grund j-p. c. (2015). redução de danos princípios e estratégias (harm reduction-principles &...
TRANSCRIPT
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
Drug
Set
Life
Structure
Availability
Rituals
&
Rules
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
LIFE
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
Harm & harm reduction (2)
Source of harm
• Mountain sports
Harm reduction
• Licencing, clubs,
training standards,
professional guides,
marked trails and
pistes, equipment
standards
Harm & harm reduction (3)
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. N.
N = 236
Pskov
N = 201
R-N-D
N = 199
St. Petersb.
N = 221
Volgograd
N = 219
Total
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
22
33
33
12
47
31
10
12
18
22
25
35
43
27
16
14
26
41
26
6
30
32
23
15
Drug Injected1,2
(%)
Homemade opiates
Powder Heroin
Amphetamine
83
47
9
15
53
61
84
5
24
6
96
9
21
90
4
42
59
20
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
for
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
0
20
40
60
80
100
120
140
160
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
0
20
40
60
80
100
120
140
160
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,
& HIV Transmission © Jean-Paul Grund 1999
Cooking Utensils, Pskov, Russia
© Jean-Paul Grund 1999
Cooking Cheornaya in Nizhniy Novgorod, Russia
© Jean-Paul Grund 1999
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.”
© Jean-Paul Grund 1999
Frontloading Cheornaya, Nizhniy Novgorod, Russia
© Jean-Paul Grund 1999
Group Injecting, Nizhniy Novgorod, Russia
© Jean-Paul Grund 1999
Group Injecting, Nizhniy Novgorod, Russia
© Jean-Paul Grund 1999
Group Injecting, Volgograd, Russia
© Jean-Paul Grund 1999 © Jean-Paul Grund 1999
Initiation into Injecting Drug Use
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
61
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.
Social Setting of the First Hit
“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.
Source: Balakireva, Grund, Barendregt, et al. (2006). Risk and protective factors in the initiation
of injecting drug use. Kiev: UNICEF/UISR.
Learning to Inject is Social Behavior
Indicator 2006 (N=220)
Got help on first injection
Baseline Survey Results (2006)
85.9%
Who are these
helpers?
Who are these
helpers?
Source: Preliminary findings from a 2006 study among IDUs in Uzbekistan and Kyrgyzstan
Learning to Inject: A Family Affair
Sibling/Cousin
53 percent
Friend
33 percent
Dealer
2 percent
Other
12 percent
First Injection Helpers Uzbekistan & Kyrgyzstan (N=220)
Source: Preliminary findings from a 2006 study among IDUs in Uzbekistan and Kyrgyzstan
“Who gave you the first injection?” by gender (%)
3
7
3
15
67
3
4
2
32
4
55
1
6
8
13
64
5
5
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
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.
67
• 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
Source: Preliminary findings from a 2006 study among IDUs in Uzbekistan and Kyrgyzstan
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
© Jean-Paul Grund 1999
Strategies to Avoid Law Enforcement
Strategies to Avoid Law Enforcement
Drug Use & Harm Reduction
in the 21st Century
Results
© Jean-Paul Grund 1999
© Jean-Paul Grund 1999
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
Harm Reduction in the 21st Century
Courtesy of Dr. Fernando Caudevilla
Photo Credits
Black & White Photographs:
© John Ranard
Color Photographs: © Jean-Paul Grund
Miscellaneous Images: Internet
Black & White Photographs:
© John Ranard
Color Photographs: © Jean-Paul Grund
Miscellaneous Images: Internet
Thank you for your attention!
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