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Harm reduction is a realistic, pragmatic and non-judgmental approach based upon openness, understanding and respect. It was initially adopted as an ‘alternative’ approach to try to engage people using banned drugs in the 1980s, partly because the dominant abstinence approach was failing, but largely because agencies were worried about the spread of HIV/AIDS to the wider community. To encourage safer sex and safer drug use governments reluctantly adopted harm reduction drug policies as a means to reach and engage the cooperation injecting drug users.
The global threat posed by AIDS in the 1990s has now subsided, by no coincidence so has the government commitment to harm reduction. However, harm reduction has proven to be effective in engaging people with drug problems into treatment, reducing the spread of infectious diseases, reducing fatal overdose, and reducing addiction. But in some countries harm reduction has stalled and failed to move much further than needle exchange schemes.
Having proved so effective harm reduction has evolved, and now harm reduction is no longer confined to reducing harms from disease, but more significantly it’s more broadly about reducing the harm caused by prohibitionist drug policies.
Has your country moved on from a 1980s model of harm reduction which was largely confined to running needle exchanges? To check out just how far your country has progressed and evolved with it’s harm reduction philosophy here are thirty-one harm reduction policies:
- Naloxone take home kits for users and friends
- Naloxone available without prescription at pharmacies
- Naloxone in public areas alongside AEDs
- Good Samaritan laws
- Legalisation of all injecting equipment
- Drug Consumption Rooms/Injecting Facilities
- Drug Consumption Rooms for those who don’t inject
- Drug checking at Drug Consumption Rooms
- Prescribing the drug the person is addicted to
- Oral, inhale-able and injectable prescribing
- Injectable heroin prescribing
- Injectable methadone prescribing
- Client led maintenance prescribing
- Free Needle/syringe distribution* in cities
- Free Needle/syringe distribution* outreach mobile units
- Drug checking at Needle/syringe distribution centres
- Condom distribution at all drug agencies
- Sharps boxes in public toilets
- Sharps boxes in all drug agencies
- Drug checking at needle/syringe distribution centres
- Decriminalise all drug possession for personal use
- Decriminalise all cultivation/production for personal use
- Drug checking at public events/festivals
- Social media early warning system for rogue drugs
- Substitute prescribing in prisons
- Needle/syringe exchange in prisons
- Wet houses for people with drink problems
- Rehabs that support oral & ampoule maintenance prescribing
- Injecting technique advice at DCRs
- Injecting technique advice at Needle Exchanges
- Basic health care (showers, laundry room & nurse) at DCRs
*Facilitating collection – not exchange only
- Drug testing identifies substance ‘use’ rather than any substance disorder/problem. This misguidedly widens the net of concern, which should be directed towards the person with a drug problem not towards the recreational user.
- Most people with a chronic drug problem have endured damaging personal and social circumstances before drugs became an issue and need considerable help and support in life, more generally. Drug testing can lead to a pre-occupation on drug presence, and this narrow focus risks overlooking the real underlying issues, which if not addressed, will almost certainly lead to drug problem relapse.
- Women drug users with child care responsibilities are often forced to undertake regular or even daily drug tests to prove they are ‘drug’ free, this disproportionately focuses attention on drug presence rather than fitness to parent. Regular positive drug tests are then used wrongly as evidence as to why the child should be ‘looked after’ by the state. Any assessment of a mothers parental capability to care for her child should never be reduced to a drug test.
- A pre-occupation with drug testing by key stakeholders can result in a paradigm shift in which abstinence and so-called ‘clean’ drug tests become the desired measure of any successful outcome. Not only does harm reduction get marginalised in the process, but the messy and challenging process of rehabilitation and social reintegration may be forgotten in the satisfaction that the person appears to be drug free.
- Around 30-70% of young people in most western countries have used illicit drugs and the vast majority manage to avoid: a criminal record; a drug problem; harm to themselves or harm to others. Widespread random drug testing in schools, at the roadside, in employment, on benefit claimants etc., will only waste resources and result in capturing mainly non-problematic drug users who then risk being ascribed damaging labels as ‘deviant’ or ‘addicts’ that will pose serious damage to future life opportunities (education, employment, travel, insurance, housing etc) and in relationships.
- Resources for public and voluntary services are limited and money that could be used to deliver much needed harm reduction services is wasted on expensive drug testing for people who don’t use drugs, or those who use drugs in a non-problematic recreational manner.
- Random drug testing of pupils, students and children often accompanied by police and sniffer dogs as a health promotion strategy is misguided. Cultural behavioural change is not achieved through policing, confronting and punishing, but it is facilitating by meaningful, culturally relevant, reliable information exchange, harm reduction education, relationships and peer dialogue.
- The most widely used illicit drug (cannabis) is much less harmful than the promoted legal drugs alcohol and tobacco, it is therefore, untenable or indeed hypocritical to pursue drug testing and punish cannabis use and not drug test and punish alcohol and tobacco use.
- Drug testing regimes with sanctions, such as random drug tests in schools to exclude students who test positive, create a ‘cat and mouse’ game in which an adversarial relationship is established, both sides then seek to out-smart the other with new technology or deceptive techniques. The winners in this game are the drug testing businesses and underground laboratories; but the losers are honesty, trust and communication.
- Tougher drug testing regimes to stamp out illicit drug use, such as drug testing in employment, have spawn the proliferation of new synthetic designer ‘legal’ highs to avoid detection (such as Spice). However, once these new drugs have been detected and subsequently outlawed the drug testing ‘net’ widens, then new legal highs are further developed and the never ending spiral continues. These ‘legal highs’ may be considerably more dangerous than commonly used illicit drugs.
- Some drugs such as cannabis can stay in the body for over four weeks whereas drugs like cocaine can be out of the body within 48 hours. Random drug testing regimes (such as those in prisons) have inadvertently pressurised people to switch from the less harmful cannabis to the more dangerous heroin, spice or cocaine.
- Drug testing concentrates attention towards illegal drug use and unhelpfully firms up the misguided bifurcation between licit and illicit substances. It is not the use of any illicit drug that warrants attention but rather the misuse of any drug legal and illegal that should warrants attention. The legally promoted drugs (alcohol, caffeine, tobacco and sugar) can pose serious risks, sometimes greater than their illegal counterparts.
- A positive drug test may reduce the risk of people who are intoxicated from using machinery, driving a car or flying a plane, however, testing positive for a drug doesn’t necessarily mean that the person is intoxicated or impaired – for example cannabis can be detected a month after not using, so a positive drug test could result in misguided concern, and unfair dismissals.
- Some maintenance opioid substitute prescribing regimes rooted in harm reduction engage in regular drug testing, but as a consequence of a positive drug test for illicit drug use some automatically suspend or even terminate prescribing. The use of drug testing in this manner transforms what was a low threshold harm reduction prescribing philosophy into a punitive abstinence only regime.
- A positive drug test indicates drug presence but not necessarily drug impairment, but as in the case of drug driving government campaigns are often conflating drug presence with drug impairment, ascribing much more to drug testing than it is telling us. Association does not mean causation.
- A positive drug test may be incorrect due to a small percentage of ‘false positives’ caused by equipment failure or human error, and conversely ‘false negative’ can occur.
- An accurate positive drug test still maybe misleading. It is assumed that the person has taken illicit drugs when those drugs may have been ingested legally. For example, consuming poppy seeds in bread can lead to a positive drug test for opiates, or if the person took a paracodeine tablet for a headache they’d show positive for opiates.
The most vulnerable need advocates to campaign on their behalf: The New Zealand experience of naloxone
No naloxone available? No excuse.
No excuse either for drug agencies failing to formally lend their support for naloxone distribution to users, families, and friends.
Getting naloxone into the community was recommended by the World Health Organisation, and some countries like the USA, Australia, Scotland, Wales have made excellent progress, but here in New Zealand it has been difficult to get naloxone on the drug policy agenda let alone into the community, despite the fact that Coroner data indicates that every week someone dies of an opioid overdose.
Why should this be so difficult when naloxone has no abuse potential, is relatively cheap, easy to administer and is so effective at reversing overdose? Unfortunately, the failure to deliver a humane and effective drug policy has little to do with a lack of evidence, understanding or science, but much more to do with a lack of interest, care or regard for people who use illicit drugs, and people who inject drugs (PWID) tend to be the most marginalized. Naloxone distribution is a vital life saving service for PWID.
Numerous opportunities have existed in New Zealand to ensure naloxone is available to users, families and friends. In August 2013 sixty-seven agencies were represented at an invitiaton-only National Think Tank Event led and coordinating by the New Zealand Drug Foundation. After two days debating priorities, values and strategy, to shape the future of drug policy in Aotearoa, the NZ Drug Foundation produced a 12,000 word vision statement, that became known as the Wellington Declaration – but surprisingly in this comprehensive document outlining drug policy priorities naloxone didn’t even get a mention.
A year later in August 2014 in it’s Matters of Substance Magazine, rather than present a robust case for naloxone distribution in New Zealand, the NZ Drug Foundation Magazine framed Naloxone take-home as a contestable issue, open to debate. They offered arguments for and against naloxone. This included some spurious arguments against naloxone distribution including “there could be an unintended consequence from widening availability of naloxone” and “people could become less cautious about their drug use because they know life-saving treatment is close at hand”.
In October 2014 after a new government was elected the NZ Drug Foundation prepared a twenty page Briefing Paper to Parliament which was designed to identify key drug policy priorities to enable ‘opportunities to make real reductions in drug related harm‘ (p.3). The document emphasised the need to secure New Zealand representation at the United Nations international meetings (see below), and specifically highlighted the need to tackle deaths caused by huffing solvents, but astonishingly made no reference or representation to the new government concerning fatal opioid overdoses nor did it mention the need to distribute naloxone to users, families and friends.
With this lack of formal commitment to naloxone distribution from the lead NGO organisation for drug users/drug agencies in New Zealand, it was hardly surprising that when the new government eventually rolled out its five year Drug Policy Strategy 2015-2020 on 28th August 2015, the policy document made no mention of naloxone whatsoever. Interestingly, the new drug policy did, as promoted in the NZ Drug Foundation Briefing Paper, prioritise a commitment to ensure New Zealand would be represented at international UNGASS meetings (p.22).
Belatedly, Matters of Substance published a better informed and considered magazine feature on Naloxone after the embarrassing ‘for or against’ debate, the Foundation produced a stand alone Naloxone Background Paper. However, while this discussion paper includes some excellent sources and appeared to offer a robust argument for reducing overdose, it also undermined the campaign with some odd statements and inclusions, such as “Due to the controversial nature of drug harm reduction and naloxone access”, and it confusingly recommends consideration for: “legal protection from arrest for drug possession and/or the act of injecting someone for people who administer naloxone in an emergency situation”, [my highlight in red], as well as recommending “reclassifying naloxone as restricted medication” rather than pharmacy only, largely it seems, to ensure that anyone who accesses naloxone must receive training. The briefing paper also aired some odd arguments against naloxone: “There may also be views that wider access is not necessary with naloxone already available in hospitals and with advanced paramedics” and it further “[naloxone] will lead to greater risk taking behaviour”.
There are other disconcerting aspects buried within what might otherwise give the impression of a solid report arguing for greater naloxone distribution, such as the omission of data concerning the high percentage of overdose deaths that occur before the medics arrive, for example, a London study by Hickman et al (2007:320) found that when an ambulance was called the person who overdosed was already dead before the arrival of the ambulance in 85% of cases. Had this information been understood and included in the NZ Drug Foundation background paper they would surely have given greater emphasis to ensuring naloxone is in the hands of People Who Inject Drugs (PWID), their friends and family, but the report seems to prioritise naloxone training over naloxone distribution. The recommendations in the paper also includes loop holes that seem to almost invite a piecemeal approach to distributing naloxone, by suggesting various components of naloxone distribution could be seen as possible ‘separate options’ for consideration.
a London study by Hickman et al (2007:320) found that when an ambulance was called the person who overdosed was already dead before the arrival of the ambulance in 85% of cases
While this paper was primarily about the role of naloxone to reduce overdose death, it was an ideal opportunity to mention closely related strategies known to reduce OD deaths in New Zealand, such as the benefit of allowing prescribing injectable drugs in New Zealand to people who continually inject rather than restrict them to oral methadone which is then invariably injected, or the effectiveness of Drug Consumption Rooms in reducing overdose. Here’s a link to the report that includes my highlighted concerns and critique.
Despite the absence of any clear formal commitment to wider naloxone distribution, the campaigning in Aotearoa NZ must continue for naloxone take-home, and indeed for other strategies to reduce overdose and drug policy harm, including: drug checking; prescribing injectable opioids to opioid injectors; a Good Samaritan Law to end arrests for possession and manslaughter when co-users call for emergency help; end the risk of criminalisation for possession of needles and utensils in New Zealand (unless proven to be obtained from the needle exchanges); and establishing Drug Consumption Rooms.
In view of this failure to put naloxone on the formal agenda, it was somewhat incongruous see the Director of the NZ Drug Foundation on International Overdose Day showcase a persuasively well-argued newspaper article (with no sense of irony or doublespeak), asserting that New Zealand must do more to tackle overdose and distribute naloxone. If the New Zealand Drug Foundation had proactively promoted the need for naloxone, it could have been quite different. It’s New Zealand Drug Foundation, in its pivotal drug policy advisory role, that needs to do more to tackle overdose and push for naloxone distribution.
It is hard to understand given the insights clearly displayed in their newspaper piece on International Overdose Day why the New Zealand Drug Foundation have omitted naloxone from important documents (the Wellington Declaration & subsequently the Harm Reduction Briefing to Parliament), and why they haven’t campaigned when and where it matters, for naloxone take-home from the outset. Staff from the NZ Drug Foundation did however, as promoted and prioritised in the harm reduction Briefing to Parliament, go to Vienna and New York (see here) and engage in the inertia of the UN drug control system that is committed to a ‘drug’ free world.
With an alternative emphasis on national drug policy reforms in New Zealand rather than international networking, important drug policy harms could be tackled. Key drug policy issues that need tackling here in New Zealand include:
2. There is no naloxone take home.
3. There is no injectable maintenance prescribing.
4. There is no heroin prescribing.
5. There is no Good Samaritan law.
6. There are no Drug Consumption Rooms / Supervised Injection Facilities.
7. Unemployed people on state benefits are drug tested and lose benefits if they repeatedly test positive for illegal drugs.
8. People with life limiting illnesses are criminalised if caught self medicating with cannabis.
9. The Police and Air Force scour the countryside every year digging up millions of dollars worth cannabis plants.
10. The Alcohol and Other Drug Treatment Courts adopted from the USA and based on an abstinence and disease model of addiction that uses scram bracelets and random alcohol and drug testing, have had their five year ‘pilot’ extended a further three years.
11. New legislation to enforce Compulsory Assessment & Compulsory Treatment of Addiction came in force in February 2018.
12. The Psychoactive Substances Act 2013 made possession and supply of all NPS an offence – unless approved by the state (none have been approved).
13. Housing NZ have fuelled a needless moral panic about methaphetamine contaminated houses and awarded over $50m to companies to decontaminate houses.
The 2016 and 2017 CND and UNGASS meetings predictably delivered no tangible positive outcomes or progress. It’s now International Overdose Awareness Day 2017 and New Zealand users, families and friends are still struggling to gain access to naloxone. Distribution has been agreed in principle, but procrastination concerning the cost and production of additional health education material to accompany the naloxone have stalled distribution.
Having failed to even mention naloxone in the weighty 2013 Wellington Drug Policy Declaration, and failed to mention it in the 2015 Briefing to Parliament, the urgent need for naloxone was finally acknowledged in the New Zealand Drug Foundation December 2017 Briefing to Parliament;
While nations like New Zealand, inexcusably fail to deliver easy to implement drug policy reforms at a national level, and instead invest considerable energy on high maintenance, but low outcome international drug policy reform gatherings, serious harms continue. A growing number of drug reformers are recognising the need for genuine policy transformation. It is time to stop talking the talk and start delivering outcomes, one in particular Low Threshold, Easy Access, Naloxone Take Home.
In the meantime, people who use illicit drugs in New Zealand are needlessly suffering, some are dying. No naloxone take home – no excuse.
It is literally a matter of life or death.
Dr Julian Buchanan, is a retired Associate Professor, Victoria University of Wellington, Institute of Criminology
31st August 2015 on International Overdose Day. (updated 5th January 2018)