Accepting drug realities to save lives

Accepting drug realities to save lives

Dr. Alex Wodak, Director of Alcohol and Drug Service, St Vincent's
Hospital, Sydney, Australia, and President of The International Harm
Reduction Association. Joyce Djaelani Gordon Chairperson, Yayasan Kita
Addiction Treatment and Community Recovery Center, Cipayung, West Java,
Jakarta

Indonesia now faces a serious threat from HIV among its
rapidly increasing number of injecting drug users (IDUs). A
recent report from Monitoring the AIDS Pandemic (MAP) Network
notes a stark increase of HIV levels among Indonesian IDUs from
15 percent in 1999 to 40 percent in 2000, followed by an
equivalent increase of HIV levels among sex workers.

It will soon be followed by an increase of HIV among the
general population, including pregnant women, just like in
Thailand.

In 1987, HIV in Thailand grew from less than 1 percent to more
than 40 percent of IDUs in just 10 months. Within five to six
years in the northeast of Thailand, one in six male military
recruits and one in eight pregnant women had become infected.
Now, almost 2 percent of the Thai population is infected.

Similar epidemics have occurred in other parts of the world.
Yet countries which adopted harm reduction approaches such as
Australia, New Zealand and the Netherlands have managed to either
avoid these epidemics altogether or bring small epidemics quickly
back under control.

In contrast, countries that focused on eliminating illicit
drug use, such as the U.S., have not only failed to create drug-
free nations, but have also seen HIV spread rapidly among IDUs
and their general populations. More than a quarter of the 40,000
new HIV infections in the U.S. each year involves IDUs.

Harm reduction refers to policies and programs that primarily
aim to reduce complications of mood altering drugs; be healthy,
socially or economically. Most often, it is used to ensure that
HIV does not spread rapidly among the IDU communities, and from
them to the general population.

Harm reduction approaches started becoming established in the
developing world from early 1990s. Nepal, India, Bangladesh,
Vietnam and some other Asian countries have now established harm
reduction programs to control HIV among IDUs. The problem is that
they are not established fast enough to control the spread of
HIV.

As a pragmatic way to respond to illicit drug use, harm
reduction recognizes that we do not know how to ensure that IDUs
would stop injecting immediately. Some drug users do not want to
stop, while others badly want to, but are unable to.

Harm reduction deals with those who are unable or unwilling to
stop. It includes explicit education about the risks of sharing
needles and syringes, preferably with active involvement of drug
users in designing and implementing education campaigns.

Also, sterile needle and syringe utilization programs are
required to try and ensure that as many injecting episodes as
possible involve the use of sterile injecting equipment. Needle
and syringe exchange or distribution programs are at the center
of this work.

Drug treatment is required which is attractive, readily
available and based on evidence of effectiveness. While a diverse
range of options work best, methadone programs for heroin users
have been shown to be most effective in attracting and keeping
large numbers in treatment and slowing the spread of HIV.

Finally, community development among drug users is needed to
ensure that they become part of the solution rather than part of
the problem.

There are many parallels between a harm reduction approach to
injecting drug use and traditional public health responses to
many common health problems. Attempts to control sexually
transmitted infections cannot be based on efforts to achieve
total abstinence from sexual activity. That is unachievable.

Use of the term "harm reduction" and interest in the
philosophy increased substantially in the early 1980s, following
recognition of the AIDS epidemic and the realization that the
sharing of injection equipment was a major risk for the
transmission of HIV. When attempts to reduce risk episodes have
been pursued to their maximum, sensible public policy requires
that attempts are also made to reduce the hazardousness of each
remaining risk episode.

The defining characteristic of the major alternative approach
to harm reduction is an overriding emphasis on reducing or even
eliminating consumption. The level of adverse consequences then
becomes very much a secondary consideration. However, reducing
the consumption of drugs does not necessarily reduce harm and has
often inadvertently exacerbated it.

The well-intentioned closure of opium dens throughout Asia one
or two generations ago saw opium smoking in elderly men
disappear, only to be replaced by heroin injecting among young
and sexually active men. This has prepared the fertile soil for a
public health catastrophe of unimaginable proportions.

Some mistakenly regard harm reduction and abstinence as
mutually exclusive options. True, abstinence is the most complete
form of harm reduction, however, abstinence is often the least
feasible and sustainable option. Relapse is very common,
accompanied by increased risk of adverse outcomes.

The single-minded pursuit of abstinence can have serious
unintended negative consequences and exacerbate harm.

Attempts to reduce the demand or supply of drugs are not
incompatible with harm reduction, provided that the overriding
objective remains the reduction of harm, rather than the
reduction of consumption per se.

The way Indonesia responds to the threat of HIV infection
among IDUs will affect the health and well being of several
future generations.

If Indonesia responds by attempting to create a drug-free
nation, there will be many unnecessary deaths, much misery,
occupied hospital beds and extremely high social and economic
costs. A burden Indonesia can do without in the light of its
current economic and financial condition.

If Indonesia is to avoid such high costs, it must adopt harm
reduction strategies immediately. If we respond pragmatically,
acknowledging that injecting drug use cannot be eliminated, many
of the serious adverse effects of drug use can be minimized.

Dave Purchase, who founded the first needle syringe program in
the U.S., said "we may not be able to stop young people being
silly, but we can stop them being dead".