Harm Reduction and Injection Drug Use: Pragmatic Lessons from a Public Health Model.

The spread of HIV infection among injection drug users (IDUs) is one of the most challenging and tenacious aspects of the drug problem plaguing the United States. Injection drug use represents a major public health challenge because of the multiple health, psychological, and social problems that must be overcome to address this addictive behavior and disease transmission (Office of National Drug Control Policy [ONDCP], 2000). National statistics indicate that injection drug use continues unabated with an estimated 1.1 to 1.5 million IDUs in the United States (Holmberg, 1996). The twin epidemic of injection drug use and AIDS has exacted a tremendous strain on the U.S. health care system, with the estimated treatment costs for IDUs infected with HIV and in the later stages, AIDS, totaling $3.7 billion (Harwood, Fountain, & Livermore, 1998). According to the Centers for Disease Control and Prevention (2000), 753,907 cumulative cases of AIDS were reported in the United States as of June 2000. Approximately 36 percent (n = 270,721) of the reported AIDS cases occurred among IDUs, their sexual partners, and their children. Because HIV can be transmitted both sexually and perinatally, drug injectors are also placing their potential children at increased risk. This is evidenced by 8,804 cumulative pediatric AIDS cases reported by midyear 2000, with more than half of these cases caused by injection drug use by the mother, or by the mother having sex with an IDU. A disproportionate number of members of racial and ethnic minority groups is being ravaged by the disastrous consequences of AIDS, with African Americans and Latinos accounting for 76 percent of the injection-related AIDS cases in the United States. Until a cure for AIDS is found, or a vaccine for HIV is developed, there is a critical need to reduce the spread of HIV transmission among individuals who choose to inject illicit substances. Harm-reduction interventions and policies have emerged as viable strategies to ameliorate the adverse health, social, or economic consequences associated with injection-related behaviors (Brettle, 1991; Des Jarlais, 1995; Des Jarlais & Friedman, 1993; Inciardi & Harrison, 2000; Marlatt, 1998; Nadelmann, 1998). PRAGMATIC LESSONS FROM A PUBLIC HEALTH MODEL Harm reduction, also called damage limitation, risk reduction, and harm minimization, is a goal of public health policies and interventions aimed at decreasing the deleterious consequences spurred by illicit drug use (Marlatt, Somers, & Tapert, 1993; Newcombe, 1992; Single, 1995). Present drug control measures and treatment philosophies in the United States deem abstinence as the most effective means of reducing the individual and public health risks associated with injection drug use (ONDCP, 2000). Harm reduction is a point of departure from these traditional beliefs. Proponents of the harm reduction model do not view abstinence as the only desirable objective for drug users. By acknowledging the prevalence of illicit drug use in our communities and that drugs may not always be used in a safe manner, harm reduction seeks to remedy these problems through pragmatic, incremental, and nonjudgmental interventions and policies (Des Jarlais, 1995; Des Jarlais, Friedman, & Ward, 1993; Schilling & El-Bassel, 1998). Harm reduction measures do not ascribe to a specific formula, but should reflect specific individual and community needs. Therefore, practitioners should always be conscious of starting "where the client is" during the course of the therapeutic process. The common principles that are central to harm-reduction practice are as follows: * The harm-reduction approach does not attempt to minimize or ignore the pervasive public health consequences associated with injection drug use, but rather accepts that the nonmedical use of psychoactive drugs is an inevitable occurrence in a society that has access to such drugs (Des Jarlais, 1995). …