Sober N Clean

By giving drug addicts a sterile syringe and a warm place to shoot up, are we saving lives or condoning substance abuse?

To illuminate the double standard surrounding "harm reduction," Dr. Stephen Hwang, a medical researcher and associate professor of medicine at the University of Toronto, offers the following scenario:

Suppose that an innovative but controversial intervention is launched to reduce complications of Type 2 Diabetes, and 7,000 subjects take part in a trial. Researchers, funded by Health Canada to study the intervention's effectiveness, find that while not curing diabetes, the intervention improves health, reduces infections and prevents premature deaths -- with no adverse effects. The findings are published in the world's leading medical journals.

But the federal government deems the findings inconclusive and says the only acceptable therapies for diabetes are those that either prevent or cure the condition -- even though no such therapies exist. Columnists, community leaders and national organizations expound that the intervention "enables" bad lifestyle choices, and that without the dire complications of diabetes, people with the condition would eat more, exer cise less and become increasingly obese. And those who didn't have diabetes would forgo healthy diets and exercise because they'd no longer fear the disease. The government considers banning the intervention.

Sound far-fetched? Not, says Hwang, if you replace the word diabetes with drug addiction, and the word intervention with Insite, the safe-injection site pilot project that began in Vancouver's Downtown Eastside in 2003. Insite has allowed addicts to inject drugs under secure, clean conditions, and all under the supervision of a nurse.

"I wanted people to see how hypocritical we are in the way that we treat two chronic conditions that have a lot of associated harms," says Hwang. A specialist in inner-city medicine, he wrote the diabetes scenario for the peer-reviewed online journal Open Medicine, arguing that when it comes to drug abuse, ideology trumps science in a way that would not be tolerated with other chronic health conditions. Hwang's treatise was endorsed by more than 130 prominent Canadian scientists, doctors and public-health professionals.

Think there's a huge difference between drug addiction and diabetes? There isn't, says Hwang: Both arise through a complex mix of predisposed genetic and environmental factors -- triggered by lifestyle choices, behaviour and bad luck -- that result in disorders of body chemistry. Both have potentially severe complications, such as infections or premature death, that can be reduced with good medical care. Just as some addicts can kick their addictions, some people with diabetes, through weight loss, gastric bypass surgery or extreme exercise, can eliminate their symptoms and their need for medication -- though drug-free addicts and insulin-free diabetics both risk relapse. Yet do we refuse to treat the health complications of people with diabetes who cannot wean themselves off medication? Never.

"A heroin addict needs heroin as much as a diabetic needs insulin," says Norm Stamper, a former chief of the Seattle police department. "That need is real. It is physiological." After witnessing the failure of the United States' strict "war on drugs" to stem narcotic use and its associated problems, Stamper is now a leading advocate of safe-injection sites, methadone-treatment, needle-exchange and other harm reduction programs that aim to refocus efforts from policing to medical management.

Here's what more than 20 studies --all by independent evaluators, published in prominent journals -- have found: Insite has reduced instances of needle sharing and drug injecting in public places, and there has been a decrease in the amount of injectionrelat ed litter. In the Insite neighbourhood, there have been no increases in drug trafficking or assaults, and instances of vehicle break-ins and car theft have decreased. Despite almost 900 overdose events at Insite -- a common hazard of drug use -- no overdose deaths have occurred at the facility, compared with an average of 60 a year in Metro Vancouver. Additionally, since Insite began, the number of drug addicts who have entered detox programs, addiction counselling and drug-addiction treatment has increased by over 30%.

Dr. Perry Kendall, the B. C. Health Officer, says opposition to Insite is not based on evidence of effectiveness but on the notion that drug addicts have made bad choices and must change or live with their fate. "The belief," he says, "is that if health providers remove or lessen the harms of addicts' behaviour, addicts won't hit bottom and therefore won't have the motivation to go clean."

"The issue is not whether the addict would be better off without his addiction--of course he would--but whether we are going to abandon him to illness or death if he is unable to give it up," says Dr. Gabor Mate, who has served as staff physician at Insite and is the author of In the Realm of Hungry Ghosts: Close Encounters with Addiction. Mate's book is a must-read for those who reject harm reduction as "coddling" drug addicts or who believe "Just Say No" is a realistic policy. In his book, Mate shows his patients' struggles and demons, how they became addicts and how they found a way out. The book illus trates a central premise of HR: accepting those with drug addictions and trying to move them along the continuum to better health -- keeping them alive and well long enough to have a chance to quit later.

Some who were once adamantly against Insite have come to support it. One such person is George Chow, former president of the Chinese Benevolent Association of Vancouver. Chow successfully ran for city councillor on a ticket of rejecting Insite -- the centre was on China town's doorstep -- gathering some 18,000 signatures from the Chinese community. Yet, after Insite had been in operation for three years, he changed his mind. "I am keenly aware of the debate surrounding [Insite]. But I am pleased to say that the initial fears of the community -- a potential increase in crime and public disorder -- have not materialized," Chow wrote in a letter to Prime Minister Stephen Harper in the fall of 2007.

If only more of us were willing to change our positions based on evidence, we might finally begin to make progress against this terrible affliction called drug addiction.
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source: The National Post, http://www.nationalpost.com