Drugs and Crime Prevention Committee …...6. The core elements of a harm-minimisation framework 7. Locating harm-minimisation in the context of some other major illicit drug themes

Drugs and Crime Prevention Committee PARLIAMENT OF VICTORIA

OCCASIONAL PAPER No. 1

“Harm-Minimisation : Principles & Policy Frameworks”

T h e v i e w s e x p r e s s e d i n t h i s p a p e r d o n o t r e f l e c t c u r r e n to r p r o p o s e d V i c t o r i a n G o v e r n m e n t p o l i c y , a n d t h e y d o

n o t n e c e s s a r i l y r e f l e c t t h e f i n a l p o s i t i o n o f t h eV i c t o r i a n P a r l i a m e n t a r y D r u g s a n d C r i m e P r e v e n t i o n

C o m m i t t e e .

Preface

Illicit drug policy, just like any other form of social policy, cannot be developed and implementedin an arbitrary and unsystematic way. It needs to be based upon and guided by rationallydefended “first-principles” and ideals. The various programs and interventions that flow fromdrug policy also need to be implemented within a systematic, cohesive and goal-directedframework of activity.

There are differing views as to what the goals and purposes of illicit drug policy should be, andcorrespondingly different pictures of what an ongoing framework for implementing those policieswould look like. It is not always the case, though, that these differing views are carefullyelaborated, analysed or compared. The purpose of this document is to do just that. It seeks toclarify and refine what seem to be the most rationally justified “first-principles” and policyframework for an enduringly effective state-sponsored illicit drug strategy.

A goal of harm-minimisation is widely adopted in Australian drug policy, including theNational Drug Strategy. This document endorses harm-minimisation as the most justifiedfundamental guiding principle for the development of illicit drug policy. There are different views,though, as to how harm-minimisation should be defined and what might be involved in realisingit. This document refines and defends a particular conception of harm-minimisation, and it alsooutlines some of the characteristics of a systematic harm-minimisation framework for theimplementation of drug programs, interventions and activities. The primary purpose of thediscussion is to locate and identify certain key criteria that might be relevant to assessing thequality and progress of purportedly harm-minimising drug strategies. This accords centrally withthe brief of the Victorian Parliamentary Drugs and Crime Prevention Committee to evaluateVictoria’s “Turning the Tide” drug reform strategy – a strategy based on a goal of harm-minimisation.

* * * * * * * * * * * * * * * * *

A number of people have made helpful comments on earlier drafts of thisdocument, and their contribution is greatly appreciated. Any furtherfeedback can be directed to the following email address:

[email protected]

Contents

PART ONE:

HARM-MINIMISATION, THE CONCEPT

1. Drug policies, principles and frameworks2.1 Harm-minimisation as the fundamental goal of drug policy2.2 Drug-related harm2.3 Reduce harm or minimise it?2.4 Defining harm-minimisation: aims or outcomes?3.1 Minimisation of harm or reduction of use: Questions of justification3.2 Integrating use-reduction – “use-targeted” and “use-tolerant”

harm-reduction

PART TWO:

HARM-MINIMISATION, A FRAMEWORK FOR ACTIVITY

4. Relative harms: comparisons and priorities within a harm-minimisation framework

5.1 The structure of a harm-minimisation framework5.2 Balance of effort in a harm-minimisation framework. Targeting

harms and coordinating actions5.3 Supply reduction versus demand reduction5.4 Social Justice within a harm-minimisation framework5.5 Threats to a harm-minimisation framework: managing the message6. The core elements of a harm-minimisation framework7. Locating harm-minimisation in the context of some other major

illicit drug themes

Page 1

PART ONE:

HARM-MINIMISATION – THE CONCEPT_______________

1: Drug Policies, Principles and Frameworks

A lot of effort is often put intoimplementing policies, programs andactivities to deal with the social andpersonal problems associated with illicitdrug use. The same amount of attention,though, is not always paid to thequestion of which “first principles”should guide and inform drug policy andpractice. Many of the criticisms that aremade about state and national drugstrategies – for instance, that they arenot efficient or cost-effective, are poorlycoordinated, bring about inappropriateoutcomes, and lack consistent direction– are made because the fundamental orprimary goals of these strategies are notclearly defined nor sufficiently wellthought-out. It is important to have aclear and justified conception of theprimary goals of a drug strategy if policy-makers and practitioners are to developand enact consistently effectiveprograms.

A clear conception is important forevaluation, too, since well-defined anddefensible goals can act as thefundamental yard-stick against whichdrug policy and practice can be rationallyand systematically assessed. With theright primary goals in hand, the way willbe clear for a sound and principledunderstanding of how good drug policyand practice should be developed, andalso what criteria should guide theirevaluation.

Just which primary goals are appropriate,though, is a question about which therewill be varied and competing views. The

whole issue of the aims of drug policyand practice is a hotly contested anddeeply controversial one, both nationallyand internationally. This controversy isall the more reason for becoming asclear as possible right from the startabout what the best goals would be for acomprehensive drug strategy.

In doing this, it is important to keep inmind the difference between the primarygoal(s) of a drug strategy as a whole, andthe more local and immediate objectivesof the particular projects, practices andinitiatives that are the components ofthat strategy (Newcombe, 1992). Theseimmediate local objectives may not bethe same as the overarching goal(s) ofthe broad strategy as a whole. Thereason for this is that there are often awide variety of ways of achieving thesame overall social result. For example, adrug strategy may include particularinterventions whose specific purpose is,say, to provide accommodation supportfor users. Clearly, though, providingaccommodation will not be the overallgoal of the entire drug strategy. Thatgoal will be something broader, which isserved in some way by providingaccommodation.

Given the great diversity ofcircumstances, client needs, and socialand personal problems that prevail inrelation to widespread drug abuse, itmakes sense to have a comparablediversity of activities and interventions,each with its own specific methods andobjectives (Erickson & Ottway, 1993).

2.1: Harm Minimisation as the Fundamental Goal of Drug Policy

Page 2

The fact that different objectives operateat different levels of a drug strategyshould not be a problem, as long as thestrategy as a whole is integrated and theintended outcomes of the specificactivities contribute effectively to theachievement of the strategy’s underlyingprimary goal(s).

This suggests that the primary goal(s) ofa drug strategy should be comprehensive

enough to encompass the diversity of“lower-level” interventions, activitiesand objectives needed to address therange of problems that the strategyhopes to deal with. The goal(s) shouldalso be comprehensive enough to berelevant to all domains of policy activityand practice in the drug world, such ashealth, education, law enforcement,justice administration, and so on.

2.1 : Harm Minimisation as the Fundamental Goal of Drug Policy

Increasingly, harm reduction or harmminimisation is coming to be viewed bymany as the right primary goal for drugpolicy and practice (Hamilton, Kellehear& Rumbold, 1998). To decide if thisview is indeed correct, it is important toexplore two closely tied issues: firstly,what the proper definition or conceptionof harm-reduction should be, andsecondly, whether harm-reduction, sounderstood, is in fact the most justifiedor rationally defensible primary goal fordrug policy and practice.

The importance of a clear and coherentunderstanding of harm reduction orminimisation cannot be overstated.[Strang, 1993; 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 goals – that is, thethings that are most worth achieving indrug policy and practice – the definitionof harm-minimisation and its defence asa worthwhile goal will be closely linked.A simple dictionary definition of thewords “harm-minimisation” will not do.

We need to refine an ideal of harmminimisation that is fit for the purposesof guiding and assessing drug policy andpractice.

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 endshould be the one that can be mostsuccessfully defended in the context ofother possible conceptions of harm-minimisation. In refining and defendingsuch an ideal, the following issues willneed to be clearly and convincinglyaddressed:

� What should count as a drug-relatedharm?

� Should harm-minimisation bedefined with the emphasis on itsaims or on its outcomes?

� Should “harm-reduction” or “harm-minimisation” be considered thecentral goal of drug policy andpractice?

� How are different drug-relatedharms to be compared and givenpriorities in line with their relativeseriousness or urgency?

� How can the different methods ofminimising drug-related harm fit

2.2: Drug-related Harm

Page 3

together to form a well-balanced andefficient harm-minimisationframework for drug policy andpractice?

� What key criteria for evaluating drugpolicies and programs will be impliedby the ideal of harm-minimisationthat we settle on?

� How does a primary goal of harm-minimisation fit in with other policyprinciples, regimes and intervention

approaches such as zero tolerance,abstinence-based programs, andlegalisation, decriminalisation andprohibitionism?

The discussion in the rest of thisdocument tackles these and relatedquestions.

2.2 : Drug-related Harm

When talking of problematic drug useand responses to it, it is natural to focuson the idea of harm. Any major socialpolicy program like a national orstatewide drug strategy will need to bedeveloped and implemented in a waythat is sensitive to human rights. In aclear sense, human rights are simplyrights against being harmed in certainways, or suffering certain sorts of harm.The human rights orientation in socialpolicy, therefore, will naturally suggestthat the focus in drug policy should beon the reduction of drug-related harms.We really need to begin, then, with aclearer idea of what is meant by the ideaof a “drug-related harm”.

It should be kept in mind from thebeginning that the very notion of harm,whether it is drug-related or not, is avalue-laden one. It is not a matter ofmere fact whether something is“harmful” or not, but a matter thatneeds to be decided in the light of valuesand norms. It is a notion thereforewhich is subject to possible argumentand debate (Newcombe, 1992).

Notwithstanding this, it is generallyagreed that the harms associated withproblematic drug use can usefully bedivided into those experienced byindividual users themselves, and those

experienced by third-parties or bysociety collectively. The harmsexperienced by individuals will span anumber of dimensions. For example,

health related harms such as:- risk of death;- serious injury and physical sickness;- psychological/emotional problems;economic harms, such as:- foregone personal employment

opportunities;- heavy financial expenditures to

support personal use;personal/social harms such as:- risk of drug related violence;- family breakdown;- breakdown of friendship and peer

relationships and networks;- stigma attached to criminal

conviction;- risk of incarceration;- social isolation, stigmatisation and

loss of personal dignity.

The third-party harms and costs tosociety cover similar dimensions. Forexample,- 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;

2.3: Reduce Harm or Minimise it?

Page 4

- other broader financial “opportunitycosts” associated with money beingspent on problematic drug use whichcould 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 andchanging, and the notion of a drug-related harm should be sensitive to thisfact, as well.

With changing circumstances and socialpriorities, we may sometimes need toexpand our conception of what countsas a drug-related harm, to include things

that are not quite as tangible andquantifiable as most of the harmsmentioned above. For example, theoverall 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 theimportance of remaining vigilant, andmaintaining an open and inclusivedialogue about what should count as adrug-related harm.

2.3 : Reduce Harm or Minimise it?

Should the focus be on harm-reduction oron harm-minimisation when it comes todefending primary goals for drug policyand practice? A lot depends on exactlywhat “minimisation” is taken to imply.Reducing harm simply means decreasingit, even if only by a tiny bit. But if a tinydecrease in harm still counts as harmreduction, even when harms could easilybe reduced to a much greater degree,then simply having harm-reduction asthe primary goal seems too weak.

Minimisation, on the other hand, makesfor a stronger primary goal because itasks for harms to be reduced as much aspossible. Sure enough, it is much easierto know when harms have simply beenreduced than to know when they havebeen reduced as much as possible. Butstill, it does seem true that if it is

important to reduce harms at all, then itmakes no sense to want to reduce themonly a little and not as much as theycould be. Minimisation, for this reason,is the better and more fundamentaloption.

So, in the following section ondefinition, the focus will be on clarifyingthe most plausible meaning for “harm-minimisation”. By exploring and refiningthis concept, it will become clearer whatis implied by harm-minimisation inpractice. It is hoped, also, that a range ofkey criteria will eventually emerge asbroad guides for understanding thenature and evaluation of harm-minimising drug strategies.

2.4 : Defining Harm-minimisation: Aims or Outcomes?

2.4: Defining Harm-minimisation: Aims or Outcomes?

Page 5

The importance of carefully refining theideal of harm-minimisation is clear.Issues of definition have direct practicalimpact. What harm-minimisation istaken to mean or imply in principle willdetermine just what practices andpolicies are pursued in its name. If weget the principled understanding ofharm-minimisation wrong, then we willget the practice wrong, and drug-relatedharms will not be minimised in the waythey should be. In the discussion tofollow, the meaning of harm-minimisation will be refined in a numberof stages, leading to a full definition afterquestions about the justification ofprimary goals have been settled.

Before we go on, though, there is onefurther matter that needs to be clarifiedin connection with “reduction” versus“minimisation”. It was said that harm-reduction is not demanding enough, andthat minimisation is better in that way.But minimisation, understood in anunqualified sense, turns out to be toodemanding. If harm-minimisation istaken to mean that harms should simplybe reduced as much as possible, that willmean at any cost, or at the expense ofeverything else. Clearly, though, open-ended harm-minimisation like this willnot be realistic. Many other socialpriorities have a legitimate claim tosociety’s efforts and resources. Thereneed to be plausible limits placed onharm-minimisation, to take this intoaccount.

A more sensible conception of harm-minimisation will require the overall netlevel of drug related harms in society tobe reduced as much as possible in thecontext of other competing socialdemands and limitations of resources. Itis harm-minimisation in this qualifiedsense – more demanding than merereduction but less demanding thanminimisation at any cost – that will bethe focus of the discussion to come.

What, then, are the central or definingcharacteristics of harm-minimisation?Should harm-minimisation policy andpractice be defined by its aims, or by itsactual outcomes, or by something inbetween? (Lenton & Midford, 1996).Because the whole language of drugpolicy and intervention development is afuture-looking language – relating towhat is anticipated to be effective –there is clearly something in the idea thatif a policy or practice aims to minimiseharm, then it should count as harmminimisation (Single and Rohl, 1997).

However, focusing solely and simply onaims like this will not provide the wholestory. (Single, 1995; 1997). What actuallyhappens, and not simply what is intendedto happen, seems to be just as relevantto the definition of harm minimisation.An example might show why. Therecent precursor legislation requiring thereporting of suspect sales ofamphetamine chemical precursors wasdesigned to make amphetaminemanufacture more difficult. As far asaims are concerned, this legislationmight look harm-minimising since itseeks to considerably decrease the use ofamphetamines and so minimise theharms associated with their use. Inreality, however, the actual outcome ofthe legislation has been to increase theincidence of poor quality and dangerousforms of amphetamine, to encouragemore dangerous routes of administration(ie., injecting), and to displace usagepatterns toward cocaine (AustralianBureau of Criminal Intelligence 1996).

In other words, even though the centralaim of the legislation was to reduceharm, its actual outcomes fell well shortand probably increased harms, and forthis reason there is some uneasinessabout calling it an exercise in eitherharm-reduction or minimisation. So,actual consequences or outcomes seemto be relevant when it comes to deciding


Page 6

whether a policy or practice is harmminimising or not.

The example above also serves to showthat whether the intended outcomes ofsome intervention actually come toprevail depends very much oncircumstance, and often on unforeseenand unanticipated factors. Just as thefuture can’t be foreseen, the actualoutcomes of policies and interventionscan’t be foreseen either. But now, if thisis so, harm-minimising policies andinterventions cannot be distinguishedsolely on the basis of their actualoutcomes either, since these can only beknown after the fact. As was said, weneed a definition that is suited to the“future-looking” nature of policy andintervention development, and whichallows us to say now whether the thingswe are about to do count as harmminimisation or not.

This presents the following question: Ifaims are important, but harm-minimisation can’t be defined solely interms of these, and if actual outcomesare also relevant but these can’t beknown in advance, how should harm-minimisation then be defined? Somemiddle-path is needed between aims andoutcomes. But one that recognises orincorporates the role of both in someway.

It turns out that this middle-path mightlie with the idea of a “reasonableexpectation”. Even if one can’tunreservedly predict the outcomes of apolicy or intervention, the expectation thatcertain consequences will actually comeabout in some specified circumstancecan be either reasonable orunreasonable. There are degrees ofreasonableness, though, and just howreasonable an expectation is will dependon the extent to which it is informed by,and based upon, the relevant evidence.A fully reasonable or justified expectationwill be one that is formed in the light of

the best available evidence. The policiesand practices based on such expectationsare those that are most likely to succeedin achieving their intended outcomes.These suggestions might provide thefirst elements of a possible definition ofharm minimisation:

a policy or practice is harm-reducing if it isfully reasonable to expect that it will reduceexisting or future drug-related harm, given theparticular context of its application;

a policy or practice or strategy is harm-minimising if it is fully reasonable to expectthat it will reduce existing or future harm to thegreatest degree allowed by the resources andconditions that prevail in the particular contextof its application.

By speaking in terms of expectations, therole of aims is recognised, and byspeaking of expectations that are fullyreasonable (and thus, outcomes that arehighly likely), the importance of actualoutcomes is reflected as well.i

Another important thing this workingdefinition highlights is the fact that thesuccess of a policy or practice inachieving its aim, and actually reducingor minimising harm, depends very muchon the context and conditions in whichit is applied. The very same policy ortype of intervention might be successfulin one context, but fail in another. Forexample, interventions that emphasisethe harms to one’s fellows of drug use(as well as oneself) may be very effectivein Asian minority communities wherebonds of kinship and loyalty are strong,but not so in a more individualisticanglo-mainstream cultural community.

The right question, therefore, is notwhether a policy or practice or form ofintervention is harm reducing or harm-minimising once and for all, but whetherit is harm reducing or harm-minimisingin this or that context. It might be fullyreasonable to expect a certain practice orintervention to minimise harm in one set

3.1: Minimisation of Harm or Reduction of Use: Questions of Justification

Page 7

of conditions, but not fully reasonable toexpect it to under other conditions.Context is central to an understanding ofwhat should count as harm-minimisation, and sensitivity toprevailing contextual factors is crucial tothe intelligent development of drugpolicies and interventions. An

expectation that some policy orintervention will be harm reducing orminimising will only ever be fullyreasonable if that expectation has arisenthrough an accurate, evidence-based,understanding of the proposed contextof its application.

3.1 : Minimisation of Harm or Reduction of Use: Questions of Justification

This working definition of harmminimisation is not complete, and willnot be without some clarification of howthe reduction or minimisation of drug usefits into the picture. This issue is perhapsbest approached through asking howthese two compare as potential primarygoals when it comes to their respectiveintrinsic appeal, achievability, andcomprehensiveness (Caulkins & Reuter,1997).

Clearly enough, reducing or minimisingproblematic use and minimising harmare both worthwhile aims. But which isultimately more defensible as theprimary and fundamental drug strategygoal? There are a number of generalreasons – conceptually-based reasons aswell as pragmatic ones – for thinkingthat harm-minimisation ought to beconsidered the more fundamental goal.These reasons can be listed as follows:

Harm-minimisation is moreconceptually fundamental: What is itthat is problematic about drug use, whenit is problematic? In answering this, it ishard to avoid the conclusion that it is theconsequences of problematic drug use, i.e.,the harms that it creates, rather than themere activity of using itself, which is theproblem. If the primary goal of drugpolicy and practice were simply andsolely to reduce or minimise use, theninterventions into drug use would befulfilling their purpose even when theyeither create harms or leave existing onesunresolved. Clearly, though, something

crucial would have been overlooked withthis.

The upshot of these observations is that,as far as priorities of importance areconcerned, it is the drug-related harmsrather than the drug use itself thatappears to matter fundamentally. If thereduction of drug use is important indrug policy and practice, it willconceptually presuppose the prior andmore basic goal of reducing orminimising the harms of that use.

A goal of harm-minimisation willrecognise important differences thatare overlooked by a goal of reducinguse: If the goal of drug policy andpractice is simply to reduce the level ofdrug use – that is, to reduce the totalnumber of people using drugs or theoverall amount of drugs being used –then issues about the type of drug thatpeople use, or whether they use it in ahigh risk or a low risk way, or howheavily they use, will not be a centralconcern of public policy (Caulkins &Reuter, 1995). Differences between, say,the injecting use of heroin and thesmoking use of heroin will not register asimportant from the mere point of viewof use reduction. The difference is onlyimportant from a point of view wheredrug-related harms are a concern.

Similarly, if all that matters is reducingthe total number of people using drugs,the heavy and problematic user of heroinwill be viewed as being on the same

3.1: Minimisation of Harm or Reduction of Use: Questions of Justification

Page 8

footing as the occasional, casual user ofheroin. According to pure use-reductioncriteria, each will count for the same – asa person whose drug use needs to cease– with neither greater nor lesser prioritybeing given to one over the other whenit comes to policy and intervention(Caulkins & Reuter, 1995). There is,however, an important differencebetween problematic and casual heroinuse, a difference which ought not beoverlooked in drug policy and practice.When the level of harm produced bydrug use is considered fundamental, thisimportant difference will be recognised.

Again, in a policy regime geared simplyand solely toward minimising thenumber of users, policy and interventionactivity will focus greatest attention onthose whose use is most easily stoppedor deterred. In other words, efforts willbe directed at light or recreational users(Caulkins & Reuter, 1997). Clearlythough, it makes better sense to focus onexactly the opposite – on those whoseuse is heavier and involves a greater riskof harm to themselves or others. Such afocus would be maintained by a policyregime whose fundamental guidingprinciple is the minimising of harm.When it comes to registering significantdifferences between drug using patterns,behaviours and priorities, harm-minimisation is a much superior goal touse-reduction.

Harm-minimisation is morecomprehensive as a primary goal:Any foundational goal for a drug strategyneeds the capacity to comprehensivelyintegrate the different domains ofactivity in the world of drug policy andpractice, such as public health,education, law enforcement, justiceadministration, and so on. A goal ofharm-minimisation has a natural capacityto inform the range of activities thatoften occur in the areas of treatment,rehabilitation, and public health.

Reduction of use, although it sometimeshas a role to play, seems to have limitedcapacity to provide impetus anddirection to many of the interventionstypically employed in these areas. Forexample, public health programsdesigned to deal with drug related blood-borne diseases are more naturallymotivated and conducted under theumbrella of harm-minimisation ratherthan use-reduction. Similarly, withtreatments such as methadone andalternative pharmacotherapies, theimmediate aim is to reduce many of theharms associated with drug use (eg, tostabilise lifestyle, reduce the need toresort to criminal activity, etc.).

Drug law enforcement andadministration of justice havetraditionally been seen in terms of theaim of reducing use. However, harm-minimisation still has a key role in theseareas. It is often thought, for instance,that law enforcement and police activityin the drug world is more acceptable andeffective when it is conducted in a“harm-sensitive” way. That is, in a waythat seeks to minimise the harms thatmay possibly arise from these use-activities (eg., making sure that street-level policing does not deter users fromaccessing needle-exchanges). Similarlywith the administration of justicethrough legislation, the courts,sentencing and the corrections system.Although deterring drug use is a centralgoal in these areas, harm-reduction stillhas a key part to play. This is evidencedby the increasing emphasis on courtdiversion practices, and drug treatmentand rehabilitation options ascomponents of bail sentencing andcorrectional orders.

Harm-minimisation seems to be morecomprehensive to the extent that it hasmore potential to guide a greater rangeof drug interventions and activities thanmere use-reduction. Certainly, reductionof use has a role to play, but it is a role

3.2 : Integrating use-reduction “use-targeted” and “use-tolerant” harm reduction

Page 9

that does not speak to as great a diversityof activities as harm-minimisation.

Harm-minimisation is a morepragmatic and achievable goal: Fewwould disagree that a world completelyfree of drug use would be a virtuallyunattainable goal, if current andhistorical experience is anything to goby. Despite continuing efforts to stopthe use of illicit drugs in this country,that use continues to grow. And even ata more personal level, the goal ofcomplete abstinence for individuals is, inmany cases, a very difficult one toachieve. Given this, a pragmatic policyapproach would recommend that anachievable goal such as reducing theharms associated with use is better(Strang & Farrell, 1992; Mugford, 1991)

Harm-minimisation can encompassuse-reduction: Harm-minimisation canbe thought of as a more fundamentalgoal than use-reduction in the sense thatharm-minimisation can include use-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 umbrellaof harm-reduction or minimisation willbe those that are pursued in a harm-sensitive way. They must attempt toreduce use in ways that can bereasonably expected to reduce orminimise current or imminent harm, andto not create other “collateral” harms, sothat the outcome would be an overallnet reduction of harm. Clearly, not allinstances of activities designed to reducecurrent or future use are harm-reducingin this way. For example, intensivepolicing near needle-exchanges,incarceration of minor drug offenders,saturation policing, and so on, all tend toeither increase the risk of harms or failto reduce them in the long run. Suchuse-reduction activities are notcompatible with a framework governedby harm-minimisation.

It would be fair to say, at this stage, thatthe preceding paragraphs stronglysuggest that the minimisation of harm ispreferable to the other leading candidate– the reduction of use - as the primarygoal for drug policy and practice.

3.2 : Integrating use-reduction - “use-targeted” and “use-tolerant”harm reduction

Some of the last few points highlightthe fact that use-reduction and harm-reduction can coexist within the oneframework of drug policy and practice,as long as the use reduction is harm-sensitive in the right way. In fact, it mayeven be useful to talk of “use-targeted”forms of harm-reduction. That is,activities which it is fully reasonable toexpect will successfully reduce harmthrough reducing use. The other side ofthis coin is that there will be cases whereharms can only be effectively reduced byavoiding efforts to reduce use, or byrecognising that reduction of use or

abstinence is unachievable in thecircumstances. Refraining from policingaround needle-exchanges is an exampleof this, as is educating at-risk adolescentsabout safe methods of drug use. In thesecases harm-reduction does not requirethe discouragement, reduction or ceasingof drug use, and in the first case actuallyrequires that such attempts be avoided.It may be useful, then, to speak of “use-tolerant” forms of harm-reduction, aswell as use-targeted ones.

These last few observations throw somelight on how our conceptual refinementof the principle of harm-minimisation

3.2 : Integrating use-reduction - “use-targeted” and “use-tolerant” harm reduction

Page 10

should be completed. It was seen thatuse-reduction policies and programswhich are harm-sensitive (ie., use-targeted forms of harm-reduction) arecompatible with harm-minimisation. Butan equally important observation is thefact that harm-reduction or minimisationcan also be use-tolerant. It does notnecessarily involve attempts to reduce oreliminate use (Wodak & Saunders, 1995).This point can be factored in to finallycomplete the definition of harm-minimisation as follows:

a policy or practice is harm-reducing if itis fully reasonable to expect that it will reduceexisting or future drug-related harm given theparticular context of its application, withoutnecessarily requiring the reduction or eliminationof drug use;

a policy or practice or strategy is harm-minimising if it is fully reasonable to expectthat it will reduce existing or future harm to thegreatest degree allowed by the resources andconditions that prevail in the particular contextof its application, without necessarily requiringthe reduction or elimination of drug use.

One important thing to keep in mindwith this is that not every particularpolicy, practice and intervention within aharm-minimising strategy or frameworkneeds itself to minimise the harms that ittargets. Paradoxically, the goal ofminimising the overall net balance ofdrug-related harms across society might,in some circumstances, be betterachieved if certain policies orinterventions within the strategy actuallyrefrain from seeking to minimise theharms they target and only seek toreduce them. For example, attempting tominimise (as opposed to simply reduceto some degree) the harms connected

with blood-borne virus infection mightprove so great a drain on the resourcesavailable to a drug strategy that it wouldstifle the reduction of other harms,which reduction might collectively havea greater impact on the overall netminimisation of harm across society.

So, a well-balanced harm-minimisationstrategy will efficiently target someharms for minimisation and others forreduction in a way that is sensitive to theprevailing conditions, and which makesit most likely that the overall net harmwill be minimised across society.

To a considerable extent, just whichharms should be minimised and whichreduced on any occasion will depend onthe particular conditions that prevail atthe time. So, no “once and for all” recipeexists for this. However, there are somegeneral things that ought to be takeninto account in making that decision:

(i) whether some sorts of harm aregenerally more worthy of attention thanothers, and

(ii) whether some components of aharm-minimisation regime are worthy ofmore effort and resources than others(for example, prevention & earlyintervention, as opposed to supply-interdiction, as opposed to treatment &rehabilitation).

These issues will be taken up in the nextfew sections.

4: Relative harms: comparisons and priorities within a harm-minimisation framework.

Page 11

While the discussion so far has mostlybeen about the concept or principle ofharm-minimisation, the discussion tofollow will turn to what the basicstructure of a harm-minimisationframework for drug policy andintervention activity might ideally looklike. In other words, how the principleof harm-minimisation (as we havedefined it) should be reflected within acomplex scheme of activity.


Page 12

PART TWO:

HARM-MINIMISATON - A FRAMEWORK FOR ACTIVITY_______________


The sorts of harms associated withproblematic drug use are widelydiscussed. What is less widely discussed,however, is the question of which sortsof harm are more important to addressthan others. Arguably, not all types ofdrug-related harm are equally serious orurgent. Most would agree, for instance,that drug-related death is worse than theinability to maintain employment due todrug use. If society is to expend socialresources and effort in the mosteffective harm-minimising way, it needsto at least address the issue of whatpriorities should exist between thedifferent types of drug-related harm, andwhat criteria might underlie thosepriorities. This is made all the moreimportant by the fact that differentstakeholders in the drug area weightdifferent harms (and benefits) differently[Hawks & Lenton, 1998].

In deciding whether to devote moreresources to employment programs forusers, for example, or to family and peersupport, or to retraining programs andre-education initiatives for users, policymakers and implementers need to makejudgements about the relativeseriousness of the harms that theseinterventions target. Is the loss of users’employment more serious than thedeterioration of their family andfriendship networks, or the deteriorationof their cognitive capacities? Similarly,legislators are increasingly called upon tomake judgements about the harmfulnessof occasional cannabis experimentationamong young people compared to the

social stigma and life disadvantagesassociated with a criminal conviction.

Also, in order to efficiently target theirefforts at intercepting the supply ofharmful drugs, police and customs needto compare the relative harmfulness ofdifferent drugs. Is it more important tocurb the supply of crack cocaine becauseof its tendency to cause users to becomeviolent, or more important to interceptheroin and amphetamines with thedangers associated with their intravenoususe. And again, the harms experiencedby individual users sometimes need to bemeasured against harms or perceivedharms to the broader community. Forexample, which of the following harmsought to carry more weight in policydecision-making: the health risks to alimited number of individual users whoregularly inject in an alleyway, or thepossible apprehensions and objectionsof a large number of local residents atthe presence of a safe injecting facility inthe community?

The question of how these types ofharm are to be compared and“measured” against each other is adifficult and intractable one. Sometimesit is relatively clear that some harms aremore important than others. As was said,few would disagree that fatal overdose ismore serious than the unemployment ofusers. But it is much less clear whetherdeterioration of cognitive capacity is aworse harm than the deterioration offriendship networks or the stigma of acriminal conviction. Sure enough, thenumber of people who are in need of


Page 13

particular interventions or services andthe degree to which they need them willbe relevant to determining where policyand resource priorities should lie. Butthis calculation of need cannot be thewhole story, since the question stillremains as to which needs are moreimportant and which less, when differentneeds compete for attention. And this,again, is a normative and value-ladenquestion.

The issue of the measurement andcomparability of drug-related harms is adifficult one, and no easy answer has sofar presented itself. Certainly, someharms do seem clearly much moreimportant to address than some others.But what is still elusive is some reliableway of completely and consistentlyranking and assigning priorities betweenall drug-related harms.

In the absence of criteria for completelyranking drug-related harms, thefollowing pragmatic ‘next-best’ optionssuggest themselves:

Make the most informed and justifieddecisions possible: Even if there is anelement of controversy and uncertaintyas to how to completely organisepriorities between different interventionsaddressing different harms, decisionsabout priorities still need to be made.The element of controversy oruncertainty should not be allowed toparalyse decision-making. It is important,however, that the decisions that aremade about which activities to give moreattention to and which less are made inas rational, informed and justified a wayas possible.

Give precedence to harms that can bereadily addressed. An underlying focus

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 continuingdialogue about drug-related harmsand their relative importance. As waspointed out earlier, the notion of a drug-related harm is a value-laden andcontestable one, as is the question ofwhat criteria ought to be employed todetermine the priorities and urgenciesthat exist between harms. Given thatsocial attitudes change and differentvalues emerge and become ascendantover time while others decline, it isimportant to keep the debate aboutharms and their priorities open andongoing. It is important also, to ensurethat this dialogue is as socially inclusiveand informed as possible, including theperspectives of users themselves.

A substantial emphasis should beplaced on efforts at prevention andearly intervention. If it is not alwaysclear 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 itarises, do your best to make sure theproblem doesn’t arise.

With this emphasis, the question ofpriorities becomes that of determiningand targeting those personal and socialfactors that are known to pose thegreatest risks to either beginningproblematic drug use (primaryprevention), or progressing to moreproblematic drug use (secondaryprevention and early intervention).

5.1 : The structure of a harm-minimisation framework


Page 14

Effective harm-minimisation will seekto reduce harms through acomprehensive range of means,spanning all three of the harm-reducingdimensions of a harm-minimisationstrategy – supply reduction, demandreduction, and treatment andrehabilitation.ii It will involve appropriatelaw enforcement, supply interdiction andcriminal justice administration, as well asearly intervention, education, prevention,and treatment and rehabilitation. All ofthese means will be supported byresearch, evaluation, appropriate trainingand planned and coordinated action. It is

useful to picture the structure of a harm-minimisation framework in terms of anarchway (see Figure 1), whereachievement of the goal of harm-minimisation (the roof) rests on thethree strategically placed pillars of supplyreduction interventions (lawenforcement), demand reductioninterventions (prevention and earlyintervention), and treatment andrehabilitation interventions. Thosepillars, in turn, are embedded andsupported within foundations ofcoordinated action, and research,evaluation, and training.

Figure 1: The Harm-minimisation archway

5.2 : Balance of effort in a harm-minimisation framework. Targetingharms and coordinating action

This idea of an archway is a useful wayof depicting how the differentcomponents of a harm-minimisationframework are related to each other.However, it doesn’t throw much light onanother important question, the questionof what the right balance should bebetween those components. How mucheffort should be thrown behind law

enforcement and supply interdiction asopposed to education or rehabilitation orresearch, for instance, and what factorsand criteria are relevant in determiningthis? This, effectively, is a question aboutthe distribution of resources and policyefforts within a harm-minimisationframework, and relates to strategy

5.4: Social Justice Within a Harm-minimisation Framework

Page 15

efficiency and the social justice issue ofequity.

The balance between the different areasof drug activity will inevitably beinfluenced by the nature of the drug-related harms that need to be confrontedfrom time to time. Drug-related propertycrime, for instance, will be addressed bylaw enforcement iii while drug-relatedmorbidity will be addressed throughtreatment. The relative prevalence ofthese different harms, too, should betaken into account in deciding howresources and efforts are to be sharedbetween law enforcement and treatment.This makes sense because it makes senseto use resources efficiently within aharm-minimisation framework.

Harm-minimisation requires the overalllevel of drug-related harms to bereduced to the greatest degree they canbe in the circumstances. If harms are notreduced to the greatest effect relative tothe level of resources involved (ie., ifthey are not reduced efficiently) then harmhas not been minimised in that case,because it could have been reducedmore in the circumstances. Resourcesneed to be used optimally to achieve thedesired result within a harm-minimisation framework. This need forefficiency can help to throw light onhow the components of a harm-minimisation strategy might best bebalanced and inter-related.

Policies and interventions within a harm-minimisation strategy will target a rangeof things from the attitudes, knowledge,expectancies, behaviour and practices ofindividuals, through to the locations andcontexts of their use. And, from time totime, interventions will also seek totarget particular drugs used by certainsubgroups of the population in specificways. Precision and efficiency in all thistargeting is crucial. Properly planned,informed and coordinated decision-making is just as crucial, and thereforehas a central importance in the structure

of a harm-minimisation framework. Tobe most effective, the process ofdecision-making will need to be planned,informed and coordinated in a certaingeneral way, as follows.

Two basic types of decisions are centralto the effective minimisation of harm:

(i) decisions about what harms, ingeneral, need to be targeted; and

(ii) decisions about how these targetedharms can best be reduced.

The former decisions are about where, ingeneral, resources need to be directed,and the latter are about how they aremost effectively used when they getthere.

The best agencies to make the first typeof decision will arguably be centralisedones that have a sufficiently wide-ranging perspective on what ishappening at a state-wide or regionallevel to be able to make informedjudgements about which types of harmseem more pressing overall, and whichless. On the other hand, judgementsabout exactly how resources should beused to address the specific harms in aparticular place and time should be madeby agencies that are directly acquaintedwith those harms, and which are morelikely to have insight into what thepossible solutions might be. In otherwords, local agencies that can maintain adegree of discretion and flexibility as toexactly how resources are best put towork to address specific local problems.

The decision-making between these twolevels needs to be properly coordinated,however, if resources are to be usedefficiently, in a harm-minimising way.Central agencies will only make the rightdecisions about the types of harms totarget, and the particular localities ingreatest need, if they have regular,accurate and coordinated feedback fromthe local level about the nature andintensity of the problems being

5.3: Supply Reduction versus Demand Reduction

Page 16

experienced. Central agencies need to beresponsive to that feedback as well, sothat centralised coordination does notsimply become a disguise for centralisedcontrol.

Coordination amongst agencies isparamount as well. This is true of bothlocal and central agencies. At the locallevel, it is important for agencies not todouble-up on efforts or leave gaps. Thisis best achieved through the coordinatedsharing of information and resourcesbetween local agencies within regions.The real-life problems experienced atground-level are also often very complexones. This means they will rarely beeffectively addressed through only onemode of activity or intervention – purelythrough law enforcement, for example,or education, or health. Complexproblems warrant comprehensiveresponses, and this in turn requires theintegration of services and interventionsacross a range of sectors of activity(Hamilton, Kellehear & Rumbold, 1998).At the local level of program operation,this intersectoral integration will involvethe establishment of such things asongoing local community partnershipsand coordination networks. Integrationat the more centralised level ofdepartmental operation would requirethe joint interdepartmental developmentand management of policies and projectsthat facilitate integrated and efficientservice delivery at the local level.

So, it is clear from this why it is crucialwithin a harm-minimising framework togive a central supportive role to properlyplanned and coordinated decision-making, as well as integrated local anddepartmental activity and intersectoralcooperation.

The need to use resources and efforteffectively also explains the central roleof each of the different means or pillarsof harm minimisation cited in Figure 1.Clearly, an adequate regime of treatmentand rehabilitation is necessary to addressthe existing harms of problematic druguse, many of which are urgent andimmediate, and need priority attention.But also, potential harms as well asexisting ones need to be addressed.Significant effort and attention needs tobe directed at prevention through earlyintervention, education, and thetargeting of youth use. Reducing the riskfactors for problematic use amongadolescents reduces the need to spend agreater level of future resources on theharms that would arise if problematicyouth 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 &Rohl, 1997).

There is also an important role forsupply reduction. Carefully targeted,harm-sensitive efforts at detecting drugtrafficking, for example, can beinstrumental in reducing the potentialharms that would arise if such effortswere not made. So, demand reduction,supply reduction and treatment andrehabilitation are all central to a balancedharm-minimisation framework.

And finally, harm-minimisation isunlikely to be achieved at all by any ofthe above means without thefoundational support of appropriatetraining and the regular input of timely,targeted data-collection, research andevaluative feedback.

5.3 : Supply reduction versus demand reduction

5.2: Balance of effort in a harm-minimisation framework. Targeting harms and coordinating action

Page 17

Should demand reduction and supplyreduction be given equal emphasis in aharm-minimisation framework when itcomes to determining where effort andresources should go? The degree towhich the goal of supply reductionshould be pursued compared to othergoals will depend on how effectively thesupply reduction goal can be achievedcompared to those others. Pastexperience shows that despite vigorousefforts on the part of customs and lawenforcement agencies to stem the supplyof illicit drugs, and despite significantexpenditures, supply and trafficking stillcontinue and at an increasing rate. Giventhis, and given that there are otherimmediate and urgent risks and harmsthat can be effectively addressed, itmakes sense within a harm-minimisationregime to direct a significant amount ofattention to reducing demand.

There is reason to think also that aconcerted effort at demand reduction

will achieve two goals at the one time byhaving an indirect impact on supply.Where there is a continuing decline indemand for drugs, there is likely to be adecreasing incentive to supply them, andthis suggests that, on balance, resourcesmay be more effectively used in thepursuit of demand reduction.

This is not to say that efforts at supplyreduction should be abandoned, onlythat those efforts should be pursued in away that can be reasonably expected tosignificantly reduce harm. This mightmean, for instance, that instead ofsetting out to eliminate drug marketscompletely through policing (which canin fact be harm-creating), policingshould rather target its activities so as toreshape those markets in ways that makethem operate less harmfully (Sutton &James, 1996).

5.4 : Social justice within a harm-minimisation framework

Efficient resource use is by no meansthe only, nor the most important, issuerelating to the implementation of aharm-minimisation framework. It isimperative within such a framework thatresources also be distributed justly andequitably between all those individualsand identifiable groups who eitherexperience, or are at risk of harm. Theinterests of all should be given fairconsideration in decisions about whereeffort and resources will be directed.

This means that a harm-minimisationframework should be especially sensitiveto groups in society who have specialneeds, either in the type of resourcesthey require or in the amount. Thegroups that have special needs willchange over time, as will the needs theyhave. But many such groups are readilyidentifiable. NESB communities,

Aboriginal and Torres Strait Islandercommunities, women users, adolescentas well as older users, and disabled andhomeless users, to name only some, areall known to have special needs or toexperience special circumstancesassociated with their drug use, or inaccessing help.

Ministering to these groups in a just andequitable way will mean catering for theparticular differences that exist in themand which impact on the degree towhich drug-related harms can bereduced in these groups. For instance,there is evidence that residentialtreatment options for women that allowchildren to live in, tend to improvetreatment outcomes for women.Similarly, drug-related harms in NESBand indigenous communities will be bestaddressed only through the provision ofresources that allow the development

5.5: Threats to a harm-minimisation framework. Managing the message6: The Core Elements of a Harm-minimisation Framework

Page 18

and implementation of culturallysensitive treatments and interventions.Ministering to these groups in a just andequitable way will also mean devotingspecial attention to the antecedentsociocultural, psychological andeconomic conditions that make theproblems greater for them than others.Because of the pre-existingdisadvantages, differences, and specialneeds among some groups, a fair andsocially just response to drug-relatedharms may require a special effort to bemade and a greater than normal amountof resources to be devoted to addressingthe needs particular to those groups. Asocially just approach to harm-minimisation will also be particularlyattuned to the nature of the changing

needs, disadvantages and specialcircumstances that arise in differentgroups from time to time. Some of thesewill be clearer or more apparent thanothers. The disadvantages associatedwith a non-English speakingbackground, for example, will generallybe more apparent than the disadvantagesof distance associated with rural living,and the need to have an appropriateregional distribution of services.

Full sensitivity to all this requiresongoing research and feedback from thecoal-face of harm reduction activity.Most of all, it is imperative to haverepresentatives of those in-need groupsinvolved in the whole process ofdecision-making and problem-solving.

5.5 : Threats to a harm-minimisation framework. Managing the message

A comprehensive and complex drugstrategy will succeed in minimising harmonly if it also has the capacity to managethose things that threaten its continuedviability. Different threats will arise indifferent ways at different times, andstrong social and political vigilance andcommitment to harm-minimisation willbe needed to overcome them as theyarise. But two major forms of threat areworth explicitly noting here: (i)objections to a harm-minimisationapproach that result frommisinformation or misunderstanding ofits meaning and purposes; and (ii) the

public misperception that the “use-tolerant” dimension of harm-minimisation constitutes an officialacceptance of drug use, with the effectthat this acts to normalise that use. Toaddress both threats, a harm-minimisation framework should comebundled with appropriately targetedpublic education that outlines themotives, rationales and processes ofharm-minimisation, and also seeks toredress any inadvertent normalisation ofdrug use that “use-tolerant” harm-reduction might engender.

6: The Core Elements of a Harm-minimisation Framework

The previous discussion sought to givean indication of what harm-minimisationmeans, what makes it justified as a

fundamental goal of drug policy, andalso what the basic structure of aframework for pursuing harm-


Page 19

minimisation involves. The hope indoing this was to isolate some of thegeneral characteristics that emerge as thehallmarks of a good harm-minimisationframework, with an eye to reservingthese as key criteria for understandingand evaluating harm-minimising policy

and practice. These criteria are listedbelow. It is true that they are demanding,but it should be kept in mind that theyare intended as the hallmarks or criteriaconnected with an ideal framework forharm-minimisation.

A. Being evidence-based is pivotal: The previous discussion revealed two keyreasons for this: Firstly, it follows from the definition presented here thatharm-minimising policies and practices must be based on a fully reasonableexpectation that they will reduce harm to the greatest degree allowed by theparticular context of their application. What makes such an expectation fullyreasonable, is its reliance on the best evidence that is currently availableconcerning those contexts of application. Secondly, accurate evidence,information, and research is essential to the appropriate targeting of efforts andcoordination of decision-making, both of which are required for the efficientuse of resources.

B. Sensitivity to context is important: As we have defined it, harm-

minimisation is context dependent in the sense that a policy or practice maysucceed in reducing or minimising harm in one set of circumstances, but fail todo so in another (or else to a completely different degree). Contextual factorssuch as differences in the nature of users, usage behaviours, drug-types, socialand environmental influences, and so on, will underlie this possibility. A harm-minimising drug framework needs to be sensitive to the many contextualfactors and differences that can affect the degree to which harm is actuallyreduced. Sensitivity to context is particularly important with interventions indomains of activity that are traditionally aligned with use-reduction (policingand law enforcement, corrections, justice administration), to ensure that theywill in fact be harm-sensitive.

C. A harm-minimisation strategy ideally needs to be comprehensive in scope:

The range of harms confronting any system of drug policy and practice will bebroad, varied and changing. The effective minimisation of such harms,therefore, requires an approach that is as comprehensive as possible andincorporates interventions that span all domains of social activity, from health-care and education to law enforcement and legislation.

D. Diversity, flexibility and innovation are important: The nature of the

drug-related harms that confront a drug strategy are varied, and thecircumstances of their occurrence are changeable as well. A drug strategy willarguably have little prospect of minimising harm under these conditions if itdoes not employ a diverse range of interventions which are delivered in a waythat is sufficiently flexible to respond to new information and changingconditions. As Patricia Erickson observes, ‘Flexibility of response is thekeynote.’ (Erickson, 1993). Similarly, a harm-minimising strategy, if it is to

7. Locating harm-minimisation in the context of some other major illicit drug themes.

Page 20

efficiently and effectively pursue its goal, needs to have the capacity toexperiment and develop innovative responses to drug-related harms, especiallythose entrenched hard cases which seem to resist responding to traditionalapproaches.

E. Coordinated policy and targeted program activity is central to harm-

minimisation: By definition, a harm-minimising strategy needs to direct itsefforts and resources in the most efficient and effective way it can to reduceharms. It was seen that this efficiency will not be possible without theappropriate targeting and systematic coordination of decision-making andprogram operation. This coordination, it was argued, requires a balancedsharing of decision-making between the local and centralised levels.

F. An ideal harm-minimisation strategy will be integrated and cohesive:

Having different specific activities with their own lower-level objectives withina strategy was seen to be an effective way to respond to diverse problems andcircumstances. This diversity of objectives and activities, however, will be quitepointless and counter-productive if there are tensions and antagonisms amongthem - if one policy or activity frustrates or interferes with the other. Whatevertheir particular and immediate purposes, they will need to be cohesive witheach other to ensure that their overall collective effect is to achieve the primarygoal of minimising harm. This means that harm-minimising policies, programsand interventions spanning different domains of social activity cannot bedeveloped and enacted in isolation from each other. They need to be perceivedin an integrated way, and viewed in terms of the part they and other activitiesplay in the overall goal of minimising harm.

G. The full range of drug-related harms will only be identified and minimised

through the inclusion and “humanisation” of users in decision-makingprocesses about potential solutions. It is clear that problematic drug users aresocially marginalised in various ways, and this in itself is a substantial harm.Care should be taken, therefore, not to further compound this marginalisationthrough the sorts of solutions that the state or professionals propose for thedrug problem. Including users, or representatives of users’ interests, at all levelsof the harm-minimisation process will go a considerable way to ensuring thatthis marginalisation is curbed, and that users are empowered to assume somecontrol of their lives. Having users play a part in the dialogue concerning drugpolicy also ensures that accurate information about users’ needs andperspectives on use is reflected in policy decisions and intervention approaches(Des Jarlais & Friedman, 1993).


Page 21

H. Ongoing dialogue and communication between key stakeholdersis essential. There are two sorts of reasons for this – those arising from thevaried nature of the drug problem, and those connected with the variety ofstakeholders and interest groups that are involved in its solution. Despite theclear need to assign priorities to different sorts of drug-related harm, it wasseen that there is no obvious systematic criteria-based way to do this. In theabsence of this, one viable second-best option is to maintain open socialdialogue about the nature of drug-related harms and their relative urgency.Ongoing communication is also instrumental to the development of flexible,coordinated and enduring responses to those harms.

Just like any major social problem, there will be a variety of stakeholders and

groups having vested interests in how the drug problem is approached. Therewill be service providers, clients, policy-makers, members of the general publicof different persuasions, and other special interest groups. The interests of allthese will not necessarily converge, but some sort of working consensus iscertainly necessary in order to sustain major programs and initiatives, or to varythem if need be. The only way to negotiate this sort of social consensus and totake account of these interests is for all those concerned to engage in opendialogue where differing views are heard and moderated in the light of others.

I. Harm-minimisation gives special emphasis to prevention and

demand reduction: Experience has shown that efforts at reducing harmsthrough supply reduction have met with limited success to date, despiteconsiderable expenditure. In comparison, harms can be effectively reducedthrough prevention and demand reduction initiatives. The absence ofsystematic criteria for prioritising harms also provides supplementary reasonsfor an emphasis on prevention. When it is unclear how existing harms shouldbe prioritised, it was suggested that a good pragmatic second-best option is tofocus as much effort as possible on making sure harms do not arise in the firstplace, by preventing problematic use.

J. Harm-minimisation can be “use-targeted”, and therefore

compatible with use-reduction, as long as the use-reduction is harm-sensitive, and succeeds in reducing the harms associated with use withoutcausing other “collateral” harms.

K. Harm-minimisation can be “use-tolerant”, and does not necessarily

require reduction or cessation of use: In some contexts, efforts at reducinguse can simply act to create harms or magnify existing ones. A good harm-minimisation strategy will not seek to reduce use in these contexts.


Page 22

L. 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 andequitable. This means targeting resources and efforts to those groups whosecharacteristics or particular differences or social circumstances disadvantagethem in various ways and leave them susceptible to harms or risks of harm, orelse less accessible to help.

M. Evaluation is paramount: Because circumstances change and are rarely

constant, and because not all of the contextual factors that influence successfulreduction of harm are immediately apparent, it is important to evaluateprogram activity to gain regular, accurate feedback. It is important to evaluateon the basis of meaningful comparisons, too. Appropriate research, monitoringand evaluation is pressed upon us by the context dependent nature of harm-minimisation, and the need to maximise the long-term reduction of harm.

N. Managing the message of harm-minimisation is 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 notinadvertently act to normalise drug use through being seen by the public as anofficial acceptance of drug use.

7. Locating harm-minimisation in the context of some other major illicitdrug themes.

The previous discussion has hopefullygiven some indication of what harm-minimisation amounts to and what aframework of policies and practicesguided by that primary goal looks like.What has not been discussed so far,though, is what implications harm-minimisation has with respect to someother key themes that often arise inrelation to illicit drugs. Having now afuller understanding of harm-minimisation, some of thoseimplications can be teased out.

Abstinence-based interventions: Itwould be reasonable to think thatbecause harm-minimisation, as thatconcept has been refined, does notrequire the cessation of drug use, it isincompatible with abstinence, and that adrug strategy guided by harm-minimisation could not consistentlyinclude interventions with abstinence asan objective. This perception, though, isnot correct.

There are a number of reasons tosuggest that abstinence-basedinterventions might have a place within aharm-minimisation framework. It was


Page 23

noted that such a framework can quiteconsistently contain programs, policiesand interventions that have a variety ofimmediate “local” objectives, as long asthose objectives contribute effectively tothe minimisation of harm. It is a virtueto have a broad range of approaches tomatch the equally broad range ofclientele, circumstances and harms thatneed to be addressed. It may well be thatsome users respond much moreeffectively to programs geared towardabstinence than others. Importantly also,it was seen that harm-minimisation iscompatible with interventions that seekto reduce (or stop) use, as long as thoseinterventions do so in a harm-sensitiveway (ie, in a way that can reasonably beexpected to reduce harm). There may becontexts in which abstinence-basedprograms are harm-sensitive in this way.

Added to these considerations is the factthat the eventual cessation of use canalways be a secondary objective of harm-minimising interventions. For instance,although the central purpose of therecent Swiss heroin trials was to stabiliseand improve users’ lives in various ways,another aim was to consistently exposeusers to treatment and rehabilitationoptions with the hope of themeventually ceasing their use. In this case,the central goal of harm-reduction wassupplemented with a secondary objectiveof eventual abstinence. So there is aplace for abstinence-based programswithin a harm-minimisation framework,but only those programs that are harm-reducing in the right way, and great careneeds to be taken to include only thatsort.

Zero-tolerance: If this is taken to meanan absolute prohibition of drug use underany circumstances, where education andhealth-care interventions and the law areall geared to enforce or reinforce this atall times, then it is clearly incompatiblewith a harm-minimisation framework. Ifzero-tolerance never tolerates or allowsthe use of drugs, then it will be opposed

to harm-reduction or minimisationwhich, as we have refined it, willsometimes tolerate the continued use ofdrugs when this is necessary to ensurethe reduction of harm, or to avoidcreation of harm.

Prohibition, decriminalisation andlegalisation: Unlike abstinence, whichrelates to particular types of interventionor program, prohibitionism is a generalpolicy to do with controlling theavailability and use of drugs. Broadlydefined, prohibitionism denotes any legaland policy regime which does not alloweither the possession, use or supply ofscheduled drugs, and which activelydiscourages these through (i) policing,detection and enforcement, and (ii) theapplication of penalties and sanctions.

There can be strong forms ofprohibition and weaker ones (SouthAustralia, 1978), depending on thedegree of seriousness or strictness withwhich penalties and/or enforcement areapplied. The strongest form – totalprohibition – for instance, will applysevere criminal penalties in conjunctionwith vigorous policing, intervention andenforcement. Weaker forms, includingdecriminalisation, will still disallow drugpossession, use or supply, but will applyweaker civil penalties with levels ofpolicing and enforcement that reflectthis. Prohibitionism, therefore, denotes afamily of approaches which involvevarying degrees of severity.Prohibitionism is opposed tolegalisation, which does allow thepossession, use or supply of drugs, butcan also involve similar variations in theconditions under which they are allowed.

It is sometimes argued that harm-minimisation is neutral regarding policyand legislative regimes (Erickson, 1995;Single, 1997). This is true to the extentthat the goal of harm-minimisation doesnot by definition presuppose anyparticular policy or legislative regime(Strang, 1993). But harm-minimisation


Page 24

will not be neutral in the implications ithas for different policy approaches. Itwill simply favour those approaches thatcontribute most effectively to thereduction of harm, and of course, thenature of prevailing circumstances willalways be relevant in determining this.

Clearly, a full exploration of therelationship between prohibitionism andharm-minimisation would by far exceedthe scope of the present discussion.What can be pointed out, however, aresome of the factors and considerationsthat are relevant to clarifying thatrelationship.

It is crucial to keep clear sight of thedifference between the aims ofprohibition and its realities. One of thekey aims of prohibition is ideally to stopor reduce people’s use of illicit drugs.And it may even be, as it is oftenclaimed, that the fundamental andunderlying point of this is to reduce orminimise the harms of use. If harm-minimisation were to be defined simplyin terms of aims, then prohibition in thiscase would count as harm-minimisationby definition. But, as harm-minimisationwas eventually defined, it was theoutcomes that could be reasonablyexpected that became central, and notaims. This means that to determine howprohibitionism stands with respect toharm-minimisation, we need to bemindful of the reality of its known or

likely effects. The following twoobservations are relevant to this:

� The use of illicit drugs has notdecreased as a result ofprohibitionism in Australia, althoughit is difficult to say how much druguse (and resulting harms) therewould have been withoutprohibitionism.

� Many harms have been attributed toprohibitionism, mainly in connectionwith the black-market trade in drugsand the clandestine circumstances ofusage. These include crime, violenceand corruption, and harms resultingfrom unsafe use.

The upshot of these observations is thatif some form of prohibitionism (ordecriminalisation, or even legalisation,for that matter) is to be blended into aharm-minimisation framework, it willneed to be a form that is very harm-sensitive. Prohibitionism will need tooperate in a way that is acutely aware ofthe potential it can have for creatingharms. There is probably truth in theview that no regime of legal control orregulation 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 indoing so.

i 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 notfully reasonable (ie. not a case of harm-reduction/minimisation, on our definition).

ii 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 filtersthroughout all 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 25

reduction and treatment & rehabilitation together encompass all of the possible interventionactivities within a harm-minimisation strategy, and all seek to be harm-reducing in clearly andsufficiently distinct ways.

iii Or, perhaps in a more deferred way, through legal and policy reform to address the influenceof the drug black-market on drug prices.

REFERENCES

Caulkins, J. P., and Reuter, P., 1995. ‘Redefining the Goals of National Drug Policy:Recommendations from a Working Group’, American Journal of Public Health. Vol. 85(8). pp. 1059-1063.

Caulkins, J. P., and Reuter, P., 1997. ‘Setting Goals for Drug Policy: Harm Reduction orUse Reduction?’, Addiction, Vol. 92, (9), pp. 1143-1150.

Collins, D. J., and Lapsley, H. M. 1992. ‘Drug Abuse Economics: Cost Estimates andPolicy Implications’. Drug and Alcohol Review v. 11 pp 379-388.

Des Jarlais, D. C., & Friedman, S. R. 1993. ‘AIDS, injecting drug use and harm-reduction.’ in N. Heather, A. Wodak, E. Nadelmann, P. O’Hare eds.. Psychoactive Drugsand Harm-reduction: From Faith to Science. London: Whurr.

Erickson, P. G., 1993 ‘Prospects of harm reduction for psychostimulants’, in N Heather,A Wodak, E Nadelmann, P O’Hare eds.. Psychoactive Drugs and Harm-reduction: From Faithto Science. London: Whurr.

Erickson, P. G., 1995. ‘Harm reduction: What it is and what it is not’, Drug and AlcoholReview. Vol. 14, pp. 283-285.

Erickson, P. G. and Ottaway C. A., 1993. ‘Policy – Alcohol and Other Drugs’ AnnualReview of Addictions Research and Treatment. Vol. 3, pp. 331-341.

Hamilton, M., Kellehear, A., & Rumbold, G. 1998. ‘Addressing Drug Problems: TheCase for Harm Minimisation’, in Rumbold, Greg & Hamilton, Margaret., (eds) Drug Usein Australia: A Harm Minimisation Approach. Oxford University Press

Hawks, D. and Lenton, S. 1998. ‘Harm-minimisation: a Basis for Decision Making inDrug Policy?’ Risk, Decision and Policy, v. 3 (2) pp.157-163.

Lenton, S. & Midford, R.. 1996. ‘Clarifying “Harm Reduction”?’ Drug and Alcohol Review.Vol. 15, p. 411-413.

Mugford, S., 1991. ‘Least Bad Solutions to the ‘Drugs Problem’, Drug and Alcohol Review,Vol. 10, pp. 401-415.

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 DrugRelated Harm. London Routledge.

Single. E., 1995, ‘Defining Harm Reduction’, Drug and Alcohol Review, Vol. 14, pp. 287-290

Single, E., 1997, ‘The Concept of Harm Reduction and Its Application to Alcohol: The6th Dorothy Black Lecture’, Drugs: Education, Prevention and Policy, Vol. 4, (1), p. 10

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.‘Cannabis a Discussion Paper’. South Australian Government, Adelaide.

Strang, J. & Farrell, M., 1992. ‘Harm-minimisation for Drug Misusers: When SecondBest May be Best First’, British Medical Journal, v. 304, no. 6835, pp. 1127-29.

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:From Faith to Science. London: Whurr.

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, Vol. 14, pp. 269-271.

Documents

Drugs and Crime Prevention Committee …...6. The core elements of a harm-minimisation framework 7. Locating harm-minimisation in the context of some other major illicit drug themes