Harm Reduction Journal - Latest Comments

Perspective on current situation regarding drug treatment in Cambodia

Mark Elliot Barrett — 2012-06-20T12:04:39Z

I should mention that I participated in the project that is the subject of this article as the research consultant who did the commune survey analysis and report write-up (referenced below).

The H-83 project did take many twists and turns from its original conception as an attempt to introduce evidence-based drug treatment services in Cambodia, which really had nothing at the time. The authors are right in that an opportunity was missed in providing a model that could have been used to provide an alternative to the "boot camp" type programs run by military and police. UNODC has recently began to introduce a TREATNET community-based model with linkages to the public health centres and hospitals. However, H-83 did not really provide much o.f a foundation for the new initiative (at least based on an assessment I led in Banteay Meanchey, the first site to begin the TREATNET approach). There was little indication of any on-going work at the time of the TREATNET assessment (Sep 2010), probably due to the cessation of any continuing project inputs or support.

The figure of 500 USD provided to each CCT member was incorrect-- that may have referred to the entire team budget for one year. Budget provisions for the provincial teams were minimal in comparison to the tota budgetl. Also, it is often the case that when funding for projects such as this ceases most or all project activity also ceases.

The problem of alcohol use was not really addressed; but alcohol and tobacco are probably the cause of many more serious health problems than illicit drug use in Cambodia. These were given an almost equal focus in the initial survey, Interesting alcohol is a problem that public health facilites are mandated to work with; whereas drug cases are usually referred to the compulsory drug treatment centres. Thus, another opportunity to get a foothold for substance abuse treatment by starting with alcohol abuse and dependent clients was missed here.

A substantial number of drug users are being helped by Harm Reduction programs (such as Mith Samlanh, as mentioned, or Korsang, Seado, and others which were not mentioned), There are also shelters and special NGO programs that cater to many at-risk populations.

While the title suggested something about a "low cost drug treatment system for Cambodia" , the authors provide only a vague reference to informal activities that may or may not have occured on any kind of regular basis. There is no description of what kind or quality of services these persons actually received (even a short case study or two would have helped here). About the only thing that we can probably agree on is that it was definitely "low cost" and may (or may not) have helped in diverting drug users away from the compulsory centers, although, there was no real evidence provided for this claim. I would also agree that this project may have been helpful in identifying a cadre of persons who gained knowledge regarding drug prevention and treatment, as well as HIV and other associated problems. However, without an ongoing mechanism these networks have probably mostly disbanded by now.

I would refer the reader to the h-83 Survey for more detiail (both quantitative and qualitative descriptions of a fairly large sample of drug and alcohol users). I thought this might have deserved mention as an accomplisment of the project, but it was only briefly mentioned in the introduction.) The reference is posted below, and I would be happy to send the PDF version to anyone upon request (at the email given : mebarrett@yahoo.com.

Barrett, M.E. (2008, May). H-83 Baseline Behavioral Survey in 60 Badly Affected Communes in Cambodia. Pnom Penh: UNODC.

Other considerations...

Dan Bigg — 2012-01-05T01:38:29Z

While the dangers of tobacco abuse are well known I am left wondering if the reduced harm apparent from the Narghile smoking is created through its lower frequency of use, dose and social surroundings.

The authors quote "one can not consider NS as a "safer" alternative to cigarettes when discussing the important issues of young age and female gender" is not entirely clear to me but seems to suggest a 'no use only' approach which misses the mark.

Safer Hookah use seems possible in some ways mentioned here as well as with electronic ignition, well-ventilated rooms, reducing or stopping while pregnant, etc.

As a long-time advocate for 'smoking or health' I have been there before but as a harm reductionist now I feel much of the safer health aspects of this form of tobacco consumption have been under-appreciated in this article.

If Nafghile use leads to less harm it should be valued in this way for those who choose to smoke, or even as a model for safer drug ingestion of any kind.

Great website about this issue is at

http://www.sacrednarghile.com

Leukoencephalopathy associated with heroin inhalation: a proxy for bad drug policy

Jean-Paul Grund — 2011-03-16T08:57:01Z

Dear Editor,

Although smoking heroin is a much less hazardous mode of administration than injecting this (or any other) drug, it is clearly not without risks. While HIV or overdose are uncommon among heroin chasers, in particular long term chasers are at great risk of pulmonary and cardiovascular damage. Leukoencephalopathy associated with chasing heroin is rare, but with great consequences. When carefully administered, unadulterated opioids themselves cause little harm to the human body. Indeed, with the exception of incidental overdoses and seizures (that were neither fatal nor caused irreversibe damage, due to the medical supervision), no major health concequences have been reported from the use of prescribed pharmaceutical grade heroin in Heroin Assisted Treatment (HAT) in for example The Netherlands, Switzerland, Germany or Canada, whether injected or smoked (chasing the dragon). Furthermore, all of these countries reported clinically relevant improvements in physical and mental health, as well as in social functioning and (reduced) illicit drug use among those in HAT (Blanken, 2011).

This paper brings home the message of the pernicious role of drug prohibition. Within illegal, unregulated markets any combination of substances may be sold as heroin. The present (global) drug control regime results in a complete absence of control over what people put into their bodies. What is often called drug related harm is, in fact, drug policy related harm.

I noticed two small errors in the paper, both on P4:

"According to a recent report from the UN Office of the Drug Commission, 96% of heroin seizures (2002-2007) in the US originated from Mexico and Columbia..." This should be the UN Office of Drug Control;

"However , heroin used for smoking is usually 30% to 40% pure as higher grade cuts char too quickly for effective smoking." I assume this should read higher grade drugs.

Reference: Blanken P. (2011) Heroin-assisted treatment. From efficacy to effectiveness and long-term outcome. Amsterdam, University of Amsterdam (http://dare.uva.nl/record/369330).

Keep up the good work

brett davis best — 2010-09-01T22:32:24Z

I would like to say that in my opinion also my hands on experience that Harm reduction is by far the greatest positive factor for the decrease of Hiv/Hep-c in the downtown eastside.Vancouver Coastal Health must continue to fund the these needle exchange programs.A greater focus must be put on arranging needle programs in other parts of the greater Vancouver area!!

Correction by the author

Carl Phillips — 2010-07-03T12:57:18Z

It has been called to my attention that one of my conclusions does not match the calculation that is presented. In particular, the statement in the abstract, “for the average smoker, smoking for just one more month before quitting causes greater health risk than switching to a low-risk nicotine source” should read either “for a smoker who is doomed to die from smoking if he does not quit, smoking for just one more month….” or “for the average smoker, smoking for just a few more months….”. The latter is probably better as the take-away message from the analysis.

The explanation is that I ran two different calculations when carrying out this analysis, one for the average smoker and one for those smokers who are doomed to die from smoking if they do not quit. The advantage of looking at the former is that it describes an identifiable characteristic; the advantage of the latter is that it distills the analysis to those smokers we are most concerned about. Obviously the average smoker is at less risk from smoking another month than the doomed-but-for-quitting smoker, since the population of non-doomed smokers dilutes the average risk (by a factor of 2, 2.5, 3, or whatever the reciprocal of one’s estimate of the proportion of lifetime smokers who die from their habit). In the published version of the paper I ended up including only the calculation for the doomed smokers, but erred by describing it as applying to the average smoker.

Had I observed such a switch in an analysis that was intended to attack tobacco harm reduction (THR), or something similar in an empirical study to spin it as anti-THR, I would have characterized it as certainly misleading and probably dishonest. I hope I can avoid the latter accusation for the following reasons: (a) I am highlighting the error and voluntarily running this correction with contrition (I do not recall anti-THR activists ever doing such a thing despite the enormous flaws that have been identified in some of their articles); and (b) When I have previously cited my results, including in a press release about the article, I believe I always described the break-even point as “a few months” or something similar, the accurate result I had in my head but did not correctly put on paper (which contrasts with anti-THR activists who often make claims to the public that are far stronger than what their studies support).

Frankly, I doubt the quantitative error really matters to anyone. It should not. Is anyone really going to think “you had me sold on promoting THR when you said that smoking for only one more month is just as bad as a lifetime of a low-risk alternative, but if it is two or three months then forget it – let them keep smoking”? This makes it no less an error, but it means that it changes nothing about the practical implications of the paper.

Always the teacher and social scientist, I cannot resist drawing two interesting conclusions from this error. I wish I could say that I planted it as an Easter Egg to teach these lessons, but I might as well take advantage of it anyway.

First, this is a great reminder that the status “peer-reviewed publication” is far from sufficient to conclude that something is correct. A version of this paper that included the error was read and checked many times over many months before being published (of course, I do not blame referees or anyone else who reviewed this for my error). We can only guess how often there are comparable errors in the health science papers where it is impossible for peer reviewers, editors, or readers to check the authors’ work (the 99% of papers where, unlike this one, the authors do not report enough information to assess the accuracy of the conclusions). Moreover, when confidence intervals or other error statistics are reported (which would have been completely inappropriate for something like this, but is disturbingly common in other cases where it is equally inappropriate), they are based on countless assumptions, many of which are false (e.g., the assumption the author did not switch what he was calculating in the middle of reporting his results). This illustrates how such statistics typically serve to obscure the most important sources of uncertainty, giving a false sense of accuracy to non-expert readers by pretending to quantify the potential inaccuracy.

Second, the paper was in a journal (free online) for half a year before anyone pointed it out the problem. While it may seem nice to be able to “get away with it” for that long, the broader implications are disturbing. This correction to an overly-strong pro-THR claim did not come from one of the tens-of-thousands of people whose job descriptions (self-determined or institutionally defined) include advocating against THR. (It was discovered by Peter Lee, who, while not an activist, conducts analyses that have strongly supported the case for THR and was in the process of contributing to our THR yearbook.) No one took advantage of the opportunity to catch the error and use it to undermine the analysis. Since the article is quite damning to both the ethics and quantitative health claims of anti-THR activism, why might the anti-THR activists not care to read it carefully enough to find the error? It would be too glib to suggest that none of them can do the math – it is actually pretty easy and was all laid out for the reader. The only apparent explanation that is also consistent with other evidence is that the anti-tobacco extremists have decided that getting what they want is purely a matter of exercising their immense wealth and political power (a not unreasonable expectation). It is not merely that they adopted a worldview that is something like a religion, and thus no mere scientific argument could ever change their views. (Why bother to read scientific or ethical analysis when you do not care whether you are wrong by either of these standards?) It is that they are completely uninterested in ethical or scientific analyses – whether it be criticizing mine or presenting their own – because they expect to get what they want through the exercise of pure power, and so figure it really makes no difference that the legitimate arguments are arrayed against them.

About our work

larry pasco — 2010-07-03T12:55:09Z

We in Indiana have always done distribution rather then exchange it much easier , it has caused us some problems with some in the community, but we also provide sharps to users, so for us we direct the states's largest Harm Reduction organization and the largest network of peer to peer exchangers and for 17yrs it has worked.when we did do street exchage it we had so many problems but since allowing users to take care of their needs it is working.It might not be right for all projects .

Author of this article has moved to a new Institution

David Thaler — 2009-08-16T18:38:15Z

I am the author of this article and have recently moved.
My new contact mail address and email are:

David Thaler
Price Genetic and Translational Research Center Room 550
Howard Hughes Medical Institute
Albert Einstein College of Medicine
1301 Morris Park Ave
Bronx, NY 10461

new email: dthaler@aecom.yu.edu

Which vaporizer was used for the studies?

Taylor Murray — 2009-07-18T14:32:02Z

I couldn't seem to find any information in this article that describes which vaporizer in particular was used for these studies. I believe this is an important factor, because different vaporizers will produce different results. This question is being addressed in vaporizer articles from a large vaporizer store.

Validating findings of qualitative and quantitative research

Arshad Altaf — 2009-07-07T14:12:21Z

Naeem Hasan Saleem, Arshad Altaf

In reference to the article published in June 2009 issue of HRJ by Adnan A Khan and colleagues titled “Large sharing networks and unusual injection practices explain the rapid rise in HIV among IDUs in Sargodha, Pakistan” we would like to bring to your attention and readers certain issues that we believe are pertinent to qualitative research particularly focus group discussions. The authors state that 150 IDUs were interviewed in four focus group discussion (FGD) and 30 out reach workers in another focus group discussion. This is a major methodological flaw of conducting an FGD. While this process provides rich information due to flexibilities in the method however, having about 38 persons in one FGD does not seem right. Methodological issues of FGD were discussed in a review in 2004 by McLafferty (1). The article states that experiences of conducting focus group interviews demonstrated that smaller groups were more manageable. In a different study in Nigeria FGD (2) were conducted to improve condom negotiating skills among women and the number of participants in each FGD was 8-10. The authors also mention in the method that IDUs moved freely during the discussion, which also seem like a distraction and more importantly whether the discussion was tape recorded or how the notes were taken is not stated at all. It is also not clear how the consent was obtained and whether the study was ethically reviewed.

In the results it is mentioned that used syringes cost about the same as new one is incomprehensible simply because it is not possible that an old syringe can cost like a new one.

We conducted integrated behavioral and biological surveillance along with geographic mapping during 2006-07 (3). We recruited four hundred IDUs from the population of 2,450 by deploying probability sampling. Our findings were contrary to author’s observation to which he acknowledges at the later part of discussion. Our field experience indicates that in the medium size town of Sargodha IDUs are widely found except in cantonment area. They have satellite shooting sites which are away from main dwelling, situated where heroin is easily available and law enforcement is rarely operational. These lively sites among fields are managed by drug peddlers and are venues of their sale. Any sample from these sites does not reflect the overall situation within the city. Our findings indicate that mean age of IDUs is 31.6 years and they inject on average for the last four years contrary to author’s two years. Almost half of them are married and the same number is illiterate as well. Mean number of per day injection is 2.8 + 1.6, and 39.4% of sampled required services of professional injector (PI). PI are generally hired because of in-accessibility of veins and advanced thrombophlebitis leading to hardening of vessel. We found that the high frequency of daily injections i.e., >4 times to be 38.2% in sample of four hundred. However, this is exceptionally high compared to other four cities sampled within the province.

Our data indicate that only 2.5% were injecting 6-7 injections daily. Though high cost of these daily injections (Rs 60*30 days= Rs 1,800/- or USD 22.5) is less affordable for the average income of Rs 2,800 i.e., USD 35. Present findings are less suggestive of actual high rise of HIV as we don’t have base line HIV prevalence data. However, it may explain the local situation in small community where main injection behavior of “double pump” can be blamed even though it is performed during normal injection to ensure that needle is in the vein. Undoubtedly, reuse of “scale” even in the chance of ABO incompatibility, exposed to dry and hot conditions can lead to rapid spread of HIV among its beneficiaries. Despite this explanation in our opinion there are multiple causes of rapid rise. A more detailed operational research with proper methodology shall provide more insight to the milieu of Sargodha. We also enforce that main thrust of service delivery in such setting remain consistent supply of syringes, increased quota for frequent injectors, rapid collection of used syringes and strong BCC messages for IDUs.

References
1.McLafferty I. Focus group interviews as a data collecting strategy. J Adv Nurs. 2004 Oct;48(2):187-94
2.Mccallister S. Focus group discussions -- a tool for learning and organizing. Hesperian Found News. 1998 Summer:4-5.
3.Punjab AIDS Control Program & Canada-Pakistan HIV/AIDS Surveillance Project (HASP), HIV Second Generation Surveillance in Pakistan, Provincial Report Round II, 2006-07, p 36.

Prohibition of Qat (Khat) Chewing and Tobacco Smoking Does Not Work. Harm Reduction and Consistent Drug Education Do

Kamal Chaouachi — 2009-06-25T02:35:29Z

Thanks to the Harm Reduction Journal for publishing this very interesting article on Qat (Khat) by Dr Hussein Ageely [1]. The reader may regret however that the author have not sufficiently underscored the importance of the sociologic and anthropologic context of Qat (Khat) use. For instance, 10 years ago, a retired professor of chemical pathology concluded the narration of his own participating experience in a Qat party with these words:

“Every society has its own forms of chemical escape”[2].

Also, unlike most authors, Dr Ageely did not apparently deem relevant to mention the co-occuring use of one of the different local water pipes during the Qat parties. This tall pipe is called Mada'a (whereas it is named Argeely in Lebanon, Palestine, Syria and Jordan). The Mada’a is used with plain tobacco -and perhaps now the mellow Shisha, a newcomer to Yemen, with its numerous and powerful flavours – is indeed a key element during the long ritual Qat parties of each afternoon [3].

Medical anthropologists have rebutted most of the allegations regarding the direct effects of Qat use on health by Western visitors to Yemen. They concluded that while “[Qat] cannot be completely discounted as a health threat, yet […] the majority view of the Yemenis is most plausible, particularly since most of the people are moderate or light users: the most harmful effects of Qat are probably in the realm of economics rather than in the realm of health"[4].

Drug education is undoubtedly very important and Dr Ageely is right to suggest awareness raising among students through television and religious programmes [1]. However, the “prohibition of cultivation of khat” and the “destruction of khat trees and ban imports of khat from Yemen” might be steps that would jeopardise the social cohesion of an entire region already affected by more serious problems.

Consequently, instead of considering prohibition as the unique alternative, why not contemplate and put forward harm reduction techniques just as those emerging in the field of tobacco smoking ? Indeed, the prohibition of drugs, and tobacco in particular, has never worked [5], does not work and coercion often ends up in human and public health catastrophes [5][6[7]. A long series of articles in the Harm Reduction Journal shows this.

A good example is smokeless tobacco of the Swedish SNUS type. Indeed, tobacco chewing is particularly hazardous if one uses low quality products such as those widely available in Asia and Africa. Dr Ageely probably knows a similar product called Shamma in the Middle East. However, comparative studies on smokeless tobaccos have shown that SNUS is much more safer [8].

Millions of lives could be saved in these parts of the world and a recent study published in the Harm Reduction Journal suggested that it could be an alternative to heavy hookah smokers [9]. However, smokeless tobacco of the Swedish SNUS type has a universal ambition and can be an efficient alternative to tobacco smoking among US-Americans as well [10].

Consequently, why not envisage for Qat users who do not want to quit a small bag -of, either concentrated qat juice or raw leaves- that they would place inside their mouth just as SNUS tobacco users do ? Within such a conceptual framework, the promotion of such a harm reduction alternative should normally be the mission of an agency like the WHO (World Health Organisation). Unfortunately, for its experts, all smokeless products are “deadly” [9].

Against this gloomy background, and instead of blindly importing from the West public health and prevention models more or less based on prohibition, a more socially and culturally adapted policy could be implemented. It would rely on the local creativity of local scientists in Asia and Africa, who, for the great majority of them, have been working independently from the direct or indirect influence of pharmaceutical companies and other transnational interests. Furthermore, from a geopolitical and health viewpoint, the Qat issue is amazingly similar to that of the coca leaf, isn’t it ? United Nations bodies and agencies such as the INCB (International Narcotics Control Board) or the WHO, are known to have erred more than once and produced and disseminated highly controversial recommendations and reports [11][12][13][14].

Dr Ageely is kindly invited to forward this proposal to the officials of the Kingdom of Saudi Arabia and its scientific community.

Kamal Chaouachi

__________________

REFERENCES:

[1] Ageely HM. Prevalence of khat chewing in students of Jazan region. Harm Reduct J 2009, 6:11 (20 June 2009)

http://www.harmreductionjournal.com/content/6/1/11

[2] Baron DN, The qat party. BMJ. 1999 Aug 21;319(7208):500.

[3] Chaouachi K. Qat chewing and water pipe (mada'a) smoking in Yemen: a necessary clarification when studying health effects on oral mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104: 731-733.

[4] Kennedy JG, Teague J, Rokaw W, Cooney E. A medical evaluation of the use of qat in North Yemen. Soc Sci Med. 1983;17(12):783-93.

[5] Marks J. Drug Misuse and Social Cost. Br J Hosp Med. 1994 Jul 13-Aug 16;52(2-3):65, 67.

[6] Snowdon C: Velvet Glove, Iron Fist. United Kingdom, Little Dice, 2009, 415 pages.

http://www.velvetgloveironfist.com/

[7] Chaouachi K. Harm reduction techniques for hookah (shisha, narghile, “water pipe”) smoking of tobacco based products. Medical Hypotheses 2009 [in press]

[8] Ibrahim SO, Vasstrand EN, Johannessen AC, Lillehaug JR, Magnusson B, Wallström M, Hirsch JM, Nilsen R: The Swedish snus and the Sudanese toombak: are they different? Oral Oncol. 1998 Nov;34(6):558-566.

[9] Sajid KM, Chaouachi K, Mahmood R. Hookah smoking and cancer. Carcinoembryonic Antigen (CEA) levels in exclusive/ever hookah smokers. Harm Reduct J 2008 24 May;5(19)

http://www.harmreductionjournal.com/content/5/1/19

[10] Rodu B, Phillips CV. Harm Reduct J. 2008 May 23;5:18. Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey.

http://www.harmreductionjournal.com/content/5/1/18

[11] Oxman AD, Lavis JN, Fretheim A. Use of evidence in WHO recommendations. Lancet. 2007 Jun 2;369(9576):1883-9.

[12] Chaouachi K. A Critique of the WHO's TobReg "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators. Journal of Negative Results in Biomedicine 2006 (17 Nov); 5:17.

http://www.jnrbm.com/content/5/1/17

[13] Small D, Drucker E. Return to galileo? The inquisition of the international narcotic control board. Harm Reduct J. 2008 May 7;5:16.

http://www.harmreductionjournal.com/content/5/1/16

[14] Chaouachi K. The Lessons of May, 58th. How We Tried to Change the World at the 58th Session of the United Nations INCB (International Narcotics Control Board) - Vienna, 9 May 1995 [a comment on above reference]

http://www.harmreductionjournal.com/content/5/1/16/comments