Dr Louise A Sell
Dr. Sell is an Addiction Psychiatrist and former Medical Director in the North West of England. She trained in general medicine before undertaking specialist psychiatric training in Oxford and London. Whilst in Oxford she developed an interest in injectable opiate prescribing and in the Home Office licensing system. She has looked after patients on injectable opiate prescriptions in Oxford, London and the North West. She contributed to the DH review of heroin prescribing, and chaired the Data Monitoring and Ethics Committee of the RIOTT. Her publications include a chapter on injectable methadone prescribing in “Methadone Matters” (Tober and Strang, 2003). Louise has researched and published on the neurobiology of addiction, while working at the National Addiction Centre. She also has an interest in service development, having developed and led a large alcohol and drugs directorate. She is currently the Chair of the North West division of the RCPsych, and is a qualified executive coach with an interest in medical leadership and engagement.
What is harm reduction and how can its efficacy be measured?
Harm reduction is by its nature evidence-based, but it is impossible to measure comprehensively. Almost all interventions to treat substance misuse can be argued to achieve harm reduction. One may differentiate conceptually between interventions within an explicit harm reduction philosophy and those which achieve intermediate goals and a reduction of harm overall, while espousing another philosophy. In order to assess the evidence for a harm reduction intervention one needs to know the outcome of intervening, of doing nothing or of doing something different. Harm and benefit accruing from the substance misuse and from the intervention need to be measured along five dimensions describing the type of harm or benefit, the level in society at which it occurs, the time in relation to the substance misuse at which it occurs, its duration and its severity. The task is complex. Several currently used harm reduction strategies were introduced as pragmatic responses before evidence of their efficacy was available. In this paper the concept of harms and benefits along the above five dimensions is applied to considering the extent to which both well-established strategies, including needle exchange and methadone maintenance, and novel or potential strategies including the use of fluoxetine for ecstasy users are supported by evidence. It is concluded that many fall well short of comprehensive evidence of efficacy. Where the weight of evidence is sufficiently favourable, novel harm reduction strategies should continue to be adopted and the outcome be subject to long-term comprehensive assessment of benefit and harm.