Adam Prokopowicz
Reduction of harm associated with psychoactive substance use
Redukcja szkód związana z przyjmowaniem substancji psychoaktywnych
Zakład Szkodliwości Chemicznych i Toksykologii Genetycznej, Instytut Medycyny Pracy i Zdrowia Środowiskowego w Sosnowcu
Streszczenie
Uzależnienie od substancji psychoaktywnych jest schorzeniem trudnym do leczenia, niosącym ogromne szkody dla organizmu i niepomyślne konsekwencje socjalne i ekonomiczne dla osób uzależnionych, ich rodzin i społeczeństwa, a terapia odwykowa jest często długotrwała i obarczona dużą liczbą niepowodzeń. Stąd też potrzeba podejmowania szerokich działań mających na celu zminimalizowanie niekorzystnych skutków przyjmowania substancji psychoaktywnych. Jednym z programów włączonych do strategii redukcji szkód jest terapia substytucyjna. Polega ona na zastępowaniu nielegalnego narkotyku substancją legalną o podobnym lub takim samym działaniu farmakologicznym, co ma miejsce w terapii uzależnień od narkotyków. Natomiast w nikotynizmie polega na przyjmowaniu tej samej substancji psychoaktywnej (nikotyny), pozbawionej większości innych substancji toksycznych znajdujących się dymie tytoniowym. Wprowadzenie na rynek konsumencki alternatywnych form dostarczania nikotyny (elektroniczne papierosy, bezdymne wyroby tytoniowe) na nowo wywołało kontrowersje na temat efektywności redukcji szkód opartej na zastąpieniu tradycyjnych wyrobów tytoniowych produktami o zmniejszonej emisji substancji toksycznych, jednak w dalszym ciągu dostarczających nikotynę. Zdaniem przeciwników leczenia substytucyjnego, uniemożliwia ono osiągnięcie abstynencji dającej możliwość pełnego wyeliminowania szkód generowanych przez przyjmowanie substancji psychoaktywnych. Znalezienie wspólnej płaszczyzny pomiędzy zwolennikami redukcji szkód i zwolennikami terapii ukierunkowanej na całkowitą abstynencję odbyłoby się z korzyścią dla osób uzależnionych.
Summary
Psychoactive substance addiction is difficult to treat, brings huge damage to the body and has negative social and economic consequences for the addicted, their families and society. Rehabilitation therapy is often long and has a high failure rate. For this reason, there is a need for extensive action to minimise the negative effects of psychoactive substance use. Substitution therapy is one of the programmes included in the harm reduction strategy. It involves the replacement of an illicit drug with a legal substance with similar or identical pharmacological effects and is applied in drug addiction therapy. In the case of nicotine addiction, substitution therapy involves taking the same psychoactive substance (nicotine) in a form which is devoid of the majority of other toxic substances that are found in tobacco smoke. The introduction of alternative forms of nicotine supply (electronic cigarettes, non-smoking tobacco products) have renewed the controversy around the topic of efficacy of harm reduction involving the replacement of traditional tobacco products with those with reduced emission of toxic substances, but which still deliver nicotine. According to the opponents of substitution therapy, it prevents one from achieving abstinence that allows for full elimination of harm generated by psychoactive substances. Finding a common platform between the proponents of harm reduction and advocates of complete abstinence-based therapy would be of benefit to the addicted individuals.
The term “harm reduction&rdquop; refers to any activity to minimise various types of damage and risks associated with risky behaviour. It therefore covers a number of areas of everyday life, but initially it was limited to the problem of illicit drug use in the literature. This was associated with the attempts to introduce methadone, a diphenylpropylamine derivative and an opioid receptor agonist, into the clinical practice in the sixties. At the time, in the United States heroin addiction was spreading rapidly, which resulted in an increase in the number of cases of lethal overdose and in the number of infectious diseases, particularly HIV, which was associated with injecting drugs. Over the next few decades a number of studies documenting the safety and efficacy of methadone therapy were published. Due to the strict adherence to the rules and norms in place in the USA at the time which did not allow such therapies, it was only 35 years later, in 1999, that the National Institute of Health published a report showing definite benefits associated with using methadone in heroin addiction therapy (1).
This was also a time of introducing needle and syringe exchange programmes aiming at reducing the health damage associated with intravenous drug use. Needle exchange programmes were intended to reduce the duration of injection equipment use and to minimise the need to borrow and exchange it between addicted individuals. The addicted individuals were also educated on safe injection practices and safer sexual behaviour as well as being informed about medical care options and drug rehabilitation.
The forms and methods of harm reduction have developed over the last few decades, but the essence of it has remained the same (2). At the beginning of the nineties of the last century harm reduction was defined as a philosophically and pragmatically developed strategy aiming at ensuring that the consequences of drug use were as safe as possible in a given situation. It included supplying information, sources, education and skills as well as modifying attitudes in order to minimise the negative consequences of drug use both for the users and society at large. In 1996 the Canadian Centre on Substance Abuse formulated five leading principles for harm reduction programmes (3). These include:
– pragmatism – the harm reduction strategy assumes that the use of some psychoactive substances is unavoidable (substitution therapy) and some level of use of such substances is a norm in society,
– focus on harmful consequences – the level of substance abuse is of lesser importance than the significance of its effects,
– humanistic values – the decision of a human being to use psychoactive substances is accepted as a fact, as an individual choice. No moralistic judgement is made and the dignity and rights of the person who uses drugs are respected,
– balancing expenditure and gains – pragmatic identification, measurement and estimation are performed of the consequences of psychoactive substance use, the associated damage as well as costs and gains resulting from the interventions applied. Based on this, priorities are established which take into account the interests of not only substance users but also those of wider community and society at large,
– hierarchy of goals – the majority of harm reduction programmes have a hierarchy of goals with a direct focus on the most urgent needs.
Based on this, Lenton and Single (4) suggested that a policy, programme or intervention can constitute harm reduction if:
– its fundamental aim is to reduce the harm associated with drug use than to reduce drug use as such,
– alongside strategies aimed at complete drug abstinence, the aim of harm reduction among those who have not ceased taking drugs is also included,
– strategies are able to demonstrate, based on the balance of probabilities, that net drug use harm reduction is possible.
The harm reduction strategies developed at the time were traditionally directed at drug users. For this reason, they often have been and still are considered to involve drugs only. However, the formal assumptions and proposed practical solutions of harm reduction can be directly applied to other addictions, including to anti-alcohol and anti-tobacco policy (5).
This is accommodated by the current definition of harm reduction whose scope has been extended to all psychoactive substances. According to the International Harm Reduction Association the term “harm reduction&rdquop; refers to strategies, programmes and practices which aim primarily at limiting health, social and economic consequences of using legal and illegal psychoactive substances without the need to limit their consumption (6).
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Piśmiennictwo
1. Kreek MJ: Methadone-related opioid agonist pharmacotherapy for heroin addiction. History, recent molecular and neurochemical research and future in mainstream medicine. Ann N Y Acad Sci 2000; 909: 186-216.
2. Gaś ZB: Redukcja szkód a profilaktyka uzależnień. Remedium 2002; VII-VIII: 32-33.
3. Beirness DJ, Jesseman R, Notarandrea R, Perron M: Harm Reduction: What’s in a Name? Canadian Centre on Substance Abuse 2008. http://www.ccdus.ca/Eng/Pages/default.aspxorward.
4. Lenton S, Single E: The definition of harm reduction. Drug Alcohol Rev 1998; 17(2): 213-219.
5. Jabłoński P: Filozofia redukcji szkód. Świat Problemów. Warszawa 2014; 5(256); http://www.swiatproblemow.pl/filozofia-redukcji-szkod/.
6. International Harm Reduction Association: What is harm reduction? https://www.hri.global/what-is-harm-reduction.
7. World Health Organization (WHO): Global health risks: mortality and burden of disease attributable to selected major risks. Genewa 2009.
8. Dubiel E: Strategia redukcji szkód w pracy z osobami uzależnionymi od narkotyków i alkoholu. Resocjalizacja Polska 2016; 11: 63-81.
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11. Special Eurobarometer 458: Attitudes of Europeans towards tobacco and electronic cigarettes. Report. DOI: 10.2875/804491. European Union, 2017 (http://ec.europa.eu/COMMFrontOffice/PublicOpinion).
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13. Benowitz NL, Hall SM, Herning RI et al.: Smokers of low-yield cigarettes do not consume less nicotine. N Engl J Med 1983; 309(3): 139-142.
14. Committee to Assess the Science Base for Tobacco Harm Reduction; Stratton K, Shetty P, Wallace R et al. (eds.): Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction. The National Academies of Sciences, Engineering, Medicine 2001.
15. Hunt N, Ashton M, Lenton S et al.: A review of the evidence-base for harm reduction approaches to drug use. Forward Thinking on Drugs a Release Initiative, 2002. http://www.forward-thinking-on-drugs.org/review2-print.html.
16. Fairchild AL, Lee JS, Bayer R, Curran J: E-Cigarettes and the Harm-Reduction Continuum. N Engl J Med 2018; 378(3): 216-219.
