Harm Reduction: Policies in Public Health
Elizabeth Nodine, M.D.
April 25, 2006
Harm reduction is a philosophy intended to be an alternative to prohibition of high-risk lifestyle choices. At the core of harm reduction philosophy is the acknowledgment that some people will always be engaged in behaviors that carry risks, like intravenous drug use (IVDU), unsafe sex, and smoking. A harm reduction approach attempts to lessen the consequences of such behavior when eliminating the behavior altogether is not realistic. Furthermore, instead of criminalizing these behaviors, harm reduction pursues a social justice response. Harm reduction philosophy supports the idea that people should not be denied health care and social services just because they take risks1.
Critics of harm reduction believe
that this philosophy condones and may even encourage risky behavior. They feel these programs are socially
destabilizing. Although many of these
illegal activities are popularly known as “victimless crimes”, opponents argue
that there are indeed victims, such as family members and society at large. Advocates of harm reduction counter that
these initiatives are not incompatible with abstinence-based programs. They believe that since risk is a universal
part of life, and since change and recovery are processes with many stages,
harm reduction is a needed part of public health programs. Opinions regarding this debate are not
divided neatly along party lines, as many Republicans as well as Democrats
support harm reduction policies. Harm
reduction remains a polarizing subject in the
II. Applications of Harm Reduction Policy
Needle exchange programs are one
of the oldest examples of harm reduction policy in the
Methadone is a synthetic drug used to reduce the
harm caused by opiate addiction (usually heroin). It is not associated with the euphoria of
opiates, but does reduce and may even eliminate the strong cravings that accompany
opiate withdrawal. Methadone is a
legal medication prescribed under a physician’s supervision within a carefully
monitored program. In contrast to heroin
use, it does not affect mental capabilities or employability. Methadone Maintenance Treatment (MMT) has
been repeatedly shown to be cost effective, averaging about $13 a day. MMT has also been found to reduce criminal
behavior and promote better health and productivity. Cost benefit analyses indicate that for every
treatment dollar, $4 to $5 is saved in social and health costs. Additionally, because it can eliminate
unsafe needle use, MMT significantly decreases the spread of HIV, Hepatitis B
and C and other blood born diseases4. A relatively newer target of MMT intervention
is the prison population. A recent
Many harm reduction initiatives focus on legalization or decriminalization of certain illicit substances, particularly those drugs felt to cause relatively little harm compared with the costs of law enforcement (e.g. marijuana). Legalization refers to a system in which no aspect of the production and possession cycle is considered an offense. One model of legalization is known as regulation, which is used in the alcohol model of a control board. Decriminalization, by contrast, refers to prohibition with certain civil penalties but with no criminal charges for possession of small quantities of drugs. These strategies mandate that intervention be based on the relative harmfulness of a particular drug to society6. Harm reductionists feel that current drug policies overemphasize arrest, incarceration and military source control in other countries as a means of dealing with illicit substance abuse.
By many measures, incarceration does little to
reduce the harm caused by illicit drug use, yet it is very costly. Of the nearly 700,000 drug-related arrests in
2002, 88% were for possession (as opposed to selling to others) and most of
these were for marijuana7. Approximately 4 billion dollars is spent on
minor marijuana offenses per year in the
Examples of legalization and
decriminalization strategies abound in
B. Alcohol- Related Programs
Perhaps the best-known
example of a
The Depression brought a demand for increased employment and tax revenues and in 1933, after 13 years, Prohibition ended. By most accounts the policy of was a failure. Although Prohibition disrupted the manufacturing and distributive agencies through which alcohol had been legally supplied, the demand for it persisted. It can be said that the current system of alcohol regulation is a form of harm reduction policy replacing Prohibition. In the rest of the world, with the exception of some Muslim areas, no government has succeeded in eliminating alcohol use10.
A highly successful and widely accepted harm reduction initiative involves safe driving alternatives for intoxicated individuals. These programs are popularly known as designated driver campaigns. Most alcohol users are aware of these safe ride techniques and many cities offer free-ride-home programs (free taxicab rides), as well as free subway fare during holidays commonly involving over consumption of alcohol. According to the U.S. Department of Transportation, these initiatives have been very successful: since 1982, when these programs were first publicized, fatalities from drunk driving are down by 41%. A similar, although much less well accepted intervention known as “Contract for Life”, has also seen significant success. These agreements, originally promoted by Students Against Drunk Driving (SADD), have high school students sign a pledge to attempt to abstain from alcohol use, but to agree to call their parents if they are ever in a situation that threatens their safety. Their parents sign a pledge to provide transportation and defer discussion for a later, calmer time. However, many parents still express alarm about such contracts, claiming they send a message that underage drinking is acceptable11.
Controlled drinking as an alternative to abstinence for certain problem drinkers is reported as a viable option by some researchers. Controlled drinking research from various studies has shown that a certain percentage (usually reported to be around 18-20%) of alcoholic patients can successfully reduce their level of consumption to non-problematic levels. Furthermore, these alcoholics seemed to be at no greater risk for relapse than abstainers. However, moderation management with respect to alcoholism continues to invoke hostilities within the field of addiction medicine12. As binge-drinking morbidity and mortality remains a prominent issue on college campuses, moderation initiatives will likely continue to spark debate.
Tobacco use remains the leading
cause of preventable death and disease in the
From a public health standpoint, many of these PREPs are problematic, primarily because most of these products are completely unregulated. Tobacco companies are free to make claims about these products without independent scientific scrutiny. In the past, “light” cigarettes were marketed as being safer than regular cigarettes. However, we now know that there were no meaningful reductions in nicotine intake due to subtle design features (the cigarettes were designed to allow the smoker to inhale more deeply and thus negate the effects of a lower level of nicotine). Most researchers of tobacco addiction strongly believe that a regulatory agency like the Food and Drug Administration must evaluate all products if harm reduction initiatives are to succeed13.
In the case of chewing tobacco,
the health outcome differences are clearer.
Although smokeless tobacco is not risk-free, it does pose significantly
less risk than smoking. For example,
while smokers live roughly 6-7 years less than non-smokers, smokeless tobacco
users lose only .04 years (15 days) compared to nonsmokers. While smokeless tobacco increases the risk
for oral cancer, most studies show that smoking has an even higher risk. Most importantly, smokeless tobacco caries no
increased risk for lung cancer or heart disease. The best case study in support of smokeless
tobacco is in
D. Sex-Related Programs
The 1995 Youth Risk Survey found that 20.9% of high school males and 14.4% of high school females had had sex with 4 or more partners, yet only 54.4 % reported using condoms. Accordingly, approximately 3 million adolescents are infected with sexually transmitted diseases (STDs) each year, constituting 25% of new cases annually. One fourth of new HIV infections in the U.S. occur in those under age 22. Adolescents face many obstacles to using condoms, including access, cost, confidentiality, embarrassment and their perception that risk of infection and pregnancy is low14.
Recent increases in sexually transmitted diseases (STDs), including HIV, among teenagers in the United States have prompted communities to institute harm reduction programs to protect their youth. Among these have been sex education programs in schools that provide condoms to sexually active students. School condom availability as a public health policy is supported by many national health organizations, including the Institute of Medicine and the American Academy of Pediatrics. Comparison studies of high schools show an increase in condom use when condoms are made available in schools (50% compared to 37%). Additionally, studies have consistently shown no increase in sexual activity with this rise in condom use. Specifically, the World Health Organization review of studies on sexual education found that access to counseling and contraceptive services did not lead to earlier or increased sexual activity. This may in part be due to the fact that approximately 98% of school condom programs provide students with counseling, which includes abstinence information as well as safe sex discussions. Despite this data, many social conservatives oppose these initiatives on the premise that they undermine abstinence-only programs14.
Confidentiality and Adolescent Abortion
Approximately one million adolescents become pregnant each year in the U.S. and roughly 40% of these teens will choose an abortion. Many states require that parents of pregnant minors be notified before an abortion is performed. These laws were put into place because many parents feel they have a right to know about any significant health issues of their underage teens. However, adolescent pregnancy brought to term is associated with clear physical and mental health risks15. Because of these risks, many professional societies, including the American Medical Association, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists, oppose compulsory parental notification of teen abortions. They argue that if one service at a health clinic mandates parental notification then teens will be less likely to seek other services such as family planning. They feel this would lead to an actual increase in abortions, especially “back-alley” abortions. Likewise, such laws might discourage treatment of STDs, including HIV, which could also threaten lives16.
Government policies toward prostitution vary greatly around the world. In some Muslim countries prostitutes are given the death penalty, whereas in the Netherlands prostitutes are tax paying, unionized professionals. Prostitution is also legal in Australia, Germany, Switzerland and New Zealand, although most areas require licensing. In the U.S., regulated brothels are permitted in some counties in Nevada, but in the rest of the country prostitutes are considered criminals. Because of their criminal status, prostitutes are less likely to seek legal or medical help if they are harmed, making them prime targets for predators. Street prostitutes, as opposed to those in brothels or escort services, are at greatest risk of violent crime. Because the average American prostitute has 868 partners a year, they are often significant vectors in the spread of sexually transmitted diseases, including HIV. Many harm reduction advocates therefore recommend either registering prostitutes for required health checks or providing education to encourage barrier contraception and greater interaction with health care. In Australia, education campaigns have been very successful, with non-IV drug-using sex workers being among the lower HIV-risk communities there17. Criminalizing prostitution can make addressing these issues much more difficult.
There are many new applications of harm reduction philosophy related to public health that are just beginning to gain attention. DanceSafe is a national program aimed at reducing the health risks associated with adverse reactions to and overdoses of Ecstasy at so-called rave parties. This program provides free testing of pills purchased at these parties to ensure purity. Critics believe these programs only encourage drug use by making the drugs seem safer1. Unfortunately, data regarding effectiveness of this program is still lacking.
Another initiative that is gaining new popularity is harm reduction as an alternative to dieting. The current obesity epidemic, along with the dismal track record of standard diets, has made this approach more popular with many weight management counselors in recent years. Diet protocol often mandates severe changes in food quantity and content as well as stringent exercise programs. The vast majority of people are unable to adhere to this and end up gaining more weight in the long term. Harm reductionists believe in more realistic, attainable goals that focus on changing aspects of the patients’ lifestyle that they are most able to change. They feel this empowers the patient and therefore will result in better long-term outcomes. Similarly, to prevent the negative consequences of repeated weight loss and regain (yo-yo dieting), some advocates champion weight maintenance as opposed to weight losses as the goal of such weight management programs18.
Harm reduction focuses on what and how we provide information and support to those practicing risky behaviors in our community. Although currently associated predominantly with substance abuse, harm reduction strategies can be applied to many other public health matters, as detailed in this chapter. Because harm reduction policies avoid the huge barriers to public health associated with prohibition and abstinence, they may offer more effective and sustainable alternatives. Although they continue to spark debate, many harm reduction initiatives have clearly been successful at improving public health and we should expect them to continue to play an important role in shaping public health policy in the future.
1 Marlatt, G.A., Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors, The Guilford Press, July 2002.
5 Heimer, R., Catania, H., Newman, R., Zambrano, J., Brunet, R., Ortiz, A., “Methadone Maintenance in Prison: Evaluation of a Pilot Program in Puerto Rico,” December 2005. Available from www.ncbi.nlm.nih.gov
15 Flemming, G., O’Connor, K., “Adolescent Abortion: Views of the Membership of the American Academy of Pediatrics,” American Academy of Pediatrics, 91(3), March 1993.
16 Robinson B., “Parental Consent/Notification for Teen Abortions: The Pros and Cons of Compulsory Parental Involvement,” Ontario Consultants on Religious Tolerance, March 2006. Available from www.religioustolerance.org
17 Weitzer, R., “Prostitution Control in America: Rethinking Public Policy,” Crime, Law and Social Change, 32(1), pp. 83-102, March 1999.
Recommended Websites for More Information: