Harm Reduction: what's in a name?

On 3rd October, the Parliamentary Assembly of the Council of Europe “ unanimously proposed preparation of a European convention to promote public health policies aimed at fighting drug abuse”. Such policies specifically include the promotion of substitute prescribing and needle exchange programmes across Europe. In other words, ‘harm reduction’. Yet nowhere in the accompanying documentation is that phrase obviously used.

The concept of harm reduction is simple enough. It is based on the humane and civilised notion that if a drug user dies prematurely, then the chances of treatment success are severely limited. A much better idea is to try and keep people alive to give them a chance of recovery when they are ready.

The idea was a response to the arrival of HIV in the UK and the discovery that one of the highest risk groups were injecting drug users. Government experts told the Conservative administration of the day that it was more important to stop the spread of disease than get people off drugs. The net result was that the UK had the lowest HIV rates in Europe – a situation which still prevails, although there are signs that we are losing ground especially when considering the rates of Hepatitis C infection in this same group.

But harm reduction remains a controversial subject. The USA and the organs of United Nations drug control remain implacably opposed to most aspects of harm reduction. Those on the political and religious right routinely declare that HR is tantamount to condoning drug use and is simply a conspiracy among drug law reformers to sneak in legalisation through the back door. Well, if it is, then all UK administrations back to Margaret Thatcher stand accused of being fifth columnists for the legalisers – as do the Iranian government which allows needle exchange in its country and now the Council of Europe.

But there are problems with HR. Nowadays, everybody says they are committed to ‘harm reduction’ including the police and the Serious Organised Crime Agency. It has become a drug strategy catch phrase without any clear idea what this means outside the health context. Exaggerating to make a point – harm reduction for a community blighted by street drug dealing could mean a police policy of ‘shoot to kill’.

And as mentioned above, harm reduction has morphed from a front-line health intervention into an ‘ideology’ - which is now positioned ‘against’ the prohibitionists. Politically it may be necessary to carve out a very specific landscape which is diametrically opposed to the view of those who not only support the status quo, but who want to see the ‘war on drugs’ significantly ramped up.

However, the fact that the Council of Europe does not appear to be adopting the phrase while at the same time backing the concept, means perhaps it is time to think of another form of words. One phrase which immediately resonates with the public while at the time pulling HR firmly back in the health arena, is ‘Health and Safety'.

As a society we are becoming unrealistically risk averse, but people nevertheless understand that there is inherent risk in virtually all human activity and the idea of ‘Health and Safety' is to minimise risks that exist. Wearing a seat-belt is a health and safety measure – nobody talks about a ‘harm reduction’ strategy for minimising road accidents. One advantage in rethinking the terminology is to help reduce stigma. Health and Safety is a much more inclusive, positive and familiar term than ‘Harm Reduction’ which of itself is ‘drug industry’ jargon meaning little if anything to the general public.

http://assembly.coe.int/ASP/NewsManager/EMB_NewsManagerView.asp?ID=3241

Contingency Management

Quite a billy-do this week about another even more excrutiating piece of industry jargon – often helpfully redefined by the tabloids as ‘I-pods for junkies’. Only this time it was extra drugs for treatment compliance. It kicked off with an investigation by the BBC’s Mark Easton who uncovered a report commissioned by the National Treatment Agency and published in April revealing that some agencies were increasing methadone doses and the provision of other drugs to those clients presenting with clean urines. An initial interview with NTA boss Paul Hayes was cut short while he was briefed by his staff and then he returned to denounce the practice.

It turned out that there was an element of misrepresentation here, because the study was not looking at service clients generally, but at those who were being treated both for crack and heroin problems. And as another NTA report from this year admitted, many of those services providing specifically for crack users are not performing well. So there may be a case for going the extra mile to encourage an especially challenging client group to stay in treatment.

But as another interviewee on the Today programme pointed out, contingency management could easily be a device utilised by poor services to retain clients so they are able to tick all the right boxes in our target-driven treatment system.

Only a summary of the research is available on the NTA website. But it might be illuminating to be able to map those agencies providing additional drugs against an appraisal of their overall performance.