Treating Addictions: Harm Reduction in Clinical Care and Prevention.

This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which shows that some ways of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: (1) through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, (2) by developing innovative clinical programmes that employ harm reduction, and thereby (3) changing the standard of care to include routine use of these evidence-based (but often misunderstood) approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations.

Time series modeling of heroin and morphine drug action.

RATIONALE: Clinical observations and recent findings suggested different acceptance of morphine and heroin by intravenous drug users in opiate maintenance programs. We postulated that this is caused by differences in the perceived effects of these drugs, especially how desired and adverse effects of both drugs interacted. OBJECTIVES: We measured the desired and adverse effects of high doses of injected morphine and heroin in patients to determine the causal interactions between both types of effects and test the hypothesis of a differential mechanism of action. METHODS: Thirty-three patients (five females, 28 males; mean duration of previous street heroin use 10.7 years, mean age 30.1 years) were randomly allocated double-blind to the substance groups. The average daily dose per participant in the heroin condition (n=17) was 491 mg, in the morphine condition (n=16) 597 mg. The observation period lasted 3 weeks; an average of 70 injections was received. After each injection of either substance, various aspects of drug effects were recorded systematically. Ratings were summarized into the factors "euphoria" and "adverse effects". Time series models were computed for each participant on the basis of the factor scores, using vector autoregression (VAR). RESULTS: A highly significant difference between the substances was found in the interaction between "euphoria" and "adverse effects". Adverse effects of heroin preceded higher euphoria, whereas adverse effects of morphine preceded subsequent lower euphoria. Additionally, the finding of a higher level of adverse effects in morphine was replicated. CONCLUSIONS: Results point to different mechanisms of action of the two opioids when the perceived drug effects are evaluated in a field setting. This may explain the better acceptance of heroin in opiate-assisted treatment of intravenous drug patients. The method used can be a valuable tool for the comparison of substance groups other than opioids.