Harm+Reduction+,+Injecting+Drug+Use+&+Risk+Environments

Jason Joiner Student Number: 08566828 Tutor: Michelle Cornford



__** Cultural Artefact **__

This photo represents what one might typically see if they decided to access the services of a needle and syringe exchange, which provides access to sterile syringes and other injecting related equipment such as swabs and a sharps container. Services such as these come under public health initiatives under the umbrella of harm minimization.

__** Public Health Issue **__

Needle exchange programs are one of the primary harm reduction measures which aim to stop the spread of blood borne viruses such as HIV and Hepatitis C among intravenous drug users. Injecting drug users remain a key population in global health, accounting for many blood borne related infections worldwide. This is in addition to the numerous financial, social and public health burdens associated with overdose and drug dependence, leading to the acknowledgement by some who believe an important determinant affecting HIV and HCV transmission and prevention involve ‘risk environments’ where social or physical factors may combine to increase ones risk to drug related harm.

__** Literature Review **__

The term ‘harm reduction’ is one which often evokes varying emotional responses within the world of drug policy. Those who are conservative tremble under the belief that traditional values and the war to control drugs will be undermined. Supporters of drug legalisation envision chances for radical law reform; while somewhere in the midst, service providers and advocates within the community cling to the hope of more realistic interventions based upon evidence (Ball, 2007).One could say that these emotions are roused thanks in part to the lack of a clear definition, made more difficult by a compelling discourse that at times has created more displeasure than delight.

The International Harm Reduction Association’s website defines harm reduction as referring to policies, programs and practices that aim to reduce the adverse health, social and economic consequences’ regarding the use of both legal and illegal forms of drugs, without necessarily reducing consumption (Harm Reduction International, 2012). This has encompassed the provision of sterile injecting equipment, outreach programs, substitution therapies and the establishment of supervised injecting facilities (Duff, 2010). While recognising differences in terminology exist, this paper will primarily focus on reviewing select literature relating to various views towards the harm reduction approach, within the context of injecting drug use.

In many parts of the world, the spread of blood-borne viruses (BBVs) such as the human immunodeficiency virus (HIV) and hepatitis C (HCV) have been driven by injecting drug use. According to a 2010 report by the United Nations Office of Drugs and Crime (UNDOC), estimations of global drug use for 2008 alone was in the vicinity of 155 to 250 million people. Furthermore, latest population estimates suggested that up to 21 million of these were injecting drug users, with the highest proportion of injectors living in China, the USA and Russia. Of the 158 countries and territories documented, 76 hand no syringe exchanges. Those who inject drugs remain a key population in global health, accounting for around 3 million HIV infections and 10 million HCV infections. This is in addition to the numerous financial, social and public health burdens associated with overdose and drug dependence (Harm Reduction International, 2012).

This has led to the acknowledgement by some who believe that one of the crucial determinants affecting HIV and HCV transmission and prevention involve ‘risk environments’ whereby a variety of social or physical factors may combine, ultimately increasing an person’s risk to drug related harm (Rhodes, 2009;Rhodes, Singer, Burgois, Friedman, & Strathdee, 2005;Rhodes, 2002; Friedman & Reid, 2002).

In his work, Rhodes (2009) looks upon the array of social situations and areas where harm is created and minimised, describing two aspects of risk environments. These aspects include an environmental classification which incorporates physical, social, economic and policy spheres, while secondly relating to measures of environmental influence, using an array of factors at the macro and micro level. Duff (2010) notes that these two aspects underline the ways in which drug related harms are structurally determined in particular situations such as the impact of poverty, reforms in policy, changes economically or variations in the labour market; similar to how they are brought about through influences at the micro level such as low level of education, social rules and group norms.

Furthermore, Duff (2010) argues that in order for public policy makers and social planners to deliver further ground breaking policies and programs regarding harm reduction, it is essential to look beyond the everyday methods of harm reduction approaches like needle and syringe programs, to that of ‘enabling places’ and ‘enabling resources’. Additionally he implores those to see harm reduction as more than a mere tool for supplying drug users with the necessary resources to minimize individual harm, instead claiming the need to utilize the array of material, social and affective resources throughout the complex locations, in which the use of drugs can occur (Duff, 2010).

Many, who advocate for harm reduction claim to adopt value neutral approach towards drug use and drug users, with some critics seeing this as a major advantage of harm reduction in an area which is otherwise, highly moralised (Pates & Riley, 2012).Furthermore, others suggest that this approach is a necessary tactic in order to accomplish its objectives within prohibitionist policy settings (Keane, 2003). Kleinig (2008) makes the argument however that this claim of moral neutrality is improbable for a number of reasons. His first argument suggests that harm reduction inevitably makes ethical assumptions in recognising harms and within its core principle which suggests that limiting drug related harms experienced by individuals is a worthwhile social goal. Additionally, he argues about ethical issues regarding who decides which harms are more important in setting drug policies but also questions where should ethical priorities relating to different drug related harms be that, in the context of a liberal diverse society is often resolved by means of social and political debates (Kleinig, 2008).

In contrast, Fry and colleagues (2006) argue that this general lack of orientation towards ethics in harm reduction and more specifically the lack of attention to these types of ethical hurdles signify a problematic area which may ultimately increase the possibility of ethical breaches, otherwise seen as preventable, but also damage quality of research, funding and public acceptance.

While critics of harm minimisation approaches may argue that such programs like needle and syringe programs promote drug use, send mixed messages or fails to get people off drugs, the evidence of the associated benefits of a harm reduction approach towards reducing drug related morbidity and mortality has increased substantially over the last two decades (Irwin & Fry, 2007; Wodak & Cooney, 2006). Furthermore many have failed to find evidence that such programs affect either frequency of injecting, recruitment to injecting or increased needle sharing. Other bodies of international research such as Cochrane reviews seem to support this argument also (Ritter, King & Hamilton, 2013).

__** Cultural and Social Analysis **__

Research on illicit drug use has largely been guided by an array of sociological and criminological theoretical approaches. One of the earliest and most influential relates to the social disorganization perspective which was conceived during the 1920s and made popular by scholars such as Clifford Shaw, Henry McKay, Robert Park and Ernest Burgess. It looks into the social environment in which substance use occurs, fluctuates, persists or desists. Additionally it examines how particular physical conditions promote moral decay or issues relating to value adjustment, which in turn leads to substance abuse and deviancy.

According to Shaw (2002) this disorganization often occurs when a particular society undergoes major change within a short period of time, either through reform, industrialization, urbanization or modernization. The author notes two particular dimensions in which it may occur. Firstly, within the material dimension, this includes areas such as urban slums and rundown housing. Secondly, it may occur in the non-material dimension whereby social disorganization often solicits varied emotional states like panic, moral confusion, depression and mental illness. These 2 areas reinforce one another as those in misery find little support in this environment, ultimately providing the conditions for substance use to start and continue.

Evidence from industrialised countries highlights how structural factors associated with neighbourhood disadvantage and urban development can influence vulnerability to HIV and HCV, particularly within disadvantaged populations. In his work, Rhodes (2005) notes that poverty and deprivation are key structural factors which impact on HIV transmission through injecting drug use in both poorer nations and those who are more industrialised.

Social networks may also influence pathways into drug injecting and associated patterns of risky injecting behaviour. These injecting consequences are often shaped by shared societal and group norms and social drug networks (Laitkin, Forman, Knowlton & Sherman, 2003). In addition to social suffering, the social and economic marginalisation of particular intravenous drug populations may support unhealthy social bonds within drug networks, ultimately leading to increased encouragement towards use (Rhodes, 2005). Furthermore, environmental factors relating to changes in policing practices and drug policy may also have an effect, leading to disruption within the structure and subsequent risk and associative patterns within injecting drug networks, ultimately creating new pathways for HIV spread (Rhodes, 2005). As a consequence the ‘war on drugs’ as a source of social disruption within such minority communities may play a significant part in increased HIV and HCV risk among intravenous drug users.

Currently those most successful in controlling or avoiding HIV related epidemics among injecting populations have kept in line with the principles of effective public health endorsed by the World Health Organization. Future prevention to a large degree is subject to the extent in which environmental change interventions are endorsed, with harm reduction being ingrained within programmes in order to alleviate the social and economic disparities within these marginalised populations (Rhodes, 2005; Ball, 2007).

__** Analysis Of Artefact and Reflection **__

Our society has interesting ways of thinking about what is considered to be acceptable and unacceptable drug use. Unfortunately it seems that ignorance is still all too common in some parts of the world, especially when it comes down to discussions relating to drug policy, when it seems all to conclusive from current available evidence that harm reduction methods such as needle exchanges are effective in preventing the spread of blood borne viruses, while at the same time improving the lives of those who make the decision to use drugs intravenously. Coming from the GLBT community where the evidence points to a higher prevalence of illicit drug use among us, the adoption of such approaches in my mind has no doubt reduced the spread of HIV, particularly among gay men. I realise that the issue is very complex however I now understand the importance of the harm reduction approach towards improved public health outcomes.


 *  __References__ **

Ball, A. L. (2007). HIV, injecting drug use and harm reduction: A public health response. Addiction, 102(5), 684-684. doi:10.1111/j.1360-0443.2007.01761.x

Duff, C. (2010). Enabling places and enabling resources: New directions for harm reduction research and practice. Drug and Alcohol Review, 29(3), 337. doi: 10.1111/j.1465-3362.2010.00187.x

Friedman, S. R., & Reid, G.. (2002). The need for dialectical models as shown in the response to the HIV/AIDS epidemic. International Journal of Sociology and Social Policy, 22(4/5/6), 177-200. doi:10.1108/01443330210790067

Fry, C. L., Madden, A., Brogan, D., & Loff, B. (2006). Australian resources for ethical participatory processes in public health research. Journal of Medical Ethics, 32(3), 186-186. doi:10.1136/jme.2005.013243

Harm Reduction International, (2012). The Global State of Harm Reduction 2012 Retrieved October 1, 2013, from http://www.ihra.net/files/2012/07/24/GlobalState2012_Web.pdf

Irwin, K. S., & Fry, C. L. (2007). Strengthening drug policy and practice through ethics engagement: An old challenge for a new harm reduction. International Journal of Drug Policy,18(2), 75-83. doi:10.1016/j.drugpo.2006.12.002

Keane, H. (2003). Critiques of harm reduction, morality and the promise of human rights. International Journal of Drug Policy,14(3), 227-232. doi:10.1016/S0955-3959(02)00151-2

Kleinig, John (2008). "The ethics of harm reduction". Substance use & misuse, 43 (1), p. 1. doi:10.1080/10826080701690680

Latkin, C. A., Forman, V., Knowlton, A., & Sherman, S. (2003). Norms, social networks, and HIV-related risk behaviors among urban disadvantaged drug users. Social Science & Medicine (1982), 56(3), 465-476. doi:10.1016/S0277-9536(02)00047-3

Pates, R., & Riley, D. M. (2012). Harm reduction in substance use and high-risk behaviour: International policy and practice. Chichester, West Sussex: Wiley-Blackwell.

Ritter, A., King, T., & Hamilton, M. (2013). Drug use in Australian society. South Melbourne, Vic: Oxford University Press.

Rhodes, T. (2002). The 'risk environment': A framework for understanding and reducing drug-related harm. International Journal of Drug Policy, 13(2), 85-94. doi:10.1016/S0955-3959(02)00007-5

Rhodes, T. (2009). Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy, 20(3), 193-201. doi:10.1016/j.drugpo.2008.10.003

Rhodes, T., Singer, M., Bourgois, P., Friedman, S. R., & Strathdee, S. A. (2005). The social structural production of HIV risk among injecting drug users. Social Science & Medicine,61(5), 1026-1044. doi:10.1016/j.socscimed.2004.12.024

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">United Nations Office of Drugs and Crime, (2010). World Drug Report 2010 Retrieved October 5, 2013 from http://www.unodc.org/documents/wdr/WDR_2010/World_Drug_Report_2010_lo-res.pdf

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Wodak, A., & Cooney, A. (2006). Effectiveness of sterile needle and syringe programmes. International Journal of Drug Policy,16(supp 1), 31-44. doi:10.1016/j.drugpo.2005.02.004


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Reflection **

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