grund j-p. c. (2015). redução de danos princípios e estratégias (harm reduction-principles &...

Redução de Danos: Princípios e Estratégias (Harm Reduction: Principles & Strategies)

Jean-Paul Grund, PhD CVO – Addiction Research Centre, Utrecht Department of Addictology, Charles University, Prague Freudenthal Institute for Science and Mathematics Education, Utrecht University

Overview

Principles & Foundation

Harms & Harm Reduction Strategies

Case Studies

Needle Exchange Programs: From “provider-client” to Peer Driven

Secondary Exchange

Outreach

Overdose prevention

Drug use rituals

Initiation into injecting drug use

Drugs and the law

Drug Use & Harm Reduction in the 21st Century

Principles & Foundation

Harm Reduction

Use of psychoactive substances is not necessarily

abnormal or a sign of psychopathology

Use of psychoactive substances is

the norm among humans; both

globally and historically

Changing consciousness has been

termed the “Fourth Drive” (in

addition to eating, drinking and

sexual activity)

Other species ingest drugs as well

Humans engage in a wide range

of potentially risky behaviors

• Driving cars,

• Mountaineering, cave clambering,

para sailing, surfing, diving

• sex

• Drug use is part of that spectrum

• Pleasure & Pain

• Many positive effects, potential

for negative consequences

Drug Setting Set

22/02/16 strana 6

Pharmacology Sociology Psychology Psycho-

pharmacology Social Work

Perspectives on Drug Use & Addiction

Setting

Structure

Availability

Rituals

Drug, Set & Setting (Zinberg, 1984)

The Risk Environment (Rhodes, 2002; 2009)

22/02/16 strana 8

Levels:

– Macro

– Micro

Types:

– Physical

– Social

– Economic

– Policy

Levels of Influence:

Types of Influence:

Drug use or misuse is never an isolated

phenomenon.

A social-cultural setting around the use

of any drug--legal or illegal.

Ergo, abuse of drugs or addiction can

never be blamed on a substance alone.

Drugs are here to stay.

We better learn to live with their presence

Ergo, the goal of drug policy should not

be to prevent the use of drugs at all costs

(globally we are not doing a good job at

that anyway), but to minimize the

negative consequences of both drug

consumption and of our efforts to control

this private behaviour

Priorities

Health & Well Being

Social & Economic Justice

Social Fabric

Ecology

Reduction of harms related to drug

use, drug production, drug market

and drug policy

Harm Reduction

22/02/16 strana 12

Harm reduction

22/02/16 strana 13

Harm Reduction

Demand Reduction

Supply Reduction

(Regulation?) Research

First, 𝐷𝑜 𝑁𝑜

𝑅𝑒𝑑𝑢𝑐𝑒 HARM!

Risk reduction:

Lowering the overall prevalence of a

potential harmful activity

Harm reduction:

Changing the potential harmful activity

towards lowering the harms associated

with the activity

Is Harm reduction unique or specific

to drug (ab)use?

NO, it is a widely applied social

organization principle!

Harm reduction policies are applied to

behaviors and commodities that are

considered useful or desirable, but also

include a certain risk for harm.

Annual number of deaths USA

• Tobacco* 418,690

• Secondhand smoke** 53,000

• Alcohol (incl. drunk driving)* 105,000

• Motor-vehicle accidents**** 42,000

• AIDS* 33,745

• Suicide*** 31,000

• Homicide*** 22,000

• Food poisening***** 9,000

• Drowning***** 4,800

• Cocaine & Crack*** 3,300

• Heroin & Morphine*** 2,400

Sources: *CDC; **EPA; ***NCHS; ****NSC; *****CR

Note: Data is from around 2000, merely for the sake of comparison. E.g. in 2013 there were

nearly 44.000 acute drug-related deaths reported in the USA (TFAH and RWJF, 2015)

Harm associated with motorized transport*

• World:

– Deaths 300,000

– Injuries 10-15 Million

• USA:

– Leading cause of death in ages 6 - 33

– Cause of death in 37% in ages 10 - 24

– Killed 5546 pedestrians, injured 96,000 -1992

– Risk of death/person-year 1/20,000

of being struck by a car**

Source: *Centers for Disease Control; ** JAMA

Harm & harm reduction (1)

Source of harm

• Motorized transport

Harm reduction

• Traffic regulations,

designated areas

(roads), seat belts,

airbags, stop lights,

anti lock brakes, age

limitations, drivers

licencing, stop lights

Mortality rates related to

mountaineering (10,000/year)*

All mountain sports 4 (climbing, mountain hiking and biking, skiing, snow boarding, hunting)

Members of Swiss alpine club 3.3

Professional guide 24

Matterhorn 30

members of Gr. Haute Montagne 70

Himalaya 200

Eiger north face 1670

* Source: Neue Zuercher Zeitung

Source of harm

• Mountain sports

Harm reduction

• Licencing, clubs,

training standards,

professional guides,

marked trails and

pistes, equipment

standards

Source of harm

• Illicit drug use (incl.

primary harm (drug-

related) and

secondary harm

(drug policy related))

Harm reduction

• Honest drug

information,

safer drug use,

outreach,

substitution Tx.,

needle exchange,

Naloxone distribution,

treatment on request,

community policing

Excessive behaviors occur

along a continuum of risk from

MINIMAL to EXTREME

Behavior Change is

a Stepwise Process

Abstinence

is not for

Everybody

Harm reduction doesn’t exclude

abstinence, but abstinence is

perceived as one among a wide

range of possible interventions

“In essence, a policy of harm reduction

requires an approach of pragmatism

rather than purism --an acceptance that

it may sometimes be better to go for a

probable silver than a possible gold.”

Dr. John Strang

Harms & Harm

Reduction Strategies -

Case Studies

Needle Exchange Programs

Slide:Courtesy of S. Strathdee

No table manners without silverware!

Silverware Guidance on table manners

Community involvement: From “provider-

client” to “Peer Driven” approaches

• “Fellow network” approaches

– Secondary needle exchange

– Overdose prevention & naloxone distribution

– Respondent driven sampling (RDS); Peer Driven Intervention (PDI)

Peer support approaches are in line with the International Guidelines on HIV/AIDS and Human Rights (United Nations, 2006)

“The most effective responses to the epidemic grow out of people’s action within their [own] community

and national context” (UNAIDS/IPU 1999).

From 1-4-1 to collective exchange &

distribution

Example: the HADON NSP, Rotterdam, NL, mid 1980s.

The HADON NSP & Client Zero

• First period (<1986): only needle exchange at the office and

during street outreach: the clients highly appreciated the

needle exchange, but we felt that we were only serving a small

proportion of the IDUs in area.

• 1986: Client Zero (CZ)

CZ was a relatively new, but regular client of the needle

exchange; one day he came to exchange and told me that many

other IDUs inject at his apartment.

• CZ and subsequent clients with similar stories made us realize

that we had to find ways to get clean needles where these were

needed most, at those places where IDUs meet to inject drugs.

• Serious reconsideration of needle exchange rules; from 1-4-1

exchange to distribution… …“Collective Exchange”

Introducing “Collective Exchange”

• “Collective exchange” was experimentally

initiated to determine if outreach component of

the program could be extended and improved.

• Examined whether visitors could be motivated

to both distribute new needles to their IDU

friends and collect used needles.

• Turning them from service consumers into

providers of services to their peers, stimulating

them to take more responsibility for their own

and their peers’ health.

Where have all the needles gone?

Karel agrees to let Jerry take a shot at his place. Jerry wants to shoot up cocaine. He puts his syringe on the table and asks Karel for a spoon. Karel asks, "Is that an old spike you want to use?" Jerry replies, "Well, old, I've used it one time before, so it's still good for use." Karel says, "I've got some new ones left from HADON," and hands one over to Jerry, asking him, "Do you want some more for tonight or the weekend?" Jerry replies, "If you can spare them, I'll take some with me." Karel gives him four.

• At present, secondary exchange is the primary mode of needle exchange in the US (Des Jarlais et al., 2009).

Drug Use Characteristics of Russian

Syringe Exchange Participants N = 1,076

N = 236

N = 201

N = 199

St. Petersb.

N = 221

Volgograd

N = 219

N = 1,076

Age First IDU1 (Mean/SD) 19 (4) 21 (5) 21 (5) 18 (3) 19 (4) 20 (4)

Years Injecting1 (%)

< 3 years

3+ – 6 years

6+ – 10 years

>10 years

Drug Injected1,2

Homemade opiates

Powder Heroin

Amphetamine

Reported Secondary Exchange (%) 40 46 40 43 48 44

1 N differs because results are derived from intake questionnaires that linked with risk assessment questionnaires, only, so that N

Nizhny Novgorod = 165; N for Pskov = 153; N for Rostov-na-Donu = 109; N for St. Petersburg = 56; N for Volgograd = 160;

and the total N for the five programs = 643.

2 Percents may sum to > 100; more than one response may apply.

Almost half of Russian Syringe Exchange Participants reported Secondary Exchange (40-48%), whether the program encouraged it or not.

Outreach

From “provider-client” outreach

• Qualitative studies documented successes but also

limitations to traditional (professional) outreach

model (e.g. Broadhead & Fox).

• The traditional outreach model:

– Relies on hiring former or current drug users, or people

with “street credentials” to serve as outreach workers

– Assumes a Provider-Client Relationship with IDUs:

outreach workers become new “providers” who begin to

work with their peers by turning them into “clients”

– OWs venture out into targeted areas, seek to identify IDUs,

develop trusting relationships with them, educate them in

the community, give out risk reduction materials, and

recruit IDUs into services

Problems with traditional outreach

Qualitative study of traditional outreach (Broadhead

& Fox) in San Francisco, USA

Observed outreach workers in different US cities

Main findings: Traditional Outreach projects tend to

stagnate and exhibit high levels of mal- and

nonperformance by outreach workers

They found:

“Good Organizational Reasons For

Bad Organizational Performance”

Why Traditional Outreach Projects

Performed Poorly: Agency Problems

• Low salaries

• Problematic supervision

• Adverse selection problems

• Occupational risks of outreach in drug scenes

• Black Market opportunities

• Work-related monotony and powerlessness

• Identity conflicts (e.g. harm reduction approaches vs. religious beliefs)

• High staff turnover

• all of the above in combination

But, PWID responded positively

to outreach projects!

• Volunteered and helped outreach workers

• Introduced outreach workers to new IDUs, and

eased IDUs distrust of them

• Revealed the drug scene to outreach workers

• Helped outreach workers distribute risk

reduction materials (bleach, condoms)

• Responded to interviews and education

sessions

Remarkable results and useful insights

• These and other studies demonstrated dramatic decreases in risk behavior.

• Revealed that IDUs were far more capable and responsive to interventions than researchers previously thought.

• Demonstrated that IDUs could play active roles in helping themselves and others.

• Results dovetailed with research mentioned above: IDUs are not isolated individuals, but part of larger networks of users, within a(n underground) community with defined social rules and standards of conduct. – The “scene” — “secret societies” (Cf. MSM & sex

work) (Howard Becker, Insiders)

to peer driven prevention?

Researchers and community activists (in many

places) started thinking about developing

prevention models that rely on active drug users to

carry out core outreach tasks

“Why not develop a model that works with

drug users as colleagues rather than as

“sick” people, “criminals,” or “disabled”

people, because IDUs demonstrated that they

were more capable, responsive, and willing

to work than previously recognized.” (Robert Broadhead)

Overdose Prevention

69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

No. Of ODs under "No Tolerance" Policy No. Of ODs under "Harm Reduction" Policy

Overdose Deaths in Frankfurt/M, 1969-1999

85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

SOURCE: Slide: Schneider, 2000; Data: Police Department, City of Frankfurt/M

Overdose Deaths in Frankfurt/M, 1985-1999

50 Methadone Maintenance Treatment Slots (Pilot Project)

300 MMT Slots

1000 MMT Slots

Drug related Mortality

Czech Republic

– 49 overdoses per year

– Affects primarily

people who use

heroin, MA

– 292 family tragedies

in 2005-2010

• “Got Naloxone?”

Year / Characteristics

Drug related deaths

after acute drug

intoxication

2010 55

2009 49

2008 44

2007 40

2006 42

2005 62

Principal drug (2010)

Heroin 34.5%

Methamphetamine 32.7%

Inhalants (cases, 2009; 2010) 8; 16

♂ Gender 89.1%

May 1. 2003 Serendipity J-P Grund

Drug Use as a Social Ritual

Collective Drug

Preparation & Injecting,

Friendship Networks,

Cooking Utensils, Pskov, Russia

Cooking Cheornaya in Nizhniy Novgorod, Russia

A Culture of Collective Drug Use

“It is very seldom when you use alone. At minimum you use with

two or three people. … “Somebody has money for drugs, a

second knows where to get good drugs, a third has some

anhydride or a place to cook and yet another has syringes. … It is

also much cheaper to use in groups.”

“It is very seldom when you use alone. At minimum you use with

two or three people. … “Somebody has money for drugs, a

second knows where to get good drugs, a third has some

anhydride or a place to cook and yet another has syringes. … It is

also much cheaper to use in groups.”

Frontloading Cheornaya, Nizhniy Novgorod, Russia

Group Injecting, Nizhniy Novgorod, Russia

Group Injecting, Volgograd, Russia

Initiation into Injecting Drug Use

1. Proximity

2. Exposure

3. Curiosity

4. Enablers

What Puts Young People at Risk for Injecting Drug Use?

Source: Preliminary findings from a 2006 study among IDUs in Uzbekistan and Kyrgyzstan

Enablers

• The majority of IDUs surveyed report that they

received help when they initiated.

• In most cases, the young person pressures the

IDU to help them initiate.

• Roughly half of IDUs report they started

injecting with the help of a sibling or cousin. A

third received help from friends.*

*Source: Preliminary findings from a 2006 study among IDUs in Uzbekistan and Kyrgyzstan

Average age of first injection: 17.7 years

Average age of “Initiator”: 22.8 years

Initiator is usually an IDU friend

First drug of injection is usually obtained from a close friend,

free of charge

Most common location of IDU initiation: A friend‘s apartment

Social Setting of the First Hit

Source: Balakireva, Grund, Barendregt, et al. (2006). Risk and protective factors in the initiation

of injecting drug use. Kiev: UNICEF/UISR.

“Who was present at your first injection?”*

Company %

Friends or good acquaintances 80

Person I did not know very well 20

Sexual partner 17

Stranger 7

Alone 5

* More than one answer possible.

Learning to Inject is Social Behavior

Indicator 2006 (N=220)

Got help on first injection

Baseline Survey Results (2006)

Who are these

helpers?

Who are these

helpers?

Learning to Inject: A Family Affair

Sibling/Cousin

53 percent

Friend

33 percent

Dealer

2 percent

12 percent

First Injection Helpers Uzbekistan & Kyrgyzstan (N=220)

“Who gave you the first injection?” by gender (%)

0 10 20 30 40 50 60 70 80

O ther persons

Running body

Drug dealer

Sexual partner

Self-made

Friend, acquantance

Men Women All

• BTC reduces exposure of non-

IDUs to injecting and reduces IDU

enabling of others to initiate

injecting.

• It does so by encouraging and

supporting IDUs not to:

• Help others initiate IDU

• Inject in presence of non-IDUs

• Talk about ‘benefits’ of IDU

Break The Cycle: A program to reduce

exposure of non-IDUs to injecting

Drugs & the Law

Carrying Injection Equipment

Connecticut,

USA (1995)

Russia

(1999)

Moldova

(2001)

Carries normally no works 70% 40% 67%

Reason: Fear of Police 65% 58% 67%

Source: Grund, Heckathorn, Broadhead, Anthony (1995). In Eastern Connecticut,

IDUs Purchase Syringes from Pharmacies But Don’t Carry Syringes. JAIDS

Close Ties between Narcology and Law

Enforcement

“The relations with

the police are good,

they do a lot of

mutual work.”

(Psychologist @ N.D.

South Russia)

Strategies to Avoid Law Enforcement

Drug Use & Harm Reduction

in the 21st Century

Results

Online discussions of NPS: (1) uncovering substance facts, (2) dosage and administration, (3) subjective effects, (4) support and safety

“The main characteristics of the discussions

in general were a concern for safety and harm

reduction.”

Towards Harm Reduction 2.0

Silk Road

Where there used to be Grass, Acid, Speed, Brown & Blow…

Harm Reduction in the 21st Century

Courtesy of Dr. Fernando Caudevilla

Harm Reduction in the 21st Century

Courtesy of Dr. Fernando Caudevilla

Photo Credits

Black & White Photographs:

Miscellaneous Images: Internet

Black & White Photographs:

Miscellaneous Images: Internet

Thank you for your attention!

E: jpgrund@drugresearch.nl

T: @HeisenbergXL

(Most images: Internet. Thanks2Authors!)

Epilogue

Alle Ding' sind Gift, und nichts ohn'

Gift; allein die Dosis macht, daß ein Ding kein Gift ist.

Philippus Aureolus Theophrastus Bombastus von Hohenheim

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