The harm reduction model of drug addiction treatment Mark Tyndall
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)