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International Journal of Drug Policy 18 (2007) 88–91

Response

Using words: The harm reduction conceptionof drug use and drug users

Nick Stafford ∗

La Trobe University, 1 Saratoga Ave., Barwon Heads, 3227 Melbourne, Australia

Received 4 December 2006; received in revised form 17 December 2006; accepted 2 January 2007

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I dream about drug law reform. . . I wake up everyday hop-ing against hope that today might be the day that somethingfinally changes. . . .[]. . . I want an end to prohibition. I wantan end to the war on drug users. I want a better quality oflife for myself and my peers and I am going to achieveit by being strategic, pragmatic and coalitionist and I amnot going to stop, no matter what, until I have reached myultimate goal”. (Madden, 2001)

ntroduction

Tammi and Hurme (2006) draw four theses from theirexcursion” around the founding texts of harm reduction that:a) drug use as such should be viewed neutrally, not moral-stically, (b) a drug user is a sovereign citizen and memberf a community, not a deviant individual or only an objectf measures, (c) drug policy should be based on practice andcience, not on ideologies and dogmatism and that (d) drugolicy should respect human rights and support justice, notrample on them in the name of a ‘war on drugs’ or the goalf a drug-free society (Tammi and Hurme, 2006).

These principles, the authors write, express the way harmeduction as a drug policy reform movement, seeks to artic-late how it differs from the approach we have inherited:punitive prohibition” (Tammi and Hurme, 2006). The prin-iples represent part of a “powerful rhetorical intervention inhe highly moralised landscape of drug debate” rather thansomething that would be achieved in practice” (Tammi and

urme, 2006).As Annie Madden makes clear in the quote that begins

his essay, people who use currently illegal drugs dream of

∗ Tel.: +61 3 5254 3356.E-mail address: catnip twist@yahoo.com.

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whole lot more than a powerful rhetorical interventionrom harm reduction, as do those applying harm reductionrinciples in their work with people. However, Tammi andurme’s doubt, I would suggest, haunts us all. For on the oneand, harm reduction ideas has led reforms unimaginable in980 including the distribution of injecting equipment, opi-te maintenance programmes, practical guides on consumingllegal drugs and drug user organisations. On the other hand,rohibitionary laws continue to produce and exacerbate drugelated harms, and prohibition ideology still remains the dom-nant global paradigm. Further, as the Australian Injecting &llicit Drug Users League (AIVL) and the Australian Feder-tion of AIDS organisations (AFAO) have stated in a recentolicy papers, harm reduction’s principles, policies and prac-ices, have come under renewed attack from prohibitionistsAFAO, 2004; AIVL, 2006).

our theses of harm reduction

As a rhetorical intervention, the first thesis, that “drugse as such should be viewed neutrally, not moralistically”Tammi and Hurme, 2006), has accompanied significanthanges in way many health workers speak about the usef illegal drugs. The moral condemnation of illegal drug usend especially drug dependence has become less where healthorkers have taken on harm reduction principles. However,stance of neutrality is a moral stance with consequences.s a public health strategy it has worked well as a position

o advocate for health services like needle and syringe distri-ution but it has proved less effective in advocating for drug

aw reform.

The Network Against Prohibition (NAP), Northern Ter-itory Chapter, based in Darwin Australia states that: “Weake a non-judgemental approach to drug use and recognise

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he fundamental role that drug use has played historically inociety (NAP, 2006)”. Non-judgementalism does not, in theyes of drug user activists equal a neutral stance towards pro-ibitionary drug laws. As AIVL states in their policy papern harm reduction:

Harm Reduction does indeed include the goal of achievingthe end of prohibition, which remains the greatest contrib-utor to the harms associated with illicit drug use. (AIVL,2006, p. 3)

NAP elaborates on this:

In a nutshell, the NAP is a human rights campaigningbody, working to end the war on drugs. NAP membersview the war on drugs as a major human rights catastrophewith a serious impact on drug users and the populations ofdeveloping countries around the world. (NAP, 2006)

In relation to thesis two, that “a drug user is a sovereignitizen and member of a community, not a deviant individualr only an object of measures” Tammi and Hurme write:

From the user’s point of view getting rid of these deviant’sstigmas is to be freed from many forms of the exercise ofpower. On the other hand, getting rid of the stigmas alsomeans giving up the societal privileges related to them,such as the right of a sick person to a certain degree ofpassivity, and even giving up the right to treatment (cf.Parsons, 1951, p. 437). It also imposes new responsibilitieson the user towards society. (Tammi and Hurme, 2006)

For people who use illegal drugs the issues of stigma andiscrimination that this thesis alludes to are central principlesf harm reduction. Discrimination within health care as wells other settings is considered endemic:

Some days I just feel like scum, I read the paper and I amevil, I so to the chemist and I am invisible, yet they watchme as they think I will steal something and I get my fits[syringes] and the worker just grunts at me. I don’t thinkabout discrimination, not until you asked me. This is howmy days are . . . I can’t remember the last time someonejust smiled and said hi how are you, just treated me like Iwas normal. (“Steve” quoted in AIVL, 2006)

In their list of goals the National Alliance of Methadonedvocates include: “To eliminate discrimination towardethadone patients” (NAMA, 2006). This last quote ques-

ions Tammi and Hurme’s suggestion quoted above that theemoval of this stigma will also involve giving up the sickole. I believe this is not the case and that this confusion

rises out of the ambiguity of the concept of “drug user”.

We can make a distinction between people who are manag-ng their drug use in a way that creates no or little difficultiesor them in their lives and people who are either drug depen-

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Drug Policy 18 (2007) 88–91 89

ent or experiencing problems that are having adverse effectsn their lives. Putting aside for the moment how we measurehe line between non-problematic and problematic consump-ion, these two groups have different relationships with healthnd criminal justice systems. If we name these groups drugsers and drug dependent people, we can say that drug usersave no interest or need in accessing health services, whereasrug dependent people do and tend to become involved in theriminal justice system to a higher degree than drug users. Tonsist that the use of drugs for non-medical purposes, evenhen those drugs are currently illegal for non-medically man-

ged consumption, is normal, does not in any way precludehose people experiencing problems from accessing healthervices and taking on the sick role.

Further, while the principles of harm reduction imply thatiscrimination and stigma are not part of the provision ofarm reduction services, the quote from Steve about access-ng a needle exchange and NAMA’s emphasis on the needo eliminate discrimination suggest that this is often not thease in practise.

For me a “sovereign citizen” is someone who has auton-my over their life. The authors quote Erickson et al. toxpand this idea:The user is regarded as an active rather thanpassive entity, capable of making choices about his/her own

ife, taking responsibility for these choices, and playing anmportant role in prevention, treatment and the recovery pro-ess. (Erickson et al., 1997, p. 8, quoted in Tammi and Hurme,006)

This is not how many people have experienced one ofarm reduction’s key strategies; medically managed opiateaintenance. The rationale behind such a programme is that

piate dependent individuals are not only unable to self-anage their drug use, but will never be able to. Further,

he restrictions imposed by many opiate maintenance pro-rammes reduce the ability of people to participate in theirommunities. There is a tension here between harm reductiondeals and the prohibition policy framework through whichhey are experienced.

Thesis three, that “Drug policy should be based on prac-ice and science, not on ideologies and dogmatism” (Tammind Hurme, 2006) is reflected in drug user literature (AIVL,006). Thesis four, “Drug policy should respect human rightsnd support justice, not trample on them in the name of awar on drugs’ or the goal of a drug-free society” (Tammind Hurme, 2006), brings forward the tension around harmeduction and drug policy reform for people who use illegalrugs.

A policy that prohibits the legal purchase and consump-ion of a drug that an individual wants to use, does notespect the right of that individual to self-manage their drugse, and therefore, their body and consciousness. Therefore,arm reductionists who support the current legal status of

he various drugs, who Mugford describes as “progressiverohibitionists” (Mugford, 1993, p. 39), are not, respectinghe rights of individuals regarding their drug use. Humane asell as punitive prohibition likewise.

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arm reduction’s conception of “drug use” anddrug user”

While harm reduction has attempted to articulate an under-tanding of “drug use” and “drug users” that contrasts sharplyith prohibitionist conceptions, there is an ambiguity presentue to the language employed.

The heart of the matter is that the use of drugs is nothe central distinguishing characteristic that defines a “drugser”. Putting aside the use of drugs for medical purposes,t is clear that the use of drugs for a range of purposess an accepted and normal part of most if not all humanocieties. Just one indication of this is that 84% of the Aus-ralian population aged 14 years and over had consumedlcohol in the previous 12 months, 41% doing so on a weeklyasis (Australian Institute of Health and Welfare, 2005,. 15).

In media, government policy, prohibitionist and harmeduction discourse, a drug user is someone who usesn illegal drug, or a prescription drug for non-medicallyuthorised purposes. Tammi and Hurme clearly meanillegal drug use” and “illegal drug user” when using theerm “drug use” and “drug user”. However, the leaving outf the word illegal results in illegal drug use being presenteds the only form of drug use that occurs in our society. Tout it another way, prohibitionists speak about drug use as ifhey themselves do not use drugs.

The social scientific tradition of positioning oneselfs an author outside the phenomenon being discussedas meant that the prohibition strategy of speaking aboutrug use from the position of a non-drug user remainsuthoritative. There is clearly hypocrisy in alcohol, tobaccond caffeine users speaking as non-drug users. Drugser activists and others regularly mention this to me inonversation, yet a key to harm reduction’s success inontaining and preventing HIV epidemics amongst peopleho inject drugs has been not challenging prohibitionary

aws.At the same time, drug user activists have also struggled

ith ambiguity when defining drug use and who is and is notdrug user. The transmission of HIV and other viruses via

lood-to-blood contact has meant the focus of harm reduc-ion has been on injecting drug use. The drug user movements, for this reason, best described as an injecting drug userovement. It is clear that, in Australia at least, people whose illegal drugs but do not inject, have not formed a sig-ificant part of drug user group membership. Memberships predominantly made up of people who use opiates and/orocaine and/or amphetamine.

There has always been ambiguity between the ideas of“drug user” and “drug addiction”. Recognising that the

eeds of drug dependent and non-drug dependent people

re, in many ways, different, Raffi Balian and Cheryl Whiteave argued that by “drug user” the drug user movementhould mean a drug dependent person. This is regularlyut not always the meaning used by self-identified “drug

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Drug Policy 18 (2007) 88–91

sers” in drug user magazines like Whack, Pure S, Usersews in Australia. However, representing the “drug user”s “drug dependent” continues the prohibitionist practisef presenting all (illegal) drug users as drug addicted/ependent.

Tammi and Hurme (2006) also claim that harm reductionas catalysed an “identity movement” of drug users. Harmeduction has shifted the response towards people whose illegal drugs in many different societies in a positiveirection, but the criminalisation of our family and friendsredates harm reduction as does organising by people whonject their drugs.

People who have used illegal drugs have always sought torganise in order to facilitate drug use and to resist and some-imes challenge current prohibitionist policies. The Nationalrganization for the Reform of Marijuana Laws (NORML) of

he USA, founded in 1970 demonstrates this (NORML 2006).Further, as Pat O’Hare remarks in the introduction to the

rst “founding text”:

The model for syringe exchange schemes, now a centralpart of many strategies for reducing the transmission ofHIV, was devised not by doctors or sociologists or psy-chologist, but by drug users. The first syringe exchangewas devised by the Amsterdam junkiebond, a drug-users’self-help organization, and was aimed at reducing the trans-mission of the hepatitis B virus. (O’Hare, 1992, p. xiv)

Rather than saying that harm reduction catalysed andentity movement, we can say that prohibitionary policiesnd ideology created a criminalised subculture of peopleabelled “drug users”. One part of this legal category ofeople, those who inject, were stimulated by blood borneiruses to organise. Harm reduction likewise was stimulatedy blood borne viruses.

onclusion

After this brief engagement I think it is clear that the fourheses identified by Tammi and Hurme resonate in drug userriting. However, a different emphasis is suggested in drugser writing. The arrival of HIV provided the catalyst foreople who inject drugs and health professionals to force gov-rnments into accepting up front provision of sterile injectingquipment. It also provided the catalyst for the harm reduc-ion movement to bring about the most significant changes inealth care since the criminalisation of various drugs since thearly 20th century. Harm reduction’s most significant point ofontrast with the punitive prohibition position is in the rela-ionship between health workers and people who use illegal

armful effects of prohibitionary laws however they con-ain no hint of the key principle for “drug users”: we seekovereignty over how we interact with our bodies and minds,ncluding what drugs we use.

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eferences

FAO. (2004). A critical time for harm reduction. AFAO discussion paper.Accessed 21/11/06 from http://www.afao.org.au/library docs/policy/harm reduction oct04.pdf

IVL. (2006). Policy position—Harm reduction. Accessed 20/11/06 fromhttp://www.aivl.org.au/files/PPHarmReduction.pdf

ustralian Institute of Health Welfare. (2005). Statistics on drug usein Australia 2004. Drug statistics series no. 15 AIHW: Canberra.[AIHW Cat. No. PHE 62]. Accessed 2-12-06 from http://www.aihw.gov.au/publications/phe/sdua04/sdua04.pdf

adden, A. (2001). Law reform—Moving beyond the rhetoric. In Paper

presented at the 12th international conference on the reductionof drug related harm. Accessed 20/11/06 from http://www.aivl.org.au/files/Annie.Madden.LawReformMovingBeyondtheRhetoric.pdf

ugford, S. (1993). Harm reduction: Does it lead where its proponentsimagine? In N. Heather, A. Wodak, E. Nadelmann, & P. O’Hare (Eds.),

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Drug Policy 18 (2007) 88–91 91

Psychoactive drugs and harm reduction. From faith to science. London:Whurr Publishers Ltd.

ational Alliance of Methadone Advocates. (2006). NAMA’s goals.Accessed 27/11/06 from http://www.methadone.org/library/what isnama.html

etwork Against Prohibition. (2006). About NAP. Accessed 24/11/06 fromhttp://www.napnt.org/what we do.htm

ational Organization for the Reform of Marijuana Laws. (1999).Mission statement. Accessed 22/11/06 from http://www.norml.org/index.cfm?Group ID=3414

’Hare, P. (1992). Preface: A note on the concept of harm reduction. In P.O’Hare, R. Newcombe, A. Matthews, E. Buning, & E. Drucker (Eds.),

The reduction of drug-related harm. London: Routledge.

arsons, T. (1951). The social system. Glencoe, IL: Free Press.ammi, T. & Hurme, T. (2006). Huumeiden kayttajan asema ja huumepoliti-

ikan terveystaju (The role of drug user and drug policy’s sense of health).In A. Puuronen (Ed.), Terveystaju. Helsinki: Nuorisotutkimusseura.