By MNLSpayday loans

ALL BOOKS
Seeds

Pharmacology

Substances
Overdose
mod_vvisit_countermod_vvisit_countermod_vvisit_countermod_vvisit_countermod_vvisit_countermod_vvisit_countermod_vvisit_counter
mod_vvisit_counter Today 7326
mod_vvisit_counter Yesterday 7490
mod_vvisit_counter This week 40868
mod_vvisit_counter Last week 61170
mod_vvisit_counter This month 153830
mod_vvisit_counter Last month 256077
mod_vvisit_counter All days 3126848

We have: 32 guests, 22 bots online
Your IP: 207.241.226.153
Mozilla 5.0, 
Today: Apr 18, 2013
Visitors Counter

JoomlaWatch Agent

Visitors hit counter, stats, email report, location on a map, SEO for Joomla, Wordpress, Drupal, Magento and Prestashop

JoomlaWatch Users

JoomlaWatch Visitors



56.4% United States  United States
12.9% United Kingdom  United Kingdom
5.8% Canada  Canada
4.8% Australia  Australia
3.4% Philippines  Philippines
2.5% India  India
1.9% Netherlands  Netherlands
1.2% Germany  Germany
1.1% France  France
0.9% Ireland  Ireland

Today: 628
Yesterday: 664
This Week: 2609
Last Week: 4265
This Month: 10641
Last Month: 16705
Total: 47851


PDF Print E-mail
User Rating: / 0
PoorBest 
Articles - International & national drug policy
Written by Richard M Pates   
Sunday, 17 December 1995 00:00

alt

1995 VOL 6 NO 1

Copyright© IJDP Ltd. The following pages are produced in cooperation and with approval of the International Journal on Drug Policy Ltd.

THE EFFECTS OF POLICY-MAKING ON HARM REDUCTION: WHOSE PROBLEM?

Richard M. Pates, Consultant Clinical Psychologist, Cardiff Community Drug Team, UK

INTRODUCTION

Policy has a major influence on how measures designed to reduce drug-related harm are implemented. This may seem self-evident because it is clear that good health in a population has to come from adequate provision of resources and the implementation of policies designed to promote healthy living. It appears, however, that a belief in the need for high levels of general health in a population does not necessarily include, in some countries, people whose activities are illegal or where behaviour may be defined as leading to 'self-inflicted harm'. This applies particularly to those involved in drug use or the sex industry. Attitudes towards and services for both these groups of people vary greatly both between and within countries. Thus policies designed to promote good health in this section of the population, e.g. harm-reduction measures, often run counter to national or local policy, and promote such discomfort in the sections of the population controlling policy-making that these measures either do not get implemented or such barriers are put in the way to make them ineffective.

Those who would offer a moralistic view of drug use may argue that enshrining harm-reduction measures in health promotion policies is indefensible. They may argue that those whose activities are illegal and health negating should be punished or discouraged from their activities. Therefore the provision of needle and syringe exchanges, drugs substitute and maintenance programmes, greater access to primary health care for those in the sex industry or greater tolerance of drug users should not be part of health policy. However, this assumes that those who use drugs or work in the sex industry are not part of the general population, as if they are a subset of the population, yet they are clearly us and of us and interact closely with the rest of the population. The sex industry has clients, drug users have partners and families and these groups are as much a part of the population as any other.

It is also clear that the great crack-down on drug use through more costly law enforcement, crop eradication, greater prohibition, and even capital punishment in some countries for drug dealing or trafficking, have done little to reduce the problems of drug use and the spread of HIV. It may well be that strict prohibition and moral censorship which make drug use more elusive to public gaze encourage the spread of HIV. Indeed, countries where repressive measures exist still have large problems, made worse by doing it out of sight. Malaysia, which has a mandatory death penalty for trafficking more than certain quantities of drugs, has had a palpable drug problem and New York which has a high prevalence of HIV and high levels of drug use has large numbers of drug users in prison, the incarceration of whom is more likely to lead to health-negating behaviour. It is also clear that where services are well organised and run on pragmatic, non-moralistic bases, the effect on the number of drug users in contact with services and the associated action against the spread of RIV is marked.

The Advisory Council on the Misuse of Drugs (ACMD, 1988), a committee that advises the British government, has stated in one of its reports that:

'HIV is a greater threat to public and individual health than drug misuse. The first goal of work with drug users must therefore be to prevent them from acquiring or transmitting the virus. In some cases this will be achieved through abstinence. In others, abstinence will not be achievable for the time being and efforts will have to focus on risk reduction. Abstinence remains the ultimate goal but efforts to bring it about in individual cases must not jeopardise any reduction in HIV risk behaviour which has already been achieved.'

The Ottawa Charter of the World Health Organization, a charter resulting from the first international conference on health promotion, propose five areas of action for achieving 'Health for All' by

the year 2000. This Charter was signed by representatives from 38 countries including the USA, Australia, New Zealand and 28 European countries.

The Charter defined health promotion as the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental and social well-being, an individual must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasising personal and social resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector but goes beyond healthy lifestyles and well-being (WHO, 1986).

This statement has a clear framework for effecting policy and facilitating personal responsibility for health and as a 'resource of everyday life' has implications for drug users, sex workers and those working with them. The Charter defined five areas of health promotion action as follows:

  1. Building healthy public policy.
  2. Creating supportive environments.
  3. Reorienting health services.
  4. Strengthening community action.
  • 5. Developing personal skills.

WHEN POLICY AFFECTS SERVICES

New York

The New York Needle Exchange Scheme is a good example of a situation where there is a great need for a service but where policy-makers have frustrated the implementation of an effective service.

A needle-exchange programme functioned for only a short time before being closed (Gillman, 1990). This is in a city with an estimated 200 000 injecting drug users, with an estimation that maybe more than 50% of them are HIV positive. In setting up the programme, conditions were placed upon the. exchange that only one sterile needle per visit was to be issued. No needle exchange would be within 100 ( yards of a school which in a heavily populated city like New York is virtually impossible. It was eventually sited at the Department of Health. The entrance to the facility was opposite the correctional centre where drug users are taken when arrested and it is in an area where it is claimed there is the highest concentration of narcotic agents in the Western World. These clearly do not lead to user-friendly facilities i.e. creating a supportive environment.

New York has a large homeless population and great urban deprivation, and a public medical care system that is overloaded, underfunded and unable to respond to drug users' needs beyond emergencies It is also a city with strict laws regarding possession of drugs, and where the possession of a syringe is a misdemeanour. With a large number of drug users in prison at any one time in the city, the potential for the further spread of HIV and other infections is obvious.

President Bush said during his term of office that he opposed clean needle programmes under any circumstances, and Charles Rangel, a US Congressman from Harlem and Chairman of the Congressional Committee of Narcotic Abuse and Control, contended that exchange programmes do not merit hearings because they encourage and support drug addiction. Thus the national and federal leaders in America cannot be said to be reorienting Health Services, creating a supportive environment or strengthening community action.

Edinburgh

For an example of where policies were implemented too late and policy-makers appeared to wait for the epidemic to spread before taking action, one can look at Edinburgh.

Edinburgh, a much smaller city than New York but with an HIV prevalence of similar proportions, is now tackling the problem (Greenwood, 1990). The situation in Edinburgh from the early to mid-1980s was that a combination of circumstances had led to more than 50% of its 3000 injecting drug users being HIV positive. This is by far the highest prevalence more than 50% of them are HIV positive. In setting up the programme, conditions were placed upon the exchange that only one sterile needle per visit was to be issued. No needle exchange would be within 1000 yards of a school which in a heavily populated city like New York is virtually impossible. It was eventually sited at the Department of Health. The entrance to the facility was opposite the correctional centre where drug users are taken when arrested and it is in an area where it is claimed there is the highest concentration of narcotic agents in the Western World. These clearly do not lead to user-friendly facilities, i.e. creating a supportive environment.

New York has a large homeless population and great urban deprivation, and a public medical care system that is overloaded, underfunded and unable to respond to drug users' needs beyond emergencies. It is also a city with strict laws regarding possession of drugs, and where the possession of a syringe is a misdemeanour. With a large number of drug users in prison at any one time in the city, the potential for the further spread of HIV and other infections is obvious.

President Bush said during his term of office that he opposed clean needle programmes under any circumstances, and Charles Rangel, a US Congressman from Harlem and Chairman of the Congressional Committee of Narcotic Abuse and Control, contended that exchange programmes do not merit hearings because they encourage and support drug addiction. Thus the national and federal leaders in America cannot be said to be reorienting Health Services, creating a supportive environment or strengthening community action.

Edinburgh

For an example of where policies were implemented too late and policy-makers appeared to wait for the epidemic to spread before taking action, one can look at Edinburgh.

Edinburgh, a much smaller city than New York but with an HIV prevalence of similar proportions, is now tackling the problem (Greenwood, 1990). The situation in Edinburgh from the early to mid- 1980s was that a combination of circumstances had led to more than 50% of its 3000 injecting drug users being HIV positive. This is by far the highest prevalence figure among drug users in the UK, and this high prevalence resulted from a number of factors including the strict policing of people with needle and syringes, inadequate services and the early arrival of the virus in the drug-using community.

In 1986 the Community Medical Officer of the local health board recommended that only drug users infected with HIV should be prescribed methadone. The only official needle and syringe exchange sanctioned by the Health Board was opened for 2 hours per week from April 1987 and was situated in a local hospital some distance from the city centre. Again these policies were not consistent with the Ottawa Charter in providing services for drug users. This has now changed with the appointment of a consultant psychiatrist who understood the need to contact drug users and provide an accessible and useful service for them. The policies appear to be showing results in terms of contact and behaviour change, and the service is being extended to include a walk-in clinic.

Greenwood comments that in a city of high prevalence of HIV among drug users, it is difficult to justify the rigid non-prescribing policies adopted by some practitioners who await incontrovertible evidence that medical intervention can appreciably alter patterns of drug use and high-risk behaviours.

Wales

An example of inconsistent policy implementation can be seen in Wales where there was an expansion of services from 1985 until 1991 under a central funding initiative. Services were invited to bid from the funding body on an equal basis, and as local geography and demography varied considerably it was seen as appropriate to develop I services suitable for the health district. Wales is a part of the UK where prevalence of HIV infection is thought to be very low but where outbreaks of hepatitis B among drug using communities are well documented (e.g. Clee and Hunter, 1987).

What happened in Wales after 1985 was that the differential bidding for funding for services was in some cases dependent on the whim of a consultant s psychiatrist. In some parts of the country needle and syringe exchanges flourished and methadone maintenance programmes continued or started afresh. In other parts of the country, however, methadone was not seen as being appropriate; there was a marked resistance to needle and syringe exchanges and a denial of injecting practices in that area. Access to services with a harm reduction commitment was dependent on which side of the country you might live in. This was in spite of access to funding on an equal basis. Local policy here was prejudicing the Ottawa Charter implementation.

The Netherlands

The Netherlands provides an example of policy being used effectively to help drug users. It is a country where policy is used as a strategy, where facilities are available for drug users on a pragmatic approach and where services are

designed to be user-friendly | and available. Needle and | syringe exchange has been | available in Amsterdam I since 1984. The famous | methadone buses have | made access to methadone | easy and have reduced I demand for methadone as a black market street drug to a point where it is no longer a problem. As well as a low- threshold methadone programme, there are detoxification centres, rehabilitation facilities and resocialisation projects as well as well-organised outreach programmes with drug users and sex workers. Where drug users in Rotterdam are found in possession of a used syringe, they are given a clean one in exchange by the police (Grund et al. 1992).

As a result it is estimated that some 70-80% o dependent drug users in Amsterdam are known to caring agencies (van Vliet, 1989) and thus can be reached with help and education if appropriate. In Amsterdam the police are also co-operating with the services in the identification and referral of drug users. Carefully planned services, arranged in a pragmatic, non-moralistic way have clearly worked in the Netherlands. Although the authorities in the Netherlands will say that the system is not perfect, it shows that a range of services plus commitments from a range of policy makers will produce a healthier environment for drug users.

Anti-drug publicity

The effects of anti drug publicity, where the policy is government led, are often contradictory. In some cases government sponsored anti drug advertising has been frightening and unrealistic, e.g. some UK drugs campaigns (Rhodes, 1990). It is inconsistent with a harm reduction model. To have services that are moving towards provision of harm-reduction methods, yet to have advertising that is aimed at abstinence, fear, the inevitability of death and the untreatability of drug problems, is inconsistent and probably does not reach those who are at risk.

It is also interesting to note that campaigns in Britain in recent years have concentrated on heroin use and thus ignored the widespread injection of other drugs with concomitant risks. Indeed, the message for some drug users may be that heroin is associated with HIV whereas amphetamine and other drugs are safe from this risk (Klee, 1991). The increasingly widespread use of anabolic steroids by injection is also causing concern, but has hardly been perceived by users or sports bodies as worthy of comment in an HIV context.

DISCUSSION

It is clear that differences between local and national policies can lead to differing standards of service availability and that the problem for the drug user is to find services that are interested in a harm reduction model. This depends on where you live. If so many countries claim to be striving towards 'Better Health for All' then they must identify drug users as part of the general population with service needs.

It is also clear that the effects of local policing can make differences to the implementation of harm reduction policies. Where there is no agreement of co-operation with the police or where there is active hostility towards drug users, harm-reduction policies are difficult to implement.

This poses the question as to whose problem this is. Policy-making has a direct effect on service provision, it causes major problems for drug users if the services are not there. It causes major problems for health services if users are not in contact with services because of the possibility of the spread of HIV and the pressure on the health services dealing with the consequent AIDS cases. It affects governments' ability to tackle their drug and HIV problem.

These brief sketches show that the policy direction and the actions of policy-makers can affect the quality of service offered to drug users. Although all the countries mentioned were represented at the presenting of the Ottawa Charter, it seems that when it comes to policy for drug users there are widely different patterns. The Ottawa Charter could be used as a platform for the promotion of harm-reduction ideas throughout the world and thus aid in the reduction of the spread of HIV. Some relevant actions arising from the Charter framework could be taken.

Building healthy public policy

It should be enshrined in public policy that drug users, like other people, are entitled to help and care and that the reduction of the spread of HIV in the drug-using population would also reduce the spread in the general population. Legislation that acts as a barrier to providing services to drug users such as needle and syringe exchanges and the availability of treatment programmes for users should be removed.

Those people running drug agencies, involved in drug policy, working with health authorities, social services or municipal authorities should lobby and educate others so that public policy might be changed. In the Netherlands it is clear that there is already police co-operation with services, and in part of the UK this is also happening with co-operation with needle and syringe exchange schemes and arrest diversion schemes. Traditional conservative policy-makers will not change without a perceived threat or an educative push from those in the 'field'. Many drug workers have traditionally been anti-establishment. This may not help in dealing effectively with police, local government, health authorities and national government.

Creating supportive environments

Issues related to drug problems need to have a higher public profile and an attempt to change the way that they are seen by the population as a whole. One approach is the wide availability of harm-reducing measures so that these are not hidden away. An example of this is the wide availability of condoms for safer sexual practices through machines and in any other places where people might congregate. A more drug-related example might be the availability of syringes through vending machines such as exist in Rotterdam and Berlin, and that are being developed in the UK by the Lifeline Project in Manchester. The availability of needles and syringes from community pharmacists as a normal pharmaceutical supply either via exchange or through direct sale is another example of creating a more supportive environment for drug users.

Mass media advertising campaigns should be developed that do not try to frighten young people and alienate drug users, but place the dangers of excessive use within context and promote the treatability of drug problems. Too many of the anti-drug promotion campaigns have either promoted a death message or concentrated on one substance. Those they aim to attract will dismiss the message because it is inconsistent with their experience. Those who do not use will not be touched by the campaign. Although we cannot promote drug use as a healthy activity we can suggest that there is a solution and that parents may understand their children better if they are not convinced that the children will soon be dead !

Reorienting services

If the accent of services is on harm reduction rather than abstinence and they are user-friendly and accessible, only then will people use the services and be more likely to effect behaviour change if the services are seen to be helping them. There should be a commitment from service suppliers such as health authorities to provide services with the same degree of access and quality as other services. This supportive environment should include access for all people. Many drug users and sex workers theoretically have no bar to the various services. However, because of the illegal nature of their activities they may be reluctant to use services seen as being part of the establishment. Mothers fear that their children may be taken from them by social services. Does a service encourage access for women, mothers with young children and for people from cultural backgrounds other than white middle class?

Hepburn ( 1990) describes a service in Glasgow for women with or at risk of HIV providing maternity and obstetric care. In many places in the UK addicted women or women with HIV are viewed negatively in terms of pregnancy and child birth Hepburn says that drug use and child care are incompatible. They have found that by providing range of services as well as medical services on site dealing with problems such as housing, welfare rights, finance and legal issues women will attend clinics. They also manage the pregnancy and ante natal detoxification which Hepburn reports as being as successful in spite of conventional reluctance do so. This service has been sympathetic, supporting and non-judgemental, and uses a truly multidisciplinary approach to women's drug problems.

Greenwood ( 1990) has discussed the way the service in Edinburgh has changed and has been reoriented to provide a harm-reduction model. By persuading general practitioners to prescribe methadone and offering support from the Community Drug Problem Service, a much wider availability of acceptable treatment has become available. Early results show that the clients of the service have stabilised drug intake and reduced high-risk behaviour.

Another model of reorienting service described by Kleinegris ( 1991). In this project a mobile drop-in centre for drug-using prostitutes is parked in the street prostitution area of Utrecht. At this centre, a number of services are available including food, shower facilities, outreach workers to help with problems and two sessions per week from a GP with free consultations. This includes supplying condoms, diagnosis and treatment of sexually transmitted diseases, and immunisation against hepatitis B. A number of other specialists including a dietitian, physiotherapist, cosmetician, acupuncturist, chiropodist and dentist have also provided services at the mobile drop-in. In arrangement with the police in Utrecht the project has also arranged that a parking lot has been established where prostitutes can work in a safer environment.

It is also clear that as drug agencies become busier, general primary health care services such as general practitioners, nurses, social workers and probation officers can also work with drug users, with training and support from drug workers. Both Greenwood and Kleinegris mentioned this and it is clearly a way to involve appropriate workers in primary health care and also identify drug users as part of the community and not as a separate population.

Strengthening community action

Nutbeam et al. ( 1991 ) acknowledged that, although strengthening community action is a major theme in health promotion, it has a difficult translation into the context of injecting drug use. There are a number of models, especially in the Netherlands, of users being involved as advocates and lobbying for legislative changes and more user-friendly service provisions. In the USA users and ex-users are involved as outreach workers on the streets involved in education towards the prevention of the spread of HIV. Wiebel ( 1991 ) discusses the use of indigenous outreach workers in street education. His data showed significant behaviour change in the sample surveyed. He also pointed out the cost saving of prevention of HIV via street work compared with the treatment costs of people with AIDS.

Grund et al. ( 1992) comment on the presence of antibiotic dealers alongside heroin and cocaine dealers in the South Bronx, New York, indicating that the street users are I interested in maintaining their health. This is a phenomenon that is led by street culture rather than by design and is an answer to poor availability of services. Grund et al. also point out that outreach programmes designed to 'rescue' users are alienating and insulting to those whom they seek to help. They say that the AIDS prevention message can only work when it fits into an existing knowledge base and everyday life of those involved.

Developing personal skills

Developing personal skills is clearly important in the prevention of the spread of HIV, because it is these skills and passing them on that will change high-risk behaviour. Many of the projects already mentioned are involved in this, and outreach work is an effective way of reaching those whose behaviour may put them at risk. Bearing in mind Grund et al.'s caveat about the need to embed AIDS prevention messages and skills in users' existing knowledge bases and everyday life, it is important that those passing on education and information receive adequate training to do this appropriately.

Needle and syringe exchanges also provide an environment where personal skills can be developed through demonstration of safe sex practices and the acknowledgement of other risky practices in drug use. The availability of basic primary health care at these sites will also encourage acknowledgement of personal responsibility for health.

The use of peer education programmes can also help in developing personal skills, whether this is in an outreach programme or a peer-led prevention or harm reduction programme through other channels. A non judgemental peer approach may be more effective in changing attitudes and behaviour than an expert-led approach.

CONCLUSION

The five action areas of the Ottawa Charter often overlap and, as can be seen from the foregoing, different initiatives may fit into one or more categories of intervention. What they show is that there are a number of projects demonstrating innovative good practice and that the responsibility for 'Health for All' is from the individual right up to government level. These few pointers act as examples but show that the implementation of good practice involves not only service providers, police, municipal and government agencies, but also users themselves.

Richard M. Pates, Cardiff Community Healthcare Community Drug Team, Cowbridge Road East, Canton, Cardiff CF1 9DU, UK.

REFERENCES

ACMD ( 1988). AIDS and Drug Misuse. Part 1. Report of The Advisory Council on the Misuse of Drugs. London: HMSO.

Clee WB, Hunter PR (1987). Hepatitis B in general practice: epidemiology, clinical and serological features and control. British Medical Journal 295.

Gillman C ( 1990). After one year, New York City's needle exchange pilot programme. International Sournalon Drug Policy 1(5): 19-21.

GreenwoodJ ( 1990) . Creating a new drug service in Edinburgh. ~ ,British Medical Journal 300: 587-9.

Grund JPC, Stern LS, Kaplan CD, Adriaans NFP, Drucker E (1992). Drug use contexts and HIV consequences: The effect of drug policy on patterns of everyday drug use in Rotterdam and the Bronx. British Journal of Addiction 87: 381-92.

Hepburn M ( 1990). Obstetrics, Drug Use and HIV in Women, HlV Drugs: Practical issues. London: ISDD.

Klee H (1991). The potential for the transmission of HIV: Heroin and amphetamine injectors compared. Paper presented at the Seventh International Conference on AIDS, Florence, TUD, p. 106.

Kleinegris CM (1991). Innovative AIDS prevention among drug using prostitutes. Paper presented at the Second Inter national Conference on the Reduction of Drug Related Harm, Barcelona, March 1991.

Nutbeam D, Blakey V, Pates R ( 1991 ) . The prevention of HIV infection from injecting drug use. A review of health promotion approaches. Social Science and Medidrle 33: 97743.

Rhodes T ( 1990). The politics of anti-drugs campaigns. Druglink5(3): 16-18.

van Vliet HJ ( 1989) . Drug policy as a management strategy. International Journal on Drug Policy 11: 27-9

WHO ( 1986). World Health Organization/Canadian Public Health Association. Ottawa Charter for Health Promotion. Health Prornotion International 1(4): iii-v.

Wiebel WW ( 1991 ). Risk reduction through indigenous outreach and intravenous users. Paper presented at Second International Conference on the reduction of Drug Related Harm, Barcelona, March 1991.






Last Updated on Monday, 20 December 2010 23:55
 

Our valuable member Richard M Pates has been with us since Sunday, 19 December 2010.

Show Other Articles Of This Author