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Harm Reduction

INTRODUCTION

Harm reduction is an intervention designed to decrease the adverse health, social and economic consequences of engaging in drug or alcohol use without requiring abstinence (although abstinence can be one of the strategies) ¹. Harm reduction is distinctly different from addiction prevention as it is focused on the prevention of alcohol- or drug-related harm rather than the prevention of alcohol or drug (substance) use. Although few want to conclude that addiction prevention and treatment efforts have failed to eradicate substance abuse, proponents of the harm reduction model argue that pressing health, social, and economic harm associated with substances must be addressed, even if it means that individuals will continue to abuse alcohol and illicit drugs.

While the first modern harm reduction study dates back as far as 1971 with a study of needle sharing and the spread of hepatitis B among San Francisco drug users ², the spread of HIV/AIDS in the early 1980s was the true start of a sustained harm reduction effort. Today, blood borne infections and overdose deaths account for much of the health damage associated with drug use but there is a wide range of physical and mental health consequences, and accidents including those caused by impaired driving.

Harm reduction is a particularly common approach among at-risk populations such as offenders, injecting drug users, and sex workers. For more information on at-risk populations refer to the Special Populations section. (1) Source: Jackson, S. (November 2005) Overview of Current Health Promotion Approaches – presentation to Canadian Health Network, Regional Workshops September 2005, and Prevention Workshop, Centre for Health Promotion, University of Toronto. (2) Source: Howard J and Borges B (1971) Needle Sharing in the Haight: Some Social and Psychological Functions, Journal of Psychedelic Drugs, 4:71-80.

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A. Harm Reduction for Heroin Addiction

Harm reduction for heroin addiction reflects the harm caused by needle injection, a common method of administration for heroin. Needle sharing leads to the transmission of both blood borne-viruses (HIV/AIDS, hepatitis B, and hepatitis C) and bacterial infections which result in abscesses, cellulitis, endocarditis, and septicemia ¹.

(1) Source: Hunt N., Trace M., Bewley-Taylor D. (December 2004) Reducing drug related harms to health: an overview of the global evidence. Beckley Foundation, Report 4, pg. 3.

A.1. needle exchange programs

Needle exchanges are designed to provide injecting drug users with free, accessible sterile needles. Used needles are also removed from circulation with needle exchange programs. By promoting the free flow of clean needles, needle exchanges reduce the need for needle sharing. Harm reduction proponents also argue that regulations or law enforcement measures that restrict the flow of clean needles tends to increase needle sharing and, thus, the spread of disease and infection. Since sharing other injecting paraphernalia can also lead to infections, cookers, filters, and water for injecting are also typically included in an injection “kit.”

Needle exchange programs have also been found to facilitate entry into structured treatment for ‘hard-core’ users. One British study found that 40% of 722 injecting drug users sought help at a needle exchange program ¹.

While needle exchange programs have good evidence for reducing HIV infection ², the higher rates of hepatitis C virus among injecting drug users shows that additional measures are needed besides just needle exchanges. Also, needle exchange programs have had little impact on overdose deaths.

(1) Source: Carvell A M et al. (1990) Help-seeking and referrals in a needle exchange: a comprehensive service to injecting drug users, British Journal of Addiction. 85:235-240.

(2) Source: Gibson D R et al. (2001) Effectiveness of syringe exchange programs in reducing HIV risk behavior and HIV seroconversion among injecting drug users. AIDS, 15:1329-1341.

A.2. supervised injection sites

Supervised injection rooms have been defined as “protected places for the hygienic consumption of pre-obtained drugs in a non-judgemental environment and under the supervision of trained staff” ¹. Most supervised injection sites, such as the Insite program in Vancouver’s Downtown East Side, are located in areas where drug use in plain view of the public is common.

In Europe, supervised injection sites are known as consumption rooms.

(1) Source: Azkept (2000) Bundesverband and Carl von Ossietzky Universitat Oldenburg (Ed.) Guidelines for the Operation and Use of Consumption Rooms. Lektorat: W Schneider & H Stover, Materialism no. 4. Munster: Azkept.

A.3. methadone and other replacement therapies

Methadone and other replacement therapies are probably the most popular form of harm reduction for heroin addiction. Of these, methadone is the most common, while buprenorphine (under the trade names Subutux™ and Suboxone™ is becoming more available. Both are taken orally and remove the risk of needle-borne infection. Buprenorphine has been available in the United States since October 2002 ¹ and in Canada since December, 2007 ².

For more information on methadone see the Methadone section.

(1) Source: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs (2005) Treatment Improvement Protocol (TIP) 43, p. 25, DHHS Publication (SMA) 05-4048.

(2) Source: personal correspondence with Schering-Plough, distributor of buprenorphine in Canada.

A.4. prescribed heroin

While oral methadone is a common substitute for heroin, not all individuals addicted to heroin are willing or able to switch to a replacement therapy. Therefore, prescribed heroin is practiced in several European countries. In fact, the UK has been prescribing heroin to treat addiction since the 1920s. Currently, Canada is conducting limited trials using prescribed heroin. Some countries, such as Switzerland and the Netherlands, have conducted clinical trials using both injectable and smokeable heroin.

A.5. early warning systems

As with the production of any illicit drug, contaminants, adulterants, and dosing errors can occur. Heroin users are particularly susceptible to overdosing when batches of high-purity product are distributed within a community. Law enforcement, public health agencies, and community programs often cooperate in targeted media campaigns where the population of injecting drug users tends to reside. 

A.6. overdose prevention

Acute drug deaths (overdoses) occur mainly among young adults in their 20s or 30s with a history of injecting heroin use, and most are accidental overdoses. Polydrug (two or more drugs) use is very common and the combined use of central nervous system (CNS) depressants (i.e. alcohol) with heroin increases overdose risk. Training injection drug users in overdose prevention can help them reduce the occurrence of self-overdosing and can help them when they observe others who have overdosed ¹.

For more information on heroin, see the Heroin section.

(1) Source: Prevention of Overdoses (March 2006) European Monitoring Centre for Drugs and Dug Addiction.

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B. Harm Reduction for Alcohol Consumption

B.1. wet housing

Wet housing is social housing provided to individuals whose alcohol consumption is an ongoing problem for crisis response – ambulance, law enforcement, and hospitals – and the courts. By providing housing and supportive services, individuals with chronic alcohol addiction can begin the process of better living through medication monitoring, regular meals, and addiction treatment ¹.

While the service has been criticized as “enabling” continued consumption (residents are allowed to drink) and rewarding the alcoholic, there are now several sites in the US including 2 locations in Minnesota and 1 location in Seattle. In Toronto, CRC Self-Help provides wet and dry housing for the homeless in the Greater Toronto Area (GTA).

Source: Downtown Emergency Service Center article.

(1) Addiction treatment is optional.

B.2. designated driver programs

Designated driver programs are a form of harm reduction since the practice only discourages alcohol consumption by the driver while passengers are not required to monitor their drinking during an outing.  Organized designated driver programs often have a system in place to identify the designated driver (i.e. wristband) and provide the designated driver with drink tokens which can be exchanged for complimentary non-alcoholic beverages.

B.3. ride service programs

Ride service programs is an alternative to designated driver programs where community partners provide taxis, vans or private vehicles to individuals who call an advertised phone number. Some ride service programs are year-round while others are provided only during holidays such as New Years Eve.

B.4. moderation management

Moderation management is an approach to alcohol consumption that offers an alternative to abstinence for light to moderate drinkers.  Moderation approaches have been studied extensively since the early 1970s. One form of moderation-focused treatment, Behavioral Self-Control Training, has over 30 controlled trials testing its efficacy ¹. The rationale behind moderate drinking is that by allowing the client to set his/her own goal of abstinence or moderation, higher motivation is likely to occur. Moderate drinking, also known as controlled or responsible drinking, has been controversial to those who recommend abstinence as a necessary first step for anyone who is a problem drinker.

In addition, an alternative self-help group to Alcoholics Anonymous (AA) called Moderation Management (MM) has been in operation for many years, although with only a fraction of available meetings compared to AA.

(1) Source: Heather N, Brodie J, Wale S, Wilkinson G, Luce A, Webb E, McCarthy S. (2000), A randomized controlled trial of Moderation-Oriented Cue Exposure. J Stud Alcohol; 61:561-70.

B.5. impaired driver programs

Impaired driving is the operation of a motor vehicle while under the influence of drugs or alcohol. In British Columbia, alcohol is a contributing factor in a quarter of all motor vehicle fatal collisions ¹.

Law enforcement test drivers suspected of impaired driving by use of a breathalyzer or road tests designed to test coordination. The legal limit of alcohol consumption is measure by Blood Alcohol Content (BAC) which varies from province-to-province but is typically 0.08 percent (or 0.08 grams of alcohol per 100 grams of blood). Drivers convicted of impaired driving face license suspension, fines, vehicle impoundment, mandatory installation of ignition interlock devices, or incarceration.

Impaired driver programs are an additional requirement for drivers convicted of multiple impaired driving offenses. However, some states with stiffer penalties may require impaired driver program participation for first-time offenders. These programs typically involve a series of counselling sessions that drivers must attend before their license can be reinstated.

(1) Source: Impaired Drivers – Drinking and Driving Fact Sheet (November 2007) BC Centre for Social Responsibility.

B.6. safe bar programs

Bars and restaurants that serve alcohol can participate in harm reduction efforts by taking steps to reduce the incidence of intoxication among its patrons. These initiatives will reduce alcohol-related injuries and assaults in these licensed premises as well as help the community reduce injuries and deaths associated with impaired driving.

Server-training programs helps managers and servers be more proactive in preventing patrons from reaching the point of intoxication or serving a patron who is underage. Violence-prevention programs help restaurant or bar owners minimize the risk of violence by addressing environmental factors such as an establishment’s physical layout, behavior of servers and security staff, and closing time.

Source: Reducing Alcohol-Related Harm in Canada: Toward a Culture of Moderation (April 2007) National Alcohol Strategy Working Group.

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C. Harm Reduction for Other Drugs

Several interventions have been developed to prevent the incidence of overdose and poisoning of other drugs.

C.1. early warning systems

When illicit drugs are manufactured, it is almost impossible to determine if they are safe to consume. Drugs are often contaminated or adulterated, or have dosing errors of high purity, causing potential harm, even death, to the consumer.

There are a variety of early warning systems ¹ which are targeted media campaigns delivered by governmental health and social care providers that alert drug users of contaminated, adulterated, or dangerous dosages.

C.2. pill testing for ecstasy and other hallucinogens

Pill testing is a growing trend in clubs and festivals where ecstasy (MDMA) is used. Pills sold as ecstasy often include other substances such as methamphetamine, ketamine, and PMA. Websites also provide detailed information warning the public about dangerous batches of pills. Pill testing often tracks closely related substances such as MDA, MDEA, and MBDB.

For more information on ecstasy see the Ecstasy section.

(1) Source: Griffiths P et al. (2000) Drug information systems, early warning and new drug trends: Can drug monitoring systems become more sensitive to emerging trends in drug consumption? Substance Use and Misuse. 35:811-844.

C.3. crack pipe exchanges

Crack pipes are another way that viruses (HIV/AIDS, hepatitis C) and bacterial infections are transmitted between individuals who use drugs. Crack pipe exchanges are primarily designed to reduce crack pipe sharing and remove crack pipes that are unsafe. A safer crack pipe includes:

  • A plastic mouthpiece (to prevent disease-spreading lip burns)
  • Shatterproof glass (to prevent disease-spreading cuts)
  • Metal screens (instead of steel wool that can be inhaled)

 

Crack pipe kits also may include condoms since unprotected sex is another way that blood-borne viruses are spread by crack smokers. Crack pipe exchanges are quite common in Canada, although controversy continues to swirl around the policy, particularly in the city of Ottawa.

For more information on crack cocaine see the Cocaine section.

C.4. nicotine replacement therapies

While many may question whether nicotine replacement therapies is a harm reduction approach, research concludes that tobacco use is the leading preventable cause of death in the United States ¹ and Canada ².  Nicotine replacement therapies include replacement products which help relieve some of the withdrawal symptoms experienced when people quit smoking.

Over the counter (OTC) products include nicotine patches, gum, and lozenges. Nicotine nasal sprays, and inhalers (Zyban) are only available with a prescription. According to Health Canada, combining behavioral counseling with nicotine replacement products doubles the chance of success ³.

(1) Women and Smoking: A Report of the Surgeon General. (September 2006) U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

(2) Makomaski Illing EM, Kaiserman MJ. Mortality attributable to tobacco use in Canada and its regions, 1991. Can J Public Health 1995;86(4):257-65.

(3) Health Canada website – Quit Smoking Aids.

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D. Other Harm Reduction Approaches

Other harm reduction approaches include those that are not targeted at the harm associated with one particular drug but, rather, at the community level such as:

D.1. Information, Education, and Communication

Information, education, and communication campaigns can be either mass media or targeted. Media campaigns can convey the risk of blood-borne infections or overdose to injecting drug users, the risk of heatstroke to club drug users, and the risk of injury due to impaired driving.

For more information on mass and targeted media campaigns see the Universal Preventions page in the Addiction Prevention section.

D.2. Community-Based Outreach

Many individuals do not participate in conventional addict treatment or prevention, as well as medical, mental health or social services. This is particularly true among homeless populations within our inner cities where addiction is often complicated by mental illness, and social stigma. Community outreach is a way to bring services to the areas where they are most needed such as the streets, housing projects, emergency rooms, Laundromats, and parks. Services are typically delivered by people that the alcohol or drug user can trust, including people in recovery. Community outreach can be a vital first step in linking drug and alcohol users with services ¹.
 
According to the World Health Organization ², “Outreach is an effective strategy for reaching hard-to-reach, hidden populations of injecting drug users (IDUs) and provides the means for enabling IDUs to reduce their risk behaviors; a significant proportion of IDUs receiving outreach based interventions reduce their risk behaviors drug using, needle and sexual practices and increase their protective behaviors; changes in behaviors have been found to be associated with lower rates of HIV infection.”

(1) Source: A Comprehensive Approach: Preventing Blood-borne Pathogen Infection Among Injection Drug Users (December 2001) Appendix A: Key Strategies for Preventing Blood-borned Pathogen Infection Among Injection Drug Users. Center for Disease Control (CDC).

(2) Source: Evidence for Action: Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users.(2004) World Health Organization (WHO).

Source: Reducing drug-related harms to health: an overview of the global evidence (2003) Neil Hunt, Mike Trace, and Dave Bewley-Taylor. Beckley Foundation.

D.3. Drug Courts

Drug courts (also known as drug diversion courts) are important interventions that seek to reduce crime as a particular harm associated with drug use. Drug courts represent the coordinated efforts of the judiciary, prosecution, defense bar, probation, law enforcement, mental health, social service, and treatment communities to actively and forcefully intervene and break the cycle of substance abuse, addiction, and crime. As an alternative to less effective interventions, drug courts quickly identify substance abusing offenders and place them under strict court monitoring and community supervision, coupled with effective, long-term treatment services ¹.

As of April 2007, there were 1,699 drug courts operating in the United States, and 349 more were in the planning phases. Currently, 50 states plus the District of Columbia, Northern Mariana Islands, Puerto Rico, Guam, two Federal Districts and 121 tribal programs have drug courts that are in operation or are being planned ². Canada’s first drug court opened in Toronto in 1998 and has since expanded to Vancouver, Edmonton, Regina, Winnipeg, and Ottawa ³.

To be an eligible candidate for drug court the offence must not be a sexual offence or an offence involving the infliction of bodily harm 4.

(1) Source: National Drug Court Institute
(2) Source: American University Justice Programs Office
(3) Source: Expanding Drug Treatment Courts in Canada
(4) Note: Eligibility criteria varies by country, state, or province.

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E. RESOURCES

E. I. PRINTED RESOURCES

General Reading on Harm Reduction

Care of Drugs Users in General Practice: A Harm Reduction Approach: 2nd Edition (2004) examines a GP’s role: past, present, and future and general health care for the drug user. Provides first-hand knowledge from contributors working the field and is essential reading for general practitioners, practice nurses, health visitors, etc. By Berry Beaumont.

Harm Reduction: National and International Perspectives (2000) provides national and international perspectives on innovative harm reduction programs and policies. James A. Inciardi, Lana D. Harrision, Editors.

Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors (1998) explains the model’s rationale and examines a range of applications in diverse communities. Provides information for front-line drug and alcohol treatment providers, AIDS educators, and community health activists. G. Alan Marlatt.

Printed Resources – Designated Driver Programs and Harm Reduction

Elder, J., et al. (2005) Effectiveness of School-Based Programs for Reducing Drinking and Driving and Riding with Drinking Drivers: A Systematic Review. American Journal of Preventive Medicine, Supplement 1, 28(5): 288-304.

Printed Resources – Moderation Management and Harm Reduction

Controlled Drinking (1981) is one of the first scholarly reviews of the literature on controlled drinking treatments. Nick Heather, Ian Robertson. 

Controlling Your Drinking: Tools to Make Moderation Work for You (1990) is a self-help book for early stage problem drinkers who want to control their use of alcohol and avoid more serious drinking problems. William R. Miller, Ricardo F. Munoz.

Moderate Drinking: The New Option for Problem Drinkers (1994) is a book written by the founder of the self-help group Moderation Management (MM).  Audrey Kishline.

Over the Influence: The Harm Reduction Guide for Managing Drugs and Alcohol (2003) provides a guide to harm reduction therapy, which calls for identifying and managing the underlying problem while maintaining an “acceptable” or functional level of substance use.  Patt Denning, Jeannie Little, Adina Glickman.

Responsible Drinking: A Moderation Management Approach for Problem Drinkers (2002) helps readers define the level of their alcohol use and decide whether moderation or abstinence is the best approach to recovery. Frederick Rotgers, Marc F. Kern, Rudy Hoeltzel.

Saying When: How to Quit Drinking or Cut Down (1994) is a step-by-step workbook for people to overcome drinking problems. Martha Sanchez-Craig, Addiction Research Foundation (ARF).

A Therapist’s Manual for Secondary Prevention of Alcohol Problems (1984) is procedures for teaching moderate drinking and abstinence. Martha Sanchez-Craig

Printed Resources – Special Populations and Harm Reduction

Harm Reduction in Prison: Strategies Against Drugs, AIDS and Risk Behaviour (1997) Joachim Nelles

For more information on special populations see the Special Populations section.

Printed Resources – Treatment and Harm Reduction

For more information on harm reduction as a treatment see the Harm Reduction section in Social Treatment Modalities.

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E. II. ONLINE RESOURCES

Websites Specific to Harm Reduction

The Canadian Harm Reduction Network
HAMS – Harm Reduction for Alcohol
International Harm Reduction Association
Vancouver Area Network of Drug Users
The UK Harm Reduction Alliance
Youth R.I.S.E.

Online Resources – General Information on Harm Reduction

Reducing Drug Related Harms to Health: An Overview of the Global Evidence (December 2004) aims to assemble and disseminate material that supports the rational consideration of complex drug issues. Neil Hunt, Mike Trace, Dave Bewley-Taylor, Beckley Foundation Drug Policy Programme (UK).

Toward a Psychology of Harm Reduction (November 1998) Robert J. MacCoun, University of California, Berkeley. American Psychologist, 1199-1208.

What do we mean by “Harm Reduction,” and how does it relate to our Unitarian values? Unitarian Universalists for Drug Policy Reform Canada.

Online Resources – Crack Pipe Exchange Programs and Harm Reduction

New Vancouver Program Gives Crack Pipes to Addicts (November 2004) details the new harm reduction effort to individuals addicted to crack cocaine. Join Together.

Online Resources – Designated Driver Programs and Harm Reduction

designateddriver.com – Anheuser-Busch
Designated Driver Program Starts in Saskatchewan (May 1995) Government of Saskatchewan.
Effect of Designated Driver Programs Questioned (May 2005) is a summary on research conducted on the effectiveness of designated driver programs to reduce drunk driving. Join Together.
Has the Designated Driver Program Been Effective?(October 2007) is an article written by DUI attorneys. Straight DUI.

Online Resources – Drug Consumption Rooms and Harm Reduction

Drug consumption rooms is the term used in Europe for sanctioned areas for drug consumption, most typically for the safe injection of heroin.

See the Supervised Injection Facilities section below.

Online Resources – Drug Courts and Harm Reduction

Drug Courts is general information provided by the Office of National Drug Control Policy (US).

Drug Treatment Courts FAQs (March 2007) provides current information to guide the discussion on relevant issues relating to the effectiveness of drug treatment courts in Canada. Canadian Centre on Substance Abuse (CCSA).

International Association of Drug Treatment Courts acts as a “clearing house” for jurisdictions outside the US that are considering starting their own DTCs, and require information and/or training. Also provides a resource to member courts about the latest developments in the field.

National Association of Drug Court Professionals

National Drug Court Institute (US)

Treatment Drug Courts: Integrating Substance Abuse Treatment with Legal Case Processing (1996) focuses on the integration of substance abuse treatment with criminal justice systems operations during the pretrial stages of criminal cases. Treatment Improvement Protocol (TIP) 23. Substance Abuse and Mental Health Services Administration (SAMHSA). DHHS Publication No. 96-3113.

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Online Resources – Drug Policy and Harm Reduction

For more information on harm reduction as a drug policy see the Harm Reduction section in drug policy.

Online Resources – Early Warning Systems and Harm Reduction

Early Warning System is a service provided by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), and the largest service of its kind.

Early Warning System on Drugs at Public Health Level in Belgium (November 2002) Edith Leus, Denise Walckiers, Epidemiology Unit, Scentific Institute on Public Health.

It’s time for Canadian community early warning systems for illicit drug overdoses (March 2007) outlines considerations and conceptual elements required to guide implementation of such systems in Canadian cities such as Vancouver. Sarah J Fielden, David C. Marsh. Institute of Health Promotion Research, University of British Columbia.

Online Resources – Heroin Use and Harm Reduction

For more information on heroin addiction see the Heroin section.

For more information on heroin-related harm see the Injection Drug Users section of Special Populations.

Online Resources – Impaired Driver Programs and Harm Reduction

Best Practices: Treatment and Rehabilitation for Driving While Impaired Offenders (2004) brings together current knowledge on the planning and delivery of driving while impaired (DWI) remedial programs (i.e. education programs and treatment and rehabilitation programs). Health Canada. Cat. H46-2/04-321E.

Young Adult Drinking (April 2006) Alcohol Alert, No. 68, National Institute on Alcohol Abuse and Alcoholism.

For more information see the Impaired Driving section in Alcohol section.

Online Resources – Methadone and Other Replacement Therapies and Harm Reduction

Methadone maintenance therapy is a biomedical modality that allows injection drug users to replace their drug of choice, heroin, with methadone. While still an opiate, methadone does not have the same euphoric effect as heroin, allowing MMT recipients to function at a level that allows for work, rest, and play.

For more information on methadone see the Methadone section.

Online Resources – Moderation Management and Harm Reduction

Moderation Management Flap Sparks Resignation (July 2000) is an article documenting the resignation of Dr. Alex DeLuca from Smithers Addiction Treatment and Research Center at St. Luke’s-Roosevelt Hospital Center in New York. Join Together.

Moderation Management: A Physicians Perspective (August 2001) was presented at the 109th Convention of the American Psychological Association. Alexander DeLuca, MD.

Research and Moderation Management (MM) (August 2001) was presented at the 109th Convention of the American Psychological Association. Frederick Rotgers, Jamieson Beals.

What is Moderation Management? Is a question-and-answer section by the self-help group, Moderation Management (MM).

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Online Resources – Needle Exchange Programs (NEPs) and Harm Reduction

Needle exchanges is one of several approaches designed at reducing the harm of injection drug use on our streets.

Assessing the Need for Prison-Based Needle Exchange Programs in Canada: A Situational Analysis (December 2005) presents a situational analysis of current trends in prison drug use, the prevalence of HIV/AIDS and HCV in prisoner populations and other information relevant to assessing the need for prison-based needle exchange programs in Canada. Canadian Centre on Substance Abuse (CCSA).

Evaluation of the AFM’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) (July 2005) Addiction Foundation of Manitoba (AFM).

Improving Our Health: Why is Canada Lagging Behind in Establishing Needle Exchange Programs in Prisons? (October 2004) proposes solutions that – if carried out by governmental and correctional institution – would contribute significantly to the prevention of HIV and other bloodborne pathogens in the prison system as well as to the community at large. Ontario Medical Association. ISBN 0-919047-47-5.

Needle Exchange Facts (June 2001) explains that needle exchanges can save lives and does not encourage drug use. AIDS Action.

Needle Exchange Programs FAQs (2005) is intended to provide current, objective, and empirically-based information to guide the discussion on the use of NEPs in Canada. Canadian Centre on Substance Abuse (CCSA).

The NIDA Community-Based Outreach Model: A Manual to Reduce the Risk of HIV and Other Blood-Borne Infections in Drug Users (September 2000) National Institute on Drug Abuse (NIDA) NIH Publication 00-4812.

Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience(2004) encourages prison systems with HIV and HCV epidemics driven by injection drug use to implement needle exchange programs. Examines the international evidence current to March 2004. Canadian HIV/AIDS Legal Network.. ISBN 1-896735-52-5.

Reducing the Harm Associated with Injection Drug Use(2001) is a framework for multi-level strategies and action plans to reduce the harm associated with injection drug use in Canada. Health Canada. Cat. No. H39-589/2001E.

Spreading the light of science – Guidelines on harm reduction related to injecting drug use (2003) details the rationale for harm reduction approaches regarding injecting drug use.International Federation of Red Cross and Red Crescent Societies.

Syringe Disinfection for Injection Drug Users (July 2004) explains that bleach disinfection started out in California in the 1980s due to laws that made it illegal for drug users to buy syringes and a crime to possess them. The distinction between a sterile and disinfected syringe is made so that people understand that disinfected syringes can still carry blood-borne infections. Center for Disease Control.

Syringe Exchange Programs(December 2005) documents the legislative roadblocks that have prevented the growth of syringe exchange programs in the United States. Center for Disease Control (CDC).

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Online Resources – Nicotine Replacement Therapies

Introducing oral tobacco for tobacco harm reduction: what are the main obstacles?(November 2007) Yves Martinet, Abraham Bohadana, Karl Fagerstrom, Harm Reduction Journal, 4:17.

Nicotine replacement therapy for quitting tobacco (August 2007) BC Health Guide.

Nicotine Replacement Therapy and Other Medications Which Aid Smoking Cessation (July 2006) American Lung Association.

Quit Smoking Aids (January 2008) Health Canada.

Online Resources – Pill Testing and Harm Reduction

DanceSafe has an adulterant screening program for ecstasy.

ecstasydata.org provides access to lab testing results for street ecstasy tablets.

On-site ecstasy pill testing – a consideration of the issues from a policing perspective (September 2006) Roger Nicholas, Australasian Centre for Policing Research

pillreports.com is a global ecstasy test results database based on both subjective user reports and scientific analysis.

Online Resources – Prescribed Heroin and Harm Reduction

North America’s first clinical trial of prescribed heroin begins today (February 2005) reports on the opening of the North American Opiate Medication Initiative (NAOMI), the first clinical trial of prescribed heroin for people with chronic heroin addiction who have not been helped by other options. Canadian Institute of Health Research.

Online Resources – Research and Harm Reduction

For information on harm reduction research see the Harm Reduction section of Addiction Research.

Online Resources – Ride Service Programs and Harm Reduction

Alternative Transportation Strategies to Prevent Alcohol Impaired Driving (October 2007) Police Notebook, University of Oklahoma Police Department.

Online Resources – Supervised Injection Sites and Harm Reduction

Drug consumption rooms (2004) assumes that if problem drug users are provided with safe private environments within which to administer drugs there will be a reduction in unsafe drug use. Marcus Roberts, Axel Klein, Mike Trace. Drug Scope and the Beckley Foundation.

I-Track: Enhanced Surveillance of Risk Behaviours among People who Inject Drugs Phase 1 Report (August 2006) describes changing patterns of drug injecting practices, HIV- and HCV-testing behaviours, and sexual behaviours among injection drug users. Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Public Health Agency of Canada. ISBN 0-662-43991-0.

The Report of the Independent Working Group on Drug Consumption Rooms (2006) provides a detailed examination of whether drug consumption rooms should be introduced in the UK. Joseph Rowntree Foundation. ISBN-13:978-1-85935-470-4.

Summary of findings from the evaluation of a pilot medically supervised safer injecting facility  (November 2006) summarizes the findings from a scientific evaluation of the impact of medically-supervised safe injection sites. Canadian Medical Association Journal (CMAJ).

Supervised Injection Facilities (SIFs) FAQs (2005) is intended to provide current, objective, and empirically-based information to guide the discussion around the use of SIFs in Canada. Canadian Centre on Substance Abuse (CCSA).

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Online Resources – Wet Housing and Harm Reduction

Can Shelter Services and Administering Alcohol Help the Homeless with Alcohol Dependence? (April 2006) reviews a Canadian program that does not require abstinence. Join Together.

Downtown Emergency Service Center is supportive housing located in downtown Seattle, Washington.

Housing for People with Alcohol and Drug Addictions: An Annotated Bibliography (January 2001) was a study conducted by the City of Vancouver to address the need for a continuum of housing services for people with addictions, including wet housing. Deborah Kraus.

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E. III. VIDEO RESOURCES

General Information on Harm Reduction

Generation E is a documentary that interviews activists and health workers who describe the philosophy and practice behind the risk prevention strategy known as harm reduction.

Harm Reduction (2003) is a video that discusses various harm reduction techniques that include Nicorette ™ gum, telling kids to stay at their friends after they drink, etc. Stanton Peele also asserts that the use of harm reduction in other countries has greatly reduced the problems associated with drug use (clean needle programs) such as the spread of HIV/AIDS. Stanton Peele.

Harm Reduction and Civil Society (March 2007) is an interview with staff Dr. Kerry Kung at the Harm Reduction and Civil Society forum.

What is Harm Reduction? (2007) is an interview with Allan Clear, Executive Director of the New York-based Harm Reduction Coalition.

Video Resources – Needle Exchange Programs and Harm Reduction

Needle Exchange in Prisons is produced by a Ryerson College student recommending that Toronto jails implement a needle exchange program.

Video Resources – Supervised Injection Sites and Harm Reductions

Insite is Vancouver’s Safe Injection site.

Video Resources – Wet Housing and Harm Reduction

Harm Reduction in Seattle is a report on a controversial program in Seattle that houses the city’s hardcore alcoholics. CNN

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