Implementation Of Harm Reduction Strategies Research Articles

Developing a Comprehensive Inventory to Define Harm Reduction Housing.

Background The City of Boston has faced unprecedented challenges with substance use amidst changes to the illicit drug supply and increased visibility of homelessness. Among its responses, Boston developed six low threshold harm reduction housing (HRH) sites geared towards supporting the housing needs of people who use drugs (PWUD) and addressing health and safety concerns around geographically concentrated tent encampments. HRH sites are transitional supportive housing that adhere to a "housing first" approach where abstinence is not required and harm reduction services and supports are co-located. Despite the importance of HRH, the specific characteristics and operations of these sites are not well understood. This study sought to address this gap by cataloging the common features of Boston's HRH sites to generate a comprehensive inventory tool for evaluating implementation of harm reduction strategies at transitional housing locations. Methods We collected data between June and September 2023 and included semi-structured qualitative interviews with HRH staff (n = 19), ethnographic observations and photos at six HRH sites. Candidate inventory components were derived through triangulation of the data. Two expert medical staff unaffiliated with data collection reviewed a draft inventory measuring awareness and utility of HRH inventory components. We then pilot tested the inventory with 3 HRH residents across two sites for readability and reliability. Inventory performance was further tested in a survey of 106 residents. Results HRH staff identified best practices, resources, and policies in HRH sites that were further contextualized with ethnographic field notes. Common to all were overdose prevention protocols, behavioral policies, security measures, and harm reduction supplies distribution. The initial 44-item inventory of services, policies and site best practices was further refined with expert and participant feedback and application, then finalized to generate a 32-item inventory. Residents identified and valued harm reduction services; medical supports were highly valued but less utilized. Conclusion The HRH inventory comprehensively assesses harm reduction provision and residents' awareness and perceived helpfulness of HRH operational components. Characterizing the critical components of HRH through this tool will aid in standardizing the concept and practice of HRH for PWUD and may assist other cities in planning and implementing HRH.

Fentanyl and xylazine crisis: Crafting coherent strategies for opioid overdose prevention

The United States is in the throes of a severe opioid overdose epidemic, primarily fueled by the pervasive use of fentanyl and the emerging threat of xylazine, a veterinary sedative often mixed with fentanyl. The high potency and long duration of fentanyl is compounded by the added risks from xylazine, heightening the lethal danger faced by opioid users. Measures such as enhanced surveillance, public awareness campaigns, and the distribution of fentanyl-xylazine test kits, and naloxone have been undertaken to mitigate this crisis. Fentanyl-related overdose deaths persist despite these efforts, partly due to inconsistent policies across states and resistance towards adopting harm reduction strategies. A multifaceted approach is imperative in effectively combating the opioid overdose epidemic. This approach should include expansion of treatment access, broadening the availability of medications for opioid use disorder, implementation of harm reduction strategies, and enaction of legislative reforms and diminishing stigma associated with opioid use disorder.

Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review

Background People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings. Methods A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature. Findings The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives. Conclusion This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

“We do it ourselves”: strengths and opportunities for improving the practice of harm reduction

BackgroundUnprecedented increases in substance-related overdose fatalities have been observed in Texas and the U.S. since the onset of the COVID-19 pandemic and have made clear there is considerable need to reduce harms associated with drug use. At the federal level, initiatives have called for widespread dissemination and implementation of evidence-based harm reduction practices to reduce overdose deaths. Implementation of harm reduction strategies is challenging in Texas. There is a paucity of literature on understanding current harm reduction practices in Texas. As such, this qualitative study aims to understand harm reduction practices among people who use drugs (PWUD), harm reductionists, and emergency responders across four counties in Texas. This work would inform future efforts to scale and spread harm reduction in Texas.MethodsSemi-structured qualitative interviews were conducted with N = 69 key stakeholders (25 harm reductionists; 24 PWUD; 20 emergency responders). Interviews were transcribed verbatim, coded for emergent themes, and analyzed using Applied Thematic Analysis with Nvivo 12. A community advisory board defined the research questions, reviewed the emergent themes, and assisted with interpretation of the data.ResultsEmergent themes highlighted barriers to harm reduction at micro and macro levels, from the individual experience of PWUD and harm reductionists to systemic issues in healthcare and the emergency medical response system. Specifically, (1) Texas has existing strengths in overdose prevention and response efforts on which to build, (2) PWUD are fearful of interacting with healthcare and 911 systems, (3) harm reductionists are in increasing need of support for reaching all PWUD communities, and (4) state-level policies may hinder widespread implementation and adoption of evidence-based harm reduction practices.ConclusionsPerspectives from harm reduction stakeholders highlighted existing strengths, avenues for improvement, and specific barriers that currently exist to harm reduction practices in Texas.

Patient perspectives on naloxone receipt in the emergency department: a qualitative exploration

BackgroundEmergency departments (EDs) are important venues for the distribution of naloxone to patients at high risk of opioid overdose, but less is known about patient perceptions on naloxone or best practices for patient education and communication. Our aim was to conduct an in-depth exploration of knowledge and attitudes toward ED naloxone distribution among patients who received a naloxone prescription.MethodsWe conducted semi-structured telephone interviews with 25 adult participants seen and discharged from three urban, academic EDs in Philadelphia, PA, with a naloxone prescription between November 2020 and February 2021. Interviews focused on awareness of naloxone as well as attitudes and experiences receiving naloxone in the ED. We used thematic content analysis to identify key themes reflecting patient attitudes and experiences.ResultsOf the 25 participants, 72% had previously witnessed an overdose and 48% had personally experienced a non-fatal overdose. Nineteen participants (76%) self-disclosed a history of substance use or overdose, and one reported receiving an opioid prescription during their ED visit and no history of substance use. In interviews, we identified wide variability in participant levels of knowledge about overdose risk, the role of naloxone in reducing risk, and naloxone access. A subset of participants was highly engaged with community harm reduction resources and well versed in naloxone access and use. A second subset was familiar with naloxone, but largely obtained it through healthcare settings such as the ED, while a final group was largely unfamiliar with naloxone. While most participants expressed positive attitudes about receiving naloxone from the ED, the quality of discussions with ED providers was variable, with some participants not even aware they were receiving a naloxone prescription until discharge.ConclusionsNaloxone prescribing in the ED was acceptable and valued by most participants, but there are missed opportunities for communication and education. These findings underscore the critical role that EDs play in mitigating risks for patients who are not engaged with other healthcare or community health providers and can inform future work about the effective implementation of harm reduction strategies in ED settings.

Xylazine and Overdoses: Trends, Concerns, and Recommendations.

Xylazine is a nonopioid veterinary anesthetic and sedative that is increasingly detected in the illicit drug supply in the United States. Data indicate a striking prevalence of xylazine among opioid-involved overdose deaths. The emergence of xylazine in the illicit drug supply poses many unknowns and potential risks for people who use drugs. The public health system needs to respond by increasing testing to determine the prevalence of xylazine, identifying its potential toxicity at various exposure levels, and taking mitigating action to prevent harms. Currently, there is little testing capable of identifying xylazine in drug supplies, which limits the possibility of public health intervention, implementation of harm reduction strategies, or development of novel treatment strategies. (Am J Public Health. 2022;112(8):1212-1216. https://doi.org/10.2105/AJPH.2022.306881).

Immunity to Hepatitis-A virus: A nationwide population-based seroprevalence study from Iran

BackgroundThe mortality rate of acute Hepatitis A increases from 0.1% in the children to 1.2%, in the adults. Hepatitis A is efficiently prevented by HAV-vaccine, but the strategy for distributing this vaccine among countries is dependent on their level of immunity to HAV. This study aimed to detect the level of immunity to HAV in Iran. MethodsIn this population-based seroprevalence study, 5419 participants from 12 of provinces of Iran, including 57 urban and 120 rural areas were chosen through a multi-stage cluster random sampling. Participants were interviewed by filling checklists and 3 cc of blood sample was obtained from each of them. IBM SPSS statistics V.21 software was used for univariable and multivariable analysis of data. ResultsMean of age of Interviewees was 26.4 ± 16 years, ranging from 1 to 94 years with a male to female ratio 1.02. Overall, 3603 (66.5%) of subjects were seropositive for HAV-IgG. Among the age groups, 41.1% of children by the age 15 years and 82.6% of adults around 30 years old were immune to HAV. The Mid-point age of population immunity was 21 years. Residents of the borders of the country, people who had less access to the safe water or sanitary toilet, individuals with low socioeconomic status and persons who were a member of dense families had the most probability of seropositivity. ConclusionsThis study showed that Iran is among HAV low endemic countries and vaccination against HAV is recommended only in the high-risk population, including patients with chronic liver diseases, patients with coagulopathy, travelers to the high endemic areas, and homosexuals. Establishment of national HAV surveillance system, concerning of health system about the occurrence of the HAV outbreaks, implementation of harm reduction strategies, improving economic indices and sanitation and access to the safe water in the deprived regions is recommended.

“You can see those concentric rings going out”: Emergency personnel’s experiences treating overdose and perspectives on policy-level responses to the opioid crisis in New Hampshire

BackgroundIn parallel to a substantial increase in opioid overdose deaths in New Hampshire (NH), emergency personnel experienced an increase in opioid-related encounters. To inform public health responses to this crisis, insights into the experiences and perspectives of those emergency personnel who treat opioid-related overdoses are warranted. AimsSystematically examine emergency personnel’s experiences treating opioid overdoses and obtain their perspectives on policy-level responses to the opioid crisis in NH. MethodsSemi-structured qualitative interviews were conducted with 18 first responders [firefighters (n = 6), police officers (n = 6), emergency medical service providers (n = 6)] and 18 emergency department personnel employed in six NH counties. Interviews focused on emergency personnel’s perspectives on fentanyl/heroin formulations, experiences treating overdoses, harm reduction strategies, and experiences with treatment referral. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. ResultsEmergency personnel cited the potency and inconsistency of fentanyl-laced heroin as primary drivers of opioid overdose. Increases in overdose-related encounters took a substantial emotional toll on emergency personnel, who described a range of responses including feelings of burnout, exhaustion, and helplessness. While some emergency personnel felt conflicted about the implementation of harm reduction strategies like syringe services programs, others emphasized the necessity of these services. Emergency personnel expressed frustration with barriers to treatment referral in the state and recommended immediate treatment access after overdose events. ConclusionsFindings suggest that interventions addressing trauma and burnout are necessary to support emergency personnel, while expanded harm reduction and treatment access are critical to support those who experience opioid overdose in NH.

Harm reduction strategies regarding the misuse of alcohol and other drugs: a review of the literature.

The present study attempts to systemize the experiences of those that have been treated in the primary health care system for alcohol and drug abuse with a view to obtaining reductions in the damages caused to Brazil and the world at large. A bibliographical study was conducted of publications in Portuguese and in English over the past ten years on the following databases SciELO, Lilacs, Medline and PsycINFO. After the selection of the corpus, meta-synthesis was carried out in order to integrate the material obtained. It was possible to identify and analyze advances and impasses in the implementation of harm reduction strategies, and to compare the different approaches identified in the services and care activities offered to users. We noticed that Harm Reduction has become consolidated as a prevention and health care strategy; therefore, it is essential that more academic and scientific research in this area is conducted.

Human immunodeficiency virus infection predictors and genetic diversity of hepatitis B virus and hepatitis C virus co-infections among drug users in three major Kenyan cities.

BackgroundDrug users act as reservoirs and transmission channels for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections to the general population worldwide. Periodic epidemiological studies to monitor the prevalence and genetic diversity of these infections to inform on interventions are limited.Objective of the studyThe objective of this study was to determine the predictors of HIV infection and genetic diversity of HBV and HCV among drug users in Kenya.Materials and methodsA cross-sectional study on previous drug use history among drug users was conducted in three Kenyan cities using a respondent-driven sampling method between January 2011 and September 2012. Blood samples were collected and analysed for the presence of HBV, HCV and HIV serological markers and to determine the genotypes of HBV and HCV.ResultsThe overall prevalence of HBV, HCV and HIV among drug users was 4.3%, 6.5% and 11.1%, respectively, with evidence of HBV/HIV, HCV/HIV and HBV/HCV/HIV co-infections. The HBV circulating genotypes were A1 (69%) and D6 (19%), whereas HCV genotypes were 1a (72%) and 4a (22%). Injection drug use was a significant predictor of HIV/HCV infections. Younger age (30 years; aOR (adjusted odds ratio) = 0.50, 95% CI (confidence interval): 0.33–0.76; p < 0.001) and early sexual debut (aOR = 0.54, 95% CI: 0.40–0.82; p < 0.05) were negatively associated with detection of any of the three infections. Injecting drug use was positively associated with HCV infection (aOR = 5.37, 95% CI: 2.61–11.06; p < 0.001).ConclusionThis high level of genetic diversity exhibited by HBV and HCV isolates requires urgent implementation of harm reduction strategies and continuous monitoring for effective management of the patients.

Traumatic brain injuries in mixed martial arts: A systematic review

Introduction Mixed martial arts is an emerging combat sport that is gaining popularity worldwide. We systematically reviewed the literature regarding the prevalence, severity and risk factors of head injuries sustained in mixed martial arts activities. Methods We conducted a comprehensive systematic review of Ovid MEDLINE, Embase, PsycINFO, EBM Reviews, CINAHL, SPORTDiscus, and Web of Science from 1990 to 2016 for studies of any design that reported associations of acute or chronic head injuries in persons participating in mixed martial arts activities. Results The initial database search yielded a total 472 citations, including 264 unique citations after duplications were removed. A total of 18 articles, primarily of observational data, showed ‘technical knockouts’ and ‘knockouts’ are prevalent in this sport (range: 28.3–46.2% of all matches) with other studies showing the lifetime average of 6.2 technical knockouts or knockouts in a career. Studies used inconsistent reporting methods for concussion, and no information regarding long-term follow-up was available. Conclusion Mixed martial arts fighting may be associated with repetitive head injuries and potential long-term neurological consequences; however, data on this topic are poor. Larger studies and stringent medical oversight are needed to improve the management and understanding of mixed martial arts head injuries, with implementation of harm reduction strategies and/or rule modifications to prevent long-term neurological sequelae. Systematic Review Registration: PROSPERO – CRD42014010019.

Harm reduction for young people who use prescription opioids extra-medically: Obstacles and opportunities

Extra-medical prescription opioid (EMPO) use – intentional use without a prescription or outside of prescribed parameters – is a public health crisis in the United States and around the world. Epidemiological evidence suggests that the prevalence of EMPO use and adverse sequelae, including opioid overdose and hepatitis C infection, are elevated among people aged 18–25. Despite these preventable health risks, many harm reduction interventions are underutilized by, or inaccessible to, EMPO-using youth. In this commentary, we describe key harm reduction strategies for young people who use prescription opioids. We examine individual, social, and policy-level barriers to the implementation of evidence-based approaches that address EMPO use and related harms among young people. We highlight the need for expanded services and new interventions to engage this diverse and heterogeneous at-risk population. A combination of medical, social, and structural harm reduction interventions are recommended. Furthermore, research to inform strategies that mitigate particularly high-risk practices (e.g., polysubstance use) is warranted. Finally, we discuss how the meaningful involvement of youth in the implementation of harm reduction strategies is a critical component of the public health response to the prescription opioid epidemic.

Using the Theory of Planned Behavior to predict implementation of harm reduction strategies among MDMA/ecstasy users.

This prospective study was designed to test whether the variables proposed by the Theory of Planned Behavior (TPB) were associated with baseline intention to implement and subsequent use of 2 MDMA/ecstasy-specific harm reduction interventions: preloading/postloading and pill testing/pill checking. Using targeted Facebook advertisements, an international sample of 391 recreational ecstasy users were recruited to complete questionnaires assessing their ecstasy consumption history, and their attitudes, subjective norms, perceived behavioral control, habit strength (past strategy use), and intention to use these two strategies. Attitudes, subjective norms, and perceived behavioral control were significantly associated with baseline intention to preload/postload and pill test/pill check. Out of the 391 baseline participants, 100 completed the two-month follow-up assessment. Baseline habit strength and frequency of ecstasy consumption during the three months prior to baseline were the only significant predictors of how often participants used the preloading/postloading strategy during the follow-up. Baseline intention to pill test/pill check was the only significant predictor of how often participants used this strategy during the follow-up. These findings provide partial support for TPB variables as both correlates of baseline intention to implement and predictors of subsequent use of these two strategies. Future investigations could assess whether factors related to ecstasy consumption (e.g., subjective level of intoxication, craving, negative consequences following consumption), and environmental factors (e.g., accessibility and availability of harm reduction resources) improve the prediction of how often ecstasy users employ these and other harm reduction strategies. (PsycINFO Database Record

“We can lose our life for the abortion”: exploring the dynamics shaping abortion care in peri-urban Yangon, Myanmar

ObjectivesInduced abortion in Myanmar is severely legally restricted and permissible only to save a woman’s life. As a result, unsafe abortion is common and contributes significantly to maternal mortality. Our overall study aimed to explore women’s reproductive health needs in peri-urban Yangon, a dynamic series of townships on the periphery of the country’s largest city characterized by poor infrastructure, slum settlements and a mobile, migrant population. In this paper, we focus specifically on the perceptions, opinions and experiences of both adult women and key informants with respect to induced abortion and postabortion care in peri-urban Yangon. Study designIn 2014, we conducted 18 key informant interviews with individuals working in reproductive health in peri-urban Yangon and seven focus group discussions with health service providers (n=2) and adult women (n=5). We analyzed these data for content and themes using a multiphased iterative approach. ResultsIn peri-urban Yangon, unsafe abortion appears to be common and is largely provided by traditional birth attendants. Women use a range of mechanical, medication and traditional methods, often in combination. Postabortion care is available but misinformation and fear of harassment keep many women from accessing timely care. ConclusionEfforts to reform the highly restrictive abortion law in Myanmar combined with implementation of harm reduction strategies have the potential to greatly improve a neglected area of women’s health. Future research on the cost of unsafe abortion to the public sector could be instrumental in achieving legal and service delivery reform. ImplicationsMeasures to increase access to safe, legal abortion care and reduce harm from unsafe abortion need to be expanded. Developing strategies to liberalize Myanmar’s abortion law, raising awareness about misoprostol, training clinicians to provide woman-centered postabortion care and documenting the cost of unsafe abortion to the public sector appear warranted.

Evaluation of Harm Reduction Programs on Seroincidence of HIV, Hepatitis B and C, and Syphilis Among Intravenous Drug Users in Southwest China

The aim of this study was to evaluate the impact of a multifaceted harm reduction program by comparing seroincidence rates of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and syphilis before and after implementation of harm reduction strategies among intravenous drug users (IDUs) in a drug-trafficking city in Southwest China. This is a prospective cohort study with 24 months of follow-up. Two prospective cohorts (cohort 2002-2004 and cohort 2006-2008) were followed up every 6 months for seroconversions of HIV, HCV, and syphilis antibodies and HBV surface antigen. After implementation of harm reduction strategies in Xichang city, Sichuan province, the HIV incidence rate among IDUs significantly dropped from 2.5 to 0.6 cases per 100 person-years. Subanalyses also indicated that the incidence rate of HBV significantly declined from 14.2 to 8.8 cases per 100 person-years. No significant changes in the seroincidence rates of HCV or syphilis were detected after implementation of IDU harm reduction strategies. Harm reduction strategies may help reduce the high incidence of certain blood-borne infectious diseases and sexual transmitted diseases among high-risk IDUs in southwest China. Additional research is needed on the implementation and evaluation of harm reduction strategies in China.

Harm reduction: lessons learned from tobacco control

The proposal that morbidity, mortality and social costs, associated with alcohol use may be reduced by developing alternatives to alcohol (either as lower-strength versions of existing alcoholic drinks, or by developing pharmacological alternatives to alcohol) is a rational argument applied to an irrational (i.e. addictive) behaviour. The history of harm reduction efforts in the field of tobacco control suggest that likely benefits will be attenuated by the ultimate desirability of correlates of the harm-inducing properties of a substance, such as the psychoactive effects of the substance. How do harm reduction efforts fare when exposed to the harsh realities of the world, and what can be learned from the experiences of the tobacco control community in the implementation of harm reduction strategies? The delivery device of the cigarette is a large part of the reason behind the addictive potential of smoking, delivering a bolus of nicotine to the brain in approximately 10–15 seconds (Shiffman et al., 2005). This generates marked arterial spikes of nicotine concentration following a puff, which typically occur in the context of a range of multi-modal cues (e.g. tastes, smells, locations, etc.) that themselves acquire incentive salience as a result (Berridge and Robinson, 1998). The best illustration of the results of this process is the relative lack of efficacy of nicotine replacement therapy for smoking cessation, where the odds ratio for active nicotine replacement therapy versus placebo is approximately 2.0 (Stead and Lancaster, 2005), against a backdrop of a base rate for cessation of less than 5% (Stead and Lancaster, 2005). Given the disparity between the delivery of nicotine via cigarette and via nicotine replacement therapy (which offers slow delivery of a relatively low dose), it is little wonder that nicotine replacement therapy is so ineffective – to paraphrase the cigarette advert: ‘It isn’t a Marlboro’. The powerful control of nicotine over behaviour is illustrated in the most common harm reduction strategies spontaneously employed by cigarette smokers: switching from high tar to low tar cigarettes, or reducing the number of cigarettes smoked. These strategies do not substantially reduce tar exposure (Jarvis et al., 2001; Hecht et al., 2005;), since the tar and nicotine content of manufactured cigarettes is derived from ‘machine-smoked’ readings, and these machines ‘smoke’ cigarettes in a standard way which bears little or no resemblance to how people smoke cigarettes. When a smoker moves from a high tar to a low tar cigarette brand, or cuts down on the number of cigarettes smoked per day, it is possible (often unconsciously) to modify subsequent smoking behaviour to titrate the amount of nicotine (and therefore tar) extracted from each cigarette to suit the smoker’s needs (Hammond et al., 2005). This can be done by taking more puffs, inhaling more deeply, closing the filter vents on the cigarette with one’s fingers, and so on. The greatest irony is that commercially available de-nicotinized cigarettes are potentially the most harmful, as smokers will inhale extremely deeply in a futile effort to extract nicotine (Dunsby and Bero, 2004). This serves to illustrate the powerful influence, at least in dependent individuals, of the need to maintain circulating levels of the drug, and the extent to which behaviours can be modified, both consciously and unconsciously, to achieve this. Therefore, offering lower strength drugs, for example, may simply lead to an increase in the volumes consumed. While pharmacological alternatives which offer comparable psychoactive effects might be attractive, it is likely that the development of these remains some distance in the future. There is also a question regarding whether marketing a substance as ‘healthier’ (which would almost certainly be done by the manufacturers) may have harmful consequences itself: it should be remembered that filtered and low tar cigarettes were both marketed as ‘healthier’ options (Warner, 2005), as low nitrosamine cigarettes are today. There is encouraging evidence that harm reduction strategies, such as the promotion of low nitrosamine smokeless tobacco products, may be effective (Levy et al., 2004; Levy et al., 2005), although their implementation remains controversial. Nevertheless, the single most effective means of tobacco control, to date, has been the reduction in availability achieved through taxation and other control measures (Wilson and Thomson, 2005). While this may disproportionately target those for whom health disparities are greatest (Wilson and Thomson, 2005), it is nevertheless the case that increased taxation on tobacco products is associated with reductions in smoking prevalence. Recent exercises in the banning of smoking in public places appear also to be reducing the prevalence of smoking (Frieden et al., 2005) by restricting avail-

Smoke near me and I smoke too': evaluation of a smoke-free homes program in central Sydney, NSW

Issues addressed: To implement and evaluate an intervention designed to increase knowledge of the harms of environmental tobacco smoke (ETS) upon young children and support the implementation of harm reduction strategies among parents/carers of young children to reduce the children's exposure to ETS in a local government area of inner Sydney. Method: An intervention was developed (based on themes derived from focus groups and the literature) and implemented over four months from February to May 1999. Pre, post and six month follow up intercept surveys were conducted with parents of children younger than seven years in the intervention area and a comparison area. Results: There were significant increases in prompted and unprompted recall of the intervention message in the intervention area, with prompted recall being sustained at six month follow up. Knowledge of ineffective strategies to protect children from ETS also significantly increased with a significant association between increased knowledge and recall of the intervention message. There was a non-statistically significant increase in the proportion of smoke-free homes from 67% to 75%. Conclusion: Although the intervention was well implemented, more substantial and longer intervention is needed to increase the proportion of smoke-free homes. (author abstract)

Harm reduction in Australia: some problems putting policy into practice

Harm minimisation has been the cornerstone of Australia's national drugs policy since the birth of the National Campaign against Drug Abuse in 1985. As a guiding principle harm minimisation has provided the rationale for a diverse range of programs targeting an equally diverse range of drug-related harms. However, the potential of Australia's national harm minimisation policy to guide intervention has been weakened by a number of forces. These include the absence of a clear understanding of what harm minimisation is and is not, the existence of a ‘zero-tolerance’ attitude toward illicit drug use among National Drug Strategy leadership and a cumbersome Commonwealth policy-making process. This paper examines these and other related obstacles to the implementation of harm reduction strategies. Some suggestions are made in relation to how Australia's harm minimisation policy could more effectively help guide both government and non-government intervention in the drug field.

Law enforcement and harm reduction: mutually exclusive or mutually compatible

This paper will attempt to answer the fundamental question of whether law enforcement and harm reduction can comfortably co-exist. This issue is highly complex, contentious, controversial, and, above all, to many operational police officers, often very confusing. In order to examine the seemingly conflicting messages of harm reduction and law enforcement within the context of the drug debate, it will be necessary to explore such areas as just what harm reduction means. In addition, the public portrayal of drugs and drug users will be briefly discussed and, to fully appreciate just what the notion of harm reduction, or harm minimisation means to the everyday operational police officer, the influence of police organisational culture on the implementation of harm reduction strategies will also be examined. From an Australian perspective, some of the harm reduction strategies that are presently in place, together with future initiatives currently being contemplated and their likely success, given the tensions that exist between harm reduction policies and mainstream law enforcement, will also be examined.

The first outreach needle exchange program in Hungary

This paper will attempt to answer the fundamental question of whether law enforcement and harm reduction can comfortably co-exist. This issue is highly complex, contentious, controversial, and, above all, to many operational police officers, often very confusing. In order to examine the seemingly conflicting messages of harm reduction and law enforcement within the context of the drug debate, it will be necessary to explore such areas as just what harm reduction means. In addition, the public portrayal of drugs and drug users will be briefly discussed and, to fully appreciate just what the notion of harm reduction, or harm minimisation means to the everyday operational police officer, the influence of police organisational culture on the implementation of harm reduction strategies will also be examined. From an Australian perspective, some of the harm reduction strategies that are presently in place, together with future initiatives currently being contemplated and their likely success, given the tensions that exist between harm reduction policies and mainstream law enforcement, will also be examined.