 |
|
|
| |
Article of the Month Archive |
|
| |
|
|
|
 |
|
|
| |
Article of the Month- International Harm Reduction Association Each month, IHRA selects a recently published journal article, study or resource which is of particular significance for harm reduction. These are featured in the IHRA e-newsletters, and on the website and, wherever possible, are made freely available to download. The articles are chosen for their capacity to advance the scientific basis of harm reduction, and their potential value for harm reduction advocates, policy makers, practitioners and researchers. If you would like to recommend an Article of the Month, please contact IHRA.
| | | | | | | | | | | | |
| December 2007 Article of the Month
| Forsyth AJM (2007) Banning Glassware from Nightclubs in Glasgow (Scotland): Observed Impacts, Compliance and Patron’s Views. Alcohol and Alcoholism Advance Access (published on October 11th 2007), doi:10.1093/alcalc/agm142.
| This study sets out to evaluate the impact of new legislation in Scotland banning bars and clubs in Glasgow City Centre from serving alcoholic beverages in standard glass containers. Instead, drinks must be served in plastic, aluminium or ‘safety’ glass in all premises serving alcohol after midnight. This legal measure was put in place as a response to the city’s “unenviable level of ‘glassings’” (violent incidences in which a drinks glass or glass bottle is used as a weapon). In 2005, there were 81 of these incidents reports in Glasgow, with the total number likely to be a lot higher (as many incidents remain unreported to the police or Accident and Emergency departments).
This study used 100 hours of participant observation in eight Glasgow City Centre late night entertainment venues, supported by detailed face-to-face interviews with a small sample of patrons. The results indicated that, although violent incidents were still relatively common in these venues, they were now a lot less likely to result in serious injury as a result of the glass ban. In many ways, therefore, this intervention is a perfect example of a practical alcohol harm reduction measure – targeting and reducing a risk rather than eliminating a behaviour.
The observers had problems in ascertaining whether or not the glass ban was being complied with – exceptions were made in the law for wine and champagne and it is difficult to distinguish between standard glassware and ‘safety glass’ (designed to be more resistant to impact and less likely to shard and cause injury) for other drinks. Indeed, in the absence of a manufacturing standard for ‘safety glass’, there have even be claims that ‘safety glass’ may be no safer or perhaps even more dangerous for bar staff themselves. Nonetheless, the glass ban appeared to have been well received by patrons, who reported feeling safer, and had few negative consequences. Despite not providing comparisons of routinely-collected data on glass-related injuries before and after the glass ban, this is an excellent example of a practical, local intervention to reduce the harms faced by people who drink alcohol in the night-time economy. The authors conclude that “as is already accepted with motor vehicles and firearms, alcohol and glass should not mix”.
This paper was published on October 11th 2007 through the Alcohol and Alcoholism journal ‘Advance Access’ service It will also be featured in IHRA’s forthcoming “50 Best Documents on Alcohol Harm Reduction” – due for release in early 2008. Please visit www.ihra.net/alcohol for more information.
| Click here to view the abstract
|  |
| November 2007 Article of the Month
| Wolfe D (2007) Paradoxes in Antiretroviral Treatment for Injecting Drug Users: Access, Adherence and Structural Barriers in Asia and the Former Soviet Union. International Journal of Drug Policy, 18 (4), pages 246 - 254.
| This commentary, by Daniel Wolfe from the Open Society Institute’s International Harm Reduction Development program (IHRD), attempts to highlight reasons why drug users are disproportionately less likely to receive life-saving antiretroviral treatment (ARV) for HIV. Whereas, historically, most of the focus at the policy and practice levels has been on moral decisions about who “deserves” treatment and who can be trusted to comply, this article expertly argues that it is the structural impediments within treatment systems which discriminate against drug users, set them up to fail and presents them with “paradoxes and double binds”.
In particular, despite guidance from the World Health Organization stating that physicians must not discriminate on the basis of drug user status, ARV systems are inherently biased – especially in the developing world, where HIV is increasingly driven by injecting drug use. Such services are rarely integrated into harm reduction programmes (such as needle exchanges and substitution treatment) despite evidence of effectiveness. They also often label drug users as untrustworthy which creates an “incentive to dishonesty” amongst those who hide their status in order to access treatment – a self-fulfilling prophecy. Additionally, services are often withheld from drug users who are seen as unable to comply with regular treatment sessions and schedules and yet, in many countries, ARV is not offered to HIV-positive prisoners who would find it easier to comply in the “closed, highly structured settings into which they are forced by the state”. This is despite universal testing for HIV upon entry into the prison systems and, in some cases, prisoner segregation on the basis of HIV status!
This article is part of a recent International Journal of Drug Policy ‘Special Issue’ on HIV treatment and care for injecting drug users. The entire issue (Volume 18, Issue 4) has been guest edited by Andrew Ball (from the World Health Organization), Michel Kazatchkine (from the Global Fund to Fight AIDS, Tuberculosis and Malaria) and Tim Rhodes (from the London School of Hygiene and Tropical Medicine). The journal is available free to Premium or Institutional IHRA Members.
| | | |  Click here to Issue 2 of ‘ARV4IDUs’ – a specialist newsletter on this topic [PDF:292KB]
| |
| |
| October 2007 Article of the Month
| Ball A (2007) Universal Access to HIV/AIDS Treatment for Injecting Drug Users: Keeping the Promise. International Journal of Drug Policy, 18 (4), pages 241 - 245.
| This month’s article is an editorial introducing the recent International Journal of Drug Policy ‘Special Issue’ on HIV treatment and care for injecting drug users. The entire issue (Volume 18, Issue 4) has been guest edited by Andrew Ball (from the World Health Organization), Michel Kazatchkine (from the Global Fund to Fight AIDS, Tuberculosis and Malaria) and Tim Rhodes (from the London School of Hygiene and Tropical Medicine).
The editorial by Andrew Ball provides an interesting overview of the current global situation with regards to access (or lack of it) to life-saving antiretroviral treatment (ART) for HIV-positive injecting drug users. In the past, ART for injecting drug users was considered to be infeasible, but the availability of ART around the world is now steadily increasing and more people living with HIV and AIDS are benefiting from expanded ART coverage. The continued ‘scaling-up’ of ART is a top priority in the global response to HIV. In June 2006, a UN General Assembly set out to achieve ‘universal access’ to HIV services (including ART) by 2010. A fundamental underlying principle to this goal is the populations that are disproportionately affected by the virus (such as injecting drug users) must be given equal access to treatments. Despite this powerful international commitment, the situation for HIV-positive injecting drug users has remained largely unchanged.
This article outlines six major challenges that must be overcome in order to scale-up ART for injecting drug users:
1) Expanded access to voluntary HIV testing and counselling is needed in order to increase the numbers of injecting drug users that know their HIV status
2) Simplified and affordable ART courses are needed in order to maximise treatment adherence amongst people who use drugs
3) Increased HIV prevention efforts (such as needle exchanges) must be targeted at drug using populations in order to reduce new infections
4) Health care systems must be strengthened in order to effectively deliver ART to vast numbers (including injecting drug users)
5) A supportive social and legal environment must be developed in order to reduce the considerable stigma and discrimination faced by injecting drug users
6) Evidence-based and context-specific interventions for injecting drug users must be implemented
In his article, Andrew Ball discusses each of these challenges in depth and refers the reader to the other journal articles that make up the ‘Special Issue’, such as the report on the need to provide integrated services to people who use drugs.
| Click here to view the ‘Special Issue’ of the International Journal of Drug Policy
| Click here to view IHRA’s ‘50-Best Collection’ on HIV Prevention and Care for Injecting Drug Users
| |
| September 2007 Article of the Month
| Kayser B, Mauron A & Miah A (2007) Current Anti-Doping Policy: A Critical Appraisal. BMC Medical Ethics, 8(2).
| This debate article questions the ethical assumptions which are the basis of the global prohibition of performance-enhancing drugs in sport. According to the authors, the prohibitionist approaches are based on ideals of sport as a “level playing field” – which, in reality, it has probably never been and certainly is not today. The authors also examine the desirability and effectiveness of the enforcement of this prohibitionist approach through increased drug testing in sport.
In this article, the authors point out that the cost of anti-doping testing regimes for elite athletes is rising steeply. In addition, there are also unintended negative public health consequences of this regime, including a lack of resources and information for the general public (where medically unsupervised and potentially more dangerous practices in amateur sport are becoming increasingly prevalent). In addition, such a regime simply acts to drive the taking of performance-enhancing drugs further underground and towards the use of untried but undetectable drugs and other dangerous practices. In this way, the harms associated with the prohibition of performance-enhancing drugs in sport mirror those associated with prohibitionist drug policies in society as a whole.
The authors then consider the ethical implications of this for the medical profession, and they propose that anti-doping agencies in sport should stop trying to attain “an unattainable goal” and focus on the harm which is being done to athletes - thus promoting a harm reduction approach.
This article is one of the most important examinations of this commonly neglected issue to be published for a long time. Anti-doping in sport is often ignored in debates and discussions by the harm reduction and drug policy reform fields. In fact, there are many people within these fields who do not regard this as an issue - arguing that ‘sport is different’ and that harm reduction measures cannot be applied to it. However, it is very much a harm reduction issue which shares so many similarities with the problems caused by drugs and alcohol in society and with the futile attempts to solve them through prohibition, law enforcement, testing and propaganda. The reported increase in anabolic steroid users accessing UK needle exchanges clearly shows how these issues overlap.
Today the war on doping has become a moral crusade which potentially induces more harm than it prevents. The recent advent of steroid clinics in the UK and Australia where harm reduction strategies are used is perhaps pointing the way towards a more pragmatic approach.
| Patrick O’Hare, IHRA Honorary President
| Click here to view the article
| |
| August 2007 Article of the Month
| Cohen J, Ezer T, McAdams P & Miloff M (Eds.) (2007) Health and Human Rights: A Resource Guide for the Open Society Institute and Soros Foundations Network. New York & Montreal: Open Society Institute & Equitas
| This six-chapter resource guide provides a practical tool for advocates working at the intersection of health and human rights. It includes fact sheets, programme descriptions, jurisprudence, case studies, bibliographies and glossary definitions on six areas of health and human rights – including harm reduction (Chapter 3). Prepared by staff from the Open Society Institute (OSI) and Equitas for a 2007 global OSI meeting on health and human rights, the guide has broader applications for anyone dedicated to the pursuit of harm reduction, public health and human rights.
One of the most useful elements of the guide (particularly for people without specific legal knowledge or training) is it’s synthesis of international human rights law and an explanation of how that law can be applied to health advocacy. The guide breaks down potentially complex case law into easy-to-use tables, highlighting fundamental legal principles and decisions and how these can be applied within the context of various health advocacy areas. Each chapter also contains case studies of effective advocacy campaigns in the various topic areas, as well as a listing of key resources, publications and websites.
The specific chapter on “Harm Reduction and Human Rights” explores advocacy campaigns in areas such as policing, peer-to-peer documentation and legal challenges. This is a welcome and much needed addition to the existing resources on health and human rights advocacy – which will be detailed in a “50 Best Collection” on ‘Harm Reduction Advocacy’ – which is due for release later in 2007.
| Click here to view the publication [PDF: 4.87MB]
| |
| July 2007 Article of the Month
| Leon DA, Saburova L, Tomkins S, Andreev E, Kiryanov N, McKee M & Shkolnikov VM (2007) Hazardous Alcohol Drinking and Premature Mortality in Russia: A population based case-control study. The Lancet, 369, pages 2001-2009.
| This article reports on hazardous drinking in Russia and its role in the low life expectancy for Russian men. In particular, it explores the high-risk behaviour of drinking alcoholic products that are not designed for human consumption (such as perfumes, cleaning products, and aftershave lotions) – referred to as “non-beverage alcohol”. The authors examined case notes and interviewed the families and friends of 1,750 Russian men who had died aged 25-54 years (and compared results against a similar sized group of living Russian men in the same age bracket). Their results revealed that over half of the deceased men were either problematic drinkers or were reported to have drunk non-beverage alcohol prior to their deaths (compared to just 13% of the control group). The authors went on to calculate that men who had drunk non-beverage alcohol in the last year were more than 9 times more likely to die than those that had not.
This article clearly demonstrates that the consumption of non-beverage alcohol is a serious problem for Russia and is a likely contributing factor in the sharp fluctuations seen in Russian mortality over the last two decades. The authors, however, do not go on to speculate why this behaviour may be so widespread in Russia – a country which has had a long-running, complex relationship with alcohol and which has seen a great deal of social, economic and political change in the last decade. In the 1980s, President Mikhail Gorbachev launched a population-level anti-alcohol campaign – including a sudden and sharp rise in alcohol taxation, sales restrictions and a workplace ban – which was very successful at the time in reducing alcohol production and increasing life expectancy and the price of alcohol. However, this has since been credited with the development a burgeoning Russian black market in alcohol and may well have also opened the doors for the levels of consumption of unregulated alcohol which this article found.
The case of Russia’s alcohol problems is an extremely complex one, and the consumption of non-beverage alcohol highlighted in this article is just one contributing factor to the low life expectancy of Russian men. International alcohol policies often overlook the problems of black market, illicit, home-produced or non-beverage alcohol consumption (which “may account for as much as 50% of total alcohol consumption worldwide” according to Moruf Adelekan at the 18th International Conference on the Reduction of Drug Related Harm. There is no simple solution to this problem, and the huge complexity of trying to change drinking culture and deter high-risk patterns of alcohol consumption requires a combination of approaches encompassing population-level, supply and demand interventions alongside targeted harm reduction interventions. In Russia, as elsewhere in the world, effective alcohol policy should be the art of the possible.
This article is available to purchase on the Lancet website, where you can also register to view the article summary.
| |
| June 2007 Article of the Month
| Brand DA, Saisana M, Rynn LA, Pennoni F & Lowenfels AB (2007) Comparative Analysis of Alcohol Control Policies in 30 Countries. PLoS Med 4(4): e151.
| This paper attempts to assess and compare national alcohol policies around the world, and explore any relations between these policy options and national alcohol consumption. The authors used routinely collected and available data from the 30 countries that compose the ‘Organization for Economic Cooperation and Development’. Each nation’s alcohol policy was scored using an “Alcohol Policy Index” – based on a number of criteria such as legal purchase age, restrictions on business hours for selling alcohol, the relative price of beer, wine and spirits, and whether or not there is a mandatory penalty for exceeding legal blood alcohol limits when driving. There were 16 criteria in total, each given a different weighting in the final policy score based on their evidence-base and effectiveness. The resulting score was out of 100 – the higher the score, the more stringent the national alcohol policy.
The Alcohol Policy Index “revealed wide variation in the strength of alcohol control policies among the 30 countries”, which were then listed in a table – with Norway, Poland, Iceland, Sweden and Australia receiving the top five scores, and Luxembourg receiving the lowest. The authors then compared these policy scores to national statistics for “per capita” alcohol consumption (the amount of alcohol consumed, on average, by each person in that country). They concluded that there was a relationship between the two – with a higher Alcohol Policy Index score generally leading to a lower per capita consumption.
This attempted policy comparison is to be commended for what it has set out to achieve. It is important to analyse national alcohol policies in an international context in order to gain understanding of what works and what does not. However, it is important to note that this paper only concentrates on the developed countries that form ‘Organization for Economic Cooperation and Development’, and do not examine data from developing countries in, say, Latin America, Africa and South Asia. This is understandable in that developed countries form a much more homogenous group for research and comparisons, and developing countries typically have less developed alcohol policies and data collection. However, it does mean that the conclusions made here can not be reliably applied to the developing world (as the authors note in the paper).
In general, developing countries have a lower incidence of alcohol related problems but, in many parts of the world, these problems are rising rapidly. Therefore, the mechanisms for dealing with alcohol related problems in developing countries will differ from those in the developed world. As a perfect example of this, developing countries tend to have more non-commercial or illicit alcohol (produced outside of commercial industry settings and with no regulation). The Alcohol Policy Index developed by Brand et al attributes high scores to policy strategies which are ineffectual on the illegal alcohol market (such as legal purchase age and beer price index), as these are not major problems for the countries which this study examined. However, this would need to be addressed for this methodology to be applied to the developing world. To demonstrate this point, the study found little relationship between Alcohol Policy Index score and per capita alcohol consumption in Mexico, with the conceding that this “may be explained by a high estimated amount of unrecorded consumption” (Mexico is a recent addition to the ‘Organization for Economic Cooperation and Development’).
Finally, population-level measures, although a useful guideline and perhaps the best available indicator for a comparative study like this, cannot account for the intricate role that alcohol may play within a country – in different groups, contexts and behaviours. The authors themselves comment that “consumption per so is not the ultimate concern… [rather] harm associated with excessive or inappropriate alcohol use”, so it is perhaps disappointing that relatively low values were attributed to “drinking context” policy measures (such as server training) in the Alcohol Policy Index calculations.
There are methodological issues associated with any international policy comparison (as Alison Ritter concluded in her response to the Brand et al paper, “The multiplicity of problems - conceptual, methodological, and political - lead some researchers and policy makers to conclude that the effort is not worth pursuing”), but, overall, the intentions of this paper are to be applauded. Alcohol policy is such an important area of public health that researchers should be encouraged to develop methods such as the Alcohol Policy Index so that we can learn more about which policies are effective in reducing harm and which ones are not.
| Click here to view the article by Brand et al
| Click here to view the response from Alison Ritter
| |
| April 2007 Article of the Month
| Yi-Ming Arthur Chen & Steve Hsu-Sung Kuo (2007) HIV-1 in Taiwan. The Lancet, 369 (9562), 623-625.
| This commentary piece in The Lancet documents the current challenges and advances being made in Taiwan in terms of HIV prevalence and harm reduction. As the authors state, “Taiwan is entering a new and dangerous phase” in terms of its HIV epidemic, with reported cases more than doubling between 2004 and 2005, and estimated prevalence suggesting one of the greatest infection rates in Asia. The authors also report “enormous increases in the amount of heroin smuggled into Taiwan”, and in injecting drug use.
In response to these concerns, Taiwan set out to learn from its Asian neighbours, many of whom had already embraced harm reduction in response to injecting drug use-related HIV epidemics. The authors specifically mention the contributions of Professor Gerry Stimson (IHRA Executive Director) and Dr. Alex Wodak (a member of the IHRA Executive Committee) – who visited Taiwan in 2005. Consultations with harm reduction experts and visits to harm reduction programmes prompted the Taiwanese Government to embark on a pilot programme of syringe exchanges, methadone maintenance therapy (including in prisons), free HAART (Highly Active Anti-Retroviral Therapy) and community-based programmes for men who have sex with men.
This article demonstrates the influence that the international harm reduction movement can have on national policies and decision making. Harm reduction is a scientifically proven response to HIV/AIDS, hepatitis B and C and a range of other drug-related health harms. The Taiwanese experience demonstrates how, even in politically challenging environments, the pragmatic nature of the harm reduction approach can win out. As well as the recent embracing of harm reduction, the NGO and civil society presence in Taiwan is growing and, as early as 1990, a law was passed to protect the human rights of people living with HIV/AIDS for treatment, education, and employment.
This commentary on Taiwan (along with many of the other articles in this edition of The Lancet) demonstrates the potential for harm reduction in the region, but also the on-going challenges that face these nations. As The Lancet states in its editorial summary, “opportunities for collaboration across all borders must be taken. Strategies that work, such as needle-exchange or methadone-maintenance programmes, need to be scaled-up, and consistently used along trafficking routes”.
To view this edition of The Lancet, you need to register on their website at http://www.thelancet.com/journals/lancet .
| |
| March 2007 Article of the Month
| Csete J & Wolfe D (2007) Closed to reason: The International Narcotics Control Board and HIV/AIDS. Toronto / New York: Canadian HIV/AIDS Legal Network & the International Harm Reduction Development (IHRD) Program of the Open Society Institute.
| Within the United Nations system (which is, by and large, responsive, open and supportive of harm reduction approaches) lies an insular, unaccountable and controversial body called the International Narcotics Control Board. This report critically analyses the performance and processes of this group in terms of harm reduction, human rights and global responses to HIV/AIDS. The authors conclude that the INCB is too secretive, their statements are often not evidence-based and contradictory, and they do not use their influence enough to support harm reduction interventions.
The INCB was established as a result of the United Nations 1961 Single Convention on Narcotic Drugs (as amended by a 1972 protocol), and acts as an independent and “quasi-judicial” group to monitor how the United Nations drug conventions are being implemented. Their main activities are an annual report (released around this time each year), and visits to around 20 countries a year. Although they do not speak on behalf of the United Nations, they have an unquestionable influence over its proceedings – the INCB annual reports are released in conjunction with the annual Commission on Narcotic Drug meetings in Vienna, and are frequently quoted and cited by the United Nations and its member states.
This report discusses the role, position and performance of the INCB in terms of harm reduction (and specifically opiate substitution treatment, safer injecting facilities, and needle and syringe exchange schemes) and the human rights of people who use drugs. Consistently over time, the INCB reports and statements have failed to acknowledge international best practice and positive developments in harm reduction (such as in Iran and Malaysia). They have also consistently failed to criticise (or even mention) international examples of worst practice or human rights violations (such as the banning of methadone in Russia, the mass incarceration and killing of drug users in Thailand, and annual public executions of drug offenders in China on June 26th (the UN’s International Day Against Drug Abuse and Illicit Trafficking).
This report was produced jointly by the Canadian HIV/AIDS Legal Network and the International Harm Reduction Development (IHRD) Program of the Open Society Institute. The authors analysed all the available reports, speeches and statements that had been accredited to the INCB and its members. This work was hampered by the fact that INCB meeting minutes are never released, no current or former INCB member responded to their requests for information, and the INCB secretariat themselves would not answer the questions that they had – further demonstrating the closed nature of the Board.
| Click here to download the report [PDF: 690KB]
| |
| February 2007 Article of the Month
| Stimson GV (2006) Drinking in context: A collective responsibility (ICAP Reviews 2). Washington: International Center for Alcohol Policies.
| Alcohol is a unique commodity, consumed in many different ways in many different cultures and with many different levels of associated harms. For many, it is consumed responsibly and with minimal harm, and enjoyed for the positive social and emotional impact that it has. For others, however, it can create a huge range of well-documented problems and harms.
Due to the inherently complex nature of alcohol consumption, policies and ideologies that seek to change behaviour, consumption and attitudes at the population-level often stutter. This document review by Professor Gerry Stimson (IHRA Executive Director) proposes a fresh approach to alcohol policies and outlines three of the key themes from a new book entitled ‘Drinking in Context: Patterns, Interventions, and Partnerships’.
The review describes how alcohol policies should be based on a balanced and full assessment of different drinking patterns within a population (rather then the simplistic measure that is often used - national ‘per capita consumption’). Population-level measurements cannot account for different cultures, age-groups, socioeconomic factors, and behaviours within a population, and cannot provide the full picture of alcohol consumption and patterns.
As a result, interventions which are aimed at entire populations (such as taxation, restricting availability, and warning labels) are insufficient on their own, as they do not account for the higher-risk groups and behaviours within a population. Targeted interventions that are aimed towards specific high-risk groups within a population are essential.
The broad range of drinking patterns, alcohol harms, and alcohol interventions requires an equally broad range of stakeholders and partners. At a governmental level, alcohol policies are the business of health, justice, culture, education, trade and finance ministries. At the front-line, alcohol has an impact on a range of specialist and non-specialist workers (such as police, ambulance staff, and bar staff). In order to develop sustain realistic, targeted interventions and policies, working partnerships must be developed involving all of these groups, alcohol consumers and the alcohol industry. Any attempts to achieve change without all of these parties involved faces insurmountable difficulties. The key is collective responsibility rather than blaming one another.
To view this review in full, for more details about the Drinking in Context book, or for a wide range of other alcohol policy resources, please visit the International Center for Alcohol Policies website (www.icap.org).
| Alternatively, click on the links below:
| ICAP Review 2 – Drinking in context: A collective responsibility (English) [PDF: 100KB]
| ICAP Review 2 – Drinking in context: A collective responsibility (French) [PDF: 12KB]
| ICAP Review 2 – Drinking in context: A collective responsibility (Japanese) [PDF: 65KB]
| ICAP Review 2 – Drinking in context: A collective responsibility (Spanish) [PDF: 10KB]
| ICAP Review 2 – Drinking in context: A collective responsibility (Swedish) [PDF:69KB]
| Drinking in Context: Patterns, Interventions and Partnerships (an executive summary of the book in English) [PDF: 45KB]
| Drinking in Context: Patterns, Interventions and Partnerships (an executive summary of the book in Russian) [PDF: 238KB]
| Drinking in Context: Patterns, Interventions and Partnerships (an executive summary of the book in Spanish) [PDF: 28KB]
| |
| January 2007 Article of the Month
| Beynon CM, Bellis MA & McVeigh J (2006) Trends in drop out, drug free discharge and rates of re-presentation: A retrospective cohort study of drug treatment clients in the North West of England. BMC Public Health, 6: 205 (Aug 11).
| Across the world, national drug strategies are placing increasing emphasis on coercive, compulsory drug treatments – often linked to criminal justice systems. This research from the Centre for Public Health attempts to find out what impact this has had on treatment quality and outcomes, by analysing routinely collected information from over 25,000 drug users in Cheshire and Merseyside in the UK. Particular attention was paid to drug users who had been “discharged drug free” (a successful treatment outcome), and those who had “dropped out” of treatment prematurely.
The authors found that the rate of people dropping out of treatment had increased from 7.2% in 1998 to 9.6% in 2001/2002. Over the same period of time, the rates of people being “discharged drug free” had fallen from 5.8% to 3.5%. This was interpreted as evidence that the United Kingdom’s emphasis on “compulsory, or quasi-compulsory drug treatment” at the turn of the century has “speeded up a revolving door both in and out of treatment”, rather than actually helping more people become drug free.
This research, albeit focusing on one region of England, has potential implications for drug policies worldwide. With an increasing focus on coercive treatment through the criminal justice system, the UK Government has increased expenditure and staffing drug treatment, as well as the numbers of drug users accessing services. However, this has not automatically improved outcomes or treatment quality. As the authors of this paper note, “coercive strategies… force people into treatment when they are not ready to contemplate changing their drug using behaviour”, and this has a deleterious affect on the outcomes and success rates of that treatment.
This article can be viewed for free on the BioMed Central website
| Click here to view article.
| |
|
|
| 2006 Archives
| |
| November/ December 2006
| Nordt C & Stohler R (2006) Incidence of heroin use in Zurich, Switzerland: A treatment case register analysis. Lancet, 367, 1830-1834.
| The authors obtained information from the case register of substitution treatments in Zurich (over 7,000 records) and analysed the data to estimate the incidence of heroin use. They concluded that the number of new heroin users in Zurich had fallen from 850 in 1990 to only 150 in 2002 (a fall of 82%). The overall population of heroin users was also falling, albeit at a lower rate of around 4% a year (as many people who left substitution treatments re-entered them within the next 10 years – leading to a lower cessation rate).
Switzerland has often been criticised for its liberal drugs policies and is one of the strongest advocate nations for the harm reduction approach (such as needle exchanges and substitution treatment programmes) and the medicalisation of opiate addiction. These criticisms were often founded on the moral assumption that such approaches were condoning or normalising drug use, and that this would increase the numbers of drug users. However, the authors claim that heroin has become less attractive to potential new users (becoming a “loser drug”) as a result of the harm reduction / medicalisation approach.
This paper provides valuable evidence in favour of harm reduction approaches and, in particular, substitution treatment interventions. Far from condoning and encouraging drug use, this medical treatment for addiction management can actually alter the perceptions of opiate drugs and reduce the initiation of new users. Similar research is required outside of Zurich and Switzerland to build the harm reduction evidence-base
| |
| October 2006
| Committee on the Prevention of HIV Infection among Injecting Drug Users in High-Risk Countries (2006) Preventing HIV Infection among Injecting Drug Users in High-Risk Countries: An Assessment of the Evidence. Washington: Institute of Medicine.
| The Institute’s study was sponsored by the United Nations Programme on HIV/AIDS and the Bill & Melinda Gates Foundation. It found considerable evidence in favour of a multi-component response to HIV/AIDS prevention for injecting drug users. Treatments with methadone and buprenorphine were found to be particularly effective in reducing an individual’s chances of contracting HIV, as were needle exchange schemes, outreach initiatives and psychological interventions.
There are estimated to be 13 million injecting drug users in the world, 78% of whom live in developing or transitional countries. This report covered countries in sub-Saharan Africa, Eastern Europe, former Soviet republics and Asia and stressed that each high-risk nation must determine the best combination of interventions in the context of economic, cultural and social circumstances.
The report also focuses on the potential barriers to treatment, harm reduction and HIV prevention. These include tensions between criminal justice and public health approaches (resulting in drug injectors avoiding services through fear of arrest), stigmatisation and discrimination of drug users and poor public health infrastructures. The authors recommend that nations “take steps to better align law enforcement and public health approaches”, tailor treatments to local cultures, involve all stakeholders and scale-up existing harm reduction and public health services.
The report is available from http://newton.nap.edu/catalog/11731.html.
| |
| September 2006
| House of Commons Science and Technology Committee (2006) Drug classification: making a hash of it? London: The Stationary Office Limited.
| The ABC drug classification system in the UK has been attacked as “antiquated” in a recent report by the House of Commons Science & Technology Committee. From expert witness testimonies and scientific sources, they found “glaring anomalies in the classification system as it stands and a wide consensus that the current system is not fit for purpose”. The report also references a forthcoming paper that attempts to rank the 20 most notorious psychoactive substances in terms of scientific evidence of harms.
The current drug classification system in Britain places illegal drugs in classes A, B or C – with class A receiving the harshest criminal penalties. The system has been in place since 1971 but has been frequently modified and changed, often through consultation between the Government and the independent ACMD (Advisory Council on the Misuse of Drugs). However, the committee’s report (part of a wider analysis of how the UK Government utilises scientific evidence) found “significant anomalies” and “a regrettable lack of consistency” in the current system – especially in terms of cannabis, magic mushrooms and ecstasy.
Cannabis was reclassified from B to C in 2004 amid widespread confusion and debate and the report criticises the “insufficient” information accompanying the change. Fresh magic mushrooms were classified as class A in 2005 without any consultation with the ACMD and the committee found that this “contravened the spirit” of the law and was based on a “striking lack of evidence”. The report also denounced the ACMD for not speaking out on this issue. Finally, the report noted that one class A drug (ecstasy) was widely used with relatively little harm and recommended “an urgent review of the classification of ecstasy”.
Overall, the report demands “a more scientifically based scale of harm than the current system [which] would undoubtedly be a valuable tool to inform policy making and education”. It also refers to a forthcoming article in The Lancet by Professor Nutt (of the ACMD) and colleagues, which lists the 20 most harmful psychoactive substances. They concluded that LSD and Ecstasy (both class A) were less harmful than legal substances such as tobacco (which would be class B or C if it was illegal) and alcohol (which would be class A or B). In the House of Commons report, it was concluded that, “there would be merit in including [tobacco and alcohol] in a more scientific scale… to give the public a better sense of the relative harms involved”.
This report is an enlightened view of the relative harms of drugs. The UK’s ABC classification has long been a target for criticism, especially during the recent reclassifications of cannabis and magic mushrooms and this report may well be another nail in the coffin. The report strongly criticises the ACMD and the mechanisms by which drug law decisions are made. It is fascinating reading for anyone interested in drug policy, reform and the criminalisation/legalisation debate.
In response, the UK Government has promised a “root and branch review” of the classification system so watch this space! The report is available for download from http://www.publications.parliament.uk/pa/cm200506/cmselect/cmsctech/1031/1031.pdf
| For a related item in the UK media, visit http://news.bbc.co.uk/1/hi/uk_politics/5230006.stm
| |
| August 2006
| Tiina Podymow, Jeff Turnbull, Doug Coyle, Elizabeth Yetisir and George Wells (2006) Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. Canadian Medical Association Journal, 174 (1), 45-49.
| The risks faced by homeless alcohol-dependent drinkers can be significantly reduced by offering shelter-based interventions whereby they have access to regular and controlled doses of alcohol, according to this study from the USA.
Co-morbid homelessness and alcohol dependency is associated with increased health problems, increased emergency department and police contact and a low likelihood of rehabilitation. To address these significant alcohol-related harms, the 15-bed, shelter-based Managed Alcohol Project (MAP) was created to deliver care to homeless adults with alcoholism.
During this study, seventeen homeless and chronically alcoholic people were admitted into MAP and were dispensed alcohol on an hourly basis. The authors examined long-term records of emergency department visits, police encounters and alcohol blood tests as well as questionnaires from MAP participants and staff.
The results showed that, when enrolled in MAP, the participants’ average monthly emergency department visits fell from 13.5 to 8, police contacts halved, alcohol consumption fell and levels of hygiene, health and compliance with medical care all increased. The participants stayed enrolled with MAP for an average of 16 months.
The authors concluded that programmes for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease emergency service encounters. The MAP scheme is an innovative program based on a harm-reduction model that, when evaluated in a small group, appeared to be effective in reducing the risks and improving the lives of the participants.
This study is available on free access from the Canadian Medical Association Journal website at http://www.cmaj.ca/cgi/content/full/174/1/45.
| |
| June 2006
| Safety first: A medical amnesty approach to alcohol poisoning at a U.S. University. Deborah K. Lewis and Timothy C. Marchell. International Journal of Drug Policy 17(4).
| In the United States, college students frequently drink heavily when under the legal age. When alcohol poisoning occurs, many students avoid seeking medical help because they don’t know if they should and are scared of police action. The authors introduced alcohol poisoning awareness and a ‘Medical Amnesty Protocol’, which safeguarded the students from legal action and provided follow-up ‘psycho-educational interventions’ to help prevent future incidents. Two years later, while drinking patterns had not apparently changed, alcohol-related emergency calls increased and fewer students reported avoiding help because they were scared of the police. There were also increases in the numbers of students receiving the brief interventions.
This research highlights an unintended, and potentially fatal, consequence of enforcing alcohol laws- the reluctance of underage drinkers to seek medical assistance in an emergency. The authors devised a unique, effective and commendable response to the problem and they recommend it’s adoption across U.S. University campuses. This article is a compelling reminder of the potential dangers of drug and alcohol policies that focus on criminalisation and law enforcement at the expense of harm reduction.
This article is part of an alcohol harm reduction special edition of the ‘International Journal of Drug Policy’- designed to tie-in with the 3rd International Conference on Alcohol and Harm Reduction in Cape Town, South Africa in October 2006.
The article can be viewed by visiting the International Journal of Drug Policy website.
| Please click here to view article (Paper 10).
| |
| April 2006
| Tina Podymow, Jeff Turnbull, Doug Coyle, Elizabeth Yetisir and George Wells. Canadian Medical Association Journal. January 3, 2006; 174 (1). doi:10.1503/cmaj.1041350. Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol.
| People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. The shelter-based Managed Alcohol Project (MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm.
The authors concluded that a managed alcohol programme for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease ED visits and police encounters.
| March 2006
| Harm reduction approaches to alcohol use: Health promotion, prevention, and treatment G. Alan Marlatt, Katie Witkiewitz Addictive Behaviors 27 (2002) 867-886.
| Marlatt and Witkiewitz argue that harm reduction approaches to alcohol problems in research and popular media are still controversial. But they contend that several studies have demonstrated that while controlled drinking is possible and that moderation-based treatments may be preferred over abstinence-only approaches, public and institutional views of alcohol treatment still only support zero-tolerance.
| February 2006
| Alcohol Harm Reduction Strategy for England, Cabinet Office. Prime Minister's Strategy Unit. March 2004.
| The four key ways to reduce alcohol-related harms identified in this report are through:
- improved, and better-targeted, education and communication;
- better identification and treatment of alcohol problems;
- better co-ordination and enforcement of existing powers against crime and disorder; and
- encouraging the industry to continue promoting responsible drinking and to continue to take a role in reducing alcohol-related harm.
| January 2006
| Kohli R et al. Mortality in an urban cohort of HIV-infected and at-risk drug users in the era of highly active antiretroviral therapy Clin Infect Dis: 41, 864 - 872, 2005. Celentano D. Mortality among urban drug users and the impact of highly active antiretroviral therapy. Clin Infect Dis: 41, 873 - 874, 2005.
| Deaths among HIV-positive drug users New York City between 1996 and 2001 have fallen substantially since effective antiretroviral (ARV) therapy became available in 1996. The study by Kohli et al, involving 400 HIV-positive drug users and 650 drug users at risk of HIV infection, was designed to find out the effect on death rates, causes of death, and factors associated with death. Although mortality amongst HIV-positive drug users fell significantly after effective ARV became available, the investigators note that, compared to other HIV-affected groups, "the mortality decline in our drug-using population was...modest".
| |
|
|
|
|
|
|
|
