Harm Reduction: National and International Perspectives

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Edited by: James A. Inciardi & Lana D. Harrison

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    Introduction: The Concept of Harm Reduction

    James A.InciardiLana D.Harrison

    During the past decade, municipal, state and national governments in Europe and Australia have responded to local drug problems with a variety of initiatives that merit close examination in the United States. Based on the evolving notion of “harm reduction,” these initiatives focus on reducing the adverse consequences of both psychoactive drug use and drug control policies without eliminating drug use.

    Nadelmann et al. (1997, p. 22)

    There is no clear consensus on the meaning of the term harm reduction, although at its hub is a focus on reducing the adverse consequences of psychoactive drug use. In fact, it would appear that with each new article or presentation on the topic, a new conceptualization is offered. At one end of the continuum is the view of Dr. Arnold S. Trebach, a professor of law at American University and the founder and former director of the Drug Policy Foundation. Dr. Trebach argues that harm reduction accepts the reality of both the desire for drugs by millions of people and the related fact that many of these individuals may be harmed by their use of drugs. Accordingly, he suggests, people should be allowed to make choices—to use drugs in either relatively harmless ways or in very destructive ways, or to use no drugs at all. Regardless of their choice, they must not be treated as enemies of the state, and if they encounter trouble as a result of their drug use, help should be available to them (Trebach & Inciardi, 1993, p. 77). Within this context, harm reduction covers a wide variety of programs and policies, including the following:

    • Advocacy for changes in drug policies—legalization, decriminalization, ending the drug prohibition, changes in drug paraphernalia laws, reduction of penalties for drug-related crimes, and treatment alternatives to incarceration
    • HIV/AIDS-related interventions—needle/syringe exchange programs, HIV prevention/intervention programs, bleach distribution, referrals for HIV testing and HIV medical care, and referrals for HIV/AIDS-related psychosocial care and case management
    • Broader drug treatment options—methadone maintenance by primary care physicians, changes in methadone regulations, heroin substitution programs, and new experimental treatments
    • Drug abuse management for those who wish to continue using drugs—counseling and clinical case management programs that promote safer and more responsible drug use
    • Ancillary interventions—housing and other entitlements, healing centers, and support and advocacy groups

    Dr. Robert L. DuPont, a faculty member at Georgetown University School of Medicine and a former director of the National Institute on Drug Abuse, offers a substantially contrasting perspective. He sees harm reduction as an alternative to both drug prohibition and drug legalization. Harm reduction, in Dr. DuPont's view, seeks to preserve prohibition while softening some of its harsh consequences (DuPont, 1996). As such, DuPont sees harm reduction as a compromise position with the aim of reducing aspects of drug-related harm.

    On the whole, there are many who would disagree with both of these positions. Furthermore, there is a problem with achieving any level of consensus because harm reduction is neither a policy nor a program. Harm reduction is a goal for policies and programs; it is a willingness to trade potential increases in drug use for potential decreases in drug-related harm (Reuter & MacCoun, 1996). Stated differently, the essential feature of harm reduction is the attempt to ameliorate the adverse health, social, or economic consequences associated with the use of mood-altering substances without necessarily requiring a reduction in the consumption of these substances.

    The Emergence of Harm Reduction

    The harm reduction movement has its roots in the drug policies of the Netherlands, which take a public health or sociomedical approach to drug use and its consequences. For example, the Dutch instituted the first needle exchange program in 1984 in an attempt to stem the rising number of hepatitis cases related to injection drug use (van Haastrecht, 1997). Because the Dutch viewed hepatitis as the greater evil, programs were established to provide new needles and syringes to injectors. And, because these syringe exchange programs were in place not too long after the beginning of the spread of HIV/AIDS among injection drug users in Western Europe, it is believed that the incidence and prevalence of HIV infection never reached the epidemic levels among drug users in the Netherlands that became apparent elsewhere (van Haastrecht, 1997).

    Several other European nations, including the United Kingdom and Switzerland, adopted harm reduction policies in response to the AIDS epidemic. Their position was that AIDS represented a greater threat to public health than did drug use, and that AIDS prevention should take precedence over antidrug efforts. Within this same perspective, Australia implemented its needle exchange policies in April 1985. Although the street drug cultures in Australia and the United States are not fully comparable, Australia has a 5% HIV infection rate among injection drug users as compared to 14% in the United States. Furthermore, it has been argued that this difference is due to the limited number of needle exchange programs in the United States (Wodak & Lurie, 1997). In fact, one recent estimate suggests that between 4,000 and 10,000 HIV infections could have been prevented in the United States had needle exchange programs followed the same pattern of growth as in Australia (Lurie & Drucker, 1997).

    Currently, the U.S. approach to drug abuse and drug control includes a variety of avenues for reducing both the supply of and the demand for illegal drugs. “Supply reduction” includes interdiction activities designed to keep illegal drugs from entering the United States, legislation and enforcement for the sake of keeping drugs off the streets and away from consumers, and foreign assistance programs designed to support U.S. antidrug policies abroad. “Demand reduction” includes a variety of treatment alternatives for drug users, education and prevention for both youths and adults, and research to determine how to best develop and implement plans for treatment, education, and prevention. For the most part, these supply-and-demand reduction strategies are grounded in the classic deterrence model: through legislation and criminal penalties, individuals will be discouraged from using drugs. By setting an example of drug users, current and potential users will be dissuaded from using illicit drugs. Furthermore, by punishing traffickers, the government can force potential dealers to seek out other economic pursuits. Drug prohibition is also meant to shape norms about the appropriateness of illicit drug use.

    Although supply reduction is the dominant feature of American drug policy, some elements of harm reduction are also apparent. For example, providing methadone to heroin users who are either unwilling or unable to abstain from narcotics use is a clear example of harm reduction. Introduced in the United States during the 1960s, methadone is a relatively long-lasting opioid that reduces some of the highs and lows associated with heroin use. A vast body of research demonstrates methadone's efficacy in reducing drug-related morbidity, mortality, and criminality, and in improving the quality of life for those dependent on heroin (Ball, Rosen, Flueck, & Nurco, 1981; Gerstein & Harwood, 1990; Nurco, Hanlon, Kinlock, & Duszynski, 1988; Speckart & Anglin, 1985). Furthermore, medical research has demonstrated that methadone has few negative health consequences (Kreek, 1983). However, because methadone maintenance treatment has not always been popular or well received by either the public or policymakers, there have been a number of consequences for those in the greatest need for the programs. For example, inadequate dosing is widespread, and there are far too few treatment slots. In much of Europe and Australia, methadone treatment was initially even more controversial than in the United States. However, in those countries that have embraced methadone maintenance, physicians have far more flexibility in prescribing methadone, and patients generally have greater access to the drug. In Belgium, Germany, and Australia, the principal means of distribution is from general practitioners, with local pharmacies filling prescriptions.

    Drug abuse treatment and drug prevention are harm reduction strategies, and both have become more prominent in American drug policy. Nevertheless, the great majority of drug control funds are earmarked for supply reduction activities, with the balance targeting demand reduction efforts. As such, much of the drug control resources are spent on the apprehension and incarceration of drug users, dealers, and traffickers (Reuter, 1992). The result has been high rates of arrest and incarceration of drug users—neither of which has significantly affected America's drug problem (Butterfield, 1998).

    In contrast to the more punitive drug strategies seen in the United States, harm reduction is a pragmatic policy aimed at minimizing the damage that drug users do to themselves, others, and society at large (Buning, Coutinho, van Brussel, & van Zadelhoff, 1986). Harm reduction approaches reject the notion of a “drug-free” society as unachievable, recognizing that drug use has been a part of human societies since their very beginning. Although the official U.S. policy tends to equate harm reduction with legalization, most advocates of harm reduction do not support the idea of legalizing drugs, expressing concern that it would substantially increase drug use. Yet they recognize that prohibition is not sufficient to stop drug use because it increases crime and marginalizes drug users. Harm reduction interventions focus on integrating or reintegrating drug users into the community, taking care not to further isolate, demonize, or ostracize them. Priority is placed on maximizing the number of drug users in contact with drug treatment, outreach, and other public health services. Drug policies are evaluated in terms of their potential effects on minimizing the harm of drugs to the user and society at large. As such, “the challenge is thus making prohibition work better, but with a focus on reducing the negative consequences of both drug use and prohibitionist policies” (Nadelmann, 1997, p. 114). Harm reduction asks questions like the following:

    • How can we reduce the likelihood that drug users will engage in criminal and other undesirable activities?
    • How can we reduce overdoses, HIV/AIDS, and the hepatitis B and C infections associated with the use of some drugs?
    • How can we increase the chances that drug users will act responsibly toward others?
    • How can we increase the likelihood of rehabilitation?
    • More generally, how do we ensure that drug control policies do not cause more harm to drug users and society than drug use itself?
    Perspectives on Harm Reduction

    The opening chapter in this book, “Harm Reduction: History, Definition, and Practice,” by Diane Riley and Pat O'Hare, provides an overview of the history and development of harm reduction worldwide. The authors point out that harm reduction policy has increased in popularity, largely in response to the AIDS epidemic among injection drug users. Because drugs can negatively affect the health, social, and economic status of the user, harm reduction seeks to minimize the consequences of drug use at the individual, community, and societal levels. Riley and O'Hare identify a wide range of harm reduction policies and programs, including needle exchange; methadone maintenance; education and outreach to reduce risks associated with drug use; “tolerance areas,” where drug users can obtain clean needles, condoms, and medical attention; and law enforcement policies that publicly support harm reduction methods. The authors suggest that although support for harm reduction policies is on the increase, there are still numerous barriers to their implementation, especially in the United States, where abstinence is often seen as the only acceptable outcome of drug abuse.

    Ernest Drucker's “From Morphine to Methadone: Maintenance Drugs in the Treatment of Opiate Addiction” provides an analysis of the history and implications of methadone maintenance programming. He points out that during the 19th century, opiates (including morphine and heroin) gained popularity as medicinal remedies. As a result, some people experienced prolonged anxiety, restlessness, sleep disturbance, and other withdrawal symptoms when they discontinued use. The concept of addiction as a disease grew from this phenomenon, and the search for effective medical treatments led to the use of narcotics (including morphine, heroin, and methadone) to loosen the bonds of addiction. Some physicians in the United States and Great Britain recognized the value of this approach and instituted narcotic maintenance treatment early in the century. In the United States, drug maintenance programs generally have been frowned upon by the medical and legal communities, so methadone—a synthetic opioid that can be taken orally with effects generally lasting 24 to 36 hours for a single dose—was first tried on the worst cases. Its efficacy was demonstrated in repeated clinical trials, although hostile attitudes toward maintenance approaches have not been abandoned, and many programs attempt to detoxify clients or provide doses too low to be of substantial benefit. However, in light of the AIDS epidemic among injection drug users, methadone maintenance has gained more acceptability.

    “The Coming of Age of Needle Exchange,” by Sandra D. Lane, Peter Lurie, Benjamin Bowser, Jim Kahn, and Donna Chen, documents the history of needle exchange programs. Although needle exchange programs have become one of the more controversial public health programs of our time, advocates see them as improving the health of drug injectors, whereas opponents believe that they encourage drug use. Many of the early needle exchange programs were operated illegally as explicit acts of civil disobedience. By the 1990s, however, needle exchange programs were active in some two dozen countries in North America, Europe, and Asia.

    Lana D. Harrison's “The Medicalization of Marijuana” provides a historical analysis of marijuana as medicine, and it also discusses the current controversy surrounding medical marijuana in the United States. Marijuana has a long history as a medicinal remedy. Recent research has shown cannabis to relieve symptoms connected with glaucoma, HIV wasting syndrome, and nausea and vomiting associated with cancer chemotherapy. The voter support for propositions in California and Arizona in November, 1996, allowing physicians to prescribe marijuana for medical purposes has generated much criticism from the U.S. government. Such federal agencies as the Drug Enforcement Agency and the Food and Drug Administration claim that more research is needed on the efficacy of marijuana's medicinal properties and side effects, as well as on marijuana's role as a “gateway” drug. Although more research has been commissioned by the federal government, 25 states currently have some form of medical marijuana laws.

    In “Pregnancy, Drugs, and Harm Reduction,” Marsha Rosenbaum and Katherine Irwin address a number of issues in the area of drug abuse among women. They point out that the increasing problem of substance abuse among women has been exacerbated, if not caused, by two national trends. First, poverty, homelessness, and substandard education and health care have increased since 1980, and as members of America's ever-growing “underclass,” drug users' lives have become more chaotic, risky, dangerous, and violent. Second, for addicts without financial resources, access to drug treatment has become increasingly problematic due to a decline in federal funding of programs. Within this context, they describe the activities in which drug-using women in general, and pregnant drug users in particular, engage to reduce drug-related harm.

    The chapter titled “Coffee Shops, Low-Threshold Methadone, and Needle Exchange,” by Dirk J. Korf and Ernst C. Buning, provides an overview of Dutch drug policy. Since 1976, Dutch policy has been a combination of legal and socio-medical control, with the aim of striking a balance between supply reduction by statutory intervention, and the reduction of demand and health hazards through a public health approach. Legal control has resulted in intensified criminalization of the drug trade. At the same time, however, there has been the decriminalization of hashish and marijuana and the toleration of small-scale vending of cannabis in coffee shops. Dutch drug policy also emphasizes sociomedical controls, which have inspired such interventions as low-threshold methadone programs, outreach, drug-free treatment centers, and syringe exchange programs. Despite criticism from prohibitionists, the predominant pattern of cannabis use in the Netherlands today is experimental and recreational, in contrast to alcohol and tobacco, which are used more habitually. Furthermore, the coffee shop phenomenon has helped to create and maintain a separation of the cannabis and heroin markets, with a consequent stabilization of heroin use in the Netherlands.

    In “The Harm Reduction Movement in Brazil: Issues and Experiences,” Hilary L. Surratt and Paulo R. Telles document the evolution of harm reduction strategies for drug users in Brazil. Harm reduction policies have emerged in Brazil only recently, and they focus almost exclusively on quelling the HIV/ AIDS epidemic among injection drug users. Central to the movement is changing the legal status of needle/syringe exchange programs, which are perhaps the key features of harm reduction in Brazil. Two sites established small needle/ syringe exchange programs in 1995, whereas others, such as Rio de Janeiro, became operational only in mid-1997. Public and police opposition to such programs remains high, leaving many injection drug users without access to such programs. Surratt and Telles also point out that there continues to be tremendous unmet need for services among noninjection drug users, who are also at risk for HIV/AIDS. To address this need, an initiative targeting segments of the Rio de Janeiro population at high risk for HIV/AIDS acquisition and transmission was implemented in 1993. The community-based HIV/AIDS prevention/intervention program for cocaine injectors and snorters provided more than 1,600 clients with risk reduction information, hygiene materials, voluntary HIV testing, and service referrals. For nearly 70% of the clients, this project provided the first AIDS risk reduction information and materials that they had ever received.

    Patricia G. Erickson's “The Harm Minimization Option for Cannabis: History and Prospects in Canadian Drug Policy” provides a historical overview of Canadian drug policy with a focus on recent harm reduction developments. Historically, drug policy in Canada and the United States has been grounded in punishing users through criminal sanctions. However, in 1987, Canada appeared to be taking a more public health-directed approach to harm minimization by declaring a new National Drug Strategy, and in 1992, it adopted harm reduction as the goal of that drug strategy. However, an analysis of the hearings debating Canada's new policy revealed the intent to continue punishing cannabis users within the legal system, thus reinforcing and upholding the traditional criminal justice approach.

    Toni Makkai's chapter, “Harm Reduction in Australia: Politics, Policy, and Public Opinion,” provides an analysis of recent drug policy developments in Australia. Over the past 10 to 15 years, Australian drug policy has focused more on public health than on the legal aspects of drug use. The National Campaign Against Drug Abuse (later renamed the National Drug Strategy) was formed in 1985 as an attempt to minimize the harmful effects of both licit and illicit drugs. Major policy initiatives have occurred with regard to alcohol and tobacco, such as taxation, lowering of the blood alcohol content used to determine impairment/drunkenness, banning smoking in many public areas, and eliminating much of the advertisements promoting these products. Additionally, the HIV risk associated with injection drug use was instrumental in establishing methadone and needle exchange programs. However, despite dedication to harm minimization in the past, a newly elected Australian conservative federal government threatens the future of this approach in dealing with illicit drug use.

    In his chapter, titled “The Harm Reduction Roles of the American Criminal Justice System,” James A. Inciardi takes the position that like it or not, America's punitive approaches to drug control are here to stay—at least for a while. Given that, and because so many drug users come to the attention of the criminal justice system, a logical approach is to make the American criminal justice system more humane. Inciardi begins his chapter with a discussion of how the punitive policies emerged and why drugs/crime tend to be so linked to policy alternatives. He then suggests how criminal justice-based treatment approaches can play a harm reduction role.

    Postscript

    Although the harm reduction movement is having a positive impact on the lives of drug users in many parts of the world, it may face some difficult times in the years ahead. Drug policies in the United States and throughout most of the world are of a punitive nature, and most will likely remain so for some time to come, especially in the United States. This seems to be the case for several reasons.

    First, a vast body of research demonstrates the relationship between drug use and criminal behavior (Hunt, Lipton, & Spunt, 1984; Inciardi, 1986; Johnson, Elmoghazy, & Dunlap, 1990; Nurco et al., 1988; Speckart & Anglin, 1985; Wish & Johnson, 1986). Alcohol is associated with criminal behavior as both a situation-specific crime (i.e., drunkenness) and a concomitant, because large numbers of incarcerated prisoners display high levels of alcohol problems (Harrison, 1992a). Prisoners also display high levels of problems with illicit drugs. Research has consistently shown that patterns of frequent and intense heroin use are accompanied by correspondingly higher rates of criminal activity (Nurco et al., 1988). The same pattern appears to be evident with heavy crack users as well (Johnson et al., 1990; Inciardi & Pottieger, 1991). Research suggests, however, that even among criminally active drug abusers, the major criminal activity is generally drug sales. Only a small number are actively engaged in non-drug crimes (i.e., robbery, burglary, shoplifting, other larcenies, prostitution, etc.), committing crimes on a daily or near-daily basis (Nurco, Hanlon, Baiter, Kinlock, & Slaght, 1991; Johnson et al., 1990).

    Some illegal drugs, especially heroin, are intertwined with patterns of relative poverty and urban inequality. For the class of users that has few skills and few opportunities for advancement in middle-class society, frequent licit and illicit drug use may become part of a lifestyle that includes participation in a number of deviant activities. The lifestyle of a criminal addict may be one of the few alternatives for a successful and rewarding lifestyle open to people suffering from socioeconomic deprivation, because the addict/crime scene offers meaning, excitement, pleasure, financial reward, and peer recognition (Harrison, 1992b).

    Research has aptly demonstrated that for many of these users, their drug use does not necessarily initiate their criminal careers, although it does tend to intensify and perpetuate them. Thus, for as long as drug users continue to commit crimes—regardless of their reasons for doing so—policies are likely to remain punitive.

    Second, many drugs will continue to pose a public health problem in terms of their morbidity and mortality—and this applies to licit as well as illicit drugs. Although use of licit drugs is relatively common, illicit drug use is, statistically, a rare behavior in most societies. The most common pattern of use, even among users, is experimental—or the experience of having tried the drug, but no longer using. Community studies of cocaine users, which were not focused on individuals drawn from the treatment and criminal justice systems, shows that the normal pattern of use is sustained light use. The next most frequent pattern was an increase in use subsequent to initiation, followed by a return to levels of use similar to those experienced in the early phases of use. Only a small proportion of cocaine users develop frequent and intense patterns of use that do not decline over time (cf. Harrison, 1994). Many of those who escalated to daily use managed to reestablish controlled recreational use patterns. Rather than cocaine overpowering user concerns with family, health, and career, the high value that most users placed upon family, health, and career achievement mitigated against abuse and addiction. Most also employed control strategies like limiting the times and spheres in which they allowed themselves to use cocaine (Reinarman, Murphy, & Waldorf, 1994). Therefore, informal social control and group norms mediate the force of pharmacological and psychological factors that can lead to addiction.

    The problem, however, is that many of the elements of informal social control that are operant in the lives of more middle-class users are absent in the lives of underclass users. As previously mentioned, illegal drugs such as heroin and crack cocaine are intertwined with patterns of relative poverty and urban inequality. Perhaps one of the most important phenomena keeping users from becoming chronically dependent is involvement in a social network and competing activities and interests. Less privileged people with fewer options are more vulnerable to deviant adaptations because of their lack of access to more conventional ones. To optimize success, a harm reduction policy needs to be embedded within an overall welfare policy that is not in place in countries with the biggest problem, such as the United States, or in Europe, Italy, and Spain.

    Rather than addicts using a fixed amount of drugs per day, research shows that they titrate their use in general, and their use of costly drugs largely in accordance with their available economic resources (Grapendaal, Leuw, & Nelen, 1992; Johnson, 1987). It appears that a strong social welfare system represses criminal involvement among users (Grapendaal et al., 1992; Reuband, 1992). But as long as drug use remains a public health problem, and particularly in those countries without a strong welfare system to help soften the linkages between use of expensive illicit drugs and crime, policies are likely to remain punitive.

    Third, there is politics or, perhaps, lack of an informed citizenry. This may be somewhat of a global problem, but it is certainly true in the United States, where the majority of individuals are either under- or miseducated about drugs, including alcohol and tobacco. The costs of alcohol and tobacco use and abuse are much greater than the costs of all illicit drugs combined in the United States (McGinnis & Foege, 1993), yet the citizenry consistently rates illicit drugs and crime as the most important problems facing the nation. This is because views about drugs are largely informed by media presentations, and the U.S. media pay disproportionate attention to the problems of illicit drug use and abuse. Certainly, not all media reporting is bad or in error, but the media present an unbalanced view of drugs. The media appear to be most interested in dealing with stories that are designed to grab the attention of their audience with reports of vice or avarice. And media are the major means of information not only for the general populace, but for policymakers as well (NIDA, 1993). Therefore, because drug users and drug dealers have been demonized, punitive policies are attractive to policymakers and the masses. In the United States, presidents, members of Congress, governors, mayors, and legislators can garner far more political fodder from the numbers of arrests and convictions that their policies yielded than from the number of drug treatment beds that were put on line or the number of needles that were exchanged. There is greater affinity for harm reduction policies in countries such as Australia, which, as part of its National Drug Strategy, has concentrated efforts on educating the public about all drugs—including alcohol and tobacco—which helps to put the illicit drug problem in perspective.

    Fourth, there is the harm reduction movement itself. As noted in the beginning of this chapter, there is tremendous diversity with respect to the definitions of harm reduction. Therefore, supporters can hold widely divergent opinions as to appropriate strategies, which has tended to splinter the movement rather than unify it. Although this is to be expected with any attempt to bring about major social changes, a high priority must be placed on building common principles and unity rather than distracting from the major foci of the movement. But as in any social movement, the harm reduction crusade has its fair share of extremists and zealots, who advocate an all-or-nothing approach and denigrate those who are not so committed. Such a position tends to limit the influence and scope of advocacy and prevent harm reduction from gaining broad acceptance.

    As a final note, it is important to note that those countries that have embraced more openly the harm reduction approach to setting drug policy have often included the legal drugs of alcohol and tobacco as well. In the opening of the 1994 Commission on Narcotic Drugs, the Director General of the United Nations's Drug Control Program (UNDCP), Giorgio Giacomelli, noted that it was “increasingly difficult to justify the continued distinction among substances solely according to their legal status and social acceptability.” At the same meetings, the Director of the World Health Organization (WHO) Programme on Substance Abuse said that

    current drug strategies are, to some extent, driven by a few industrialized countries. On the one hand, they are making strenuous efforts to exclude from their shores every conceivable kind of illegal substance. But on the other hand, these countries are also vigorously pushing their own substances, such as alcohol, tobacco, and pharmaceuticals onto the very same countries from which they are doing their best to exclude illegal drugs. (Emblad, 1994)

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  • About the Contributors

    Benjamin Bowser, PhD, is Professor of Sociology and Social Services at California State University, Hay ward, and Associate Editor of Age Race Relations Abstracts (London). His areas of research include race relations, community-based studies of drug abuse and HIV/AIDS prevention, and research methods. His most recent publications include the edited Racism and Anti-Racism in World Perspective (1995) and Impacts of Racism on White Americans (2nd ed., 1996) with Raymont Hunt. His research has been reported in more than 30 journal articles, and he has received funding from NSF, FIPSE, CDC, NIDA, NIMH, The Robert Wood Johnson Foundation, the Rockefeller Foundation, and the University of California University-wide AIDS Research program.

    Ernst C. Buning is a clinical psychologist who has been working in the drug field since 1977. He has done outreach work; set up the mobile methadone-by-bus project in Amsterdam; and has been involved in various research projects, among which was the evaluation of the Amsterdam needle exchange scheme. As a senior policy staff member of the Amsterdam Municipal Health Service, he has been active in defining the Amsterdam harm reduction approach to the drug problem. Currently, he is senior staff member at the Bureau International Affairs of the Amsterdam Municipal Health Service, where he is responsible for coordinating the European network of methadone providers (Eur-Methwork); informing visiting experts about the Dutch approach to the drug problem; and organizing workshops, training courses, and conferences.

    Donna Chen, MD, MPH, received her MPH from the University of California at Berkeley and her MD from the University of California at San Francisco. Work on needle exchange evaluation was completed while she was a researcher with the Centers for Disease Control and Prevention Needle Exchange Evaluation Project at the Center for AIDS Prevention Studies, University of California at San Francisco. She is currently Chief Resident in Psychiatry at Columbia University, College of Physicians and Surgeons and the New York State Psychiatric Institute. After completing residency training, she will be a Clinical Prevention/Services Research Scientist with the Southeastern Rural Mental Health Research Center, University of Virginia, in addition to continuing with clinical work.

    Ernest Drucker, PhD, is Director, Division of Community Health, and Professor in the Department of Epidemiology and Social Medicine at Montefiore Medical Center, Albert Einstein College of Medicine in New York, where he was founder and (from 1970–1990) Director of the Methadone Treatment Program at Montefiore. He is currently a Senior Fellow of The Lindesmith Center/Open Society Institute, and editor-in-chief of Addiction Research, an international peer review journal. Since 1985, he has been conducting epidemiological and policy studies of AIDS and its relationship to drug use and addiction in the United States and abroad. He was Founding Chairman of the Board (1990–1995) of Doctors of the World (USA) and is currently Chairman of the Board of Positive Health Project, an AIDS service and prevention program in the Times Square area of New York City. He has also been a Fogarty International Fellow of the World Health Organization, an AIDS Policy Fellow of AmFAR (studying international comparisons of AIDS and drug policies), and Visiting Professor (1992–1993) at The Woodrow Wilson School of International Affairs of Princeton University.

    Patricia G. Erickson, PhD, is a Senior Scientist with the Addiction Research Foundation Divison, Centre for Addiction and Mental Health. She is also Adjunct Professor and member of the Graduate Faculty in the Department of Sociology at the University of Toronto, and she has just completed a 3-year term there as Director of the Collaborative Graduate Program in Alcohol, Tobacco and Other Psychoactive Substances. She received her doctorate from the University of Glasgow, Scotland. Her most recent books are The Steel Drug: Cocaine and Crack in Perspective (1994) and a co-edited collection, Harm Reduction: A New Direction for Drug Policies and Programs (1997). She is the author or co-author of more than 50 scientific books, articles, or chapters dealing with illicit drugs and drug policy, and she has been invited to speak at numerous professional and community meetings.

    Lana D. Harrison, PhD, is the Associate Director and a senior scientist in the Center for Drug and Alcohol Studies at the University of Delware. She has worked on the three largest epidemiological studies of drug use in the United States: the Monitoring the Future study, the Drug Use Forecasting study, and the National Household Survey on Drug Abuse. Her research interests center on drug epidemiology, the drug-crime nexus, improving survey methodology, and comparative international research on drug use. She has numerous publications in these areas.

    James A. Inciardi, PhD, is Director of the Center for Drug and Alcohol Studies at the University of Delaware; Professor in the Department of Sociology and Criminal Justice at Delaware; Adjunct Professor in the Department of Epidemiology and Public Health at the University of Miami School of Medicine; Distinguished Professor in the Núcleo de Estudos e Pesquisas em Atençao ao Uso de Drogas at the State University of Rio de Janeiro; and Guest Professor in the Department of Psychiatry at the Federal University of Rio Grande do Sul in Porto Alegre, Brazil. He received his PhD in sociology at New York University and has a background in law enforcement, corrections, drug abuse treatment, and research. He is currently involved in a number of harm reduction projects, including the development and evaluation of prison-based treatment programs for drug-involved offenders and HIV prevention/intervention research in several parts of Brazil. Moreover, he is the author of 45 books and more than 225 articles and chapters in the areas of substance abuse, criminology, criminal justice, history, folklore, public policy, AIDS, medicine, and law, and he has extensive research, clinical, field, and teaching experience in both substance abuse and criminal justice.

    Katherine Irwin is a doctoral student in sociology at the University of Colorado, Boulder. Her related interests include deviance, criminology, qualitative methods, and gender.

    Jim Kahn, MD, MPH, is Associate Adjunct Professor of Health Policy and Epidemiology at the Institute for Health Policy Studies, University of California, San Francisco. He has extensively studied the effectiveness and cost-effectiveness of HIV prevention in injecting drug users (IDUs), including treatment of drug dependence, needle exchange, HIV counseling and testing, extended counseling, and street outreach. He is currently participating in a team modeling the effectiveness and cost-effectiveness of individual and group interventions to prevent HIV infection in IDUs. He is also a co-investigator responsible for similar analyses in two program evaluations of HIV prevention efforts in IDUs (needle exchange in San Jose, California, and multipronged HIV prevention in Sacramento, California). In addition, he is developing a testing method to do economic evaluation of treatment on behavioral and economic effects of the withdrawal of SSI benefits from injecting drug users, which occurred on January 1, 1997.

    Dirk J. Korf (MA in child psychology, PhD in criminology) is Associate Professor at the Bonger Institute of Criminology at the University of Amsterdam. Formerly, he has been an outreach worker and director of a drug service. He has done extensive research on deviance, drug use, and drug trade in particular, in the Netherlands as well as in other countries. He is Chair of the European Society of Social Drug Research (ESSD) and associate editor of the Journal of Drug Issues (JDI).

    Sandra D. Lane, PhD, MPH, RN, is a behavioral scientist at the Onondaga County Health Department in Syracuse, New York; Project Director of the Syracuse Healthy Start Project; and Research Associate in the Department of Anthropology at Syracuse University. She received her doctorate in medical anthropology from the University of California, San Francisco and Berkeley, and her MPH in epidemiology from the University of California at Berkeley. She was the Ford Foundation Program Officer for Reproductive Health for the Middle East (1988–1992) and served as a member of the World Health Organization's Steering Committee on Operational Research (1992–1995). Her research interests include health policy, bioethics, and reproductive health. She has conducted research in rural and urban Egypt, Liberia, the United States, and Canada.

    Peter Lurie, MD, MPH, is a Medical Researcher at Public Citizen's Health Research Group in Washington, D.C. After obtaining his medical degree from Albert Einstein College of Medicine, he completed residencies in family practice at the University of California, San Francisco and in preventive medicine at the University of California, Berkeley, where he also obtained an MPH. He was the principal investigator of a major study of needle exchange programs for the Centers for Disease Control and Prevention and continues to evaluate interventions for injection drugs users in the United States and Brazil. He has written on the subject of needle exchange for a number of medical journals, as well as for lay publications. He has also been involved in a number of HIV epidemiology studies in Africa, Asia, and Brazil. Through his association with Public Citizen's Health Research Group, a Ralph Nader-founded advocacy group in Washington, D.C., he conducts advocacy in occupational health, pharmaceutical policy, and research ethics.

    Toni Makkai, PhD, has recently taken up an appointment at the Australian Institute of Criminology in Canberra, Australia. Prior to this, she was Senior Lecturer in sociology at the University of Salford, Manchester, England. Her publications are on public opinion, drug policy, patterns of drug use, compliance, and regulation. Her most recent publications include Marijuana in Australia: Patterns and Attitudes (1997) with Ian McAllister, and Drugs in Australia: Patterns of Use and Policy Options (in press), also with Ian McAllister.

    Pat O'Hare is Founder and Executive Director of the International Harm Reduction Association, editor of the International Journal of Drug Policy, and Executive Director of the annual International Conference on the Reduction of Drug Related Harm (since 1990). He was Director of the Mersey Drug Training and Information Centre in Liverpool from 1988 until 1993 and Drug Policy Advisor to the Mersey Regional Health Authority in the UK, and he worked with the Regional Health Policy Unit in formulating policy. He is co-editor of three books on the reduction of drug-related harm and has written on many aspects of the phenomenon of drug use, including HIV prevention, education, and drug policy. He has been invited to speak on the subject at international conferences and seminaries in many countries, including Australia, the United States, Canada, Italy, France, Belgium, Germany, Spain, Poland, and the Netherlands.

    Diane Riley, PhD, is a policy analyst with the Canadian Foundation for Drug Policy and Assistant Professor of Medicine, Faculty of Medicine, University of Toronto. She has studied the socio- and biobehavioral effects of drug use for more than 20 years, working in Australia, Canada, England, Papua New Guinea, and Sweden. She conducted treatment research at the Addiction Research Foundation and worked with community groups to establish the first bleach kit program and first syringe exchanges in Toronto. She is a founding member of the Canadian Foundation on Drug Policy and the International Harm Reduction Association, and a member of the Board of Directors of the Canadian HIV/AIDS Legal Network. Her publications are in the areas of drug treatment and policy, AIDS, harm reduction, learning theory, and psychophysiology.

    Marsha Rosenbaum, PhD, is a sociologist and director of the San Francisco office of the Lindesmith Center, a drug policy institute. Since 1977, she has been the principal investigator on 10 grants funded by the National Institute on Drug Abuse and completed studies of women heroin addicts, methadone maintenance treatment and policy, MDMA (Ecstasy), cocaine, and drug use during pregnancy. She is the author of Women on Heroin; Just Say What? An Alternative View on Solving America's Drug Problem; Pursuit of Ecstasy: The MDMA Experience (with Jerome E. Beck); Kids, Drugs and Drug Education: A Harm Reduction Approach; Pregnant Women on Drugs: Combating Stereotypes and Stigma (with Sheigla Murphy); and numerous scholarly articles about drug use, addiction, women, treatment, and drug policy. As director of the San Francisco office of The Lindesmith Center, she sponsors educational seminars, publishes, speaks, and disseminates information about drug policy. She works with the San Francisco district attorney as well as the Department of Public Health on the implementation of a harm reduction approach to criminal justice and drug treatment. She serves on the boards of the Jewish Community Center of San Francisco, the Harm Reduction Coalition, Family Watch, and Humanistic Alternatives to Addiction Research and Treatment.

    Hilary L. Surratt, MA, is an Associate Scientist in the Center for Drug and Alcohol Studies at the University of Delaware; Project Director of an HIV/AIDS seroprevalence and prevention study in Rio de Janeiro, Brazil; and Project Director of a female condom multisite study. Both projects are funded by the National Institute on Drug Abuse. She received her MA from the University of Florida and has numerous publications in the areas of AIDS, substance abuse, and drug policy.

    Paulo R. Telles, MD, MPH, is a researcher and psychiatrist in the Núcleo de Estudos e Pesquisas em Atençao ao Uso de Drogas at the State University of Rio de Janeiro. His work includes a variety of HIV epidemiologic and prevention studies, and currently he is the director of a needle exchange program in Rio de Janeiro.


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