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Abstract
Drug addiction (substance abuse) is an issue that affects millions of people. For many IDUs (Injecting Drug Users), addiction takes over their lives, destroying their ability to function in family, workplace, and community.
While other treatment programs are either locating the problem in the person, not the substance taking demand reduction and moral theory as a solution or locating the problem in the substance, not the person with the prohibition; criminal justice, ‘War on drugs’; supply reduction models as a treatment or a cure; the harm reduction movement locates the problem in the relationship between the person and the substance which may change over time.
For injecting drug use, viral transmission is the harm that has received the most attention; there is a large range of other harms, which arise from the use of alcohol and other drugs, some of these harms are unique to the type of the drug used, the mode of administration or to the legal status of the drug.
Injection drug use is associated with a variety of serious harms to the community and to society as a whole. For example, public nuisance; the social and economic costs of health-care provision; the costs of drug-related property crime; the costs of incarceration of serious offenders and public annoyance problems associated with open drug scenes, discarded needles and other injecting paraphernalia. Drug-related criminal activity
Programs that only aim to prevent drug use are thus, by nature, inefficient at curbing the spread of HIV so it was proved that in some areas of the world, injection of drugs accounts for more than 80% of AIDS cases.
Harm Reduction began to gain public support since the First International Conference on Harm Reduction in Liverpool 1990, as IDUs can infect not only other IDUs but also their sexual partners as well as their offspring.
The traditional or old responses to injection drug users focused on arrests, incarceration and provision of abstinence-oriented treatment, but in fact the overwhelming majority of substance users either ”fails” these treatments or never effectively engaged in treatment, this fact added to the spread of HIV//AIDS and hepatitis C among injection drug users, together has led to widespread calls for alternative approaches to injection drug use. There was a particular need for measures that aim to reduce the high-risk drug use (e.g., needle sharing) either as an interim objective leading to eventual cessation of all drug use, or as a longer-term outcome for some groups or individuals. There have also been calls for new approaches to reduce high-risk sexual activities and to improve self-care among injection drug users.
These factors led to the development of harm-reduction concept which has as its first priority a decrease in the negative consequences of drug use.
Harm reduction began as a public-health approach and had placed first priority on reducing the negative consequences of drug use rather than on eliminating drug use or ensuring abstinence.
Drug problems affect each person and community differently. Drug strategies around the world have increasingly grown to accept harm reduction approaches as an important element of a comprehensive drug strategy.
It is not unheard of for services which require abstinence to argue that they deliver harm reduction; because abstinence reduces the harm incurred by people who use substances in a problematic manner
A harm reduction approach includes supporting abstinence as a valid choice or treatment, although harm reduction can be used as a framework for all drugs, including alcohol, it has primarily been applied to IDU because of the pressing nature of the harm associated with this activity.
There is a fact that despite drug education and treatment programs many individuals will choose to inject, illicit and licit drugs for varying periods of time, people must be provided with knowledge and skills necessary to make informed choices about risk behaviors. Another important issue is that the non drug using community faces a greater danger from the wide spread of HIV and hepatitis infections than it does from the effects of drug use itself. So the essence of the concept of harm reduction is to ameliorate adverse consequences of drug use while, at least in the short term, drug use continues.
The idea that any program and policy aimed at reducing drug-related harm is harm reduction. Unfortunately, this idea does not discriminate well between harm reduction and other programs, as virtually every alcohol and drug policy and program attempts to reduce harm. For example, although they are not generally considered to be harm reduction programs, the minimization of drug-related harm is the ultimate goal of abstinence oriented programs.
from the point of view of (UNIDCP) the term “harm reduction” is meant to cover activities aimed at reducing the health and social consequences of drug abuse, an integral part of the comprehensive approach to drug demand reduction. Also Harm reduction (minimization) can be illustrated as an attempt to reduce the adverse health, social, and economic consequences of drug use without necessarily reducing the drug use
Harm reduction is pragmatic and accepts that the use of drugs is a common and enduring feature of human experience. It has a humanist value which accepts the drug user’s decision to use drugs as a fact. The dignity and rights of the drug user are respected, also recognize that, for many, dependent drug use is a long term feature of their lives and that responses to drug use have to accept this.
As it do not focus on abstinence, harm reduction approaches recognize that short-term abstinence oriented treatments have low success rates, and, for opiate users, high post-treatment overdose rates. Also recognize that reduction of drug-related harms is a more feasible option than efforts to eliminate drug use entirely.
Harm-reduction strategies have been controversial, because they work to re¬duce the risks of harm, but not necessarily to reduce drug use. Balance is sought between supply reduction, demand reduction and harm reduction, and between prevention, training and research.
Harm reduction is a comprehensive approach, encompassing the harmful use of licit drugs (such as tobacco, alcohol and pharmaceutical drugs), illicit drugs, and other substances (such as inhalants and kava), and in need to promote the partnerships between health, law-enforcement, and education agencies, community-based organisations and business in tackling drug-related harm.
There is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs, also it is a way of providing contact with drug users through outreach services, individuals in areas with needle exchange programs have an increased likelihood of entering drug treatment programs.
Substitution treatment is another approach introducing another less/non harmful substance to IDUs the first one used was methadone. There have been numerous studies on the effectiveness of methadone and the vast majority of these have shown that it reduces deaths, reduces the user’s involvement in crime, curbs the spread of HIV and hepatitis, enhancing social productivity and helps drug users to gain control of their lives.
Methadone maintenance treatment, combined with attention to medical, psychiatric and socioeconomic issues, as well as drug counseling, has the highest probability of being effective. from the prospective of cost-effectiveness methadone is very beneficial so that every $1 invested in treatment reduces the costs of drug-related crime, criminal justice costs, and theft by $4 to $7.
LAAM, (levoalphaacetylmethadol) also known as ORLAAM ™, can block the effects of heroin for up to 72 hours while Buprenorphine is a partial opioid agonist; which is thought to have some advantages over methadone and LAAM, including fewer withdrawal symptoms and a lower risk of overdose. It is quite common for clients to switch between buprenorphine and methadone treatments. Furthermore, Buprenorphine treatment may contribute by a significant percentage to the drug addict becoming drug-free and being able to revert to normal life through work, activation and education rather than any other kind of therapy.
Another important approach is the education and outreach programs. Drug education materials with a harm reduction focus aimed at high risk populations are readily available in a number of countries, including the United Kingdom, Holland and Australia. While not promoting drug use, such materials tell the user how to reduce the risks associated with using drugs, teaching such things as safer injecting practices. While Outreach workers contact persons such as drug injectors and prostitutes at risk of becoming infected with HIV
Law Enforcement Policies reform is a mandatory approach as balance was sought between law enforcement (exemplified through the US approach to drug policy) and health (the UK approach to drug policy).
In reviewing the literature on drug policy there are eight options available in terms of legal controls over drugs: Free market, legalization, Legalization with “product” restrictions, Market Regulation, Allowing drugs to be available on prescription, Decriminalization, De facto decriminalization or de facto legalization, Depenalization and Criminalization. Our understanding of these eight policy options and their health, social and criminal consequences needs to be expanded and developed.
Tolerance areas, safer injection facilities (SIFs) or drug consumption rooms achieve the immediate objective of providing a safe place for lower risk, more hygienic drug consumption without increasing the levels of drug use or risky patterns of consumption. SIFs target injectors’ use of public spaces to inject drugs in order to reduce the many risks associated with the practice. Compared to conventional services, SIFs provide greater opportunities for health workers to connect with injectors, and to move them into primary care, drug treatment, and other rehabilitation services.
For Alcohol which is associated with other illicit drugs use, the Alcohol-related Harm Prevention (AHP) program is a normative education and skill-acquisition program designed to reduce serious, long-term alcohol-related harm.
Concerning tobacco which is a gate drug Harm reduction approaches to nicotine products focus on reducing the harms to the user as well as to the inhaler of second-hand smoke.
Harm reduction encourages a change in our attitudes towards people who use drugs, rather than seeking to ‘treat’ or ‘cure’ drug addicts as people who have a disease, this holistic approach considers other problems associated with the person’s harmful drug use, such as the availability of the drug in the community, the prevalence of its use, and how much is known about the drug and its effects and harms in the community.
A Rapid Situation Assessment on patterns and trends in drug abuse in Egypt (RSA), conducted by the Ministry of Health with support from UNODC in 1999, showed that the largest proportion of the drug abusing population interviewed was using cough medicine, opium and other psychotropic substances in tablet form, with only a minority injecting drugs. Among IDUs, one-third shared injecting equipment with friends and over 10% with strangers.
In a study was carried out to assess the current situation of drug abuse treatment and rehabilitation facilities and services in Egypt in 2002, the results showed that 22 treatment facilities are present, these facilities were concentrated in Greater Cairo, with two facilities in Alexandria and one facility in each of Gharbia, Sharkia, Assiut and Aswan governorates which may limit accessibility. The bedding capacity of the 22 facilities is less than 1000 beds.
Follow up and aftercare services on patients after discharge was reported by 90% of the surveyed facilities, and only 8 facilities of them provide follow up for one year or more. Rate of relapse goes as high as 95% and as low as 30%, because there is no adequate linkage and coordination between drug treatment facilities and rehabilitation treatment.
Regarding addiction treatment each facility in Egypt has its own protocol of treatment. Some medications are not available in Egypt as methadone, LAAM and buprenorphine.
A part of outreach services in Egypt the Ministry of Health and Population in Egypt had established the hotline which is a free telephone call service supplied by The Drug Combating and Treatment Fund (DCTF), for prevention and treatment of addiction. It provides services to the drug abusers, families and emergency cases; in the form of guidance, information, and referral for treatment, as well as free consultations and treatment.
Concerning tobacco policies and programs, Egypt is in need to expand the treatment capabilities by training primary care physicians to be more active in the area of smoking prevention and treatment.
A comparison of drug policies in different countries, and of drug usage and associated problems, is highly suggestive of which country has chosen the more effective approach. Under the drug problem governments have responded with policies that vary greatly from one part of the world to the other. Currently, most national drug strategies, as well as strategies at other levels of government, incorporate a balance of prevention, treatment, harm reduction and law enforcement to address the harms caused by drug use.
The Islamic Republic of Iran which has tried almost everything in its war on drugs, including digging huge trenches along its porous borders with Pakistan and Afghanistan and even using helicopter gunship and tanks against well-armed traffickers, appears to be failing alongside figures that among Iran’s 65 million people, there are an estimated 2 million injection drug users (IDUs), or 2.8 percent of the population, giving Iran the highest percentage of IDUs in the Middle East.
Iran has been undergoing a quiet revolution in its attitude to addiction in the shape of providing clean needles and even methadone to scores of users every day. They get around 100 addicts a day. Blood tests and even hospitalization are also on offer in the ”harm reduction” effort something the centre backs up with counseling as a first step toward kicking the habit. Patients are obliged to return used syringes to stop sharing them.
Now Iran is one of only 22 countries to provide harm reduction services such as bleach distribution, methadone maintenance, and detox treatment to incarcerated drug users Iran took the progressive and unusual step of introducing methadone maintenance treatment programs in prisons at the same time as the civilian community.
Drug policy in the US is based on a deeply held belief that all illicit drug use is extremely harmful and there is very little distinction made between cannabis and other drugs. Drug laws and drug policies define acceptable and unacceptable behavior and influence the nature of drug use. It could be argued, according to that sanctions actually increase drug-related problems and harms. One is the fear that harm reduction is a Trojan horse for the drug legalization movement. Another factor might be that whereas harm reduction focuses on harms to users, drug-related violence and other harms to nonusers are more salient in the U.S. than in Europe prevalence-reduction policies have failed to eliminate drug use, leaving its harms largely intact. Second, these harsh enforcement policies are themselves a source of much drug-related harm, either directly or by exacerbating the harmful consequences of drug use.
The Netherlands has a long history of harm reduction policies and practices. Harm reduction in the Netherlands is part of a comprehensive approach to drug use involving both demand and supply reduction, and policies aimed at reducing the nuisance caused by drugs. The aim of Dutch national drug policy is to protect the health of individual users, the people around them and society as a whole; drug problems are viewed as social problems. Together with the United Kingdom, the Dutch drug policy has been one of the most widely discussed approaches to addressing drug problems In terms of harm reduction, the Netherlands has a comprehensive system of methadone treatment, needle exchange services and, more recently, supervised injection sites.