Thinking beyond the individual, a response to commentaries.

Abstract

A Harm to Other (HTO) research agenda must include all the harms associated with both consumption and supply, consider pleasure and engage with the community about harms to others from people who use drugs and consume alcohol. We thank the authors of the four commentaries [1-4]. We are pleased to have stimulated a wide-ranging discussion about the application of an Alcohol's Harm to Other (AHTO) approach to illicit drug research [5]. Commentators have recognized the social and political dimensions to our argument. Ramstedt [1] reminds us of the total consumption model of alcohol and its intention to regard all people who consume alcohol as part of the problem, and argues that this in some way mitigates stigma. We disagree, because this model focuses solely upon people who consume substances. Laslett & Room [2] offer a useful contrasting insight here, with their emphasis on the role of relationships and social interactions in producing harms. To take their point one step further, the unit of analysis is the interaction between two or more individuals, not the individuals themselves, as it is this interaction that generates the harm. They also make the important point that it is alcohol's harm (not the person's harm) which is a subtlety perhaps not often enough noted within the ATHO literature. We like the notion of the interaction as the potential unit of harm, and the application of an event-level type analysis to numerate harms to others. Investigating consumption events to make more transparent the variety of harms to the various actors within each event may be a useful step forward. At the same time, as we argued originally, an event-level analysis of harm to others would necessarily include consumption but also the antecedents to that consumption including, the production, distribution and sale of illicit drugs through the multiple levels of the black market. Nicholls [3] is the only commentator to engage with what we see as the two most important key ideas in our original piece: first, that harms to people other than the person consuming the substance must include all the harms associated with both consumption and supply; and secondly that a harm-analysis must recognize pleasure. These are two key ways in which a drugs HTO research framework could proceed. All commentators agree that reducing stigma is an important goal. One small way this can be achieved is to choose non-stigmatizing language. For a number of years now, drug researchers do not refer to ‘drug users’ but to ‘people who use drugs’. The alcohol research community continues to use the term ‘drug user’ and ‘drinker’. It may be time to refer to ‘people who drink alcohol’. There is, in this language and throughout much policy discourse, a tendency to think in binaries. Legal drugs and illegal drugs; prohibition and legalization are just two examples. Here the binary is cast between two points of leverage for tackling harm to others: the individual who is consuming alcohol or other drugs and the State, responsible for governing that behaviour. However, Chikritzhs [4] reminds us that a third and perhaps most potent point of leverage is community. She terms this ‘restorative public health’ and provides a lovely example of pregnancy warning labels that have both the pregnant woman and her partner crossed out. We agree: it is up to parents, family, friends and community, in addition to individuals and the state, to reduce harms. When the focus remains upon individuals and the state, we miss the opportunity to harness community. There is substantial untapped power in mobilizing communities, building community resilience, empowering the community voice and supporting community action. This may hold the key to much more effective alcohol and other drug policy. Finally, in order to mobilize communities, we need to engage with them in a participatory dialogue about harms to others. A dialogue about a HTO research agenda that is held solely among researchers is inconsistent with an ethics of empowering community. None. Dr Claire Wilkinson is a recipient of a National Health and Medical Research Council Early Career Fellowship (APP1140292). Professor Alison Ritter is a recipient of a National Health and Medical Research Council Fellowship (APP1136944). These funding sources had no impact on the conceptualisation, write-up, or decision to submit the manuscript.