Editing Harm reduction (section)

===Substances===

====Depressants====

=====Alcohol=====
{{See also|Fomepizole|Denatured alcohol#Toxicity}}
Traditionally, [[homeless shelter]]s ban [[alcoholic beverage|alcohol]]. In 1997, as the result of an [[inquest]] into the deaths of two people experiencing homelessness who recreationally used alcohol two years earlier, [[Toronto]]'s [[Seaton House]] became the first homeless shelter in Canada to operate a "wet shelter" on a "managed alcohol" principle in which clients are served a glass of wine once an hour unless staff determine that they are too inebriated to continue. Previously, people experiencing homelessness who consumed excessive amounts of alcohol opted to stay on the streets often seeking alcohol from unsafe sources such as mouthwash, rubbing alcohol or industrial products which, in turn, resulted in frequent use of [[Emergency department|emergency medical facilities]]. The programme has been duplicated in other Canadian cities, and a study of [[Ottawa]]'s "wet shelter" found that emergency room visit and police encounters by clients were cut by half.<ref>{{Cite news |last=McKeen, Scott |date=7 March 2007 |title='Wet' shelter needs political will: Toronto project could serve as model for Edmonton |work=Edmonton Journal}}</ref> The study, published in the ''[[Canadian Medical Association Journal]]'' in 2006, found that serving people experiencing long-term homelessness and who consume excessive amounts of alcohol controlled doses of alcohol also reduced their overall alcohol consumption. Researchers found that programme participants cut their alcohol use from an average of 46 drinks a day when they entered the programme to an average of 8 drinks and that their visits to emergency rooms dropped from 13.5 to an average of 8 per month, while encounters with the police fall from 18.1 to an average of 8.8.<ref name="pmid16389236">{{Cite journal |vauthors=Podymow T, Turnbull J, Coyle D, Yetisir E, Wells G |year=2006 |title=Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. |journal=CMAJ |volume=174 |issue=1 |pages=45–49 |doi=10.1503/cmaj.1041350 |pmc=1319345 |pmid=16389236}}</ref><ref>{{Cite news |last=Patrick, Kelly |date=7 January 2006 |title=The drinks are on us at the homeless shelter: Served every 90 minutes: Managed alcohol program reduces drinking |work=National Post}}</ref>

Downtown Emergency Service Center (DESC),<ref>{{Cite web |date=3 March 2016 |title=DESC |url=http://www.desc.org/supportive_housing.html |url-status=live |archive-url=https://web.archive.org/web/20160303175712/http://www.desc.org/supportive_housing.html |archive-date=3 March 2016 |access-date=2 February 2021}}</ref> in [[Seattle]], Washington, operates several [[Housing First]] programmes which utilize the harm reduction model. [[University of Washington]] researchers, partnering with DESC, found that providing housing and support services for homeless alcoholics costs taxpayers less than leaving them on the street, where taxpayer money goes towards police and emergency health care. Results of the study funded by the Substance Abuse Policy Research Program (SAPRP) of the [[Robert Wood Johnson Foundation]]<ref name="SAPRPpressRelease">{{Cite web |date=April 2009 |title=SAPRP Project: Housing First: Evaluation of Harm Reduction Housing for Chronic Public Inebriates |url=http://www.saprp.org/m_pr_archives_detail.cfm?AppID=3836 |url-status=dead |archive-url=https://web.archive.org/web/20100729084741/http://www.saprp.org/m_pr_archives_detail.cfm?AppID=3836 |archive-date=29 July 2010 |website=SAPRP}}</ref> appeared in the ''[[Journal of the American Medical Association]]'' in April 2009.<ref>{{Cite journal |vauthors=Larimer ME, Malone DK, Garner MD, etal |date=April 2009 |title=Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems |journal=JAMA |volume=301 |issue=13 |pages=1349–1357 |doi=10.1001/jama.2009.414 |pmid=19336710 |doi-access=free}}</ref> This first controlled assessment in the U.S. of the effectiveness of Housing First, specifically targeting chronically homeless alcoholics, showed that the programme saved taxpayers more than $4 million over the first year of operation. During the first six months, the study reported an average cost-savings of 53 percent (even after considering the cost of administering the housing's 95 residents)—nearly $2,500 per month per person in health and social services, compared to the per month costs of a wait-list control group of 39 homeless people. Further, despite the fact residents are not required to be abstinent or in treatment for alcohol use, stable housing also results in reduced drinking among people experiencing homelessness who recreationally use alcohol.

======Alcohol-related programmes======
A high amount of media coverage exists informing people of the dangers of [[drunk driving|driving drunk]]. Most people who recreationally consume alcohol are now aware of these dangers and safe ride techniques like '[[designated driver]]s' and free taxicab programmes are reducing the number of drunk-driving crashes. Many cities have free-ride-home programmes during holidays involving high amounts of alcohol use, and some bars and clubs will provide a visibly drunk patron with a free cab ride.

In [[New South Wales]] groups of licensees have formed local liquor accords and collectively developed, implemented and promoted a range of harm minimisation programmes including the aforementioned 'designated driver' and 'late night patron transport' schemes. Many of the transport schemes are free of charge to patrons, to encourage them to avoid drink-driving and at the same time reduce the impact of noisy patrons loitering around late night venues.

[[Moderation Management]] is a programme which helps drinkers to cut back on their consumption of alcohol by encouraging safe drinking behaviour.

Harm reduction in alcohol dependency could be instituted by use of [[naltrexone]].<ref name="Volpicelli1992">{{Cite journal |last1=Volpicelli |first1=Joseph R. |last2=Alterman |first2=Arthur I. |last3=Hayashida |first3=Motoi |last4=O'Brien |first4=Charles P. |date=1 November 1992 |title=Naltrexone in the Treatment of Alcohol Dependence |journal=Archives of General Psychiatry |volume=49 |issue=11 |pages=876–880 |doi=10.1001/archpsyc.1992.01820110040006 |pmid=1345133}}</ref>

=====Opioids=====

======Heroin maintenance programmes (HAT)======
{{Main|Heroin assisted treatment}}
Providing medical prescriptions for pharmaceutical heroin (diacetylmorphine) to heroin-dependent people has been employed in some countries to address problems associated with the illicit use of the drug, as potential benefits exist for the individual and broader society. Evidence has indicated that this form of treatment can greatly improve the health and social circumstances of participants, while also reducing costs incurred by criminalisation, incarceration and health interventions.<ref>{{Cite web |last=Uchtenhagen |first=Ambros |date=February 2002 |title=Background |url=https://sencanada.ca/content/sen/committee/371/ille/presentation/ucht-e.htm |url-status=live |archive-url=https://web.archive.org/web/20100120061027/https://sencanada.ca/content/sen/committee/371/ille/presentation/ucht-e.htm |archive-date=20 January 2010 |access-date=15 March 2020 |website=Heroin Assisted Treatment for Opiate Addicts – The Swiss Experience}}</ref><ref>{{Cite journal |vauthors=Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D |date=July 2007 |title=Heroin-assisted treatment for opioid dependence: randomised controlled trial |journal=The British Journal of Psychiatry |volume=191 |pages=55–62 |doi=10.1192/bjp.bp.106.026112 |pmid=17602126 |doi-access=free}}</ref>

In Switzerland, [[heroin assisted treatment]] is an established programme of the national health system. Several dozen centres exist throughout the country and heroin-dependent people can administer heroin in a controlled environment at these locations. The Swiss heroin maintenance programme is generally regarded as a successful and valuable component of the country's overall approach to minimising the harms caused by illicit drug use.<ref>{{Cite web |last=Uchtenhagen |first=Ambros |date=February 2002 |title=Epidemiology |url=https://sencanada.ca/content/sen/committee/371/ille/presentation/ucht-e.htm |url-status=live |archive-url=https://web.archive.org/web/20100120061027/https://sencanada.ca/content/sen/committee/371/ille/presentation/ucht-e.htm |archive-date=20 January 2010 |access-date=15 March 2020 |website=Heroin Assisted Treatment for Opiate Addicts – The Swiss Experience}}</ref> In a 2008 [[Swiss referendum, November 2008#Revision of the federal statute on narcotics|national referendum]], a majority of 68 per cent voted in favour of continuing the Swiss programme.<ref>{{Cite web |last=Urs Geiser |date=30 November 2008 |title=Swiss to agree heroin scheme but say no to dope |url=http://www.swissinfo.ch/eng/archive/Swiss_to_agree_heroin_scheme_but_say_no_to_dope.html?cid=7071120 |url-status=dead |archive-url=https://web.archive.org/web/20140407103938/http://www.swissinfo.ch/eng/archive/Swiss_to_agree_heroin_scheme_but_say_no_to_dope.html?cid=7071120 |archive-date=7 April 2014 |access-date=21 May 2013 |website=Swissinfo.ch |publisher=Swiss Broadcasting Corporation}}</ref>

The [[Netherlands]] has studied medically supervised heroin maintenance.<ref>{{Cite book |last1=van den Brink |first1=Wim |url=http://www.ccbh.nl/rapport_engels_html/index.htm |title=Medical Co-Prescription of Heroin: Two Randomized Controlled Trials |last2=Hendriks |first2=Vincent M. |last3=Blanken |first3=Peter |last4=Huijsman |first4=Ineke A. |last5=van Ree |first5=Jan M. |date=2002 |publisher=Central Committee on the Treatment of Heroin Addicts (CCBH) |isbn=9080693227 |id={{NCJ|195635}} |access-date=21 March 2024 |archive-url=https://web.archive.org/web/20060517080050/http://www.ccbh.nl/rapport_engels_html/index.htm |archive-date=17 May 2006}}</ref> A German study of long-term heroin addicts demonstrated that [[diamorphine]] was significantly more effective than [[methadone]] in keeping patients in treatment and in improving their health and social situation.<ref>{{Cite journal |vauthors=Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D |date=July 2007 |title=Heroin-assisted treatment for opioid dependence: randomised controlled trial |journal=Br J Psychiatry |volume=191 |pages=55–62 |doi=10.1192/bjp.bp.106.026112 |pmid=17602126 |doi-access=free}}</ref> Many participants were able to find employment, some even started a family after years of homelessness and delinquency.<ref>{{Cite web |date=2 May 2010 |title=Heroin (diamorphine) supported treatment in Germany: Results and problems of implementation |url=https://www.hri.global/files/2010/05/02/Presentation_20th_C12_Michels.pdf |access-date=21 March 2024 |website=Commissioner on Narcotic Drugs |publisher=German Federal Ministry of Health}}</ref><ref>{{Cite web |url=http://relaunch.bundestag.de/bundestag/ausschuesse/a14/anhoerungen/113/stllg/ZIS.pdf |access-date=9 September 2009}}{{dead link|date=December 2021|bot=medic}}{{cbignore|bot=medic}}</ref> Since then, treatment had continued in the cities that participated in the pilot study, until heroin maintenance was permanently included into the national health system in May 2009.<ref>{{Cite web |last=Smith |first=Phillip |date=5 June 2009 |title=Europe: German Parliament Approves Heroin Maintenance |url=https://stopthedrugwar.org/chronicle/2009/jun/05/europe_german_parliament_approve |url-status=live |archive-url=https://web.archive.org/web/20090925024329/http://stopthedrugwar.org/chronicle/588/germany_approves_heroin_maintenance |archive-date=25 September 2009 |access-date=11 August 2016 |website=StoptheDrugWar.org}}</ref> As of 2021, the country offers heroin-assisted treatment by prescribing medical-grade heroin is typically prescribed in combination with methadone and [[psychosocial]] counseling.<ref>{{Cite journal |last1=van der Gouwe |first1=Daan |last2=Strada |first2=Lisa |last3=Diender |first3=Bob |last4=van Gelder |first4=Nadine |last5=de Gee |first5=Anouk |year=2022 |title=Harm reduction services in the Netherlands: recent developments and future challenges |url=https://www.trimbos.nl/wp-content/uploads/2022/02/AF1973-Harm-reduction-services-in-the-Netherlands.pdf |url-status=live |journal=Netherlands Institute of Mental Health and Addiction |publisher=Trimbos-instituut |pages=10 |archive-url=https://web.archive.org/web/20240114115012/https://www.trimbos.nl/wp-content/uploads/2022/02/AF1973-Harm-reduction-services-in-the-Netherlands.pdf |archive-date=14 January 2024 |access-date=21 December 2023}}</ref>

A heroin maintenance programme has existed in the United Kingdom (UK) since the 1920s, as drug addiction was seen as an individual health problem. Addiction to opiates was rare in the 1920s and was mostly limited to either middle-class people who had easy access due to their profession, or people who had become addicted as a side effect of medical treatment. In the 1950s and 1960s a small number of doctors contributed to an alarming increase in the number of people who are experiencing addiction in the U.K. through excessive prescribing—the U.K. switched to more restrictive drug legislation as a result.<ref name="rachel">{{Cite web |last=Rachel Lart |title=British Medical Perception from Rolleston to Brain, Changing Images of the Addict and Addiction |url=http://www.drugtext.org/library/articles/92333.html |url-status=dead |archive-url=https://web.archive.org/web/20110610141829/http://www.drugtext.org/library/articles/92333.html |archive-date=10 June 2011}}</ref> However, the British government is again moving towards a consideration of heroin prescription as a legitimate component of the National Health Service (NHS). Evidence has shown that methadone maintenance is not appropriate for all people who are dependent on opioids and that heroin is a viable maintenance drug that has shown equal or better rates of success.<ref>{{Cite web |last1=Stimson |first1=Gerry V |last2=Metrebian |first2=Nicky |date=12 September 2003 |title=Prescribing Heroin: what is the evidence? |url=https://www.jrf.org.uk/prescribing-heroin-what-is-the-evidence |url-status=live |archive-url=https://web.archive.org/web/20060209071303/http://www.jrf.org.uk/knowledge/findings/socialpolicy/943.asp |archive-date=9 February 2006 |website=Joseph Rowntree Foundation}}</ref>

A committee appointed by the Norwegian government completed an evaluation of research reports on heroin maintenance treatment that were available internationally. In 2011 the committee concluded that the presence of numerous uncertainties and knowledge gaps regarding the effects of heroin treatment meant that it could not recommend the introduction of heroin maintenance treatment in Norway.<ref>{{Cite web |date=29 March 2012 |title=Nyheter – Norges forskningsråd |url=http://www.forskningsradet.no/no/Nyheter/_For_svakt_grunnlag/1253968771212?WT.ac=forside_nyhet |archive-url=https://web.archive.org/web/20120329042435/http://www.forskningsradet.no/no/Nyheter/_For_svakt_grunnlag/1253968771212?WT.ac=forside_nyhet |archive-date=29 March 2012}}</ref>

Critics of heroin maintenance programmes object to the high costs of providing heroin to people who use it. The British heroin study cost the British government £15,000 per participant per year, roughly equivalent to average person who uses heroin's expense of £15,600 per year.<ref>{{Cite web |title=Treatable or Just Hard to Treat? |url=http://www.actiononaddiction.org.uk/news_and_campaigns/news/160_untreatable-or-just-hard-to-treat |url-status=dead |archive-url=https://web.archive.org/web/20100808085211/http://www.actiononaddiction.org.uk/news_and_campaigns/news/160_untreatable-or-just-hard-to-treat |archive-date=8 August 2010 |access-date=8 January 2011}} 2009</ref> Drug Free Australia<ref name="DrugFreeAustralia">{{Cite web |title=Arguments for Prohibition |url=http://www.drugfree.org.au/fileadmin/Media/Global/Taskforce_Arguments_for_Prohibition.pdf |url-status=dead |archive-url=https://web.archive.org/web/20110706124952/http://www.drugfree.org.au/fileadmin/Media/Global/Taskforce_Arguments_for_Prohibition.pdf |archive-date=6 July 2011 |access-date=20 April 2010 |page=3}}</ref> contrast these ongoing maintenance costs with Sweden's investment in, and commitment to, a drug-free society where a policy of compulsory rehabilitation of people who are experiencing drug addiction is integral, which has yielded to one of the lowest reported illicit drug use levels in the developed world,<ref>{{Cite web |title=World Drug Report 2000 |url=http://www.unodc.org/unodc/en/data-and-analysis/WDR-2000.html |url-status=live |archive-url=https://web.archive.org/web/20100417180244/http://www.unodc.org/unodc/en/data-and-analysis/WDR-2000.html |archive-date=17 April 2010 |access-date=4 May 2010}} 2001 pp. 162–65 (see aggregated average for each OECD country in Harm Reduction Discussion page).</ref> a model in which successfully rehabilitated people who use substances present no further maintenance costs to their community, as well as reduced ongoing health care costs.<ref name="DrugFreeAustralia" />

[[King's Health Partners]] notes that the cost of providing free heroin for a year is about one-third of the cost of placing the person in prison for a year.{{Dead link|date=May 2011}}<ref name="KHP">{{Cite web |title=Untreatable or Just Hard to Treat? |url=http://www.kingshealthpartners.org/khp/2009/09/15/untreatable-or-just-hard-to-treat/ |url-status=dead |archive-url=https://web.archive.org/web/20100328081543/http://www.kingshealthpartners.org/khp/2009/09/15/untreatable-or-just-hard-to-treat/ |archive-date=28 March 2010 |access-date=20 April 2010}}</ref><ref>{{Cite journal |last=Lintzeris |first=Nicholas |year=2009 |title=Prescription of heroin for the management of heroin dependence: current status |journal=CNS Drugs |volume=23 |issue=6 |pages=463–476 |doi=10.2165/00023210-200923060-00002 |pmid=19480466 |s2cid=11018732}}</ref>

======Naloxone distribution======
[[Naloxone]] is a drug used to counter an overdose from the effect of [[opioid]]s; for example, a heroin or [[morphine]] overdose. Naloxone displaces the opioid molecules from the brain's receptors and reverses the [[respiratory depression]] caused by an overdose within two to eight minutes.<ref>{{Cite web |year=2013 |title=Get Started |url=http://naloxoneinfo.org/get-started/about-naloxone |url-status=dead |archive-url=https://web.archive.org/web/20140314005709/http://naloxoneinfo.org/get-started/about-naloxone |archive-date=14 March 2014 |access-date=17 March 2014 |website=Open Society Foundations}}</ref> The [[World Health Organization]] (WHO) includes naloxone on their "[[WHO Model List of Essential Medicines|List of Essential Medicines]]", and recommends its availability and utilization for the reversal of opioid overdoses.<ref>{{Cite web |year=2014 |title=Treatment of opioid dependence |url=https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/ |url-status=live |archive-url=https://web.archive.org/web/20140314012311/http://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/ |archive-date=14 March 2014 |access-date=17 March 2014 |website=World Health Organization |publisher=WHO}}</ref><ref>{{Cite web |year=2014 |title=Drug use prevention, treatment and care |url=http://www.unodc.org/unodc/en/drug-prevention-and-treatment/index.html |url-status=live |archive-url=https://web.archive.org/web/20200910123842/http://www.unodc.org/unodc/en/drug-prevention-and-treatment/index.html |archive-date=10 September 2020 |access-date=17 March 2014 |website=United Nations Office on Drugs and Crime |publisher=UNODC}}</ref>

Formal programs in which the opioid [[inverse agonist]] drug naloxone is distributed have been trialled and implemented. Established programs distribute naloxone, as per WHO's minimum standards, to people who use substances and their peers, family members, police, prisons, and others. These treatment programs and harm reduction centres operate in Afghanistan, Australia, Canada, China, Germany, Georgia, Kazakhstan, Norway, Russia, Spain, Tajikistan, the United Kingdom (UK), the United States (US), Vietnam,<ref>{{Cite web |last1=Paul Dietze |last2=Simon Lenton |date=December 2010 |title=The case for the wider distribution of naloxone in Australia |url=http://www.atoda.org.au/wp-content/uploads/The_heroin_reversal_drug_naloxone_FIN2.pdf |url-status=dead |archive-url=https://web.archive.org/web/20130411150232/http://www.atoda.org.au/wp-content/uploads/The_heroin_reversal_drug_naloxone_FIN2.pdf |archive-date=11 April 2013 |access-date=30 March 2013 |website=Alcohol, Tobacco & Other Drug Association ACT |publisher=ATODA}}</ref> India, Thailand, Kyrgyzstan,<ref>{{Cite web |year=2013 |title=Tools for Starting a Naloxone Program |url=http://naloxoneinfo.org |url-status=dead |archive-url=https://web.archive.org/web/20140317165651/http://www.naloxoneinfo.org/ |archive-date=17 March 2014 |access-date=17 March 2014 |website=Open Society Foundations}}</ref> Denmark and Estonia.<ref>{{Cite web |date=14 October 2014 |title=Take home naloxone to reduce fatalities: scaling up a participatory intervention across Europe |url=https://www.emcdda.europa.eu/event/2014/10/take-home-naloxone-reduce-fatalities-scaling-participatory-intervention-across-europe_en |website=European Monitoring Centre for Drugs and Drug Addiction |location=Lisbon}}</ref> Many reviews of the literature support the effectiveness of naloxone based interventions in reducing overdose deaths where it is available at the time of the overdose event.<ref>{{Cite journal |last1=Mueller |first1=Shane R. |last2=Walley |first2=Alexander Y. |last3=Calcaterra |first3=Susan L. |last4=Glanz |first4=Jason M. |last5=Binswanger |first5=Ingrid A. |date=3 April 2015 |title=A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice |journal=Substance Abuse |volume=36 |issue=2 |pages=240–253 |doi=10.1080/08897077.2015.1010032 |pmc=4470731 |pmid=25774771|bibcode=2015JPkR...36..240M }}</ref><ref>{{Cite journal |last1=McDonald |first1=Rebecca |last2=Strang |first2=John |date=30 March 2016 |title=Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria |journal=Addiction |volume=111 |issue=7 |pages=1177–1187 |doi=10.1111/add.13326 |pmc=5071734 |pmid=27028542}}</ref> This effectiveness has been explained in a [[Realist Evaluation]] which explained the effectiveness through [[bystander effect]], [[social identity theory]], and skills training such that universal access to training supports social identity and in-group norms (of people who use drugs), which supports the conditions for the success of a peer-to-peer distribution model of naloxone-based interventions. Stigma and stigmatising attitudes reduced the effectiveness of naloxone based interventions.<ref name="hrjrealistreview">{{Cite journal |last1=Miller |first1=Nicole M. |last2=Waterhouse-Bradley |first2=Bethany |last3=Campbell |first3=Claire |last4=Shorter |first4=Gillian W. |date=23 February 2022 |title=How do naloxone-based interventions work to reduce overdose deaths: a realist review |journal=Harm Reduction Journal |volume=19 |issue=1 |page=18 |doi=10.1186/s12954-022-00599-4 |pmc=8867850 |pmid=35197057 |doi-access=free}}</ref>

====== Medication assisted treatment (MAT): Opioid agonist therapy (OAT) and Opioid substitution therapy (OST) ======
[[Medication assisted treatment]] (MAT) is the prescription of legal, prescribed opioids or other drugs, often long-acting, to diminish the use of illegal opioids. Many types of MAT exist, including opioid agonist therapy (OAT) where a safer opioid agonist is employed or opioid substitution therapy (OST) which employs partial opioid agonists. However, MAT, OAT, OST are often used synonymously.<ref>{{Cite journal |last1=Noble |first1=Florence |last2=Marie |first2=Nicolas |date=18 January 2019 |title=Management of Opioid Addiction With Opioid Substitution Treatments: Beyond Methadone and Buprenorphine |journal=Frontiers in Psychiatry |volume=9 |page=742 |doi=10.3389/fpsyt.2018.00742 |pmc=6345716 |pmid=30713510 |doi-access=free}}</ref>

[[Opioid agonist therapy]] (OAT) involves the use of a full opioid agonist treatment like methadone and is generally taken daily at a [[Methadone clinic|clinic]].<ref name="NEPOD Report">{{Cite web |last=Mattick |first=Richard P. |display-authors=etal |title=National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD): Report of Results and Recommendation |url=http://www.health.gov.au/internet/drugstrategy/publishing.nsf/Content/8BA50209EE22B9C6CA2575B40013539D/$File/mono52.pdf |archive-url=https://web.archive.org/web/20110309195541/http://www.health.gov.au/internet/drugstrategy/publishing.nsf/Content/8BA50209EE22B9C6CA2575B40013539D/$File/mono52.pdf |archive-date=9 March 2011 |website=Department of Health and Aged Care |publisher=Australian Government}}</ref><ref>{{Cite journal |last1=Soyka |first1=Michael |last2=Franke |first2=Andreas G |date=19 September 2021 |title=Recent advances in the treatment of opioid use disorders – focus on long-acting buprenorphine formulations |journal=World Journal of Psychiatry |volume=11 |issue=9 |pages=543–552 |doi=10.5498/wjp.v11.i9.543 |pmc=8474991 |pmid=34631459 |doi-access=free}}</ref> [[Opioid substitution therapy]] (OST) involves the use of the partial agonist [[buprenorphine]] or a combination of buprenorphine/naloxone (brand name [[Suboxone]]). Oral/sublingual formulations of buprenorphine incorporate the opioid antagonist naloxone to prevent people from crushing the tablets and injecting them.<ref name="NEPOD Report" /> Unlike methadone treatment, buprenorphine therapy can be prescribed month-to-month and obtained at a traditional [[pharmacy]] rather than a clinic.<ref>{{Cite web |title=Opioid Agonist Treatment (OAT): The Gold Standard for Opioid Use Disorder Treatment |url=https://drugpolicy.org/resource/opioid-agonist-treatment-oat-gold-standard-opioid-use-disorder-treatment |url-status=dead |archive-url=https://web.archive.org/web/20220608194055/https://drugpolicy.org/resource/opioid-agonist-treatment-oat-gold-standard-opioid-use-disorder-treatment |archive-date=8 June 2022 |access-date=28 June 2022 |website=Drug Policy Alliance |language=en}}</ref>

The driving principle behind OAT/OST is the program's capacity to facilitate a resumption of stability in the person's life, while they experience reduced symptoms of [[Drug withdrawal|withdrawal]] symptoms and less intense [[Craving (withdrawal)|drug cravings]]; however, a strong euphoric effect is not experienced as a result of the treatment drug.<ref name="NEPOD Report" />

In some countries, such as Switzerland, Austria, and Slovenia, patients are treated with slow-release morphine when methadone is deemed inappropriate due to the individual's circumstances. In Germany, [[dihydrocodeine]] has been used [[Off-label use|off-label]] in OAT for many years, however it is no longer frequently prescribed for this purpose. Extended-release dihydrocodeine is again in current use in Austria for this reason.{{citation needed|date=April 2014}} Research into the usefulness of [[piritramide]], extended-release [[hydromorphone]] (including polymer implants lasting up to 90 days), [[dihydroetorphine]] and other substances for OAT is at various stages in a number of countries.<ref name="NEPOD Report" />  In 2020 in Vancouver, Canada, health authorities began vending machine dispensing of hydromorphone tablets as a response to elevated rates of fatal overdose from street drugs contaminated with fentanyl and fentanyl analogues.<ref>{{Cite web |date=17 February 2020 |title=Opioid vending machine opens in Vancouver |url=http://www.theguardian.com/science/2020/feb/17/opioid-vending-machine-opens-vancouver-mysafe-canada |url-status=live |archive-url=https://web.archive.org/web/20220110180705/https://www.theguardian.com/science/2020/feb/17/opioid-vending-machine-opens-vancouver-mysafe-canada |archive-date=10 January 2022 |access-date=10 January 2022 |website=The Guardian |language=en}}</ref>

In some countries (not the US, UK, Canada, or Australia),<ref name="NEPOD Report" /> regulations enforce a limited time period for people on OAT/OST programs that conclude when a stable economic and psychosocial situation is achieved. (Patients with [[HIV|HIV/AIDS]] or [[hepatitis C]] are usually excluded from this requirement.) In practice, 40–65% of patients maintain complete abstinence from opioids while receiving opioid agonist therapy, and 70–95% are able to reduce their use significantly, while experiencing a concurrent elimination or reduction in medical (improper [[diluent]]s, non-[[Sterilization (microbiology)|sterile]] injecting equipment), psychosocial ([[mental health]], relationships), and legal (arrest and [[imprisonment]]) issues that can arise from the use of illicit opioids.<ref name="NEPOD Report" />

OAT/OST outlets in some settings also offer basic primary health care. These are known as 'targeted primary health care outlet'—as these outlets primarily target people who inject drugs and/or 'low-threshold health care outlet'—as these reduce common barriers clients often face when they try to access health care from the conventional health care outlets.<ref>{{Cite journal |last1=Islam |first1=M. Mofizal |last2=Topp |first2=Libby |last3=Day |first3=Carolyn A. |last4=Dawson |first4=Angela |last5=Conigrave |first5=Katherine M. |year=2012 |title=The accessibility, acceptability, health impact and cost implications of primary healthcare outlets that target injecting drug users: A narrative synthesis of literature |journal=International Journal of Drug Policy |volume=23 |issue=2 |pages=94–102 |doi=10.1016/j.drugpo.2011.08.005 |pmid=21996165}}</ref><ref>{{Cite journal |last1=Islam |first1=M. Mofizal |last2=Topp |first2=Libby |last3=Day |first3=Carolyn A. |last4=Dawson |first4=Angela |last5=Conigrave |first5=Katherine M. |year=2012 |title=Primary healthcare outlets that target injecting drug users: Opportunity to make services accessible and acceptable to the target group |journal=International Journal of Drug Policy |volume=23 |issue=2 |pages=109–10 |doi=10.1016/j.drugpo.2011.11.001 |pmid=22280917}}</ref> For accessing sterile injecting equipment clients frequently visit NSP outlets, and for receiving pharmacotherapy (e.g. methadone, buprenorphine) they visit OST clinics; these frequent visits are used opportunistically to offer much needed health care.<ref>{{Cite journal |last1=Islam |first1=M. Mofizal |last2=Reid |first2=Sharon E. |last3=White |first3=Ann |last4=Grummett |first4=Sara |last5=Conigrave |first5=Katherine M. |last6=Haber |first6=Paul S. |year=2012 |title=Opportunistic and continuing health care for injecting drug users from a nurse-run needle syringe program-based primary health-care clinic |journal=Drug Alcohol Rev |volume=31 |issue=1 |pages=114–115 |doi=10.1111/j.1465-3362.2011.00390.x |pmid=22145983}}</ref><ref>{{Cite journal |last=Islam, M. Mofizal |year=2010 |title=Needle Syringe Program-Based Primary Health Care Centers: Advantages and Disadvantages |journal=Journal of Primary Care & Community Health |volume=1 |issue=2 |pages=100–03 |doi=10.1177/2150131910369684 |pmid=23804370 |s2cid=8663924 |doi-access=free}}</ref> These targeted outlets have the potential to mitigate clients' perceived barriers to access to healthcare delivered in traditional settings. The provision of accessible, acceptable and opportunistic services which are responsive to the needs of this population is valuable, facilitating a reduced reliance on inappropriate and cost-ineffective emergency department care.<ref>{{Cite journal |last1=Harris |first1=Hobart W. |last2=Young |first2=D. M. |year=2002 |title=Care of injection drug users with soft tissue infections in San Francisco, California |journal=Arch Surg |volume=137 |issue=11 |pages=1217–1222 |doi=10.1001/archsurg.137.11.1217 |pmid=12413304}}</ref><ref>{{Cite journal |last1=Pollack |first1=Harold A. |last2=Khoshnood |first2=Kaveh |last3=Blankenship |first3=Kim M. |last4=Altice |first4=Frederick L. |year=2002 |title=The impact of needle exchange-based health services on emergency department use |journal=Journal of General Internal Medicine |volume=17 |issue=5 |pages=341–348 |doi=10.1007/s11606-002-0037-2 |pmc=1495047 |pmid=12047730}}</ref>

=====Cannabis=====
{{Further| Cannabis (drug)|Legal issues of cannabis|Health issues and the effects of cannabis}}

Specific harms associated with cannabis include increased crash-rate while [[Effects of cannabis#Effects on driving|driving under intoxication]], [[Cannabis dependence|dependence]], [[Long-term effects of cannabis#Psychosis|psychosis]], detrimental psychosocial outcomes for adolescents who use substances, and [[Cannabis-associated respiratory disease|respiratory disease]].<ref>{{Cite web |last1=Wayne Hall |last2=Benedikt Fischer |title=Chapter 8 : Harm reduction policies for cannabis |url=http://www.emcdda.europa.eu/attachements.cfm/att_101262_EN_emcdda-harm%20red-mon-ch8-web.pdf |url-status=dead |archive-url=https://web.archive.org/web/20110114122128if_/http://www.emcdda.europa.eu/attachements.cfm/att_101262_EN_emcdda-harm%20red-mon-ch8-web.pdf |archive-date=14 January 2011 |access-date=11 August 2016 |website=Harm reduction: evidence, impacts, and challenges}}</ref> Some safer cannabis usage campaigns including the UKCIA (United Kingdom Cannabis Internet Activists) encourage methods of consumption shown to cause less physical damage to a person's body, including oral (eating) consumption, vaporization, the usage of bongs which cool and to some extent filters the smoke, and smoking the cannabis without mixing it with tobacco.

The fact that cannabis possession carries prison sentences in most developed countries is also pointed out as a problem by [[European Monitoring Centre for Drugs and Drug Addiction]] (EMCDDA), as the consequences of a conviction for otherwise law-abiding people who use substances arguably is more harmful than any harm from the substance itself. For example, by adversely affecting employment opportunities, impacting civil rights,<ref>{{Cite web |title=Fact Sheet: Impact of Drug Convictions on Individual Lives |url=https://www.kcba.org/druglaw/pdf/drugconviction.pdf |url-status=dead |archive-url=https://web.archive.org/web/20110102162838/https://www.kcba.org/druglaw/pdf/drugconviction.pdf |archive-date=2 January 2011 |access-date=11 August 2016 |website=Kcba.org}}</ref> and straining personal relationships.<ref name="emcdda-cannabis">{{Cite web |title=Chapter 8: Harm reduction policies for cannabis |url=http://www.emcdda.europa.eu/attachements.cfm/att_101262_EN_emcdda-harm%20red-mon-ch8-web.pdf |url-status=dead |archive-url=https://web.archive.org/web/20210809220109/https://www.emcdda.europa.eu/attachements.cfm/att_101262_EN_emcdda-harm%20red-mon-ch8-web.pdf |archive-date=9 August 2021 |access-date=23 June 2010 |vauthors=Hall W, Fischer B}}</ref> Some people like [[Ethan Nadelmann]] of the [[Drug Policy Alliance]] have suggested that organized marijuana legalization would encourage safe use and reveal the factual adverse effects from exposure to this herb's individual chemicals.<ref>{{Cite news |date=13 January 2014 |title=Should Latin America End the War on Drugs? |url=https://www.nytimes.com/roomfordebate/2012/05/30/should-latin-america-end-the-war-on-drugs/regulate-drug-use-dont-criminalize-it |url-status=live |archive-url=https://web.archive.org/web/20230408034200/https://www.nytimes.com/roomfordebate/2012/05/30/should-latin-america-end-the-war-on-drugs/regulate-drug-use-dont-criminalize-it |archive-date=8 April 2023 |access-date=4 March 2017 |work=The New York Times}}</ref>

The way the laws concerning cannabis are enforced is also very selective, even discriminatory. Statistics show that the socially disadvantaged, immigrants and ethnic minorities have significantly higher arrest rates.<ref name="emcdda-cannabis" /> Drug [[decriminalisation]], such as allowing the possession of small amounts of cannabis and possibly its cultivation for personal use, would alleviate these harms.<ref name="emcdda-cannabis" /> Where decriminalisation has been implemented, such as in several states in Australia and United States, as well as in [[Portugal]] and the [[Netherlands]] no, or only very small adverse effects have been shown on population cannabis usage rate.<ref name="emcdda-cannabis" /> The lack of evidence of increased use indicates that such a policy shift does not have adverse effects on cannabis-related harm while, at the same time, decreasing enforcement costs.<ref name="emcdda-cannabis" />

In the last few years certain strains of the [[cannabis]] plant with higher concentrations of [[THC]] and [[drug tourism]] have challenged the former policy in the Netherlands and led to a more restrictive approach; for example, a ban on selling cannabis to tourists in [[Cannabis coffee shop|coffeeshops]] suggested to start late 2011.<ref>{{Cite news |date=27 May 2011 |title=Amsterdam Will Ban Tourists from Pot Coffee Shops |url=http://www.theatlanticwire.com/global/2011/05/amsterdam-ban-pot-sales-tourists/38248/ |url-status=dead |archive-url=https://web.archive.org/web/20181226021612/https://www.theatlantic.com/global/2011/05/amsterdam-ban-pot-sales-tourists/38248/%20 |archive-date=26 December 2018 |access-date=23 June 2011 |work=Atlantic Wire}}</ref> Sale and possession of cannabis is still illegal in Portugal<ref name="Emdrug">{{Cite web |title=Drug policy profiles – Portugal |url=https://www.emcdda.europa.eu/publications/drug-policy-profiles/portugal_en |url-status=live |archive-url=https://web.archive.org/web/20240204162346/https://www.emcdda.europa.eu/publications/drug-policy-profiles/portugal_en |archive-date=4 February 2024 |access-date=14 July 2023 |publisher=Europa (web portal)}}</ref><!--Law 30/2000 – Decriminalisation; The new law of 2000 maintained the status of illegality for using or possessing any drug for personal use without authorisation. However, the offence changed from a criminal one, with prison a possible punishment, to an administrative one." --> and possession of cannabis is a federal crime in the United States.

==== Psychedelics ====
The Zendo Project conducted by the [[Multidisciplinary Association for Psychedelic Studies]] uses principles from [[psychedelic therapy]] to provide safe places and emotional support for people having difficult experiences on psychedelic drugs at select festivals such as [[Burning Man]], [[Boom Festival]], and [[Lightning in a Bottle]] without medical or [[law enforcement]] intervention.<ref>{{Cite web |title=Zendo Project: Psychedelic Harm Reduction |url=https://maps.org/take-action/resources/zendo-project-psychedelic-harm-reduction/ |url-status=live |archive-url=https://web.archive.org/web/20220105181703/https://maps.org/take-action/resources/zendo-project-psychedelic-harm-reduction/ |archive-date=5 January 2022 |access-date=5 January 2022 |website=Multidisciplinary Association for Psychedelic Studies – MAPS |language=en-US}}</ref>

====Stimulants====
[[File:Drugs warning Amsterdam November-2014(3).JPG|thumb|Warning sign in Amsterdam after [[2014 Amsterdam drug deaths|3 tourists died]] after taking white heroin that was sold as cocaine]]

The [[United Nations Office on Drugs and Crime]] states, "While medical models of treatment for individuals with alcohol or opioid use disorders are well accepted and implemented worldwide, in most countries there is no parallel, long-term medical model of treatment for individuals with stimulant use disorders."<ref>{{Cite web |title=TREATMENT OF STIMULANT USE DISORDERS: CURRENT PRACTICES AND PROMISING PERSPECTIVES |url=https://www.unodc.org/documents/drug-prevention-and-treatment/Treatment_of_PSUD_for_website_24.05.19.pdf}}</ref> The neglect of stimulant-users has been widely considered to be related to the popularity of stimulants among systemically-oppressed groups, such as methamphetamine use among gay men and transgender people, and crack cocaine use among Black people.<ref>{{Cite news |last=Mangia |first=Jim |date=22 January 2020 |title=Opinion {{!}} Gay Men Are Dying From a Crisis We're Not Talking About |url=https://www.nytimes.com/2020/01/22/opinion/gay-meth-addiction.html |url-status=live |archive-url=https://web.archive.org/web/20230210184633/https://www.nytimes.com/2020/01/22/opinion/gay-meth-addiction.html |archive-date=10 February 2023 |access-date=10 February 2023 |work=The New York Times |language=en-US |issn=0362-4331}}</ref><ref>{{Cite web |last=Urell |first=Aaryn |date=9 December 2019 |title=Crack vs. Heroine Project: Racial Double Standard in Drug Laws Persists Today |url=https://eji.org/news/racial-double-standard-in-drug-laws-persists-today/ |url-status=live |archive-url=https://web.archive.org/web/20230210093745/https://eji.org/news/racial-double-standard-in-drug-laws-persists-today/ |archive-date=10 February 2023 |access-date=10 February 2023 |website=Equal Justice Initiative |language=en-US}}</ref> The [[crack epidemic in the United States]] demonstrates a discrepancy between sentencing lengths of crack cocaine and heroin users, with crack users imprisoned for longer periods of time than heroin users. In 2012, 88% of imprisonments from crack cocaine were of African American people.<ref>{{Cite report |url=https://bjs.ojp.gov/content/pub/pdf/dofp12.pdf |title=Drug offenders in federal prison: Estimates of characteristics based on linked data |last1=Taxy |first1=S |last2=Samuels |first2=J |date=October 2015 |publisher=US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics |place=Washington, DC |last3=Adams |first3=W}}</ref>

Stimulant users have increasingly been at risk for opioid overdose since 2006, due to the nonconsensual presence of fentanyl in their substances.<ref>{{Cite journal |last=Centers for Disease Control Prevention (CDC) |date=July 2008 |title=Nonpharmaceutical fentanyl-related deaths – multiple states, April 2005 – March 2007 |url=https://www.cdc.gov/mmwr/PDF/wk/mm5729.pdf |journal=MMWR Morb Mortal Wkly Rep |volume=57 |issue=29 |pages=793–796 |pmid=18650786 |archive-url=https://web.archive.org/web/20221202101157/https://www.cdc.gov/mmwr/PDF/wk/mm5729.pdf |archive-date=2 December 2022 |access-date=2 December 2022}}</ref>

=====Tobacco=====
{{Main|Tobacco harm reduction}}
Tobacco harm reduction describes actions taken to lower the health risks associated with using tobacco, especially combustible forms, without abstaining completely from tobacco and nicotine. Some of these measures include switching to safer (lower tar) cigarettes, switching to [[snus]] or [[dipping tobacco]], or using a non-tobacco nicotine delivery systems. In recent years, the growing use of [[electronic cigarette]]s (or vaping) for [[smoking cessation]], whose long-term safety remains uncertain, has sparked an ongoing controversy among medical and public health between those who seek to restrict and discourage all use until more is known and those who see them as a useful approach for harm reduction, whose risks are most unlikely to equal those of smoking tobacco.<ref>{{Cite journal |last1=Farsalinos |first1=Konstantinos |last2=LeHouezec |first2=Jacques |date=September 2015 |title=Regulation in the face of uncertainty: the evidence on electronic nicotine delivery systems (e-cigarettes) |journal=Risk Management and Healthcare Policy |volume=8 |pages=157–167 |doi=10.2147/RMHP.S62116 |pmc=4598199 |pmid=26457058 |doi-access=free}}</ref> "Their usefulness in tobacco harm reduction as a substitute for [[tobacco products]] is unclear",<ref name="Drummond2014">{{Cite journal |last1=Drummond |first1=M. Bradley |last2=Upson |first2=Dona |date=February 2014 |title=Electronic Cigarettes. Potential Harms and Benefits |journal=Annals of the American Thoracic Society |volume=11 |issue=2 |pages=236–242 |doi=10.1513/AnnalsATS.201311-391FR |pmc=5469426 |pmid=24575993}}</ref> but in an effort to [[tobacco control movement|decrease tobacco related death and disease]], they have a potential to be part of the strategy.<ref name="Cahn2011">{{Cite journal |last1=Cahn |first1=Zachary |last2=Siegel |first2=Michael |date=February 2011 |title=Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes? |journal=Journal of Public Health Policy |volume=32 |issue=1 |pages=16–31 |doi=10.1057/jphp.2010.41 |pmid=21150942 |doi-access=free}}</ref>