뉴질랜드의 불법 마약 관련 법과 통제정책: 한국과의 간략한 비교

Prison's second death row

The term "harm reduction" conjures up many reactions, including many political and emotional responses. What exactly is harm reduction? What is it not? Are pharmacists involved in harm reduction practices? Do they embrace the principles of harm reduction? What should the role of the pharmacist be? How far along the continuum are you as a pharmacist willing to go?Harm reduction is a concept that can be applied to areas other than drug use, but for the purposes of this discussion it "refers to policies, programs and practices that aim to reduce the negative health, social and economic consequences that may ensue from the use of legal and illegal psychoactive drugs, without necessarily reducing drug use".1 If viewed in the proper context, it can be seen as a form of health promotion2 and includes programs that increase access to accurate information, improve social determinants of health, decrease stigma, increase availability of proper housing, prevent the spread of HIV and Hepatitis C, increase safer sex practices, prevent overdose, encourage working with peers and address the impact of trauma on individuals and society. Simply put, harm reduction is anything that seeks to reduce the harms associated with illicit drug use.The spectrum of harm reduction activities varies from those generally accepted, such as smoking cessation pharmacotherapies and methadone maintenance treatment, to those both innovative and controversial, such as supervised injection facilities and heroin assisted therapy. Contrary to some popular belief, the full harm reduction continuum does not hold abstinence in disdain, but rather sees it as a valid choice. While critics may feel that harm reduction is 'enabling' drug users, proponents feel it merely takes a pragmatic approach and realizes that one type of treatment is not suitable for everyone.So where do pharmacists fit in? At this point most would see our role as dispensers of methadone and buprenorphine, smoking cessation counselors, and possibly as providers of clean needles and syringes and sharps disposal.3 The reality is far more complicated. For example, one study of pharmacists providing Methadone Maintenance Therapy (MMT) found that they not only dispensed, but "almost half (48%) provided information on drug interactions with OST [Opioid Substitution Therapy] medication; side effects of medication (38%); accessing support services (30%); smoking cessation (30%); blood-borne virus exposure risks (10%); vein care (8%); and other services or information (12%), including dental hygiene, general health, practical parenting advice, internet-based resources and counselling."4In 1988 I wrote a paper for my pharmacy ethics class looking at the issue of pharmacist involvement in needle exchange programs, a relatively controversial topic at the time. Since then needle exchange programs have become a mainstay in harm reduction practices. A literature search of "pharmacist" and "harm reduction" was dominated by this topic.5–12 Services still vary greatly from country to country and even city to city. Some efforts are hampered by strict regulations, while pharmacists and pharmacy staff attitudes can also affect these services. The next step in supply provision pharmacists may need to consider is full clean injection kits with supplies such as cookers and Vitamin C powder, and safer crack kits. Already there are studies looking at the feasibility of pharmacies providing naloxone kits to aid in the treatment of opioid overdoses.13The logical extension of the supervised injection site in Vancouver (Insite), perhaps one of the most controversial harm reduction initiatives, is heroin assisted therapy (HAT). While HAT has been used as a treatment in Europe since 1926, the first North American clinical trial faced numerous obstacles getting off the ground. A fascinating paper by Gartry et al traces the history of NAOMI, the North American Opiate Medication Initiative, from the Canadian Government Commission on Inquiry into the Non-Medical Use of Drugs in 1972 to the launch of the Phase III randomized, controlled trial comparing injectable opioid agonist maintenance (primarily with heroin but also with hydromorphone) to oral methadone. HAT is not legal nor being studied currently in the United States.14The NAOMI trial treatment retention rate was 87.8% in the heroin group (compared to 54.1% in the methadone group), and there was a 67% reduction in illicit-drug use or other illegal activity in the same group (compared to 47.7% in the methadone group).15 Sadly, "even those who were responding to HAT had to stop this treatment and go back to the same options that had not worked for them in the past because the study team could not legally continue to prescribe [heroin] outside of the clinical trial treatment period."14So what does HAT have to do with pharmacists? The Director of Pharmacy for the NAOMI and SALOME trials, Amin Janmohamed, BSc Pharm, MSci, RPh, explains that pharmacists play a key role in navigating the complex regulatory and clinical trials documentation requirements. For the SALOME trial, beyond preparing the medications, the pharmacy staff are responsible for accountability for the medications, inventory control, forecasting medication needs far in advance, complex regulatory and clinical trials reporting, maintenance of participant and investigator blinding, and medication destruction. Because the pharmacists are not blinded to the randomization, they cannot have direct patient contact. Still, Amin Janmohamed enjoys the problem solving, complex scenarios and implementation of the project. He finds it rewarding to work with "incredible researchers who have dedicated their careers to helping marginalized, vulnerable people" (personal communication, September 12, 2013).The investigators and pharmacists from NAOMI are now undertaking a new project, the Study to Assess Long-term Opioid Maintenance Effectiveness (SALOME). The aim of this trial is to compare the benefits of hydromorphone to heroin in refractory opioid-dependent patients. If hydromorphone is found to be as efficacious as heroin, this may lead to a legal alternative for supervised injection. More details of the trial can be found on its website.Another interesting area of recent study in harm reduction is in the sale and use of over-the-counter (OTC) medications. As with all products with potential for abuse, in general, pharmacists seem to be expected to take a 'policing role' and merely refuse to sell to someone who may be misusing. Back in 1998, when I was a locum pharmacist in Saskatchewan, the province put a maximum on OTC codeine products; a person could not buy more than 50 tablets or equivalent in a one month period. There was no public awareness campaign to announce the change, pharmacists were not given any way to track this, and most importantly, were not given any strategies to help those who had been misusing the codeine. Because of my unique position as a locum pharmacist for 26 stores, I was able to 'catch' several misusers, but it usually ended up as a confrontation rather than a productive chance to get the person to try alternatives and/or seek help.Researchers of an intriguing study from Northern Ireland decided to try a 'harm minimisation' approach to OTC misuse and abuse. Pharmacists had a two day communications skills workshop, "particularly motivational interviewing and strategies to promote change in health behaviours."16 They managed to get "some clients [to agree] to stop using the product of abuse/misuse, [use] an alternative, or [switch] to a maintenance prescription under general practitioner (GP) supervision."16There are still obviously a number of barriers to accepting and providing harm reduction services. Harm reduction facilities are often inadequate, and many health providers felt they had a lack of time and staff to help.17 Pharmacist attitudes are key, and have become more open over the years.3918 In my experience, the more that one is involved with users, the more open and accepting one becomes of harm reduction as a philosophy and practice. Most papers on harm reduction recommend further education and training for pharmacists and pharmacy staff as well.7811121619My journey to being an advocate for harm reduction took time. I supported MMT and needle exchange programs as far back as my university training and the research I did for my needle exchange paper. I still did not see myself as becoming directly involved, however, until I worked at a pharmacy in Saskatoon that dispensed methadone. Getting to know the patients/clients through daily meetings, I developed a great deal of empathy towards them. Later, when I worked at the Centre for Addiction and Mental Health (CAMH), I started my work in psychiatry, but eventually picked up some shifts at the Methadone Clinic. Again, I found the methadone and buprenorphine patients to be friendly, funny, wonderful people who had experienced more than I could ever imagine. They taught me many invaluable lessons, including the role of empathy from health care providers. Often the pharmacist can be the provider that makes the patient feel a greater sense of self-worth, a great motivator to seek further help.Through my work as a speaker and media spokesperson at CAMH, I got involved with the Toronto Harm Reduction Task Force. I gave presentations on drug interactions and overdose prevention to current and former drug users. I presented a poster of my experiences at a CPNP conference.20 I was prepared for questions about mixing medications and dosing, but I was not prepared for questions such as "is it true that it is better to be a heroin addict than a crack addict?" or "what should I do about this infected abscess on my arm?" or "what is proper vein care?" These questions and others definitely challenged and then expanded my comfort level with what full harm reduction training really can be.Pharmacists can be involved in harm reduction strategies from the traditional MMT and needle exchanges through to providing overdose prevention and vein care information to intravenous drug users. Each pharmacist needs to explore his or her current comfort level, and ideally to look for reasons to challenge and expand it. Patients who use/misuse/abuse substances have complicated histories and journeys, and deserve full access to a range of health care options, many of which fall under the large umbrella of harm reduction.

Harm reduction, when applied to drug use, prioritizes improving patient-centered health outcomes and reducing drug-related harm. In order for harm reduction strategies to be adopted by people who inject drugs (PWID), they need to be promoted, accessible, and accepted in that population and the community-at-large. While PWID face stigma at multiple levels, less is known about how stigma influences uptake and acceptance of harm reduction services and strategies among PWID. We aim to characterize the stigmatizing experiences PWID have had related to harm reduction and the role of stigma in influencing their acceptance and adoption of harm reduction services and strategies. A qualitative study using in-person, semi-structured interviews. We recruited hospitalized participants, age 18 and over, with a history of injection drug use. We developed an interview guide asking about various aspects of stigma and participants' experiences with naloxone, syringe service programs, fentanyl test strips, HIV and hepatitis C testing, and any other harm reduction strategies. Key themes were generated using a thematic analysis. We reached thematic saturation at 16 participants. PWID reported multi-level stigma related to harm reduction from themselves, the public, the healthcare system, and the legal and carceral systems. Themes were grouped into four main categories: internalized, interpersonal, intervention, and structural stigma. Stigma across all of these domains negatively impacted the ability of PWID to access harm reduction resources. Positive, non-stigmatizing experiences from others, such as syringe service programs and peer navigators, countered historically negative experiences and promoted greater education and comfort about using harm reduction resources among PWID. To expand the reach of harm reduction services, it is critical to develop interventions that can reduce the stigma against PWID and harm reduction.

BackgroundThere is limited evidence of the impact of needle and syringe programmes (NSPs) and opioid substitution therapy (OST) on hepatitis C virus (HCV) incidence among people who inject drugs (PWID), nor have there been any economic evaluations.Objective(s)To measure (1) the impact of NSP and OST, (2) changes in the extent of provision of both interventions, and (3) costs and cost-effectiveness of NSPs on HCV infection transmission.DesignWe conducted (1) a systematic review; (2) an analysis of existing data sets, including collating costs of NSPs; and (3) a dynamic deterministic model to estimate the impact of differing OST/NSP intervention coverage levels for reducing HCV infection prevalence, incidence and disease burden, and incremental cost-effectiveness ratios to measure the cost-effectiveness of current NSP provision versus no provision.SettingCost-effectiveness analysis and impact modelling in three UK sites. The pooled analysis drew on data from the UK and Australia. The review was international.ParticipantsPWID.InterventionsNSP coverage (proportion of injections covered by clean needles) and OST.OutcomeNew cases of HCV infection.ResultsThe review suggested that OST reduced the risk of HCV infection acquisition by 50% [rate ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63]. Weaker evidence was found in areas of high (≥ 100%) NSP coverage (RR 0.77, 95% CI 0.38 to 1.54) internationally. There was moderate evidence for combined high coverage of NSPs and OST (RR 0.29, 95% CI 0.13 to 0.65). The pooled analysis showed that combined high coverage of NSPs and OST reduced the risk of HCV infection acquisition by 29–71% compared with those on minimal harm reduction (no OST, ≤ 100% NSP coverage). NSPs are likely to be cost-effective and are cost-saving in some settings. The impact modelling suggest that removing OST (current coverage 81%) and NSPs (coverage 54%) in one site would increase HCV infection incidence by 329% [95% credible interval (CrI) 110% to 953%] in 2031 and at least double (132% increase; 95% CrI 51% to 306%) the number of new infections over 15 years. Increasing NSP coverage to 80% has the largest impact in the site with the lowest current NSP coverage (35%), resulting in a 27% (95% CrI 7% to 43%) decrease in new infections and 41% (95% CrI 11% to 72%) decrease in incidence by 2031 compared with 2016. Addressing homelessness and reducing the harm associated with the injection of crack cocaine could avert approximately 60% of HCV infections over the next 15 years.LimitationsFindings are limited by the misclassification of NSP coverage and the simplified intervention definition that fails to capture the integrated services that address other social and health needs as part of this.ConclusionsThere is moderate evidence of the effectiveness of OST and NSPs, especially in combination, on HCV infection acquisition risk. Policies to ensure that NSPs can be accessed alongside OST are needed. NSPs are cost-saving in some sites and cost-effective in others. NSPs and OST are likely to prevent considerable rates of HCV infection in the UK. Increasing NSP coverage will have most impact in settings with low coverage. Scaling up other interventions such as HCV infection treatment are needed to decrease epidemics to low levels in higher prevalence settings.Future workTo understand the mechanisms through which NSPs and OST achieve their effect and the optimum contexts to support implementation.FundingThe National Institute for Health Research Public Health Research programme.

The accessibility of opioid substitution therapy (OST), one of the recommended treatments for opioid dependence, remains low. This study sought to explore the perceived effectiveness of OST from the perspectives of peer outreach workers and OST clients in a community-based harm reduction programme. The research was done within the Community-Oriented Substance Use Programme (COSUP) in Tshwane, South Africa. Fifteen peer educators (13 males and 2 females) took part in two focus group discussions. Thereafter, there were semi-structured interviews in which 15 OST clients (11 males and 4 females) participated. A convenience cross-sectional study was used. Interviews were audio-recorded. Using thematic analysis, themes were examined to evaluate how OST and the harm reduction approach were perceived to contribute to the improved health status of people with opioid dependence. Peer outreach workers and COSUP clients significantly endorsed OST as an effective treatment for opioid dependence. Participants perceived greater effectiveness of OST compared to abstinence-centred inpatient rehabilitation programmes. However, there were sentiments that more community education on OST was needed to motivate people with opioid dependence to access services and to address misconceptions about OST. There is a lack of multi-level and multi-sectoral engagement of various stakeholders in opioid dependence services, needed to accelerate utilisation of OST services. SO WHAT?: The research unpacks the need for an integrated approach to service use optimisation, and the need to evaluate the role that increased awareness and community education on harm reduction strategies can play in enhancing the utilisation of OST services.

BackgroundHarm reduction strategies commonly include needle and syringe programmes (NSP), opioid substitution therapy (OST) and interventions combining these two strategies. Despite the proven effectiveness of harm-reduction strategies in reducing human immunodeficiency virus (HIV) infection among injecting drug users (IDUs), no study has compared the cost-effectiveness of these interventions, nor the incremental cost effectiveness of combined therapy. Using data from the Global Fund, this study compares the cost-effectiveness of harm reduction strategies in Eastern Europe and Central Asia, using the Ukraine as a case study.MethodsA Markov Monte Carlo simulation is carried out using parameters from the literature and cost data from the Global Fund. Effectiveness is presented as both QALYs and infections averted. Costs are measured in 2011 US dollars.ResultsThe Markov Monte Carlo simulation estimates the cost-effectiveness ratio per infection averted as $487.4 [95% CI: 488.47-486.35] in NSP and $1145.9 [95% CI: 1143.39-1148.43] in OST. Combined intervention is more costly but more effective than the alternative strategies with a cost effectiveness ratio of $851.6[95% CI: 849.82-853.55].The ICER of the combined strategy is $1086.9/QALY [95% CI: 1077.76:1096.24] compared with NSP, and $461.0/infection averted [95% CI: 452.98:469.04] compared with OST. These results are consistent with previous studies.ConclusionsDespite the inherent limitations of retrospective data, this study provides evidence that harm-reduction interventions are a cost-effective way to reduce HIV prevalence. More research on into cost effectiveness in different settings, and the availability of fiscal space for government uptake of programmes, is required.

BackgroundCurrent estimates suggest that 15% of all prisoners worldwide are chronically infected with the hepatitis C virus (HCV), and this number is even higher in regions with high rates of injecting drug use. Although harm reduction services such as opioid substitution therapy (OST) and needle and syringe programs (NSPs) are effective in preventing the further spread of HCV and HIV, the extent to which these are available in prisons varies significantly across countries.MethodsThe Hep-CORE study surveyed liver patient groups from 25 European countries in 2016 and mid-2017 on national policies related to harm reduction, testing/screening, and treatment for HCV in prison settings. Results from the cross-sectional survey were compared to the data from available reports and the peer-reviewed literature to determine the overall degree to which European countries implement evidence-based HCV recommendations in prison settings.ResultsPatient groups in nine countries (36%) identified prisoners as a high-risk population target for HCV testing/screening. Twenty-one countries (84%) provide HCV treatment in prisons. However, the extent of coverage of these treatment programs varies widely. Two countries (8%) have NSPs officially available in prisons in all parts of the country. Eleven countries (44%) provide OST in prisons in all parts of the country without additional requirements.ConclusionDespite the existence of evidence-based recommendations, infectious disease prevention measures such as harm reduction programs are inadequate in European prison settings. Harm reduction, HCV testing/screening, and treatment should be scaled up in prison settings in order to progress towards eliminating HCV as a public health threat.

Harm reduction is an approach that aims to reduce harms related to using drugs. Harm reduction services often fail to consider the needs of women who inject drugs or minimise responses to women’s needs in service design and implementation (Bennett et al., 2000; Brown et al., 2005; EMCDDA, 2006; Levy, 2014a; Pinkham, Stoicesu and Myers, 2012; UNODC et al., 2014). It is therefore crucial to understand the experiences of women who inject drugs from their own perspectives, as well as those of harm reduction workers, in order to develop and implement effective responses to injecting drug use. This thesis explores how ‘harm’ and ‘harm reduction’ are conceptualised by workers and clients at a women-only day syringe exchange programme. It answers the following questions: In what ways do participants’ broader understandings of ‘harm’ and ‘harm reduction’ go beyond the traditional public health model of harm reduction in response to illicit injectable drug use? How are clients and workers’ understandings gendered? These questions were explored empirically through fieldwork in 2013 and 2014 at a harm reduction centre which featured a women-only day syringe exchange programme in Budapest, Hungary. This women-only day was the only gender sensitive harm reduction programme in the country, and the first study undertaken with Roma women who inject drugs in Hungary and female harm reduction workers. In addition, this first research project to use photovoice within a harm reduction context in Hungary. Data were co-produced with respondents according to the principles of Feminist- informed Participatory Action Research, using the method of ‘photovoice’. This method involved providing cameras for clients and employees of the women-only day to photograph their experiences and understandings of harm, harm production, and harm reduction. A significant portion of the data collected for this study was created by female harm reduction workers who worked at the women-only syringe exchange programme. Employees and clients’ images guided the research observations, interviews, and analysis. This meant collaboration between the participants and the researcher through the fieldwork, including the development and implementation of a research output in the form of a public photo exhibition and fundraiser event. The event was called ‘Chicks on the Corner’, and is the source of the thesis title as well as the title of the research project. The theoretical frameworks of zemiology (the study of harm) and black and multiracial feminist thought informed the ontological and epistemological grounding of the Chicks on the Corner project. These frameworks, coupled with the empirical data, produced an argument for the development of a feminist zemiology. The analytical themes that emerged from the Chicks on the Corner project were produced and categorised primarily using participant generated photographs. These images depict the multiple intersecting, overlapping, and mutually reinforcing sources of harm production and attempts at harm reduction in participants’ lives. Analysis of the photographs affirm that women who inject drugs experience an array of harms in addition to physical harms related to their drug use. Harms identified by research participants were categorised using Hillyard and Tombs (2004; 2005) zemiological typology. This typology consists of: physical harms, emotional harms, economic harms, and cultural harms (also known as lack of cultural safety). In addition, a new fifth category of harm was created based on participants’ responses, and is called institutional and political harms. The data from the Chicks on the Corner project show how institutional and political harms contributed to the production of the other four categories of harm. Furthermore, the analysis outlines the numerous challenges workers faced in attempting to provide adequate harm reduction responses while experiencing multiple social harms as well. These novel findings suggest the need for expanded definitions of ‘harm’ in harm reduction theory and practices. The findings from the Chicks on the Corner project complement existing literature on harm reduction theory and practice while also adding to the limited body of research on gender- sensitive approaches to harm reduction. This thesis contributes to an expansion of theoretical understandings of harm and harm reduction in relation to women who inject drugs and harm reduction workers, as well as discussing implications for gender sensitive harm reduction practices. Based on this analysis, I propose the development of feminist zemiology as a way to better understanding harm.

Keywords: Causal inference; clinical trials; heroin; opioid substitution therapy; people who inject drugs (PWID); polysubstance use; prescription drug abuse; propensity score matching; Respondent Driven Sampling (RDS)

Background Substance use disorders (SUDs) continue to impose a major global public health burden, with persistently high relapse rates and barriers to sustained recovery. While traditional harm reduction strategies—such as opioid substitution therapy, needle exchange programs, and contingency management—have improved health outcomes, additional biomedical tools are needed. Immunotherapies, including anti-drug vaccines and monoclonal antibodies (mAbs), offer a novel adjunctive approach within the broader harm reduction framework. Main body Anti-drug vaccines stimulate the production of drug-specific antibodies that bind to psychoactive substances in the bloodstream, forming complexes too large to cross the blood–brain barrier. This may reduce reinforcement and limit intoxication. mAbs, by contrast, offer passive immunity and are being investigated for rapid-onset applications, including overdose mitigation. Preclinical and early-phase clinical trials targeting nicotine, cocaine, opioids, and methamphetamine have shown encouraging pharmacological effects. However, multiple barriers have impeded translation into practice, including interindividual variability in immune responses, short-lived antibody titers requiring boosters, behavioral compensation (e.g., dose escalation), and lack of sustained clinical efficacy in large trials. In addition, real-world implementation is limited by the absence of cost-effectiveness evaluations, regulatory ambiguity, and manufacturing complexity. Ethical issues, particularly regarding informed consent in justice-involved or marginalized populations, also warrant attention. Conclusion When integrated with behavioral, pharmacological, and psychosocial interventions, anti-drug immunotherapies may enhance the effectiveness of existing harm reduction strategies. Their potential lies not in replacing current approaches but in reinforcing them. Achieving this will require further clinical research, critical evaluation of past failures, and careful navigation of ethical, regulatory, and logistical challenges.

BackgroundPeople who inject drugs (PWID) experience high risk for HIV and HCV infection, which can be mitigated by harm reduction strategies, including syringe service programs (SSP). Understanding individuals’ patterns of substance use and SSP utilization is important for optimizing harm reduction strategies and disease prevention for PWID.MethodsWe evaluated demographic characteristics and service utilization from the New Haven Syringe Services Program (NHSSP), a low-threshold service delivery site in New Haven, Connecticut that provides fully integrated harm reduction and primary healthcare services to PWID. Site-specific data were extracted from the e2ctprevention database, managed by the Connecticut Department of Public Health, and EvaluationWeb from January 2017 to October 2023. We conducted a descriptive analysis of basic demographic and social characteristics of SSP clients, transaction characteristics, and service utilization. Statistical analyses were conducted using STATA v 16.1 and IBM SPSS Statistics (v 29.0.2.0).ResultsAmong 1,189 unique individuals utilizing SSP during the observation period, most (65.2%) identified as men and white (73.3%), consistent with SSP clients regionally and nationally. The mean age of clients was 41 years (SD = 9.8); approximately half of participants were unstably housed and 80% were unemployed at intake. From June 2020 to October 2023, there were 7,238 transactions, which increased throughout the COVID-19 pandemic period. During this period, the program dispensed 1,860,621 syringes, in addition to other materials, including overdose education and naloxone distribution (OEND), and provided patient education on safer injecting techniques and wound care.ConclusionIn this first comprehensive analysis of a large SSP since its inception and through the COVID-19 pandemic, we described important client characteristics and utilization of an array of syringe services from an integrated SSP. Findings suggest the SSP attracts a high volume of clients, provides on-demand services, and reaches a wide range of clients. Future research is needed to evaluate the impact of the program’s home-delivery service and increased outreach efforts. Despite limitations, the program’s success demonstrates the SSP can serve as a model for other harm reduction programs nationally.

Assessing the student pharmacist's comfort level with harm reduction strategies via clinical exposure.

BackgroundThere is an estimate of three to five million people who inject drugs living in Asia. Unsafe injecting drug use is a major driver of both the HIV and hepatitis C (HCV) epidemic in this region, and an increase in incidence among people who inject drugs continues. Although harm reduction is becoming increasingly accepted, a largely punitive policy remains firmly in place, undermining access to life-saving programmes. The aim of this study is to present an overview of key findings on harm reduction in Asia based on data collected for the Global State of Harm Reduction 2014.MethodsA review of international scientific and grey literature was undertaken between May and September 2014, including reports from multilateral agencies and international non-governmental organisations. A qualitative survey comprising open-ended questions was also administered to civil society, harm reduction networks, and organisations of people who use drugs to obtain national and regional information on key developments in harm reduction. Expert consultation from academics and key thinkers on HIV, drug use, and harm reduction was used to verify findings.ResultsIn 2014, 17 countries in Asia provide needle and syringe programmes (NSP) provision and 15 opioid substitution therapy (OST). It is estimated that between 60 and 90 % of people who use drugs in Asia have HCV; however, treatment still remains out of reach due to cost barriers. TB testing and treatment services are yet to be established for key populations, yet nearly 15 % of the global burden of new cases of HIV-TB co-infection are attributed to southeast Asia. Eighteen percent of the total number of people living with HIV eligible for antiretroviral treatment (ART) accessed treatment. Only Malaysia and Indonesia provide OST in prison, with no NSP provision in prisons in the region.ConclusionTo reduce HIV and viral hepatitis risk among people who inject drugs, there is a necessity to significantly increase harm reduction service provision in Asia. Although there has been progress, work still needs to be done to ensure an appropriate and enabling environment. At present, people who inject drugs are extremely difficult to reach; structural and legal barriers to services must be reduced, integrated holistic services introduced, and further research undertaken.Electronic supplementary materialThe online version of this article (doi:10.1186/s12954-015-0066-x) contains supplementary material, which is available to authorized users.

Discussions about harm reduction have been in the news on and off for the past few years — largely because of Insite, North America's first safe injection site located in Vancouver, BC, and the legal cases surrounding it.1 When the Supreme Court of Canada ruled last September in favour of the continued operation of Insite (and against the federal Conservative government ministers who wanted to halt its operation as part of their removal of harm reduction elements from their anti-drug strategies), many of those cheering were health professionals who support the harm reduction model as an important component of public health.2 For those unsure of what harm reduction is (and isn't), it is a public health concept with the primary goal of decreasing the negative consequences, i.e., harms, from the use of drugs (or alcohol, tobacco and even high-risk sexual practices) to both the individual involved and society at large.3 Harm reduction is not the promotion or encouragement of illicit drug use or other addictive behaviours. It is usually accomplished using a step-wise approach, aiming to implement the easiest, most realistic goals first.4 Advocates of the method realize that abstinence may not be a realistic or even desirable goal for some users, particularly in the short term, although many clients of harm reduction programs ultimately do enter abstinence or detoxification programs. The benefits of such programs have been well documented in published research and include improvements to the health of individuals and their communities, as well as savings to the health care system.5,6 In this issue of CPJ, you will find 2 interesting articles addressing the role of pharmacists in harm reduction programs (see pages 123 and 124). In many instances, pharmacists are already participants in harm reduction efforts such as needle exchange programs and opioid substitution therapy without fully recognizing the public health benefits of their work. As pharmacist Andrea Fernandes found, it is possible to overcome any initial concerns to find practice in an addiction clinic fulfilling and rewarding.7 With a recent report recommending the implementation of supervised injection facilities in Toronto and Ottawa8 and demands for similar services in other parts of the country, it's a great time for pharmacists to become more familiar with the opportunities in this expanding practice area. As our authors conclude, future research efforts should be directed at evaluating the effectiveness of pharmacists and pharmacies in delivering harm reduction interventions.9 Let us know what you think of this or any issue — your feedback is always welcome! Contact ac.stsicamrahp@neellikr.

BackgroundDespite the widespread use of the phrase “harm reduction” and the proliferation of programs based on its principles during the current opioid epidemic, what it means in practice is not universally agreed upon. Harm reduction strategies have expanded from syringe and needle exchange programs that emerged in the mid-1980s primarily in response to the HIV epidemic, to include medication for opioid use disorder, supervised consumption rooms, naloxone distribution, and drug checking technologies such as fentanyl test strips. Harm reduction can often be in tension with abstinence and recovery models to address substance use, and people who use drugs may also hold competing views of what harm reduction means in practice. Street-based outreach workers are increasingly incorporated into harm reduction programs as part of efforts to engage with people more fully in various stages of drug use and nonuse.MethodThis paper explores how peer outreach workers, called “members,” in a street-based naloxone distribution program define and practice harm reduction. We interviewed 15 members of a street-based harm reduction organization in an urban center characterized by an enduring opioid epidemic. Inductive data analysis explored harm reduction as both a set of principles and a set of practices to understand how frontline providers define and enact them.ResultsAnalysis revealed that when members talked about their work, they often conceptualized harm reduction as a collection of ways members and others can “save lives” and support people who use drugs. They also framed harm reduction as part of a “path toward recovery.” This path was complicated and nonlinear but pursued a common goal of life without drug use and its residual effects. These findings suggest the need to develop harm reduction programs that incorporate both harm reduction and recovery to best meet the needs of people who use drugs and align with the value systems of implementers.