Community harm reduction initiatives: Essential investments for illicit drug prevention and control in the future

Harm reduction is an approach that reduces the negative consequences of health behaviours without necessarily eliminating them. It is generally accepted that the first harm reduction model emerged in the 1970s and 1980s as a response to infectious diseases such as HIV and hepatitis B. Benefits of harm reduction programs have been recognised widely since the 1990s with the emergence of methadone and other maintenance drugs.¹ Popular harm reduction programs include needle and syringe exchange, targeted and low-threshold primary health care counselling, supervised injection sites, opioid replacement therapy, naloxone distribution, drug checking for content and purity, and psychosocial support. They have shown sustainability and cost-effectiveness to reduce drug use and related harms and improve treatment engagement of people who use drugs.² Despite these advantages, many health providers who strive to improve patients' health behaviour do not formally incorporate harm reduction into their daily routines.³

While harm reduction has been identified as one of the pillars of drug prevention and control, too many obstacles still exist to make it a viable approach. Firstly, a growing number of new drugs has appeared on the market, and especially synthetic drugs have become a significant concern for many countries.⁴ For example, synthetic drugs account for 80% of drug use in Southeast Asian countries.⁵ The application of a single harm reduction intervention, such as methadone or other maintenance therapies, is reported to be significantly less effective against synthetic drugs.^6,7 Secondly, in response to the threat of social and political instability caused by synthetic drugs, many countries have tightened their arrest policies and mandatory treatment for users. Nevertheless, evidence suggests that compulsory treatment do not have a long-term effect in reducing drug misuse, meaning that the relapse rate is still high after the treatment period.⁸ Despite the apparent limitations of the law enforcement approach, many countries embrace it. As a result, people who uphold harm reduction solutions face the challenge of adapting to the contemporary context in which synthetic drugs are prevalent and advocating for the removal of law enforcement policy in many countries. Furthermore, there is a lack of scientific evidence about the effectiveness of community-based interventions for determining a different approach to new types of illicit drugs.

Harm reduction initiatives should be encouraged to develop a new sustainable approach to the problem of synthetic drugs. A recent overview of systematic reviews reveals a rapid increase in systematic reviews about the effectiveness of psychosocial interventions, but also a relatively low number of primary experimental studies supporting the results of those systematic reviews.⁹ The finding indicates enormous challenges in implementing community-based interventions, even for developed countries. In addition, many individuals using synthetic drugs deny that they suffer from a drug problem and do not seek treatment.

In the Lancet Regional Health - Western Pacific newly issue, Michel and colleagues provide harm reduction evidence from a community-based project that supports people who inject drugs with mental disorders in Hai Phong, Vietnam (the DRIVE project).¹⁰ According to the article, there is a high prevalence of mental disorders among people who inject drugs in Vietnam, and peer support is crucial to improving mental health and reducing substance use disorders. The DRIVE initiative utilises community-based organisations (CBOs) for psychological screening and support. The project team engaged peer members from different CBOs and connected them with psychiatrists to detect and treat patients with mental disorders. The unique aspect of this program is that peer advocates identified cases in the community and helped provide psychiatric care to people with substance use disorders outside of hospital settings. According to Michel and the team, people who inject drugs and receive community psychiatric care show considerable improvements in their mental illnesses. Over a one-year follow-up period, the rates of depression, psychotic disorder, and suicide risks reduced significantly from 80.6%, 44.7%, 42.4% to 15.9%, 21.8%, and 22.9%, respectively.¹⁰ This project has proven feasible through improving the mental health of people who use drugs and leveraging the human resources of CBOs.

Although this study shows a significant improvement in measured outcomes, the authors also point out several limitations, including its lack of a control group, possible measurement bias, and research outcomes being evaluated by people who performed the intervention. However, this study still provides valuable lessons for future community health interventions, for instance, how this study was conducted and how to strengthen the activities of CBOs and assist peers in becoming service providers. In the future, similar harm reduction interventions using the peer support approach may be analysed in greater detail to determine the effectiveness of this model and improve its quality.

The study also suggests that a single harm reduction intervention will not effectively assist people who use drugs. Instead, there needs to be informed coordination among related stakeholders for a comprehensive, structured design of mixed actions. Interventions should cover multiple dimensions, including psychiatric interventions, case management, administrative support, medication, counselling, linkages to clinical clinics, and other referrals. Other activities should also be implemented to educate the public and create a more supportive environment for drug users to integrate into society. Therefore, the harm reduction approach to drug use requires more investment and support from Governments and policymakers rather than focusing on punitive law enforcement.

Declaration of interests

The authors declared no competing interests.