The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke
Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?