EMCDDA MONOGRAPHS 1 0
EMCDDA monographs are comprehensive scientific publicationscontaining thematic papers prepared in the context of the Centre’sresearch studies and seminars. Topics include a wide range of issuesrelating to science, policy, theory and method.EMCDDAMONOGRAPHSHarm reduction:evidence, impacts and challengesPrice (excluding VAT) in Luxembourg: EUR 25EMCDDAMONOGRAPHSISBN 978-92-9168-419-910IS S N 1606- 1691The Centre’s publications are a prime source of information for awide range of audiences including policymakers and their advisers;professionals and researchers working in the drugs field; and, morebroadly, the media and general public.IS S N 0000- 0000The EMCDDA collects, analyses and disseminates factual, objective,reliable and comparable information on drugs and drug addiction. Indoing so, it provides its audiences with an evidence-based picture of thedrug phenomenon at European level.Harm reduction: evidence, impacts and challengesThe European Monitoring Centre for Drugs and Drug Addiction(EMCDDA) is one of the European Union’s decentralised agencies.Established in 1993 and based in Lisbon, it is the central source ofcomprehensive information on drugs and drug addiction in Europe.TD - A L- 10010- EN- CAbout the EMCDDA
EMCDDAMONOGRAPHSHarm reduction:evidence, impacts and challengesEditorsTim Rhodes and Dagmar Hedrich
Legal noticeThis publication of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)is protected by copyright. The EMCDDA accepts no responsibility or liability for anyconsequences arising from the use of the data contained in this document. The contents ofthis publication do not necessarily reflect the official opinions of the EMCDDA’s partners,the EU Member States or any institution or agency of the European Union or EuropeanCommunities.A great deal of additional information on the European Union is available on the Internet. Itcan be accessed through the Europa server (http://europa.eu).Europe Direct is a service to help you find answers to your questionsabout the European UnionFreephone number (*):00 800 6 7 8 9 10 11(*) Certain mobile telephone operators do not allow access to 00 800 numbers or these calls may be billed.Cataloguing data can be found at the end of this publication.Luxembourg: Publications Office of the European Union, 2010ISBN 978-92-9168-419-9doi: 10.2810/29497 European Monitoring Centre for Drugs and Drug Addiction, 2010Reproduction is authorised provided the source is acknowledged.Printed in SpainPrinted on white chlorine-free paperCais do Sodré, 1249-289 Lisbon, PortugalTel. (351) 211 21 02 00 Fax (351) 218 13 17 11info@emcdda.europa.eu www.emcdda.europa.eu
uctionChapter 1: Harm reduction and the mainstream19Tim Rhodes and Dagmar HedrichPart I:BackgroundChapter 2: The diffusion of harm reduction in Europe and beyond37Catherine Cook, Jamie Bridge and Gerry V. StimsonChapter 3: The development of European drug policy and the place of harmreduction within this59Susanne MacGregor and Marcus WhitingChapter 4: Perspectives on harm reduction — what experts have to say79 Harm reduction in an open and experimenting society79Jürgen Rehm and Benedikt Fischer HCV prevention — a challenge for evidence-based harm reduction85Matthew Hickman Broadening the scope and impact of harm reduction for HIV prevention,treatment and care among injecting drug users89Andrew Ball Translating evidence into action — challenges to scaling upharm reduction in Europe and Central Asia94Rifat Atun and Michel Kazatchkine People who use drugs and their role in harm reduction101Mat SouthwellHarm reduction — an ‘ethical’ perspective104Craig Fry The ambiguity of harm reduction — goal or means,and what constitutes harm?Robin Room108
Part II:Evidence and impactsChapter 5: Harm reduction among injecting drug users — evidenceof effectiveness115Jo Kimber, Norah Palmateer, Sharon Hutchinson,Matthew Hickman, David Goldberg and Tim RhodesChapter 6: The effect of epidemiological setting on the impact of harm reductiontargeting injecting drug users165Peter Vickerman and Matthew HickmanChapter 7: The fast and furious — cocaine, amphetamines and harm reduction191Jean-Paul Grund, Philip Coffin, Marie Jauffret-Roustide,Minke Dijkstra, Dick de Bruin and Peter BlankenChapter 8: Harm reduction policies for cannabis235Wayne Hall and Benedikt FischerChapter 9: Harm reduction policies for tobacco255Coral Gartner, Wayne Hall and Ann McNeillChapter 10: Alcohol harm reduction in Europe275Rachel Herring, Betsy Thom, Franca Beccaria,Torsten Kolind and Jacek MoskalewiczPart III:Challenges and innovationsChapter 11: Drug consumption facilities in Europe and beyond305Dagmar Hedrich, Thomas Kerr and Françoise Dubois-ArberChapter 12: User involvement and user organising in harm reduction333Neil Hunt, Eliot Albert and Virginia Montañés SánchezChapter 13: Young people, recreational drug use and harm reduction357Adam Fletcher, Amador Calafat, Alessandro Pirona andDeborah OlszewskiChapter 14: Criminal justice approaches to harm reduction in Europe379Alex Stevens, Heino Stöver and Cinzia BrentariChapter 15: Variations in problem drug use patterns and their implicationsfor harm reductionRichard Hartnoll, Anna Gyarmathy and Tomas Zabransky405
ConclusionsChapter 16: Current and future perspectives on harm reduction in theEuropean Union437Marina Davoli, Roland Simon and Paul GriffithsContributors449Abbreviations455Further reading461
ForewordIt is with great pleasure that I introduce the EMCDDA s latest Scientific monograph, whichprovides a state-of-the-art review of the role of harm reduction strategies andinterventions. Harm reduction has become an integral part of the European policy debateon drugs, but this was not always the case. Although harm reduction approaches have along history in the addictions field and in general medicine, our modern concept of harmreduction has its roots in the challenges posed by the rapid spread of HIV infectionamong drug injectors in the mid-1980s. Initially, there was considerable controversysurrounding the notion that preventing the spread of HIV was of paramount importanceand required immediate and effective action, even if this meant that abstinence as atherapeutic goal had to take second place.In Europe today, that controversy has to a large extent been replaced by consensus. Thisreflects not only a general agreement on the value of the approach but also recognition thatnational differences in interpretation and emphasis exist. Harm reduction as a concept is nowaccepted as part of a balanced approach, an integral element of a comprehensive strategythat includes prevention, treatment, social rehabilitation and supply reduction measures. This,I would argue, is a strong endorsement of the pragmatic and evidence-based approach thatEuropean drug policies have come to embrace.It would be wrong to overstate this position; the drug debate remains an ideological as wellas a scientific one. Nonetheless, the evidence that needle exchange and substitution treatmentcan be effective elements in a strategy to reduce HIV infection among injectors, andimportantly that these interventions do not lead to greater harms in the wider community, hashad a significant impact on European drug policies and actions. Although it would be wrongto minimise the continuing problem that we face, when comparing Europe to many otherparts of the world it is clear that overall our pragmatic approach has borne fruit. Argumentsmay still exist about the relative role played by different types of interventions, but mostinformed commentators would now agree that harm reduction approaches have beeninfluential in addressing the risks posed by drug injecting in Europe over the last 20 years.This is, then, an appropriate moment to take stock of existing scientific evidence on harmreduction and consider the issues that we will need to tackle in the future. The evidence forsome harm reduction interventions is relatively robust. For others, methodological difficultiesmake generating a solid evidence base difficult, and the current scientific bases for guidingpolicymaking need to be strengthened.The assertion that the concept of harm reduction is an accepted part of the European drugpolicy landscape does not mean that all interventions that fall under this heading are eitherwidely supported or endorsed. Many areas of controversy remain, and one purpose of thismonograph is to chart where the current fault lines now lie, with the hope that future studieswill provide a sounder basis for informed actions. Moreover, and perhaps more importantly,the drug problems and issues we face in Europe today are very different to those we7
Harm reduction: evidence, impacts and challengesstruggled with in the past. HIV remains an important issue, but it is no longer thepredominant one. From a quantitative public health point of view, drug overdose, HCVinfection, and other psychiatric and physical co-morbidities are becoming of equal or evengreater importance. In addition, drug injecting levels appear to be falling and patterns ofdrug taking are become more complex and are increasingly characterised by theconsumption of multiple substances, both licit and illicit.What role will harm reduction have within this new landscape? This monograph begins toexplore that question, as we consider how harm reduction strategies may be a usefulcomponent of our approach to the challenges that drug use in twenty-first century Europe willbring. I strongly believe that in taking drug policy forward we have a duty to learn from thepast, and that ideological positions should not stand in the way of a cool-headed analysis ofthe evidence. In the future this is likely to become imperative both to those who instinctivelysupport harm reduction approaches, and to those who instinctively oppose them. Thismonograph makes an important contribution to the debate by highlighting where we arenow, and considering how we have got here. It also draws our attention to some of thechallenges that lie ahead, if we are to understand the role and possible limits of harmreduction approaches to future European drug policies.Wolfgang GötzDirector, EMCDDA8
AcknowledgementsThe EMCDDA would like to thank all authors, editors and reviewers who have worked on thispublication. In particular, the monograph benefited from overall editorial input by TimRhodes and Dagmar Hedrich. A special mention goes to the members of the internalcoordination group who accompanied the project from inception to publication — namely toAlessandro Pirona and Anna Gyarmathy; as well as to the planning group: Roland Simon,Rosemary de Sousa, Paul Griffiths, Julian Vicente and Lucas Wiessing. The EMCDDAgratefully acknowledges the contributions from many unknown external reviewers and fromthe reviewers drawn from the EMCDDA’s Scientific Committee. Furthermore, valuable reviewcomments and input were received from EMCDDA staff members Marica Ferri, BrendanHughes, André Noor, Cécile Martel, Luis Prieto and Frank Zobel. Vaughan Birbeck providedmuch appreciated help with bibliographic references, and Alison Elks of Magenta Publishingedited the final publication.11
PrefaceHarm reduction is now positioned as part of the mainstream policy response to drug usein Europe. However, this has not always been the case, and in reflecting on this fact wefelt that the time was right to take stock of how we had arrived at this position, ask what itmeans for both policies and action, and begin to consider how harm reduction is likely todevelop in the future.This monograph builds on other titles in the EMCDDA’s Scientific monographs series,where we have taken an important and topical subject, assembled some of the bestexperts in the field, and allowed them to develop their ideas constrained only by theneed to demonstrate scientific rigour and sound argument. Our Scientific monographs areintended to be both technically challenging and thought provoking. Unlike our otherpublications we take more of an editorial ‘back seat’ and we do not seek consensus ornecessarily to produce a balanced view. Good science is best done when unconstrained,and best read with a critical eye.This volume includes a variety of perspectives on harm reduction approaches, togetherwith an analysis of the concept’s role within drug policies, both in Europe and beyond.Readers may not necessarily agree with all of the arguments made or the conclusiondrawn, but we hope it is perceived as a valuable contribution to the ongoing debate onhow to respond to contemporary drug problems in Europe.A number of contributors explore what harm reduction means and what policies it canencompass, as well as charting how the concept evolved. They reflect on the point wehave now reached in terms of both harm reduction practice and the evidence base for itseffectiveness. A major issue that many contributors touch on is the difficulty of assessinghow complex interventions occurring in real world settings can be evaluated, and whyconclusive evidence in such settings can be so elusive.With an eye to the future, we also asked our contributors to wrestle with the difficultissue of how harm reduction might be extended into new areas that are of particularrelevance to the evolving European drug situation. Here the empirical base forgrounding discussions is far less developed, and a more exploratory approach isnecessary.As a European agency, the EMCDDA has a somewhat unique perspective on thedevelopment of the drugs debate within the European Union. It is therefore appropriatefor us to make our own introductory remarks about the mainstreaming of the concept ofharm reduction at the European level, as opposed to the national one. Thisdevelopment, we would argue, is sometimes misunderstood, as there is a tendency bysome commentators to polarise the position and focus exclusively on either thedifferences, or alternatively the commonalities, that exist between Member States intheir drug policies. Europe is closer now than it once was in terms of how it responds to13
Harm reduction: evidence, impacts and challengesand views drug use, but differences still exist, reflecting national policy perspectives,cultural differences and, to some extent, simply a different experience of the drugproblem.Despite these differences in opinion and experience, there is a general consensus thatabstinence-orientated drug policies need to be supplemented by measures that candemonstrably reduce the harms that drug users are exposed to. This consensus isstrongest in the area of reducing HIV infection among injectors — although even herethere is disagreement on the appropriateness of which interventions might fall under thisgeneral heading. It is also the case that the range and intensity of harm reductionservices available in EU Member States varies considerably. Therefore, the observationthat harm reduction has played an important part in achieving the relatively positiveposition that the EU has achieved with respect to HIV infection among injectors has to betempered with the comment that some countries have maintained low rates of infectionsamong injecting drug users where the availability of harm reduction services has beenlimited.In summary, considerable debate still exists at European level on the appropriateness ofdifferent approaches, and some interventions, such as drug consumption rooms, are stillhighly contentious. However, Europe’s policy debate in this area appears now to be amore pragmatic one in which harm reduction policies are not automatically considered toconflict with measures intended to deter drug use or promote abstinence. Rather, theconsensus is increasingly moving towards a comprehensive, balanced and evidencebased approach that seamlessly includes harm reduction alongside prevention, treatmentand supply reduction measures.This monograph is comprehensive in its scope. It covers interventions that are stillcontroversial and ones that have become so mainstream that many might now find it hardto believe that this has not always been the case. We have included voices from the usercommunity, as activism has historically been an important element in the development ofthis perspective. The monograph also addresses new challenges for a harm reductionapproach, such as alcohol and tobacco use and Europe’s growing appetite for stimulantdrugs.The EMCDDA is grateful that so many experts were prepared to assist us with this work,often tackling new and demanding topics. This task would have been infinitely moredifficult if we had not benefited from having a first-class editorial team working on thisproject. We are indebted to our editors, Tim Rhodes and Dagmar Hedrich, who bothplayed a major role in conceptualising, planning and implementing this project andwithout whose input this document would have been a far less comprehensive andimpressive achievement.It is important to note that the voices presented here are not those of the EMCDDA orthe European institutions. As with other Scientific monographs, the intention is toprovide a forum for stimulating debate and collecting high-quality scientific opinion andinformed comment on a topic of contemporary relevance. The monographs are14
Prefaceintended to be of particular interest to a specialist audience and therefore some of thepapers in this collection are highly technical in nature. All papers presented here havebeen peer-reviewed to ensure an appropriate degree of scientific rigour, but the viewsexpressed by the authors remain their own.The EMCDDA’s role is as a central reference point on drug information within theEuropean Union. We are policy neutral; our task is to document and report, and never toadvocate or lobby. This neutrality is important when we address any drug use issue, asthis is an area where so many have passionate and deeply held views. However, it isparticularly important when we address a topic like harm reduction, where perspectivesare sometimes polarised and there are those on all sides of the drugs debate that see alinkage between this subject and broader issues about how societies control drugconsumption. The rationale for our work is that, over time, better policy comes fromdebate informed by a cool-headed and neutral assessment of the information available.Many of the contributors to this report are passionate and committed in their views; theyalso provide a wealth of data, analysis and argumentation. They do not speak with acommon voice, and we do not necessarily endorse all the conclusions drawn, but takencollectively we believe they make a valuable contribution to a better understanding of atopic that has become an important element in contemporary drug policies.Paul Griffiths and Roland SimonEMCDDA15
Introduction
Chapter 1Harm reduction and the mainstreamTim Rhodes and Dagmar HedrichAbstractHarm reduction encompasses interventions, programmes and policies that seek to reducethe health, social and economic harms of drug use to individuals, communities and societies.We envisage harm reduction as a ‘combination intervention’, made up of a package ofinterventions tailored to local setting and need, which give primary emphasis to reducingthe harms of drug use. We note the enhanced impact potential derived from deliveringmultiple harm reduction interventions in combination, and at sufficient scale, especiallyneedle and syringe distribution in combination with opioid substitution treatmentprogrammes. We note that harm reduction is a manifestation of mainstream public healthapproaches endorsed globally by the United Nations, and in the EU drugs strategy andaction plans, and features as an integral element of drug policy in most of the Europeanregion. However, we note evidence that links drug harms to policies that emphasise strictlaw enforcement against drug users; an unintended consequence of international drugcontrol conventions. The continuu
The Centre’s publications are a prime source of information for a wide range of audiences including policymakers and their advisers; professionals and researchers working in the drugs field; and, more broadly, the media and general public. EMCDDA monographs a
Price (excluding VAT) in Luxembourg: EUR 15 EMCDDA INSIGHTS Cannabis production and markets in Europe 12 12 About the EMCDDA The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is one of the European Union’s decentralised agencies. Established in 1993 and based in Lisbon, it is the central source of
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monographs, except those only «for veterinary use» High flexibility when using chapter 2.4.20 All individual monographs reviewed:-Specific tests for elements «intentionally added» deleted from individual monographs-Specific tests in selected monographs may be kept based on carefu
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