7 February 2011 |
drinkanddrugsnews
| 19
Soapbox |
Neil McKeganey
www.drinkanddrugsnews.com
There can be few ideas that have been more
immediately appealing than reducing the
harm associated with the use of illegal drugs.
When it was first articulated in 1988 by the Advisory Council on the
Misuse of Drugs (ACMD), harm reduction offered a way of engaging with
clients in which there were more gains, more easily achieved, than the
often slow progress to recovery from dependent drug use.
It is impossible to calculate the amount of money that has been
directed at harm reduction in the UK over even the last 15 years, but that
figure must be in the tens of billions. Methadone maintenance has
consistently absorbed the lion’s share of what is now an £800m a year
treatment budget, hundreds of millions of needles and syringes have been
given out and thousands upon thousands of drug users have been
counselled in the practices of safer drug use.
However, the position of harm reduction at the very forefront of
UK drug treatment policy is looking much less assured today than at
any time in the recent past, with the current drug strategy containing
only a single reference to the term – in a footnote. So why has harm
reduction fallen so far from its favoured position?
First, harm reduction may have suffered as a result of the success it has enjoyed in attracting massive
government support set against the evidence of continuing – and in some respects, escalating – drug
harm. Hepatitis C is now so widespread among injecting drug users that it is difficult to see how it could
be any more prevalent in the absence of harm reduction measures. Drug-related deaths have continued
at an intolerably high level and in some places, most notably Edinburgh, there have been more deaths
associated with methadone than with heroin. There are also signs that the level of HIV infection among
injecting drug users – long championed as a success of harm reduction – is starting to increase.
There are clear indications of children using drugs at an increasingly young age, we are seeing a
cocaine problem that has already overtaken our heroin problem and we estimate that there are
around 400,000 children growing up with one or both parents dependent upon illegal drugs. None
of these are the statistics of a drug problem whose harms have been effectively reduced, and there is
a growing feeling that it may only be by reducing the overall level of drug use that it will be possible
to reduce drug harms.
Second, political support for harm reduction may have waned in the face of the evidence that
most drug users entering treatment are looking for support in becoming drug free. The first research
paper reporting that finding came from Scotland and showed that nearly 60 per cent of drug users
starting a new episode of drug treatment were looking for help in achieving a single goal – to
become drug free (McKeganey et al, 2004). Initially rejected by many in the drugs field, those
findings were then backed by a large NTA survey from 2007.
The emphasis on abstinence in these studies ought not to have threatened the harm reduction
lobby, since abstinence was very much at the heart of the earliest formulations of the harm reduction
approach. The ACMD’s 1988
AIDS and drug misuse
report, for example, set out a hierarchy of goals
that combined the aim of reducing the shared use of injecting equipment with reducing the use of
prescribed drugs and increasing abstinence from all drug use. Over time, however, harm reductionists
steadily diluted their commitment to reducing all forms of drug use.
Third, political support may have waned as a result of the increasingly strident tone of some harm
reductionists lobbying in support of the drug-using lifestyle and calling for some form of relaxation in
the drug laws. Craig Reinarman, a US academic supportive of harm reduction, has identified the dangers
of an increasingly strident tone on the part of some harm reductionists in calling for drug law reform.
‘The public health principles that undergird harm reduction practices have afforded much needed
political legitimacy to controversial policies,’ he says. ‘This legitimacy is a precious resource, some of
which might be jeopardised if the movement were to give loud primacy to the right to use whatever
drugs one desires and to make legalisation its principle policy objective.’
UK drug policy is now at an intersection and one of the key questions is whether it will be possible
to combine the current focus on recovery with a commitment to support services aimed at reducing
drug-related harm. Those who have benefited from the allocation of substantial public funding for
harm reduction initiatives may well see their budgets reduced as resources are targeted on recovery-
focused services, and if the reaction to any such rebalancing of the treatment budget is an
increasingly belligerent tone, it is questionable whether such a combination will be able to develop.
Successful interlinking of these approaches may also require harm reductionists to temper their
support for drug law reform, emphasising less the rights of the individual to use illegal drugs, and
concentrating rather more on individual and public health protection.
DDN
Neil McKeganey is professor of drug misuse research at the University of Glasgow.
DDN’ s new monthly column
offers a platform for a range
of diverse views.
With government policy
now focused on recovery
Neil McKeganey asks:
‘What now
for harm
reduction?’
SOAPBOX