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Drug use and harm reduction: public health aspects

In this video, Annette Verster from WHO provides a global overview drug use and harm reduction and focusses on a public health dimension.
When we talk about drugs, it’s important to distinguish between different types of drugs and the route of administration of the drugs. So when we talk about types of drugs, heroin and opioids, cannabis, stimulants, amphetamines, and we also have tobacco and alcohol. And on a global stage, we need to remind ourselves that the numbers of people who use tobacco and alcohol is many times higher than any of the illegal substances, and that also the related harms are much higher. The harms of illegal substances are more linked to the route of administration. So injecting tends to be more risky because it brings with it the risk of infectious disease transmission such as HIV and hepatitis.
And also overdose risk is higher when people inject. It is estimated that around 275 million people use an illegal substance in the year 2017. This is data from the UNODC World Drug Report from last year 2019. Around thirty five million people used stimulants, around 50 million used opioids. Of these, 275 million people who used a substance, around 10 % can be classified as harmful use. There’s around 12 million people around the world who inject this estimated. We estimate that around 10% of them are infected with HIV and around 50 to 60 % of them are infected with hepatitis C. So they’re the people we tend to focus on with our responses.
If you look at the infectious diseases globally, a lot of attention has gone to HIV. There are around 37 million people living with HIV globally, and it is estimated that around
And there are 71 million people living with hepatitis C. And although only 8% of these have been infected through injecting drug use, we have been able to estimate what the percentage of new infections of hepatitis C is. And that is. And we can see that around 23-39% of new infections with hepatitis C are attributable to injecting drug use. And likewise, if you look at mortality rates for hepatitis C, one in three deaths are attributable to injecting drug use. In addition to the health risk of infectious diseases such as HIV and hepatitis and TB, there are other health risk and one of the main ones recently in particular is overdose death. And it was calculated by that last year,
So that’s why the Department of HIV and Hepatitis is interested in in drug use. And because there are actually these deaths and these harms and infections can be easily prevented. When you look at infectious diseases, it’s important to understand that there are generalised epidemics where everybody is at risk of infection and there are concentrated epidemics where it’s predominantly concentrated in populations because of their behavior. It is still important to focus on people with increased risk, such as people who inject drugs even in generalised epidemics.
If you don’t focus on people at increased risk, as I said, like 22 times more at risk or at higher risk than the general population, if you inject drugs for HIV, then and if you don’t focus on this population The epidemic will not stop. And of course, people who use and inject drugs have partners, sexual partners. They’re part of the community to make use for a while and not use for a while. So it is really critical to focus on people at increased risk. In addition to health risk, It’s also important to to consider social risk. And I think the top social risk is probably incarceration because
because of the environment. So it’s important to when you think of services to include close settings and people in prisons with these services.
Over the last decade we have looked at the evidence of a range of interventions and on the basis of that, come up with the public health package to addressing drug use and related problems. And we call this harm reduction And our focus comes a little bit from the infectious disease perspective. But of course, harm reduction is broader than looking just at the health aspects. But the package of interventions includes the provision of needle and syringe programs, the provision of sterile injecting equipment for people who inject drugs. We have really synthesized the evidence around the effectiveness of providing injecting equipment, sterile injecting equipment to people who inject drugs, and it’s highly effective.
Another important intervention, of course, is to provide evidence based treatment to people who are dependent or we have very good treatment for opioid dependence.
In addition to this to this treatment of opioid dependence, it to treat other substance use is a little bit more difficult because we do not have a similar medication that is as effective to treat other forms of dependence or with regard to stimulant use. The focus tends to be more on psychosocial support around and harm reduction, more broadly speaking, around this type of of use when there are problems around it. Other interventions in this public health package includes access to testing and treatment of infectious diseases.
So HIV testing and treatment and very important is the development in the last few years around hepatitis C that there is now a cure and we can treat and cure hepatitis C in people infected. And this is become increasingly important because we see that with regard to access to testing and treatment, people who use drugs always tend to lag behind. And one also important issue is that behaviors of people are criminalised in many countries and drug use. And so consumption and possession of personal use is criminalized in many, many countries. And this makes access to these services very difficult.
So that’s why, WHO even though we are a public health agency, have included the the intervention to recommend to countries to review their laws and legislation and to work towards decriminalization of use and possession for personal use. There are some other important structural structural barriers to look at stigma and discrimination is another one. And it’s, of course, related to criminalization. But in the health sector, we often see that people do not understand what substance use or substance dependence really is and how to manage and how to help people and support people. This is also related to other structural issues such as violence. And so that’s why we recommend a comprehensive package of health interventions and structural interventions.
And this is what we call harm reduction.
It is important that countries prioritize needle syringe programs, opioid substitution therapy or other treatment for other drug dependence and also provide naloxone. If people going overdose and provide them with naloxone, they survive. So it is WHO a recommendation to give this to communities, to people who are likely to assist in or be present at an overdose event. And the importance of this overall package is that you don’t just pick one or two, but that you really try to provide a set of these interventions, all of them together. And the more you do, the more impact you will have on health management of substance use, but also on infectious disease transmission.
Harm reduction is an evidence based approach, and we see, however, if you look at the overall coverage of the interventions that are recommended, this is very low and we see that at the global level, maybe half the countries that report injecting drug use and opioid dependence actually implement these services. And then if you look at where they are implemented, the scale of it and the coverage of these programs is very low. There’s actually a paper in The Lancet in 2017 that calculated that less than 1% of people who inject drugs have sufficient coverage or sufficient access to these lifesaving services. And this is important for the people themselves, but also for public health.
And if we really want to minimize the epidemics of HIV and hepatitis, the coverage of these services have to be really increased.

Now that we better understand what harm reduction stands for, how big is the problem it is trying to tackle? In the video above, Annette Verster will talk about the scale of drug use and the related health impact, as well as looking at some of the global UN recommendations on evidence based policies.

We will look into the burden of disease related to legal and illegal substances, and the different ways of using drugs. This session further illustrates the global scale of drug use and associated public health issues.

As you have heard in the first topic of this week “what is harm reduction”, we will hear about some of the core components of a comprehensive harm reduction package, as recommended by the UN agencies.

As you have heard from Dr. Magdalena Harris in the previous Step, the health consequences of drug use are often associated with contextual factors, and not just because of the drugs themselves. This is further reflected in some of the recommendations from the WHO to review country laws and legislations and to work towards decriminalization of use and possession for personal use.

We will look further into the notion of decriminalisation in week 3 of this course.


You will find several reports attached with more details on the public health notion of drug use. We highly recommend to have a look at the “consolidated guidelines on HIV prevention, diagnosis, treatment and care of key populations” from the WHO. This is a very rich document and in the executive summary you will find a useful summary of the recommendations.

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Drug Use and Harm Reduction

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