EDITORIAL
Evaluating national harm reduction progranns
Evaluating an individual harm reduction program is
quite difficult. Practical and ethical concerns usually pre-
vent the use of 'gold standard' randomized clinical trial
methods for assessing efficacy and assigning causation to
the intervention. Assessing a national program of harm
reduction programs is even more difficult. One must be
concerned about variation in the implementation of the
different programs and possible interactions of different
programs as well as different historical trends in the
country as a whole or in regions of the country.
Emmanuelli and Desenclos (this issue) [1] make an
important and generally successful attempt to assess the
harm reduction programs implemented in France from
1996 to 2003. There were complex patterns in the data.
The numbers of syringes sold or distributed first rose and
then fell. The number of people receiving methadone and
buprenorphine treatment rose continuously. Syringe
sharing and HIV prevalence declined, but HCV preva-
lence did not. Heroin overdoses and heroin arrests
declined, but cocaine arrests rose. Given the complexity
of these results. Emmanuelli and Desenclos were not able
to apply any standard statistical techniques such as time-
lagged correlations to assess the strength of any associa-
tions among these variables.
Nevertheless, taken in the context of much other rele-
vant research, the data presented by Emmanuelli and Des-
enclos suggest that the sterile syringe programs and the
substitution treatment programs did lead to reductions in
HIV and heroin use without having effects on HCV trans-
mission or cocaine use. The increase in buprenorphine
and methadone treatment probably did lead to the reduc-
tions in heroin overdoses and heroin arrests.
There is now a very considerable body of scientific evi-
dence showing that harm reduction programs can be
effective. I would like to suggest three specific questions
for a next generation of policy and research questions.
1 Why do harm reduction programs not work all of the
time for all desired outcomes.'
The HCV data from the Emmanuelli and Desenclos study
are certainly discouraging. There is no evidence the pro-
grams led to reduction in HCV infection among IDUs in
France.
2 How big do harm reduction programs have to be to
address problems successfully at the community level.'
© 2005 Society for the Study of Addiction doi:10. J 1.11 /j.l 360-0443.2005.01281 .x
One of the important aspects of the paper is that it pro-
vides data on the scale of the harm reduction programs
implemented in France—an estimated 17.7 million ster-
ile syringes in the peak year of 1999 and an estimated
101 000 drug users receiving substitution treatment in
the peak year of 2003. The paper would be strengthened
if the authors had included estimates of the numbers of
active IDUs not in treatment for each of the years in the
1996-2003 time-period so that the reader could esti-
mate the numbers of syringes distributed per drug injec-
tor per year and the percentage of drug injectors
receiving treatment each year. Determining the 'cover-
age' needed for harm reduction programs to achieve
community level positive effects is a critical question for
preventing HIV epidemics and other drug related harms
in resource constrained settings [2].
3 How do we insure that 'user friendliness' is incorpo-
rated into harm reduction programs.'
Many harm reduction programs include critical biologi-
cal components—syringes from an exchange or phar-
macy are certain to not be contaminated with HIV or
HCV, methadone and buprenorphine are potent medica-
tions. Nevertheless, the 'user friendliness' of harm reduc-
tion programs may be a necessary component of their
effectiveness. 'User friendliness' would include treating
drug users with dignity and respect, providing conve-
nient locations and hours of operation and requiring a
minimum of bureaucratic hassle to receive services.
Emmanuelli and Desenclos do not provide any systematic
data on the 'user friendliness' of the French harm reduc-
tion programs, although they do note that methadone
treatment is much more highly regulated than buprenor-
phine treatment in France.
There may be a very common tendency for political
leaders to approve controversial harm reduction pro-
grams with restrictions that serve to substantially reduce
user friendliness and the effectiveness of the programs
[3]. Limiting the numbers of syringes that can be
exchanged per visit to an exchange and imposing very
restrictive eligibility requirements on substitution treat-
ment are examples of this tendency. The paper by
Emmanuelli and Desenclos provides very important
observational data indicating the effectiveness of various
harm reduction programs in France from 1996 to 2003.
Addiclion. 100. 1575-1576
1576 Editorial

The paper also leads to policy and research questions that
need to be addressed if the full potential of programs to
reduce drug related h a r m is to be achieved,
DON C, DES JARLAIS
Baron Edmond de Rothschild Chemical Dependency Institute
I' ^ is feasible, UNAIDS/WHO/World Bank Report, in press,
Beth Israel Medical Center and National Development and
Research Institutes, Inc.
Eirst Avenue at 16th Street
New York Citu NY 10003
^'
USA
E-mail: Dcdesjarla@aol.com
References
1, Emmanuelli, J, & Desendos, J,-C, (2005) Harm reduction
interventions, behaviours and associated health outcomes in
France, 1996-2003, Addiction. TOO, 1690-1700,
2, Burrows, D, (in press) HIV prevention among injecting drug
"'^•"^'" developing and transitional countries: high coverage
3 p , , j^.i^i, ^ c,, Paone, D,, Friedman, S, R,, Peyser, N, &
Newman, R, G, (1995) Regulating controversial programs for
unpopular people: methadone maintenance and syringe
exchange programs, American journal of Public Health. 85,
1577-1584,

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