|Written by Marion Watson|
|Monday, 23 December 1991 00:00|
Changing a dysfunctional nightmare into a working alternative
Recent events, including the upsurge of HIV infection in people who inject drugs, have commanded a review of policies relating to injecting drug use/users to replace the abstinence focus with a ‘harm reduction’ focus. In view of this current climate it may be useful to apply a functional definition to the concept of harm reduction. Included in the following article are some suggestions for defining what should be available to clients. These will be contingent upon the capacity of the agency, service institution or structure that wishes to provide the service, adapting to meet the philosophical, attitudinal, staffing and environmental requirements.
Preconceptions, traditions and preconditions
For the purposes of this paper it is understood, but not discussed further, that abstinence is a perfectly respectable way of being. It is an important choice that is always available, but most importantly, abstinence has no impact on safe drug usage or harm reduction. In fact, abstinence and harm reduction are mutually exclusive.
Harm reduction requires a rethinking of the philosophical standpoint upon which education and service provision is based. Harm reduction in motion means the provision of a range of information, resources and strategies so that the client/customer becomes the bearer of the vital knowledge that can change the procedures and outcomes of drug use.
Many changes are required in ors that harm reduction concepts and strategies might take hold. These changes include alterations in: the context, content and processes of drug use; knowledge, beliefs, attitudes, skills and behaviour of users, drug treatment workers, corrective services officers . police; ‘common knowledge’ or public awareness; media representations of drugs and drug users; and finally the social, legal, political and cultural context of drug use.
The outcomes of these changes should be the development of safety, c relative safety, in drug use. The juxtaposition of ‘safety’ with the ‘risk taking’ nature of illicit drug users is a contradiction in terms for the traditional alcohol and drug worker. Harm reduction presupposes that safety is the preferred outcome for drug users (beside being intoxicated). It suppose that in the hedonistic lifestyle of the drug user there is an understanding of ‘risk’ but not necessarily a predilection for it.
My personal viewpoint is that drug users merely wish to be intoxicated - in a particular way preferably, by using the drug of choice, but in another way or with another drug if this is not available I also believe that given resources to protect themselves against transmission of disease (needles, syringes, water, swabs, knowledge of drug(s), information on how to conduct oneself with the law/police) drug users in their using career will self-protect. In their sexual lives, it is my contention that users are just as hopeless as the wider community at not only admitting that they have sex but also instigating discussion with their partners and demanding protective (barrier) measures during sexual encounters.
Harm reduction - the definition
Harm reduction in relation to drug use the philosophical and practical development of strategies so that the outcomes of drug use are as safe as is situationally possible. It involves the provision of factual information, resources, education, skills and the development of attitude change, in order that the consequences of drug use for the users, the community and the culture have minimal negative impact.
Harm reduction accepts the use of drugs while trying to educate to prevent harmful outcomes of administration of drugs.
Adoption of this concept by the community also involves a series of philosopical, policy, legislative, educational and service provision reviews that will provide for the ‘safest’ possible environment in which drug users can operate with least risk to themselves and the community. If reduction of harm is to be widespread, both the individuals and the community must benefit.
Harm reduction assumes that the individual will, given the knowledge, resources, information and access to all assistance, make the best possible choice for him/herself and will understand and accept the responsibilities for the consequences of that choice.
Harm reduction also assumes that in this changed environment where tolerance and acceptance of drug use exists, and is possibly provided for, the community will suffer less because the oppression of one particularly disadvantaged sector(drug users) will no longer be a primary focus for financial outpourings to health and social policy development, a reduction in congestion of the criminal justice system and eventually a return to the mainstream community for the currently alienated users.
Why is harm reduction apreferred concept?
As previously mentioned the rise in HIV/AIDS transmission has added the impetus to the call for the implementation of harm reduction strategies. Research in Italy, the USA and Britain has shown clearly that the route, of transmission of HIV to the non-drug using community and the children of drug users and their partners, will be through unprotected sex and sharing of needles to inject drugs.
Addicted/drug using women do bear children. This, at least, is not in doubt. Fertility is not reduced by addiction to injectable psychoactive drugs. Self-monitoring of fertility, however, is retarded because of the disruption to menstrual cycles caused by drug usage. The reliability of contraceptive methods is open to human error (forgetting to take the pill), and, it appears that use of condoms is not widespread. Non-consensual sex, i.e. rape and incest, are more frequently reported in women and negotiating barrier contraception is impossible when the choice to have sex or not, is removed.
Tradition and religion dictate that in the addicted and non-drug using population, women do not decide to have sex and women do not decide to bear children . Women also do not decide to prevent conception. When pregnant, women do not decide to terminate and r then after delivery of the child, do not decide to adopt. In essence women, after a series of non-decisions, have sex, get pregnant and become mothers. This is not reduced by drug usage or addictions. The opportunity for transmission of HIV is clear.
The wars on drugs that have been current in a large number of nations have had some successes in interdiction. The international standard of interdiction is running at some 67% of drugs in transit. In the main, however, these international drug wars have had little effect on the numbers of drug users on the street. Where one source of drug supply is suspended another quickly takes its place, the potential for very high financial returns is too enticing to allow existing marketing networks to remain idle.
The transmission of viral infections such as Hepatitis B has long been a ,: feature of injecting drug use, both through shared injection equipment and through sexual interaction. This is still a feature of drug use and reduction of the incidence of this is an anticipated outcome of harm reduction strategies.
The cost of supporting HIV infected users and their children, the cost of the war on drugs and the spiralling incidence of drug use and infected users indicates that interdiction/prevention efforts are not having the desired effect.
Additionally, these strategies serve to reduce the education opportunities for workers attempting to reduce the transmission of HIV and Hepatitis B as the users remain or retreat underground when actively involved in drug use.
Medical support and attention is expensive for those unwell infected people who do not have the complicating factor of current drug use in their personal profiles. Add injecting or addiction to illicit drugs to the characteristics of the infected and the management problems become more complex, expensive and daunting. Without the support of a community, stays in hospital are extended, staffing must be increased and fear of not only the HIV infection but of the drug user/addicted person becomes apparent. Care of the HIV infected drug user will inevitably fall to the state.
The prevention of HIV transmission in prison has proved to be a nightmare.
Refraining from using drugs because one is incarcerated has never seemed to occur to the more adamant or career users. Tolerance of the intolerable - prison - appears to become easier if intoxicated. Injecting is the preferred mode of ingestion and the availability of clean equipment, nil. Sexual activity also does not cease with gaoling. Non-negotiated sex (rape and prostitution) and willing participation in sex is rendered unsafe because of the lack of condoms and the lack of willingness to discuss the sex that occurs. A large number of prisoners are in a gaol on drug charges or charges that relate to their drug use, rendering the population of a prison at high risk of HIV transmission.
Changing the sanctions associated with drug use
There is a variety of ways in which the reduction of harm associated with drug use can become a reality. Of course, some decision of whether minimisation, absolute reduction or absence of harm is possible must be made prior to implementing projects or programmes.
In keeping with the priorities, the capacity of the agency/institution/ service/society, the objectives or intended outcomes, the political climate and other bureaucratic and/or funding issues, the following is a suggested list of areas in which projects aimed at harm reduction associated with drug use might be implemented and through which harm reduction might be achieved.
The least complex strategy to discuss, but the most difficult to implement in the harm reduction field, is that of attitude change. Introduction to services involving self-disclosure of drug use has generally involved, at best, a paternalistic attitude and, at worst, total non-acceptance of the self-disclosure. Attitudes of service delivery workers to current drug users must be changed - without this, attendance at the agency or service by users will be non-existent. In other words, accept the drug users and the drug use. Neither condone nor damn.
Changing drug users
The traditionally perceived characteristics of drug users have a negative impact on interaction. It is believed that users have neither the capacity nor the desire to change their behaviour. This is patently untrue. It is not constructive to consider users as either homogeneous or a community Injectors do not necessarily all have extensive criminal records. They do not all emanate from ‘broken homes’, are not involved in prostitution, and are not all career (full-time) users.
Users in contact with ‘drug treatment’ do represent those with these kind of characteristics, in the main, that are described above in the negative. Clients of services are clients because of their lack of resources; any person with a modicum of self respect, money or support, would avoid contact with existing services and thus retain some sense of self-direction. These people become drug free without the ‘assistance’ of counselling or residential ‘therapeutic’ communities. These people in fact, have no need to show themselves as drug users and identify themselves as powerless. In fact, they remain powerful and develop the internal fortitude required to reduce and quit their own drug use.
Changing the public perception of drug users
Over many years the media, the politicians and the populace in general have been very nervous of illicit drug users. There are rnany reasons why these fears as well founded, with the cost of drugs ever escalating and the capacity to maintain a ‘habit’ or addiction difficult without impinging on other people’s possessions or finances.
If the necessity for committing crime to maintain an addiction is removed (e.g by changing the legal availability of drugs or controlling process or purity) then the reporting of drug users would be unrelated to these behaviours, and the representations of the drugs that are consumed may take a different image. Without the co-operation of the media, heroin, amphetamines and cocaine, in particular will remain the devils of each society and will require purging.
The drugs themselves can be described in less emotional terms, with less fear associated with them, if the access to factual information is enhanced. The representations of the currently illicit drugs that have formed in the community awareness, are the result of concentrated propaganda over period of several decades. Reforming the image of drugs will be an intensive exercise, involving the negation of the concepts delivered by ‘reformed’ addicts and those whose opinions of drugs have been formulated by involvement with the causalities of the illicit drug scene.
It has been presented here that many factors, largely relating to HIV transmission prevention and the cost of not preventing its spread, provide the current background to the need for development of harm reduction philosophies and programs. In developing a definition of harm reduction, our values have been tested. In developing services that have become harm reduction oriented, our theories have been tested. In accommodating current users and dealing with those things that we are presented with to ‘fix’, our patience has been tested.
The Drug Referral and Information Centre (operating as the parent body of all A D.D. Inc services) is a non governmental agency. It has been permitted to develop, and assisted in the development of its services, by the funding and confidence of the Australian Capital Territory Department of Health (AIDS unit and alcohol and drug service). In funding this development, many risks have been taken, and adoption of harm reduction does involve the taking of risks. The response from the injectors of our community was initially suspicion. Now, co-operation seems to feature - perhaps eventually trust will develop. The situation is not stable, it is dynamic.
The influences of the police, other alcohol and drug agencies, the courts, the corrective services and the media i serve to keep the relationships between the agencies and the users fluctuating. It is apparent, though, that the contact with users is enhanced, and if the HIV infection rate is not known to be low it is believed to be so. Even if this apparently low infection rate is the lull before the storm, support networks are now in place or currently being constructed so that the impact to the users, their children and the community will be less costly, less traumatic and less of a surprise than has been the case in many other countries.