Evaluating national harm reduction progranns

Evaluating an individual harm reduction program is quite difficult. Practical and ethical concerns usually prevent the use of 'gold standard' randomized clinical trial methods for assessing efficacy and assigning causation to the intervention. Assessing a national program of harm reduction programs is even more difficult. One must be concerned about variation in the implementation of the different programs and possible interactions of different programs as well as different historical trends in the country as a whole or in regions of the country. Emmanuelli and Desenclos (this issue) [1] make an important and generally successful attempt to assess the harm reduction programs implemented in France from 1996 to 2003. There were complex patterns in the data. The numbers of syringes sold or distributed first rose and then fell. The number of people receiving methadone and buprenorphine treatment rose continuously. Syringe sharing and HIV prevalence declined, but HCV prevalence did not. Heroin overdoses and heroin arrests declined, but cocaine arrests rose. Given the complexity of these results. Emmanuelli and Desenclos were not able to apply any standard statistical techniques such as timelagged correlations to assess the strength of any associations among these variables. Nevertheless, taken in the context of much other relevant research, the data presented by Emmanuelli and Desenclos suggest that the sterile syringe programs and the substitution treatment programs did lead to reductions in HIV and heroin use without having effects on HCV transmission or cocaine use. The increase in buprenorphine and methadone treatment probably did lead to the reductions in heroin overdoses and heroin arrests. There is now a very considerable body of scientific evidence showing that harm reduction programs can be effective. I would like to suggest three specific questions for a next generation of policy and research questions. 1 Why do harm reduction programs not work all of the time for all desired outcomes.' The HCV data from the Emmanuelli and Desenclos study are certainly discouraging. There is no evidence the programs led to reduction in HCV infection among IDUs in France. 2 How big do harm reduction programs have to be to address problems successfully at the community level.'
© 2005 Society for the Study of Addiction

One of the important aspects of the paper is that it provides data on the scale of the harm reduction programs implemented in France—an estimated 17.7 million sterile syringes in the peak year of 1999 and an estimated 101 000 drug users receiving substitution treatment in the peak year of 2003. The paper would be strengthened if the authors had included estimates of the numbers of active IDUs not in treatment for each of the years in the 1996-2003 time-period so that the reader could estimate the numbers of syringes distributed per drug injector per year and the percentage of drug injectors receiving treatment each year. Determining the 'coverage' needed for harm reduction programs to achieve community level positive effects is a critical question for preventing HIV epidemics and other drug related harms in resource constrained settings [2]. 3 How do we insure that 'user friendliness' is incorporated into harm reduction programs.' Many harm reduction programs include critical biological components—syringes from an exchange or pharmacy are certain to not be contaminated with HIV or HCV, methadone and buprenorphine are potent medications. Nevertheless, the 'user friendliness' of harm reduction programs may be a necessary component of their effectiveness. 'User friendliness' would include treating drug users with dignity and respect, providing convenient locations and hours of operation and requiring a minimum of bureaucratic hassle to receive services. Emmanuelli and Desenclos do not provide any systematic data on the 'user friendliness' of the French harm reduction programs, although they do note that methadone treatment is much more highly regulated than buprenorphine treatment in France. There may be a very common tendency for political leaders to approve controversial harm reduction programs with restrictions that serve to substantially reduce user friendliness and the effectiveness of the programs [3]. Limiting the numbers of syringes that can be exchanged per visit to an exchange and imposing very restrictive eligibility requirements on substitution treatment are examples of this tendency. The paper by Emmanuelli and Desenclos provides very important observational data indicating the effectiveness of various harm reduction programs in France from 1996 to 2003.
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The paper also leads to policy and research questions that need to be addressed if the full potential of programs to
reduce drug related h a r m is to be achieved, DON C, DES JARLAIS Baron Edmond de Rothschild Chemical Dependency Institute I' ^ Beth Israel Medical Center and National Development and Research Institutes, Inc. Eirst Avenue at 16th Street New York Citu NY 10003 ^' USA E-mail: Dcdesjarla@aol.com

1, Emmanuelli, J, & Desendos, J,-C, (2005) Harm reduction interventions, behaviours and associated health outcomes in France, 1996-2003, Addiction. TOO, 1690-1700, 2, Burrows, D, (in press) HIV prevention among injecting drug "'^•"^'" developing and transitional countries: high coverage is feasible, UNAIDS/WHO/World Bank Report, in press, 3 p , , j^.i^i, ^ c,, Paone, D,, Friedman, S, R,, Peyser, N, & Newman, R, G, (1995) Regulating controversial programs for unpopular people: methadone maintenance and syringe exchange programs, American journal of Public Health. 85, 1577-1584,

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