Making the case for harm reduction: a provider organization cites the success of harm reduction efforts in Vancouver, British Columbia.

Medicine has long recognized the detrimental effects of addiction. For more than 40 years, physicians have attempted to provide those struggling with addiction solutions to moderate substance abuse's consequences. Dole and Nyswander often are recognized in the United States for their work in methadone treatment for heroin drug addiction. However, predating their work, Dr. Robert Halliday began methadone treatment for heroin addiction in Vancouver, British Columbia, in the late 1950s and introduced a methadone maintenance program in 1963. (1-3) Since that time, Vancouver has continued its pragmatic approach to moderate the effects of addictions through harm reduction, and has led the country and North America in the introduction of harm reduction measures.

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Harm reduction is based on the principles that we do no harm to those suffering from substance addiction, and that we focus on the harm caused by problematic substance use, rather than substance use per se. Communities have adopted such strategies as a means of reducing the social and economic costs of addiction, including crime and familial difficulties. Harm reduction involves establishing a hierarchy of achievable goals that, when taken step by step, can lead to a healthier life for drug users and a healthier community for everyone. Harm reduction accepts that abstinence may not be a realistic goal for some drug users, particularly in the short term. Harm reduction involves an achievable, pragmatic approach to drug issues. Furthermore, these interventions have proven successful in decreasing the open drug scene, the spread of HIV/AIDS and hepatitis, and overdoses and overdose deaths in countries such as Germany, Switzerland, and Australia. (4)

In contrast, a study by the British Columbia Centre for Excellence in HIV/AIDS found that the large-scale Vancouver police crackdown in 2003 to control illicit drug use did not alter the price of drugs or the frequency of use, and nor did it encourage IV drug users to enroll in methadone treatment programs. Instead, several study measures indicated that users moved from the area of the crackdown into adjacent areas of the city, having implications for both recruitment of new initiates into injection drug use and HIV prevention efforts. (5)

Vancouver's Four Pillars Drug Strategy emphasizes prevention, treatment, harm reduction, and enforcement. Today, harm reduction measures in Vancouver include the long-standing methadone maintenance treatment programs and a spectrum of other measures, including drug courts, needle exchange programs (NEPs), a supervised injection site, street health outreach services, and clinical trials of methadone for chronic opiate dependency. Through medical training for physicians, a federal drug law exemption, and behavioral healthcare counseling, individuals are provided supports and resources to reduce their personal harm and that to the community from the sale and use of legal and illegal substances. (6)

The U.S. National Institute on Drug Abuse has documented the many studies that have demonstrated the efficacy of methadone maintenance therapy in reducing use of opioids, decreasing crime associated with drug use, decreasing drug-related deaths, and preventing the spread of blood-borne diseases. (7) Methadone maintenance and harm reduction strategies increasingly have become standard practices in many countries and are used to manage a host of consequences, from diminishing risks for developing fetuses in pregnant women to reducing the social costs of criminal behaviors to support addiction. (7)

Other measures introduced in Vancouver, such as NEPs, have similarly developed a body of evidentiary support. (6) Today more than 100 NEPs exist in Canada. (8) Health experts say hypodermic needles can harbor more than 20 blood-borne diseases, including HIV and hepatitis B and C. Critics of NEPs say they encourage people to use illegal drugs and result in more needles being dumped in public places. However, according to the Centre for Addiction and Mental Health, which looked at several surveys, NEPs:

* reduce the transmission of disease in drug users;

* do not increase injection drug use; and

* do not increase the number of needles discarded (NEPs collect more needles than they give out). (9)

BC Partners for Mental Health and Addictions Information reports that in 2000, the Vancouver NEP distributed nearly 3.5 million needles with a return rate of 101%, (10) thus disposing of millions of needles safely and ensuring that they are not discarded inappropriately. BC Partners also cites a study by Gibson et al that found injecting drug users in the United States who used a syringe exchange had a sixfold decrease in HIV risk behavior compared to injection drug users who used syringes from other sources, concluding that sterile needles are an inexpensive means of preventing greater healthcare costs. (11)

Heavy IV drug users, such as crack cocaine users, inject upward of 20 times a day and often in groups. For these users, NEPs, while reducing exposures, may not result in reduced transmission rates of blood-borne infectious diseases because of the frequency of exposure. To combat this population's health risks, in September 2003 Vancouver opened North America's only supervised injection site, Insite, funded by the provincial and federal governments and operated under the supervision of the Vancouver Coastal Health authority. The clinic, open 18 hours a day, is located in the heart of the city's drug corridor, the Downtown Eastside. It provides a safe place and clean "tools" for addicts to shoot up. The health authority's outcomes study for the first years of operations details:

* 7,278 unique individuals registered with an average of 607 visits daily

* 453 overdoses resulted in no fatalities

* 4,084 referrals were made, with 40% of them for addiction counseling

* 368 referrals were made to supervised detox and other forms of addictions withdrawal management

* 2 referrals weekly, on average, to methadone maintenance therapy

* 6,227 nursing care interventions, 2,055 for abscess care (12)

In order to operate Insite legally, Health Canada granted the Vancouver Coastal Health authority a three-year operating exemption, ending December 31, 2007, under Canada's Controlled Drugs and Substances Act. Negotiations are under way with the federal government to extend the exemption. Spokespeople for Insite express confidence in the outcome of the negotiations.

Other measures such as drug courts have proven similarly effective in Vancouver. However, Vancouver continues to work toward reducing street crimes linked to addictions.

Vancouver Mayor Sam Sullivan has called for a three-year clinical trial to address cocaine and crystal meth addiction. (13) The mayor is lobbying the federal government for an exemption from Canada's narcotics laws. Sullivan's plan, called CAST (chronic addiction substitution treatment), would use legally prescribed drugs (such as opiate-based OxyContin) dispensed by local pharmacies as substitutes for the stimulant-type illegal drugs. Lois Johnson, head of the Inner Change, the committee applying to Health Canada for the exemption, reports that five different drug trials were under consideration and were expected to be finalized for submission to Health Canada by the end of June. Individuals would be provided with counseling and resources for mental health issues, housing, and possibly employment. Thus, in keeping with its more than 40-year history, the city seeks to address the frequently documented health problems of chronic drug users, provide effective treatment, and provide safer streets for its citizens.

For more information, e-mail shawn.bayes@elizabethfry.com.

References

1. Fischer B. Prescriptions, power and politics: The turbulent history of methadone maintenance in Canada. J Public Health Policy 2000;21(2):187-210.

2. Paulus I, Halliday R. Rehabilitation and the narcotic addict: Results of a comparative methadone withdrawal program. Can Med Assoc J 1967;96(11):655-9.

3. Halliday R. Management of the narcotic addict. British Columbia Medical J 1963;5(10):412-14.

4. Centre for Addiction and Mental Health. Harm Reduction: Its Meaning and Application for Substance Use Issues Position Statement. www.camh.net/Public_policy/Public_policy_papers/harmreductionposition.html.

5. Wood E, Spittal PM, Small W, et al. Displacement of Canada's largest public illicit drug market in response to a police crackdown. CMAJ 2004;170(10):1551-6.

6. City of Vancouver. Four Pillars Drug Strategy. www.city.vancouver.bc.ca/fourpillars/index.htm.

7. National Institute on Drug Abuse. Methadone Research Web Guide. http://international.drugabuse.gov/methadone/methadone_web_guide/intro.html.

8. CBC News Online. In depth: Drugs. Point for point: Canada's needle exchange programs. October 27, 2004. www.cbc.ca/news/background/drugs/needleexchange.html.

9. Zbogar H. Needle exchange users take fewer HIV risks. CrossCurrents Winter 2004/05. www.camh.net/Publications/Cross_Currents/Winter_2004-05/researchupdate_crcuwin0405.html.

10. BC Partners for Mental Health and Addictions Information. State of the Knowledge: Needle Exchange Programs. September 2003. www.heretohelp.bc.ca/publications/stateofknowledge/needleexchange.pdf.

11. Gibson DR, Brand R, Anderson K, et al. Two- to sixfold decreased odds of HIV risk behavior associated with use of syringe exchange. J Acquir Immune Defic Syndr 2002;31(2):237-42.

12. Vancouver Coastal Health. Insite--Supervised Injection Site. Research Results. www.vch.ca/sis/rcsearch.htm.