Harm reduction and other treatments

Policies of harm reduction financed primarily by the National Fund remain fragile, mainly due to a narrow interpretation limited to health interventions.

Such strategies in Italy mainly relate to tertiary prevention or rehabilitation treatment. As a result, the interventions are occasional, fragmented and feeble;

they depend on the individual commitment of professionals or specific services. Harm reduction initiatives are supported by occasional funds for

94 Published in the Official Gazette n°48 on 27th February 2006 - Ordinary Supplement n°45.

particular projects and what harm reduction projects there are differ greatly between what is available in the north compared to the south of Italy.

The major misunderstanding on a national basis is that harm reduction policies are considered to be of a lower priority compared to the ‘real objective’ of drug policy, which is abstinence and self discipline. Harm reduction is a complex strategy⁹⁵ that contributes to strengthening the abilities of self-determination in those who use substances, and to acknowledge the related risks, such as;

diseases, marginalisation, imprisonment and mortalities. It is important to highlight that between harm reduction policies and demand-reduction policies (prevention and rehabilitation) there must be mutual support and strategic interdependence. Available data provides support to the fact that that it is necessary to implement initiatives aimed at the reduction of mortality, diseases, marginalisation and imprisonment. The political will to play a cultural and education role is essential. In explaining harm reduction interventions to citizens, four major motivations are emphasised:

• harm reduction interventions are helpful for the individual;

• there are public health interventions that limit infections and diseases that are beneficial for the entire population;

• harm reduction interventions have a positive impact on public order and contribute significantly to the safety of the cities;

• harm reduction interventions are an economical way to reduce the spread of communicable diseases.

It is important to highlight that adequate strategies of harm reduction require investment toward:

• an acknowledgment of the right to cure and the therapeutic freedom (methadone therapies and experimentation of substitutive

therapies);

• an increase in investments for social integration, without which, health interventions are going to be reductive and ineffective;

• the acknowledgment of the importance of social rehabilitation within working activity;

• empowerment policies, such as the active involvement of clients, based on their will to be recognised, integrated and emancipated;

• possible options to shorten prison sentences and improve the quality of the time when people leave prison and are continuing to wait for community interventions.

In 1999, the advisory commission for the re-organisation of the health care system in prisons proposed to provide syringes and condoms for prisoners. The Ministerial decree sent to the regions and to the prison institutions on 29th December 1999 says that ‘among the priorities in this field there is the increase

95 Starting from a cultural dimension of tolerance of the consumption and of decriminalisation of the consumer

of the prevention, information and education activities for the reduction of the risk from pathologies due to drug use’;

The Regional Decree n. 1588, dated 11 April 2000, of the Regional Committee of the Veneto Region includes the Guidelines for the prevention and the treatment of overdose and the acute effects of ecstasy.

In November 2000, the Guidelines on Harm Reduction were published by the Ministry of Health. In the section ‘Harm Reduction and Detention’, it underlines the risk behaviours that are particularly related to promiscuity, and to the lack of syringes and of correct procedures of sterilisation of injecting equipment. Also common under these circumstances is tattooing, usually under unsafe conditions, which can often lead to the spread of communicable diseases (HIV, hepatitis). Under these circumstances, it is appropriate to conclude that serious consideration must be given to harm reduction interventions, especially those that are not yet provided systematically in the current activities within prison institutions.

Public opinion in Italy supports the concept of abstinence as the response to problematic drug or alcohol use. This is reinforced by campaigns on public safety that stress the relationship between problematic drug use and crime with the result that abstinence is the major objective of treatment interventions resulting in further marginalisation of people with problematic drug use and of increasing social anxiety. The absence of an effective drug reform strategy coupled with the lack of a serious harm reduction strategy are leading to a potential increase in problematic drug use and increasing spread of communicable diseases. In an attempt to address the perceived ‘need for public safety’, policy makers implement further repressive and punishing measures for people with problematic drug use.

3.6.10 The healthcare system

In 1998, the reorganisation of the National Health System began to include the reorganisation of prison health care. All prisons are under the control of the local health system and all prisoners are registered in the National Health Service and do not have to pay health insurance. Foreign prisoners during their imprisonment also have the right to the same health care as those in the community, regardless of their legal permission to live in Italy (Articles 1–5, legislative decree 22nd June 1999 n.230).

The Ministry of Health plays a key role in providing guidelines for and coordinating the health service in prisons. The regional health authorities also have a key role in provision of services in the local area and manage of and provide of services for prisons. The SERT, the community drug agency that is part of the National Health Service, has the responsibility of care and treatment for problematic drug and or alcohol users. The financial resources, included in the budget of the Ministry of Justice for prison health care, are to be transferred to the National Health Fund (Article 7 of D.Lgs. 230/1999).

In Italy, since the introduction of Law 230 of the penal code introduced in 2000, drug treatment for prisoners has been provided by SERT. SERT can start drug treatment in the prison with prisoners who have had no previous contact with the SERT in the community. In addition SERT can arrange drug treatment in the community as an alternative to staying in prison and many prisoners with problematic drug use benefit from this.

SERT has no formalised agreement with the police to work with problematic drug and or alcohol users in police custody. There are some local initiatives such as the presence of SERT in the Milan courts that provide individual programmes for drug users prior to their court hearing that offer an alternative to the individual being sent to prison. Another initiative is that provided by Villa Maraini in Rome who work closely with the police in every police station. The police notify staff at the Villa Maraini, who go to the police station to attend to the needs of the prisoners with problematic drug use.