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Drugs and Crime Prevention Committee PARLIAMENT OF VICTORIA OCCASIONAL PAPER No. 1Harm-Minimisation : Principles & Policy Frameworks” The views expressed in this paper do not reflect current or proposed Victorian Government policy, and they do not necessarily reflect the final position of the Victorian Parliamentary Drugs and Crime Prevention Committee. 2.1: Harm Minimisation as the Fundamental Goal of Drug PolicyThe fact that different objectives operateintended outcomes of the specificactivities contribute effectively to theachievement of the strategy’s underlyingprimary goal(s).This suggests that the primary goal(s) ofenough to encompass the diversity of“lower-level” interventions, activitiesand objectives needed to address therelevant to all domains of policy activityhealth, education, law enforcement, :Harm Minimisation as the Fundamental Goal of Drug Policyminimisation is coming to be viewed bymany as the right primary goal for drugview is indeed correct, it is important toexplore two closely tied issues: firstly,understood, is in fact the most justifieddrug policy and practice.actice. Single, 1995; Lenton &Midford, 1996.]. As Eric Single pointsout, “Lacking a clear definition, theconcept of harm-reduction or harm-minimisation is in danger of being co-opted by persons who have verydifferent conceptions of what harm-reduction means in terms of policies andprograms.” (Single 1997).Because we are in the business ofdiscussing fundamental goalsthings that are most worth achieving inof harm-minimisation and its defence asa worthwhile goal will be closely linked.words “harm-minimisation” will not do.practice.Once we start talking in terms of policyideals, we have moved into the realm ofdebate, argument and justification. Thismeans that the particular ideal of harm-minimisation we settle on in the endsuccessfully defended in the context ofsuch an ideal, the following issues willneed to be clearly and convincinglyWhat should count as a drug-relatedShould harm-minimisation bereduction” or “harm-minimisationpractice?priorities in line with their relativeseriousness or urgency? .3:Reduce Harm or Minimise it?costs” associated with money beingcould have been spent in other moresocially productive ways (Collins &Lapsley, 1992).These few examples are of harms thatare widely recognised. However, druguse and the social and personal contextsin which it occurs are dynamic andrelated harm should be sensitive to thisfact, as well.With changing circumstances and socialpriorities, we may sometimes need toas a drug-related harm, to include thingsthat are not quite as tangible andoverall anxiety, concern, uncertainty andimpotence a community may feel as thedrug problem becomes increasinglywidespread and seemingly intractable,surely counts as a significant harm.Indeed, this social anxiety and sense ofimpotence can sometimes threaten to beself-fulfilling, and to paralyse thecollective will to rise to the challenge thedrug problem presents for society. Thisexample serves to reinforce themaintaining an open and inclusivedrug-related harm. :Reduce Harm or Minimise it?reductionminimisation when it comes todefending primary goals for drug policywhat “minimisation” is taken to imply.Reducing harm simply means decreasingdecrease in harm still counts as harmreduction, even when harms could easilybe reduced to a much greater degree,the primary goal seems too weak.for a stronger primary goal because itpossible. Sure enough, it is much easierreduced than to know when they havebeen reduced as much as possible. Butstill, it does seem true that if it ismakes no sense to want to reduce themonly a little and not as much as theyis the better and more fundamentalSo, in the following section ondefinition, the focus will be on clarifyingthis concept, it will become clearer whatis implied by harm-minimisation in :Defining Harm-minimisation: Aims or Outcomes? .1:Minimisation of Harm or Reduction of Use: Questions of JustificationContext is central to an understanding ofprevailing contextual factors is crucial topolicies and interventions. Anexpectation that some policy orminimising will only ever be fullythrough an accurate, evidence-based,:Minimisation of Harm or Reduction of Use: Questions of Justificationfits into the picture. This issue is perhapsthese two compare as potential primarygoals when it comes to their respectiveintrinsic appeal, achievability, andcomprehensiveness (Caulkins & Reuter,goal? There are a number of generalconsidered the more fundamental goal.These reasons can be listed as follows:What is itit is problematic? In answering this, it isconsequencesthe harms that it creates, rather than themere activity of using itself, which is thepolicy and practice were simply andfulfilling their purpose even when theyeither create harms or leave existing onesunresolved. Clearly, though, somethingcrucial would have been overlooked withconcerned, it is the drug-related harmsrather than the drug use itself thatappears to matter fundamentally. If theA goal of harm-minimisation willrecognise important differences thatuse:practice is simply to reduce the level ofdrug use – that is, to reduce the totalthen issues about the type of drug thatpeople use, or whether they use it in aheavily they use, will not be a centralReuter, 1995). Differences between, say,the injecting use of heroin and thesmoking use of heroin will not register asof use reduction. The difference is onlydrug-related harms are a concern.Similarly, if all that matters is reducingwill be viewed as being on the same .2 : Integrating use-reduction “use-targeted” and “use-tolerant” harm reductionof activities as harm-minimisation. Fewwould disagree that a world completelythe use of illicit drugs in this country,that use continues to grow. And even atcomplete abstinence for individuals is, inapproach would recommend that anharms associated with use is betteruse-reduction: Harm-minimisation cangoal than use-reduction in the sense thatharm-minimisation can reducing activities as a means. If pursuedsensitively, policies and interventionsdesigned to reduce use can be a veryeffective way of reducing drug-relatedharms (Caulkins & Reuter, 1997).However, the only use-reducingactivities that can fall under the umbrellasensitive way. They must attempt toreduce use in ways that can bereasonably expected to reduce orcurrent or future use are harm-reducingin this way. For example, intensiveeither increase the risk of harms or failto reduce them in the long run. Suchuse-reduction activities are notcompatible with a framework governedby harm-minimisation.the preceding paragraphs stronglypreferable to the other leading candidate– the reduction of use - as the primary3.2 : Integrating use-reduction - “use-targeted” and “use-tolerant”harm reductionthe fact that use-reduction and harm-reduction can coexist within the oneframework of drug policy and practice,sensitive in the right way. In fact, it mayactivities which it is fully reasonable toexpect will successfully reduce harmthis coin is that there will be cases whereharms can only be effectively reduced byavoiding efforts to reduce use, or byrecognising that reduction of use orabstinence is unachievable in thecircumstances. Refraining from policingof this, as is educating at-risk adolescentsIt may be useful, then, to speak of “use-well as use-targeted ones.These last few observations throw some : Relative harms: comparisons and priorities within a harm-minimisation framework.While the discussion so far has mostlyfollow will turn to what the basicstructure of a harm-minimisationframeworkintervention activity might ideally look of activity. : Relative harms: comparisons and priorities within a harm-minimisation framework.the degree to which they need them willand resource priorities should lie. Butwhole story, since the question stillremains as to which needs are moreneeds compete for attention. And this,The issue of the measurement andcomparability of drug-related harms is afar presented itself. Certainly, someharms do seem clearly much moreBut what is still elusive is some reliableway of completely and consistentlyranking and assigning priorities between drug-related harms.In the absence of criteria for completelysuggest themselves:Make the most informed and justifieddecisions possible: Even if there is anelement of controversy and uncertaintypriorities between different interventionsabout priorities still need to be made.The element of controversy orhowever, that the decisions that aremade about which activities to give moreas rational, informed and justified a wayGive precedence to harms that can bereadily addressed.with harm-minimisation is the pursuit ofrealisable, practical goals. It makes sensethat the degree to which a harm can besuccessfully addressed should play a rolein determining its priority for attention.There should be open and continuingrelated harm is a value-laden andwhat criteria ought to be employed todetermine the priorities and urgenciesthat exist between harms. Given thatvalues emerge and become ascendantover time while others decline, it isthat this dialogue is as socially inclusiveand informed as possible, including theperspectives of users themselves.A substantial emphasis should beplaced on efforts at clear which drug-related harms deservethe most attention when they arise, itmakes sense to ensure that as few harmsas possible arise in the first place. Thatis, if the problem can’t be solved when itpriorities becomes that of determiningprevention and early intervention). : The structure of a harm-minimisation framework 2.4:Defining Harm-minimisation: Aims or Outcomes?ffective harm-minimisation will seekto reduce harms through areduction, and treatment andlaw enforcement, supply interdiction andcriminal justice administration, as well asearly intervention, education, prevention,these means will be supported byuseful to picture the structure of a harm-archway (see Figure 1), whereachievement of the goal of harm-three strategically placed pillars of supplyenforcement), demand reductionintervention), and treatment andrehabilitation interventions. Thosepillars, in turn, are embedded and :Balance of effort in a harm-minimisation framework. Targetingharms and coordinating actionhis idea of an archway is a useful wayframework are related to each other.However, it doesn’t throw much light onbetween those components. How muchenforcement and supply interdiction asopposed to education or rehabilitation orresearch, for instance, and what factorsthis? This, effectively, is a question aboutefforts within a harm-minimisationframework, and relates to strategy 5.3: Supply Reduction versus Demand Reductionexperienced. Central agencies need to besimply become a disguise for centralisedamongst agencies isparamount as well. This is true of bothlocal and central agencies. At the locallevel, it is important for agencies not tosharing of information and resourcesbetween local agencies within regions.The real-life problems experienced atones. This means they will rarely beeffectively addressed through only onethrough law enforcement, for example,this intersectoral integration will involvethe establishment of such things asat the more centralised level ofthe joint interdepartmental developmentservice delivery at the local level.So, it is clear from this why it is crucialwithin a harm-minimising framework tomaking, as well as integrated local anddepartmental activity and intersectoralThe need to use resources and efforteffectively also explains the central roleof each of the different meansClearly, an adequate regime of treatmentand rehabilitation is necessary to addressBut also, potential harms as well asbe directed at prevention through earlytargeting of youth use. Reducing the riskadolescents reduces the need to spend agreater level of future resources on theyouth use were allowed to develop. AsEric Single and Timothy Rohl state intheir evaluation of the National DrugStrategy, “Targeting youth is aninvestment in the future” (Single &There is also an important role forsupply reduction. Carefully targeted,harm-sensitive efforts at detecting drugtrafficking, for example, can beharms that would arise if such effortssupply reduction and treatment andharm-minimisation framework.And finally, harm-minimisation isthe above means without thetargeted data-collection, research andevaluative feedback.:Supply reduction versus demand reduction 5.5:Threats to a harm-minimisation framework. Managing the message6: The Core Elements of a Harm-minimisation Frameworksensitive treatments and interventions.Ministering to these groups in a just andequitable way will also mean devotingspecial attention to the antecedentBecause of the pre-existingharms may require a special effort to bemade and a greater than normal amountminimisation will also be particularlyattuned to the nature of the changingneeds, disadvantages and specialcircumstances that arise in differentothers. The disadvantages associatedof distance associated with rural living,Full sensitivity to all this requirescoal-face of harm reduction activity.Most of all, it is imperative to haveinvolved in the whole process of :Threats to a harm-minimisation framework. Managing the messagecomprehensive and complex drugstrategy will succeed in minimising harmthose things that threaten its continuedviability. Different threats will arise instrong social and political vigilance andcommitment to harm-minimisation willbe needed to overcome them as theyarise. But two major forms of threat areobjections to a harm-minimisationits meaning and purposes; and (ii) thepublic misperception that the “use-acceptance of drug use, with the effectthat this acts to normalise that use. Tomotives, rationales and processes ofharm-minimisation, and also seeks toreduction might engender.6: an indication of what harm-minimisationmeans, what makes it justified as aalso what the basic structure of aframework for pursuing harm- 7. Locating harm-minimisation in the context of some other major illicit drug themes.efficiently and effectively pursue its goal, needs to have the capacity to experiment and develop innovative responses to drug-related harms, especially those entrenched hard cases which seem to resist responding to traditional approaches. Coordinated policy and targeted program activityis central to harm- By definition, a harm-minimising strategy needs to direct its efforts and resources in the most efficient and effective way it can to reduce harms. It was seen that this efficiency will not be possible without the appropriate targeting and systematic coordination of decision-making and program operation. This coordination, it was argued, requires a balanced sharing of decision-making between the local and centralised levels. An ideal harm-minimisation strategy will be integrated and cohesive Having different specific activities with their own lower-level objectives within a strategy was seen to be an effective way to respond to diverse problems and circumstances. This diversity of objectives and activities, however, will be quite pointless and counter-productive if there are tensions and antagonisms among them - if one policy or activity frustrates or interferes with the other. Whatever their particular and immediate purposes, they will need to be cohesive with each other to ensure that their overall collective effect is to achieve the primary goal of minimising harm. This means that harm-minimising policies, programs and interventions spanning different domains of social activity cannot be developed and enacted in isolation from each other. They need to be perceived in an integrated way, and viewed in terms of the part they and other activities play in the overall goal of minimising harm. The full range of drug-related harms will only be identified and minimised inclusion and “humanisation” of usersin decision-making processes about potential solutions. It is clear that problematic drug users are socially marginalised in various ways, and this in itself is a substantial harm. Care should be taken, therefore, not to further compound this marginalisation through the sorts of solutions that the state or professionals propose for the drug problem. Including users, or representatives of users’ interests, at all levels of the harm-minimisation process will go a considerable way to ensuring that this marginalisation is curbed, and that users are empowered to assume some control of their lives. Having users play a part in the dialogue concerning drug policy also ensures that accurate information about users’ needs and perspectives on use is reflected in policy decisions and intervention approaches (Des Jarlais & Friedman, 1993). 7. Locating harm-minimisation in the context of some other major illicit drug themes. Efficiency is not the only guiding constraint on the goal of harm-minimisation. The minimisation of harm should ideally be achieved in a way that is just and . This means targeting resources and efforts to those groups whose characteristics or particular differences or social circumstances disadvantage them in various ways and leave them susceptible to harms or risks of harm, or else less accessible to help. is paramount: Because circumstances change and are rarely constant, and because not all of the contextual factors that influence successful reduction of harm are immediately apparent, it is important to evaluate program activity to gain regular, accurate feedback. It is important to evaluate on the basis of meaningful comparisons, too. Appropriate research, monitoring and evaluation is pressed upon us by the context dependent nature of harm- minimisation, and the need to maximise the long-term reduction of harm. Managing the message of harm-minimisationis crucial to ensure that (i) the public is fully informed about the meaning and point of harm- minimisation, and (ii) that “use-tolerant” forms of harm-reduction do not inadvertently act to normalise drug use through being seen by the public as an official acceptance of drug use. 7. Locating harm-minimisation in the context of some other major illicitdrug themes.guided by that primary goal looks like.What has not been discussed so far,minimisation has with respect to someother key themes that often arise inrelation to illicit drugs. Having now a: Itbecause harm-minimisation, as thatincompatible with abstinence, and that ainclude interventions with abstinence asnot correct.There are a number of reasons tosuggest that abstinence-basedinterventions might have a place within aharm-minimisation framework. It was 7. Locating harm-minimisation in the context of some other major illicit drug themes.will simply favour those approaches thatcontribute most effectively to thenature of prevailing circumstances willalways be relevant in determining this.relationship between prohibitionism andharm-minimisation would by far exceedthat are relevant to clarifying thatIt is crucial to keep clear sight of thedifference between the aims ofor reduce people’s use of illicit drugs.claimed, that the fundamental andcase would count as harm-minimisationwas eventually defined, it was theexpected that became central, and notaims. This means that to determine howlikely effects. The following twoThe use of illicit drugs has notdecreased as a result ofuse (and resulting harms) therewith the black-market trade in drugsand the clandestine circumstances ofusage. These include crime, violencefrom unsafe use.decriminalisation, or even legalisation,harm-minimisation framework, it willsensitive. Prohibitionism will need tooperate in a way that is acutely aware ofthe potential it can have for creatingregulation is completely harm free in itsimpact, and that the choice is really amatter of finding a regime that reducesthe most harm and creates the least in A virtue of this, too, is that it allows a policy or intervention to still count as an example ofharm reduction/minimisation, even though it might, in the very end, fail to reduce/minimiseharm. But it will only still count as harm reduction or minimisation if the failure was due tosomething unforeseeable. A foreseeable failure would mean that the expectation that harm wouldbe reduced or minimised was not based on all the relevant available evidence, and so was not The recent National Drug Strategic Framework document sees a harm-minimisationframework as incorporating supply reduction, demand reduction and harm-reduction as itsdimensions. While it is clear what is intended in this, it is argued here that harm-reduction filters areas of a harm-minimisation framework, and is consequently not a distinct andseparable dimension in itself. In the structure preferred here, demand reduction, supply Page 26 Newcombe R., 1992. ‘The Reduction of Drug-related Harm. A Conceptual Frameworkfor Theory, Practice and Research’ in O’Hare, P.A., et al. (eds.) The Reduction of Drug London Routledge.Single. E., 1995, ‘Defining Harm Reduction’, Drug and Alcohol Review, Vol. 14, pp. 287-Single, E., 1997, ‘The Concept of Harm Reduction and Its Application to Alcohol: The Dorothy Black Lecture’, Drugs: Education, Prevention and Policy, Single, E. & Rohl, T., 1997. The National Drug Strategy: Mapping the Future Department ofHealth and Family Services.South Australia, 1978. Royal Commission into the Non Medical Use of Drugs, 1978.Strang, J. & Farrell, M., 1992. ‘Harm-minimisation for Drug Misusers: When SecondBest May be Best First’, Strang, J., 1993, ‘Drug Use and Harm Reduction: Responding to the Challenge’ in NHeather, A Wodak, E Nadelmann, P O’Hare eds.. Psychoactive Drugs and Harm-reduction:Sutton, Adam and James, Steve 1996. Evaluation of Australian Drug Anti-Trafficking LawEnforcement. National Police Research Unit. Payneham, SA.Wodak, A. & Saunders, B. 1995. ‘Harm-reduction means what I choose it to mean’,Drug and Alcohol Review