Friday 26 May 2017
News from the 25th International Harm Reduction Conference (HR17)
25th International Harm Reduction Conference
took place in Montréal, Canada, last week. NAM is the official scientific
reporter for the conference.
reduction means reducing the harms associated with using drugs. This includes
providing services such as needle and syringe exchange, opioid substitution
therapy (such as methadone or buprenorphine), and overdose prevention. Harm
reduction also refers to policies that aim to reduce negative consequences of
drug use. It is an approach which is informed by good public health practice
and focused on individual human rights.
our news coverage is available on our website at www.aidsmap.com/hr17
summary bulletin from the conference is being sent to you because you are a
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can visit the HR17 conference
website for further information about the conference.
North America overdose epidemic at the forefront of HR17
Health Minister Jane Philpott and protestors at the HR17 opening ceremony © Charles Mackay / HRI
International Harm Reduction Conference (HR17) in Montréal, Canada, kicked off with a
dramatic opening session last week, featuring Jane Philpott, Canadian Minister
of Health, along with a group of angry protesters chanting ‘They talk, we die’.
The minister’s speech and the protest
focused on the soaring rate of overdose deaths dominating the work of harm
reduction organisations across Canada.
Dramatic increases in heroin
and fentanyl-based overdoses in Canada and the US have been compared to the
worst of the days of the AIDS crisis. Last year, an estimated 2300 people died
of heroin and fentanyl-related overdoses in Canada. It looks likely that this
figure will increase in 2017.
Across North America,
widespread use of synthetic opioids such as the painkiller fentanyl, and heroin
contaminated with illicitly manufactured fentanyl, is leading to dramatic
numbers of overdose deaths.
Fentanyl is 50 to 100 times
more potent than heroin and is used by illicit manufacturers to intensify the
euphoric effects of heroin. For users of street heroin, it is impossible to
tell by looking whether their heroin is contaminated with fentanyl.
Dan Ciccarone at HR17. Photo by Liz Highleyman, hivandhepatitis.com
Data on fentanyl seizures presented at the conference show a strong correlation between
higher rates of fentanyl seizure and higher rates of overdose in the United
States. Fentanyl seizures increased by 134% between 2009 and 2014, with the
biggest increases taking place in the Midwest and Northeast. Along with
Kentucky, Tennessee, Alabama and Mississippi, these regions also saw the
largest increases in heroin overdose during the same period.
Professor Dan Ciccarone of
University of California San Francisco said that more could be done with drugs seized
by law enforcement officials to inform a public health response to the overdose
“Currently in the US seized
drugs most often end up in a county crime lab and are not tested. Information
is power, we need to get creative and promote drug testing and dissemination of
the data, ensuring law enforcement and public health authorities are working
together,” said Ciccarone.
Ciccarone argued that the
opioid epidemic should be treated less as a drug epidemic and more as a
poisoning epidemic, warranting more proactive surveillance and testing of drugs
themselves – not just people who use drugs. He also urged faster response to
overdose by making naloxone widely available to people who use drugs and their
loved ones, more harm reduction services and more evidence-based treatment for
“If synthetic opioids are in
fact becoming the new norm in terms of distribution and consumption then drug
checking and supervised injection sites ought to become the new public health
norms too,” said Rick Lines, Executive Director of Harm
convenors of HR17.
Drug checking in Vancouver to detect fentanyl
Mark Lysyshyn at HR17. Photo by Liz Highleyman, hivandhepatitis.com
A pilot project
to check the purity of drugs at Vancouver's Insite safe injection facility
found that around 80% of tested samples contained fentanyl, and people who
learned their drugs were contaminated were more likely to reduce their drug
doses and less likely to overdose, researchers reported at the conference.
Like the United
States, Canada is experiencing a sharp increase in deaths due to overdose. In
British Columbia alone, 922 overdose deaths were recorded by the province’s
Coroner’s Service in 2016. Fentanyl was detected in 61% of all drug overdose
deaths in the province, the Coroner’s Service reported.
Users at the
supervised injecting facility were offered the option to have their drugs
tested for fentanyl before or after injecting.
A total of 1138 drug checks
were performed between July 2016 and March 2017, about 40% before consumption
and about 60% afterwards.
The researchers found that,
overall, 79% of all drug samples contained fentanyl. Contamination was more
common in heroin and crystal methamphetamine samples (83 and 82%,
respectively), and less so in samples of cocaine (40%) or other drugs (48%).
Thirteen per cent of people with fentanyl-positive drug
samples experienced overdose, compared to just 2% of those with negative
samples – more than a sixfold higher risk. Similarly, 10% of clients with
fentanyl-positive samples required naloxone, compared to 2% of those with
During the conference a new law came
into effect in Canada that will speed up the opening of supervised
injecting facilities. Insite, Canada’s first public supervised injecting
facility, opened in 2003 and remains the only public facility (Montréal will
open a facility soon).
Robin Pollini at HR17. Photo by Liz Highleyman, hivandhepatitis.com
overdose risk – overdosing of methamphetamine or other stimulants – is an
under-recognised problem in a harm reduction community that more often focuses
on opioid overdose, the conference heard.
effects of ‘overamping’ are much more varied than opioid overdose. They may
include severe physical health events
such as heart attack, stroke, seizure or intense overheating, or severe mental
health events such as extreme panic, paranoia, anxiety or agitation,
hallucinations, or psychosis.
A survey of 494
people who inject drugs in Fresno, California, found that a third of participants
had experienced overamping or stimulant overdose. Ten per cent had done so in the previous three
months. The most common symptoms were
racing heartbeat, overheating, severe anxiety and panic, and shortness of
breath or irregular breathing. Currently there is no known way to reverse a stimulant overdose, as
naloxone does for an opioid overdose. One in four who experienced an episode
had gone to an emergency room for help.
Of those who had
experienced overamping, 41% said that they had also used heroin in the days
before the episode.
Another study, carried out in Australia, showed that people using heroin and
methamphetamine together were often using heroin to moderate the effects of
methamphetamine, as a form of harm reduction.
of the overamping study suggest that combining education on stimulant and
opioid overdose may be appropriate, especially where stimulant use is frequent.
New report from Harm Reduction International
UK-based NGO Harm
(HRI) warns in a new report that if the roll back of funding harm reduction
services such as needle and syringe programmes and methadone provision in the
European Union remains unchecked, renewed spikes in HIV and hepatitis C
infections amongst people who use drugs are inevitable.
The report – Harm Reduction investment in the
European Union – current spending, challenges and successes – was released ahead of the 25th International
Harm Reduction Conference (HR17).
Harm Reduction International also presented further
findings from its 2016 Global State of Harm Reduction report, highlighting the lack of new needle
and syringe programme provision. Of the 90 countries that report provision of
needle and syringe programmes, only 17 countries are expanding these services,
whilst 20 countries report a decrease of needle and syringe programmes.
Katie Stone of Harm Reduction
“This is the first time that
there has been no increase since we started monitoring coverage of harm
reduction services in 2008. Access to one of the most important HIV prevention
and harm reduction services is stagnating, while rates of injecting drug use
A UN target to halve HIV
transmission among people who inject drugs by 2015 was not only missed, but HIV
rates amongst people who inject drugs increased by a third between 2011 and 2015 according to UNAIDS.
“The Sustainable Development
Goals pledge to end AIDS by 2030, but there is no way we’ll ever achieve this
goal in the current climate given the lack of leadership and funding for harm
reduction for people who inject drugs,” said Stone.
Harm Reduction International
says that a shift away from a failed ‘war on drugs’ approach to policing of
drug use, including a massive reduction in imprisonment of people who use drugs,
could save up to $100 billion a year. A change in approach would allow
reinvestment of money saved in harm reduction – $10 billion a year would finance
all global efforts to reach the prevention and care targets for people who use
drugs, says Harm Reduction International.
Hydromorphone and other opioid substitution treatments
David Marsh at HR17. Photo by Liz Highleyman, hivandhepatitis.com
Prescribing an alternative to street
drugs may help some people who inject drugs to stabilise their drug use, stop
sharing injecting equipment and improve their health.
buprenorphine are the standard medications used for opioid substitution
therapy, but they do not work for everyone. Around 15 to 25% of people who
inject heroin will not respond well to methadone and need other options, such
as prescription of heroin.
But, use of
medical heroin (diacetylmorphine) on prescription remains illegal for this
purpose in most countries (although Canada recently legalised its prescription for people who do not respond to opioid
substitution therapy). Hydromorphone (brand name Dilaudid) is a
semi-synthetic morphine derivative that works similarly to heroin, but it is an
approved painkiller and is widely legally available for medical use.
The phase 3 SALOME
(Study to Assess Long-term Opioid Medication Effectiveness) trial, conducted at
the Providence Health Crosstown Clinic in Vancouver's Downtown Eastside,
evaluated whether hydromorphone is as effective as diacetylmorphine for the
treatment of long-term opioid addiction.
The study found
that hydromorphone was just as effective as diacetylmorphine in reducing
illicit use of heroin. The researchers recommend that hydromorphone should be
available as an alternative to diacetylmorphine, in order to expand the range
of options available to help people who have not responded to opioid
AA amyloidosis and kidney disease in people who inject drugs
Magdalena Harris at HR17. Photo by Liz Highleyman, hivandhepatitis.com
a condition resulting from skin and soft tissue infections that can lead to
kidney failure, may be more common than previously recognised among people who
inject drugs, according to the findings of a
systematic review presented at HR17.
occurs when abnormal proteins known as amyloid fibrils build up in body
tissues. The AA type of amyloidosis is caused by chronic inflammation.
Untreated skin and soft tissue infections in people who inject drugs cause
chronic inflammation, which encourages the build-up of abnormal proteins in
body tissues in a minority of people.
kidneys are usually affected first. Symptoms of AA amyloidosis kidney disease
include proteinuria (protein in the urine) and swelling of the extremities.
Over time it can lead to renal failure, the need for dialysis, kidney
transplantation or death.
was first reported among injection drug users in the 1970s. Later that decade
the condition was linked to skin and soft tissue infections, and informally
dubbed 'skin popper's disease'. The first cases in Europe were reported in the
In the UK, up
to 60% of people who inject drugs report recent skin and soft tissue
infections, and about 10% – or 20,000 individuals – are hospitalised for this
reason each year. UK drug treatment services have seen a growing number of
clients with AA amyloidosis or on kidney dialysis in recent years, said
Magdalena Harris of the London School of Hygiene and Tropical Medicine.
She is working
with colleagues in the UK to investigate the care and prevention of soft tissue
infections in drug users, and find out what people who inject drugs need. Her
research will also investigate the prevalence of AA amyloidosis among a sample
of people who inject drugs in the UK.
Other news from HR17
Jason Grebely at HR17. Photo by Liz Highleyman, hivandhepatitis.com
Most people on
opiate substitution therapy were successfully treated for hepatitis C with an
interferon-free regimen of grazoprevir/elbasvir (Zepatier), and only a small number became reinfected during three
years of follow-up, researchers reported at the conference. Read more >>
Sindi Putri at HR17. Photo by Liz Highleyman, hivandhepatitis.com
community-led buyers club in Indonesia has helped more than 100 people get
generic direct-acting antiviral (DAA) drugs to treat hepatitis C and is seeing
a high cure rate, according to a presentation at the conference. Read more >>
Benjamin Kirimo at HR17. Photo by Liz Highleyman, hivandhepatitis.com
programme offering medication-assisted drug addiction treatment and services
aimed at preventing mother-to-child HIV transmission led to improved outcomes
for opioid-dependent HIV-positive mothers and their babies, according to a
presentation at the conference. Read more >>
Elena Argento at HR17. Photo by Liz Highleyman, hivandhepatitis.com
workers who used psychedelic drugs such as LSD were less likely to think about
or attempt suicide, while some other drugs increased the risk, according to
study results presented at the conference. Read more >>
veterinary care can be a good way to bring homeless and marginally housed
people into contact with health care, harm reduction and other services,
according to a presentation at the conference. Read more >>
Thank you to Harm Reduction International for their contribution towards NAM's work in covering the International Harm Reduction Conference. NAM's wider conference news reporting services have been supported by Abbvie, Gilead, Janssen, Merck & Co., Inc. and ViiV Healthcare.