HIV is killing a lot of people around the world. More than a third of those infected contracted the virus by using someone else's syringe while injecting drugs. This might not have happened if full-scale harm reduction programs, which are recognized as the most effective method of dealing with the effects of illicit drugs, had been in place in all countries. The BB team will tell you how the world came to this method of combating addiction and the spread of HIV and hepatitis in the world.
According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2020 report, there were an estimated 690,000 deaths due to AIDS-related illnesses worldwide in 2019.
According to the Centers for Disease Control and Prevention (CDC) 2019 HIV Surveillance Report, there were 14,963 deaths attributed to HIV disease in the United States and dependent areas in 2018. The number of deaths due to HIV has been decreasing in recent years. In 2010, there were 18,344 deaths attributed to HIV disease, showing a positive trend in the reduction of HIV-related deaths in the United States.
According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) 2020 report, there were an estimated 690,000 deaths due to AIDS-related illnesses worldwide in 2019.
According to the Centers for Disease Control and Prevention (CDC) 2019 HIV Surveillance Report, there were 14,963 deaths attributed to HIV disease in the United States and dependent areas in 2018. The number of deaths due to HIV has been decreasing in recent years. In 2010, there were 18,344 deaths attributed to HIV disease, showing a positive trend in the reduction of HIV-related deaths in the United States.
One of the main methods of HIV prevention among people who use drugs is a harm reduction program. Programs based on this method have been operating in the United States, Canada, Eastern Europe and Central Asia for over forty years.
Despite this, some countries consider such programs absurd and say that they promote tolerance of drug use in society and may even cause «the destruction of the demographic, intellectual, and creative potential of the country».
Harm reduction programs, including substitution maintenance therapy, are one of the most effective methods of treating opioid dependence. Experts from WHO, the UN Office on Drugs and Crime, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) are convinced of this.
Despite this, some countries consider such programs absurd and say that they promote tolerance of drug use in society and may even cause «the destruction of the demographic, intellectual, and creative potential of the country».
Harm reduction programs, including substitution maintenance therapy, are one of the most effective methods of treating opioid dependence. Experts from WHO, the UN Office on Drugs and Crime, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) are convinced of this.
What is harm reduction?
Harm reduction is a set of health, social, and legal measures aimed at minimizing the negative consequences of substance use. Around the world, people who use drugs are tortured, imprisoned — and even killed, as in the Philippines. The harm reduction philosophy is to accept them for who they are and help them — without prejudice, coercion or discrimination.
WHO, UNAIDS, and UNODC have developed an evidence-based package of interventions to reduce the harms of injecting drug use. It has several strands:
Harm reduction is a set of health, social, and legal measures aimed at minimizing the negative consequences of substance use. Around the world, people who use drugs are tortured, imprisoned — and even killed, as in the Philippines. The harm reduction philosophy is to accept them for who they are and help them — without prejudice, coercion or discrimination.
WHO, UNAIDS, and UNODC have developed an evidence-based package of interventions to reduce the harms of injecting drug use. It has several strands:
- Needle and syringe programs — people who use drugs intravenously risk contracting not only HIV but also viral hepatitis B and C because they often share needles and syringes. The logic is simple: it is wise to choose the lesser of two evils and solve at least one of the existing problems by giving such people access to clean equipment. The World Health Organization recommends supplying every person who injects drugs with at least 200 sterile syringes and needles a year in order to prevent transmission of infection.
- Opioid substitution therapy and other evidence-based drug dependence treatment — in this type of therapy, an opioid user is given drugs that block their euphoric effects and allow them to socialize, engage in their health and rebuild a broken life. Methadone and buprenorphine are the drugs most often used for this purpose.
- Counseling and HIV testing of drug users.
- Antiretroviral therapy for the treatment of HIV infection.
- Prevention, diagnosis and treatment of sexually transmitted infections and tuberculosis and viral hepatitis.
- Condom distribution programs for people who inject drugs and their sexual partners.
Today, WHO, UNODC and UNAIDS cite substitution maintenance therapy as one of the most effective treatments for opioid dependence.
The practice of harm reduction in some countries also includes:
- Organization of safe drug use rooms — there one can consume brought-in substances in a safe and friendly environment, as well as receive sterile injection equipment, information about drugs, basic medical care, and referrals to treatment. These rooms save lives: in the Canadian province of Alberta, for example, they have prevented more than 4,300 fatal overdoses since November 2017.
- Providing people who use drugs with housing and jobs.
- Testing drugs for impurities — there are about 70,000 fatal overdoses each year in the United States. Most of these overdoses are caused by the addition of the even more powerful opioid, fentanyl, to heroin. The consumer does not know this, so checking for deadly impurities can save lives.
- Psychosocial support.
- Providing information on safer substance use.
- Overdose prevention — in the case of opiates, the most effective treatment is naloxone. In many countries, it is available in pharmacies and is offered free of charge. However, in some countries naloxone is still available only with a prescription in medical institutions.
Principles of harm reduction
- Respect for the rights of people who use psychoactive substances. Drug dependence does not deprive a person of the right to live, to receive social services, to maintain their health — and certainly should not serve as an excuse for humiliation and abuse, against which they are protected by law in the same way as non-drug users are.
- Using only scientifically proven evidence. Harm reduction programs rely on a rigorous evidence base. Most of their interventions are simple to implement, do not require huge expenditures and have a significant positive impact both on the individual and on society.
- The principle of social justice, which in the context of harm reduction is interpreted as countering discrimination and guaranteeing access to social and medical services.
- Cooperation with networks of people who use drugs: they should participate in the development, implementation and evaluation of policies and programs that directly affect them.
- Avoiding stigma. Evaluative language should be avoided when referring to people who use drugs.
The use of such terms as «brothel», «junkie» is a direct road to drugophobia. In addition, it is impossible to allow drugs to be divided into «good» and «bad», so one must be very careful in the choice of linguistic means.
A bit of history
The term «harm reduction» gained prominence in the mid-1980s, when HIV infection began to spread worldwide. But the basic principles of this approach were formulated at the beginning of the last century.
At the turn of the 19th and 20th centuries, 300,000 people in the United States were addicted to smoking opium and medical opioids such as laudanum and morphine sulfate. Physicians prescribed laxatives, baths, electrotherapy, diets, and placed these people in private hospitals to practice healing techniques on them.
From 1912 to 1923, 35 so-called «narcotic maintenance clinics» operated in the United States, where registered opioid addicts could buy morphine and sometimes cocaine and heroin cheaply.
Some institutions were willing to supply patients with psychoactive substances for as long as they wanted, while others believed that they should be phased out.
Some tried to make money on it, and some barely made ends meet, because they sincerely wanted to help people with addiction. All such institutions had one thing in common: they were shut down by the federal government, usually within a year of being launched.
The last drug support clinic in the country ceased operations in 1923.
The term «harm reduction» gained prominence in the mid-1980s, when HIV infection began to spread worldwide. But the basic principles of this approach were formulated at the beginning of the last century.
At the turn of the 19th and 20th centuries, 300,000 people in the United States were addicted to smoking opium and medical opioids such as laudanum and morphine sulfate. Physicians prescribed laxatives, baths, electrotherapy, diets, and placed these people in private hospitals to practice healing techniques on them.
From 1912 to 1923, 35 so-called «narcotic maintenance clinics» operated in the United States, where registered opioid addicts could buy morphine and sometimes cocaine and heroin cheaply.
Some institutions were willing to supply patients with psychoactive substances for as long as they wanted, while others believed that they should be phased out.
Some tried to make money on it, and some barely made ends meet, because they sincerely wanted to help people with addiction. All such institutions had one thing in common: they were shut down by the federal government, usually within a year of being launched.
The last drug support clinic in the country ceased operations in 1923.
Meanwhile in Great Britain in 1924 the Rolleston Committee for Heroin and Morphine Addiction was created, named after Sir Humphry Davy, 1st Baronet, the famous doctor who was asked to head the organisation.
In 1926 his famous report came out, which allowed doctors to prescribe morphine to people who were already addicted to heroin and morphine. Patients were divided into two categories: those capable of recovery through gradual withdrawal from the drug, and those who could no longer function without a regular low dose of opiates. The report also stated that most heroin and morphine addicts belonged to the middle class, so criminal sanctions against these people were unnecessary.
«The Rolleston era» was replaced in 1968 by the «clinic era», when specialized facilities to help addicts began to open across the United Kingdom.
The typical English clinic included a prescription for heroin (from the early 1970s — for methadone), counseling by social workers and psychologists. With the spread of HIV, needle and syringe exchange programs, also supported by the state, were added to the list.
In 1926 his famous report came out, which allowed doctors to prescribe morphine to people who were already addicted to heroin and morphine. Patients were divided into two categories: those capable of recovery through gradual withdrawal from the drug, and those who could no longer function without a regular low dose of opiates. The report also stated that most heroin and morphine addicts belonged to the middle class, so criminal sanctions against these people were unnecessary.
«The Rolleston era» was replaced in 1968 by the «clinic era», when specialized facilities to help addicts began to open across the United Kingdom.
The typical English clinic included a prescription for heroin (from the early 1970s — for methadone), counseling by social workers and psychologists. With the spread of HIV, needle and syringe exchange programs, also supported by the state, were added to the list.
And now back to North America. In 1963, physicians Mary Niswander and Vincent Dole developed the first program to treat opioid addiction with methadone, an opioid synthesized in Germany in 1942.
Because the substance was long-lasting and blocked the euphoric effects of heroin, people could go about their normal activities, such as working or reconnecting with family, rather than wasting all their time searching for illegal substances.
Despite opposition from the Federal Bureau of Narcotics, two years later an entire department of methadone substitution therapy was opened at Manhattan General Hospital. In neighboring Canada, the approach was introduced around the same time.
Because the substance was long-lasting and blocked the euphoric effects of heroin, people could go about their normal activities, such as working or reconnecting with family, rather than wasting all their time searching for illegal substances.
Despite opposition from the Federal Bureau of Narcotics, two years later an entire department of methadone substitution therapy was opened at Manhattan General Hospital. In neighboring Canada, the approach was introduced around the same time.
In Europe, the first methadone treatment programs also appeared in the 1960s: first in Sweden, then in the Netherlands, the UK and Denmark. In 1984, in Holland, organizations of people who use drugs began distributing sterile injection equipment to prevent a hepatitis B epidemic.
Three years later, similar programs were already operating in Denmark, Spain, Sweden, Great Britain and Malta. Some countries experimented with alternative methods of distributing sterile injecting equipment, such as kiosk machines and pharmacies. And in 1986, the first legal safe drug use room started operating in Bern.
In Asia, the first needle exchange program was launched in 1991 in Nepal's Kathmandu Valley. The following year, needle and syringe programs appeared in Thailand. In 1993, India launched a sublingual buprenorphine treatment project for drug addicts.
According to the 2018 Global Status of Harm Reduction report, 86 countries had all such programs in operation. Heroin substitution therapy, or the prescription of synthetic diamorphine, was practiced in Belgium, Canada, Denmark, Germany, the Netherlands, Switzerland, and the United Kingdom.
Three years later, similar programs were already operating in Denmark, Spain, Sweden, Great Britain and Malta. Some countries experimented with alternative methods of distributing sterile injecting equipment, such as kiosk machines and pharmacies. And in 1986, the first legal safe drug use room started operating in Bern.
In Asia, the first needle exchange program was launched in 1991 in Nepal's Kathmandu Valley. The following year, needle and syringe programs appeared in Thailand. In 1993, India launched a sublingual buprenorphine treatment project for drug addicts.
According to the 2018 Global Status of Harm Reduction report, 86 countries had all such programs in operation. Heroin substitution therapy, or the prescription of synthetic diamorphine, was practiced in Belgium, Canada, Denmark, Germany, the Netherlands, Switzerland, and the United Kingdom.
Research is now underway to answer the question of whether the same methods can be used to treat people who take psychostimulants.
In the Americas, the potential of using coca leaves to replace crack cocaine is being studied, as well as the use of pharmaceutical substances such as modafinil for amphetamine and cocaine addiction.
As of last year, safe rooms were operating in 12 countries; three more are expected by early 2024. In ten states, including Kyrgyzstan, Moldova, and Tajikistan, needle and syringe programs operated in prisons, and some form of substitution therapy was used in 54 prisons.
In the Americas, the potential of using coca leaves to replace crack cocaine is being studied, as well as the use of pharmaceutical substances such as modafinil for amphetamine and cocaine addiction.
As of last year, safe rooms were operating in 12 countries; three more are expected by early 2024. In ten states, including Kyrgyzstan, Moldova, and Tajikistan, needle and syringe programs operated in prisons, and some form of substitution therapy was used in 54 prisons.