This response is modified from an answer that Dr. Stephen Gaetz gave during the webinar launch of the report “A Safe and Decent Place to Live: Towards a Housing First Framework for Youth”.
This is an important question but I would like to broaden it further. It isn’t just how governments approach substance use and harm reduction that we should be concerned about, but the attitudes of many members of the general public and communities as well, because sometimes we get the governments and (bad) policies we deserve. The problem in Canada and elsewhere is that our approach to substance use and illicit drugs is complicated by a lack of understanding about what works, and by contradictory lenses through which we make sense of drug use and misuse. On one hand, most Canadians have internalized the notion that addictions are a medical issue and perhaps an illness. If this is the case, then we need to wonder why we continue to use law enforcement, and ‘get tough on crime’ approaches. Would we put people in jail if they had lyme disease or cancer?
The reason we go down this road is in spite of the belief that many hold, about addictions being a health issue, we equally hold to the Victorian and prohibitionist era notion that addictions are indicative of moral failure; that people who are drug addicts or alcoholics are ‘bad people’ who should pay the price for their decisions. These underlying values – held by many Canadians, and many communities in Canada – are what propel governments to make bad policies. The War on Drugs has been an established approach to substance abuse, not only in the United States, but most certainly in many jurisdictions in Canada.
For many years, people have raised valid questions about the effectiveness and efficacy of the War on Drugs. A recent report by the London School of Economics reviewed the literature and provided compelling evidence that the prohibitionist model that uses law enforcement as a key strategy to address substance use and addictions is in fact very expensive, counter productive and in essence a ‘wasted effort’.
Are there other approaches that make sense? Most certainly harm reduction programs and philosophies, which are well-established in Canada, provide some insight into where and how we should proceed.
While many people associate harm reduction with issues such as drugs or alcohol, we all engage in harm reduction activities that are so entrenched into our daily lives we don’t even think about them. Mandatory use of seat belts in cars, bike helmets, hand washing, safe sex practices, infant and toddler car seats or speed limits are all methods of harm reduction.
From a substance use perspective we can say:
Harm reduction is an approach or strategy aimed at reducing the risks and harmful effects associated with substance use and addictive behaviours for the individual, the community and society as a whole. It is deemed a realistic, pragmatic, humane and successful approach to addressing issues of substance use. Recognizing that abstinence may be neither a realistic or a desirable goal for some users (especially in the short term), the use of substances is accepted as a fact and the main focus is placed on reducing harm while use continues.
Harm reduction is often controversial at any level of government, because in many communities there continues to be active resistance to it. Indeed, many agencies, programs and residences in the homelessness sector don’t support harm reduction, or at best only pay lip service to it. It is not uncommon for homeless individuals to be barred or denied service, because they come in under the influence of legal (alcohol) or illicit drugs.
And yet, at the same time there are many that do. In 2010, Toronto became the first city in the world (and the first government in North America) to endorse the Vienna Declaration which advocates harm reduction as a method of lowering HIV transmission rates caused by injection drug use. In fact, harm reduction is one of the four pillars of Toronto’s drug strategy (the others are law enforcement, treatment and prevention). Toronto also published a Supervised Injection Services Toolkit in 2013.
The federal government funds harm reduction approaches: the Insite program in Vancouver being an example. As Stephen Hwang has pointed out in the past, the strong evidence base for the effectiveness of the Insite program should put to rest questions about whether this approach makes sense or not. Other communities have managed alcohol programs, wet or damp shelters, housing and harm reduction frameworks, needle exchange programs and other programs that support harm reduction philosophies.
For those interested in Housing First programs as a response to homelessness, it is worth noting that harm reduction or recovery orientation is seen to be a central component of that approach.
So one needs to really think about, when you do harm reduction, how are you engaging your community around this issue? How are you going to be able to build supports for harm reduction? How will you provide training for staff and volunteers? How are you going to help people understand what it means? Because I think often where things fall down is that people have these ideas about harm reduction that are completely inaccurate.
The criticisms of harm reduction are often driven once again by moral arguments that people use substances are somehow bad, or, you know, deviant people. The views are often that harm reduction is about giving people drugs and keeping them dependent. In fact, it’s a much more complex and supportive approach than that. Plus, one point that much of the general public doesn’t realize is that the link between substance use and homelessness isn’t necessarily causative but rather reactive. That is, homelessness may lead to substance use more often than substance use being the reason that one becomes homelessness.
But be aware that harm reduction can be controversial in any community and yet it’s really, really, really crucial. There are some communities in Canada that have been doing great work on this for years, there are agencies that have. But there are many communities where it’s not even in the picture yet. So we need to move forward on that.