The comorbidity data have led to research that has demonstrated the positive effects of integrating psychiatric and medical care within agonist and other substance abuse treatment programs. Clinical experience and National Institute on Drug Abuse demon-stration projects have shown that integration of these services can be done, and with very positive results since patients are seen fre-quently and treatment retention is high (Umbricht-Schneiter et al., 1994). Related to this line of research are studies that have shown improved compliance with directly observed antituberculosis pharmacotherapy. These findings have important implications for tuberculosis control policies in methadone programs since intra-venous drug users are at very high risk for tuberculosis infection and because maintenance programs provide settings in which di-rectly observed therapy can be easily applied. Similar principles apply to administration of psychotropic medication in noncompli-ant patients with schizophrenia or other major Axis I disorders.
Harm reduction is concerned with minimizing various negative consequences of addiction. As such, the focus is shifted away from drug use to the consequences of use and its attendant be-haviors. Examples of harm reduction include needle exchange programs, efforts directed at reducing drug-use-associated be-haviors that may result in the transmission of HIV, and making changes in policies (including increasing treatment availability) that reduce heroin use and the criminal behavior associated with drug procurement. Harm reduction refers not only to reducing harm to the individual addict, but also to family, friends and to society generally. A number of authors have identified the limi-tations of harm reduction when it is used as a sole strategy to combat the adverse effects of addiction.
With regard to opioids, much of the health-related harm from their improper or illicit use is secondary to elements other than the substances themselves. Sequelae from unhygienic methods of administration and poor injection technique are typically more serious than the constipation or other side effects of the drugs themselves, acute overdoses notwithstanding. At current levels of use, greater harm is expected to result from the use of alcohol and tobacco than from opioids. With regard to opioid addiction treatment, medications such as methadone, LAAM and buprenorphine, among others (including supervised heroin substitution) used for maintenance agonist treatment, may be considered harm-reduction measures