Harm Reduction for Stimulants

This post is also available in: Português (Portuguese (Brazil))

The use of stimulant drugs is growing in different parts of the world. In 2018, the World Drug Report showed that amphetamine-type substances (ATS) are the second most commonly used illicit drug – after cannabis – with an estimated 34.2 million past-year users. ATS is mostly used in North America and Oceania, but its use has sharply increased in many countries in East and South-East Asia. Cocaine had an estimate of 18.2 million past-year users worldwide, and its use is also rising in some parts of the world, such as Europe. In Latin America, North America and the Caribbean, cocaine has had a long-lasting presence, and it is still the primary drug of concern, after cannabis. Besides, many of the New Psychoactive Substances are synthetic stimulants.

In most of the world, however, many harm reduction services focus predominantly on people who inject opioids. People who use stimulants, and especially those who do not inject, have limited access to harm reduction and other services. Many have different health-related harms and problems and do not identify with (problematic) opioid use. They also often belong to other (social) networks of people who use drugs and may perceive harm reduction services as irrelevant or inaccessible to them. Many reduction programs struggle to offer care to people who use stimulants. These programs either feel they do not have enough knowledge on stimulants or have difficulties in getting funding for interventions which are not related to syringe exchange or Opioid Substitution Treatment.
There is a need to know what works to reduce the harms of stimulants use. That is why, between 2017-2018, we* (see text box at the end) produced a report dedicated to mapping harm reduction interventions for stimulants use which are evidence-based. “Speed Limits,” our study, focused on interventions for problematic stimulant use, mostly related to methamphetamine and smokable cocaine (crack, pasta base). We produced:

  • Literature review

    A review of the literature on effective harm reduction interventions for people who use stimulants

  • Description of good practices

    The description of seven cases of good harm reduction practices for people who use stimulants in different world regions

Take me to the report!
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In the literature review, we clustered the available evidence in 12 types of interventions which, according to studies, showed to be effective in reducing the harms of stimulant use. Here are the 12 evidence-based interventions we found:
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Safer smoking kits, for instance, help people to increase safe-smoking practices; decrease injection; decrease/cease use of home-made pipes; reduce burns to mouth and throat; reduce damage to lungs.

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Using cannabis (plant-based substitution) helps some people to diminish anxiety, aggression, and paranoia for crack use. It also helps them reduce craving, stimulate appetite and promote sleep.

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To enhance self-regulation strategies allows people to be aware and increasingly use their own self-care strategies. It also helps to deal with emotions without recurring to problematic drug use.

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Drug Consumption Rooms help people to have a safe, non-rushed environment; access sterile equipment (such as safer smoking kits|); access care services; prevent overdoses, enhance safer drug use practices, and prevent transmission of infectious diseases.

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Simple therapeutic interventions (mental health-related) can help people who use stimulants suffering from paranoid thoughts, anxiety, hallucinations or withdrawal. They also help to identify problems and commit to change and to create a support network and manage drug use.

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To offer people a safe place to be during the day in drop-in centers help them to improve wellbeing, (mental) health, social engagement, reduce drug use and reduce the exchange of sex for drugs.

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Providing people with housing (housing first) reduces their exposure to drug use; decrease use; increases treatment adherence and autonomy; helps to develop healthier sleep/eating patterns.

You can delight yourself with lots of information about these and the other five interventions in our full report or get a sneak peek in our executive summary.
Executive summary
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Are you wondering how these interventions would work in practice? We were too! We selected seven harm reduction projects in different regions of the world, addressing various interventions, and described them in our study as good practice cases. We have contacted more than 50 different projects in around 30 countries! It was a difficult task to choose only seven. We wanted those with comparatively more evidence on the effectiveness and reasonable sustainability and cost-effectiveness. We also considered how feasible it could be to replicate the projects, and to what extent they were recognized as a good practice in their region among professionals and people who use drugs. We finally selected seven cases:
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  • Atitude

    Offering housing first, drop-in centers, shelter, and outreach work for people using crack cocaine in Brazil;

  • Contemplation groups

    Enhancing self-regulation strategies for people using methamphetamine in South Africa;

  • Drug Consumption Rooms

    Assisting people using crack cocaine in the Netherlands;

  • Karisma

    Offering outreach work for people using methamphetamine in Indonesia;

  • El Achique

    A drop-in center for people using cocaine base paste in Uruguay;

  • COUNTERfit

    A multi-service program distributing safer smoking kits for people using methamphetamine and/or freebase cocaine in Canada, and

  • Chem-Safe

    An online intervention for people using stimulants while practicing chemsex in Spain.

In each place, we spoke to staff and service users. It was beautiful to learn more about these incredible practices! In a nutshell, what we learned from the case studies is that harm reduction for people who use stimulants should consider:
  • Addressing poly-drug use
  • Providing low-threshold services
  • Focusing on belonging and acceptance
  • Promoting self-care and self-control
  • Tackling social exclusion
  • Providing stable housing and income sources
  • Meaningfully involving peers
  • Providing factual, non-sensational information
  • Improving sleep and nutrition
  • Integrating services
  • Providing mental health care
  • Broadening the understanding of harm reduction
In our report, you can find how the programs work, how they contribute to reducing the harms of the people they assist, and which challenges they still have. Give it a check and get inspired!

Do we need specific harm reduction for stimulants?

The short answer is, YES, WE DO! But we do not need to reinvent the wheel. To a large extent, harm reduction for people who use stimulants follows the same fundamental principles as for other substances. Excellent harm reduction services start by providing low-threshold services, meeting people where they are, providing information and materials based on people’s needs, providing outreach and mobile services for those unwilling or unable to visit fixed sites, involving peers as staff members, and ensuring people have access to other relevant services. Besides, drug use happens in a context, and we need to address the socio-economic and legal conditions in which people who use stimulants live. These include addressing unemployment, poverty, homelessness, violence, unstable housing, incarceration, drug impurities, (lack of) availability of harm reduction services, drug legislation which criminalizes drug use, law enforcement practices, and public policies.
On the specific side of stimulants, some interventions are essential. They are often related to the sleep deprivation resulting from prolonged use – particularly (acute) mental health issues, such as paranoia, hallucinations, and anxiety. Addressing these and providing mental health care is essential. Other specific interventions include stimulating safer sex, a healthy sleeping pattern and healthy diets, preventing dehydration, taking care of general and dental hygiene, and promoting safer ways of smoking stimulants.
We have received many positive feedback on our work. Many programs are using the study’s results to advocate for funding. Some of the good-practice cases we described are now being scaled-up or replicated in other countries. Karisma’s shabu outreach, for instance, has expanded to other cities in Indonesia, and new contemplation groups are starting in Vietnam. We have been invited to present the study in many countries (see map below), and our report is now translated into Portuguese!
We have a pocket full of ideas to develop further research and practice related to harm reduction for stimulants. If you have any ideas or comments you would like to share, please bring them on!

*Technical facts (or who are "we"):

  • Research team: Rafaela Rigoni (me, as a lead researcher), Joost Breeksema & Sara Woods.
    Organization: Mainline
    Period: September 2017 – June 2018

  • Funder: GPDPD (Global Partnership for Drug Policy and Development) program, implemented by GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development.

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