Evaluation of Harm Reduction

EDITORIAL
Evaluating national harm reduction progranns
Evaluating an individual harm reduction program is One of the important aspects of the paper is that it pro-
quite difficult. Practical and ethical concerns usually pre- vides data on the scale of the harm reduction programs
vent the use of 'gold standard' randomized clinical trial implemented in France—an estimated 17.7 million ster-
methods for assessing efficacy and assigning causation to ile syringes in the peak year of 1999 and an estimated
the intervention. Assessing a national program of harm 101 000 drug users receiving substitution treatment in
reduction programs is even more difficult. One must be the peak year of 2003. The paper would be strengthened
concerned about variation in the implementation of the if the authors had included estimates of the numbers of
different programs and possible interactions of different active IDUs not in treatment for each of the years in the
programs as well as different historical trends in the 1996-2003 time-period so that the reader could esti-
country as a whole or in regions of the country. mate the numbers of syringes distributed per drug injec-
Emmanuelli and Desenclos (this issue) [1] make an tor per year and the percentage of drug injectors
important and generally successful attempt to assess the receiving treatment each year. Determining the 'cover-
harm reduction programs implemented in France from age' needed for harm reduction programs to achieve
1996 to 2003. There were complex patterns in the data. community level positive effects is a critical question for
The numbers of syringes sold or distributed first rose and preventing HIV epidemics and other drug related harms
then fell. The number of people receiving methadone and in resource constrained settings [2].
buprenorphine treatment rose continuously. Syringe 3 How do we insure that 'user friendliness' is incorpo-
sharing and HIV prevalence declined, but HCV preva- rated into harm reduction programs.'
lence did not. Heroin overdoses and heroin arrests Many harm reduction programs include critical biologi-
declined, but cocaine arrests rose. Given the complexity cal components—syringes from an exchange or phar-
of these results. Emmanuelli and Desenclos were not able macy are certain to not be contaminated with HIV or
to apply any standard statistical techniques such as time- HCV, methadone and buprenorphine are potent medica-
lagged correlations to assess the strength of any associa- tions. Nevertheless, the 'user friendliness' of harm reduc-
tions among these variables. tion programs may be a necessary component of their
Nevertheless, taken in the context of much other rele- effectiveness. 'User friendliness' would include treating
vant research, the data presented by Emmanuelli and Des- drug users with dignity and respect, providing conve-
enclos suggest that the sterile syringe programs and the nient locations and hours of operation and requiring a
substitution treatment programs did lead to reductions in minimum of bureaucratic hassle to receive services.
HIV and heroin use without having effects on HCV trans- Emmanuelli and Desenclos do not provide any systematic
mission or cocaine use. The increase in buprenorphine data on the 'user friendliness' of the French harm reduc-
and methadone treatment probably did lead to the reduction programs, although they do note that methadone
tions in heroin overdoses and heroin arrests. treatment is much more highly regulated than buprenor-
There is now a very considerable body of scientific evi- phine treatment in France.
dence showing that harm reduction programs can be There may be a very common tendency for political
effective. I would like to suggest three specific questions leaders to approve controversial harm reduction pro-
for a next generation of policy and research questions. grams with restrictions that serve to substantially reduce
1 Why do harm reduction programs not work all of the user friendliness and the effectiveness of the programs
time for all desired outcomes.' [3]. Limiting the numbers of syringes that can be
The HCV data from the Emmanuelli and Desenclos study exchanged per visit to an exchange and imposing very
are certainly discouraging. There is no evidence the pro- restrictive eligibility requirements on substitution treat-
grams led to reduction in HCV infection among IDUs in ment are examples of this tendency. The paper by
France. Emmanuelli and Desenclos provides very important
2 How big do harm reduction programs have to be to observational data indicating the effectiveness of various
address problems successfully at the community level.' harm reduction programs in France from 1996 to 2003.
© 2005 Society for the Study of Addiction doi:10. J 1.11 /j.l 360-0443.2005.01281 .x Addiclion. 100. 1575-1576
1576 Editorial
The paper also leads to policy and research questions that References
need to be addressed if the full potential of programs to
1, Emmanuelli, J, & Desendos, J,-C, (2005) Harm reduction
reduce drug related h a r m is to be achieved, interventions, behaviours and associated health outcomes in
France, 1996-2003, Addiction. TOO, 1690-1700,
DON C, DES JARLAIS 2, Burrows, D, (in press) HIV prevention among injecting drug
Baron Edmond de Rothschild Chemical Dependency Institute "'^•"^'" developing and transitional countries: high coverage
I' ^ is feasible, UNAIDS/WHO/World Bank Report, in press,
Beth Israel Medical Center and National Development and 3 p , , j^.i^i, ^ c,, Paone, D,, Friedman, S, R,, Peyser, N, &
Research Institutes, Inc. Newman, R, G, (1995) Regulating controversial programs for
Eirst Avenue at 16th Street unpopular people: methadone maintenance and syringe
New York Citu NY 10003 exchange programs, American journal of Public Health. 85,
^' 1577-1584,
USA
E-mail: [email protected]
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EDITORIAL

Evaluating national harm reduction progranns

© 2005 Society for the study of Addiction Addiction. tOO, 1 5 7 5 - 1 5 7 6

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