In the case of
recreational substance use, harm reduction is put forward as a useful perspective alongside the more conventional approaches of
demand and
supply reduction. Many advocates argue that prohibitionist laws criminalise people for suffering from a disease and cause harm for example, by obliging people who use substances to obtain substances of unknown purity from unreliable criminal sources at high prices, thereby increasing the risk of overdose and death. The web forum
Bluelight allows users to share information and first-hand experience reports about various psychoactive substances and harm reduction practices. The website
Erowid collects and publishes information and first-hand experience reports about all kinds of substances to educate people who use or may use substances. While the vast majority of harm reduction initiatives are educational campaigns or facilities that aim to reduce substance-related harm, a unique social enterprise was launched in Denmark in September 2013 to reduce the financial burden of illicit substance use for people with a drug dependence. Michael Lodberg Olsen, who was previously involved with the establishment of a substance consumption facility in Denmark, announced the founding of the
Illegal magazine that will be sold by people who use substances in
Copenhagen and the district of Vesterbro, who will be able to direct the profits from sales towards drug procurement. Olsen explained: "No one has solved the problem of drug addiction, so is it not better that people find the money to buy their drugs this way than through crime and prostitution?"
Substances Depressants Alcohol Traditionally,
homeless shelters ban
alcohol. In 1997, as the result of an
inquest into the deaths of two people experiencing homelessness who recreationally used alcohol two years earlier,
Toronto's
Seaton House became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, people experiencing homelessness who consumed excessive amounts of alcohol opted to stay on the streets, often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of
emergency medical facilities. The programme has been duplicated in other Canadian cities, and a study of
Ottawa's "wet shelter" found that emergency room visit and police encounters by clients were cut by half. The study, published in the
Canadian Medical Association Journal in 2006, found that serving people experiencing long-term homelessness and who consume excessive amounts of alcohol controlled doses of alcohol also reduced their overall alcohol consumption. Researchers found that programme participants cut their alcohol use from an average of 46 drinks a day when they entered the programme to an average of 8 drinks and that their visits to emergency rooms dropped from 13.5 to an average of 8 per month, while encounters with the police fall from 18.1 to an average of 8.8. Downtown Emergency Service Center (DESC), in
Seattle, Washington, operates several
Housing First programmes which utilize the harm reduction model.
University of Washington researchers, partnering with DESC, found that providing housing and support services for homeless alcoholics costs taxpayers less than leaving them on the street, where taxpayer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the
Robert Wood Johnson Foundation appeared in the
Journal of the American Medical Association in April 2009. This first controlled assessment in the U.S. of the effectiveness of Housing First, specifically targeting chronically homeless alcoholics, showed that the programme saved taxpayers more than $4 million over the first year of operation. During the first six months, the study reported an average cost-savings of 53 percent (even after considering the cost of administering the housing's 95 residents)—nearly $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among people experiencing homelessness who recreationally use alcohol.
Alcohol-related programmes A high amount of media coverage exists informing people of the dangers of
driving drunk. Most people who recreationally consume alcohol are now aware of these dangers and safe ride techniques like '
designated drivers' and free taxicab programmes are reducing the number of drunk-driving crashes. Many cities have free-ride-home programmes during holidays involving high amounts of alcohol use, and some bars and clubs will provide a visibly drunk patron with a free cab ride. In
New South Wales groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programmes including the aforementioned 'designated driver' and 'late night patron transport' schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.
Moderation Management is a programme which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behaviour. Harm reduction in alcohol dependency could be instituted by use of
naltrexone.
Opioids Heroin maintenance programmes (HAT) Providing medical prescriptions for pharmaceutical heroin (diacetylmorphine) to heroin-dependent people has been employed in some countries to address problems associated with the illicit use of the drug, as potential benefits exist for the individual and broader society. Evidence has indicated that this form of treatment can greatly improve the health and social circumstances of participants, while also reducing costs incurred by criminalisation, incarceration and health interventions. In Switzerland,
heroin assisted treatment is an established programme of the national health system. Several dozen centres exist throughout the country and heroin-dependent people can administer heroin in a controlled environment at these locations. The Swiss heroin maintenance programme is generally regarded as a successful and valuable component of the country's overall approach to minimising the harms caused by illicit drug use. In a 2008
national referendum, a majority of 68 per cent voted in favour of continuing the Swiss programme. The
Netherlands has studied medically supervised heroin maintenance. A German study of long-term heroin addicts demonstrated that
diamorphine was significantly more effective than
methadone in keeping patients in treatment and in improving their health and social situation. Many participants were able to find employment, some even started a family after years of homelessness and delinquency. Since then, treatment had continued in the cities that participated in the pilot study, until heroin maintenance was permanently included into the national health system in May 2009. As of 2021, the country offers heroin-assisted treatment by prescribing medical-grade heroin is typically prescribed in combination with methadone and
psychosocial counseling. A heroin maintenance programme has existed in the United Kingdom (UK) since the 1920s, as drug addiction was seen as an individual health problem. Addiction to opiates was rare in the 1920s and was mostly limited to either middle-class people who had easy access due to their profession, or people who had become addicted as a side effect of medical treatment. In the 1950s and 1960s a small number of doctors contributed to an alarming increase in the number of people who are experiencing addiction in the U.K. through excessive prescribing—the U.K. switched to more restrictive drug legislation as a result. However, the British government is again moving towards a consideration of heroin prescription as a legitimate component of the National Health Service (NHS). Evidence has shown that methadone maintenance is not appropriate for all people who are dependent on opioids and that heroin is a viable maintenance drug that has shown equal or better rates of success. A committee appointed by the Norwegian government completed an evaluation of research reports on heroin maintenance treatment that were available internationally. In 2011 the committee concluded that the presence of numerous uncertainties and knowledge gaps regarding the effects of heroin treatment meant that it could not recommend the introduction of heroin maintenance treatment in Norway. Critics of heroin maintenance programmes object to the high costs of providing heroin to people who use it. The British heroin study cost the British government £15,000 per participant per year, roughly equivalent to average person who uses heroin's expense of £15,600 per year. Drug Free Australia contrast these ongoing maintenance costs with Sweden's investment in, and commitment to, a drug-free society where a policy of compulsory rehabilitation of people who are experiencing drug addiction is integral, which has yielded to one of the lowest reported illicit drug use levels in the developed world, a model in which successfully rehabilitated people who use substances present no further maintenance costs to their community, as well as reduced ongoing health care costs.
Naloxone distribution Naloxone is a drug used to counter an overdose from the effect of
opioids; for example, a heroin or
morphine overdose. Naloxone displaces the opioid molecules from the brain's receptors and reverses the
respiratory depression caused by an overdose within two to eight minutes. The
World Health Organization (WHO) includes naloxone on their "
List of Essential Medicines", and recommends its availability and utilization for the reversal of opioid overdoses. Formal programs in which the opioid
inverse agonist drug naloxone is distributed have been trialled and implemented. Established programs distribute naloxone, as per WHO's minimum standards, to people who use substances and their peers, family members, police, prisons, and others. These treatment programs and harm reduction centres operate in Afghanistan, Australia, Canada, China, Germany, Georgia, Kazakhstan, Norway, Russia, Spain, Tajikistan, the United Kingdom (UK), the United States (US), Vietnam, India, Thailand, Kyrgyzstan, Denmark and Estonia. Many reviews of the literature support the effectiveness of naloxone based interventions in reducing overdose deaths where it is available at the time of the overdose event. This effectiveness has been explained in a
Realist Evaluation which explained the effectiveness through
bystander effect,
social identity theory, and skills training such that universal access to training supports social identity and in-group norms (of people who use drugs), which supports the conditions for the success of a peer-to-peer distribution model of naloxone-based interventions. Stigma and stigmatising attitudes reduced the effectiveness of naloxone based interventions.
Medication assisted treatment (MAT): Opioid agonist therapy (OAT) and Opioid substitution therapy (OST) Medication assisted treatment (MAT) is the prescription of legal, prescribed opioids or other drugs, often long-acting, to diminish the use of illegal opioids. Many types of MAT exist, including opioid agonist therapy (OAT) where a safer opioid agonist is employed or opioid substitution therapy (OST) which employs partial opioid agonists. However, MAT, OAT, OST are often used synonymously.
Opioid agonist therapy (OAT) involves the use of a full opioid agonist treatment like methadone and is generally taken daily at a
clinic.
Opioid substitution therapy (OST) involves the use of the partial agonist
buprenorphine or a combination of buprenorphine/naloxone (brand name
Suboxone). Oral/sublingual formulations of buprenorphine incorporate the opioid antagonist naloxone to prevent people from crushing the tablets and injecting them. The driving principle behind OAT/OST is the program's capacity to facilitate a resumption of stability in the person's life, while they experience reduced symptoms of
withdrawal symptoms and less intense
drug cravings; however, a strong euphoric effect is not experienced as a result of the treatment drug. In some countries (not the US, UK, Canada, or Australia), For accessing sterile injecting equipment clients frequently visit NSP outlets, and for receiving pharmacotherapy (e.g. methadone, buprenorphine) they visit OST clinics; these frequent visits are used opportunistically to offer much needed health care. These targeted outlets have the potential to mitigate clients' perceived barriers to access to healthcare delivered in traditional settings. The provision of accessible, acceptable and opportunistic services which are responsive to the needs of this population is valuable, facilitating a reduced reliance on inappropriate and cost-ineffective emergency department care.
Cannabis Specific harms associated with cannabis include increased crash-rate while
driving under intoxication,
dependence,
psychosis, detrimental psychosocial outcomes for adolescents who use substances, and
respiratory disease. Some safer cannabis usage campaigns including the UKCIA (United Kingdom Cannabis Internet Activists) encourage methods of consumption shown to cause less physical damage to a person's body, including oral (eating) consumption, vaporization, the usage of bongs which cool and to some extent filters the smoke, and smoking the cannabis without mixing it with tobacco. The fact that cannabis possession carries prison sentences in most developed countries is also pointed out as a problem by
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), as the consequences of a conviction for otherwise law-abiding people who use substances arguably is more harmful than any harm from the substance itself. For example, by adversely affecting employment opportunities, impacting civil rights, and straining personal relationships. Some people like
Ethan Nadelmann of the
Drug Policy Alliance have suggested that organized marijuana legalization would encourage safe use and reveal the factual adverse effects from exposure to this herb's individual chemicals. The way the laws concerning cannabis are enforced is also very selective, even discriminatory. Statistics show that the socially disadvantaged, immigrants and ethnic minorities have significantly higher arrest rates. Sale and possession of cannabis is still illegal in Portugal and possession of cannabis is a federal crime in the United States.
Psychedelics The Zendo Project conducted by the
Multidisciplinary Association for Psychedelic Studies uses principles from
psychedelic therapy to provide safe places and emotional support for people having difficult experiences on psychedelic drugs at select festivals such as
Burning Man,
Boom Festival, and
Lightning in a Bottle without medical or
law enforcement intervention.
Stimulants after taking white heroin that was sold as cocaine The
United Nations Office on Drugs and Crime states, "While medical models of treatment for individuals with alcohol or opioid use disorders are well accepted and implemented worldwide, in most countries there is no parallel, long-term medical model of treatment for individuals with stimulant use disorders." The neglect of stimulant-users has been widely considered to be related to the popularity of stimulants among systemically-oppressed groups, such as methamphetamine use among gay men and transgender people, and crack cocaine use among Black people. The
crack epidemic in the United States demonstrates a discrepancy between sentencing lengths of crack cocaine and heroin users, with crack users imprisoned for longer periods of time than heroin users. In 2012, 88% of imprisonments from crack cocaine were of African American people. Stimulant users have increasingly been at risk for opioid overdose since 2006, due to the nonconsensual presence of fentanyl in their substances.
Tobacco Tobacco harm reduction describes actions taken to lower the health risks associated with using tobacco, especially combustible forms, without abstaining completely from tobacco and nicotine. Some of these measures include switching to safer (lower tar) cigarettes, switching to
snus or
dipping tobacco, or using a non-tobacco nicotine delivery systems. In recent years, the growing use of
electronic cigarettes (or vaping) for
smoking cessation, whose long-term safety remains uncertain, has sparked an ongoing controversy among medical and public health between those who seek to restrict and discourage all use until more is known and those who see them as a useful approach for harm reduction, whose risks are most unlikely to equal those of smoking tobacco. "Their usefulness in tobacco harm reduction as a substitute for
tobacco products is unclear", but in an effort to
decrease tobacco related death and disease, they have a potential to be part of the strategy.
Routes of administration Needle exchange programmes (NEP) allowing for safe disposal of
needles in a
public toilet in
Caernarfon, WalesThe use of some illicit drugs can involve hypodermic needles. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, people who use heroin and other substances frequently share the syringes and use them more than once or participate in unsafe practices such as
blood flashing. As a result, infections such as HIV or
hepatitis C can spread from person to person through the reuse of syringes contaminated with infected blood. The principles of harm reduction propose that syringes should be easily available or at least available through a needle and syringe programmes (NSP). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries people who use substances are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name. A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour. It has been shown in the many evaluations of needle-exchange programmes that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programmes have reduced HIV incidence by 33% in
New Haven and 70% in New York City. The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated for a protracted time period. Research organisation the Burnet Institute completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum, City of Yarra and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. During the period between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the local government area the City of Yarra, of which Richmond and Abbotsford are parts of, 1550 syringes were collected each month from public syringe disposal bins in 2012. Furthermore, ambulance callouts for heroin overdoses were 1.5 times higher than for other Melbourne areas in the period between 2011 and 2012 (a total of 336 overdoses), and drug-related arrests in North Richmond were also three times higher than the state average. The Burnet Institute's researchers interviewed health workers, residents and local traders, in addition to observing the drug scene in the most frequented North Richmond public injecting locations. On 28 May 2013, the Burnet Institute stated in the media that it recommends 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area's drug culture continues to grow after more than ten years of intense law enforcement efforts. The institute's research concluded that public injecting behaviour is frequent in the area and inappropriately discarding injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken open syringe disposal bins to reuse discarded injecting equipment. The British public body, the
National Institute for Health and Care Excellence (NICE), introduced a new recommendation in early April 2014 due to an increase in the presentation of the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services are not advised for people under the age of 18 years, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programs. In the updated guidance, NICE recommended the provision of specialist services for "rapidly increasing numbers of steroid users", and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.
Supervised injection sites (SIS) Supervised injection sites (SIS), or
Drug consumption rooms (DCR), are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers. The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programmes prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be people who inject substances, but generally in Europe they do not exclude people with substance use disorders who consume their substances through other means. The Netherlands had the first staffed injection room, although they did not operate under explicit legal support until 1996. Instead, the first center where it was legal to inject drugs was in Berne, Switzerland, opened 1986. In 1994, Germany opened its first site. Although, as in the Netherlands they operated in a "gray area", supported by the local authorities and with consent from the police until the Bundestag provided a legal exemption in 2000. In Europe, Luxembourg, Spain and Norway have opened facilities after year 2000.
Sydney's Medically Supervised Injecting Center (MSIC) was established in May 2001 as a trial and Vancouver's
Insite opened in September 2003. In 2010, after a nine-year trial, the Sydney site was confirmed as a permanent public health facility. As of late 2009 there were a total of 92 professionally supervised injection facilities in 61 cities. and two in United States. The sites in United States opened in 2021. The European Monitoring Centre for Drugs and Drug Addiction's latest
systematic review from April 2010 did not find any evidence to support concerns that DCR might "encourage drug use, delay treatment entry or aggravate problems of local drug markets." The EMCDDA review noted that research into the effects of the facilities "faces methodological challenges in taking account of the effects of broader local policy or ecological changes", still they concluded "that the facilities reach their target population and provide immediate improvements through better hygiene and safety conditions for injectors." Further that "the availability of safer injecting facilities does not increase levels of drug use or risky patterns of consumption, nor does it result in higher rates of local drug acquisition crime." While its usage is "associated with self-reported reductions in injecting risk behaviour such as syringe sharing, and in public drug use" and "with increased uptake of
detoxification and
treatment services." point to the most rigorous evaluations, those of Sydney and Vancouver. Two of the centers, in Sydney, Australia and Vancouver, British Columbia, Canada cost $2.7 million and $3 million per annum to operate respectively, yet Canadian mathematical modeling, where there was caution about validity, indicated just one life saved from fatal overdose per annum for Vancouver, while the Drug Free Australia analysis demonstrates the Sydney facility statistically takes more than a year to save one life. The Expert Advisory Committee of the Canadian Government studied claims by journal studies for reduced HIV transmission by Insite but "were not convinced that these assumptions were entirely valid." while the Vancouver facility had an observable impact. but not evident for the Vancouver facility. The structure of such programs is more flexible than
opioid agonist therapy. Safer supply projects exist in a number of Canadian cities. Critics of these programs point to the risk of
drug diversion and argue that patients should be encouraged to enter
drug rehabilitation programs instead of being given drugs. ==Sex==