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.