Harm reduction

Harm reduction (or harm minimization) is a range of public health policies designed to reduce the harmful consequences associated with various human behaviors, both legal and illegal. Harm reduction policies are used to manage behaviors such as recreational drug use and sexual activity in numerous settings that range from services through to geographical regions. Critics of harm reduction typically believe that tolerating risky or illegal behaviour sends a message to the community that such behaviours are acceptable and that some of the actions proposed by proponents of harm reduction do not reduce harm over the long term.[1][2]

Needle-exchange programmes reduce the likelihood of users of heroin and other drugs sharing the syringes and using them more than once. Syringe-sharing can lead to infections such as HIV or hepatitis C can spread from user to users through the reuse of syringes contaminated with infected blood. Needle and syringe programme (NSP) and Opioid Substitution Therapy (OST) outlets in some settings offer basic primary health care. Safe injection site are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers. The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff.

Opioid replacement therapy (ORT), or opioid substitution therapy (OST), is the medical procedure of replacing an illegal opioid, such as heroin, with a longer acting but less euphoric opioid; methadone or buprenorphine are typically used and the drug is taken under medical supervision. Another approach is Heroin assisted treatment, in which medical prescriptions for pharmaceutical heroin (diacetylmorphine) are provided to heroin-dependent people. Toronto's Seaton House became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, homeless alcoholics opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities.

A high amount of media coverage exists informing users of the dangers of driving drunk. Most alcohol users are now aware of these dangers and safe ride techniques like 'designated drivers' and free taxicab programmes are reducing the number of drunk-driving accidents. Many schools now provide safer sex education to teen and pre-teen students, who may engage in sexual activity. Since some adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STIs. Since 1999 some countries have legalized prostitution, such as Germany (2002) and New Zealand (2003).

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in injecting drug users and sex-workers.[3] HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease.[3]

Drugs

In the case of recreational drug use, harm reduction is put forward as a useful perspective alongside the more conventional approaches of demand and supply reduction.[4] Many advocates argue that prohibitionist laws criminalise people for suffering from a disease and cause harm; for example, by obliging drug addicts to obtain drugs of unknown purity from unreliable criminal sources at high prices, thereby increasing the risk of overdose and death.[5] The website Erowid.org collects and publishes information and first-hand experience reports about all kinds of drugs to educate (potential) drug users.

While the vast majority of harm reduction initiatives are educational campaigns or facilities that aim to reduce drug-related harm, a unique social enterprise was launched in Denmark in September 2013 to reduce the financial burden of illicit drug use for people with a drug dependence. Michael Lodberg Olsen, who was previously involved with the establishment of a drug consumption facility in Denmark, announced the founding of the Illegal magazine that will be sold by drug users in Copenhagen and the district of Vesterbro, who will be able to direct the profits from sales towards drug procurement. Olsen explained: "No one has solved the problem of drug addiction, so is it not better that people find the money to buy their drugs this way than through crime and prostitution?"[6]

Needle exchange programmes

A bin allowing for safe disposal of needles in a public toilet in Caernarfon, Wales.

The use of some illicit drugs can involve hypodermic needles. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, users of heroin and other drugs frequently share the syringes and use them more than once. As a result, infections such as HIV or hepatitis C can spread from user to users through the reuse of syringes contaminated with infected blood. The principles of harm reduction propose that syringes should be easily available or at least available through a needle and syringe programmes (NSP). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries users are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name.

A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour.[7] It has been shown in the many evaluations of needle-exchange programmes that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programmes have reduced HIV incidence by 33% in New Haven and 70% in New York City.[8]

The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated for a protracted time period. Research organisation the Burnet Institute completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum, City of Yarra and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. During the period between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the local government area the City of Yarra, of which Richmond and Abbotsford are parts of, 1550 syringes were collected each month from public syringe disposal bins in 2012. Furthermore, ambulance callouts for heroin overdoses were 1.5 times higher than for other Melbourne areas in the period between 2011 and 2012 (a total of 336 overdoses), and drug-related arrests in North Richmond were also three times higher than the state average. The Burnet Institute's researchers interviewed health workers, residents and local traders, in addition to observing the drug scene in the most frequented North Richmond public injecting locations.[9]

On 28 May 2013, the Burnet Institute stated in the media that it recommends 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area's drug culture continues to grow after more than ten years of intense law enforcement efforts. The Institute's research concluded that public injecting behaviour is frequent in the area and inappropriately discarding injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken open syringe disposal bins to reuse discarded injecting equipment.[10]

The British public body, the National Institute for Health and Care Excellence (NICE), introduced a new recommendation in early April 2014 due to an increase in the presentation of the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services are not advised for people under the age of 18 years, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programs. In the updated guidance, NICE recommended the provision of specialist services for “rapidly increasing numbers of steroid users”, and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.[11]

Targeted and low-threshold primary health care outlet

NSP and Opioid Substitution Therapy (OST) outlets in some settings offer basic primary health care. These are known as 'targeted primary health care outlet'- as these outlets primarily target people who inject drugs and/or 'low-threshold health care outlet'- as these reduce common barriers clients often face when they try to access health care from the conventional health care outlets.[12][13] For accessing sterile injecting equipment clients frequently visit NSP outlets, and for receiving pharmacotherapy (e.g. methadone, buprenorphine)they visit OST clinics; these frequent visits are used opportunistically to offer much needed health care.[14][15] These targeted outlets have the potential to mitigate clients' perceived barriers to access to healthcare delivered in traditional settings. The provision of accessible, acceptable and opportunistic services which are responsive to the needs of this population is valuable, facilitating a reduced reliance on inappropriate and cost-ineffective emergency department care.[16][17]

Safe injection sites

A clandestine kit containing materials to inject illicit drugs (or legitimate ones illegitimately).
Injection kit obtained from a needle-exchange programme.
Main article: Safe injection site

Safe injection sites (SIS), or Drug consumption rooms (DCR), are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers.

The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programmes prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be injection drug users, but generally in Europe they don't exclude addicts who consume by other means.

The Netherlands had the first staffed injection room, although they did not operate under explicit legal support until 1996. Instead, the first center where it was legal to inject drug was in Berne, Switzerland, opened 1986. In 1994, Germany opened its first site. Although, as in the Netherlands they operated in a "gray area", supported by the local authorities and with consent from the police until the Bundestag provided a legal exemption in 2000.[18]

In Europe, Luxembourg, Spain and Norway have opened facilities after year 2000.[19] As did the two existing facilities outside Europe, with Sydney's Medically Supervised Injecting Center (MSIC) established in May 2001 as a trial and Vancouver's Insite, opened in September 2003.[20][21][22] In 2010, after a nine-year trial, the Sydney site was confirmed as a permanent public health facility.[23][24] As of late 2009 there were a total of 92 professionally supervised injection facilities in 61 cities.[19]

The European Monitoring Centre for Drugs and Drug Addiction's latest systematic review from April 2010 did not find any evidence to support concerns that DCR might "encourage drug use, delay treatment entry or aggravate problems of local drug markets."[19] Jürgen Rehm and Benedikt Fischer explained that while evidence show that DCR are successful, that "interpretation is limited by the weak designs applied in many evaluations, often represented by the lack of adequate control groups." Concluding that this "leaves the door open for alternative interpretations of data produced and subsequent ideological debate."[25]

The EMCDDA review noted that research into the effects of the facilities "faces methodological challenges in taking account of the effects of broader local policy or ecological changes", still they concluded "that the facilities reach their target population and provide immediate improvements through better hygiene and safety conditions for injectors." Further that the facilitates "does not increase levels of drug use or risky patterns of consumption, nor does it result in higher rates of local drug acquisition crime." While its usage is "associated with self-reported reductions in injecting risk behaviour such as syringe sharing, and in public drug use" and "with increased uptake of detoxification and treatment services."[19] However, "a lack of studies, as well as methodological problems such as isolating the effect from other interventions or low coverage of the risk population, evidence regarding DCRs — while encouraging — is insufficient for drawing conclusions with regard to their effectiveness in reducing HIV or hepatitis C virus (HCV) incidence." Concluding with that "there is suggestive evidence from modelling studies that they may contribute to reducing drug-related deaths at a city level where coverage is adequate, the review-level evidence of this effect is still insufficient."[19]

Critics of this intervention, such as drug prevention advocacy organisations, Drug Free Australia and Real Women of Canada[24][26][27] point to the most rigorous evaluations,[28] those of Sydney and Vancouver. Two of the centers, in Sydney, Australia and Vancouver, Canada cost $2.7 million[29] and $3 million per annum to operate respectively,[30] yet Canadian mathematical modeling, where there was caution about validity, indicated just one life saved from fatal overdose per annum for Vancouver,[31][32] while the Drug Free Australia analysis demonstrates the Sydney facility statistically takes more than a year to save one life.[33] The Expert Advisory Committee of the Canadian Government studied claims by journal studies for reduced HIV transmission by Insite but “were not convinced that these assumptions were entirely valid."[31] The Sydney facility showed no improvement in public injecting and discarded needles beyond improvements caused by a coinciding heroin drought,[34] while the Vancouver facility had an observable impact.[31] Drug dealing and loitering around the facilities were evident in the Sydney evaluation,[35] but not evident for the Vancouver facility.[31]

Opioid replacement therapy (ORT)

Total number of U.S. overdose deaths involving opioid pain relievers from 2001 to 2014.[36]

Opioid replacement therapy (ORT), or opioid substitution therapy (OST), is the medical procedure of replacing an illegal opioid, such as heroin, with a longer acting but less euphoric opioid; methadone or buprenorphine are typically used and the drug is taken under medical supervision.[37] Some formulations of buprenorphine incorporate the opiate antagonist naloxone during the production of the pill form to prevent people from crushing the tablets and injecting them, instead of using the sublingual (under the tongue) route of administration.[37]

In some countries, such as Switzerland, Austria, Slovenia, patients may be treated with slow-release morphine when methadone is deemed inappropriate due to the individual's circumstances. In Germany, dihydrocodeine has been used off-label in ORT for many years, however it is no longer frequently prescribed for this purpose. Extended-release dihydrocodeine is again in current use in Austria for this reason. Research into the usefulness of piritramide, extended-release hydromorphone (including polymer implants lasting up to 90 days), dihydroetorphine and other drugs for ORT is at various stages in a number of countries.[37]

The driving principle behind ORT is the program's capacity to facilitate a resumption of stability in the user's life, while they experience reduced symptoms of withdrawal symptoms and less intense drug cravings; however, a strong euphoric effect is not experienced as a result of the treatment drug.[37] In some countries (not the USA, UK, Canada, or Australia),[37] regulations enforce a limited time period for people on ORT programs that conclude when a stable economic and psychosocial situation is achieved. (Patients suffering from HIV/AIDS or Hepatitis C are usually excluded from this requirement.) In practice, 40-65% of patients maintain complete abstinence from opioids while receiving opioid replacement therapy, and 70-95% are able to reduce their use significantly, while experiencing a concurrent elimination or reduction in medical (improper diluents, non-sterile injecting equipment), psychosocial (mental health, relationships), and legal (arrest and imprisonment) issues that can arise from the use of illicit opioids.[37]

Heroin maintenance programmes

Total number of U.S. overdose deaths involving heroin from 2001 to 2014.[36]

Providing medical prescriptions for pharmaceutical heroin (diacetylmorphine) to heroin-dependent people has been employed in some countries to address problems associated with the illicit use of the drug, as potential benefits exist for the individual and broader society. Evidence has indicated that this form of treatment can greatly improve the health and social circumstances of participants, while also reducing costs incurred by criminalisation, incarceration and health interventions.[38][39]

In Switzerland, heroin assisted treatment is an established programme of the national health system. Several dozen centres exist throughout the country and heroin-dependent people can administer heroin in a controlled environment at these locations. The Swiss heroin maintenance programme is generally regarded as a successful and valuable component of the country's overall approach to minimising the harms caused by illicit drug use.[40] In a 2008 national referendum, a majority of 68 per cent voted in favour of continuing the Swiss programme.[41]

The Netherlands has studied medically supervised heroin maintenance.[42] A German study of long-term heroin addicts demonstrated that diamorphine was significantly more effective than methadone in keeping patients in treatment and in improving their health and social situation.[43] Many participants were able to find employment, some even started a family after years of homelessness and delinquency.[44][45] Since then, treatment had continued in the cities that participated in the pilot study, until heroin maintenance was permanently included into the national health system in May 2009.[46]

A heroin maintenance programme has existed in the United Kingdom (UK) since the 1920s, as drug addiction was seen as an individual health problem. Addiction to opiates was rare in the 1920s and was mostly limited to either middle-class people who had easy access due to their profession, or people who had become addicted as a side effect of medical treatment. In the 1950s and 1960s a small number of doctors contributed to an alarming increase in the number of drug-addicted people in the U.K. through excessive prescribing—the U.K. switched to more restrictive drug legislation as a result.[47] However, the British government is again moving towards a consideration of heroin prescription as a legitimate component of the National Health Service (NHS). Evidence has clearly shown that methadone maintenance is not appropriate for all opioid-dependent people and that heroin is a viable maintenance drug that has shown equal or better rates of success.[48]

A committee appointed by the Norwegian government completed an evaluation of research reports on heroin maintenance treatment that were available internationally. In 2011 the committee concluded that the presence of numerous uncertainties and knowledge gaps regarding the effects of heroin treatment meant that it could not recommend the introduction of heroin maintenance treatment in Norway.[49]

The first, and only, North American heroin maintenance project is being run in Vancouver, B.C. and Montreal, Quebec. Currently, over 80 long-term heroin addicts who have not been helped by available treatment options are taking part in the North American Opiate Medication Initiative (NAOMI) trials. However, critics have alleged that the control group gets unsustainably low doses of methadone, making them prone to fail and thus rigging the results in favor of heroin maintenance.[50]

Critics of heroin maintenance programmes object to the high costs of providing heroin to users. The British heroin study cost the British government £15,000 per participant per year, roughly equivalent to average heroin user's expense of £15,600 per year.[51] Drug Free Australia[52] contrast these ongoing maintenance costs with Sweden's investment in, and commitment to, a drug-free society where a policy of compulsory rehabilitation of drug addicts is integral, which has yielded the one of the lowest reported illicit drug use levels in the developed world,[53] a model in which successfully rehabilitated users present no further maintenance costs to their community, as well as reduced ongoing health care costs.[52]

A substantial part of the money for buying heroin is obtained through criminal activities, such as robbery or drug dealing. King's Health Partners notes that the cost of providing free heroin for a year is about one-third of the cost of placing the user in prison for a year.[54][55]

Naloxone distribution

Naloxone is a drug used to counter an overdose from the effect of opioids; for example, a heroin or morphine overdose. Simply put, naloxone displaces the opioid molecules from the brain's receptors and reverses the respiratory depression caused by an overdose within two to eight minutes.[56] The World Health Organization (WHO) includes naloxone on their "List of Essential Medicines", and recommends its availability and utilization for the reversal of opioid overdoses.[57][58]

Formal programs in which the opioid inverse agonist drug naloxone is distributed have been trialled and implemented. Established programs distribute naloxone, as per WHO's minimum standards, to drug users and their peers, family members, police, prisons, and others. These treatment programs and harm reduction centres operate in Afghanistan, Australia, Canada, China, Germany, Georgia, Kazakhstan, Norway, Russia, Spain, Tajikistan, the United Kingdom (UK), the United States (US), Vietnam,[59] India, Thailand, Kyrgyzstan,[60] Denmark and Estonia.[61]

United States

Officers in Quincy, Massachusetts, US began carrying the nasal spray form of the drug in October 2010, following the completion of a Department of Public Health pilot program, in which naloxone was distributed to friends and families of opiate users, in 2007. Quincy officers have administered the drug 221 times and reversed 211 overdoses since the commencement of the initiative. Espanola Valley, New Mexico and Ocean County, New Jersey police officers then followed the Quincy example in 2013. Quincy mayor Thomas Koch explained in early 2014: "It's easy for the cynical person to say, 'Oh, they're druggies, they're junkies, let them die. But when you put a name and a face and a family to that, then it's a different story. Some people who go down this road will never come back, but if we can bring them back, there's always hope."[62]

Following the use of the nasal spray device by police officers on Staten Island in New York, an additional 20,000 police officers will begin carrying naloxone in mid-2014. The state's Office of the Attorney General will provide US$1.2 million to supply nearly 20,000 kits and Police Commissioner William Bratton said: "Naloxone gives individuals a second chance to get help".[63]

Australia

In March 2013, trial programs commenced in the Australian states of New South Wales (NSW) and the Australian Capital Territory (ACT).[64] Following the publication of its position statement on the peer-based distribution and administration of naloxone in August 2013,[65] Harm Reduction Victoria, based in the Australian state of Victoria, commenced training workshops with drug users on the administration of naloxone in the event of an opiate overdose. During the week beginning March 3, 2014, 19 workshops had been completed by HRV and 156 drug users had been provided with naloxone, paid for by community health agencies.[66]

Cannabis

Specific harms associated with cannabis include increased accident-rate while driving under intoxication, dependence, psychosis, detrimental psychosocial outcomes for adolescent users and respiratory disease.[67] Some safer cannabis usage campaigns including the UKCIA (United Kingdom Cannabis Internet Activists) encourage methods of consumption shown to cause less physical damage to a users body, including oral (eating) consumption, vaporization, the usage of bongs which cool and to some extent filters the smoke, and smoking the cannabis without mixing it with tobacco.

The fact that cannabis possession carries prison sentences in most developed countries is also pointed out as a problem by European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), as the consequences of a conviction for otherwise law-abiding users arguably is more harmful than any harm from the drug itself. For example, by adversely affecting employment opportunities, impacting civil rights,[68] and straining personal relationships.[69] Some people like Ethan Nadelmann of the Drug Policy Alliance have suggested that organized marijuana legalization would encourage safe use and reveal the factual adverse effects from exposure to this herb's individual chemicals.[70]

The way the laws concerning cannabis are enforced is also very selective, even discriminatory. Statistics show that the socially disadvantaged, immigrants and ethnic minorities have significantly higher arrest rates.[69] Drug decriminalisation, such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, would alleviate these harms.[69] Where decriminalisation has been implemented, such as in several states in Australia and United States, as well as in Portugal and the Netherlands no, or only very small adverse effects have been shown on population cannabis usage rate.[69] The lack of evidence of increased use indicates that such a policy shift does not have adverse effects on cannabis-related harm while, at the same time, decreasing enforcement costs.[69]

In the last few years certain strains of the cannabis plant with higher concentrations of THC and drug tourism have challenged the former policy in the Netherlands and led to a more restrictive approach; for example, a ban on selling cannabis to tourists in coffeeshops suggested to start late 2011.[71] Sale and possession of cannabis is still illegal in Portugal[72] and possession of cannabis is a federal crime in the United States.

Alcohol

See also: Fomepizole

Traditionally, homeless shelters ban alcohol. In 1997, as the result of an inquest into the deaths of two homeless alcoholics two years earlier, Toronto's Seaton House became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, homeless alcoholics opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of emergency medical facilities. The programme has been duplicated in other Canadian cities and a study of Ottawa's "wet shelter" found that emergency room visit and police encounters by clients were cut by half.[73] The study, published in the Canadian Medical Association Journal in 2006 found that serving chronic street alcoholics controlled doses of alcohol also reduced their overall alcohol consumption. Researchers found that programme participants cut their alcohol use from an average of 46 drinks a day when they entered the programme to an average of 8 drinks and that their visits to emergency rooms drop to an average of eight a month from 13.5 while encounters with the police fall to an average of 8.8 from 18.1.[74][75]

Downtown Emergency Service Center (DESC), in Seattle, Washington, operates several Housing First, harm reduction model, programmes. University of Washington researchers, partnering with DESC, found that providing housing and support services for homeless alcoholics costs tax-payers less than leaving them on the street, where tax-payer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the Robert Wood Johnson Foundation[76] appeared in the Journal of the American Medical Association in April 2009.[77] This first US controlled assessment of the effectiveness of Housing First specifically targeting chronically homeless alcoholics showed that the programme saved tax-payers more than $4 million over the first year of operation. During the first six-months, even after considering the cost of administering the housing, 95 residents in a Housing First programme in downtown Seattle, the study reported an average cost-savings of 53 percent—nearly US $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among homeless alcoholics.

Alcohol-related programmes

A high amount of media coverage exists informing users of the dangers of driving drunk. Most alcohol users are now aware of these dangers and safe ride techniques like 'designated drivers' and free taxicab programmes are reducing the number of drunk-driving accidents. Many cities have free-ride-home programmes during holidays involving high alcohol abuse, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In New South Wales groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programmes including the aforementioned 'designated driver' and 'late night patron transport' schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.

Moderation Management is a programme which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behaviour.

The HAMS Harm Reduction Network is a programme which encourages any positive change with regard to the use of alcohol or other mood altering substances. HAMS encourages goals of safer drinking, reduced drinking, moderate drinking, or abstinence. The choice of the goal is up to the individual.

Harm reduction in alcohol dependency could be instituted by use of naltrexone.[78]

Tobacco

Tobacco harm reduction describes actions taken to lower the health risks associated with using tobacco, especially combustible forms, without abstaining completely from tobacco and nicotine. Some of these measures include switching to safer (lower tar) cigarettes, switching to snus or dipping tobacco, or using a non-tobacco nicotine delivery systems. In recent years, the growing use of electronic cigarettes for smoking cessation, whose long-term safety remains uncertain, has sparked an ongoing controversy among medical and public health between those who seek to restrict and discourage all use until more is known and those who see them as a useful approach for harm reduction, whose risks are most unlikely to equal those of smoking tobacco.[79] "Their usefulness in tobacco harm reduction as a substitute for tobacco products is unclear,[80] but in an effort to decrease tobacco related death and disease, they have a potential to be part of the strategy.[81]

It is widely acknowledged that discontinuation of all tobacco products confers the greatest lowering of risk. However, there is a considerable population of inveterate smokers who are unable or unwilling to achieve abstinence. Harm reduction may be of substantial benefit to these individuals.

Psychedelics

The Zendo Project conducted by the Multidisciplinary Association for Psychedelic Studies uses principles from psychedelic therapy to provide safe places and emotional support for people having difficult experiences on psychedelic drugs at select festivals such as Burning Man, Boom Festival, and Lightning in a Bottle without medical or law enforcement intervention.[82]

Also, MDMA commonly sold by the slang names "ecstasy" and "molly" is often adulterated. The nonprofit organization DanceSafe offers on-site testing of the contents of pills and powders at various electronic music events around the US. They also sell kits for users to test the contents of drugs themselves. PillReports.com invites ectasy users to send samples of drugs for laboratory testing and publishes the results online.

Sex

Safer sex programmes

Many schools now provide safer sex education to teen and pre-teen students, who may engage in sexual activity. Since some adolescents are going to have sex, a harm-reductionist approach supports a sexual education which emphasizes the use of protective devices like condoms and dental dams to protect against unwanted pregnancy and the transmission of STIs. This runs contrary to abstinence-only sex education, which teaches that educating children about sex can encourage them to engage in it.

These programmes have been found to decrease risky sexual behaviour and prevent sexually transmitted diseases.[83] They also reduce rates of unwanted pregnancies.[84] Abstinence only programmes do not appear to affect HIV risks in developed countries with no evidence available for other areas.[85]

Legalized prostitution

Since 1999 some countries have legalized prostitution, such as Germany (2002) and New Zealand (2003). However, in most countries the practice is prohibited. Gathering accurate statistics on prostitution and human trafficking is extremely difficult. This has resulted in proponents of legalization claiming that it reduces organized crime rates while opponents claim exactly the converse. The Dutch prostitution policy, which is one of the most liberal in the world, has gone back and forth on the issue several times. In the period leading up to 2015 up to a third of officially sanctioned work places had been closed down again after reports of human trafficking. Prostitutes themselves are generally opposed to what they see as "theft of their livelihood"[86]

Sex work and HIV

Despite the depth of knowledge of HIV/AIDS, rapid transmission has occurred globally in sex workers.[8] The relationship between these two variables greatly increases the risk of transmission among these populations, and also to anyone associated with them, such as their sexual partners, their children, and eventually the population at large.[8]

Many street-level harm-reduction strategies have succeeded in reducing HIV transmission in injecting drug users and sex-workers.[3] HIV education, HIV testing, condom use, and safer-sex negotiation greatly decreases the risk to the disease.[3] Peer education as a harm reduction strategy has especially reduced the risk of HIV infection, such as in Chad, where this method was the most cost-effective per infection prevented.[3]

Decriminalisation

The threat of criminal repercussions drives sex-workers and injecting drug users to the margins of society, often resulting in high-risk behaviour, increasing the rate of overdose, infectious disease transmission, and violence.[87] Decriminalisation as a harm-reduction strategy gives the ability to treat drug abuse solely as a public health issue rather than a criminal activity. This enables other harm-reduction strategies to be employed, which results in a lower incidence of HIV infection.[3]

Psychiatric medications

With the growing concern about psychiatric medication adverse effects and long-term dependency, peer-run mental health groups Freedom Center and The Icarus Project published the Harm Reduction Guide to Coming Off Psychiatric Drugs. The self-help guide provides patients with information to help assess risks and benefits, and to prepare to come off, reduce, or continue medications when their physicians are unfamiliar with or unable to provide this guidance. The guide is in circulation among mental health consumer groups and has been translated into ten languages.[88]

Criticism

Critics, such as Drug Free America Foundation and other members of network International Task Force on Strategic Drug Policy, state that a risk posed by harm reduction is by creating the perception that certain behaviours can be partaken of safely, such as illicit drug use, that it may lead to an increase in that behaviour by people who would otherwise be deterred.

We oppose so-called 'harm reduction' strategies as endpoints that promote the false notion that there are safe or responsible ways to use drugs. That is, strategies in which the primary goal is to enable drug users to maintain addictive, destructive, and compulsive behavior by misleading users about some drug risks while ignoring others.
— "Statement on so-called 'Harm Reduction' polices" made at a conference in Brussels, Belgium by signatories of the drug prohibitionist network International Task Force on Strategic Drug Policy[89]
...some organizations and local governments actively advocate the legalization of drugs and promote policies such as “harm reduction” that accept drug use and do not help drug users to become free from drug abuse. This undermines the international efforts to limit the supply of and demand for drugs. “Harm reduction” is too often another word for drug legalization or other inappropriate relaxation efforts, a policy approach that violates the UN Conventions.
— "Declaration of the World Forum Against Drugs Stockholm Sweden, September 10, 2008[90]

However, in Switzerland the incidence of heroin abuse has declined sharply since the introduction of heroin assisted treatment. As a study published in The Lancet concluded:

The harm reduction policy of Switzerland and its emphasis on the medicalisation of the heroin problem seems to have contributed to the image of heroin as unattractive for young people."
— Nordt, Carlos, and Rudolf Stohler, "Incidence of Heroin Use in Zurich, Switzerland: A Treatment Case Register Analysis,"[91]

Critics furthermore reject harm reduction measures for allegedly trying to establish certain forms of drug use as acceptable in society:

Harm reduction has come to represent a philosophy in which illicit substance use is seen as largely unpreventable, and increasingly, as a feasible and acceptable lifestyle as long as use is not 'problematic'. At its root of this philosophy lay an acceptance of drug use into the mainstream of society. We reject this philosophy as fatalistic and faulty at its core. The idea that we can safely use drugs is a dangerous one. ... It is in fact an unsafe choice that brings great harm to individuals, families, and communities across. And it sends the wrong message to the most valuable yet vulnerable group of Canadians – our children and youth.
— Drug Prevention Network of Canada[92]
Even though the world is against drug abuse, some organizations and local governments actively advocate the legalization of drugs and promote policies such as 'harm reduction' that accept drug use and do not help drug users to become free from drug abuse. This undermines the international efforts to limit the supply of and demand for drugs. 'Harm reduction' is too often another word for drug legalization or other inappropriate relaxation efforts, a policy approach that violates the UN Conventions.

There can be no other goal than a drug-free world. [...]

We support the INCB statement that 'harm reduction' programmes are not substitutes for demand reduction programmes and should not be carried out at the expense of other important activities to reduce the demand for illicit drugs, such as drug prevention activities.

— Declaration of World Forum Against Drugs, Stockholm, 2008, a conference with participation from 82 countries.[93]

Pope Benedict XVI strongly criticised harm reduction policies with regards to HIV/AIDS, saying that it was "a tragedy that cannot be overcome by money alone, that cannot be overcome through the distribution of condoms, which even aggravates the problems".[94] This position was in turn widely criticised for misrepresenting and oversimplifying the role of condoms in preventing infections.[95][96]

See also

References

  1. ↑ "INCB 2001 Annual Report - Oceania" (PDF). p. 559. Retrieved 2010-03-28.
  2. ↑ "Anger as Vice Girls Get Free Condoms". Retrieved 2010-04-20.
  3. 1 2 3 4 5 6 Rekart ML (December 2005). "Sex-work harm reduction". Lancet 366 (9503): 2123–34. doi:10.1016/S0140-6736(05)67732-X. PMID 16360791.
  4. ↑ Marlatt, G. Alan (2002). "Highlights of Harm Reduction". Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors. Guilford Press. p. 3. ISBN 978-1-57230-825-1.
  5. ↑ Inciardi, James A.; Harrison, Lana D. (2000). Harm reduction: national and international perspectives. Thousand Oaks, California: SAGE. pp. vii–viii.
  6. ↑ Daniel Boffey (8 September 2013). "Dane launches street magazine to help drug users fund their habit". The Guardian. Retrieved 6 November 2013.
  7. ↑ Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D (May 2010). "Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews". Addiction 105 (5): 844–59. doi:10.1111/j.1360-0443.2009.02888.x. PMID 20219055.
  8. 1 2 3 Hilton BA, Thompson R, Moore-Dempsey L, Janzen RG (February 2001). "Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature". J Adv Nurs 33 (3): 357–70. doi:10.1046/j.1365-2648.2001.01672.x. PMID 11251723.
  9. ↑ Lucie Van Den Berg (20 May 2013). "Syringe machine push for addicts in Melbourne's heroin hot spots". The Australian. Retrieved 20 May 2013.
  10. ↑ Bridie Byrne (28 May 2013). "Drug experts propose needle vending machines for Footscray". Herald Sun Maribyrnong Leader. Retrieved 29 May 2013.
  11. ↑ Charlie Cooper (9 April 2014). "NICE: Needle exchanges should supply safe equipment to under-18 steroid users". The Independent (London). Retrieved 9 April 2014.
  12. ↑ Islam, MM, Topp, L, Day, CA, Dawson, A and Conigrave, KM (2012). "The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature". International Journal of Drug Policy 23 (2): 94–102. doi:10.1016/j.drugpo.2011.08.005. PMID 21996165.
  13. ↑ Islam, MM, Topp, L, Day, CA, Dawson, A and Conigrave, KM (2012). "Primary healthcare outlets that target injecting drug users: Opportunity to make services accessible and acceptable to the target group". International Journal of Drug Policy 23 (2): 109–110. doi:10.1016/j.drugpo.2011.11.001. PMID 22280917.
  14. ↑ Islam, MM, Reid, SE, White, A, Grummett, S, Conigrave, KM and Haber, PS (2012). "Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary health-care clinic". Drug Alcohol Rev 31: 114–115. doi:10.1111/j.1465-3362.2011.00390.x. PMID 22145983.
  15. ↑ Islam, MM (2010). "Needle Syringe Program-Based Primary Health Care Centers: Advantages and Disadvantages". Journal of Primary Care & Community Health 1 (2): 100–103. doi:10.1177/2150131910369684.
  16. ↑ Harris, HW and Young, DM (2002). "Care of injection drug users with soft tissue infections in San Francisco, California". Arch Surg 137: 1217–1222. doi:10.1001/archsurg.137.11.1217.
  17. ↑ Pollack, HA, Khoshnood, K, Blankenship, KM and Altice, FL (2002). "The impact of needle exchange-based health services on emergency department use". Journal of General Internal Medicine 17: 341–348. doi:10.1007/s11606-002-0037-2.
  18. ↑ Dolan, Kate; Kimber, Jo; Fry, Craig; Fitzgerald, John; Mcdonald, David; Trautman, Franz (2000). "Drug consumption facilities in Europe and the establishment of supervised injection centres in Australia" (PDF). Drug and Alcohol Review 19 (3): 337–346. doi:10.1080/713659379.
  19. 1 2 3 4 5 EMCDDA 2010 Hedrich D, et al. "Chapter 11: Drug consumption facilities in Europe and beyond" (PDF).
  20. ↑ Pollard R (July 8, 2006). "1700 overdoses that didn't end in death". The Sydney Morning Herald (Fairfax Media).
  21. ↑ "Timeline: Insite". CBC.ca (Canadian Broadcasting Corporation). 2009-03-13. Archived from the original on December 7, 2009. Retrieved 2010-06-09.
  22. ↑ "Sydney gets first supervised heroin injecting room". The Independent (London: Independent Print Limited). April 5, 2001. Retrieved 2010-09-21.
  23. ↑ "Drug experts support injecting centre". The Sydney Morning Herald (Fairfax Media). October 15, 2010. Retrieved 2010-10-21.
  24. 1 2 Simmons, Amy (September 16, 2010). "Injecting centre approval fails to quell controversy". ABC News (Australian Broadcasting Corporation). Retrieved 2010-10-21.
  25. ↑ EMCDDA 2010 Rehm J, et al. "Chapter 4: Perspectives on harm reduction — what experts have to say" (PDF).
  26. ↑ "Drug Free Australia Detailed Evidence on Sydney MSIC" (PDF). Retrieved 2010-01-09.
  27. ↑ "The Vancouver Drug Injection site must be shut down". Real Women of Canada. Retrieved 2010-01-09.
  28. ↑ EMCDDA 2010, p. 308
  29. ↑ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 p 35
  30. ↑ see "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
  31. 1 2 3 4 see Executive Summary of "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
  32. ↑ Clement, T. "Canadian Parliament 39:2 Hansard — 103 (2008-06-02)". Retrieved 2010-05-31.2 June 2008
  33. ↑ "The Case for Closure: Detailed Evidence" (PDF). Drug Free Australia. Retrieved 2010-01-09. pp 26, 27
  34. ↑ "The Case for Closure: Detailed Evidence" (PDF). Drug Free Australia. Retrieved 2010-01-09. pp 31-34
  35. ↑ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 147
  36. 1 2 Overdose Death Rates. By National Institute on Drug Abuse (NIDA).
  37. 1 2 3 4 5 6 Richard P. Mattick et al.: National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of Results and Recommendation
  38. ↑ Uchtenhagen, Ambros (February 2002). "Background". Heroin Assisted Treatment for Opiate Addicts – The Swiss Experience.
  39. ↑ Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D (July 2007). "Heroin-assisted treatment for opioid dependence: randomised controlled trial". The British Journal of Psychiatry 191: 55–62. doi:10.1192/bjp.bp.106.026112. PMID 17602126.
  40. ↑ Uchtenhagen, Ambros (February 2002). "Epidemiology". Heroin Assisted Treatment for Opiate Addicts – The Swiss Experience.
  41. ↑ Urs Geiser (30 November 2008). "Swiss to agree heroin scheme but say no to dope". Swissinfo.ch. Swiss Broadcasting Corporation. Retrieved 21 May 2013.
  42. ↑ Results of two major clinical studies involving 547 heroin treatment patients are available from the CCBH (Central Committee on the Treatment of Heroin Addicts) website.
  43. ↑ Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D (July 2007). "Heroin-assisted treatment for opioid dependence: randomised controlled trial". Br J Psychiatry 191: 55–62. doi:10.1192/bjp.bp.106.026112. PMID 17602126.
  44. ↑ http://www.ihra.net/Assets/1828/1/Presentation_20th_C12_Michels.pdf
  45. ↑ http://relaunch.bundestag.de/bundestag/ausschuesse/a14/anhoerungen/113/stllg/ZIS.pdf
  46. ↑ http://stopthedrugwar.org/chronicle/588/germany_approves_heroin_maintenance
  47. ↑ Rachel Lart BRITISH MEDICAL PERCEPTION FROM ROLLESTON TO BRAIN, CHANGING IMAGES OF THE ADDICT AND ADDICTION
  48. ↑ Access a British report on heroin maintenance entitled Prescribing Heroin: what is the evidence?
  49. ↑ Norges forskningsråd:For svakt grunnlag,01.09.2011
  50. ↑ Kahan, M; Srivastava, A; Shen, K (2006). "Why we object to NAOMI: Heroin maintenance in Canada". Canadian Family Physician 52 (6): 705–6, 709–11. PMC 1780152. PMID 16812955.
  51. ↑ "Treatable or Just Hard to Treat?". Retrieved 2011-01-08. 2009
  52. 1 2 Drug Free Australia "Arguments for Prohibition" (PDF). Retrieved 2010-04-20.p 3
  53. ↑ UNODC "World Drug Report 2000". Retrieved 2010-05-04. 2001 pp 162-165 (see aggregated average for each OECD country in Harm Reduction Discussion page).
  54. ↑ "Untreatable or Just Hard to Treat?". Archived from the original on March 28, 2010. Retrieved 2010-04-20.
  55. ↑ Lintzeris, Nicholas (2009). "Prescription of heroin for the management of heroin dependence: current status". CNS Drugs 23 (6): 463–76. doi:10.2165/00023210-200923060-00002. PMID 19480466.
  56. ↑ "Get Started". Open Society Foundations. Open Society Foundations. 2013. Retrieved 17 March 2014.
  57. ↑ "Treatment of opioid dependence". World Health Organization. WHO. 2014. Retrieved 17 March 2014.
  58. ↑ "Drug use prevention, treatment and care". United Nations Office on Drugs and Crime. UNODC. 2014. Retrieved 17 March 2014.
  59. ↑ Paul Dietze and Simon Lenton (December 2010). "The case for the wider distribution of naloxone in Australia" (PDF). Alcohol, Tobacco & Other Drug Association ACT. ATODA. Retrieved 30 March 2013.
  60. ↑ "Tools for Starting a Naloxone Program". Open Society Foundations. Open Society Foundations. 2013. Retrieved 17 March 2014.
  61. ↑ EMCDDA event: 'Take home naloxone to reduce fatalities: scaling up a participatory intervention across Europe 14 October 2014, Lisbon.
  62. ↑ Donna Leinwand Leger (3 February 2014). "Police carry special drug to reverse heroin overdoses". USA Today. Retrieved 8 April 2014.
  63. ↑ Jessica Durando (27 May 2014). "NYPD officers to carry heroin antidote". USA Today. Retrieved 30 May 2014.
  64. ↑ Stonetreeus (23 March 2013). "THANKS FOR THE NALOXONE, BUT WHY DO WE HAVE TO WAIT?". Stonetree Harm Reduction. Stonetree Harm Reduction. Retrieved 30 March 2013.
  65. ↑ Loki (28 August 2013). "Naloxone Position Statement". Harm Reduction Victoria. HRV. Retrieved 17 March 2014.
  66. ↑ Jane (3 March 2014). "Naloxone Update". Harm Reduction Victoria. HRV. Retrieved 17 March 2014.
  67. ↑ http://www.emcdda.europa.eu/attachements.cfm/att_101262_EN_emcdda-harm%20red-mon-ch8-web.pdf%20%7Ctitle=Chapter%208:
  68. ↑ https://www.kcba.org/druglaw/pdf/drugconviction.pdf
  69. 1 2 3 4 5 EMCDDA 2010 Hall W, Fischer B. "Chapter 8: Harm reduction policies for cannabis" (PDF).
  70. ↑ "Should Latin America End the War on Drugs?". The New York Times. 2014-01-13.
  71. ↑ "Amsterdam Will Ban Tourists from Pot Coffee Shops". Atlantic Wire. May 27, 2011. Retrieved 2011-06-23.
  72. ↑ EMCDDA:Drug policy profiles, Portugal, June 2011
  73. ↑ McKeen, Scott (March 7, 2007). "'Wet' shelter needs political will: Toronto project could serve as model for Edmonton". Edmonton Journal.
  74. ↑ Podymow T, Turnbull J, Coyle D, Yetisir E, Wells G (2006). "Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol.". CMAJ 174 (1): 45–9. doi:10.1503/cmaj.1041350. PMC 1319345. PMID 16389236. Harm_reduction#Alcohol
  75. ↑ Patrick, Kelly (January 7, 2006). "The drinks are on us at the homeless shelter: Served every 90 minutes: Managed alcohol program reduces drinking". National Post.
  76. ↑ "SAPRP Project: Housing First: Evaluation of Harm Reduction Housing for Chronic Public Inebriates". SAPRP. April 2009.
  77. ↑ Larimer ME, Malone DK, Garner MD, et al. (April 2009). "Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems". JAMA 301 (13): 1349–57. doi:10.1001/jama.2009.414. PMID 19336710.
  78. ↑ Volpicelli, Joseph R. (1992). "Naltrexone in the Treatment of Alcohol Dependence". Archives of General Psychiatry 49 (11): 876. doi:10.1001/archpsyc.1992.01820110040006. ISSN 0003-990X.
  79. ↑ Farsalinos, Konstantinos; LeHouezec, Jacques (2015). "Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes)". Risk Management and Healthcare Policy (8): 157–167. doi:10.2147/RMHP.S62116. ISSN 1179-1594. PMC 4598199. PMID 26457058.
  80. ↑ Drummond, MB; Upson, D (February 2014). "Electronic cigarettes. Potential harms and benefits.". Annals of the American Thoracic Society 11 (2): 236–42. doi:10.1513/annalsats.201311-391fr. PMID 24575993.
  81. ↑ M., Z.; Siegel, M (February 2011). "Electronic cigarettes as a harm reduction strategy for tobacco control: a step forward or a repeat of past mistakes?". Journal of public health policy 32 (1): 16–31. doi:10.1057/jphp.2010.41. PMID 21150942.
  82. ↑ "Psychedelic Harm Reduction". Multidisciplinary Association for Psychedelic Studies. Retrieved 31 May 2014.
  83. ↑ Johnson, BT; Scott-Sheldon, LA; Huedo-Medina, TB; Carey, MP (January 2011). "Interventions to reduce sexual risk for human immunodeficiency virus in adolescents: a meta-analysis of trials, 1985-2008". Archives of pediatrics & adolescent medicine 165 (1): 77–84. doi:10.1001/archpediatrics.2010.251. PMID 21199984.
  84. ↑ Oringanje, C; Meremikwu, MM; Eko, H; Esu, E; Meremikwu, A; Ehiri, JE (2009-10-07). Oringanje, Chioma, ed. "Interventions for preventing unintended pregnancies among adolescents". Cochrane database of systematic reviews (Online) (4): CD005215. doi:10.1002/14651858.CD005215.pub2. PMID 19821341.
  85. ↑ Underhill, K; Operario, D; Montgomery, P (2007-10-17). Operario, Don, ed. "Abstinence-only programs for HIV infection prevention in high-income countries". Cochrane database of systematic reviews (Online) (4): CD005421. doi:10.1002/14651858.CD005421.pub2. PMID 17943855.
  86. ↑ AlwaysUnite (2015-04-11). "Paar honderd prostituees protesteren tegen sluiting raambordelen". National Daily.
  87. ↑ Hathaway AD, Tousaw KI (February 2008). "Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver". Int. J. Drug Policy 19 (1): 11–6. doi:10.1016/j.drugpo.2007.11.006. PMID 18164610.
  88. ↑ Hall, Will (September 2007). "Harm Reduction Guide to Coming Off Psychiatric Drugs".
  89. ↑
  90. ↑
  91. ↑ Nordt C, Stohler R (June 2006). "Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis". Lancet 367 (9525): 1830–4. doi:10.1016/S0140-6736(06)68804-1. PMID 16753485.
  92. ↑
  93. ↑
  94. ↑ "Condoms 'not the answer to AIDS': Pope". World News Australia. SBS. 17 March 2009.
  95. ↑ Kamerow D (2009). "The papal position on condoms and HIV". BMJ 338: b1217. doi:10.1136/bmj.b1217. PMID 19321547.
  96. ↑ Roehr B (2009). "Pope claims that condoms exacerbate HIV and AIDS problem". BMJ 338: b1206. doi:10.1136/bmj.b1206. PMID 19321545.

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