Harm Reduction Journal

Background:
Injection drug users (IDU) commonly seek manual assistance with illicit drug injections, a practice known to be associated with various health-related harms. We investigated the social structural factors that shape risks related to assisted injection and the harms that may result.
Methods:
Twenty semi-structured qualitative interviews were conducted with IDU enrolled in the ACCESS or Vancouver Injection Drug Users Study (VIDUS) who reported requiring assistance injecting in the past six months. Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted.
Results:
Barriers to self-injecting included a lack of knowledge of proper injecting technique, a loss of accessible veins, and drug withdrawal. The exchange of money or drugs for assistance with injecting was common. Harms experienced by IDU requiring assistance injecting included theft of the drug, missed injections, overdose, and risk of blood-borne disease transmission. Increased vulnerability to HIV/HCV infection within the context of intimate relationships was represented in participant narratives. IDU identified a lack of services available for those who require assistance injecting, with notable mention of restricted use of Vancouver's supervised injection facility.
Conclusions:
This study documents numerous severe harms that arise from assisted injecting. Social structural factors that shape the risks related to assisted injection in the Vancouver context included intimate partner relations and social conventions requiring an exchange of goods for provision of injecting assistance. Health services for IDU who need help injecting should include targeted interventions, and supervised injection facilities should attempt to accommodate individuals who require assistance with injecting.

Background:
Substance use during pregnancy often leads to involvement in the child welfare system, resulting in multiple social service systems and service providers working with families to achieve successful child welfare outcomes. The Vulnerable Infants Program of Rhode Island (VIP-RI) is a care coordination program developed to work with perinatal substance-users to optimize opportunities for reunification and promote permanency for substance-exposed infants. This paper describes services used by VIP-RI participants and child welfare outcomes.
Methods:
Data collected during the first four years of VIP-RI were used to identify characteristics of program participants, services received, and child welfare outcomes: closed child welfare cases, reunification with biological mothers and identified infant permanent placements.Descriptive Results: Medical and financial services were associated with positive child welfare outcomes. Medical services included family planning, pre- and post-natal care and HIV test counseling. Financial services included assistance with obtaining entitlement benefits and receiving tangible support such as food and clothing.
Conclusions:
Findings from this study suggest services that address basic family needs were related to positive child welfare outcomes. The provision of basic services, such as health care and financial assistance through entitlement benefits and tangible donations, may help to establish a foundation so mothers can concentrate on recovery and parenting skills. Identification of services for perinatal substance users that are associated with more successful child welfare outcomes has implications for the child welfare system, treatment providers, courts and families.

Background:
Tobacco retailers are potential public health partners for tobacco harm reduction (THR). THR is the substitution of highly reduced-risk nicotine products, such as smokeless tobacco (ST) or pharmaceutical nicotine, for cigarettes. The introduction of a Swedish-style ST product, du Maurier snus (dMS) (Imperial Tobacco Canada Limited), which was marketed as a THR product, provided a unique opportunity to assess retailers' knowledge. This study examined retailers' knowledge of THR and compliance with recommendations regarding tobacco sales to young adults.
Methods:
Male researchers, who may have looked younger than 18 years old, visited 60 stores in Edmonton that sold dMS. The researchers asked the retailers questions about dMS and its health risks relative to those from other tobacco products. They also attempted to purchase dMS to ascertain whether retailers would ask for identification to verify that they were at least 18 years old.
Results:
Overall, the retailers were only moderately knowledgeable about THR and the differences between dMS and other tobacco products. About half of the retailers correctly indicated that snus is safer than cigarettes; half of whom knew it is safer because it is smoke-free. Fifty percent incorrectly believed that snus causes oral cancer. Less than fifty percent indicated that dMS differs from chewing tobacco because it is in pouches and is used without spitting or chewing (making it more promising for THR). Most (90%) of the retailers asked the researchers for identification when selling dMS.
Conclusion:
Tobacco retailers are potentially important sources of information about THR, particularly since there are restrictions on the promotion of all tobacco products (regardless of the actual health risks) in Canada. This study found that many retailers in Edmonton do not know the relative health risks of different tobacco products and are therefore unable to pass on accurate information to smokers.

Drug use is prevalent throughout prison populations, and, despite advances in drug treatment programmes for inmates, access to and the quality of these programmes remain substantially poorer than those available for non-incarcerated drug users. Because prisoners may be at greater risk for some of the harms associated with drug use, they deserve therapeutic modalities and attitudes that are at least equal to those available for drug users outside prison. This article discusses drug use by inmates and its associated harms. In addition, this article provides a survey of studies conducted in prisons of opioid substitution therapy (OST), a clinically effective and cost-effective drug treatment strategy. The findings from this overview indicate why treatment efforts for drug users in prison are often poorer than those available for drug users in the non-prison community and demonstrate how the implementation of OST programmes benefits not only prisoners but also prison staff and the community at large. Finally, the article outlines strategies that have been found effective for implementing OST in prisons and offers suggestions for applying these strategies more broadly.

Background:
Solvent abuse is a particularly serious issue affecting Aboriginal people. Here we examine the association between solvent use and socio-demographic variables, drug-related risk factors, and pathogen prevalence in Aboriginal injection drug users (IDU) in Manitoba, Canada.
Methods:
Data originated from a cross-sectional survey of IDU from December 2003 to September 2004. Associations between solvent use and variables of interest were assessed by multiple logistic regression.
Results:
A total of 266 Aboriginal IDU were included in the analysis of which 44 self-reported recent solvent use. Hepatitis C infection was 81% in solvent-users, compared to 55% in those reporting no solvent use. In multivariable models, solvent-users were younger and more likely to be infected with hepatitis C (AOR: 3.5; 95%CI: 1.3,14.7), to have shared needles in the last six months (AOR: 2.6; 95%CI:1.0,6.8), and to have injected talwin & Ritalin (AOR: 10.0; 95%CI: 3.8,26.3).Interpretation: High hepatitis C prevalence, even after controlling for risky injection practices, suggests that solvent users may form closed networks of higher risk even amongst an already high-risk IDU population. Understanding the social epidemiological context of inititation and maintenance of solvent use is necessary to address the inherent inequalities encountered by this subpopulation of substance users, and may inform prevention strategies for other marginalized populations.

Background:
An important challenge in conducting social research of specific relevance to harm reduction programs is locating hidden populations of consumers of substances like cannabis who typically report few adverse or unwanted consequences of their use. Much of the deviant, pathologized perception of drug users is historically derived from, and empirically supported, by a research emphasis on gaining ready access to users in drug treatment or in prison populations with higher incidence of problems of dependence and misuse. Because they are less visible, responsible recreational users of illicit drugs have been more difficult to study.
Methods:
This article investigates Respondent Driven Sampling (RDS) as a method of recruiting experienced marijuana users representative of users in the general population. Based on sampling conducted in a multi-city study (Halifax, Montreal, Toronto, and Vancouver), and compared to samples gathered using other research methods, we assess the strengths and weaknesses of RDS recruitment as a means of gaining access to illicit substance users who experience few harmful consequences of their use. Demographic characteristics of the sample in Toronto are compared with those of users in a recent household survey and a pilot study of Toronto where the latter utilized nonrandom self-selection of respondents.
Results:
A modified approach to RDS was necessary to attain the target sample size in all four cities (i.e., 40 'users' from each site). The final sample in Toronto was largely similar, however, to marijuana users in a random household survey that was carried out in the same city. Whereas well-educated, married, whites and females in the survey were all somewhat overrepresented, the two samples, overall, were more alike than different with respect to economic status and employment. Furthermore, comparison with a self-selected sample suggests that (even modified) RDS recruitment is a cost-effective way of gathering respondents who are more representative of users in the general population than nonrandom methods of recruitment ordinarily produce.
Conclusions:
Research on marijuana use, and other forms of drug use hidden in the general population of adults, is important for informing and extending harm reduction beyond its current emphasis on 'at-risk' populations. Expanding harm reduction in a normalizing context, through innovative research on users often overlooked, further challenges assumptions about reducing harm through prohibition of drug use and urges consideration of alternative policies such as decriminalization and legal regulation.

Using Geographic Information System (GIS), the spatial distribution of methadone clinic clients and their utilization of a treatment service in Hong Kong was analysed. A majority (93.7%) of the 63 methadone users recruited were residing in the same district, of which 84.1% spent not more than 15 minutes for traveling. Walking (55.6%) was the commonest transport mode followed by cycling (30.2%). There was no distance decay effect on traveling time, but an association between distance and transport selection could be demonstrated. The residence locations displayed a compact distribution, merging with the general population without any evidence of clustering. Though the distribution of methadone users could have been shaped by the location of clinic, it can also be concluded that methadone clinics at convenient locations are needed if maintenance is a key determinant of service effectiveness.

Recent work has criticized the evidence base for the effectiveness of addiction treatment under social controls and coercion, suggesting that the development of sound policies and treatment practices has been hampered by numerous limitations of the research conducted to date. Implicit assumptions of the effectiveness of coerced treatment are evident in the organization and evolution of treatment, legal, and social service systems, as well as in related legislative practices. This review builds upon previous work by focusing in greater detail on the potential value of incorporating client perspectives on coercion and the implications for interpreting and applying existing research findings. Reviewing the existing empirical and theoretical literature, a case is made for greater accuracy in representing coercive experiences and events in research, so as to better align the measured concepts with actual processes of treatment entry and admission. Attention is given to studies of the effectiveness of treatment under social controls or pressures, the connections to coercion and decision-making, and theoretical perspectives on motivation and behaviour change, including Self-Determination Theory in particular. This synthesis of the available research on coerced addiction treatment suggests that it remains largely unclear to what extent many of the commonly employed methods for getting people into treatment may be detrimental to the treatment process and longer-term outcomes. The impact of coercion upon individual clients, treatment systems, and population health has not been adequately dealt with by addiction researchers to date.

Background:
The severity of HIV/AIDS pandemic linked to injecting drug use is one of the most worrying medical and social problems throughout the world in recent years. Myanmar has one of the highest prevalence rates of HIV among the IDUs in the region.AimThe objective of the study was to determine the risk behaviours among HIV positive injecting drug users in Myanmar.
Methods:
A non matched case control study was conducted among 217 respondents registered with a non governmental organization's harm reduction center. 78 HIV positive IDUs were used as cases and 139 non HIV positive IDUs as controls. The study was conducted between April-May 2009. Data was analysed using SPSS version 15 and the study was ethically conducted.
Results:
Factors like age, marital status, age first used drugs, drug use expenditure, reason for drug use, age first used injection were found to be significant. Other risk factors found significantly associated with HIV among IDU were education (OR 2.3), location of respondent (OR 2.4) type of syringe first used (OR 5.1), sharing syringe at the first injection (OR 4.5) and failure of drug detoxification programme (OR 4.9). More HIV positive IDUs were returning used syringes in the centre (OR 3.3).
Conclusions:
Prudent measures such as access to sterile syringes and continuous health education programmes among IDUs and their sexual partners are required to reduce high risk behaviours of IDUs in Myanmar.

IntroductionIn 2008, one of the oldest fixed site neelde exchanges in a large urban city in western Canada was closed due to community pressure. The service had been in existence for over 20 years.Case Description: This case study focuses on the consequences of the switch to mobile needle exchange services after the closure and examines the impact of the closure on clients' risk behavior related to drug use, needle distribution and access to other services. The context surronding the closure was also examined.Discussion and Evaluation: After the closure of the fixed site needle exchange, access to needle exchange services decreased as evidenced by the sharp decline in number of clients reached, and the numbers of needles distributed and collected monthly. Reports related to needle reuse and selling of syringes suggest changes in risk behaviors. Thousands of needles remain unaccounted for in the community. To date, a new fixed site has not been found.
Conclusion:
Closing the fixed site needle exchange had an adverse effect on already vulnerable clients and reduced access to effective comprehensive harm reduction services. While offical public policy supports a fixed site, politicization of the issue has meant a significant setback for harm reduction with reduced potential to meet public health targets related to reducing the the spread of blood borne diseases. This situation is unacceptable from a public health perspective.

Background and objectives:Narghile is becoming the favorite form of tobacco use by youth globally. This problem has received more attention in recent years. The aim of this study was to investigate the prevalence and pattern of narghile use among students in three public Jordanian universities; to assess their beliefs about narghile's adverse health consequences; and to evaluate their awareness of oral health and oral hygiene.
Methods:
The study was a cross-sectional survey of university students. A self-administered, anonymous questionnaire was distributed randomly to university students in three public Jordanian universities during December, 2008. The questionnaire was designed to ask specific questions that are related to smoking in general, and to narghile smoking in specific. There were also questions about oral health awareness and oral hygiene practices.
Results:
36.8% of the surveyed sample indicated they were smokers comprising 61.9 % of the male students and 10.7 % of the female students in the study sample. Cigarettes and narghile were the preferred smoking methods among male students (42%). On the other hand, female students preferred narghile only (53%). Parental smoking status but not their educational level was associated with the students smoking status. Smokers had also significantly poor dental attendance and poor oral hygiene habits.
Conclusion:
This study confirmed the spreading narghile epidemic among young people in Jordan like the neighboring countries of the Eastern Mediterranean region. Alarming signs were the poor oral health awareness among students particularly smokers.

Background:
Although previous studies have identified high levels of drug-related harm in Thailand, little is known about illicit drug overdose experiences among Thai drug users. We sought to investigate non-fatal overdose experiences and responses to overdose among a community-recruited sample of injection drug users (IDU) in Bangkok, Thailand.
Methods:
Data for these analyses came from IDU participating in the Mit Sampan Community Research Project. The primary outcome of interest was a self-reported history of non-fatal overdose. We calculated the prevalence of past overdose and estimated its relationship with individual, drug-using, social, and structural factors using multivariate logistic regression. We also assessed the prevalence of ever witnessing an overdose and patterns of response to overdose.
Results:
These analyses included 252 individuals; their median age was 36.5 years (IQR: 29.0 - 44.0) and 66 (26.2%) were female. A history of non-fatal overdose was reported by 75 (29.8%) participants. In a multivariate model, reporting a history of overdose was independently associated with a history of incarceration (Adjusted Odds Ratio [AOR] = 3.83, 95% Confidence Interval [CI]: 1.52 - 9.65, p = 0.004) and reporting use of drugs in combination (AOR = 2.48, 95% CI: 1.16 - 5.33, p = 0.019). A majority (67.9%) reported a history of witnessing an overdose; most reported responding to the most recent overdose using first aid (79.5%).
Conclusions:
Experiencing and witnessing an overdose were common in this sample of Thai IDU. These findings support the need for increased provision of evidence-based responses to overdose including peer-based overdose interventions.

Background:
Injection drug users continue to be at high risk of HIV and HCV. Research has shown needle exchange programs (NEP) decrease injection frequency, reduce syringe reuse, and reduce needle sharing, though some results have been mixed.
Methods:
This evaluation of a small, peri-urban, legal NEP near Ypsilanti, Michigan describes the operation of the NEP and its clients. It uses interviews conducted with NEP participants between 2003 and 2006, describing the population served by the program, and draws on limited comparisons between matched baseline and follow-up measures as well as aggregate baseline and follow-up comparisons.
Results:
The HIV/AIDS Resource Center (HARC) Harm Reduction NEP serves a diverse population from a wide geographical area. NEP participants at follow-up reused their syringes significantly fewer times before getting new ones, were significantly less likely to report giving another IDU a previously used syringe, and were more likely to clean their skin with alcohol either before or after injecting than the baseline comparison group.
Conclusions:
The limited data presented here suggest that a NEP can be an effective method of harm reduction even in low-volume, non-urban settings and are an important venue for intervention in peri-urban areas.

Background:
Reports from Thailand suggest that a growing number of people who inject drugs (IDU) are now injecting midazolam, a legal benzodiazepine with potent amnestic and ventilatory depressant effects. We therefore sought to examine midazolam injection among a community-recruited sample of Thai IDU.
Methods:
We examined the prevalence and correlates of midazolam injection among 252 IDU participating in the Mitsampan Community Research Project, Bangkok, using multivariate logistic regression. We also examined the use of midazolam in combination with other drugs.
Results:
252 IDU participated in this study, including 66 (26.2%) women. In total, 170 (67.5%) participants reported ever having injected midazolam, and 144 (57.1%) reported daily midazolam injection in the past six months. In multivariate analyses, a history of midazolam injection was independently associated with using drugs in combination (adjusted odds ratio [AOR] = 5.86; 95% confidence interval [CI]: 2.96-11.60), younger age (AOR = 0.43; 95%CI: 0.22-0.83), having a history of methadone treatment (AOR = 3.12, 95%CI: 1.55-6.90), and binge drug use (AOR = 2.25, 95%CI: 1.09-4.63). The drugs most commonly used in combination with midazolam were heroin (72.3%) and yaba (methamphetamine) (30.5%).
Conclusion:
We observed a high rate of midazolam injection among Thai IDU. Midazolam injection was strongly associated with polysubstance use and binge drug use, and was most commonly used in combination with both opiates and methamphetamines. Our findings suggest that midazolam injection has become increasingly common within Thailand. Evidence-based approaches for reducing harms associated with midazolam injection are needed.

Background:
Assisted injection and public injection have both been associated with a variety of individual harms including an increased risk of HIV infection. As a means of informing local IDU-driven interventions that target or seek to address assisted injection, we examined the correlates of receiving assistance with injecting in outdoor settings among a cohort of persons who inject drugs (IDU).
Methods:
Using data from the Vancouver Injection Drug Users Study (VIDUS), an observational cohort study of IDU, generalized estimating equations (GEE) were performed to examine socio-demographic and behavioural factors associated with reports of receiving assistance with injecting in outdoor settings.
Results:
From January 2004 to December 2005, a total of 620 participants were eligible for the present analysis. Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The proportion of participants who reported assisted injection outdoors ranged over time between 8% and 15%. Assisted injection outdoors was independently and positively associated with being female (Adjusted Odds Ratio (AOR) = 1.74, 95% Confidence Intervals (CI): 1.21-2.50), daily cocaine injection (AOR = 1.70, 95% CI: 1.29-2.24), and sex trade involvement (AOR = 1.44, 95% CI: 1.00-2.06); negatively associated with Aboriginal ethnicity (AOR = 0.58, 95% CI: 0.41-0.82).
Conclusions:
Our findings indicate that a substantial proportion of local IDU engage in assisted injecting in outdoor settings and that the practice is associated with other markers of drug-related harm, including being female, daily cocaine injection, and sex trade involvement. These findings suggest that novel interventions are needed to address the needs of this subpopulation of IDU.

We sought to explore the effect of crystal methamphetamine use on the risk of experiencing malnutrition among street-involved youth in Vancouver, Canada. Risk of malnutrition was defined as being hungry but not having enough money to buy food. Socio-demographic and drug use factors associated with risk of malnutrition were investigated using univariate and multivariate analysis among a prospective cohort of street-involved youth known as the At-Risk Youth Study (ARYS). Between September 2005 and December 2006, 509 street-involved youth were enrolled in ARYS, among whom 21% reported being at risk of malnutrition as defined above in the previous six months. In multivariate analysis, only non-injection crystal methamphetamine was significantly associated with being at risk of malnutrition among this cohort (Adjusted Odds Ratio [AOR] = 1.60, 95% Confidence Interval [CI]: 1.03 - 2.48, p = 0.036). Interventions seeking to address food insecurity among street youth may benefit from considering drug use patterns since methamphetamine use predicted higher risk in this setting.

Illicit drug use has become popular in China. Acknowledging the challenge of illicit drug use, China has adopted several new policies on the management of illicit drug use in recent years. This study reviews the current policies on drug use and assesses the harm reduction interventions among drug users in China. The review documents that the new policies on drug use provide a variety of choices of detoxification treatment for drug users. The methadone maintenance treatment and needle exchange programs have been adopted as harm reduction models in China. Most of the reviewed harm reduction programs have been successfully implemented and yielded positive effects in reducing drug-related risk behaviors among drug users. Although there remain barriers to the effective implementation of policies on drug use and harm reduction programs, the Chinese government has shown their commitment to support the expansion of harm reduction interventions for drug users throughout the country.

Background:
The rise of authorized marijuana use in the U.S. means that many individuals are using cannabis as they concurrently engage in other forms of treatment, such as substance abuse counseling and psychotherapy. Clinical and legal decisions may be influenced by findings that suggest marijuana use during treatment serves as an obstacle to treatment success, compromises treatment integrity, or increases the prevalence or severity of relapse. In this paper, the author reviews the relationship between authorized marijuana use and substance abuse treatment utilizing data from a preliminary pilot study that, for the first time, uses a systematic methodology to collect data examining possible effects on treatment.
Methods:
Data from the California Outcomes Measurement System (CalOMS) were compared for medical (authorized) marijuana users and non-marijuana users who were admitted to a public substance abuse treatment program in California. Behavioral and social treatment outcomes recorded by clinical staff at discharge and reported to the California Department of Alcohol and Drug Programs were assessed for both groups, which included a sample of 18 reported medical marijuana users.
Results:
While the findings described here are preliminary and very limited due to the small sample size, the study demonstrates that questions about the relationship between medical marijuana use and involvement in drug treatment can be systematically evaluated. In this small sample, cannabis use did not seem to compromise substance abuse treatment amongst the medical marijuana using group, who (based on these preliminary data) fared equal to or better than non-medical marijuana users in several important outcome categories (e.g., treatment completion, criminal justice involvement, medical concerns).
Conclusions:
This exploratory study suggests that medical marijuana is consistent with participation in other forms of drug treatment and may not adversely affect positive treatment outcomes. These findings call for more extensive sampling in future research to allow for more rigorous research on the growing population of medical marijuana users and non-marijuana users who are engaged in substance abuse treatment.

Background:
Our objective was to examine factors associated with distributive injection equipment sharing and how needle exchange programs (NEPs) can help reduce distributive sharing among injection drug users (IDUs).
Methods:
145 English speaking, Canadian IDUs ages 16 years and over who had injected in the past 30 days were recruited for a cross-sectional survey. Participants were asked about their socio-demographic characteristics, HIV risk behaviours, social support, drug treatment readiness, program satisfaction, health and social service use and NEP drug use. Bivariate statistics and logistic regression were used to characterize the population and examine correlates of sharing behaviour.
Results:
More IDUs reported distributive sharing of cookers (45%) than needles (36%) or other types of equipment (water 36%; filters 29%; swabs 8%). Regression analyses revealed the following factors associated with distributing used cookers: a history of cocaine/crack injection, an Addiction Severity Index (ASI) score indicative of a mental health problem, and older than 30 years of age. Factors associated with giving away used water included: male, injected methadone injected other stimulants and moved 3+ times in past 6 months. Factors associated with giving away used filters included injected cocaine/crack or stayed overnight on the street or other public place. Factors associated with giving away swabs included an ASI mental health score indicative of a mental health problem, and HCV negative status.
Conclusions:
Our findings show that more IDUs give away cookers than needles or other injection equipment. While the results showed that correlates of sharing differed by piece of equipment, each point to distributive sharing by the most marginalized IDUs. Targeting prevention efforts to reduce equipment sharing in general, and cookers in particular is warranted to reduce use of contaminated equipment and viral transmission.

Needle exchange programs chase political as well as epidemiological dragons, carrying within them both implicit moral and political goals. In the exchange model of syringe distribution, injection drug users (IDUs) must provide used needles in order to receive new needles. Distribution and retrieval are co-existent in the exchange model. Likewise, limitations on how many needles can be received at a time compel addicts to have multiple points of contact with professionals where the virtues of treatment and detox are impressed upon them. The centre of gravity for syringe distribution programs needs to shift from needle exchange to needle distribution, which provides unlimited access to syringes. This paper provides a case study of the Washington Needle Depot, a program operating under the syringe distribution model, showing that the distribution and retrieval of syringes can be separated with effective results. Further, the experience of IDUs is utilized, through paid employment, to provide a vulnerable population of people with clean syringes to prevent HIV and HCV.

Background:
Injections of mixtures prepared from crushed tablets contain insoluble particles which can cause embolisms and other complications. Although many particles can be removed by filtration, many injecting drug users do not filter due to availability, cost or performance of filters, and also due to concerns that some of the dose will be lost.
Methods:
Injection solutions were prepared from slow-release morphine tablets (MS Contin(R)) replicating methods used by injecting drug users. Contaminating particles were counted by microscopy and morphine content analysed by liquid chromatography before and after filtration.
Results:
Unfiltered tablet extracts contained tens of millions of particles with a range in sizes from < 5 um to > 400 um. Cigarette filters removed most of the larger particles (> 50 um) but the smaller particles remained. Commercial syringe filters (0.45 and 0.22 um) produced a dramatic reduction in particles but tended to block unless used after a cigarette filter. Morphine was retained by all filters but could be recovered by following the filtration with one or two 1 ml washes. The combined use of a cigarette filter then 0.22 um filter, with rinses, enabled recovery of 90% of the extracted morphine in a solution which was essentially free of tablet-derived particles.
Conclusions:
Apart from overdose and addiction itself, the harmful consequences of injecting morphine tablets come from the insoluble particles from the tablets and microbial contamination. These harmful components can be substantially reduced by passing the injection through a sterilizing (0.22 um) filter. To prevent the filter from blocking, a preliminary coarse filter (such as a cigarette filter) should be used first. The filters retain some of the dose, but this can be recovered by following filtration with one or two rinses with 1 ml water. Although filtration can reduce the non-pharmacological harmful consequences of injecting tablets, this remains an unsafe practice due to skin and environmental contamination by particles and microorganisms, and the risks of blood-borne infections from sharing injecting equipment.

To redress gaps in injection drug users' (IDUs) knowledge about hepatitis risk and prevention, we developed a brief intervention to be delivered to IDUs at syringe exchange programs (SEPs) in three US cities. Following a month-long campaign in which intervention packets containing novel injection hygiene supplies and written materials were distributed to every client at each visit, intervention effectiveness was evaluated by comparing exposed and unexposed participants' self-reported injection practices. Over one-quarter of the exposed group began using the novel hygiene supplies which included an absorbent pad ("Safety Square") to stanch blood flow post-injection. Compared to those unexposed to the intervention, a smaller but still substantial number of exposed participants continued to inappropriately use alcohol pads post-injection despite exposure to written messages to the contrary (22.8% vs. 30.0%). It should also be noted that for those exposed to the intervention, 8% may have misused Safety Squares as part of pre-injection preparation of their injection site; attention should be paid to providing explicit and accurate instruction on the use of any health promotion materials being distributed. While this study indicates that passive introduction of risk reduction materials in injection drug users through syringe exchange programs can be an economical and relatively simple method of changing behaviors, discussions with SEP clients regarding explicit instructions about injection hygiene and appropriate use of novel risk reduction materials is also needed in order to optimize the potential for adoption of health promotion behaviors. The study results suggest that SEP staff should provide their clients with brief, frequent verbal reminders about the appropriate use when distributing risk reduction materials. Issues related to format and language of written materials are discussed.

Background:
Substitution can be operationalized as the conscious choice to use one drug (legal or illicit) instead of, or in conjunction with, another due to issues such as: perceived safety; level of addiction potential; effectiveness in relieving symptoms; access and level of acceptance. This practice of substitution can be observed among individuals using cannabis for medical purposes. This study examined drug and alcohol use, and the occurrence of substitution among medical cannabis patients.
Methods:
Anonymous survey data were collected at the Berkeley Patient's Group (BPG), a medical cannabis dispensary in Berkeley, CA. (N=350) The sample was 68% male, 54% single, 66% White, mean age was 39; 74% have health insurance (including Medical), 41% work full time, 81% have completed at least some college, 55% make less than $40,000 a year. Seventy one percent report having a chronic medical condition, 52% use cannabis for a pain related condition, 75% use cannabis for a mental health issue.
Results:
Fifty three percent of the sample currently drinks alcohol, 2.6 was the average number of drinking days per week, 2.9 was the average number of drinks on a drinking occasion. One quarter currently uses tobacco, 9.5 is the average number of cigarettes smoked daily. Eleven percent have used a non-prescribed, non OTC drug in the past 30 days with cocaine, MDMA and Vicodin reported most frequently. Twenty five percent reported growing up in an abusive or addictive household. Sixteen percent reported previous alcohol and/or drug treatment, and 2% are currently in a 12-step or other recovery program. Forty percent have used cannabis as a substitute for alcohol, 26% as a substitute for illicit drugs and 66% as a substitute for prescription drugs. The most common reasons given for substituting were: less adverse side effects (65%), better symptom management (57%), and less withdrawal potential (34%) with cannabis.
Conclusions:
The substitution of one psychoactive substance for another with the goal of reducing negative outcomes can be included within the framework of harm reduction. Medical cannabis patients have been engaging in substitution by using cannabis as an alternative to alcohol, prescription and illicit drugs.

In the summer of 2009, I visited a humble orphanage for children with HIV/AIDS in Vietnam. Here, like many parts in the world, the very existence of marginalized people with stigmatized illness is hidden away. Relegated to the shadows of society, these children lacked something more fundamental than housing, shelter, nutrition and medications. They lacked families to love and care for them unconditionally. One might think it self-evident that a visit to an orphanage for children with HIV would be profound, but the profundity wasn't where I expected to find it. It was in how the children had created their own family, loving each other like brothers and sisters, and the way the priest who operated the shelter was more than a Father, he was a dad to dozens of children. This is an account of love as harm reduction in the Mai Tam orphanage in Ho Chi Minh City.

Recent data suggest that globally, between 5% and 10% of all new HIV cases are the result of unsafe injecting practices, and experts agree that reducing these practices is key to tackling the spread of HIV. And yet, despite the overwhelming evidence that providing sterile syringes to injection drug users (IDU) through syringe exchange programs (SEPs) or other means is an effective way of reducing HIV transmission among high-risk subpopulations, IDU in most settings still do not have access to sterile injecting equipment or if they do, access remains too restricted to effectively reduce the risk of HIV transmission. Vorobjov and colleagues have presented in this journal an interesting and timely study from Estonia comparing individuals who obtain syringes from SEPs and those who obtain syringes from pharmacies. As the authors point out, Estonia faces an unacceptably high HIV incidence rate of 50 new HIV cases per 100,000, this rate driven primarily by injection drug use. As such, the authors argue that Estonia's SEP network does not have the capacity to serve a growing IDU population at risk of transmitting HIV and pharmacy dispensation of clean syringes may be one potential approach to decreasing syringe sharing among high-risk injectors. It may be overly optimistic to consider the impact of higher threshold interventions such as pharmacy-based SEPs, given that IDU populations that engage in HIV risk behaviours such as syringe sharing are often hidden or hard to reach. Despite the need for a cautious approach, however, the findings presented by Vorobjov et al. may chart one potential course towards a more comprehensive societal response to reducing the health harms associated with injection drug use.

Background:
There is a need for services that effectively and comprehensively address the complex needs of women with substance use issues and their children. A growing body of literature supports the relevance of integrated treatment programs that offer a wide range of services in centralized settings. Quantitative studies suggest that these programs are associated with positive outcomes. A qualitative meta-synthesis was conducted to provide insight into the processes that contribute to recovery in integrated programs and women's perceptions of benefits for themselves and their children.
Methods:
A comprehensive search of published and unpublished literature to August 2009 was carried out for narrative reports of women's experiences and perceptions of integrated treatment programs. Eligibility for inclusion in the meta-synthesis was determined using defined criteria. Quality assessment was then conducted. Qualitative data and interpretations were extracted from studies of adequate quality, and were synthesized using a systematic and iterative process to create themes and overarching concepts.
Results:
A total of 15 documents were included in the meta-synthesis. Women experienced a number of psychosocial processes during treatment that played a role in their recovery and contributed to favourable outcomes. These included: development of a sense of self; development of personal agency; giving and receiving of social support; engagement with program staff; self-disclosure of challenges, feelings, and past experiences; recognizing patterns of destructive behaviour; and goal setting. A final process, the motivating presence of children, sustained women in their recovery journeys. Perceived outcomes included benefits for maternal and child well-being, and enhanced parenting capacity.
Conclusions:
A number of distinct but interconnected processes emerged as being important to women's addiction recovery. Women experienced individual growth and transformative learning that led to a higher quality of life and improved interactions with their children. The findings support the need for programs to adopt practices that focus on improving maternal health and social functioning in an environment characterized by empowerment, safety, and connections. Women's relationships with their children require particular attention as positive parenting practices and family relationships can alter predispositions toward substance use later in life, thereby impacting favourably on the cycle of addiction and dysfunctional parenting.

Several reports suggest that antimicrobial resistance is an increasing global problem; but like most pandemics, the greatest toll is in the less developed countries. The dismally low rate of discovery of antimicrobials compared to the rate of development of antimicrobial resistance places humanity on a very dangerous precipice. Since antimicrobial resistance is part of an organism's natural survival instinct, total eradication might be unachievable; however, it can be reduced to a level that it no longer poses a threat to humanity. While inappropriate antimicrobial consumption contributes to the development of antimicrobial resistance, other complex political, social, economic and biomedical factors are equally important. Tackling the menace therefore should go beyond the conventional sensitization of members of the public and occasional press releases to include a multi-sectoral intervention involving the formation of various alliances and partnerships. Involving civil society organisations like the media could greatly enhance the success of the interventions

Background:
Five cases of severe neutropenia (neutrophil counts < 0.5 per 109 cells/L) associated with exposure to cocaine and levamisole, an antihelimithic agent no longer available in Canada, were identified in Alberta in 2008. Alberta and British Columbia (BC) public health officials issued an advisory and urged health care professionals to report cases to public health. This paper presents the findings of the public health investigations.
Methods:
Cases were identified prospectively through reporting by clinicians and a retrospective review of laboratory and medical examiners data from January 1, 2006 to March 31, 2009. Cases were categorized as confirmed, probable or suspect. Only the confirmed and probable cases are included in this paper.
Results:
We compare cases of severe neutropenia associated with tainted cocaine (NATC) identified in Alberta and BC between January 1, 2008 to March 31, 2009. Of the 42 NATC cases: 23(55%) were from Alberta; 19(45%) were from British Columbia; 57% of these cases reported crack cocaine use (93% of those who identified type of cocaine used); 7% reported using cocaine powder; and the main route of cocaine administration was from smoking (72%). Fifty percent of the NATC cases had multiple episodes of neutropenia associated with cocaine use. Cases typically presented with bacterial/fungal infections and fever. One Alberta NATC case produced anti-neutrophil antibodies, and four were positive for anti-neutrophil cytoplasmic antibody (ANCA). Analysis of two crack pipes and one drug sample obtained from NATC cases confirmed the presence of both cocaine and levamisole. A further 18 cases were identified through the retrospective review of laboratory and medical examiner data in AlbertaInterpretation:Our findings support a link between neutropenia and levamisole tainted cocaine and particularly from smoking the crack form of cocaine. Some patients may be genetically predisposed to develop levamisole-related neutropenia. Awareness of the differential diagnosis will assist clinicians with case timely detection and appropriate management.

Nicotine is so desirable to many people that when they are given only the options of consuming nicotine by smoking, with its high health costs, and not consuming nicotine at all, many opt for the former. Few smokers realize that there is a third choice: non-combustion nicotine sources, such as smokeless tobacco, electronic cigarettes, or pharmaceutical nicotine, which eliminate almost all the risk while still allowing consumption of nicotine. Widespread dissemination of misleading health claims is used to prevent smokers from learning about this lifesaving option, and to discourage opinion leaders from telling smokers the truth. One common misleading claim is a risk-risk comparison that has not before been quantified: A smoker who would have eventually quit nicotine entirely, but learns the truth about low-risk alternatives, might switch to an alternative instead of quitting entirely, and thus might suffer a net increase in health risk. While this has mathematical face validity, a simple calculation of the tradeoff -- switching to lifelong low-risk nicotine use versus continuing to smoke until quitting -- shows that such net health costs are extremely unlikely and of trivial maximum magnitude. In particular, for the average smoker, smoking for just one more month before quitting causes greater health risk than switching to a low-risk nicotine source and never quitting it. Thus, discouraging a smoker, even one who would have quit entirely, from switching to a low-risk alternative is almost certainly more likely to kill him than it is to save him. Similarly, a strategy of waiting for better anti-smoking tools to be developed, rather than encouraging immediate tobacco harm reduction using current options, kills more smokers every month than it could possibly ever save.

In Indonesia, an ongoing government "war on drugs" has resulted in numerous arrests and anecdotal reports of abuse in detention, but to date there has been little documentation or analysis of this issue. JANGKAR (also known in English as the Indonesian Harm Reduction Network), a nongovernmental organization (NGO) based in Jakarta, surveyed 1106 injecting drug users in 13 cities about their experiences of police abuse. Of those interviewed, 667 or 60% reported physical abuse by police. These findings indicate the importance of continuing efforts to promote police reform and harm reduction in Indonesia.

Background:
Over the past decade, tobacco companies have introduced cigarettes and smokeless tobacco products (known as Potential Reduced Exposure Products, PREPs) with purportedly lower levels of some toxins than conventional cigarettes and smokeless products. It is essential that public health agencies monitor awareness, interest, use, and perceptions of these products so that their impact on population health can be detected at the earliest stages.
Methods:
This paper reviews and critiques existing strategies for measuring awareness of PREPs from 16 published and unpublished studies. From these measures, we developed new surveillance items and subjected them to two rounds of cognitive testing, a common and accepted method for evaluating questionnaire wording.
Results:
Our review suggests that high levels of awareness of PREPs reported in some studies are likely to be inaccurate. Two likely sources of inaccuracy in awareness measures were identified: 1) the tendency of respondents to misclassify "no additive" and "natural" cigarettes as PREPs and 2) the tendency of respondents to mistakenly report awareness as a result of confusion between PREPs brands and similarly named familiar products, for example, Eclipse chewing gum and Accord automobiles.
Conclusions:
After evaluating new measures with cognitive interviews, we conclude that as of winter 2006, awareness of reduced exposure products among U.S. smokers was likely to be between 1% and 8%, with the higher estimates for some products occurring in test markets. Recommended measurement strategies for future surveys are presented.

Background:
Naloxone has been widely evidenced as a means of reducing mortality resulting from opiate overdose, yet its distribution to drug users remains limited, yet it is drug users who are most likely to be available to administer naloxone at the scene and who have been shown to be willing and motivated to deliver this intervention. The current study builds on a national training evaluation in England by assessing 6-month outcome data collected primarily in one of the participating centres.
Methods:
Seventy patients with opioid dependence syndrome were trained in the recognition and management of overdoses in Birmingham (n=66) and London (n=4), and followed up over a 6-month period. After successful completion of the training, participants received a supply of 400 micrograms of naloxone (in the form of a preloaded syringe) to take home. The study focused on whether participating users still had their naloxone, whether they retained the information on follow up, and whether they had naloxone available if and when they had witnessed an overdose.Results & Discussion: The results were mixed - although the majority of drug users had retained the naloxone prescribed to them, and retention of knowledge was very strong in relation to overdose recognition and intervention, most participants did not carry the naloxone with them and consequently it was generally not available if they witnessed an overdose. The paper discusses the reasons for the reluctance to carry naloxone and potential opportunities for how this might be overcome. Future issues around training and support around peer dissemination are also addressed.
Conclusions:
Our findings confirm that training of bystanders constitutes a valuable resource in the assessment and management of opiate overdoses that may not otherwise be recognised or addressed. Obstacles have been identified at individual (transportability, stigma) and at a systems level (police involvement, prescription laws).Training individuals does not seem to be sufficient for these programmes to succeed and a more applied approach is necessary.

Background:
Smoking cessation has important immediate health benefits. The comparative short-term effectiveness of smoking cessation interventions is not well known. We aimed to determine the relative effectiveness of nicotine replacement therapy (NRT), bupropion and varenicline at 4 weeks post-target quit date.
Methods:
We searched 10 electronic medical databases (inception to October 2008). We selected randomized clinical trials [RCTs] evaluating interventions for our primary outcome of abstinence from smoking at at-least 4 weeks post-target quit date, with biochemical confirmation. We conducted random-effects odds ratio (OR) meta-analysis and meta-regression. We compared treatment effects across interventions using head-to-head trials and calculated indirect comparisons.
Results:
We combined a total of 101 trials evaluating delivery of NRT versus inert controls at approximately 4 weeks post-target quit date (total n=31,321). The pooled overall OR is OR 2.05 (95% Confidence Interval [CI], 1.89-2.23, P=<0.0001). We pooled data from 31 bupropion trials contributing a total n of 11,118 participants and found a pooled OR of 2.25 (95% CI, 1.94-2.62, P=<0.0001). We evaluated 9 varenicline trials compared to placebo. Our pooled estimate for cessation at 4 weeks post-target quit date found a pooled OR of 3.16 (95% CI, 2.55-3.91, P=<0.0001). Two trials evaluated head to head comparisons of varenicline and bupropion and found a pooled estimate of OR 1.86 (95% CI, 1.49-2.33, P=<0.0001 at 4 weeks post-target quit date. Indirect comparisons were: NRT and bupropion, OR, 1.09, 95% CI, 0.93-1.31, P=0.28; varenicline and NRT, OR 1.56, 95% CI, 1.23-1.96, P=0.0002; and, varenicline and bupropion, OR 1.40, 95% CI, 1.08-1.85, P=0.01.
Conclusions:
Pharmacotherapeutic interventions are effective for increasing smoking abstinence rates in the short-term.

The reuse of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalized HIV epidemics. The U.S. and the WHO have begun to support large scale injection safety interventions, increased professional education and training programs, and the development and wider dissemination of infection control guidelines. Several African governments have also taken steps to control injecting equipment, including banning syringes that can be reused.However injection drug use (IDU), of heroin and stimulants, is a growing risk factor for acquiring HIV in the region. IDU is increasingly common among young adults in sub-Saharan Africa and is associated with high risk sex, thus linking IDU to the already well established and concentrated generalized HIV epidemics in the region. Demand reduction programs based on effective substance use education and drug treatment services are very limited, and imprisonment is more common than access to drug treatment services.Drug policies are still very punitive and there is widespread misunderstanding of and hostility to harm reduction programs e.g. needle exchange programs are almost non-existent in the region. Among injection drug users and among drug treatment patients in Africa, knowledge that needle sharing and syringe reuse transmit HIV is still very limited, in contrast with the more successfully instilled knowledge that HIV is transmitted sexually. These new injection risks will take on increased epidemiological significance over the coming decade and will require much more attention by African nations to the range of effective harm reduction tools now available in Europe, Asia, and North America.

Background:
Ukraine has experienced an increase in injection drug use since the 1990s. An increase in HIV and hepatitis C virus infections has followed, but not measures of prevalence and risk factors. The purposes of this study are to estimate the prevalence of HIV, HCV, and co-infection among injection drug users (IDUs) in central Ukraine and to describe risk factors for HIV and HCV.
Methods:
A sample of 315 IDUs was recruited using snowball sampling for a structured risk interview and HIV/HCV testing (81.9% male, 42% single, average age 28.9 years [range = 18 to 55]).
Results:
HIV and HCV antibodies were detected in 14.0% and 73.0%, respectively, and 12.1% were seropositive for both infections. The most commonly used drug was hanka, home-made from poppy straw and often mixed with other substances including dimedrol, diazepines, and hypnotics. The average period of injecting was 8.5 years; 62.5% reported past-year sharing needles or injection equipment, and 8.0% shared with a known HIV-positive person. More than half (51.1%) reported multiple sexual partners, 12.9% buying or selling sex, and 10.5% exchanging sex and drugs in the past year. Those who shared with HIV positive partners were 3.4 times more likely to be HIV positive than those who did not. Those who front- or back-loaded were 4 times more likely to be HCV positive than those who did not.
Conclusions:
Harm reduction, addiction treatment and HIV prevention programs should address risk factors to stop further spread of both HIV and HCV among IDUs and to the general population in central Ukraine.

Background:
The HIV epidemic in Russia has been driven by the unsafe injection of drugs, predominantly heroin and the ephedrine derived psychostimulants. Understanding differences in HIV risk behaviors among injectors associated with different substances has important implications for prevention programs.
Methods:
We examined behaviors associated with HIV risk among 900 IDUs who inject heroin, psychostimulants, or multiple substances in 2002. Study participants completed screening questionnaires that provided data on sociodemographics, drug use, place of residence and injection- and sex-related HIV risk behaviors. HIV testing was performed and prevalence was modeled using general estimating equation (GEE) analysis. Individuals were clustered by neighborhood and disaggregated into three drug use categories: Heroin Only Users, Stimulant Only Users, and Mixed Drug Users.
Results:
Among Heroin Only Users, younger age, front/backloading of syringes, sharing cotton and cookers were all significant predictors of HIV infection. In contrast, sharing needles and rinse water were significant among the Stimulant Only Users. The Mixed Drug Use group was similar to the Heroin Only Users with age, front/back loading, and sharing cotton significantly associated with HIV infection. These differences became apparent only when neighborhood of residence was included in models run using GEE.
Conclusions:
The type of drug injected was associated with distinct behavioral risks. Risks specific to Stimulant Only Users appeared related to direct syringe sharing. The risks specific to the other two groups are common to the process of sharing drugs in preparation to injecting. Across the board, IDUs could profit from prevention education that emphasizes both access to clean syringes and preparing and apportioning drug with these clean syringes. However, attention to neighborhood differences might improve the intervention impact for injectors who favor different drugs.

ObjectiveThe role of needle and syringe sharing behavior of injection drug users (IDUs) in spreading of blood-borne infections - specially HIV/AIDS - is well known. However, very little is known in this regard from Iran. The aim of our study was to determine the prevalence and associates of needle and syringe sharing among Iranian IDUs.
Methods:
In a secondary analysis of a sample of drug dependents who were sampled from medical centers, prisons and streets of the capitals of 29 provinces in the Iran in 2007, 2091 male IDUs entered. Socio-demographic data, drug use data and high risk behaviors entered to a logistic regression to determine independent predictors of lifetime needle and syringe sharing.
Results:
749(35.8%) reported lifetime experience of needle and syringe sharing. The likelihood of lifetime needle and syringe sharing was increased by female gender, being jobless, having illegal income, drug use by family members, pleasure/enjoyment as causes of first injection, first injection in roofless and roofed public places, usual injection at groin, usual injection at scrotum, lifetime experience of nonfatal overdose, and history of arrest in past year and was decreased by being alone at most injections.
Conclusion:
However this data has been extracted from cross-sectional design and we can not conclude causation, some of the introduced variables with association with needle and syringe sharing may be used in HIV prevention programs which target reducing syringe sharing among IDUs.

Background:
The concept of risk dominates the HIV/AIDS literature pertaining to People Who Use Injection Drugs (PWUID). In contrast the concept of worry is infrequently applied, even though it can produce important perspectives of PWUID's lives. This study asked a sample (n=105) of PWUID enrolled in a Victoria, British Columbia needle exchange program to evaluate their degree of worry about fourteen factors they may encounter in their daily lives.
Methods:
Exploratory factor analysis was used to analyze their responses.
Results:
Factor analysis delineated three factors. From most to least significant these constituted worry about: 1) overall personal security, 2) injection drug use-specific risks including overdosing and vein collapse and, 3) contracting infectious diseases associated with injection drug use, e.g. HIV/AIDS and Hepatitis C.
Conclusions:
PWUID in this study first and foremost worry about stressful factors in their daily life which have been linked to both increased HIV/AIDS risk behaviour and decreased anti-retroviral treatment adherence. The importance PWUID give to these concerns emphasizes the need to place HIV/AIDS intervention and /or treatment programs within a broader harm-reduction framework that incorporates their perspectives on both worry and risk.

Among persons who inject drugs (IDU), illicit drug use often occurs in hospitals and contributes to patient expulsion and/or high rates of leaving against medical advice (AMA) when withdrawal is inadequately managed. Resultant disruptions in medical care may increase the likelihood of several harms including drug resistance to antibiotics as well as costly readmissions and increased patient morbidity. In this context, there remains a clear need for the evaluation of harm reduction strategies versus abstinence-based strategies with respect to addressing ongoing issues related to substance use among addicted hospitalized patients. While hospitalization can be used to stabilize addicted patients as they recover from their acute illness and help them to achieve abstinence, patients unable to maintain abstinence should not be penalized for failing to do so at the expense of their health. This article describes harm reduction activities within hospitals and areas for future investigation.

Background:
Health promotion strategies ultimately rely on people perceiving the consequences of their behaviour as negative. If someone is indifferent towards death, it would logically follow that health promotion messages such as safe using messages would have little resonance. This study aimed to investigate attitudes towards death in a group of injecting drug users (IDUs) and how such attitudes may impact upon the efficacy/relevance of 'safe using' (health promotion) messages.
Methods:
Qualitative, semi-structured interviews in Geelong, Australia with 60 regular heroin users recruited primarily from needle and syringe programs.
Results:
Over half of the interviewees reported having previously overdosed and 35% reported not engaging in any overdose prevention practices. 13% had never been tested for either HIV or hepatitis C. Just under half reported needle sharing of some description and almost all (97%) reported previously sharing other injecting equipment. Most interviewees reported being indifferent towards death. Common themes included; indifference towards life, death as an occupational hazard of drug use and death as a welcome relief.
Conclusions:
Most of the interviewees in this study were indifferent towards heroin-related death. Whilst interviewees were well aware of the possible consequences of their actions, these consequences were not seen as important as achieving their desired state of mind. Safe using messages are an important part of reducing drug-related harm, but people working with IDUs must consider the context in which risk behaviours occur and efforts to reduce said behaviours must include attempts to reduce environmental risk factors at the same time.