1. A multi-disciplinary theory of drug-related harm reduction
Dr. Russell Newcombe
3D Research Bureau, Liverpool
IHRA’s 21st International Conference
Liverpool, April 2010

2. The 2-sided coin of drug policy
Abstentionism
Demand reduction: stopping non-users from starting
(prevention) & helping current users stop (recovery)
Supply reduction: preventing production/distribution
Risk/Harm Reduction
Risk reduction: preventing unsafe drug consumption
Harm reduction: preventing negative consequences & promoting positive consequences of drug use
THESE 2 APPROACHES ARE COMPLEMENTARY – NOT COMPETING

3. Why do we need a theory of HR?
“Experience without theory is blind” (Kant 1787)
Improve communication between various groups
Help design and develop policies and interventions
Organise and interpret research findings
Evaluate effectiveness of interventions/policies
Map out the territory and identify the gaps
In short: it’s time to stop making it up as we go along
MY PAPER AT THIS CONFERENCE PRESENTS A STARTING POINT FOR A THEORY OF HR
THIS THEORY IS ROOTED IN MY PAPER IN: P. O’HARE et al (Eds) (1992), ‘THE REDUCTION OF DRUG-RELATED HARM’ (ROUTLEDGE)

4. Harm Reduction Theory: definitions of 4 core concepts
Stages of drug use: Causes: factors underlying drug consumption & its riskiness (notably genes, traits, memes & policies) Consumption: preparing & administering drugs, and drug intoxication [immediate effects] Consequences: positive and negative outcomes of drug consumption - harms and benefits [ultimate effects] Intervention: a strategy, service or product aimed at modifying causes, consumption and/or consequences

5. Risk & Harm Conceptual Model
Causes Consumption Consequences
promoting-
protecting risky – safer harmful - beneficial
strong-weak high - medium major - moderate
(causality) low (risk) minor (outcome)
physical drug, set & setting health
mental [Risk CAMP-MAP] socio-legal
social economic
__________________________________________________________________________________________________
Red: primary dimension of each stage of drug use Green: salience levels
Purple: core classes of cause/consumption/consequence
THIS IS THE ‘BIG PICTURE’ – THE OVERALL CONCEPTUAL FRAMEWORK

6. Levels of Risk
Risk levels indicate the general propensity of a drug consumption behaviour (eg. injecting) for producing a particular harmful consequence (eg. overdose). Example: overdose risk from 3 methods of heroin use: Lower risk: smoking heroin Medium risk: snorting heroin Higher risk: injecting heroin Example: health risk of alcohol doses for male drinkers: No risk/healthy: about 7 units per week (1 per day) Lower risk: from 8 to 21 alcohol units per week Medium risk: from 22 to 34 alcohol units per week Higher risk: over 35 alcohol units per week
ALSO: MORE SPECIFIC ‘SAFETY DEGREE UNITS’ BASED ON 9 STATISTICAL PROBABILITIES OF RISK/HARM:
Maximum, Extremely High, Very High; Quite High, Medium, Quite Low; Very Low, Extremely Low, Minimum.

7. The 3 classes of drug-related risk
drug policy l m
help
laws
DRUG
body
mind
time
place
SET
SETTING
DRUG = contents & consumption
Source: Zinberg (1984) 7

8. The Risk CAMP-MAP
Context set & setting Amount dose (per use) & quota (per period) Method preparation & administration Pattern frequency & stability Mixture multi-use & poly-use Access source (who) & means (how) Product chemistry & adulterants
‘CAMP-MAP’ IS A USEFUL ACRONYM FOR REMEMBERING THE 7 TYPES OF RISK

9. Consequences: Harms & Benefits
3 levels x 3 types = 9 categories
Harm/Benefit Levels (negative/positive consequences)
Individual drug users
Community family, friends, colleagues etc.
Societal organisations & institutions
Types of Harm/Benefit
Health physical & mental functioning
Social order/disorder; inclusion/exclusion
Economic financial costs & gains
OTHER IMPORTANT DIMENSIONS OF HARM ARE: SERIOUSNESS (major/minor) & CONTROL (easy/hard to change)
ASSESSMENTS OF RISKS OF DRUG USE ARE GENERALLY COST-COST – WE NEED COST (HARM)-BENEFIT ASSESSMENTS

10. Harm-reduction interventions
Causes a
Consumption a
Consequences h h h h
harm
prevention/ benefit
promotion
harm con tainment/ benefit
expansion
risk prevention /
safety promotion

11. HR interventions: 3 classes
HR interventions are aimed at three aspects of drug use: (1) drug consumption & its causes (risk & safety factors) (2) links between drug consumption & its consequences (3) drug-related consequences (harms & benefits) In short, there are 3 classes of harm-reduction intervention: (1) Risk prevention eg. clean needles (2) Harm prevention eg. HBV vaccine (3) Harm containment eg. HBV treatment
POLICY-MAKERS NEED TO PROVIDE HR INTERVENTIONS IN EACH OF THESE THREE AREAS

12. Measures of Effectiveness
The magnitude of change (reduction or increase) in a risk or harm/benefit can be measured on 3 levels:
Example of risk: sharing needles
Prevalence number of needle-sharers
Frequency number of sharing occasions
Intensity number of co-sharers
ALSO: DOES THE HR INTERVENTION CHANGE THE PREVALENCE OF DRUG USE (eg. does needle exchange increase levels of injecting?)

13. 8 core HR interventions, 2010
Provision of drug-taking equipment (esp. NX)
Health-care for drug users (eg. HBV vaccine)
Substitute prescribing (methadone etc.)
Information & education on safer drug use
Drug consumption rooms/sites
Antidotes & treatments for overdose
Testing of drug products (eg. E-testing kits)
Drug law reform & drug users’ rights

14. Gaps in Harm Reduction Work
Neglected risks
Causes genes, memes, knowledge
Access HR with drug dealers (eg. adulterants)
Methods drug-using equipment (eg. foil, pipes, tubes)
Mixtures multi-use & poly-use
Neglected harms
Social criminalization, discrimination, families
Health beyond injecting & infectious diseases
Economic massive costs of drug prohibition
Neglect of benefits: almost total!
AND OTHERS TOO NUMEROUS TO MENTION
ALSO: THIS THEORY IS A FLAWED STARTING-POINT – MOST NOTABLY, IT IS EUROCENTRIC AND NOT PREDICTIVE

15. This paper is dedicated to all casualties of the Drug War
Especially:
Huw Wauchope (imprisoned for cannabis supply – RIP)
Casey Hardison (serving 20 years in prison in UK for ‘trafficking’ LSD & psychedelic drugs)
Full version of HR theory is available by June 2010 from:
“Imagination is more important than knowledge”
(Albert Einstein 1931)
THANKS TO MICHELLE JOHNSON, JANE & JACK NEWCOMBE, SALLY WOODS, ALLAN PARRY, MIKE LINNELL, JOHN MARKS, MIKE JAY, LYNETTE LEWIS AND OTHERS TOO NUMEROUS TO MENTION - YOU KNOW WHO YOU ARE (IF NOT, FIND OUT).