This is a welcome and timely review of the policy and practice of harm reduction, particularly for UK policy makers and practitioners working with people with drug misuse, who are being encouraged to embrace the concept of ‘recovery’. Characteristically for addiction, a polarised debate is raging. In one corner there are those who believe that harm reduction, underpinned by opiate replacement therapy, simply perpetuates dependence and is a barrier to living a healthy and rewarding life, whereas abstinence from all drugs, both medicinal and non-medicinal, is the only valid measure of recovery. Russell Brand has been a recent vociferous champion of this view. Others have argued that harm reduction and recovery are not mutually exclusive concepts.
The editors have recruited a broad church of authors from many parts of the world - policy makers, academics, clinicians, educators, policemen, philanthropists and service users. It is refreshing and enriching to the field to have such an eclectic mix of contributions. At almost 500 pages, the book is a substantial tome, but it is easy to dip in and out of and never turgid.
The first section sets the scene with a historical overview of harm reduction and how it has been conceptualised around the world. There is a good account of the guiding principles of education, which underpins so much of the effectiveness of harm reduction, and how it differs from propaganda.
The next section focuses on international policy institutions, policy initiatives in the police service and in prisons, and the failure of the securitising approach in global drug control. There are some interesting contributions from advocates of drug use and ethicists who discuss harm reduction in the context of balancing benefits to the individual and society.
Section three describes specific harm reduction interventions across the main classes of addictive drugs, including alcohol and tobacco. The chapter on problematic compulsive behaviours focuses on gambling, which is now recognised as an addictive disorder in DSM-5.
Complications from injecting and the role of needle exchanges in harm reduction are highlighted. Supervised injecting facilities merited greater discussion in view of the current interest in the expansion of these services, particularly in the UK. I was disappointed that the chapter on stimulant use made no mention of contingency management, for which there is an increasingly robust evidence base. The chapter on reconciling harm reduction with recovery is helpful for those caught in the headlights of this hot topic.
The final section takes the reader around the world (although there is no mention of China) and it is clear the UK is punching above its weight. The reluctance to let go of the prohibitionist model by politicians in North America is particularly apparent.
The multi-authorship brings with it considerable strengths, but some lack of harmony as well. For example, the chapter on cannabis discusses the psychopharmacological changes in dependence in great detail, but leaves the question of how to beat cannabis addiction in the air. There are no analogous accounts of the effects of opiate and alcohol addiction on the brain elsewhere in the book, which is a shame, because this awareness is critical to understanding the biological basis of both the compulsion to use drugs and relapse. Too often in addiction the profound effects of drug use on the brain are ill understood, and addictive drug use is simplistically conceptualised as a ‘lifestyle choice’.
The authors all have one thing in common. They bring an informed, thoughtful, compassionate, sometimes championing approach to the role of harm reduction interventions in improving the lives of people with substance misuse. It would have been interesting to give the abstentionist lobby the right of reply.
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