The harm reduction model of drug addiction treatment | Mark Tyndall

Summary

The speaker recounts their experience in Vancouver's Downtown East Side, witnessing the desperate need for harm reduction in the face of drug use and HIV. They argue for the effectiveness of harm reduction strategies like needle exchanges and supervised injection sites, despite opposition and stigma. Highlighting the success of Portugal's decriminalization, the speaker calls for a shift from punitive to health-focused approaches to address the drug crisis and save lives.

Takeaways

• 🏥 The Downtown East Side of Vancouver was a hub for marginalized drug users, leading to the city declaring a public health emergency in 1997.
• 💉 Harm reduction services were expanded in response to the crisis, including needle distribution and supervised injection sites, to make drug use less hazardous.
• 🚫 Despite evidence of success, harm reduction is still controversial and illegal in some places, with a focus on arresting drug users rather than offering therapy.
• 🤔 The speaker questions the prevailing attitude that abstinence is the only solution and highlights the importance of considering harm reduction as a viable approach.
• 🌐 The opposition to supervised injection sites in cities like Seattle, Baltimore, and New York contradicts the scientific evidence supporting harm reduction.
• 🏥 The purpose of harm reduction is not to stop drug use but to minimize the harm associated with it, acknowledging that people will still use drugs despite sanctions.
• 🔑 The speaker emphasizes that providing clean needles and safe injection sites is a crucial first step towards treatment and recovery, not giving up on people.
• 👶 Critics' concerns about harm reduction sending the wrong message are countered by the fact that drug users are often 'our children' and need care, not judgment.
• 🏛 The story of Vancouver's first supervised injection site at 327 Carol Street illustrates the community's commitment to harm reduction despite legal challenges.
• 🏆 The Supreme Court of Canada's decision to keep INSITE open was a significant victory for harm reduction, validating its effectiveness in preventing overdose deaths.
• 🌟 The success of harm reduction programs like needle exchanges, methadone, and supervised injection sites is evident in the reduction of suffering and death related to drug use.
• 🌍 The speaker calls for a reevaluation of drug policies, advocating for decriminalization and a focus on public health and social solutions, citing Portugal's successful model as an example.

Q & A

What was the speaker's first impression of the Downtown East Side in Vancouver?

The speaker was shocked by the sight of people injecting drugs in the lobby of the Portland Hotel, which is a supportive housing project for marginalized individuals.

What measures did Vancouver take in response to the public health emergency declared in 1997?

Vancouver expanded harm reduction services, distributed more needles, increased access to methadone, and opened a supervised injection site to make drug use less hazardous.

What is the main purpose of harm reduction services?

The main purpose of harm reduction services is to minimize the negative effects of drug use, such as the spread of HIV and other health risks associated with unsafe drug injection practices.

Why do some critics argue against harm reduction strategies like supervised injection sites?

Critics believe that harm reduction strategies might send the wrong message, encourage drug use, and give up on the idea of helping people recover from addiction.

How does the speaker refute the criticism that harm reduction services encourage drug use?

The speaker argues that the purpose of harm reduction is not to encourage drug use but to keep people alive and provide a safer environment for those who still use drugs, which is a crucial first step towards treatment and recovery.

What was the significance of the Supreme Court of Canada's decision regarding INSITE?

The Supreme Court's decision to keep INSITE open was significant because it recognized the importance of harm reduction services in saving lives and reducing the risk of death and disease among drug users.

What is the current situation regarding harm reduction programs in North America?

Despite evidence of their effectiveness, harm reduction programs have not been widely adopted, and there is still a strong focus on law enforcement rather than public health approaches to drug use.

What is the speaker's view on the portrayal of drug users in the media and society?

The speaker believes that the portrayal of drug users is largely negative and stigmatizing, which contributes to a lack of understanding and compassion for those struggling with addiction.

How does the speaker describe the current approach to drug use in healthcare?

The speaker describes the current approach as upside down, focusing on abstinence as the primary treatment method rather than offering safer alternatives and comprehensive care.

What example does the speaker provide to illustrate a successful alternative approach to drug policy?

The speaker cites Portugal's decriminalization of all drug possession and redirection of resources to health and rehabilitation programs, which resulted in a significant decrease in drug use and overdoses.

What is the speaker's call to action for addressing the drug crisis?

The speaker calls for the full embrace, funding, and scaling up of harm reduction programs, as well as a serious conversation about prohibition and criminal punishment, advocating for treating drug use as a public health issue.

Outlines

00:00

🏥 The Emergence of Harm Reduction in Vancouver

This paragraph introduces the speaker's first encounter with drug injection in Vancouver's Downtown East Side, a region notorious for its high rates of HIV and marginalized population. It discusses the city's declaration of a public health emergency in 1997, which led to the expansion of harm reduction services like needle distribution and supervised injection sites. Despite these efforts, the concept of harm reduction is still controversial, with critics arguing against its effectiveness and fearing it sends the wrong message. The speaker emphasizes the importance of harm reduction as a step towards treatment and recovery, not an endorsement of drug use.

05:03

🏛 The Legal Battle for Supervised Injection Sites

The second paragraph delves into the legal fight to keep the supervised injection site INSITE open, which reached the Supreme Court of Canada. The court's decision to keep the site operational was based on the significant benefits it provided to the community, such as reducing the risk of death and disease among drug users. Despite this victory, new harm reduction sites faced bureaucratic hurdles. The paragraph also highlights the success of overdose prevention sites in British Columbia, which operated without federal approval and significantly reduced overdose deaths. The speaker calls for a broader acceptance of harm reduction programs as a compassionate and effective approach to drug use.

10:07

🚑 The Stigmatization and Health Impacts of Drug Policies

This paragraph addresses the deep-seated stigma associated with drug use and its impact on healthcare access for drug users. It describes how the current medical approach to drug use is flawed, focusing on abstinence rather than providing safe alternatives. The speaker criticizes the lack of empathy and understanding for those with addiction, pointing out that most drug users have complex backgrounds involving trauma or mental health issues. The paragraph also discusses the unprecedented scale of the current overdose crisis, attributing it to the liberal distribution of prescription opioids and the subsequent shift to more dangerous street drugs like heroin and fentanyl.

15:10

🌍 Learning from Portugal's Decriminalization of Drug Use

The final paragraph presents Portugal's decriminalization of all drug possession as a successful model for addressing drug crises. By redirecting resources from enforcement to health and rehabilitation, Portugal has seen a significant decrease in drug use and overdoses, with more people receiving treatment. The speaker calls for a reevaluation of current drug policies, advocating for a public health approach that prioritizes care and support over criminalization and punishment, in order to address the suffering caused by the war on drugs.

Keywords

💡Harm reduction

Harm reduction is a public health approach aimed at minimizing the negative consequences of drug use for individuals and communities. In the context of the video, it includes measures like distributing clean needles, providing methadone therapy, and establishing supervised injection sites. The script emphasizes the importance of harm reduction in preventing the spread of HIV and reducing drug-related deaths, as seen in Vancouver's Downtown East Side and the INSITE program.

💡Supervised injection site

A supervised injection site is a location where people can inject drugs under medical supervision, reducing the risk of overdose and the spread of infectious diseases. The video script describes the first such site in Vancouver, which operated despite police intervention, highlighting the benefits of a safe and clean environment for drug users and the community.

💡Methadone

Methadone is a medication used to treat opioid addiction, reducing withdrawal symptoms and cravings without causing the high associated with the drug. The script discusses increasing access to methadone as part of harm reduction services, illustrating its role in managing addiction and preventing relapse.

💡Stigma

Stigma refers to the negative attitudes and discrimination associated with a particular group or condition, in this case, drug users. The video script discusses the deep-rooted stigma against drug users, which affects their access to healthcare and perpetuates the cycle of addiction and social exclusion.

💡Overdose

An overdose occurs when a person consumes a sufficient dose of a drug to produce life-threatening symptoms or death. The script mentions the overdose crisis and the role of Naloxone in reversing overdoses, emphasizing the urgency of the situation and the need for harm reduction measures.

💡Addiction

Addiction is a chronic brain disorder characterized by compulsive drug-seeking behavior despite harmful consequences. The video script addresses addiction as a complex health issue, not merely a choice or moral failing, and argues for a shift in societal and policy responses from punishment to treatment and support.

💡Decriminalization

Decriminalization refers to the removal of criminal penalties for the possession and use of drugs, treating drug use as a health issue rather than a criminal one. The script cites Portugal's decriminalization of all drug possession as a successful model that reduced drug use and overdose deaths, suggesting a similar approach for North America.

💡Public health emergency

A public health emergency is a situation in which the health of a community is at significant risk, necessitating immediate action. The video script recounts how Vancouver declared a public health emergency in 1997 due to high rates of HIV and drug-related issues, leading to the expansion of harm reduction services.

💡Opioids

Opioids are a class of drugs that include both prescription pain relievers and illegal drugs like heroin, known for their pain-relieving and addictive properties. The script discusses the widespread distribution of opioid painkillers, the subsequent epidemic of opioid abuse, and the current crisis of synthetic opioid overdoses.

💡Naloxone

Naloxone is a medication that can reverse an opioid overdose, restoring normal respiration to someone whose breathing has slowed or stopped. The video script highlights the use of Naloxone in overdose prevention sites, demonstrating its life-saving potential in the face of the overdose crisis.

💡INSITE

INSITE is North America's first government-sanctioned supervised injection site, which opened in Vancouver in 2003. The script details the legal battles to keep INSITE open, emphasizing its role in preventing overdose deaths and serving as a gateway to treatment and recovery for drug users.

Highlights

The first encounter with drug injection in Vancouver's Downtown East Side, highlighting the desperate situation in the Portland Hotel.

Vancouver's declaration of a public health emergency in 1997 to address the crisis of drug use, poverty, violence, and HIV rates.

Introduction of harm reduction services including needle distribution and supervised injection sites to mitigate drug use hazards.

The ongoing perception of harm reduction as a radical concept and the illegality of carrying clean needles in some places.

The opposition to supervised injection sites in cities like Seattle, Baltimore, and New York, contrary to scientific understanding of addiction.

Criticism of harm reduction not preventing drug use and the counterargument that it aims to reduce harm, not use.

The misconception that harm reduction放弃s on people by not focusing on treatment and recovery, when it actually supports life preservation for potential recovery.

The argument that harm reduction sends the wrong message to children, countered by the reality that drug users are often 'our children'.

The true purpose of supervised injection sites to provide a safer alternative to alleyway injections and reduce health risks.

The history and significance of North America's first government-sanctioned supervised injection site, INSITE, established in 2003.

The Supreme Court of Canada's ruling in favor of keeping INSITE open, emphasizing the importance of harm reduction services.

The rapid establishment of overdose prevention sites in British Columbia in response to the overdose crisis, circumventing federal approval.

The success of INSITE in preventing overdose deaths, with no fatalities recorded over 14 years.

The question of why harm reduction programs have not been more widely adopted despite evidence of their effectiveness.

The deep-rooted stigma towards drug users and the societal and media narratives that contribute to this stigma.

The false narrative of drug users as irresponsible individuals and the reality of their often complex backgrounds involving trauma and illness.

The need to view drug policies as a social justice issue and to focus on comprehensive social and health solutions rather than criminalization.

The success of Portugal's decriminalization of all drug possession and the redirection of resources to health and rehabilitation programs.

A call to action for embracing, funding, and scaling up harm reduction programs across North America as a critical first step in addressing the drug crisis.

The importance of having a serious conversation about prohibition and criminal punishment in the context of the current drug crisis.

Transcripts

I remember the first time that I saw people injecting drugs.

I had just arrived in Vancouver to lead a research project

in HIV prevention in the infamous Downtown East Side.

It was in the lobby of the Portland Hotel,

a supportive housing project that gave rooms

to the most marginalized people in the city,

the so-called "difficult to house."

I'll never forget the young woman standing on the stairs

repeatedly jabbing herself with a needle, and screaming,

"I can't find a vein,"

as blood splattered on the wall.

In response to the desperate state of affairs, the drug use,

the poverty, the violence, the soaring rates of HIV,

Vancouver declared a public health emergency in 1997.

This opened the door to expanding harm reduction services,

distributing more needles,

increasing access to methadone,

and, finally, opening a supervised injection site.

Things that make injecting drugs less hazardous.

But today, 20 years later,

harm reduction is still viewed as some sort of radical concept.

In some places, it's still illegal to carry a clean needle.

Drug users are far more likely to be arrested

than to be offered methadone therapy.

Recent proposals for supervised injection sites

in cities like Seattle, Baltimore and New York

have been met with stiff opposition:

opposition that goes against everything we know about addiction.

Why is that?

Why are we still stuck on the idea

that the only option is to stop using -- that any drug use will not be tolerated?

Why do we ignore countless personal stories

and overwhelming scientific evidence

that harm reduction works?

Critics say that harm reduction doesn't stop people

from using illegal drugs.

Well, actually, that is the whole point.

After every criminal and societal sanction

that we can come up with,

people still use drugs, and far too many die.

Critics also say that we are giving up on people

by not focusing our attention on treatment and recovery.

In fact, it is just the opposite.

We are not giving up on people.

We know that if recovery is ever going to happen

we must keep people alive.

Offering someone a clean needle or a safe place to inject

is the first step to treatment and recovery.

Critics also claim that harm reduction

gives the wrong message to our children about drug users.

The last time I looked, these drug users are our children.

The message of harm reduction is that while drugs can hurt you,

we still must reach out to people who are addicted.

A needle exchange is not an advertisement for drug use.

Neither is a methadone clinic or a supervised injection site.

What you see there are people sick and hurting,

hardly an endorsement for drug use.

Let's take supervised injection sites, for example.

Probably the most misunderstood health intervention ever.

All we are saying is that allowing people

to inject in a clean, dry space with fresh needles,

surrounded by people who care

is a lot better than injecting in a dingy alley,

sharing contaminated needles and hiding out from police.

It's better for everybody.

The first supervised injection site in Vancouver was at 327 Carol Street,

a narrow room with a concrete floor, a few chairs and a box of clean needles.

The police would often lock it down,

but somehow it always mysteriously reopened,

often with the aid of a crowbar.

I would go down there some evenings

to provide medical care for people who were injecting drugs.

I was always struck with the commitment and compassion

of the people who operated and used the site.

No judgment, no hassles, no fear,

lots of profound conversation.

I learned that despite unimaginable trauma,

physical pain and mental illness,

that everyone there thought that things would get better.

Most were convinced that, someday, they'd stop using drugs altogether.

That room was the forerunner to North America's

first government-sanctioned supervised injection site, called INSITE.

It opened in September of 2003 as a three-year research project.

The conservative government was intent on closing it down at the end of the study.

After eight years, the battle to close INSITE

went all the way up to Canada's Supreme Court.

It pitted the government of Canada

against two people with a long history of drug use

who knew the benefits of INSITE firsthand:

Dean Wilson and Shelley Tomic.

The court ruled in favor of keeping INSITE open by nine to zero.

The justices were scathing in their response to the government's case.

And I quote:

"The effect of denying the services of INSITE to the population that it serves

and the correlative increase in the risk of death and disease

to injection drug users is grossly disproportionate to any benefit

that Canada might derive

from presenting a uniform stance on the possession of narcotics."

This was a hopeful moment for harm reduction.

Yet, despite this strong message from the Supreme Court,

it was, until very recently,

impossible to open up any new sites in Canada.

There was one interesting thing that happened in December of 2016,

when due to the overdose crisis,

the government of British Columbia allowed the opening of overdose prevention sites.

Essentially ignoring the federal approval process,

community groups opened up about 22 of these de facto illegal

supervised injection sites across the province.

Virtually overnight,

thousands of people could use drugs under supervision.

Hundreds of overdoses were reversed by Naloxone, and nobody died.

In fact, this is what's happened at INSITE over the last 14 years:

75,000 different individuals have injected illegal drugs

more than three and a half million times,

and not one person has died.

Nobody has ever died at INSITE.

So there you have it.

We have scientific evidence and successes from needle exchanges

methadone and supervised injection sites.

These are common-sense, compassionate approaches to drug use

that improve health, bring connection

and greatly reduce suffering and death.

So why haven't harm reduction programs taken off?

Why do we still think that drug use is law enforcement issue?

Our disdain for drugs and drug users goes very deep.

We are bombarded with images and media stories

about the horrible impacts of drugs.

We have stigmatized entire communities.

We applaud military-inspired operations that bring down drug dealers.

And we appear unfazed by building more jails

to incarcerate people whose only crime is using drugs.

Virtually millions of people are caught up

in a hopeless cycle of incarceration, violence and poverty

that has been created by our drug laws and not the drugs themselves.

How do I explain to people that drug users deserve care and support

and the freedom to live their lives

when all we see are images of guns and handcuffs and jail cells?

Let's be clear:

criminalization is just a way to institutionalize stigma.

Making drugs illegal does nothing to stop people from using them.

Our paralysis to see things differently

is also based on an entirely false narrative about drug use.

We have been led to believe that drug users

are irresponsible people who just want to get high,

and then through their own personal failings

spiral down into a life of crime and poverty,

losing their jobs, their families and, ultimately, their lives.

In reality, most drug users have a story,

whether it's childhood trauma, sexual abuse, mental illness

or a personal tragedy.

The drugs are used to numb the pain.

We must understand that as we approach people with so much trauma.

At its core, our drug policies are really a social justice issue.

While the media may focus on overdose deaths like Prince and Michael Jackson,

the majority of the suffering

happens to people who are living on the margins,

the poor and the dispossessed.

They don't vote; they are often alone.

They are society's disposable people.

Even within health care, drug use is highly stigmatized.

People using drugs avoid the health care system.

They know that once engaged in clinical care

or admitted to hospital, they will be treated poorly.

And their supply line, be it heroin, cocaine or crystal meth

will be interrupted.

On top of that, they will be asked a barrage of questions

that only serve to expose their losses and shame.

"What drugs do you use?"

"How long have you been living on the street?"

"Where are your children?"

"When were you last in jail?"

Essentially: "Why the hell don't you stop using drugs?"

In fact, our entire medical approach to drug use is upside down.

For some reason,

we have decided that abstinence is the best way to treat this.

If you're lucky enough, you may get into a detox program.

If you live in a community with Suboxone or methadone,

you may get on a substitution program.

Hardly ever would we offer people what they desperately need to survive:

a safe prescription for opioids.

Starting with abstinence is like asking a new diabetic to quit sugar

or a severe asthmatic to start running marathons

or a depressed person to just be happy.

For any other medical condition,

we would never start with the most extreme option.

What makes us think that strategy

would work for something as complex as addiction?

While unintentional overdoses are not new,

the scale of the current crisis is unprecedented.

The Center for Disease Control estimated

that 64,000 Americans died of a drug overdose in 2016,

far exceeding car crashes or homicides.

Drug-related mortality is now the leading cause of death

among men and women between 20 and 50 years old in North America

Think about that.

How did we get to this point, and why now?

There is a kind of perfect storm around opioids.

Drugs like Oxycontin, Percocet and Dilaudid

have been liberally distributed for decades for all kinds of pain.

It is estimated that two million Americans are daily opioid users,

and over 60 million people

received at least one prescription for opioids last year.

This massive dump of prescription drugs into communities

has provided a steady source for people wanting to self-medicate.

In response to this prescription epidemic,

people have been cut off, and this has greatly reduced the street supply

The unintended but predictable consequence

is an overdose epidemic.

Many people who were reliant on a steady supply of prescription drugs

turned to heroin.

And now the illegal drug market has tragically switched

to synthetic drugs, mainly fentanyl.

These new drugs are cheap, potent and extremely hard to dose.

People are literally being poisoned.

Can you imagine if this was any other kind of poisoning epidemic?

What if thousands of people started dying

from poisoned meat or baby formula or coffee?

We would be treating this as a true emergency.

We would immediately be supplying safer alternatives.

There would be changes in legislation,

and we would be supporting the victims and their families.

But for the drug overdose epidemic,

we have done none of that.

We continue to demonize the drugs and the people who use them

and blindly pour even more resources into law enforcement.

So where should we go from here?

First, we should fully embrace, fund and scale up

harm reduction programs across North America.

I know that in places like Vancouver,

harm reduction has been a lifeline to care and treatment.

I know that the number of overdose deaths

would be far higher without harm reduction.

And I personally know hundreds of people who are alive today

because of harm reduction.

But harm reduction is just the start.

If we truly want to make an impact on this drug crisis,

we need to have a serious conversation about prohibition

and criminal punishment.

We need to recognize that drug use is first and foremost a public health issue

and turn to comprehensive social and health solutions.

We already have a model for how this can work.

In 2001, Portugal was having its own drug crisis.

Lots of people using drugs, high crime rates

and an overdose epidemic.

They defied global conventions and decriminalized all drug possession.

Money that was spent on drug enforcement

was redirected to health and rehabilitation programs.

The results are in.

Overall drug use is down dramatically.

Overdoses are uncommon.

Many more people are in treatment.

And people have been given their lives back.

We have come so far down the road of prohibition, punishment and prejudice

that we have become indifferent to the suffering

that we have inflicted on the most vulnerable people in our society.

This year even more people will get caught up

in the illegal drug trade.

Thousands of children will learn that their mother or father

has been sent to jail for using drugs.

And far too many parents will be notified

that their son or daughter has died of a drug overdose.

It doesn't have to be this way.

Thank you.

(Applause)