Drug Treatment Matrix cell E1: Local and national systems; Reducing harm

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Alcohol Treatment Matrix

Effectiveness Bank Alcohol Treatment Matrix

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Effectiveness Bank Drug Treatment Matrix

Includes harm reduction

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Local and national systems; Reducing harm

Seminal and key studies relating to local, regional and national systems for effectively and cost-effectively reducing harm.

S Seminal studiesK Key studiesR ReviewsG Guidancemore Search for more studies

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S Wake up call to tackle “sleeping giant” of hepatitis C (1993). It was in the early ’90s when Roger Holmes and Dr Tom Waller alerted Britain to the (until 1989) invisible hepatitis C epidemic: “It may be wise to let sleeping dogs lie, but not sleeping giants,” warned the authors. Though not letting the virus lie, Britain has yet to mount an offensive commensurate with the epidemic. For related discussion click here and scroll down to highlighted heading.

S Methadone clinic staff influenced to adopt a more pro-maintenance stance (1998). In Australia an official campaign and educational efforts shifted staff preferences from withdrawal and abstinence towards long-term treatment aimed at reducing harm. The campaign helped de-link disapproval of drug use from an abstinence-only orientation.

K Controlling hepatitis C requires methadone and needle exchange plus treatment of infection (2012). Simulation model highlights the need to increase the proportion of injectors concurrently engaged in adequate needle exchange and methadone services, and also to extend effective treatment of hepatitis C infection. UK predictions based on a synthesis of six studies which calculated that injectors who had consistently been in methadone maintenance treatment and had adequate access to fresh injecting equipment were only a fifth as likely to become infected as injectors whose service use fell short of these benchmarks. Similar message below from Scotland and the Netherlands. For discussions click here and/or here and scroll down to highlighted headings.

K New hepatitis C infections in Scotland halved as exchanges and methadone meet needs of higher proportions of injectors (2014). A combination of needle exchange, methadone maintenance and a shift away from injecting meant that between 2008 and 2012, 1000 fewer Scottish injectors had to face chronic infection with hepatitis C. Similar message above from the UK as a whole and below from the Netherlands. For related discussions click here and/or here and scroll down to highlighted headings.

K Combined high impact treatment/exchange reduces infection risk in Amsterdam (2007). Only injectors who benefited both from adequate dose methadone maintenance and high coverage needle exchange were less likely to become infected with HIV or hepatitis C. Similar message above from the UK as a whole and from Scotland. For related discussions click here and/or here and scroll down to highlighted headings.

K Build your mortality-reduction system on long-term opioid substitute prescribing (2015). Estimates that across the entire population of problem opiate users in England, between 2008 and 2011 addiction treatment (mainly substitute prescribing) reduced opioid-related overdose deaths from what would have been 6372 to 3731. From other UK (1 2 3) and international studies (cell C1) we know that prescribing needs to be long-term to maximally save lives.

K Low threshold methadone extends life expectancy in Barcelona (2005). Mainly due to fewer overdoses, on average 21 years were added to the lives of heroin users entering treatment when across the city methadone maintenance was made easier to enter and stay in, raising the issue of whether to extend access to programmes oriented to harm-reduction or reach fewer patients with more recovery-oriented services. For discussion click here and scroll down to highlighted heading.

Trends in maintenance prescribing and deaths and hospital admissions due to opiate dependence or misuse in Stockholm 2000–2006. Shows how deaths and illness fell as treatment expanded

K De-restricting opioid substitute prescribing in Sweden led to reductions in opiate-related deaths and illness (2010). Expanded access, advent of buprenorphine, and a stronger focus on retention, were among the changes followed by a reduction in opiate-related deaths, suggesting that the previously highly restricted access and more disciplinary approach to illegal drug use had cost lives chart. For related discussion click here and scroll down to highlighted heading.

K Outlet diversification helped cut HIV risk in Vancouver (2010). Among the policy changes which seem to have led to a step down in risk behaviour and HIV incidence were decentralising and diversifying needle and syringe provision to more exchange sites and generic and peer-led services, and separating equipment supply from collection of used equipment. More in an Effectiveness Bank case study of Vancouver (turn to p. 3 of the PDF file, numbered p. 26) and a review of research on HIV and needle exchange in the city.

K Finland’s national programme reverses HIV escalation (Finnish National Public Health Institute and Department of Infectious Disease Epidemiology and Control, 2008). Steeply rising HIV incidence in injectors reversed in Finland shortly after it launched a national health counselling and needle exchange programme. Emerging challenge was how to retain a harm-reduction focus and user-friendly ethos while extending access by integrating exchange into mainstream health services.

R Diversify injecting equipment outlets and combine with treatment and health care (2013). Extensive UK review updated in 2013 which underpinned the NICE guidance below. To control infection supports a combination of injecting equipment provision from outlets including mobile services and vending machines to attract different user groups, methadone maintenance, integrated health care, and promotion of treatment entry.

R Combine high-coverage needle exchange with opioid substitute prescribing to prevent spread of hepatitis C (2017). Amalgamated results from studies of injectors indicate that spread of hepatitis C has been prevented by programmes like methadone maintenance and (in Europe) high-coverage needle exchange. Used together by the same injector these services are yet more strongly associated with fewer infections. Based on analysis (2017) conducted for the Cochrane collaboration. Similar earlier analysis (2011) also found no evidence that other types of treatments, or programmes to encourage disinfection of used needles and syringes, had the same effects. For related discussions click here and/or here and scroll down to highlighted headings.

R WHO review finds needle and syringes needed but not enough to prevent HIV spread (World Health Organization, 2004). WHO-commissioned experts conclude needle and syringe provision is necessary but not sufficient to control HIV. Also needed are education, substitute prescribing and community development. Findings also in two journal articles (1 2).

G NICE says good quality addiction treatment incorporates harm reduction ([UK] National Institute for Health and Clinical Excellence, 2012). According to the UK’s official health intervention assessor, the markers of a good quality drug treatment service include offering testing and referral for treatment for hepatitis B, hepatitis C and HIV infections, vaccination against hepatitis B, advice about harm-reduction options, and continued treatment or support for at least six months after patients have become abstinent.

G UK harm reduction systems should deliver more equipment than injectors need ([UK] National Institute for Health and Clinical Excellence, 2014). UK’s official health intervention assessor recommends that commissioners assess coverage and aim for every injector to have even more sterile injecting equipment than they need for every injection. Based on review above. NICE-endorsed checklist (2015) can be used to audit compliance with the guidance.

G Commissioning to prevent and treat blood-borne infections (Public Health England, 2015). Information and checklist of action-prompts for substance use service commissioners. Reflects the chapter on addressing health harms in overall commissioning advice (Public Health England, 2017).

G UN guide on planning, coordinating and managing HIV and hepatitis C programmes for injectors (United Nations Office on Drugs and Crime, 2017). Shows what a comprehensive national or regional programme would look like, from community empowerment, law reform and destigmatisation to specific services including needle exchange, substitute prescribing, treatment of infection, naloxone distribution, risk-reduction education, and addressing sexual transmission. For discussion click here and scroll down to highlighted heading.

G Seven key components of anti-disease strategy for injectors (European Centre for Disease Prevention and Control and European Monitoring Centre for Drugs and Drug Addiction, 2011). Identifies seven key intervention components which when combined generate maximal synergistic impact, including needle exchange, treatment of both addiction and infections, testing for infection, vaccination, and health promotion. For discussion click here and scroll down to highlighted heading.

G WHO “strongly recommends” needle exchange and maintenance prescribing to prevent HIV transmission (World Health Organization, 2014). Consolidates WHO guidance on HIV prevention, diagnosis, treatment and care for key populations including prisoners and people who inject drugs. Strongly advocates universal access of injectors to needle exchange and of dependent opioid users to indefinite, high-dose methadone and buprenorphine maintenance.

G Scottish guidance on running and commissioning needle exchanges (Scottish Government, 2010). Includes needs assessment, locations, opening hours, staff training, policies on providing injecting equipment, and integration with other services.

G UK government’s advisers outline strategy to reduce opioid-related deaths ([UK] Advisory Council on the Misuse of Drugs, 2016). UK’s official drugs policy advisory body stresses the need to maintain investment in harm-reduction oriented substitute prescribing and to assertively reach out to heroin users to engage them in treatment, but also to provide naloxone, heroin-assisted treatment, drug consumption clinics, and treatment for alcohol problems, and to improve access to medical, mental health and welfare services which could reduce vulnerability to drug-related death.

G Local area systems to curb drug-related deaths (Public Health England, 2014). Checklist for service commissioners/planners offering ideas for reducing deaths by (among other things) promoting consistent attention to the issue across local services and ensuring they collaborate to safely see patients through transitions between service types and treatment phases.

G Opioid overdose deaths – intervention menu and social determinants (European Harm Reduction Network [etc], 2014). EU-funded guidelines from European experts in drug-related deaths. Provides a menu of specific interventions but also analyses risk-inducing environmental factors such as poverty, lack of education, discriminatory drug laws, insufficient or prohibited services, and marginalising attitudes producing stigma and fear. For related discussion click here and scroll down to highlighted heading.

G Responding to public injecting in a British city ([Scotland] NHS Greater Glasgow and Clyde, 2016). Report which led to preparations for a centre in Glasgow where injectors can more safely inject. Recommendations offer a template for a coordinated response in cities affected by public injecting.

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For subtopics go to the subject search page and this Effectiveness Bank hot topics on controlling the spread of hepatitis C, safer injecting centres, and the need for counselling in substitute prescribing programmes.

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