Harm Reduction for Gambling

A Public Health Approach

Henrietta Bowden-Jones, Cheryl Dickson, Caroline Dunand, Olivier Simon, Henrietta Bowden-Jones, Cheryl Dickson, Caroline Dunand, Olivier Simon

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138590953
• eBook ISBN: 9780429955846
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

This edited volume aims to facilitate the evolution of the new public health approach towards gambling. Bringing together the work of international experts, it gives a current overview of the field, highlighting the need for a coordinated framework of prevention and harm reduction measures to replace current "player protection" measures.

Chapters begin by exploring the impact of problem gambling, looking at its effects on several levels, ranging from the individual to the family and society. Subsequently an overview of prevention and harm reduction models is presented, bringing the reader to an in-depth understanding of what a public health approach to gambling would entail. Later chapters focus on potential challenges to monitoring and evaluation, inviting the reader to envisage possible barriers towards implementation and ways of overcoming these. The book concludes with recommendations on how to take a harm reduction approach, from a political and human rights perspective.

This work gives a rare synopsis of the present-day issues when considering the implementation of a harm reduction strategy for gambling. Recent work by key professionals is presented in order to encourage further developments in this ever-changing domain. Such issues will be relevant to all those with an interest in the field of problem gambling, from clinicians, students and healthcare professionals, to politicians.

SECTION II
Harm reduction models and initiatives

7
DEFINING HARM REDUCTION AS PART OF A PUBLIC HEALTH APPROACH TOWARDS GAMBLING

Olivier Simon, Jean-Félix Savary, Gabriel Guarrasi and Cheryl Dickson

If the concept of “harm reduction” (HR) is as old as the hippocratic principle “primum non nocere”, its application to the field of addictive behaviours is recent. The HR premise is found in institutional texts from the 1970s (World Health Organisation, WHO, 1974). At this time, harm reduction was restricted to local initiatives by street workers and people using substances, as an attempt to reduce the adverse consequences of psychoactive substance consumption. At the end of the twentieth century, the HIV epidemic brought about a focus on intravenous non-medical use of substances, in particular, heroin and cocaine. The harm reduction perspective was able to respond to this crisis, where traditional treatment-oriented services could do very little. Two measures were found to be especially effective: the provision of injecting equipment and broad access to methadone by prescription, which has been practiced since the end of the 1960s through a very restrictive framework. These two emergency measures represented a radical questioning of previous practices. The “war on drugs” prioritised the criminalisation of their use and injunctions relating to abstinence (Chappard, Couteron, & Morel, 2012). It was therefore crucial to identify a generic name for these heterogeneous and controversial measures, highlighting a series of democratic duties, other than international conventions prohibiting the nonmedical use of substances. These obligations include the right to life, prevention of discrimination, prohibition of torture, human rights and the right to health.¹ Thus, the concept of HR pragmatically emerged, putting the user at the centre of the right to support and to survival, as the person “does not want to, or has not yet been able to give up” the nonmedical use of substances.

This original political and polemic of the concept of HR highlights the lack of consensus, to accept a scientifically and legally established public health definition. If there is a significant body of publications relating to the keyword “harm reduction” applied to controlled substances,² it will be quite different from other themes that may be associated with development of addictive behaviours. We can cite, for example, therapeutic programmes aiming to control alcohol (Cournoyer, Simoneau, Landry, Tremblay, & Patenaude, 2010), vaping instead of cigarette consumption (Etter & Bullen, 2011) or even measures to limit expenses during gambling sessions (Blaszczynski, Ladouceur, & Nower, 2007). Aren’t these measures indeed from HR? This is far from obvious, especially when it comes to regulation or therapeutic measures which are not in line with the HR concept. Can we speak of HR measures or policies applied to the field of gambling? Can corporate social responsibility measures for businesses, proposed by gambling operators, be considered – under certain conditions – as HR measures? In this chapter, we will revisit the scientific meaning of the term “harm reduction” within the field of substances. We will review the main areas of controversy related to definition efforts, and we will finish with the specific requirements of a public health definition of HR that is compatible with the gambling field.

From the “political” definition of HR to definitions used in the scientific community

The first HR definitions are illustrated in institutional and regulatory documents of support services for individuals using psychoactive substances. Reference is made to the people who are not ready – or according to certain formulations “may not yet be ready” – to give up the use of these substances (Lenton & Single, 1998). From this perspective, HR concerns any policy or programme to improve the health or social status of individuals consuming substances, without aiming to reduce consumption. It acknowledges the fact that some people are not in a situation where they could stop consuming but sometimes fails to see the human rights perspective, that takes into account the “choice” of the person. The concept of HR stipulates that user responsibility is at its centre, so it is not only a question of “being able” to reduce or stop consumption but also a matter of whether the person wishes to do so. Restricting HR to the clinical perspective that someone may not yet be ready to change, fails to provide this dimension of choice. This approach is, however, essential from a human rights perspective and a “non-judgmental” position that respects users. The harsh political context explains how the narrow vision of HR, has been presented as a solution for those who “cannot” stop. The human rights approach advocates, however, for a broader vision of HR, to be seen as a service for all people who use substances, without judgment of their practices. According to Lenton and Single (1998), the main criticism of this historical definition lies in the dichotomy that it creates in relation to measures either to reduce the supply or reduce the demand. On one side are the “pragmatists” aiming to improve health here and now and, on the other, the “idealists” for whom abstinence or reduced consumption would be a non-negotiable goal. The evolution of public policies, which have been in developed in Europe from the 1990s onwards, suggests that fears over the impact of this dichotomy have not been realised.

In opposition to these definitions, which focus on the target audience rather than on public processes or outcomes, different health actors have proposed to focus on the ultimate goal of HR. Thus, Wodak and Sanders (1995, p. 269) have proposed that the term HR could cover “the employment of any means to reduce the harm resulting from illicit drugs”. This offers the advantage of going beyond the previously arising dichotomy. The authors note, however, that there is a risk of confusion here.

Therefore, this raises a question about the measurable nature of harm, and the scientific methods for calculating the “net gain or loss for a given policy or programme” and “those which display a net gain are said to be harm-reducing” (Lenton & Single, 1998, p. 215). We understand that this wish to give an empirical anchor to the concept of HR raises new questions, relating to the limits of knowledge and assessment methods for public policies. If methods exist which enable measurement of the social costs or the loss of quality of life and basic rights, in practice, they rely on studies, which are costly and limited by the standard monitoring framework. Such constraints ultimately face a political agenda in a democratic environment. Beauchet and Morel (2010) distinguish three phases in the development of the HR approach: the first generation had the prevention of HIV/AIDS as their objective, including access to sterile syringes and availability of methadone and other opioid agonist treatment; the second generation aimed to reduce harm due to use in party settings, by providing drug checking and relevant information; and the third generation aimed to broaden the focus by including other addictive behaviours (particularly alcohol and tobacco but also possibly behavioural addictions). We should also add that the traditional HR advocates have always stressed the need for “social” harm reduction that goes beyond pure health issues to involve, for example, housing, employment and social inclusion.

Today, in scientific publications, two definitions are particularly mentioned: the WHO-European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)-UNAIDS reference document (2014), and that of Harm Reduction International (International Harm Reduction Association, 2010). These two definitions illustrate two trends: on the one hand there are definitions arising from a consensus developed under the aegis of intergovernmental bodies, which do not call into question the international treaties on the control of substances; on the other hand there are definitions proposed by nongovernmental organisations, which benefit from being more centred on the basic needs of the individual and their community. The latter point more towards the inherent conflict between fundamental rights and the treaties relating to substances.

Example of a definition from the UN and the EU

Here, the approach is to define HR by structural elements rather than processes or goals. In this case nine groups of interventions are combined to address the HIV risk for people injecting substances. This narrow perspective is often linked to controversy over the HR concept, itself. By naming the measures and not the concept, it allows multilateral bodies to endorse some measures, without making explicit reference to HR. It should, therefore, be seen as a lack of support for the HR concept on the part of these large organisations. Moreover, it demonstrates the need to continue advocacy efforts in order to finally achieve a legitimate HR concept. The definition is therefore only based on measures that have proven effective, according to scientific knowledge:

A Comprehensive Package of interventions for the prevention, treatment and care of HIV amongst people who inject drugs has been endorsed widely, by WHO, UNAIDS, United Nations Office on Drugs and Crime (UNODC), the UN General Assembly, the Economic and Social Council, the UN Commission on Narcotic Drugs, the UNAIDS Programme Coordinating Board, the Global Fund and the President’s Emergency Plan for Aids Relief. The Comprehensive Package (WHO, 2012, p. 10) includes:

• Needle and syringe programmes
• Opioid substitution therapy and other evidence-based drug dependence treatment
• HIV testing and counselling
• Antiretroviral therapy
• Prevention and treatment of sexually transmitted infections
• Condom programmes for people who inject drugs and their sexual partners
• Targeted information, education and communication for people who inject drugs and their sexual partners
• Prevention, vaccination, diagnosis and treatment for viral hepatitis
• Prevention, diagnosis and treatment of tuberculosis.

Definition from the civil society: Harm reduction international

Here, the approach puts at its forefront human rights, the person and the community and the reduction of negative consequences, not only for health but also at the wider societal level.

The definition proposed by the International Harm Reduction Association (IHRA, a society which has since become Harm Reduction International) is that

HR refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. HR benefits people who use drugs, their families and the community. […] The HR approach to drugs is based on a strong commitment to public health and human rights.

(International Harm Reduction Association, 2010, p. 1)

Main controversies from a “gambling” perspective

These historical definitions highlight the main controversies that animate the actors in the field of addictions. We will briefly look at the questions and implications relating the nature of HR (measures, policies, concept), to its different components (person-centred prevention, structural prevention, consumption reduction) and finally to its links with public health (human rights links, bottom up person-centred approach, evaluation and research) (Langham et al., 2015; see also Chapter 1, Chapter 2, Chapter 8).

Does HR refer to a concept, as has always been advocated by specialised HR groups, or to measures that can be considered separately, as often imposed by government agencies, or even to public policies that are based, above all, on the combined character of the measures? This is a significant debate, where gambling is concerned. If HR is a “concept”, let alone a simple “measure”, then it could be susceptible to including “harm minimisation” measures, developed by the industry (Blaszczynski, 2001). This could lead to a marketing approach, for which the net result is an increase in supply, and subsequently an increase in global burden, at a community level.

In order to pursue HR goals, it is possible to implement a set of co-ordinated approaches. It is important that these measures are combined in a balanced way and subject to both pre and post set-up evaluations (Simon, Blaser, Müller, & Waelchli, 2013). The very nature of these combined measures can be varied (for example strategies addressing stigma, measures to encourage those who consume substances to participate in public debates, access to specialised support). Such an approach invites us to answer the question of whether structural prevention measures (e.g., an increase in taxes or protection against passive smoking) form part of HR (Chaloupka, Straif, & Leon, 2011). We see that there is a big risk of confusion over the concepts of prevention and HR, which should be avoided. The big difference between the two is that one addresses the decision to consume (prevention), and the other the consequences of the consumption, for which the decision has already been taken (HR). Moreover, prevention enforces social norms, whilst HR implies a non-judgmental position. Both can be articulated but should not be confused. Another controversial point is the place of risk-related information or even the promotion of low-risk consumption, if commercial interests are involved.

Ultimately is HR considered to be a public health approach based mainly on epidemiological methods? Or is it, above all, an ethical stance towards wider public policy, typically including actors from public safety and the economic sphere? We note that a modern public health approach can hardly be conceived, without an analysis of stakeholders (Brugha & Varvasovszky, 2000), making this opposition somewhat theoretical. The right to the highest possible standard of health, as a fundamental right to access a collective set of services but also the right to have control over one’s own body are inseparable from other human rights including the prohibition of discrimination, the prohibition of inhuman and degrading treatment, the right of access to fair legal proceedings and the right ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• Contributor biographies
• Preface
• Acknowledgements
• Introduction
• SECTION I Impact and current understanding of gambling disorder
• SECTION II Harm reduction models and initiatives
• SECTION III Challenges to evaluation and monitoring
• Conclusion
• Index