Treatment harm reduction

The increase in illicitly manufactured heroin is at least consistent with the view that the clinics, in the attempt to avoid supplying the black market, went too far the other way and erred on the side of too restrictive prescribing. It is important to note that this does not mean that, in the very different situation of the late 1980s, an increasing liberalisation of opiate prescribing would necessarily have any significant impact on the extent of the illicit market. However, now that there is a relatively reliable black market in heroin, and very little (particularly for new patients) at the clinics, there is less incentive to enter treatment harm reduction can therefore be offered to a smaller proportion of users via this setting. 

Substitution therapy with methadone or buprenorphine has been veiy successfiil in terms of harm reduction. Some opiate addicts might also benefit from naltrexone treatment. One idea is that patients should undergo rapid opiate detoxification with naltrexone under anaesthesia, which then allows fiuther naltrexone treatment to reduce the likelihood of relapse. However, the mode of action of rapid opiate detoxification is obscure. Moreover, it can be a dangerous procedure and some studies now indicate that this procedure can induce even more severe and long-lasting withdrawal symptoms as well as no improvement in relapse rates than a regular detoxification and psychosocial relapse prevention program. 

Treatment aimed at short-term cessation of amphetamine use was considered completely unrealistic. After the necessary discussions the substitution prescribing option was initiated, with the harm-reduction objective of at least reducing Peter s injecting and use of street amphetamine. He was given dexamphetamine sulphate liquid 60mg per day, with a plan to reduce gradually over the following months. 

Much of the ethos of community drug treatment as it has developed has been firmly grounded in harm-reduction policies. There is frequent debate as to exactly what such principles entail, and even how appropriate they are in countries at different stages of development. Those interested in the philosophy are referred to a paper by AL Ball (2007) from the department of HIV/Aids at the World Health Organization, which clearly still sees avoidance of HIV as one of the key aims of this policy agenda. A short commentary on that article succinctly sums up the areas of importance in drug service provision, as follows ... 

It was the threat of widespread transmission of HIV that led to national policy recommendations for more maintenance opioid substitution treatment to be used in the UK, as part of a package of harm-reduction measures. Two decades on there appears little doubt that the overall approach in this country was successful in limiting HIV rates in injecting addicts (Farrell et al. 2005), although with voluntary testing the true prevalence is unknown, and may possibly be rising at the present time. The resources provided at the time of the... 

Treatment - often methadone - made easy to obtain, as part of a harm-reduction approach... 

Khngemann HKH (1996). Drug treatment in Switzerland harm reduction, decentrahsa-tion and community response. Addiction, 91. 723-36... 

Mattson ME, Del Boca FK, Carroll KM, Cooney NL, DiClemente CC, Donovan D, Kadden RM, McRee B, Rice C, Rycharik RG Zweben A (1998). Compliance with treatment and follow-up protocols in project MATCH predictors and relationship to outcome. Alcoholism Clinical and Experimental Research, 22, 1328-39 Maxwell S Shinderman MS (2002). Optimizing long-term response to methadone maintenance treatment a 152-week followup using higher-dose methadone. Journal of Addictive Diseases, 21, 1-12 McBride AJ, Sullivan JT Blewett A (1997). Amphetamine prescribing as a harm reduction measure a preliminary study. Addiction Research, 5, 95-112... 

However, harm reduction was not the official role of the clinics so whether or not they were achieving some success at it, they were in any case being judged by other criteria. From outside they were assessed from the perspective of social control, while from the inside a treatment model was stressed. Eventually they were viewed as failing on both counts. 

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