Chapter 1 Harm reduction and the mainstream

Tim Rhodes and Dagmar Hedrich

Abstract
Harm reduction encompasses interventions, programmes and policies that seek to reduce
the health, social and economic harms of drug use to individuals, communities and societies.
We envisage harm reduction as a ‘combination intervention’, made up of a package of
interventions tailored to local setting and need, which give primary emphasis to reducing
the harms of drug use. We note the enhanced impact potential derived from delivering
multiple harm reduction interventions in combination, and at sufficient scale, especially
needle and syringe distribution in combination with opioid substitution treatment
programmes. We note that harm reduction is a manifestation of mainstream public health
approaches endorsed globally by the United Nations, and in the EU drugs strategy and
action plans, and features as an integral element of drug policy in most of the European
region. However, we note evidence that links drug harms to policies that emphasise strict
law enforcement against drug users; an unintended consequence of international drug
control conventions. The continuum of ‘combination interventions’ available to harm
reduction thus extends from drug treatment through to policy or legal reform and the
removal of structural barriers to protecting the rights of all to health. We end by introducing
this monograph, which seeks to reflect upon two decades of scientific evidence concerning
harm reduction approaches in Europe and beyond.

Introduction
Harm reduction encompasses interventions, programmes and policies that seek to reduce
the health, social and economic harms of drug use to individuals, communities and
societies. A core principle of harm reduction is the development of pragmatic responses to
dealing with drug use through a hierarchy of intervention goals that place primary
emphasis on reducing the health-related harms of continued drug use (Des Jarlais, 1995;
Lenton and Single, 2004). Harm reduction approaches neither exclude nor presume a
treatment goal of abstinence, and this means that abstinence-oriented interventions can
also fall within the hierarchy of harm reduction goals. We therefore envisage harm
reduction as a ‘combination intervention’, made up of a package of interventions tailored
to local setting and need that give primary emphasis to reducing the harms of drug use. In
relation to reducing the harms of injecting drug use, for example, this combination of
interventions may draw upon needle and syringe programmes (NSPs), opioid substitution
treatment (OST), counselling services, the provision of drug consumption rooms (DCRs),
peer education and outreach, and the promotion of public policies conducive to protecting
the health of populations at risk (WHO, 2009).

Harm reduction as mainstream public health
Harm reduction in the drugs field has a long history, variably traced back to the prescription
of heroin and morphine to people dependent on opioids in the United Kingdom in the 1920s
(Spear, 1994), the articulation of public health concerns of legal drugs, alcohol and tobacco,
and the introduction of methadone maintenance in the United States in the 1960s (Bellis,
1981; Erickson, 1999). By the 1970s, the World Health Organization (WHO) recommended
policies of harm reduction to ‘prevent or reduce the severity of problems associated with the
non-medical use of dependence-producing drugs’, noting that this goal is at once ‘broader,
more specific’ as well as ‘more realistic’ than the prevention of non-medical use per se in
many countries (WHO, 1974; Ball, 2007).
The concepts of risk and harm reduction are closely aligned to that of health promotion and
public health more generally. Yet in relation to illicit drugs, debates about developing public
health approaches to reducing drug-related harms are often clouded by harm reduction
positioned as a symbol of radical liberalisation or attack upon traditional drug control. Public
health has at its core the idea of protecting individual and population health through the
surveillance, identification and management of risk to health (Ashton and Seymour, 1988;
Peterson and Lupton, 1996). It is essentially a model of risk and harm reduction. The new public
health movement of the mid-1980s coincided with the emergence of human immunodeficiency
virus (HIV) epidemics in many countries. This new vision of public health was heralded as a shift
beyond narrowly defined biomedical understandings towards one that envisaged health and
harm as also products of the social and policy environment, and which gave greater emphasis
to community-based and ‘low-threshold’ interventions (WHO, 1986). Contemporary public
health thus characterises risk and health decision-making as a responsibility of health conscious
individuals whilst also emphasising the significance of the social environment in producing harm
and in shaping the capacity of individuals and communities to avoid risk (Peterson and Lupton,
1996; Rhodes, 2002). Consequently, mainstream public health approaches recognise the need
to create ‘enabling environments’ for risk reduction and behaviour change, including through
the strengthening of community actions and the creation of public policies supportive of health
(WHO, 1986). Harm reduction is an exemplar of mainstream public health intervention.

Harm reduction as mainstream drug policy in Europe
European intergovernmental collaboration and information exchange in the drugs field dates
back to the early 1970s. While drug policy in the European Union (EU) remains primarily the
responsibility of the Member States, cooperation in matters of drug policy between EU
countries increased over the 1990s, resulting in the adoption of a joint EU drugs strategy as
well as the elaboration of detailed action plans (MacGregor and Whiting, 2010).
The EU drugs strategy aims at making ‘a contribution to the attainment of a high level of health
protection, well-being and social cohesion by complementing the Member States’ action in
preventing and reducing drug use, dependence and drug-related harm to health and society’
and at ‘ensuring a high level of security for the general public’ (Council of the European Union,
2004, p. 5). For over a decade, EU drug action plans have given priority to preventing the

transmission of infectious disease and reducing drug-related deaths among drug using
populations. In a Recommendation adopted by the European Council of 18 June 2003 on the
‘prevention and reduction of health-related harm associated with drug dependence’ (Council of
the European Union, 2003), a framework for action is outlined to assist Member States to
develop strategies to reduce and prevent drug-related harm through the implementation of
harm reduction services for problem drug users. The Recommendation seeks to reduce the
number of drug-related deaths and extent of health damage, including that related to HIV,
hepatitis B (HBV), hepatitis C (HCV) and tuberculosis (TB). These aims are reiterated in the
priorities of the current EU drugs strategy 2005–12 related to demand reduction, aiming at the
‘measurable reduction’ of drug use, dependence and drug-related health and social risk
through a package of interventions combining harm reduction, treatment and rehabilitation,
and which emphasise the need to enhance both the ‘quality’ and ‘effectiveness’ of services.
Under the responsibility of the EU Commission, progress reviews of the implementation of the
EU drugs action plans are carried out with the Member States and additional studies are
commissioned to assess broader policy aspects. Such studies suggest a growing emphasis
placed upon demand and harm reduction in national drug policies in the EU (van der
Gouwe et al., 2006; European Commission, 2002, 2006, 2008, 2009). The reduction of
drug harms thus features as a public health objective of all EU Member States (van der
Gouwe et al., 2006; Cook et al., 2010; MacGregor and Whiting, 2010), with a trend in
Europe towards the ‘growth and consolidation of harm reduction measures’ (EMCDDA,
2009a, p. 31). The European Commission has noted ‘a process of convergence’ in the drug
policy adopted by Member States and, as a consequence, increased evidence of ‘policy
consistency’ across the region (European Commission, 2008, p. 67). This convergence
towards harm reduction in drug policy in Europe has been described as the ‘common
position’ (Hedrich et al., 2008, p. 513).
The ‘mainstreaming’ of harm reduction is also evidenced by its transference across
substances, including those causing the greatest burden of global health harm at a
population level, such as alcohol and tobacco (Rehm et al., 2009; Mathers and Loncar,
2006; Rehm and Fischer, 2010; Room, 2010). While the adoption of harm reduction
measures in relation to tobacco is relatively developmental (Sweanor et al., 2007; Gartner et
al., 2010), alcohol harm reduction has a long tradition and is a core feature of alcohol policy
in many countries (Robson and Marlatt, 2006; Herring et al., 2010). Harm reduction may
also feature as a stratagem of public health intervention in relation to cannabis, recreational
and stimulant drug use (Hall and Fischer, 2010; Fletcher et al., 2010; Grund et al., 2010).

Global drug control and harm reduction
A recent EU Commission study on global illicit drug markets found no evidence that the global
drug problem had been reduced in the past decade, but judged that the enforcement of drug
prohibition had caused substantial unintended harms (European Commission, 2009). This
latter finding was shared by the United Nations Office on Drugs and Crime (UNODC) in an
evaluation of a century of international drug control efforts 1909–2009 (UNODC, 2009). The
report clarifies that public health was the driving concern behind drug control, the

fundamental objective of the international drug control conventions being to limit the licit trade
in narcotic drugs to medical requirements. It states: ‘Public health, the first principle of drug
control, has receded from that position, over-shadowed by the concern with public security’,
and that ‘looking back over the last century, one can see that the control system and its
applications have had several unintended consequences’ (UNODC, 2009, pp. 92–3), among
them the emergence or growth of illicit drug markets, and a ‘policy displacement’ to investing
in law enforcement responses, with a corresponding lack of investment in tackling the public
health harms of drug use. International drug control is framed by three major UN drug
treaties (of 1961, 1971 and 1988), which encourage UN Member States to develop national
policies based on strict law enforcement (Bewley-Taylor, 2004; Wood et al., 2009). There is an
increased momentum, contextualised by a ‘preponderance of evidence’, in support of
recognising that the current international drug control framework is associated with multiple
health and social harms, and that these iatrogenic effects can include the exacerbation of HIV
epidemics among injecting drug users (IDUs) (Wood et al., 2009, p. 990).
Agencies within the UN system have recently re-focused their attention on the primacy of
public health, embracing harm reduction interventions as part of a balanced approach with
complementarity to prevention and treatment interventions. In December 2005, the United
Nations (UN) General Assembly adopted a resolution encouraging global actions towards
‘scaling-up HIV prevention, treatment, care and support with the aim of coming as close as
possible to the goal of universal access to treatment by 2010 for all those who need it’
(United Nations General Assembly, 2006). This led to the development of the WHO, UNODC
and United Nations Joint Programme on HIV/AIDS (UNAIDS) joint technical guide for
countries on target setting for universal access to HIV prevention, treatment and care for
injecting drug users, and focused advocacy efforts on the need for greater coverage towards
‘universal access’ (Donoghoe et al., 2008; WHO et al., 2009; ECOSOC, 2009). Scaling-up
access to, and achieving adequate coverage of, a ‘comprehensive package’ of harm
reduction for problem drug users is a major driver of current global drug policy initiatives
(WHO, 2009; Ball, 2010; Atun and Kazatchkine, 2010).

Harm reduction as a ‘combination intervention’
As a ‘combination intervention’, harm reduction comprises a package of interventions
tailored to local setting and need, including access to drug treatment. In reducing the harms
of drug injecting, for example, a harm reduction package may combine OST, NSPs, DCRs
and counselling services with peer interventions as well as actions to lobby for policy change.
Envisaging harm reduction as a combination intervention is not merely pragmatic and borne
out of need, but is also evidence-based. Evidence points towards the enhanced impact of
harm reduction services when they work in combination. Cohort and modelling studies have
shown that the impact of NSP and OST on reduced incidence of infectious disease among
IDUs can be minimal if delivered as ‘stand-alone’ interventions but are markedly more
effective when delivered in combination, with sufficient engagement among participants to
both (Van Den Berg et al., 2007). This may be especially the case in reducing the incidence
of HCV among IDUs (Hickman, 2010). While epidemiological studies associate NSP and OST

with reduced HIV risk and transmission (Gibson et al., 2001; Wodak and Cooney, 2005;
Farrell et al., 2005; Institute of Medicine, 2007; Palmateer et al., 2010; Kimber et al., 2010),
the evidence for these interventions impacting on HCV risk and transmission is more modest
(Muga et al., 2006; Wright and Tompkins, 2006; Hallinan et al., 2004; Goldberg et al.,
2001; Palmateer et al., 2010; Kimber et al., 2010). To date, there is only one European study
showing that ‘full participation’ across combined harm reduction interventions (NSP and
OST) can reduce HIV incidence (by 57 %) and HCV incidence (by 64 %) (van den Berg et al.,
2007). A recent cohort study in the United Kingdom also links OST with statistically significant
reductions in the incidence of HCV (Craine et al., 2009). Findings noting the enhanced effect
of OST in combination with NSP on reduced HIV and HCV incidence among IDUs have
particular relevance for countries experiencing explosive outbreaks of infectious disease.
Just as the effectiveness of NSP and OST services may be enhanced when combined, there is
an ‘enhanced impact’ relationship between participation in OST and adherence to HIV
treatment and care among IDUs (Malta et al., 2008; Palepu et al., 2006; Lert and
Kazatchkine, 2007). There is a potential HIV prevention effect derived from maximising
access to HIV treatment (Ball, 2010; Montaner et al., 2006). Similarly, low-threshold access to
HIV testing is an important combinative component of harm reduction. In the EU, there is a
considerable level of homogeneity in policy priorities regarding measures to limit the spread
of infectious diseases among drug users, with NSP being offered either in combination with
voluntary testing and counselling for infectious disease, or in combination with the
dissemination of information, education and communication materials (EMCDDA, 2009a, p.
83; EMCDDA, 2009c). Evidence also suggests an enhanced impact relationship between
hepatitis C treatment and access to drug treatment and social support services (Grebely et
al., 2007; Birkhead et al., 2007). Additionally, the integration of HIV treatment services with
TB treatment and prevention services is a critical feature in determining health outcomes in
people living with HIV (Sylla et al., 2007), especially in transitional Europe, which is
‘especially severely affected’ by TB drug resistance among drug using populations (WHO et
al., 2008). Moreover, in HIV prevention there may be combined intervention effects resulting
from sexual risk reduction being delivered alongside harm reduction (Lindenburg et al.,
2006; Copenhaver et al., 2006). Harm reduction integrates with treatment and care in a
combined intervention approach (Ball, 2010).

Harm reduction and ‘enabling environments’ for health
A fundamental tenet of public health intervention is to create environments conducive to
individual and community risk avoidance, including through the creation and maintenance of
public policies supportive of health (WHO, 1986). The continuum of ‘combination
interventions’ available to harm reduction extends from drug prevention and treatment
through to policy reform and the removal of structural barriers to protecting the rights of all
to health. WHO makes specific recommendation for ‘laws that do not compromise access to
HIV services for drug users through criminalisation and marginalisation’ (Ball, 2007). If public
policies or laws generate harm then these too fall within the scope of the combination of
interventions that make up harm reduction. Structural interventions for public health seek to
remove contextual or environmental barriers to risk and harm reduction while enabling social

and environmental conditions that protect against risk and vulnerability (Blankenship et al.,
2006). The delineation of the ‘risk environment’ surrounding the production of drug harms in
different settings has led to the identification of structural interventions with the potential for
encouraging community-level change (Rhodes, 2002, 2009).
Of critical concern — as evidenced by multiple studies in multiple settings — is how the legal
environment can constrain risk avoidance and promote harm among problem drug users,
especially among people who inject drugs (Small et al., 2006; Rhodes, 2009; Kerr et al.,
2005). In some settings, intense street-level police surveillance and contact can be associated
with reluctance among IDUs to carry sterile needles and syringes for fear of arrest, caution, fine
or detention (Rhodes et al., 2003; Cooper et al., 2005; Miller et al., 2008). Evidence associates
elevated odds of syringe sharing with increased police contact (Rhodes et al., 2004),
confiscation of injecting equipment (Werb et al., 2008), and rates of arrest (Pollini et al., 2008),
yet rates of arrest can show no deterrent effect on levels of injecting (Friedman et al., 2010).
High-visibility policing, and police ‘crackdowns’, have been linked to the interruption of safer
injecting routines, leading to safety ‘short-cuts’ or hasty injections, exacerbating the risk of viral
and bacterial infections as well as overdose (Blakenship and Koester, 2002; Bluthenthal et al.,
1999; Small et al., 2006). Such policing practices may displace drug users geographically,
disrupt social networks of support, contribute to the stigmatisation of drug use, and limit the
feasibility, coverage and impact of public health responses (Burris et al., 2004; Davis et al.,
2005; Friedman et al., 2006; Broadhead et al., 1999). In turn, prison and incarceration are
linked to elevated odds of HIV transmission among people who use drugs (Dolan et al., 2007;
Jürgens et al., 2009; Stevens et al., 2010).
Harm reduction may therefore include interventions that seek to reduce the harms generated
by drug and other public policies, including through policy reform and legal change. For
instance, as Room (2010, p. 110) notes: ‘If the harm arises from heavy use per se, reducing
or eliminating use or changing the mode of use are the logical first choices for reducing the
harm. But if the harm results from the criminalisation per se, decriminalising is a logical way
of reducing the harm.’ WHO also notes that ‘the alignment of drug control measures with
public health goals [is] a priority’ (Ball, 2007, p. 687). It is therefore important to note the
potential public health gains of engaging policing and criminal justice agencies as part of
local public health partnerships, including in the delivery of harm reduction interventions in
community and closed settings (see Stevens et al., 2010).

Coverage and scale-up
2010 is the year for achieving the UN General Assembly target of ‘near universal access’ to
HIV prevention, treatment and care for populations affected by HIV. In Europe, considerable
progress has been made towards achieving greater coverage of harm reduction services for
IDUs (see Cook et al., 2010). Every EU Member State has one or more needle and syringe
programmes (EMCDDA, 2009a). Pharmacy-based NSPs operate in at least 12 Member
States. All Member States provide opioid substitution treatment for those with opioid
dependence (EMCDDA, 2009a). An estimated 650,000 people were receiving OST in
Europe in 2007, though large national variations in coverage exist (EMCDDA, 2009a).

Evidence suggests coverage is an important determinant of drug-related risk and harm. In a
recent comparison of the incidence of diagnosed HIV among IDUs and the coverage of OST
and NSP in the EU and five other middle- and high-income countries, those countries with
greatest provision of both OST and NSP in 2000 to 2004 had lower HIV incidence in 2005
and 2006 (Wiessing et al., 2009). In this study, the availability and coverage of harm
reduction measures was considerably lower in Russia and Ukraine where the incidence of
HIV was considerably higher when compared to Western European countries. Whereas HIV
transmission rates are stabilising or decreasing in most of Western and Central Europe, they
are increasing in the Eastern part of the continent, outside the EU, where harm reduction
services are ‘insufficient and need to be reinforced’ (Wiessing et al., 2008).
Coverage of harm reduction interventions is variable within the EU. While recent estimates of
the total number of OST clients represent around 40 % of the estimated total number of
problem opiate users in the EU, the level of provision is far from uniform across the region.
Estimates of coverage from 10 countries where such data are available range from below
5 % to over 50 % of opioid users covered by OST (EMCDDA, 2009e).
European trends in the provision of NSP between 2003 and 2007 show a 33 % increase in
the number of syringes distributed through specialised programmes, with steady increases
in most countries, except several countries in northern and central Europe (EMCDDA,
2009d). Although country-specific coverage estimates of NSP are scarce, the number of
syringes distributed by specialist NSPs per estimated IDU per year seems to vary widely
between countries (EMCDDA, 2010). European-level estimates suggest that on average
some 50 syringes are distributed per estimated IDU per year across the EU (Wiessing et al.,
2009). Overall availability of sterile syringes is also dependent upon pharmacy provision, in
turn influenced by legislation, regulations, and pricing, as well as by the attitudes of
pharmacists.
In its evaluation of the EU drug action plan, the European Commission emphasised that the
‘availability and accessibility of [harm reduction] programmes are still variable among the
Member States’ and that ‘further improvements are still needed in [the] accessibility,
availability and coverage’ of services (European Commission, 2008, p. 66). In the European
region more generally, scaling up comprehensive service provision is a priority, with
strengthening health systems, engaging civil society, and securing political commitment for
harm reduction considered key determinants to effective scale-up (Atun and Kazatchkine,
2010). There is then considerable variability in how harm reduction is enacted in policy and
even more so in practice, as well as resistance to the mainstreaming of harm reduction in
some settings. Understanding the failure to implement evidence-based programmes and
policies has been identified as a major topic for future research (Des Jarlais and Semaan,
2009). In countries where heroin epidemics are recent and rates of HIV infection among drug
users low, implementation of harm reduction measures such as NSP or OST may be
perceived by some as difficult to justify. This may be especially so in the context of finite and
retracting economic resources in the health sector. Evidence, however, indicates the costeffectiveness
of the introduction and scale-up of harm reduction (Zaric et al., 2000; National
Centre in HIV Epidemiology and Clinical Research UNSW, 2009).

Voices of resistance to the mainstreaming of harm reduction in drug policy can be found
within the EU (see MacGregor and Whiting, 2010), but are most vociferous within the
broader European region, and especially Russia, which today has one of the largest
epidemics of HIV associated with drug injecting in the world, has a policy that places strong
emphasis on law enforcement, prohibits the introduction of OST and limits the development
of NSP and other harm reduction interventions to adequate scale (Sarang et al., 2007;
Human Rights Watch, 2007; Elovich and Drucker, 2008).

Evidence, impacts and challenges
An effective harm reduction policy, programme or intervention is one that ‘can be
demonstrated, to a reasonable and informed audience, by direct measurement or otherwise,
that on balance of probabilities has, or is likely to result in, a net reduction in drug-related
harm’ (Lenton and Single, 2004, p. 217). This monograph aims to reflect upon over two
decades of harm reduction research, evidence and impact in Europe and beyond.
There are now multiple systematic and other reviews of the scientific evidence in support of
different harm reduction interventions, especially in the context of HIV, hepatitis C and
injecting drug use (Wodak and Cooney, 2005; Farrell et al., 2005; Institute of Medicine,
2007; Palmateer et al., 2010). Chapters in this monograph take stock of such evidence in
European perspective, including regarding the effectiveness of interventions to prevent HIV
and HCV among injecting drug users (Chapter 5 — Kimber et al., 2010), the role of DCRs
(Chapter 11 — Hedrich et al., 2010), the effect of epidemiological setting on intervention
impact (Chapter 6 — Vickerman and Hickman, 2010) and the implications that variations in
drug use patterns have on harm reduction interventions (Chapter 15 — Hartnoll et al., 2010).
While diffusing throughout Europe primarily in response to health harms linked to injecting
drug use (Chapter 2 — Cook et al., 2010; Chapter 3 — MacGregor and Whiting, 2010),
harm reduction approaches have mainstream applicability. Chapters consider the specific
challenges of harm reduction interventions and policies regarding alcohol (Chapter 10 —
Herring et al., 2010), tobacco (Chapter 9 — Gartner et al., 2010), cannabis (Chapter 8 —
Hall and Fischer, 2010), recreational drug use among young people (Chapter 13 — Fletcher
et al., 2010), and stimulants (Chapter 7 — Grund et al., 2010). The potential role — often
unrealised — of drug user engagement and criminal justice interventions are also discussed
(Chapter 12 — Hunt et al., 2010; Chapter 14 — Stevens et al., 2010). Taken together, this
monograph seeks to synthesise, as well as critically appraise, evidence of the impacts and
challenges of harm reduction interventions and policies in Europe and beyond.
Harm reduction, like any public policy, is inevitably linked to political debate, and it is naive
to assume otherwise, but it is precisely because of this that it is imperative that interventions
are also developed upon evidence-based argument and critique. Europe is experiencing
significant political change, which in 2004 enabled the most extensive wave of European
Union enlargement ever seen. Following the ratification of the Lisbon Treaty by all 27
Member States in 2009, the importance of the Union as a major political player in the region
will grow. Among the new challenges to be faced is maintaining a strong public health
position in controlling and preventing HIV and HCV epidemics linked to drug use. This may

be in a context of harsher economic conditions as well as increased migration, including
from countries with large HIV epidemics driven by drug injecting and where evidence-based
harm reduction measures are not always met with political commitment. The relative success
of harm reduction strategies adopted in many European countries over the past two decades,
and the evidence gathered in their support, provides a framework for the development,
expansion and evaluation of harm reduction across multiple forms of substance use.

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