Chapter 16 - Prevention

Risk reduction and harm reduction

 

The harm reduction approach has become a preferred tool in preventing AIDS/HIV contamination through intravenous drug use. It was discovered in the late 1980s that IV drug users were a key vector for the transmission of HIV. Needle exchange programs came about as a result.

However, the harm reduction approach creates a number of conceptual and theoretical problems. The first problem is terminology. “Harm reduction” is the term most commonly used in English, but “risk reduction” is also sometimes used. In French, “harm reduction” has been rendered as “réduction des méfaits”, but also as “réduction des dommages” and “réduction des risques”.

Further, the concept and practice of harm reduction have been criticized by some observers who see them as veiled strategies for legalizing drugs.

 

When I say a ‘harm reduction drug policy,’ I do not mean as we have already initiated in the response to drugs so far. We have tried many things such as needle exchanges and we have tried a harm reduction approach to drinking and driving. I have developed many programs for youth, which is my specialty. If I were called upon to develop a program to teach youth with any certainty about how to use drugs that are now illegal in a safe and moderate way, I do not think I could do so. Drugs fundamentally have effects. They do affect us. For example, it may be the cleanest heroin in the world, but is the person functioning in the family and at work, and are they able to pay for the habit that they will develop? Those are questions that need to be answered.

 

When I use the term, I mean harm reduction as it has been promoted. The term has become sullied, unfortunately. It began as a noble thing, but has become a key code word for decriminalization or legalization of substances. I would caution you against using the term as it is. [1][41]

 

Granted, harm reduction strategies are often on a collision course with law enforcement strategies: the situation has arisen often in cities across Canada where heroin addicts leaving needle exchange clinics come face to face with police.

The term “harm reduction” refers more specifically to strategies aimed at reducing the adverse effects of drug use on health, economic status and the social environment for users and those around them.[2][42]  In addition to needle exchange, harm reduction strategies for drug users include such measures as prescription methadone for heroin addicts, medically supervised prescription heroin programs and “safe injection rooms”, or clinics where no prescription is required.  Canadian stakeholders agree that these measures are underdeveloped in Canada. Health Canada recently announced that a prescription heroin program would be tested in three major cities. The number of methadone places is said to be insufficient. Moreover, there are no safe injection rooms.

What are the implications of a harm reduction strategy for cannabis? What applications might there be for such a strategy? Harm reduction strategies related to heroin, for example, have been based on knowledge of some of the harmful effects of injecting the drug: HIV and hepatitis C for users (needle exchange programs), unsanitary conditions and risk of violence in places where the drug is injected (safe injection rooms), and petty property crime to get money to buy drugs (prescription heroin). In order to develop harm reduction strategies, we therefore have to know at least something about the ways the drug is used and its direct and indirect harmful effects. What are the harmful effects of cannabis?

We identified some of those harmful effects in Chapters 7 and 8. They include:

··               risks for youth under 16 because of their physiological immaturity, in particular the immaturity of their endogenous cannabinoid system;

··               risks associated with use that could be described as “occupational” (as opposed to recreational): the person uses marijuana alone, in the morning, to do school work or to carry out a job;

··               risks associated with heavy, frequent use over a long period;

··               risks associated with inhalation over a long period;

··               risks associated with impaired driving, especially when the marijuana is mixed with alcohol.

 

Based on this knowledge, harm reduction strategies could be developed for cannabis:

··               discourage use by youth under 16;

··               detect at-risk users, especially among youth;

··               provide information on the risks of inhaling and point out that deep inhalation is part of the folklore and is not necessary to obtain the effects;

··               use strong measures to discourage impaired driving.

 

Obviously, like harm reduction strategies for other drugs, these tools are based on recognition of use and an approach that does not call for abstinence. We know full well that these two points may elicit strong reactions from those who believe that cannabis is fundamentally dangerous and may put us at odds with the current legal context.