Preamble
This paper is being written in
response to the recent initiative taken by the provincial government
to institute of a program of "harm reduction" for drug
abusers. The harm reduction program in British Columbia seems
to have been initiated after a report by British Columbia's chief
coroner, Vince Cain, in which he made "63 recommendations
to government and the BC College of Physicians and Surgeons on
ways to reduce the number of deaths due to illicit drugs"
(1). Health Minister Paul Ramsey noted that "illicit drug
abuse is now the biggest killer of British Columbians between
30 and 44 years old, and heroin was involved in 90 per cent of
those deaths in 1993" (2).
The main recommendation is a shift
from enforcement to harm reduction "which aims to reduce
the human and financial costs to society arising from drug use
and distribution" (3). The basic components of the harm reduction
model are as follows:
What the harm reduction model attempts to address is the damage that occurs to addicts (alcoholics are addicted to alcohol). Unfortunately, what it does not address is the increased risk that this model places on the larger community that the same substance abusers are a part of.
The Issues
The first component of the harm reduction model states that the 'non-medical use of psychoactive drugs is inevitable if those drugs are accessible'. It would be in society's better interest to make those drugs more inaccessible than to try to eradicate the problem once it has been allowed to become a problem. Although figures for Canadian efforts could not be found, it is interesting to note that:
the Clinton administration has
overseen a controlled shift in drug policy from an aggressive
interdiction policy to one of harm reduction. The [US] federal
government's ability to disrupt drug shipments has been reduced
by 64 percent. Foreign anti-drug programs have been cut by 55
percent and domestic marijuana eradication by 59 percent. Meanwhile,
between 1992 and 1996 funds for treatment rose [just] 19 percent
(5).
Continuing with the harm reduction
model, the second component states that 'non-medicinal drug use
will inevitably produce important social and individual harm'.
What it does not state is the harm that could result from just
one instance of use. Women who use drugs while pregnant place
their unborn children at risk. "One study has implicated
prenatal exposure to cocaine in an increased risk of stillbirth
[while other] . . . studies have implied that cocaine may be implicated
in irregular neonatal respiratory patterns that may be related
to an elevated rate of SIDS. [Yet another] . . . study implies
that infants exposed to cocaine in utero may have an increased
risk of motor dysfunction [and that] exposure may be related to
Central Nervous System (CNS) abnormalities"(6).
Marijuana, still thought by many
to be a 'harmless' drug, has been implicated in prenatal (heavy
- at least one marijuana cigarette per day) use with: "low
birth weight; a shortened gestational period; meconium staining;
[and] neonatal neurobiological abnormalities" (7). Furthermore,
"[r]esearch implicates alcohol in a wide range of perinatal
effects including: an increased risk of spontaneous abortion and
stillbirth; shorter gestation periods; [and] reduced birth size
and weight. The long-term effects of prenatal exposure to alcohol
include fetal alcohol syndrome (FAS) and fetal alcohol effects
(FAE)" (8).
The third component of the harm
reduction model states that drug policies 'must be assessed on
their actual consequences' - not the messages they are sending.
Being told that it is OK to use drugs is not the message we should
be sending to anyone. One recovering addict stated that, "the
A and D counselor in ... (city deleted to protect confidentiality) told me that I shouldn't use cocaine
so much but it was all right to use 'pot' if I wanted to"
(9). One section of The Code of Ethics for Alcohol and Drug Service
Providers in British Columbia states that service providers "ensure
that client's best interests are paramount . . ." (10). One
of the health goals of the Adult Clinical & Addictions Services
(BC) is to improve "the health and well-being of people affected
by addictions" (11). Condoning the use of illicit drugs is
not the message that counselors, who know the devastating effects
of addiction, should be giving out. Adolescents and young adults
rely heavily on their peer groups in their need to 'belong'. As
one psychology text book points out, "[e]specially influential
is the immediate friendship circle: a careful longitudinal study
found that the single most important factor encouraging drug abuse
among young adults - even more important than life stress, temperament,
and personal attitudes - was having friends who used drugs"
(12). Many of the above quoted addict's friends were told what
the counselor had said. I wonder what message they got?
The fourth component of the model
stresses that drug users are a part of the larger community and
that the health of the community as a whole 'requires protecting
the health of drug users'. It is interesting to note that the
health of the community is mentioned. Every time needle exchange
participants 'ditch' a used syringe to avoid arrest, they are
practicing 'harm reduction'. When someone picks up that 'dirty'
syringe (most often a child), they are at risk of contracting
whatever disease was present in that syringe. Whenever a drug
users spend all day traveling around in search of 'good' drugs,
they are practicing a form of 'harm reduction'. Countless numbers
of people are put at risk on the streets as the drug user's ability
to drive responsibly are diminished through increased frustration,
desperation, and craving. Every time registered methadone patients
'beat' their urine sample to stay in the program they are practicing
harm reduction. Methadone prescriptions are often sold to or shared
with lovers, spouses, family and friends. A term that comes to
mind which is often used in addiction circles is 'enabling'. Although
needle exchange programs have been established in an effort to
prevent the spread of the HIV AIDS virus, a user who frequents
a needle exchange site can find connections to good drugs within
half an hour. In 1993, Dr. Karl Gunning, a Dutch physician and
a harm reduction opponent, wrote, "The harm reduction Dutch
policy of containing heroin addiction through distribution of
free needles and syringes and through methadone distribution
has not prevented the spread of heroin addiction, curtailed drug-related
crime, nor has it proven to decrease the level of HIV infection"
(13).
The first sentence of the fifth
component of the harm reduction model is most satisfactory however,
the last two sentences must be addressed - in particular, 'enabling
(there's that word again) users to switch to safer forms of drug
use'. It has been determined that the consequences of smoking
(of any drug - including tobacco) "include symptoms of chronic
bronchitis, an increased frequency of acute chest illnesses, a
heightened risk of pulmonary infection, a variable tendency to
airways obstruction and a possible increased risk of malignancy
involving both the upper airway and the lungs" (14). "Drinking
alcohol can lead to liver cirrhosis, gastritis, and pancreatitis"
(15) as well as swelling of the brain in which the user becomes
a 'vegetable' (16). The only other ways left to ingest drugs are
to eat them, to 'snort' them, or to inject them - eating them can be extremely
hazardous: "The doctor told me that my whole insides had
literally shut down. The cocaine that I had swallowed in order
to avoid arrest had 'frozen' the workings of my esophagus, stomach,
large and small intestine, and liver. I was lucky to be alive"
(17). 'Snorting' drugs through the nostrils can lead to serious permanent damage.
Residue from cocaine left in the nostrils can eat away at the linings (much like cancer)
and leave the user with permanent holes from one nostril to the other or even eat away the sinuses
completely, leaving huge cavities which never heal and are constantly susceptible to infection.
The only alternative left is injection. Using the harm reduction
model , we can teach drug users how to: properly clean a syringe
with bleach; sharpen the end of a used needle; safely store and
care for a syringe; find needle exchange centers and how to find
veins that haven't already collapsed through repeated punctures.
In reality, what harm reduction would actually be doing is prolonging
the drug users dependence on the 'system' rather than empowering
them to make conscientious decisions for themselves.
The final sentence of the fifth component states that 'it is not always necessary to reduce non-medical drug use in order to reduce harms'. What of the harm done to those who cannot help themselves?:
Whether or not they live in at-risk
communities, children who live in families abusing alcohol and
other drugs are exposed to more immediate risks. The quality of
the caregiving environment, reflected in family discord, stability,
and status, has been related to children's development in study
after study . . . . Substance abuse results in behaviors that
are in conflict with secure and nurturing caregiving: social isolation;
poor coping skills; and difficulty in managing finances, accessing
community resources, making child-care arrangements, or pursuing
vocational and educational activities . . . . Some research has
tied alcohol and drug abuse directly to an increased risk of child
abuse and neglect . . . . Between 1984 and 1989, there was a 3,000
percent increase in the number of drug-related abuse/ neglect
petitions in the U.S. juvenile courts. Today, 22 states report
that chemical dependency is now a dominant factor in child protective
custody cases. (18)
Conclusion
There is evidence that societal
reactions produce their own set of problems. We know that interdiction
efforts against injection drug users accelerated the spread of
HIV among those groups. We have indication that much of the harm
to property and persons caused by people dependent on illicit
drugs is determined by a system which has failed to discourage
use while inflating price. Typical measures of harm are incomplete.
They provide us with an inadequate, and misleading picture of
the damage caused by drug use.
I agree that responsible
harm reduction policies, if accompanied by a restrictive
response to drugs - 'the war on drugs' - helps to alleviate the
spread of problems. Irresponsible policies drain resources away
from more cost effective prevention and treatment activities.
I suggest that a comprehensive strategy to reduce drug-related
harm is only possible if we begin using an extensive system of
indicators - a system that clearly acknowledges causes and effects.
It is only when harms and their origins become definable and measurable
that we can come up with successful policies to reduce drug-related
harm and improve public health. Giving drug users more drugs,
and providing them the means to use them is not the answer - using
a harm reduction model which moves toward abstinence does. As
any substance abuser who wants to do something about their problem
knows: "One is too many, and a thousand never enough"
(19).
copyright: LJSilver
February 25, 1997
Endnotes