Harm minimisation has underpinned the Australian National Drug Strategy since 1993 (Single & Rohl, 1997). Harm minimisation supports a mix of three kinds of strategies: supply reduction, demand reduction and harm reduction. The last of these is by far the most contentious as its focus is not on reducing drug use per se but rather the adverse consequences it brings. Because it includes harm reduction strategies alongside efforts to reduce drug use, harm minimisation is an approach that rests on an acceptance that total prevention or eradication is not always possible, and that therefore health educators and others should include strategies to minimise harmful consequences.
Harm reduction strategies rarely feature in the response to VSM. This is for four reasons. First, some Indigenous communities are uncomfortable with the idea of implementing strategies which do not have drug abstinence as their primary goal (Brady, 1995; Brady 2004; Gray, Sputore, Stearne, Bourbon, & Stremple, 2002; Pearson, 2001). Second, the young age of many inhalant users makes it hard to imagine them as capable of managing risks associated with drug use and thus many people believe that adults have a responsibility to intervene. Third, substances such as petrol or spray paint are considered so harmful and unpredictable in their effects as to make risk reduction impossible. Finally, many harm reduction measures tend to attract political controversy, making some politicians unwilling to endorse them. In the case of VSM, this was graphically demonstrated in Victoria in 2002 by a media furore about 'supervised chroming' and the subsequent political reaction (see below for an example of 'supervised chroming' in Victoria, 2002). In light of the high risk of serious, even fatal, consequences of VSM, we believe that harm reduction has received insufficient attention in Australian responses to VSM.
Two main strategies for VSM harm reduction may be identified from the literature. The first pertains to ensuring that the settings in which VSM occurs are such that risks for users are reduced as far as possible; the second covers practices which users themselves may adopt when sniffing in order to minimise risk of adverse consequences.
9.1 Harm reduction in drug use settings
9.2 Harm reduction practices for individuals
9.1 Harm reduction in drug use settingsA proportion of VSM-associated deaths occur because of characteristics of the settings in which these substances are misused. For instance, injury may occur because no responsible person is present and able to call an ambulance when someone passes out from the effects of inhaling toxic chemicals. Other deaths occur when people become intoxicated in hazardous places, for instance near a busy road. Two measures are therefore available to reduce harms in drug use settings: altering the environments where people use drugs, or providing supervised spaces where young people may use volatile substances.
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Few examples of the first measure are available. Police in Wyndham (Victoria) cleared out undergrowth at a known chroming 'hotspot' so that young people were less easily able to hide away from view (Parliament of Victoria Drugs and Crime Prevention Committee, 2002, p. 397).
In Canada the grandmother of a sniffer requested that old dumped cars where young people were hiding in order to sniff be removed (cited in Charles & Coleman, 1999, p. 41).
Almost all participants in a study of homeless young people who chromed in Brisbane indicated that they wanted a safe place where they could chrome and feel reassured that someone was looking out for their welfare (Cheverton et al., 2003). In only a few instances are efforts to establish relatively safe places where people can use volatile substances documented in the literature.
One such effort attracted considerable negative media attention in Victoria in 2002. Berry Street's Child and Family Services provides residential care for young people on protective care orders who cannot live with family. One component of the organisation's harm minimisation approach to substance misuse was to allow young people in their care who could not be persuaded to desist from chroming to do so under observation where their safety could be monitored by staff. The agency argued that monitoring young people who were chroming enabled staff to ensure they took breaks from inhaling and to call medical assistance if necessary. Most importantly this strategy enabled staff to stay connected to young people so that eventually they might persuade them to substitute other activities. This approach to VSM was one among many described in the draft report of the Victorian Parliamentary Inquiry into Inhalation of Volatile Substances (Drugs and Crime Prevention Committee, 2002).
From here it found its way into the media headlines in Victoria in early January 2002. The 'supervised sniffing' story evoked such outcry that the Victorian Premier Steve Bracks quickly announced that any agency which failed to forbid VSM on its premises would lose its funding. Attention to the issue quietened only after the then minister for Community Services was demoted. Some commentators argued that media attention to supervised chroming was part of a broader campaign to discredit harm minimisation (Mendes, 2002; Rayner, 2002). For Bessant (2003), the story incited a 'moral panic' by resonating with other unresolved community concerns. The lasting effect of the furore has been to make governments in Australia wary of supporting harm reduction approaches to VSM. Although some drug treatment providers have argued that young people are placed at additional risk of harm through the banning of harm reduction responses, and that harm reduction can be consistent with a worker's duty of care (Fairbairn & Murray, 2004), the National Inhalant Task Force 2006 policy framework, National Directions on Inhalant Abuse (2006), which has been endorsed by the Ministerial Council on Drug Strategy, does not mention supervised inhalant use as a policy option.
Two other recommendations relating to settings in which inhalant use occurs are reported in the literature, namely:
- Avoid sniffing in small, secret, enclosed spaces such as caravans and cupboards, as reducing oxygen supply may lead sniffers to lose consciousness.
- Avoid VSM in areas near busy roads or where they may fall while intoxicated. As with all forms of drug use, use is safer if someone is around and sufficiently sober to call an ambulance if necessary (Brady, 1985; Jacobs, 2005).Top of page
9.2 Harm reduction practices for individualsA less controversial harm reduction strategy than facilitating supervised use is to advise drug users of means by which they may lessen the likelihood of death or injury as a result of VSM. Western Australia has endorsed an approach which includes provision of harm reduction education for regular and chronic users of volatile substances (Drug and Alcohol Office (Western Australia), n.d.).
In Victoria a harm-reduction education resource called the 'Chroming Wheel' was produced some years ago by the Youth Substance Abuse Service (Youth Substance Abuse Service, n.d.). Several harm reduction practices are described in the literature (Bellhouse, Johnson, & Fuller, 2001; Brady, 1985; Cheverton et al., 2003; Jacobs, 2005). These include:
- Choosing small containers with small surface areas from which to inhale products. For instance if petrol is sniffed from a wide-mouthed container less air will be inhaled at the same time. Bottles with small mouths produce less risk of overdose than do plastic bags.
- Being aware of the risk of suffocating on the container which has been used to administer a volatile substance. Petrol sniffing-associated deaths in Indigenous communities have occurred when people have gone to sleep with a tin propped against their nose, and in some instances also with blankets over their heads, continuing to sniff fumes until they die from asphyxia (South Australia Coroner's Court, 2002). Spray paints are frequently inhaled from plastic bags. The practice of covering the head with a plastic bag to intensify exposure to fumes is extremely risky. Inhalant users should be encouraged to select small bags or bottles to reduce the risk of passing out with a bag over their head or inadvertently covering their mouth and nose.
- Choking on vomit is a significant cause of VSM-associated mortality. Anyone who witnesses a person pass out as a result of VSM (or due to any other cause) should be encouraged to ensure the person can breathe and to call an ambulance as soon as possible.
- Using other drugs concurrently with inhalants (particularly drugs such as alcohol, heroin or cannabis which are also central nervous system depressants) increases the risk of overdose.
- Precautions should be taken against accidental burning as a result of igniting petrol or other volatile substances. Cigarettes should not be smoked while inhaling these products.
- Anyone affected by volatile substances should not be suddenly alarmed, or engage in violent physical exercise, as sudden death appears more likely when sniffers' heart rate is elevated.
- Some people have given sniffers milk to line and protect their stomachs (Cheverton et al., 2003). While there is no research evidence to support this strategy, it may well improve overall nutrition and certainly functions as an expression of care.
Young people in one Australian study indicated that they found it hard to implement harm reduction strategies because their principal objective in using volatile substances was to become acutely intoxicated (MacLean, 2006). Nonetheless some groups of young people who use volatile substances have developed their own harm minimisation measures. A study of incarcerated Aboriginal volatile substance users in Western Australia found that these people practised harm minimisation through their choice of inhalant; rejecting, where possible, petrol in favour of what they saw as less harmful inhalants such as 'Kwikgrip' (Sandover et al., 1997). The study found that young people in remote areas where other volatile substances are hard to procure sniffed petrol, while those in urban areas preferred more readily accessible toluene and glues. Petrol sniffers in the Sandover et al. study also alternated sniffing through the nose and mouth to reduce harm, and sniffed in public places or in company so that help could be sought if necessary.Top of page
- The application of harm reduction approaches to VSM is controversial, insofar as its primary objective is not reducing drug use per se, but rather reducing risk of adverse consequences among those who choose to engage in VSM. However, precisely because VSM does entail such a high risk of serious, including fatal, consequences, there is a strong case for making inhalant users aware of harm reduction options.
- Two main harm-reduction strategies are available: minimising risk associated with the settings in which VSM occurs, and adopting practices when sniffing that reduce the risk of accidental harm.
Harm reduction settings
- Options relating to settings include: (1) avoiding small, enclosed spaces where reduced oxygen supply may lead to loss of consciousness; (2) avoiding areas near busy roads, or other places where an accidental fall may have dangerous consequences; (3) being in the presence of someone who is not intoxicated, and who can therefore seek help if necessary. Another strategy—supervising people who will not otherwise desist from VSM while they inhale—is highly contentious.
Harm reduction practices
- Options relating to sniffing practices include: choosing small containers with small surface areas from which to inhale; avoiding covering the head with a plastic bag to intensify exposure; avoiding concurrent use of other drugs.
- Precautions should be taken against: asphyxia resulting from sniffers falling asleep with containers against their faces or blankets over their heads; choking on vomit; accidental burning; suddenly alarming sniffers.
- Whether or not sniffers should be advised that some inhalants are more or less dangerous than other inhalants is a matter of controversy.