Editing Harm reduction (section)

====Needle exchange programmes (NEP)====
[[File:800px-Caernarfon womens toilets.jpg|thumb|A [[Wastebin|bin]] allowing for safe disposal of [[syringe|needles]] in a [[washroom|public toilet]] in [[Caernarfon]], Wales]]
{{Main|Needle-exchange programme}}
The use of some illicit drugs can involve hypodermic needles. In some areas (notably in many parts of the US), these are available solely by prescription. Where availability is limited, people who use heroin and other substances frequently share the syringes and use them more than once or participate in unsafe practices such as [[Flashblood|blood flashing]]. As a result, infections such as HIV or [[hepatitis C]] can spread from person to person through the reuse of syringes contaminated with infected blood.<ref name="flashbloodnyt">{{Cite news |last=McNeil |first=Donald G. |date=12 July 2010 |title=Desperate Addicts Inject Others' Blood |url=https://www.nytimes.com/2010/07/13/health/13blood.html |url-status=live |archive-url=https://web.archive.org/web/20230528202755/http://www.nytimes.com/2010/07/13/health/13blood.html |archive-date=28 May 2023 |access-date=8 July 2022 |work=The New York Times |id={{Gale|A231383957}}}}</ref> The principles of harm reduction propose that syringes should be easily available or at least available through a needle and syringe programmes (NSP). Where syringes are provided in sufficient quantities, rates of HIV are much lower than in places where supply is restricted. In many countries people who use substances are supplied equipment free of charge, others require payment or an exchange of dirty needles for clean ones, hence the name.

A 2010 review found insufficient evidence that NSP prevents transmission of the hepatitis C virus, tentative evidence that it prevents transmission of HIV and sufficient evidence that it reduces self-reported injecting risk behaviour.<ref name="pmid20219055">{{Cite journal |vauthors=Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D |date=May 2010 |title=Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews |journal=Addiction |volume=105 |issue=5 |pages=844–859 |doi=10.1111/j.1360-0443.2009.02888.x |pmid=20219055}}</ref> It has been shown in the many evaluations of needle-exchange programmes that in areas where clean syringes are more available, illegal drug use is no higher than in other areas. Needle exchange programmes have reduced HIV incidence by 33% in [[New Haven]] and 70% in New York City.<ref name="pmid11251723">{{Cite journal |last1=Hilton |first1=B. Ann |last2=Thompson |first2=Ray |last3=Moore-Dempsey |first3=Laura |last4=Janzen |first4=Randy G. |date=28 February 2001 |title=Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature |journal=Journal of Advanced Nursing |volume=33 |issue=3 |pages=357–370 |doi=10.1046/j.1365-2648.2001.01672.x |pmid=11251723}}</ref>

The Melbourne, Australia inner-city suburbs of Richmond and Abbotsford are locations in which the use and dealing of heroin has been concentrated for a protracted time period. Research organisation the Burnet Institute completed the 2013 'North Richmond Public Injecting Impact Study' in collaboration with the Yarra Drug and Health Forum, City of Yarra and North Richmond Community Health Centre and recommended 24-hour access to sterile injecting equipment due to the ongoing "widespread, frequent and highly visible" nature of illicit drug use in the areas. During the period between 2010 and 2012 a four-fold increase in the levels of inappropriately discarded injecting equipment was documented for the two suburbs. In the local government area the City of Yarra, of which Richmond and Abbotsford are parts of, 1550 syringes were collected each month from public syringe disposal bins in 2012. Furthermore, ambulance callouts for heroin overdoses were 1.5 times higher than for other Melbourne areas in the period between 2011 and 2012 (a total of 336 overdoses), and drug-related arrests in North Richmond were also three times higher than the state average. The Burnet Institute's researchers interviewed health workers, residents and local traders, in addition to observing the drug scene in the most frequented North Richmond public injecting locations.<ref>{{Cite news |last=Lucie Van Den Berg |date=20 May 2013 |title=Syringe machine push for addicts in Melbourne's heroin hot spots |url=http://www.theaustralian.com.au/news/syringe-machine-push-for-addicts-in-melbournes-heroin-hot-spots/story-e6frg6n6-1226646482548 |url-status=live |archive-url=https://web.archive.org/web/20200313222704/https://www.theaustralian.com.au/news/syringe-machine-push-for-addicts-in-melbournes-heroin-hot-spots/story-e6frg6n6-1226646482548?nk=1af960cf2727aa913e412d84b160fb07-1584138424 |archive-date=13 March 2020 |access-date=20 May 2013 |work=The Australian}}</ref>

On 28 May 2013, the Burnet Institute stated in the media that it recommends 24-hour access to sterile injecting equipment in the Melbourne suburb of Footscray after the area's drug culture continues to grow after more than ten years of intense law enforcement efforts. The institute's research concluded that public injecting behaviour is frequent in the area and inappropriately discarding injecting paraphernalia has been found in carparks, parks, footpaths and drives. Furthermore, people who inject drugs have broken open syringe disposal bins to reuse discarded injecting equipment.<ref>{{Cite news |last=Bridie Byrne |date=28 May 2013 |title=Drug experts propose needle vending machines for Footscray |url=https://www.heraldsun.com.au/leader/west/drug-experts-propose-needle-vending-machines-for-footscray/news-story/dd1597ab69e70c2f165b0efeefbf8a6f |access-date=12 February 2023 |work=Herald Sun}}</ref>

The British public body, the [[National Institute for Health and Care Excellence]] (NICE), introduced a new recommendation in early April 2014 due to an increase in the presentation of the number of young people who inject steroids at UK needle exchanges. NICE previously published needle exchange guidelines in 2009, in which needle and syringe services are not advised for people under the age of 18 years, but the organisation's director Professor Mike Kelly explained that a "completely different group" of people were presenting at programs. In the updated guidance, NICE recommended the provision of specialist services for "rapidly increasing numbers of steroid users", and that needles should be provided to people under the age of 18—a first for NICE—following reports of 15-year-old steroid injectors seeking to develop their muscles.<ref>{{Cite news |last=Charlie Cooper |date=9 April 2014 |title=NICE: Needle exchanges should supply safe equipment to under-18 steroid users |url=https://www.independent.co.uk/life-style/health-and-families/health-news/nice-needle-exchanges-should-supply-safe-equipment-to-under18-steroid-users-9247087.html |url-access=subscription |url-status=live |archive-url=https://ghostarchive.org/archive/20220509/https://www.independent.co.uk/life-style/health-and-families/health-news/nice-needle-exchanges-should-supply-safe-equipment-to-under18-steroid-users-9247087.html |archive-date=9 May 2022 |access-date=9 April 2014 |work=The Independent |location=London}}</ref>

=====Supervised injection sites (SIS)=====<!-- This section is linked from Harm reduction -->
[[File:Clandinjectkit.JPG|thumb|A clandestine kit containing materials to inject drugs]]
[[File:Who needs a virtual world?.jpg|thumb|Injection kit obtained from a needle-exchange programme]]
{{Main|Supervised injection site}}
''Supervised injection sites'' (SIS), or ''Drug consumption rooms'' (DCR), are legally sanctioned, medically supervised facilities designed to address public nuisance associated with drug use and provide a hygienic and stress-free environment for drug consumers.

The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programmes prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be people who inject substances, but generally in Europe they do not exclude people with substance use disorders who consume their substances through other means.

The Netherlands had the first staffed injection room, although they did not operate under explicit legal support until 1996. Instead, the first center where it was legal to inject drugs was in Berne, Switzerland, opened 1986. In 1994, Germany opened its first site. Although, as in the Netherlands they operated in a "gray area", supported by the local authorities and with consent from the police until the Bundestag provided a legal exemption in 2000.<ref name="dolan">{{Cite journal |last1=Dolan |first1=Kate |last2=Kimber |first2=Jo |last3=Fry |first3=Craig |last4=Fitzgerald |first4=John |last5=McDonald |first5=David |last6=Trautmann |first6=Franz |date=September 2000 |title=Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia |journal=Drug and Alcohol Review |volume=19 |issue=3 |pages=337–346 |doi=10.1080/713659379}}</ref>

In Europe, Luxembourg, Spain and Norway have opened facilities after year 2000.<ref name="emcdda-dcr">{{Cite web |title=Chapter 11: Drug consumption facilities in Europe and beyond |url=http://www.emcdda.europa.eu/attachements.cfm/att_101273_EN_emcdda-harm%20red-mon-ch11-web.pdf |url-status=dead |archive-url=https://web.archive.org/web/20210225053932/https://www.emcdda.europa.eu/attachements.cfm/att_101273_EN_emcdda-harm%20red-mon-ch11-web.pdf |archive-date=25 February 2021 |access-date=23 June 2010 |vauthors=Hedrich D, etal}}</ref> [[Sydney]]'s Medically Supervised Injecting Center (MSIC) was established in May 2001 as a trial and Vancouver's [[Insite]] opened in September 2003.<ref>{{Cite news |last=Pollard R |date=8 July 2006 |title=1700 overdoses that didn't end in death |url=http://www.sydneymsic.com/Bginfo.htm/sydney_morning_herald_1700_overdoses_that_didnt_end_in_death |url-status=dead |archive-url=https://web.archive.org/web/20110219122438/http://www.sydneymsic.com/Bginfo.htm/sydney_morning_herald_1700_overdoses_that_didnt_end_in_death |archive-date=19 February 2011 |access-date=9 June 2010 |work=The Sydney Morning Herald }}</ref><ref>{{Cite news |date=13 March 2009 |title=Timeline: Insite |url=http://www.cbc.ca/fifth/2008-2009/staying_alive/timeline.html |url-status=dead |archive-url=https://web.archive.org/web/20091207101004/http://www.cbc.ca/fifth/2008-2009/staying_alive/timeline.html |archive-date=7 December 2009 |access-date=9 June 2010 |publisher=Canadian Broadcasting Corporation}}</ref><ref>{{Cite news |date=5 April 2001 |title=Sydney gets first supervised heroin injecting room |url=https://www.independent.co.uk/news/world/australasia/sydney-gets-first-supervised-heroin-injecting-room-753197.html |access-date=21 September 2010 |work=The Independent |publisher=Independent Print Limited |location=London}}{{dead link|date=August 2021|bot=medic}}{{cbignore|bot=medic}}</ref> In 2010, after a nine-year trial, the Sydney site was confirmed as a permanent public health facility.<ref>{{Cite news |date=15 October 2010 |title=Drug experts support injecting centre |url=http://news.smh.com.au/breaking-news-national/drug-experts-support-injecting-centre-20100915-15b4b.html |url-status=live |archive-url=https://web.archive.org/web/20120820152248/http://news.smh.com.au/breaking-news-national/drug-experts-support-injecting-centre-20100915-15b4b.html |archive-date=20 August 2012 |access-date=21 October 2010 |work=The Sydney Morning Herald }}</ref><ref name="ABCSimmons2010-09-16">{{Cite news |last=Simmons, Amy |date=16 September 2010 |title=Injecting centre approval fails to quell controversy |url=http://www.abc.net.au/news/stories/2010/09/16/3013995.htm |url-status=dead |archive-url=https://web.archive.org/web/20110625104809/http://www.abc.net.au/news/stories/2010/09/16/3013995.htm |archive-date=25 June 2011 |access-date=21 October 2010 |work=ABC News |publisher=Australian Broadcasting Corporation}}</ref> As of late 2009 there were a total of 92 professionally supervised injection facilities in 61 cities.<ref name="emcdda-dcr" /> In North American, as of 2023 there are supervised injection sites operating in a number of Canadian cities,<ref name="canada-map">{{Cite web |last=Government of Canada |first=Health Canada |date=22 May 2018 |title=Interactive map: Canada's response to the opioid crisis |url=https://health.canada.ca/en/health-canada/services/drugs-medication/opioids/responding-canada-opioid-crisis/map.html |url-status=live |archive-url=https://web.archive.org/web/20240111110615/https://health.canada.ca/en/health-canada/services/drugs-medication/opioids/responding-canada-opioid-crisis/map.html |archive-date=11 January 2024 |access-date=9 June 2023 |website=health.canada.ca}}</ref> and two in United States. The sites in United States opened in 2021.<ref>{{Cite web |last=Plante |first=Alexandra |date=5 October 2022 |title=Understanding Morals Is Key to Accepting Safe Injection Sites |url=https://www.scientificamerican.com/article/understanding-morals-is-key-to-accepting-safe-injection-sites/ |url-status=live |archive-url=https://web.archive.org/web/20230928021530/https://www.scientificamerican.com/article/understanding-morals-is-key-to-accepting-safe-injection-sites/ |archive-date=28 September 2023 |access-date=28 September 2023 |website=Scientific American |language=en}}</ref>

The European Monitoring Centre for Drugs and Drug Addiction's latest [[systematic review]] from April 2010 did not find any evidence to support concerns that DCR might "encourage drug use, delay treatment entry or aggravate problems of local drug markets."<ref name="emcdda-dcr" /> Jürgen Rehm and Benedikt Fischer explained that while evidence show that DCR are successful, that "interpretation is limited by the weak designs applied in many evaluations, often represented by the lack of adequate control groups." Concluding that this "leaves the door open for alternative interpretations of data produced and subsequent ideological debate."<ref>{{Cite web |title=Chapter 4: Perspectives on harm reduction – what experts have to say |url=http://www.emcdda.europa.eu/attachements.cfm/att_101267_EN_emcdda-harm%20red-mon-ch4-web.pdf |url-status=dead |archive-url=https://web.archive.org/web/20210809220128/https://www.emcdda.europa.eu/attachements.cfm/att_101267_EN_emcdda-harm%20red-mon-ch4-web.pdf |archive-date=9 August 2021 |access-date=23 June 2010 |vauthors=Rehm J, etal}}</ref>

The EMCDDA review noted that research into the effects of the facilities "faces methodological challenges in taking account of the effects of broader local policy or ecological changes", still they concluded "that the facilities reach their target population and provide immediate improvements through better hygiene and safety conditions for injectors." Further that "the availability of safer injecting facilities does not increase levels of drug use or risky patterns of consumption, nor does it result in higher rates of local drug acquisition crime." While its usage is "associated with self-reported reductions in injecting risk behaviour such as syringe sharing, and in public drug use" and "with increased uptake of [[Drug detoxification|detoxification]] and [[Drug rehabilitation|treatment services]]."<ref name="emcdda-dcr" /> However, "a lack of studies, as well as methodological problems such as isolating the effect from other interventions or low coverage of the risk population, evidence regarding DCRs—while encouraging—is insufficient for drawing conclusions with regard to their effectiveness in reducing HIV or hepatitis C virus (HCV) incidence." Concluding with that "there is suggestive evidence from modelling studies that they may contribute to reducing drug-related deaths at a city level where coverage is adequate, the review-level evidence of this effect is still insufficient."<ref name="emcdda-dcr" />

Critics of this intervention, such as drug prevention advocacy organisations, Drug Free Australia and [[Real Women of Canada]]<ref name="ABCSimmons2010-09-16" /><ref>{{Cite web |title=Drug Free Australia Detailed Evidence on Sydney MSIC |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |url-status=dead |archive-url=https://web.archive.org/web/20110215222645/http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |archive-date=15 February 2011 |access-date=9 January 2010}}</ref><ref>{{Cite web |title=The Vancouver Drug Injection site must be shut down |url=http://www.realwomenca.com/alerts.htm |url-status=usurped |archive-url=https://web.archive.org/web/20021103234906/http://www.realwomenca.com/alerts.htm |archive-date=3 November 2002 |access-date=9 January 2010 |website=Real Women of Canada}}</ref> point to the most rigorous evaluations,<ref>{{harvnb|EMCDDA|2010|p=308}}</ref> those of Sydney and Vancouver. Two of the centers, in Sydney, Australia and Vancouver, British Columbia, Canada cost $2.7 million<ref>{{Cite web |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |url=http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |url-status=dead |archive-url=https://web.archive.org/web/20091029190140/http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |archive-date=29 October 2009 |access-date=9 January 2010 |page=35}}</ref> and $3 million per annum to operate respectively,<ref>{{Cite web |date=3 April 2008 |title=Final Report of the Vancouver Insite Expert Advisory Committee |url=http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |url-status=live |archive-url=https://web.archive.org/web/20170514082746/http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |archive-date=14 May 2017 |access-date=19 April 2010}} 2008</ref> yet Canadian mathematical modeling, where there was caution about validity, indicated just one life saved from fatal overdose per annum for Vancouver,<ref name="hc-sc.gc.ca">{{Cite web |date=3 April 2008 |title=Final Report of the Vancouver Insite Expert Advisory Committee |url=http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |url-status=live |archive-url=https://web.archive.org/web/20170514082746/http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |archive-date=14 May 2017 |access-date=19 April 2010}}</ref><ref>{{Cite web |last=Clement, T. |title=Canadian Parliament 39:2 Hansard – 103 (2008-06-02) |url=http://www2.parl.gc.ca/housechamberbusiness/ChamberPublicationIndexSearch.aspx?arpist=s&arpit=vancouver+insite&arpidf=2006/01/01&arpidt=2010/05/31&arpid=True&arpij=False&arpice=False&arpicl=&ps=Parl0Ses0&arpisb=Publication&arpirpp=100&arpibs=False&Language=E&Mode=1&Parl=39&Ses=1&arpicid=3535078&arpicpd=3537184#Para1130935 |url-status=live |archive-url=https://web.archive.org/web/20121013211418/http://www.parl.gc.ca/housechamberbusiness/ChamberPublicationIndexSearch.aspx?arpibs=False&arpice=False&arpicid=3535078&arpicl=&arpicpd=3537184&arpid=True&arpidf=2006%2f01%2f01&arpidt=2010%2f05%2f31&arpij=False&arpirpp=100&arpisb=Publication&arpist=s&arpit=vancouver%2binsite&Language=E&Mode=1&Parl=39&ps=Parl0Ses0&Ses=1#Para1130935 |archive-date=13 October 2012 |access-date=31 May 2010}}</ref> while the Drug Free Australia analysis demonstrates the Sydney facility statistically takes more than a year to save one life.<ref>{{Cite web |title=The Case for Closure: Detailed Evidence |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |url-status=dead |archive-url=https://web.archive.org/web/20110215222645/http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |archive-date=15 February 2011 |access-date=9 January 2010 |website=Drug Free Australia |pages=26–27}}</ref> The Expert Advisory Committee of the Canadian Government studied claims by journal studies for reduced HIV transmission by Insite but "were not convinced that these assumptions were entirely valid."<ref name="hc-sc.gc.ca" /> The Sydney facility showed no improvement in public injecting and discarded needles beyond improvements caused by a coinciding heroin drought,<ref>{{Cite web |title=The Case for Closure: Detailed Evidence |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |url-status=dead |archive-url=https://web.archive.org/web/20110215222645/http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |archive-date=15 February 2011 |access-date=9 January 2010 |website=Drug Free Australia |pages=31–34}}</ref> while the Vancouver facility had an observable impact.<ref name="hc-sc.gc.ca" /> Drug dealing and loitering around the facilities were evident in the Sydney evaluation,<ref>{{Cite web |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |url=http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |url-status=dead |archive-url=https://web.archive.org/web/20091029190140/http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |archive-date=29 October 2009 |access-date=9 January 2010 |page=147}}</ref> but not evident for the Vancouver facility.<ref name="hc-sc.gc.ca" />