Pole to pole

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mike-ashton-269x300Is harm reduction the primary goal, or acceptable only in the service of eliminating drug use? Mike Ashton examines two very different sets of beliefs

Drugs are an evil, and with evil you can’t give way or compromise.’ For Pope Francis, harm reduction in the form of prescribing substitute drugs is just such a compromise: ‘drugs are not defeated with drugs!… Substitutive drugs… are not a sufficient therapy but a veiled way of surrendering to the phenomenon.’ His words derive from a view of drug use as either inherently wrong, or so inevitably and extremely damaging that ‘no use’ is the only justifiable aim.

More temperate variants see harm reduction aims and services as permissible, but only as steps towards stopping drug use altogether. Others elevate harm reduction to an overriding objective which should never be sacrificed to an anti-drugs agenda. Between these poles UK policy has shifted, driven by the threat of HIV from its default anti-drugs base towards the harm-reduction pole.

When in the 1980s harm reduction emerged in Britain, what it was for was clear: to stop the spread of HIV among injectors, and even more so from injectors to the rest of the population. Sometimes reluctantly, its proponents accepted that prioritising this objective meant de-prioritising others, including treatment of addiction and achieving abstinence. The turning point came in 1986 in the report of a committee set up by Scotland’s chief medical officer. Using the new test for HIV, in 1985 an Edinburgh GP discovered that half his injecting patients were infected. Facing this frightening challenge was a committee drawn largely from outside the drugs field, led by Brian McClelland from Edinburgh’s blood transfusion service.

Looking through the eyes of infection control specialists, they relegated to side issues reservations deriving from treatment philosophies focused on abstinence. For them, saving lives was the name of the game. Since ‘Infection with HIV poses a much greater threat to… life… than the misuse of drugs,’ they straightforwardly concluded: ‘On balance, the prevention of spread should take priority over any perceived risk of increased drug misuse.’

What that meant was that injectors who won’t stop must be given clean injecting equipment, and that maintenance prescribing was a way to reduce injecting and maintain contact with injectors, not primarily a step towards detoxification and abstinence. Even enforcement was to be subjugated to the anti-HIV imperative: ‘Police policies in relation to individual drug misusers should be reviewed to ensure so far as possible that they do not prejudice the infection control measures recommended.’

The following year McClelland’s report was cited when the UK’s Conservative government announced pilot needle exchanges to test if they could combat the deadly infection. Also in 1987, harm reduction emerged as a coherent philosophy, not just an emergency response to HIV. It was ‘high time for harm reduction’, argued Russell Newcombe in Druglink magazine. Rather than a ‘deviation’ to be rectified, ‘In many cases, even “dependent” drug use can be reconstrued as just another example of the basic human desire to repeat pleasurable activities.’ Across drug policy, ‘controlled use (rational choice, care and moderation)’ would displace the focus on abstinence.

In 1988 government’s official drug policy advisers echoed McClelland, asserting that ‘The spread of HIV is a greater danger to individual public health than drug misuse.’ Though abstinence remained the ‘ultimate goal’, for the Advisory Council on the Misuse of Drugs, ‘services which aim to minimise HIV risk behaviour by all available means should take precedence in development plans’. They urged that ‘The different goals for drug misusers must not be seen as in competition’, but in fact they were. HIV could only be curbed by accepting drug use rather than primarily trying to stop it.

Hedged about as it was, at first this reversal of priorities from tackling illegal drug use to tackling HIV was not fully embraced by government. But by 1989, on the streets of England a government campaign poster forefronted the risks of sharing needles. Only the small print sought to reduce injecting, miles away from the ‘Heroin screws you up’ campaign of a few years before.

 

By 2012 policy had definitively reversed back. The UK government’s ‘roadmap’ to recovery-oriented treatment subjugated ‘all our work on combating blood-borne viruses’ to the ‘strategic recovery objective’, arguing that ‘It is self-evident that the best protection against blood borne viruses is full recovery’. For the UK Harm Reduction Alliance and co-signatories, including the UK Recovery Federation, this was not at all self-evident. Their response transformed the government’s Putting full recovery first title into Putting public health first, challenging what they characterised as an ‘ideologically-driven hierarchy’ which places ‘full recovery’ at the top, with ‘any other achievement marked as inferior’.

Attacking the roadmap, the Australian Injecting and Illicit Drug Users League insisted that ‘harm reduction is the goal – not a step along the “road to recovery”,’ a formulation derived from their core belief that ‘all other approaches (eg demand reduction, supply reduction) can have validity only where there is strong evidence that they are appropriate, practical and equitable means of reducing drug-related harm.’

These polarities are endemic in debates about methadone maintenance, seen both as a treatment for dependence and a harm-reducing way to maintain dependence. In 2012 an expert group drawn largely from the UK drugs field attempted to reconcile these objectives. Complaining that ‘the protective benefits [ie harm reduction] have too often become an end in themselves rather than providing a safe platform from which users might progress towards further recovery,’ they were prepared to see recovery pursued even if this ‘potentially more hazardous path’ risked relapse. At the same time, ‘preservation of benefit’ was seen as a reason for continuing treatment. Again the attempt was made to mount horses galloping in different directions – possible at a clinical level, but at a policy level, choices have to be made.

 

For some, the harm reduction benefits of remaining on methadone are a clinching argument in its favour, and a warning that an evangelistic recovery agenda will cost lives. Others think the risks worth it, arguing that ‘Leaving the protection of methadone maintenance treatment may increase the risk of death. But it might also be the way to a brand new life beyond your wildest dreams, where you find jobs, homes and friends.’ Leaving methadone is a dangerous business, but a proportion of former patients will swim rather than sink, and for some on the banks, the sight of those ‘recovered’ swimmers leaving methadone and addiction behind seems worth the loss of others.

Peacemakers try to gloss over the divides with, ‘We are all in the same game in the end, aren’t we?’, posing harm reduction and abstinence-based recovery as ends of an unbroken continuum of helping the patient, to which all can sign up. But in reality these are different games, their rules and aims deriving from differences in what we value most and how we see drug use: as always bad, or only bad if it causes harm.

This article is based on the Drug and Alcohol Findings Effectiveness Bank hot topic, Harm reduction: what’s it for? Full text with links to documentation at here.

Mike Ashton is editor of Drug and Alcohol Findings, findings.org.uk.