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Why 'harm reduction' won't work

From the Vancouver Sun (British Columbia)
March 19, 2005 Saturday
Final Edition

Vancouver's latest plan -- maintenance for heroin users -- overlooks an elementary fact: The problem with drug use is, oddly enough, drug use

By Kevin Sabet, Special to the Sun

Vancouver has one of the highest rates of drug abuse and infection in the world, according to scientific studies published about the city.

That is why Vancouver's latest plan to maintain heroin users on their drugs of choice -- cornering more addicts into a life of despair and sickness -- is worrying me and scores of public health officials worldwide.

As in most major cities around the world, Vancouver's drug problem is multifaceted and complex: The regular consumption of multiple drugs by a significant minority of the population, rising purity rates, and crippling violence exacerbated by regimented criminal organizations exhaust policy-makers looking for a "quick fix" to the drug problem.

To make matters worse, a disproportionate number of drug addicts in this city have HIV (at least 30 per cent) and Hepatitis C (a staggering 90 per cent), either perpetuated by risky sexual behaviour under the influence of drugs or as a direct result of sharing infected needles.

Even the most extreme anti-drug hawk, then, might be able to understand why so many well-meaning officials and social workers would raise the white flag with policies like government-sponsored drug shooting galleries.

Supporters of these legal injection rooms constantly remind us of the "great Swiss example." Swiss government-funded scientists hailed their heroin maintenance project a success since it concluded that addicts experienced "improvements in health and well-being" and less criminal behaviour. This single review of the Swiss trials has been showcased worldwide as a success of government-sanctioned drug maintenance.

But independent evaluations of the program have been less than sanguine. One of those evaluations -- the official line from the United Nations -- chided the study on the basis of its shoddy design and poorly drawn conclusions. The World Health Organization concluded that the Swiss studies "have not provided convincing evidence that . . . the medical prescription of heroin generally leads to better outcomes."

Science tells us that heroin maintenance is a sloppy alternative to drug treatment strategies like methadone and buprenorphine. Common sense and compassion dictate that, no matter how difficult, uneasy, or uncomfortable, we cannot hide sufferers of addiction in a drug den on the outskirts of town -- we must confront their disease.

It is astonishing that we must perpetually remind ourselves that drug-taking behaviour can be changed when thousands of people in recovery today are living examples of this truth.

So, what is a country or city to do? A lot.

When Sweden found in 1985 that HIV prevalence was more than 50 per cent in its capital city, it established a comprehensive approach of HIV testing and methadone maintenance treatment coupled with hospital units, drug education and counselling for drug users with infectious diseases.

The result? HIV among injection drug users in that city stands today at five percent. Drug use there is the lowest in Europe.

Evidence from elsewhere suggests that when the criminal justice system and public health community work together (in the form of specialized "drug courts," for example), our problems get smaller.

Meanwhile, some officials in this city still respond to this social and biological disease by prolonging it. HIV and Hepatitis C rates continue to soar; Vancouver's overdose rate is the highest in Canada. One Vancouver police drug squad inspector, Mark Horsley, recently said that Vancouver is the "warehouse distribution centre of drugs in Canada."

Cross-country comparisons are problematic, but giving in to harmful behaviour by supporting drug use gets us nowhere. So-called "harm reduction" measures, no matter how well-intentioned, fail to stop drug use and redirect drug addicts. Instead, these policies accept the inevitability of addiction when we know this disease can be prevented or at least treated.

Reducing total harm, on the other hand, must begin by cutting drug use.

Rejecting heroin maintenance doesn't mean that restrictive drug policies, such as those sanctioned and supported by the UN and U.S., are our magic bullet. They have implementation and effectiveness problems of their own. But our overarching goal should always be to reduce total harm and to make our drug policies work better within that context of reducing drug use.

As elementary as it sounds, it seems that some people still need to be reminded that the problem with drug use is drug use.

A so-called "harm reduction" policy is essentially flawed because it has at its core narrow goals that deny the complex social, legal and biological context of drug use and addiction.

Reducing total harm, then -- to one's self, community, and society, users and non-users -- must be the true goal of prevention and treatment providers who understand that drug abuse is a treatable, yet fundamentally preventable, disease of the brain and body.

It is inhumane to perpetuate this disease when history and science tell us that it can be prevented and its attendant consequences reduced, if not eliminated.

Kevin A. Sabet is a Ph.D. student at Oxford University. He was a senior drug policy speechwriter in both the Clinton and Bush Administrations. His book, Dealing With Drugs, will be published this spring.