Harm reduction in Australia: has it worked? A review

Methadone maintenance therapy outcomes in Iran

INTRODUCTION

Because of the increasing number of injecting drug users (IDUs) in Iran and the risk of the spread of HIV infection, harm reduction programs have been considered for conventional law enforcement measures. The aim of this study was to evaluate the efficacy of methadone maintenance therapy (MMT) in IDUs and the associated health and social outcomes.

MATERIAL AND METHODS

This case-control study was conducted at the Persepolis Harm Reduction Center in Tehran during the year 2006. Data were gathered from two groups of randomly chosen patients. The first group consisted of 75 IDU patients who had undergone at least 6 months of methadone treatment (the MMT group), and second group consisted of 75 newly admitted clients (the control group). Participants were assessed on their dangerous injection and sexual behaviors, social well-being, and patterns of drug use. The results were compared between the two groups.

RESULTS

The mean age of participants in the two groups was almost the same (34.28 years in the control group and 35.68 years in the MMT group, p >.05). Prevalence of drug injection in the MMT group was less than that in the control group (16% vs. 100%). There was also a dramatic difference in needle and syringe sharing (40% in the control group vs. 4% in the MMT group) but not in crimes and arrests (p = .4). Those in the MMT group had a better relationship with their families, partners, coworkers, and neighbors compared with controls. There was no considerable difference in dangerous sexual behaviors between the two groups.

CONCLUSIONS

Given the large number of HIV-positive cases among IDUs and considering that injection drug use is the main spreading factor for HIV, MMT would play a major role in controlling the HIV epidemic through reduction of heroin injection and the risk behaviors related to it. High inflation rate, lack of interorganization coordination, budget limitation, and no follow-up were the most important limitations of this study.

Approaches to preventing alcohol-related problems: the experience of New Zealand and Australia

New Zealand and Australia have experienced similarities in their drinking cultures and patterns since colonization. This paper briefly reviews those experiences and looks at the approaches both countries have taken in dealing with alcohol-related problems. Over 10 years ago Australia developed a national strategy embracing a harm reduction approach and more recently New Zealand embarked upon a similar process. As well as examining the development of these, other initiatives are examined. These include approaches to licensing of alcohol sales, taxation, alcohol promotion, control of drinking on licensed premises, drinking and driving intervention, community action, initiatives by Maori and Aboriginal people and efforts to educate the individual drinker.

Support for harm-reduction among staff of specialized addiction treatment services in Ontario, Canada

In a mail survey of staff of specialized addiction treatment services in Ontario, respondents from different types of services varied in their level of support for a variety of harm reduction initiatives. Across all types of services support was common for needle exchange services (82-95% in favour) and for short-term non-abstinence goals for clients with alcohol or drug problems (51-98% in favour). However, mean ratings for the effectiveness of methadone maintenance were negative or near zero, and only in assessment/referral and out-patient samples did the majority (61% in each case) have a positive view of methadone maintenance programmes. Only a minority of respondents (15% to 35%) indicated support for the prescription of heroin to heroin addicts. In multivariate analyses, support for harm-reduction strategies was found to be positively related to belief in the effectiveness of pharmacological and cognitive-behavioural interventions and working in an out-patient treatment service, and negatively related to belief in interventions based on the disease model.

Cannabis policy in Australia and New Zealand

This paper describes and compares current developments in policies to deal with cannabis in Australia and New Zealand. Both countries are bound by international conventions to control cannabis and in each case cannabis use, possession, cultivation and supply is illegal. In both countries almost all the supply is grown locally and patterns of use and health concerns appear to be similar. Strategies used to deal with cannabis include: demand reduction through enforcement of legislation, drug education and treatment; supply reduction through enforcement of legislation and crop recovery operations; and harm reduction through diversion of some offenders from the courts system, lenient enforcement policies for users and, in Australia, the formal decriminalization of cannabis use in two states/territories and de facto decriminalization in another. Australia has had a co-ordinated national drugs policy with a stated harm reduction focus for over a decade, while in New Zealand efforts to co-ordinate policy have been delayed by ongoing debates about cannabis's harm potential and what constitutes an appropriate approach. However, a national drugs policy with a professed harm reduction focus is currently being finalized. Despite these developments, government cut-backs and international and local prohibitionist influences on policy in both countries suggest that a harm reduction model may not necessarily be secure.

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.

[Prevention of HIV in injecting drug addicts. What has been done - what could be better?]

Efficient prevention of HIV in drug users has had to overcome major political opposition in the last decade. Even today many evidence-based measures for the prevention of infections in drug users are still not being applied. Only a few preventive approaches are broadly carried out in the GFR: methadone maintenance performed by general practitioners, antiretroviral therapy and information about safer use given by AIDS- and drug-consultants and syringeexchange by pharmacies and at special institutions. In contrast, injection room facilities, street workers council, vaccination programs and low threshold medical treatment are only implemented in isolated cases. Nevertheless, HIV prevalence among drug users has been reduced successfully and the rate of new infections has decreased from 13.2% in 1994 to 9% in 2006. These strategies, however, do not seem to have any effect on the spread of hepatitis C among drug users. Here we still face a prevalence of 45-70%. Therefore, future research should focus on preventive measures against HCV infection of drug users.

Barriers to the dissemination of four harm reduction strategies: a survey of addiction treatment providers in Ontario

A sample of service providers at addictions agencies' in Ontario were interviewed by telephone to assess attitudes toward, anticipated internal and external barriers to implementing, and expected benefits of four harm reduction strategies: needle exchange, moderate drinking goals, methadone treatment, and provision of free condoms to clients. Respondents were also asked to define harm reduction, list its most important elements, and describe what they find most troubling and most appealing about harm reduction. Attitudes toward harm reduction in general and the services provided at each agency were also assessed. Results indicated that the service providers surveyed had positive attitudes toward each of the four harm reduction strategies and harm reduction in general, and the majority of respondents were aware of the benefits associated with each strategy. Almost all of the agencies surveyed allowed for moderate drinking outcomes in the treatment of alcohol problems, and most agencies provided free condoms to clients. In terms of barriers, anticipated negative community reaction to needle exchange, methadone treatment, and free condoms was a major concern for the majority of respondents. Lack of staff, of funding, or anticipated staff resistance were also cited as potential barriers to introducing these strategies. In the case of methadone maintenance, the unavailability of a qualified physician was listed as the primary constraint. Implications for future efforts directed at encouraging the adoption of these strategies and suggestions for future research are discussed.

A framework for the evaluation of activities and programs with harm-reduction objectives

This paper presents a framework for the evaluation of activities and programs with harm-reduction objectives that draws attention to the logic, implementation, outcomes, costs, and cost-effectiveness of these initiatives and encompasses stakeholder concerns and theoretical models. Evaluations of harm-reduction initiatives are essential if their proponents wish to establish them as viable alternatives to abstinence-oriented approaches. [Translations are provided in the International Abstracts Section of this issue.]