Harm Reduction Methods Research Articles

Young Peoples’ Perspectives on the Role of Harm Reduction Techniques in the Management of Their Self-Harm: A Qualitative Study

Objective Self-harm is a common phenomenon amongst young people, often used to regulate emotional distress. Over the last decade harm reduction approaches to self-harm have been introduced as a means to minimize risk and reinforce alternative coping strategies. However, there is a stark absence of research into the perceived usefulness of such techniques amongst adolescents, and previous studies have highlighted ethical concerns about advocating ‘safer’ forms of self-harm. This study aimed to investigate the perceived usefulness of harm reduction techniques for adolescents who self-harm. Method We purposively recruited current clients of a British early intervention program supporting young people in managing self-harm. We conducted semi-structured interviews and analyzed transcripts using thematic analysis. Results Eleven interviews with service users aged 14–15 years identified three main themes: (1) Controlling the uncontrollable; (2) Barriers to practising safer self-harm; and (3) Developing a broad repertoire of harm reduction techniques. Participants expressed mixed views regarding the usefulness of such approaches. Some described greater competence and empowerment in self-harm management, whilst others described the utility of harm reduction methods as either short-lived or situation-specific, with the potential for misuse of anatomical knowledge to cause further harm to high-risk adolescents. Conclusion The findings from our sample suggest harm reduction techniques have a place in self-harm management for some individuals, but their usage should be monitored and offered alongside alternative strategies and therapeutic support. Our study highlights the need for further research on who would benefit from these techniques and how they can be implemented successfully. HIGHLIGHTS Harm reduction can help people who self–harm manage distress and maintain autonomy People who self-harm have a broad repertoire of harm reduction techniques Harm reduction can help reduce long-term damage and frequency of self-harm

Engagement in Harm Reduction Strategies After Suspected Fentanyl Contamination Among Opioid-Dependent Individuals.

The evolving opioid epidemic in the United States has increased drug-related overdose rates exponentially (Centers for Disease Control and Prevention in Opioid overdose, 2020c, https://www.cdc.gov/drugoverdose/data/otherdrugs.html#:~:text=Polysubstance%20drug%20use%20occurs%20with,or%20other%20non%2Dopioid%20substances ). Fentanyl, a synthetic opioid, has recently fueled the epidemic, increasing overdose death rates (Centers for Disease Control and Prevention in Drug overdose deaths involving fentanyl, 2011-2016, 2019a, https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf ). Harm reduction strategies (drug checking, naloxone administration, etc.) are at the forefront of preventing opioid-related overdoses in high-risk populations (Kennedy et al. in Drug Alcohol Depend 185:248-252, 2018, https://doi.org/10.1016/j.drugalcdep.2017.12.026 ; Laing et al. in Int J Drug Policy 62:59-66, 2018, https://doi.org/10.1016/j.drugpo.2018.10.001 ). Little is known, however, about how people who inject drugs (PWID) may modify their drug use behaviors after suspected fentanyl contamination in their drugs. We conducted a cross-sectional survey among 105 opioid-dependent PWID enrolled in a methadone maintenance program. We assessed their willingness to engage in various harm reduction methods (i.e., slowing down drug use, not using drugs, carrying naloxone, using with someone who has naloxone) after suspected fentanyl contamination of their drugs. In a multivariable analysis, participants who were white, low-income, polysubstance users, and had previously experienced an overdose or had previously administered naloxone were more likely to report a willingness to engage in harm reduction measures. These findings provide an evidence-based understanding of PWID's engagement in harm reduction behaviors after suspecting potential fentanyl exposure as well as a basis for tailoring intervention strategies in the context of fentanyl-adulterated markets.

Perceived Safety and Effectiveness of Electronic Cigarettes among Malaysian Adults and Public Support for Regulations.

ABSTRACTContext:Electronic cigarettes have been used as a harm reduction method toward tobacco cessation. Malaysian government has enforced a strict policy to regulate the sale of electronic cigarette products because its liquid contains nicotine.Aims:This study aimed to explore the general public’s perception toward electronic cigarette use. Public support toward electronic cigarette regulation was also examined.Settings and Design:This was a Malaysian population-based survey.Materials and Methods:Data were obtained from the National E-Cigarette Survey (NECS) 2016, which used a multistage stratified cluster sampling household survey representing all Malaysian adults aged 18 years old. A cross-sectional survey was conducted among a total of 4288 adults.Statistical Analysis Used:Descriptive and logistic regression analysis.Results:Majority were aged 25–44 years old (44%), completed at least secondary education (69%), of Malay ethnicity (73%), and married (68%). Majority (88.1%) have never used electronic cigarette. A quarter (25.5%) perceived electronic cigarette helps people quit cigarette smoking, whereas 20.3% perceived electronic cigarette helps people to maintain cigarette abstinence. Approximately 85% believed that electronic cigarette use does not help in improving breathing and coughing. Majority (91.8%) disagreed that electronic cigarettes should be allowed in places where tobacco smoking is banned. Thus, 63.4% agreed that electronic cigarette should be banned completely rather than regulated.Conclusion:Majority of general public had negative perception about electronic cigarette use.

316. Hepatitis C and Engagement in Health Care Among Persons Who Inject Drugs and Persons Who Use Non-Injection Drugs, Philadelphia

BackgroundThe growing opioid epidemic is driving increasing rates of hepatitis C virus (HCV) infections in the United States. HCV transmission is most frequently attributed to unsafe injection behaviors, but can occur via other unsafe drug use and sexual behaviors. Differences in demographics, HCV rates and associated risk factors in non-injecting PWUD (NIPWUD), compared with people who inject drugs (PWID) must be understood in order to target elimination strategies.MethodsChange is Philadelphia’s program to eliminate HCV among PWUD and enrollment includes HCV testing, linkage services, and an interviewer-administered survey including risk behaviors and healthcare engagement. This interim analysis includes the first 835 enrollees that identified as PWUD. For this analysis, PWID are enrollees who indicated ever injecting drugs and those who had not are NIPWUD.ResultsAmong enrollees, 76% (N = 637) reported ever injecting drugs. PWIDs were younger and non-Hispanic (NH) white while NIPWUD were older and NH Black (age: P = 0.003; race/ethnicity: P < 0.0001). NIPWUDs had a high seropositivity rate though significantly lower than PWIDs (24% vs. 85%, respectively; P < 0.0001). Among PWID enrollees, 94% (N = 596) ever snorted. Of enrollees, 63% (N = 124) of NIPWUD and 56% (N = 356) of PWID identified having a PCP (P =0.07). PWIDs are more likely than NIPWUD to have overdosed (OD) (40% vs. 9%; P < 0.0001) though high rates of both groups ever witnessed an OD (84% vs. 67%, respectively). While 80% (N = 105) of NIPWUDs know how to use Narcan, 60% (N = 79) carry it, {94% (N = 503) and 71%(N = 381) in PWID, respectively}. NIPWUDs are more likely to be interested in drug treatment (P < 0.0001) and to have received it in the last 12 months (P = 0.0008).ConclusionNotable HCV infection exists among non-injecting PWUD reinforcing the need for harm reduction counseling and access to drug use equipment used for smoking and snorting. NIPWUD may be able to access drug and HCV treatment through PCPs and fatal ODs may be prevented by ensuring NIPWUDs have access to Narcan. In addition, PWID are likely to snort as well and should be counseled on non-injecting harm reduction methods. To succeed in micro elimination among PWUD, a focus on NIPWUDs as well as PWIDs is necessary to mitigate transmission of HCV.Disclosures All authors: No reported disclosures.

Adulterants and altruism: A qualitative investigation of “drug checkers” in North America

Background“Drug checking” has become a common harm reduction method used to test illicit substances, such as ecstasy, for purity and/or the presence of adulterants. Formal drug-checking services have been operating for decades, and the use of personal reagent test kits appears to be relatively common; however, little attention has been devoted to understanding the role and broader experiences of ‘drug-checkers’ (i.e., people who test their own and/or other people's substances). As such, it remains unknown who is engaging in this practice, their motivations for drug-checking, and what barriers they may experience. We addressed this research gap by interviewing people who check drugs about their experiences, with a goal of better understanding drug checking practices. MethodsWe conducted in-depth interviews with 32 adults in North America who reported testing drugs. Coding was conducted in an inductive manner and thematic analysis was used to identify relevant themes. ResultsOver half (56.2%) of our sample was affiliated with a drug checking organization. Among non-affiliated checkers (43.8%), the majority (57.1%) tested for friends, 21.4% tested only for themselves, and 21.4% were people who sold drugs and tested for their clients. Motivations were driven largely by altruism, described by checkers as wanting to protect their peers from exposure to adulterants. People interviewed who sold drugs were altruistic in the same manner. Barriers to checking—particularly at nightclubs and festivals—included perceived illegality of test kits and denied approval to test drugs at venues, although many checkers circumvented this barrier by checking drugs without such approval. ConclusionsDrug checkers in North America seek to educate people who use drugs about the risk of exposure to unexpected substance types, but they face various barriers. Policy change could help ensure that these potentially life-saving services can be provided without fear of fines and/or criminal prosecution.

Non-Prescribed Buprenorphine Use Mediates the Relationship between Heroin Use and Kratom Use among a Sample of Polysubstance Users

ABSTRACTIn Asia, Mitragyna speciosa (e.g., “kratom”) has been used to mitigate alcohol and drug dependence. Some preliminary findings suggest kratom’s potential use as an informal harm-reduction method in the United States, such as an opioid substitute or as a means of lessening opioid withdrawal symptoms. To determine correlates of past-year kratom use among a sample of polysubstance users enrolled in residential recovery programs in Kentucky, an anonymous survey was completed by clients in April 2017. Logistic regression was used to identify significant associations with past-year kratom use. Of the final sample (N = 478), 10.4% reported past-year kratom use. Past-year heroin use, but not past-year prescription opioid (e.g., oxycodone, hydrocodone) use, was significantly associated with kratom use, such that individuals who reported past-year heroin use were 2.5 times more likely to also report past-year kratom use. Non-prescribed buprenorphine (i.e., Suboxone) use partially mediated the relationship between past-year heroin and kratom use by explaining 36% of the association between the two drugs. Though amphetamines were highly preferred, past-year use was negatively correlated with past-year kratom use. Rates of past-year kratom use were lower than rates of alcohol and illicit drug use. Kratom was not preferred over heroin or prescription opioids.

Journal Club-Electronic Cigarettes and Vaping as a Harm Reduction Alternative: Really?

Journal Club-Electronic Cigarettes and Vaping as a Harm Reduction Alternative: Really?

Harm-reduction approaches for self-cutting in inpatient mental health settings: Development and preliminary validation of the Attitudes to Self-cutting Management (ASc-Me) Scale.

WHAT IS KNOWN ON THE SUBJECT?: Nurses in mental health inpatient settings use a range of methods to try and help service users who self-harm Harm-reduction approaches are intended to help service users reduce the impact of their self-harm rather than simply to prevent them self-harming Harm-reduction techniques might be helpful for people who cut themselves because there are some clear ways harm can be minimized such as providing advice about cutting No one has previously tried to measure whether harm-reduction techniques are more or less acceptable to mental health practitioners and service users than traditional methods. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper describes the development of the Attitudes to Self-cutting Management scale. It met the criteria required of a good measurement tool. Each method of managing self-cutting has a unique acceptability profile Harm-reduction methods like advising on wound care and providing a first aid kit are endorsed by nurses and former service users Nurses providing sterile razors or remaining present during self-cutting attract more divergent opinions but are preferred to seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses should talk through the approaches to management with service users and agree which techniques are preferred. ABSTRACT: Introduction Harm-reduction approaches for self-harm in mental health settings have been under-researched. Aim To develop a measure of the acceptability of management approaches for self-cutting in mental health inpatient settings. Methods Stage one: scale items were generated from relevant literature and staff/service user consultation. Stage two: A cross-sectional survey and statistical methods from classical test theory informed scale development. Results/Findings At stage one, N=27 staff and service users participated. At stage two, N=215 people (n=175 current mental health practitioners and n=40 people with experience of self-cutting as a UK mental health inpatient) completed surveys. Principal components analysis revealed a simple factor structure such that each method had a unique acceptability profile. Reliability, construct validity and internal consistency were acceptable. The harm-reduction approaches "advising on wound care" and "providing a first aid kit" were broadly endorsed; "providing sterile razors" and "maintaining a supportive nursing presence during cutting" were less acceptable but more so than seclusion and restraint. Discussion The Attitudes to Self-cutting Management scale is a reliable and valid measure that could inform service design and development. Implications for practice Nurses should discuss different options for management of self-cutting with service users. Harm-reduction approaches may be more acceptable than coercive measures.

Justice Dept. Threatens Action Against Planned Safe Injection Sites

Justice Dept. Threatens Action Against Planned Safe Injection Sites

Spiritual Influence Towards Relapse in Opioid Addicts in Therapy

Introduction: Substance abuse is both a social and public health problem with a substantial burden to society. Opioid dependence results in unemployment, crimes, family disruption, and transmission of diseases. In Malaysia, methadone maintenance therapy (MMT) has been introduced as a harm reduction method. However, relapse during treatment remains an issue to be resolved that hinders successful outcome in the therapy. Spirituality in the treatment of substance abuse disorders has yet to be fully explored. This study aims to examine how MMT clients who relapsed perceive spiritual deficits as an influence and association of spiritual practice with relapse. Methods: This is a cross-sectional study done from June-July 2016. All MMT clients undergoing therapy at 3 treatment centers in Terengganu, Malaysia who fulfilled the inclusion and exclusion criteria and consented were included in the study. A semi-structured questionnaire was filled via face to face interview and spiritual practice was assessed using Hatta Islamic Religiosity Scale. 121 questionnaires were assessed and data was analyzed using SPSS version 22 for quantitative data. Results: All respondents were males of Malay race and Islamic religion. Current relapse, defined as any episode of intake of opioid for the past one month after a period of abstinence was 34%. Only three out of 42 clients who relapsed had some spirituality theme in their perceived cause of their relapse. However, a significant majority of those relapsed had a spiritual practice score of less than the mean practice score. Conclusion: Relapse in opioid addiction remains high in those receiving MMT in Terengganu, Malaysia. Spirituality may have a subconscious influence towards relapse in addiction in MMT clients. Further effort should be taken to inculcate spirituality intervention effective to prevent relapse which may contribute towards achieving a more successful therapy outcomes.

Treatment outcomes in patients with opioid use disorder initiated by prescription: a systematic review protocol

BackgroundIn North America, opioid use has become a public health crisis with policy makers declaring it a state of emergency. Opioid substitution therapy (OST) is a harm-reduction method used in treating opioid use disorder. While OST has shown to be successful in improving treatment outcomes, there is still a great degree of variability among patients. This cohort of patients has shifted from young males using heroin to a greater number of older people and women using prescription opioids. The primary objective of this review is to examine the literature on the association between the first exposure to opioids through prescription versus illicit use and OST treatment outcomes.MethodAn electronic search will be conducted on the EMBASE, MEDLINE, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Two independent reviewers will conduct the initial title and abstract screenings using predetermined criteria for inclusion and exclusion. Reviewers will then conduct full-text data extraction using a pilot-tested data extraction form in duplicate. A third author will resolve disagreements if consensus cannot be reached. Quality and risk of bias assessment will be conducted along with a sensitivity analysis for all included studies. Qualitative summary of the evidence will be provided, and when possible, a meta-analysis will be conducted, along with heterogeneity calculation. The reporting of this protocol follows the PRISMA-P.DiscussionWe expect that this review will help determine whether patients that were initially exposed to opioids through a prescription differ in OST treatment outcomes in comparison to people who used opioids through illicit means. We hope that this review will provide evidence related to prescription opioids exposure and future treatment outcomes, which will aid clinicians in their decisions to prescribe opioids or not for specific populations at risk.Systematic review registrationPROSPERO CRD42017058143

Associated Factors for Relapse in Opioid Addicts undergoing Therapy

Substance abuse is both a social and public health problem with a substantial burden to society. Opioid dependence results in unemployment, crimes, family disruption, and transmission of diseases. In Malaysia, Methadone Maintanence Therapy (MMT) has been introduced as a harm-reduction method. However, relapse during treatment remains an issue to be resolved that hinders successful outcome in the therapy. This study aims to determine the prevalence of relapse in opioid addicts undergoing MMT and its associated potential risk factors. This is a cross-sectional study done from June-July 2016. All patients with MMT in primary care therapy centres in Kuala Nerus district, Terengganu, Malaysia who fulfilled the inclusion and exclusion criteria was included. A semi-structured questionnaire was filled via face-to-face interview and reference to the case records was done. 122 questionnaires were assessed. All respondents were males of Malay race. Mean age was 36.2. Mean duration in MMT was 1.4 years. Current relapse, defined as any episode of intake of heroine for the past one month after a period of abstinence was 34.4%. The significant factors found in our study for relapse were: the patients’ goal for treatment (p<0.001), status of parents prior to addiction (p<0.038), duration of therapy (p<0.001), and taking of amphetamine during therapy (p<0.013), respectively. Relapse in opioid addiction remains high in those receiving MMT. Clients need to be properly educated regarding reasonable goals for treatment, which may contribute towards achieving more successful therapy outcomes.

Securitizing Narcotics: The Politics and Prospects of Russian Counterdrug Policies

AbstractRussia is suffering from a serious and worsening challenge from narcotics, with 6% of the population using or addicted to drugs, which is also leading to a growing public health crisis. A particular problem is the growing availability of heroin from Afghanistan, with Russia an increasingly important transit country, as well as market. Efforts to control this have been severely limited by issues of resourcing, political will and turf wars between security agencies. Russia’s growing economic problems have also led to a need for liquidity on the part of many financial institutions that leads them to turn a blind eye to dirty money. However, the fundamental issues are that the Kremlin regards this as a nationalist, securitized and moral problem. The influx of Afghan heroin reflects at best Western failure and at worse a malign attempt to damage Russia. This needs to be considered a security threat and is therefore best addressed through interdiction and punitive measures rather than harm reduction and civil outreach, especially because drug addiction is considered a moral rather than a medical issue. Thus, Russia needs to adopt a more inclusive and comprehensive strategy that balances policing with treatment, prevention and harm reduction methods, in partnership with local governments, communities and NGOs, as well as foreign partners. Not only must law enforcement cooperation not continue to be a hostage to geopolitical rivalries, but policy over Afghanistan needs to be about encouraging productive efforts to reduce production rather than using the issue as a means to asserting regional hegemony.

Medical cannabis use in Canada: vapourization and modes of delivery.

BackgroundThe mode of medical cannabis delivery—whether cannabis is smoked, vapourized, or consumed orally—may have important implications for its therapeutic efficacy and health risks. However, there is very little evidence on current patterns of use among Canadian medical cannabis users, particularly with respect to modes of delivery. The current study examined modes of medical cannabis delivery following regulatory changes in 2014 governing how Canadians access medical cannabis.MethodsA total of 364 approved adult Canadian medical cannabis users completed an online cross-sectional survey between April and June 2015. The survey examined patterns of medical cannabis use, modes of delivery used, and reasons for use. Participants were recruited through a convenience sample from nine Health Canada licensed producers.ResultsUsing a vapourizer was the most popular mode of delivery for medical cannabis (53 %), followed by smoking a joint (47 %). The main reason for using a vapourizer was to reduce negative health consequences associated with smoking. A majority of current vapourizer users reported using a portable vapourizer (67.2 %), followed by a stationary vapourizer (41.7 %), and an e-cigarette or vape pen (19.3 %). Current use of a vapourizer was associated with fewer respiratory symptoms (AOR = 1.28, 95 % CI 1.05–1.56, p = 0.01).ConclusionsThe findings suggest an increase in the popularity of vapourizers as the primary mode of delivery among approved medical users. Using vapourizers has the potential to prevent some of the adverse respiratory health consequences associated with smoking and may serve as an effective harm reduction method. Monitoring implications of such current and future changes to medical cannabis regulations may be beneficial to policymakers.

Effects of Prohibition and Decriminalization on Drug Market Conflict

Research SummaryTo reduce individual and social harms, most nations prohibit certain psychoactive drugs. Yet, prior scholarship has suggested that prohibition reduces illicit drug sellers’ access to law and thereby increases predation against and retaliation by them. No prior study, however, has directly tested that theory by comparing drug sellers of different legal statuses operating in a single place and time. This study analyzes rates of victimization, legal mobilization, and violent retaliation in three retail drug markets in Amsterdam, the Netherlands: the legally regulated alcohol trade of cafés, the decriminalized cannabis market of “coffeeshops,” and the illegal street drug market. Results from interviews conducted with 50 sellers in each market indicate, as expected, that illicit drug dealers have the highest rates of victimization and violent retaliation and the lowest rates of legal mobilization. Contrary to expectations, we find coffeeshops experience less victimization than cafés and have similar rates of violent retaliation and legal mobilization.Policy ImplicationsOur findings suggest that state regulation of drug markets affects victimization and conflict management of sellers, but the relationship does not seem to be linear. Prohibition undercuts the state's regulatory capacity by producing zones of virtual statelessness in which formal means of dispute resolution are unavailable, and thus, victimization and retaliation are more common. At the other extreme is laissez faire regulation, which may make sellers more likely to address problems only after they occur (instead of preventing their occurrence). The Dutch government originally instituted coffeeshops as a harm‐reduction method meant to separate the market for cannabis from that of hard drugs. The policy also seems to work well when it comes to reducing victimization, perhaps by encouraging the use of preventive measures by coffeeshop owners and employees. The Dutch experience offers lessons for drug policy reforms elsewhere.

A safer alternative: Cannabis substitution as harm reduction.

Substitution is operationalised as a conscious choice made by users to use one drug instead of, or in conjunction with another based on: perceived safety, level of addiction potential, effectiveness in relieving symptoms, access and level of acceptance. Harm reduction is a set of strategies that aim to minimise problems associated with drug use while recognising that for some users, abstinence may be neither a realistic nor a desirable goal. In this paper, we aim for deeper understandings of older adult cannabis users' beliefs and substitution practices as part of the harm reduction framework. We present selected findings from our qualitative study of Baby Boomer (born 1946-1964) marijuana users in the San Francisco Bay Area. Although the sample consisted of primary cannabis users, many had personal experience with other drugs throughout their lifetimes. Data collection consisted of an audio-recorded, semi-structured in-depth life history interview followed by a questionnaire and health survey. Qualitative interviews were analysed to discover users' harm reduction beliefs and cannabis substitution practices. Study participants described using cannabis as a safer alternative for alcohol, illicit drugs and pharmaceuticals based on their perceptions of less adverse side effects, low-risk for addiction and greater effectiveness at relieving symptoms, such as chronic pain. Cannabis substitution can be an effective harm reduction method for those who are unable or unwilling to stop using drugs completely. More research is needed on cannabis as a safer alternative.

Responsible and controlled use: Older cannabis users and harm reduction

BackgroundCannabis use is becoming more accepted in mainstream society. In this paper, we use Zinberg's classic theoretical framework of drug, set, and setting to elucidate how older adult cannabis users managed health, social and legal risks in a context of normalized cannabis use. MethodsWe present selected findings from our qualitative study of Baby Boomer (born 1946–1964) cannabis users in the San Francisco Bay Area. Data collection consisted of a recorded, in-depth life history interview followed by a questionnaire and health survey. Qualitative interviews were analyzed to discover the factors of cannabis harm reduction from the users’ perspectives. ResultsInterviewees made harm reduction choices based on preferred cannabis derivatives and routes of administration, as well as why, when, where, and with whom to use. Most interviewees minimized cannabis-related harms so they could maintain social functioning in their everyday lives. Responsible and controlled use was described as moderation of quantity and frequency of cannabis used, using in appropriate settings, and respect for non-users. Users contributed to the normalization of cannabis use through normification. ConclusionParticipants followed rituals or cultural practices, characterized by sanctions that helped define “normal” or “acceptable” cannabis use. Users contributed to cannabis normalization through their harm reduction methods. These cultural practices may prove to be more effective than formal legal prohibitions in reducing cannabis-related harms. Findings also suggest that users with access to a regulated market (medical cannabis dispensaries) were better equipped to practice harm reduction. More research is needed on both cannabis culture and alternative routes of administration as harm reduction methods.

Can the Use of Smokeless Tobacco Products Be Accepted as a Harm Reduction Method in Tobacco Addiction?

Can the Use of Smokeless Tobacco Products Be Accepted as a Harm Reduction Method in Tobacco Addiction?

Filtration of crushed tablet suspensions has potential to reduce infection incidence in people who inject drugs.

The medical complications of injecting preparations from crushed tablets can be severe, and most can be attributed to the injection of insoluble particles and micro-organisms. Previously we have shown that most of the particles can be removed by filtration, but it was not known whether bacteria could also be filtered in the presence of a high particle load. This study aims to determine the feasibility of filtration to remove bacteria from injections prepared from tablets. Injections were prepared from crushed slow-release morphine tablets, in mixed bacterial suspensions of Staphylococcus aureus, Streptococcus pyogenes and Pseudomonas aeruginosa. The injection suspensions were passed through syringe filters of porosity 0.45 or 0.20 μm, or combined 0.8 then 0.2 μm, and the bacterial load was counted. Bacterial concentrations in unfiltered injections were 2.5-4.3 × 10(6) colony forming units mL(-1) . Both the 0.20 and 0.45 μm filters blocked unless a prefilter (cigarette filter) was used first. The 0.2 μm filter and the combined 0.8/0.2 μm filter reduced the bacteria to the limit of detection (10 colony forming units mL(-1) ) or below. Filtration through a 0.45 μm filter was slightly less effective. Use of a 0.2 μm filter, together with other injection hygiene measures, offers the prospect of greatly reducing the medical complications of injecting crushed tablets and should be considered as a highly effective harm reduction method. It is very likely that these benefits would also apply to other illicit drug injections, although validation studies are needed.

Cutting down: insights from qualitative studies of smoking in pregnancy

The adverse effects of smoking in pregnancy are minimised if the mother quits completely in early pregnancy. Smokers are therefore advised to quit abruptly; cutting down is not recommended either as a method of, or alternative to, quitting. However, most pregnant smokers do not quit and cutting down is widely reported. Evidence comes primarily from quantitative studies; qualitative research has contributed little to understandings of cigarette consumption in pregnancy. In consequence, little is known about the place and meaning of cutting down for pregnant smokers. The paper investigates this important dimension of maternal smoking. It explores perceptions and experiences of cutting down among pregnant smokers by examining data from a systematic review of qualitative studies of smoking in pregnancy. The studies were located in high-income countries and published between 1970 and 2012. Twenty-six studies, reported in 29 papers, were included, representing over 640 women. Meta-ethnography guided the analysis and synthesis. Data (participants' accounts and authors' interpretations) were extracted and coded; codes were progressively combined to identify overarching themes ('lines of argument'). Running through the lines of argument was evidence on cutting down; the paper presents and analyses this evidence. The analysis indicates that cutting down figured centrally as both a method of quitting and, for persistent smokers, a method of harm reduction. While pregnant women were aware that official advice was to quit abruptly, cutting down was seen as a positive behaviour change in often-difficult domestic circumstances, and one that health professionals condoned. Our findings suggest that cutting down in pregnancy, as an aid and an alternative to quitting, requires greater recognition if healthcare and tobacco control policies are to be sensitive to the perspectives and circumstances of pregnant smokers.