Harm+minimisation+-+an+oxymoron?


 * //Brad Beauchamp, n8793557, Dr Jey Rodgers//**

**The** Artefact


The illustration was presented by caricaturist Edd Aragon for the Sydney Morning Herald article “//Harm minimisation: just say no//”. The article and the artefact portray the inherent damage caused by harm minimisation and emphasises the fact that there is no safe level of illicit drug use. Furthermore the article and the artefact emphasises that harm minimisation does not allow users the ability to be drug free but keeps them trapped in addiction and misery.

**Public Health Issue**
The cultural artefact represents the public health issue of illicit drug use, more precisely the artefact represents the dilemma between the two major approaches to the treatment of illicit drug use, harm minimisation and abstinence. The artefact and the associated article argue that the only way to completely minimise the harm associated with illicit drug use is to abstain altogether. But this approach can be seen by many as being a one dimensional approach to illicit drug use and although experts believe abstinence should be the final goal of treatment for illicit drug use, harm minimisation policies have a role to play in supporting these goals (Fiorentine, 1999).

**Literature Review**
The Minnesota model is the worlds leading model for the treatment of substances of addiction abuse in individuals ( Shorkey & Uebel, 2009 ). The Minnesota model of abstinence treats alcoholism and drug abuse foremost as an illness with an emphasis on managing the illness but without necessarily a focus on the positive potential outcomes. The abstinence based treatment method recognises that there is no cure for the disease of addiction but focuses on recovery through peer support and positive lifestyle changes. This approach removes the stigma and negativity associated with illicit drug use by focusing on the disease and not the person where a relapse is considered part of the journey and not a failure. Therefore because of this approach success is hard to quantify and programs are often criticised for their high drop out rate, one size fits all approach, and for encouraging unattainable goals (Fiorentine, 1999). Despite this Fiorentine (1999) states most experts believe that abstinence should still be the primary goal for treatment of illicit drug use. Furthermore 53% of adults who where treated with this model of care where still abstinent from their drug use at a 1 - year follow up ( Shorkey & Uebel, 2009 ).

Since 1985 the national drug strategy has focused on a coordinated approach of harm minimisation (AIHW,2011). This approach to harm minimization is a collaborative effort between the commonwealth and state and territory governments which encompasses three specific objectives


 * Demand reduction
 * Supply reduction
 * Harm reduction

Demand reduction are processes which support users of illicit drugs to reduce dependence and to reorientate them with their families and communities. A prime example of demand reduction in Australia are methadone clinics. Methadone clinics have been operating in Australia since the 1970s and are generally considered a policy success (Ward, et el, 1992; Mcdonald et al, 1988). This success has been born through two primary mechanism, the reduction in HIV transmission through the sharing of needles and the reduction in criminal activity associated with heroin use, but not necessarily abstinence. Although early treatment programs using methadone did promote a goal of abstinence many programs now have broader goals of limiting the secondary negative effects of heroin use. Despite the positive effects of demand reduction these strategies can also generate harm. Few users of drugs stop using them because of their pharmacological effects but to limit problems with the police, reduce expenditure on the illicit drugs and to improve the negative lifestyle effects associated with illicit drug use (Weatherburn, 2009). Harm can also be generated in a more indirect way, as by reducing demand on heroin, prices will drop thus enticing new users into illicit drug use (Weatherburn, 2009). Furthermore users may sell their methadone to others, give it children or spend their spare money on other illicit drugs such as cocaine (Weatherburn, 2009).

Supply reduction is the process of reducing, controlling and managing supply of illicit drugs. Australia has a long history of supply reduction policies stemming form severe alcohol problems in the colonies in the 17th, 18th and 19th centuries (UNODC, 2008). Australia was also one of the first countries to ratify drug control conventions through the League of Nations and the United Nations. In more recent times the “tough on drugs policy” was enacted in late 1997 which placed more emphasis on enforcement but without reducing the effort in demand reduction and harm minimisation (UNODC, 2008). These measures of supply reduction where accomplished through increasing resources to police, customs and supporting agencies to find, intercept and track illicit drug related transactions (UNODC, 2008). There is no effective argument that supply control does not reduce the harm associated with illicit drug use as the risk associated with trafficking and supply of these drugs increases prices and reduces affordability (Weatherburn, 2009). This demand reducing effect of increasing heroin prices was evident in Australia from 2001 when a jump in heroin prices caused not only a reduction in the prevalence of heroin use but related crime, overdoes and hepatitis C and HIV seroprevalence (Degenhardt, Reuter, Collins, & Hall, 2005). Despite this supply control policy can also generate harm including the loss of civil liberties, future career and earning prospects and potential long term imprisonment (Weatherburn, 2009). Another potential source of harm occurs through the success of supply reduction policies, when limited supply forces the prices up of one product users will in many cases simply switch to another substance, therefore the root causes of drug use are not addressed through supply reduction policies (Weatherburn, 2009).

Harm reduction seeks to limit the consequences illicit drug use has on users, families and the general community. There is no denying the positive effects harm reduction has had on not only drug users but to their families and the general community. The most common and widely known harm reduction policies in Australia are needle and syringe exchange programs and injection rooms. Needle and syringe programs have been an important part of the public health policies targeting HIV/AIDS and hepatitis C. On average needle exchange programs have caused an 18.5% decrease in HIV seroprevalence in communities with needle exchange programs compared with an 8.1% increase in those areas which did not have needle exchange programs available. The most common form of needle exchange programs are primary service providers, specifically established to provide safe injecting equipment and supplies and sometimes staffed by primary medical care staff such as registered nurses and doctors. Alternatively there are secondary providers which tend to only provide clean injecting equipment at a relatively small cost or in some cases such as in NSW free of charge. Another example of harm reduction policy although not widespread across Australia is the decriminalisation of cannabis use (Weatherburn, 2009). Although these methods of harm reduction do successfully reduce the harm associated with illicit drug use through their mechanisms they also have the ability to promote harm. By reducing the negative effects associated with illicit drugs use it can be argued that more people may be initiated into using illicit drugs. Weatherburn (2009) argues the harm caused by using illicit drugs is the most important barrier associated with their use and thus should be used as a deterrent.

As you can see both approaches to the treatment of illicit drug use have both positive and negative consequences. One promotes treatment through active engagement and support with a goal of eliminating dependence where as the other seeks to reduce overall harm to individuals, families and the broader community despite having the ability to induce harm in the process. Therefore both approaches are needed to both treat the disease of addiction in individuals whom consciously seek a better life and to minimise the harm to those whom have not yet been able to face and acknowledge the disease of addiction.

**Cultural and Social Analysis**
The recognition of which social groups are most at risk of harm from illicit drug use is essential in addressing the issue from a public health perspective. Several social groups have disproportionate levels of illicit drug use and illicit drug use related harm. For example 21% of Aboriginal and Torres Straight Islanders had reported recently using an illicit drug in a 2008 study (Gilles, Swingler, Craven, & Larson, 2008). Furthermore other groups disproportionally represented as illicit drug users include those in socioeconomically disadvantages areas, those living in remote locations, the unemployed and those whom identify as homosexual or bisexual (AIHW, 2011). Social disadvantage, illicit drugs use and incarceration are intrinsically linked especially in the indigenous population where a long history of dispossession has had a causation effect on social disadvantage, illicit drug use and the subsequent associated criminal activity (Gilles, Swingler, Craven, & Larson, 2008). Young adults are also a key risk group exposed to illicit drug use. Drug use has become an increasingly normalised part of everyday youth subculture. This normalisation is primarily driven through the acceptability, identity and expression that drug use allows and the intoxication it provides (Blackman, 2010). These effects have negative consequences including unsafe sexual activity, increased likelihood of problematic drug use, criminal activity and reduced educational attainment (Degenhardt, Lynskey, & Hall, 2000).

**Analysis of the Artefact and Learning Reflections**
As previously mentioned the artefact represents the dilemma between harm minimisation and abstinence. Furthermore the article promotes the notion that harm minimisation policies are in their own right harmful. The artefact depicts a young girl being offered a “safer” option by a doctor or healthcare worker wearing a coat with a stethoscope around his or her neck. But the message of the artefact is that these so called safe options are not safe at all and can in their own right be just as harmful. This harm is represented by the face of death or despair on the healthcare worker. The artefact is a good representation of the potential harm that can be induced by harm minimisation policies. As discussed harm minimisation can induce harm and can in some cases be as harmful as drug use itself. But harm minimisation is about much more than simply replacing one substance with another. The view that harm minimisation is simply about taking drugs in a safe way or using other options such as methadone is overly simplistic. Abstinence is a macro approach to drug use where people whom so seek to battle the disease of addiction use the support of other to do so. Where as harm minimisation is both a macro and micro approach to dealing with illicit drug use by taking into consideration both individual and societal factors whilst also seeking to aid users whom are not yet able to face the disease of addiction.

Prior to researching this topic I viewed the treatment of drug addiction as simply a personal issue of abstinence but like the treatment of all addictive substances the problem is far from this simple. I learnt that both methods play an important part in the treatment of illicit drug use by enabling illicit drug users the support to beat the disease of addiction whilst seeking to minimise the damage caused to those whom cannot or do not wish to face this chronic disease.

**References**
Australian Institute of Health and Welfare. (2011). //Drugs in Australia 2010//. Canberra: Australian Government

Blackman, S. (2010). Youth subcultures, normalisation and drug prohibition: The politics of contemporary crisis and change? //British Politics//, 5(3), 337– 366. doi:10.1057/bp.2010.12

Commonwealth Department of Health and Ageing, (2002), R//eturn on Investment in Needle & Syringe Programs in Australia,// Canberra: Australian Government.

Degenhardt, L., Lynskey, M., & Hall, W. (2000). Cohort trends in the age of initiation of drug use in Australia. //Australian and New Zealand Journal of Public Health//, 24(4), 421–426.

Degenhardt, L., Reuter, P., Collins, L., & Hall, W. (2005). Evaluating explanations of the Australian 'heroin shortage'. //Addiction,// 100(4), 459–469. doi:10.1111/j.1360-0443.2005.01000.x

Fiorentine, R. (1999). After drug treatment: are 12-step programs effective in maintaining abstinence? //The American journal of drug and alcohol abuse,// 25(1), 93–116.

Gilles, M., Swingler, E., Craven, C., & Larson, A. (2008). Prison health and public health responses at a regional prison in Western Australia. //Australian and New Zealand Journal of Public Health//, 32(6), 549–553. doi:10.1111/j.1753-6405.2008.00308.x

McDonald, D., Brown, H., Hamilton, M., Miller, M. and Stephenson, R. (1988), //Australian// //Drug Policies 1988 and Beyond - A Drugs Campaign Evaluation' Australian Drug and// // Alcohol Review 7 //, pp 499-505

Musto D. F. (1987) //The American Disease: Origins of Narcotic Control.// New York: Oxford University Press.

Shorkey, C., & Uebel, M. (2009). //Minnesota model.// In G. Fisher, & N. Roget (Eds.), Encyclopedia of substance abuse prevention, treatment, & recovery. (pp. 548-551). Thousand Oaks, CA: SAGE Publications, Inc. doi: 10.4135/9781412964500.n191

United Nations Office on Drug and Crime, (2008), //Drug Policy and Results in Australia,// New York: United Nations

Weatherburn, D. (2009). Dilemmas in harm minimization. //Addiction//, 104(3), 335–339. doi:10.1111/j.1753-6405.2011.00708.x

Ward, J., Mattick, R. and Hall, W. (1992) //Key Issues in Methadone Maintenance Treatment,// // National Drug and Alcohol Research Centre, // New South Wales University Press,Kensington

**Discussion**
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