What's in a Name?

How important is it for the addiction field to continue to use the phrase ‘harm reduction’ to capture the shared rationale for a package of interventions that reduce the adverse impact that injecting drug use has on the health of users and public health? Those who fought to have these measures introduced two decades ago in the face of considerable opposition may understandably favour its retention [1]. The more pragmatic observer may wonder whether it is worth retaining a term that means so many different things to different people and that provokes such strongly opposed views. Harm reduction is anathema to North American drug warriors, who regard it as a Trojan horse for ‘legalization’: a none-too-precise term that covers a range of more liberal drug policies that are advocated by some in the harm reduction movement. These range from medical prescription of heroin to registered addicts to the more radical (and less plausible) view that all the harms of illicit drugs would disappear if they were made legal, as are alcohol and tobacco. In this pragmatic view ‘harm reduction’ has probably reached its ‘use-by date’, having exceeded the usual half-life of a terminology in the addictions field of around 20 years. It is time we found another phrase that will serve the same purpose. I am inclined to the pragmatic view, perhaps because I entered the addictions field after the battles for needle and syringe programmes had been won in Australia. The major advantage of ‘harm reduction’ from my perspective is that it serves as a shorthand for a package of interventions for which there is the happy conjunction of good evidence of public health benefit and a good case for providing on humanitarian grounds; namely, providing clean injecting equipment to injecting drug users (IDU); agonist maintenance treatment for opioid dependence; education about blood-borne virus (BBV) risk behaviour and ways of reducing it; HIV testing and counselling; and access to antiretroviral therapy (ART) and more effective treatments for hepatitis C virus (HCV) to IDU infected with these BBV. If better evidence becomes available, one might add to the list supervised injecting facilities in settings with high rates of high-risk street injecting. One can add to the disadvantages of ‘harm reduction’ that have already been mentioned the growing controversy within the tobacco control community about ‘tobacco harm reduction policies’; that is, policies that aim to reduce the harms caused by tobacco smoking by encouraging tobacco smokers who do not want to quit to shift to non-smoked forms of tobacco. For all these reasons, I suggest that we simply describe the strategies collected currently under the ‘harm reduction’ banner (and any new measures that prove to be similarly efficacious) as ‘public health’ measures for injecting drug use and HIV/AIDS. After all, that is what they are and that is how they can best be justified.