (hellard@burnet.edu.au).

Wednesday, July 29, 2009

Behavior change among drug users must consider attitudes towards death

The below article makes the point that successful behavior change among people who are ambivalent towards death can not simply focus on delivering information about how to protect your health.

Summary and link below.


Safe using messages may not be enough to promote behaviour change amongst injecting drug users who are ambivalent or indifferent towards death
Peter G Miller

Go to: http://www.harmreductionjournal.com/content/6/1/18

Harm Reduction Journal 2009, 6:18doi:10.1186/1477-7517-6-18

Published: 25 July 2009

Abstract (provisional)

Health promotion strategies ultimately rely on people perceiving the consequences of their behaviour as negative. If someone is indifferent towards death, it would logically follow that health promotion messages such as safe using messages would have little resonance. This study aimed to investigate attitudes towards death in a group of injecting drug users (IDUs) and how such attitudes may impact upon the efficacy/relevance of 'safe using' (health promotion) messages.

Qualitative, semi-structured interviews in Geelong, Australia with 60 regular heroin users recruited primarily from needle and syringe programs.

Over half of the interviewees reported having previously overdosed and 35% reported not engaging in any overdose prevention practices. 13% had never been tested for either HIV or hepatitis C. Just under half reported needle sharing of some description and almost all (97%) reported previously sharing other injecting equipment. Most interviewees reported being indifferent towards death. Common themes included; indifference towards life, death as an occupational hazard of drug use and death as a welcome relief.

Most of the interviewees in this study were indifferent towards heroin-related death. Whilst interviewees were well aware of the possible consequences of their actions, these consequences were not seen as important as achieving their desired state of mind. Safe using messages are an important part of reducing drug-related harm, but people working with IDUs must consider the context in which risk behaviours occur and efforts to reduce said behaviours must include attempts to reduce environmental risk factors at the same time.

Monday, July 27, 2009

New review of the efficacy of Buprenorphine

Please see the link below for a new Cochrane review of the efficacy of Buprenorphine to reduce withdrawl symptoms among drug users.



Buprenorphine is more effective than clonidine or lofexidine, and may have advantages over methadone, for the management of opioid withdrawal.
Dependence on opioid drugs (heroin, methadone) is a major health and social issue in many societies. Managed withdrawal from opioid dependence is an essential first step for drug-free treatment. This review of trials found that the drug buprenorphine is more effective than clonidine or lofexidine in reducing the signs and symptoms of opioid withdrawal, retaining patients in withdrawal treatment, and supporting the completion of treatment. There is no significant difference in the incidence of adverse effects, but patients treated with buprenorphine may be less likely to drop-out due to adverse effects than is the case with clonidine or lofexidine. There is limited evidence comparing buprenorphine with methadone, but it appears that completion of withdrawal may be more likely with buprenorphine and withdrawal symptoms may resolve more quickly with buprenorphine.

Hiring socially skilled workers for your front line work

Please find a link below to a short video by drug expert Mike Ashton suggesting that a socially skilled worker is the most effective on the front lines, and that research indicates it is possible to recruit on that basis.

This video clip comes from a site called Film Exchange on Alcohol and Drugs, a useful resource for your staff working on drug issues.


WHO update on HIV situation among IDUs in Asia

WHO recently published a useful 2 page brochure showing the update on the HIV situation among Asian IDUs, in graphs. Please see the link below to download it.

This could be a helpful advocacy tool, explaining in simple charts / graphs, what the problem is, and how harm reduction can (and has) helped reduce HIV among IDUs already in the region.



Monday, July 13, 2009

Petra Stankard: PSI's new IDU Focal Point in the HIV Dept

Dear IDU Stakeholders

Effective immediately, Petra Stankard is joining the IDU team as your new IDU Focal Point in the HIV Department. Petra spent the last year in the procurement and logistics department at PSI/Washington. In her former role of associate procurement officer, Petra supported operations in Asia, Latin America, Eastern Europe and Washington, D.C. Before joining PSI, Petra worked in Namibia with Africare coordinating HIV care and support interventions in the rural north. She has also supported HIV prevention, care and support interventions in South Africa and Washington, D.C., and previously advocated for increased global HIV funding with Africa Action. Petra is already working hard to get up to speed on PSI's global work with IDUs, so she can help serve your IDU needs with speed and quality!
Welcome, Petra!
Petra replaces Shimon Prohow, who has been your IDU Focal Point for the past year or so (and who is now off to graduate studies). Shimon took on the position with passion and intelligence, and leaves very big shoes to fill.
Thank you, Shimon!

Tuesday, June 30, 2009

1 in 25 Global Deaths linked to Alcohol

Some staggering figures on the global health burden related to alcohol, in the new Lancet study, below. (http://addiction-dirkh.blogspot.com/2009/06/1-in-25-global-deaths-linked-to-alcohol.html)

We (PSI) should be at least be considering how we might help reduce alcohol-related death and disability.

The report text is below.


Vodka kills more Russians than war, Lancet reports.

A team of researchers at the University of Toronto reported in Lancet that 3.8 % of global deaths could be attributed to alcohol. In Europe, the report stated, the rate of premature death from alcohol was 1 in 10 during 2004, the year studied. And in a related study, more than half of all premature deaths among adult males in Russia were attributable to booze.

The world health care burden, as spelled out by Dr. Jurgen Rehm and others at the University of Toronto, is staggering: “The costs associated with alcohol amount to more than 1% of the gross national product in high-income and middle-income countries, with the costs of social harm constituting a major proportion in addition to health costs.”

In a BBC News report,the study authors warned that the worldwide effect of alcohol-related disease was similar to that of smoking in prior decades. The report takes note of prior research indicating a health benefit from moderate drinking, stressing that any purported benefit is “far outweighed by the detrimental effects of alcohol on disease and injury.”

The Lancet study concludes that the overall mortality figures are “not surprising since global consumption is increasing, especially in the most populous countries of India and China.”

Professor Ian Gilmore of the Royal College of Physicians, quoted by the BBC, called the report “a global wake-up call,” and urged the adoption of “evidence-based measures” for reducing alcohol-related harm, such as price increases and advertising bans. “Many countries are investigating new ways to cut deaths and disease and reduce the burden on health services by using the price of alcohol to lower consumption,” Gilmore said. Pricing strategies have been used effectively in the past to lower cigarette consumption, researchers have noted.

In one of the Russian studies, Professor Richard Peto of the University of Oxford led a statistical analyses, concluding: “If current Russian death rates continue, then about 5% of all young women and 25% of all young men will die before age 55 years from the direct or indirect effects of drinking.” The Russian figures are also affected by the high rate of associated smoking in the former Soviet Union.

Peto added: “When Russian alcohol sales decreased by about a quarter, overall mortality of people of working age immediately decreased by nearly a quarter. This shows that when people who are at high risk of death from alcohol do change their habits, they immediately avoid most of the risk.”

Wednesday, June 24, 2009

World Drug Report 2009 released

The Report was launched in Washington, D.C., by UNODC Executive Director Antonio Maria Costa and the newly appointed Director of the United States Office of National Drug Control Policy, Gil Kerlikowske.

Download at:


Monday, June 22, 2009

switching injectors away from injecting

A program in Canada managed to reduce needle sharing & reduce injecting of crack cocain by promoting smoking of cocaine as an alternative - a classic application of harm reduction principles, to shift people away from the most harmful forms/types of drug use. Admittedly, this requires a progressive enabling environment, but we should all be thinking about how to actively reduce the riskiest forms of drug use in our countries.

For details, see the article below.



Sunday, June 21, 2009

Global State of Harm Reduction

The Global State of Harm Reduction e-tool is now live on the INTERNATIONAL HARM REDUCTION ASSOCIATION website.

If you want to know how many countries support harm reduction, have needle syringe programmes, have methadone or buprenorphine maintenance treatment or drug consumption rooms etc



Thursday, June 4, 2009

Helping drug users to stop smoking

Blog readers,

An audio and powerpoint presentation of a superb talk on helping drug users to stop smoking is (at the 2009 National Drug Treatment Conference) is at:


Smoking reduction/cessation, not just for drug users, is now quite effective, with drugs that are, however, unaffordable to most people in the developing world. This is, I think, a major potential growth area for PSI.


Wednesday, June 3, 2009

"Nice People Take Drugs" Campaign

A UK organization has launched a public campaign called "Nice People Take Drugs".

View the website and more info at:



Two hundred drug addicts in Montreal and Vancouver will be lining up for free heroin later this year at publicly funded clinics. And they can thank the federal Conservative government, despite its hard line against hard drugs.

The trial - which will offer the drug in pill and injectable forms as well - builds on a similar heroin experiment last year that found most participants committed far fewer crimes and their physical and mental health improved.

The three-year medical trial will put Canada on the leading edge of international addictions research "for a population that is in desperate need for alternate health options," said Michael Krausz, the lead investigator.

But the project is only proceeding with the blessing of, and $1-million in funding from, the Canadian Institutes of Health Research, an agency of Health Canada.

The federal Conservative government is currently fighting Vancouver's supervised-injection facility, Insite, in court. Prime Minister Stephen Harper has argued that taxpayer money should not fund drug use, but should be spent on prevention and treatment.

The heroin trial goes even further than Insite, not only providing a safe place to inject, but also the heroin itself.

The drug is legally purchased in Europe and brought to Canada under armed guard.

The trial is called SALOME, the Study to Assess Longer-term Opioid Medication Effectiveness, and it will build on a similar heroin experiment that wrapped up last summer. The North American Opiate Medication Initiative (NAOMI) was also funded by the Canadian Institutes of Health Research with the approval of Health Canada

The NAOMI trial was criticized by some addictions physicians but drew no comment from the federal government, which paid more than $8-million for the research.

"It's been disappointing," said Martin Schechter, who led NAOMI and is also working on SALOME. Dr. Schechter said European health authorities are very interested in the work, but Canadian authorities will not acknowledge it.

"There's a lot invested in NAOMI. We did everything we could to translate the information for decision-makers to make them understand what it meant," he said.

Dr. Krausz, a leading addictions researcher, has conducted another heroin trial in Germany, the largest such randomized clinical trial in Europe.

The Canadian research aims to determine if medically prescribed heroin is a safe and effective treatment and if users will accept the drug in pill form instead of injecting it.. It will also measure whether a licenced narcotic, Hydromorphone, can be used instead of heroin.

His team is now recruiting about 200 severe heroin addicts who have failed to respond to existing treatments and they expect to have the clinics in Vancouver and Montreal open by this fall.

Last week, Dr. Krausz's medical team sat down with Vancouver philanthropists asking for additional support for the clinics that will distribute both heroin and a legal narcotic substitute to hard-core addicts. Organizers say one business leader immediately offered a cheque for $100,000.

Trish Walsh, executive director of the InnerChange Foundation, who arranged last week's fundraiser with top Vancouver business and community leaders, said the 30 people who gathered in a corporate boardroom understood that the city cannot ignore its drug-addicted population.

"We have been sleepwalking right through the middle of this crisis."

Health Minister Leona Aglukkaq did not return calls, but her press secretary, Josee Bellemare, offered an e-mailed statement on the minister's behalf: "Our government recognizes that injection drug users need assistance. That's why we are investing in prevention and treatment, to help people recover from their drug addictions."

Overdose increase in Australia

1 June 2009, journalist Simon Palan

Heroin market back to the bad old days

Overdoses ... quality is said to have 'gone through the roof'. (File photo) (AAP : Julian Smith)

Link to story: http://www.abc.net.au/news/stories/2009/06/01/2586395.htm?section=australia

Audio: Doctors and users say heroin overdose cases are on the rise (PM) The so-called heroin drought looks like being well and truly over, as paramedics and emergency department doctors say they are treating rapidly increasing numbers of heroin overdose victims.

They say the drug has been making a comeback over the last six months. But despite the increase in overdose cases, the debate over prohibition has not gone away and there are some who say heroin should actually be legalised.

When heroin use was peaking a decade ago, Dr Gordian Fulde at Sydney's St Vincents hospital was treating at least one heroin overdose victim every day. Now, he says those days have returned. "We have an increase of people coming into the emergency department having overdosed on heroin. We also have an increase of people who admit to taking heroin - so heroin's coming back," he said.

Quality 'through the roof'

Thirty-nine-year-old Gordon has been a daily user for almost 20 years and he says there has been an increase in quantity and quality. "The quality's gone through the roof lately. It was probably about 30 per cent, 40 per cent - now it's jumped up to about 60, 70 per cent," he said. "It's the purity of it that's making people drop because they think they can handle it. "If you've got a small habit, like if you're only using one 50, two 50s a day, when the purity goes through the roof like that, you're not expecting it and people don't tell you."

Gordon says he has been lucky and has never overdosed. But he says he knows people who have. "I was speaking to a mate earlier who'd just come from the hospital who dropped today, so yeah I know a fair few people actually," he said. "In the last three or four days, actually."

Legalisation debate

In the late 1990s there was a reduction in the availability of heroin because the war in Afghanistan disrupted supplies. A big crackdown by Australian police also tightened the market here. Now it seems heroin is flooding back and some long-time observers are ambivalent about the consequences.

The pastor at Sydney's Wayside Chapel, Graham Long, helps counsel heroin users every day. "I actually think the word heroin spikes off a raw nerve in the public's mind but I don't see why that is the case actually," he said. "In fact I put it to you that alcohol's a much bigger problem. Alcohol's a nasty drug. Just because it's socially acceptable it's kind of the elephant in the room. "But the truth is, if you get any crowd and add alcohol, people want to hurt each other, and that doesn't happen with heroin or most of the other drugs. So, as drugs go, it's a nasty thing, it's quite a social problem."

Pastor Long says he thinks heroin should be legalised. "I don't quite understand why we want to fund a criminal path - why we want to hand to a criminal path a market has got me beat. I just don't understand," he said.

Soft drug?

Heroin user Gordon agrees, saying other illicit drugs are more damaging. "You don't see people going loopy on gear [heroin]," he said. "The worst that can happen to you on gear is you go to sleep, sort of thing. But with the ice, people go silly. With the amphetamines, people go silly. "I definitely think heroin would be one of the softer drugs."

But that is not so, according to Dr Fulde, who says heroin is a killer. "Crystal meth, the amphetamines, the cocaine per se don't in the first instance kill you, they just wind you up, you go mad, you do all sorts of things, but you don't stop breathing - it's not a death thing," he said. "You might die because you run in front of a train or do something stupid, and because you're totally out of it. "But heroin on its own, it's a killer. It stops you breathing and I would love heroin not to be around at all."