Harm reduction is a vital part of a comprehensive approach to drug policy. The DPMP has distinguished harm reduction from law enforcement, treatment and prevention approaches. Harm reduction here has been defined as those policies and interventions aimed at reducing harm, and excluding those interventions that reduce use (and hence harm). Therefore, this monograph considered the following as harm reduction interventions:
• Needle syringe programs • Supervised injecting facilities
• Non-injecting routes of administration • Outreach
• HIV education and information and HIV testing and counselling • Brief interventions (aimed at harm reduction)
• Overdose prevention interventions • Legal and regulatory frameworks
The key features of harm reduction include: a focus on harms rather than use; a pragmatic and achievable approach; an assumption that drugs are part of society; an underlying public health framework; and the use of an evidence-base to evaluate interventions in relation to their impact on net harm.
Harm reduction describes both an overall policy approach, as well as a set of specific interventions. Evaluating the overall policy approach is complicated – country comparisons are difficult to conduct; there are many variables that may moderate the relationship between a country’s policy stance and policy implementation; and there are a large number of confounds. Harm reduction can however be readily evaluated in relation to the efficacy and effectiveness of the individual interventions that comprise a harm reduction approach.
The needle syringe program literature is vast with many program development and descriptive reports. Aside from this, we identified 120 relevant publications that tested the efficacy or effectiveness of NSP (out of a total of 344). In itself, the significant amount of NSP evaluation literature is interesting. Perhaps because NSP are perceived to be controversial, there has been investment in evaluation. The research designs have varied between studies and the outcome measures have variously included reduced risk behaviour; reduced HIV seroconversion, and reduced HCV seroconversion. But the overall conclusion is strong – there is significant support for the efficacy, effectiveness and cost-effectiveness of NSP.
As noted in the body of the report, NSP stand out as having one of the strongest evidence-bases across all areas of illicit drug policy. So it is striking that there continues to be negative commentary around NSP and a desire to interpret single studies as evidence of ineffectiveness rather than using the full literature base. This stance appears to be driven from an ethical or moral position and is inconsistent with the evidence-base.
Despite the substantial evidence-base for NSP, they cannot be considered a stand-alone strategy. The integration of a number of harm reduction interventions will produce the greatest impact. Other harm reduction strategies that we review include supervised injecting facilities. Like NSP, these are somewhat controversial, and unlike NSP, there is a very limited evidence-base upon which to judge efficacy or effectiveness. SIF have been credited with a number of public health
and community benefits such as prevention of overdose, reduced transmission of BBV, improved public amenity and facilitation of access to medical, welfare or treatment services. We await with interest the emerging research (for example from Canada) that will add to the body of knowledge. Until more studies are completed, one cannot be definitive about the effectiveness or efficacy of SIF.
Non-injecting routes of administration (NIROA) does appear to be a promising harm reduction avenue, worthy of further exploration. Likewise the recent interest in pill-testing will hopefully stimulate controlled evaluations of the impact (both positive and negative) on party drug use. Outreach has been identified in the USA and perforce UN and WHO publications as a central harm reduction intervention for blood borne viruses. The emphasis is not misplaced, with reasonable evidentiary support for outreach. Interpreting the strength of the evidence is complicated by the fact that the outreach models are multifaceted interventions. Hence one may not be able to isolate the ‘active ingredients’.
Harm reduction reviews do not often include the more traditional blood borne virus interventions such as HIV education and information, and HIV counselling and testing. Education and information are intuitively appealing harm reduction interventions, and are likely to be among the less costly interventions. Unfortunately these positive aspects are not matched by effectiveness. There is an important role for the provision of voluntary HIV and hepatitis testing and associated counselling for the purposes of screening and early access to treatments. Whether such services actually reduce risk behaviour seems equivocal.
Brief interventions, including motivational interviewing, skills training and other cognitive behavioural approaches have received minimal attention as harm reduction interventions. This should be rectified with future research, given the known efficacy of brief interventions for various other behaviour change endeavours.
Overdose prevention interventions have included CPR training, intersectoral approaches to improve overdose management, and naloxone distribution to injecting drug users. Most recent attention has focussed on the last intervention – naloxone distribution to injecting drug users. It remains an untested but theoretically promising harm reduction intervention.
Harms arise from the illegal status of drugs and drug use. Thus, there are a number of harm reduction interventions that involve legislative or regulatory interventions. This area is complex and our review did not thoroughly uncover and evaluate all the legislative and regulatory options. We have largely relied on the analysis by MacCoun and Reuter (2001). It is apparent that the key issue in evaluating different legislative or regulatory options is consideration of the decrease in harms to users in association with the potential increase in numbers of users.
One of the goals of DPMP is to develop systems models of the dynamic interactions between law enforcement, treatment, prevention and harm reduction interventions. In order to ground these dynamic models, we require good information about the effect of interventions. This systematic review, along with those completed in law enforcement, treatment and prevention provide the building blocks for such models, enabling a comprehensive approach to formulating illicit drug policy in Australia.