We need to think more analytically about harm reduction

This is an updated form of a letter I sent to Globe & Mail columnist Margaret Wente in response to her attacks on Vancouver’s harm reduction program. Her first four columns on this topic appeared in the Globe and Mail in July 2008. I originally wrote her on October 10, 2008, and re-sent the letter on October 15. She acknowledged receipt, but did not respond to my critique. She then published another attack on harm reduction in November. This open letter addresses all five of her columns.

Dear Margaret:

Last July, you blistered Vancouver’s harm reduction programs in four of your Globe and Mail columns. You followed up with another attack on harm reduction in November.

Before I address some of your points individually, let me remind you of a few historical facts that you may have not had in mind when you wrote your five columns.

Drug and alcohol addiction has been a major source of public alarm and outrage in Canada since well before the passage of the Opium Act in 1908. Many forms of intervention have been employed over this long period. In retrospect, virtually all of these interventions, except for the strictly religious ones, can be seen as part of one of the four “pillars” of today’s Four Pillars Program in Vancouver.

All four pillars–treatment, prevention, enforcement, and harm reduction–have been used, to a greater or lesser degree, at every stage of Canadian history. Each of them has helped to ameliorate a different aspect of the problem. However, the advocates of the different pillars have always distrusted each other: Inflamed attacks on each of the pillars began scorching the pages of Canadian newspapers long ago.

Here is one slice of history to illustrate how all four pillars have always been represented. Around 1950, treatment for drug addiction was no part of official policy in Canada, but a few hospitals nonetheless provided counseling to drug addicts along with medical treatment, and a few physicians and ministers attempted drug counseling on their own. There was quite a bit of harm reduction, although it was illegal. Many physicians risked their careers by prescribing morphine or other heroin substitutes, so that their dependent patients could live relatively normal lives. There was prevention, in the form of sensationalized warnings in the popular media like Maclean’s magazine, that drug use could cause personal ruin and social collapse. However, the biggest “pillar” by far, vastly overshadowing all others in terms of public support, was law enforcement.

Successive amendments to Canada’s Opium and Narcotic Drug Act, originally passed in 1920, had created a fearsomely punitive instrument by 1950. The amended law allowed long sentences for various drug offences, whipping for convicted offenders at the discretion of judges, and deportation of drug offenders who were not citizens. Police could legally break into suspected drug users’ homes without warrants and wreck the interiors in their search for drugs. Police could legally hurt suspects, too, by choking them or punching them in the stomach hard enough to disgorge any drugs they may have swallowed to avoid detection. Some people were eventually “searched” to death in this way. Beyond legal procedures, illegal police brutality towards addicts was not the matter of public revulsion that it is now.

By 1950, the utter failure of this extraordinarily punitive regime had become evident. Panicky headlines in Vancouver and across Canada warned of a growing crime wave that was attributed to drug addicts, of the recruitment of juveniles into heroin addiction, and of the terrible sufferings of drug addicts. Vancouver’s Downtown Eastside was said to house 2,000 addicts, one for every 250 inhabitants of the city. Maclean’s estimated that, at the current rate of growth, there could soon be one junkie for every 16 inhabitants. Don’t you wonder how Steven Harper reconciles these historical facts with his celebrated tough new measures that are supposed to control drug addiction?

The Vancouver Community Chest and Council undertook an investigation which concluded in its 1952 report that punitive enforcement methods did not work well enough, and that there should be less imprisonment of addicts–along with more severe penalties for traffickers–and a greater emphasis on treatment. This same report proposed providing heroin to addicts who could not be successfully treated. In other words, the Community Chest perceived a need for the strongest form of harm reduction (heroin prescribed to addicts), because of the failure of the punitive enforcement regime.

The findings of the Vancouver Community Chest and Council were deemed so important that both daily Vancouver newspapers printed the entire report. Providing heroin to addicts was controversial, but the B.C. Medical Association, the Metropolitan Health Committee, and the Vancouver City Council all supported the idea publicly, if cautiously, as did some judges. No legal harm reduction programs, however, were actually implemented.

Slicing the historical record again, this time around 1972, we find a quite different configuration. All four pillars were still evident, but their relative weightings had changed dramatically. Treatment, which was minimal in 1950, had grown into a major pillar by 1972, as the Community Chest report had urged. The psychological and psychiatric professions had flourished in the decades following World War II and virtually all their new treatments were being tried on drug addicts and alcoholics. Alcoholics Anonymous was flourishing as well. There was so much money for treatment that an entire prison, the Matsqui Institution, had been built in the Fraser Valley in 1966 as a centre for treating drug-addicted prisoners.

The newest group therapy and therapeutic community methods were the centerpieces of treatment at Matsqui. The addict/prisoner/patients were also given generous exposure to occupational therapists, social workers, and educators. The public had pinned its hope on treatment, and government funding was generous.

The prevention pillar was conspicuous around 1972 in the form of dire media warnings, supplemented by drug education programs in the schools. Harm reduction was still small-scale, despite the Community Chest recommendations. However, small methadone maintenance programs had already been launched in Vancouver and Toronto, and some medical practitioners were still conscientiously, but illegally, supplying heroin and cocaine substitutes to their dependent patients.

The dominant pillar in terms of public intervention around 1972, however, was still law enforcement. Although whipping and deportation had disappeared as punishments under the new Narcotic Control Act of 1961, life sentences for trafficking were possible under the new law, and seven-year mandatory minimum sentences were in place for importing and exporting drugs. Brutal law enforcement methods, including warrantless home invasions by police and violent searches, were still directed at suspected drug users, although public resistance to police brutality was growing.

Despite the active use of all four pillars around 1972, the drug problem was totally out of control in the era of hippies, speed freaks, and Cheech & Chong. Although enforcement still absorbed the lion’s share of the budget for drug problems, treatment had provided the newest hope. But treatment eventually provided the bitterest disappointment of that day.

The results of the experiment in treatment of convicted drug addicts at Matsqui Institution were horrible: over 90% recidivism of treated addicts who were still alive five years after release. Worst of all, the most intense treatment produced more recidivism than the less intense treatment, although this difference, mercifully, fell short of statistical significance. Matsqui, with its well-funded, optimistically-launched program had quickly proven that it could not “treat” convicted drug users out of addiction any more than the police could “enforce” them out of it. Many optimistic psychotherapists, myself included, attempted psychological treatment with drug addicts outside of the prisons. We worked very hard, but the long-term results of our diverse psychotherapies were disappointing. There was no hard evidence that we did much good.

With this historical refresher course in mind, let’s return to the assertions that you made in your columns on harm reduction in Vancouver.

The main point in your first article of July 12, repeated in the subsequent articles, is that knowledgeable observers can just look at Vancouver’s Downtown Eastside and see that harm reduction doesn’t work. You say, “Just the opposite. It digs the pit of addiction deeper and wider.” You argue that harm reduction is the core philosophy of a “vast enabling industry.” You say that what is needed is for law enforcement to coerce people into treatment. You say, “Treatment should be a part of sentencing.” If addicts need harm reduction, “They also need a far more aggressive push into treatment and recovery.”

Part of what you say is correct and important. Although the most careful research shows that harm reduction can reduce overdose deaths and disease, it has not brought the addiction problem under control in Vancouver or anywhere else.

On the other hand, harm reduction has certainly not increased the problem, as you argued. The historical record shows that, no matter which of the four pillars is most heavily weighted, the problem of drug addiction has continued its long-term upward trend–with periodic outbreaks of public panic–for a century or more. In Canada, the biggest pillar by far in terms of public expenditure has always been law enforcement, and that remains so today, despite the publicity given to harm reduction. But it would be simplistic to say that law enforcement has caused the century-long increase in addiction, because the larger number of seriously addictive habits are legal, i.e., addictions to alcohol, money, sex, video games, shopping, work, and so forth, and they too are increasing precipitously. But it is just as simplistic to claim that harm reduction (or treatment or prevention) has caused the increase in addiction.

Contrary to the hope you expressed in your July columns, coercing people into treatment will not bring the problem of drug addiction under control. The historical record, in Canada and everywhere else, shows that coerced treatment has a low success rate. How is it that the utter failure of the well-funded, optimistically-launched, meticulously-documented Matsqui experiment is ignored in the rhetoric of those who pin their hopes on coerced treatment today?

Beyond coerced government-run treatment, privately-run treatment of voluntary patients who are addicted to drugs—or to anything else, including treatment based on the AA model–has not been more than marginally successful, either. When treatment works at all, it usually requires more than one arduous cycle of recovery, relapse, and then another try at treatment, and another. No treatment professional I know thinks treatment can control the problem of addiction, no matter how coercively it is forced on addicts. Treatment is just one of our four imperfect pillars for responding to a problem that is out of control. But this does not mean that treatment caused the spread of addiction, any more than law enforcement, harm reduction, or prevention did.

Addiction to drugs, and a thousand other habits, like gambling, sex, video games, internet pornography, shopping, overworking, and so on, is spreading inexorably around the world. You are right to point out that something urgently needs to be done, but you inexplicably ignore the cause of the inexorable spread that alarms you so. None of the four pillars and no aspect of drug policy is the cause. I am guessing, Margaret, that you know as well as I do what is digging the “pit of addiction” to drugs–and many other habits–“deeper and wider” across the globalized world. I wish you had told your readers about it in your articles.

Addiction is spreading everywhere because we live in a civilization that has become psychologically fragmented. As a people, we lack the identity that comes from secure families, stable communities, and a predictable future; we lack the sense of meaning that comes from shared values and religious beliefs; and we lack the confidence that comes from being part of a nation, a civilization, or an economic system that warrants our deep respect.

More and more people are finding that addiction and other destructive lifestyles are the most effective ways they can find to fill the social void and control the anxiety. Addictions, whether they centre a person’s life on drugs or anything else, provide some kind of a substitute for real identity, meaning, and confidence. Having found a substitute for what they lack in their inner core, people cling to it for all they are worth, that is, addictively. This is as true in enclaves of the educated and rich as it is in Vancouver’s Downtown Eastside.

Margaret, if this explanation for why addiction keeps spreading “deeper and wider” does not ring a bell, just ask your friends in your own social circle if it helps to explain their addictions–the little manageable ones as well as bigger, devastating ones. Then try out the idea on the most socially marginalized drug-addicted person you can find. I predict you will get the same answer. Many, many people, both insiders and outsiders, are eager to confirm that they know this void and that their addictions are filling it in a sub-optimal way. Once the cause of addition is understood, it becomes clear that none of the four pillars is causing it, and that none of them can eliminate it in a globalizing world that is growing ever more fragmented.

Addiction will not be controlled before society learns to domesticate modern technology and the free-market economic system so that it serves us psychologically as well as economically, rather than, as at present, dislocating us psychologically as it showers us with dubious economic blessings and intermittent recessions and collapses. Ultimately, the lasting solution will be found on the social and political level–the level where many of the people who read your columns in the Globe and Mail exert their influence.

Until we get serious about addiction on the social and political levels, our best recourse comes from the dedicated proponents of all four of our pillars as they address the problem of addiction as well as they can with the tools they have. These are smart, dedicated people who genuinely care, even though their successes are generally few and far between. All four pillars are necessary because they each can ameliorate a different aspect of the problem.

If this explanation of the cause of addiction and the remedy still does not seem true after you discuss it with your friends, or if it seems too idealistic to be useful, then, Margaret, do I have a book for you! Of course there are many books that might help, but I am modestly recommending my own, entitled The Globalization of Addiction: A Study in Poverty of the Spirit (Oxford University Press, 2008). Apart from natural vanity, I recommend my own book because I sense that you are a tough-minded person who is likely to be convinced by the same kinds of extensive, detailed evidence and rigorous logic that have convinced me.

I believe that it is important to Canada that influential people like yourself point us toward dealing with the ever-growing problem of addiction on a social and political level where success is possible, rather than enlisting yourselves in the pointless pillar fights that have been dissipating our energy for a century.

Yours sincerely,

Bruce Alexander,
Professor Emeritus,

Simon Fraser University.

* * *

P.S.–In your third column, published July 17, you amplify the theme that harm reduction doesn’t work by comparing the drug addiction rates in two European countries. You point out that Sweden has one of the lowest rates in Europe, whereas Scotland has one of the highest. Sweden has little interest in harm reduction, but favors what you approvingly call a “choice between treatment and jail.” Scotland has an advanced harm reduction system. If that were all the information available, your conclusion that harm reduction policy leads to high rates of drug addiction would be plausible. But there is much, much more information about the European drug scene that changes the picture entirely.

For example, you did not mention that the Netherlands was one of the originators of harm reduction in its modern form and still practises harm reduction more widely than most other countries, including Canada. In addition, you never mentioned that Scotland has much more serious drug problems on a national level than does Sweden, the Netherlands has somewhat less of a drug problem than Sweden.

The most interesting question is this: What do the Netherlands and Sweden have in common that makes their drug addiction problems low relative to many other European countries and that sets them apart from Scotland, whose prevalence of drug addiction is very high? The “something” cannot be the Dutch and Swedish policies concerning harm reduction, because the Netherlands enthusiastically champions harm reduction whereas Sweden opposes it.

This crucial something will jump out at you if you reflect on the evidence that the root cause of the rising tide of addiction in the modern world is social fragmentation. Both Sweden and the Netherlands have worked hard to maintain family and community structure and national integrity, even as they adopted high technology and high finance in the half-century since World War II. Although both Sweden and the Netherlands are capitalist countries, they have refused to practise the deregulated, take-no-prisoners, hypercapitalism of Milton Freedman, Ronald Reagan, Ayn Rand, Margaret Thatcher, and George Bush. Rather, they keep their countries’ corporations and financial institutions under close control to protect their social fabric. Scotland, as part of the United Kingdom, exercised the same control over its economic system in the early decades after World War II, but then the U.K. underwent a revolutionary change.

Edward Heath became Conservative Prime Minister of the U.K. in 1970 in a wave of growing enthusiasm for individualism and free-market capitalism. Margaret Thatcher surfed this wave brilliantly to become head of the Conservative party in 1975 and Prime Minister in 1979. Thatcher’s political skill, iron willpower, and charisma produced a transformation in British life that was so profound that it is called the “Thatcher Revolution.” She famously condensed her individualistic philosophy in her 1987 statement that “There is no such thing as society. There are individual men and women, and there are families…”

Thatcher’s regime led the U.K., including Scotland, into massive privatization of public institutions, international free trade, and a national commitment to individualism. Thatcher’s regime turned the U.K. against labour unions, regulation of finance and industry, social welfare, and public ownership. She changed the tax laws in a way that undermined the previously rock-solid British pension funds for the middle class. Her heroes included Ronald Reagan, Milton Friedman, Augusto Pinochet, and our own Conrad Black, whom she proposed for a peerage later in her life.

When Thatcher resigned as Prime Minister in 1990, the U.K. had been transformed from an economically weak welfare state to an individualistic prototype of free-market society. Although it stagnated as an industrial power, the British dominance in the world of finance and banking was partly restored, the gap between the rich and the poor greatly widened, unemployment increased dramatically, and the social safety net was in tatters. In its pursuit of “economic growth,” the U.K. had sold out the economic security of working people and social solidarity built up during World War II and during the welfare state era of the early post-war decades. A new, intensely competitive, hypercapitalistic culture–perhaps better called an absence of culture–arose in the U.K.

Thatcher’s policies were continued by her Conservative party successor, John Major, and by her Labour party successor, Tony Blair, following his election as prime minister in 1997.

Drug addiction had been remarkably low in the U.K., including Scotland, until about 1970. The addiction statistics began to rise significantly only around 1970, accelerated throughout the Thatcher years, and went through the roof in the 21st century. There were 670 registered heroin addicts in the U.K. in 1968, and over 100,000 by the year 2000, a 150-fold increase. By a different measure, dependent heroin users in England and Scotland increased from 5,000 in 1975 to 231,000 in 2007.

Heroin is not the only drug addiction problem that lurched out of control in the U.K. in the Thatcher era. Grotesquely excessive “binge drinking” has become a national scandal among young adults, especially women. The incidence of alcohol-related liver disease has doubled in the last decade. And, whereas ecstasy and amphetamine appear to be falling out of fashion, “crack” cocaine is coming on strong.

What caused the enormous increase in addiction during this period? Certainly poverty was not the cause because, although inequality was increasing greatly, the majority of people were getting at least a small slice of the general increase in economic growth, until the current recession devastated the British economy. Moreover, the increase in addiction was by no means restricted to the poor. The prototypical binge-drinking addict was a well-heeled young lady!

Certainly harm reduction cannot be blamed for the increase in British addiction after 1970, because, during decades of very low addiction prior to 1970, the U.K. had the mother of all harm reduction programs, which dated back to the 1920s. During this long period, most British doctors were able to prescribe all the heroin and cocaine they thought appropriate to patients whom they believed would benefit from it, including addicted patients. The amount of heroin prescribed in the U.K. was huge relative to most other countries. Legal prescription of heroin and cocaine to addicts was known as the “British System” in Canada in the days before real harm reduction was possible here. When harm reduction was cut back severely during the Thatcher years, addiction flourished.

Margaret, I imagine you shaking your head in disbelief as you read this. Indeed, my brief summary of the history of the Thatcher-Blair-Brown years is insufficient to prove that hypercapitalism and social fragmentation are the underlying cause of the devastating spread of addiction in modern times. Nor is this skimpy summary of historical fact likely to dissuade you from thinking that bashing harm reduction can solve our addiction problems. I am hoping, however, that these facts are enough to convince you to examine the detailed evidence in my book. I will send you a copy, if you like.

* * *

P.P.S.–This is the last of the postscripts to my letter that will fit into this short publication. In your November 20 Globe and Mail column, you expressed your shock and horror at the prospect of providing heroin or hydromorphone to intractable heroin addicts as follows:

“Should we be giving free heroin to addicts? Don’t choke. Researchers in Vancouver say yes… Last month…they announced that the best way to treat hard-core heroin addicts is: Give them more heroin! They argue that…heroin makes them happier, healthier, and less inclined to steal…And since they can’t kick the habit, we ought to minimize the social harm and feed their habit, legally.”

Please do a little experiment with me. Carefully replace the words “heroin” and “free heroin” with the word “capital.” Replace the words “addicts” and “heroin addicts” with the words “failed banks.” The parallel that will emerge when you do this is one of the amazing dilemmas of this extraordinary time. Here it is:

“Should we be giving capital to failed banks? Don’t choke. Researchers in Vancouver say yes…Last month…they announced that the best way to treat hard-core failed banks is: Give them more capital! They argue that…capital makes them happier, healthier, and less inclined to steal…And since they can’t kick the habit, we ought to minimize the social harm and feed their habit, legally.”

Government policy often shocks the sensibilities of some of us in the hope of achieving the greater good. Sometimes this may entail giving heroin to people who have hurt themselves badly by their addiction, or giving money to banks that have hurt themselves badly by reckless speculation.

Harm reduction feels viscerally wrong to some people, and this is an emotional response that I can respect. However, your columns treat this visceral response as if it should be the sole arbiter of Canadian policy. I have no wish to belittle anybody’s emotional responses. But you need to know that there is another emotion that is growing rapidly throughout our land, an emotion that is outraged by the stale parroting of the doctrine that our terrible addiction problems are caused by demon drugs or lax drug policies, rather than owning up to the fact that our social fragmentation and dislocation are becoming so severe that more and more people are finding it difficult to live without addiction—and not just in the Downtown Eastside of Vancouver, Margaret, but where you live, too.

Beyond the emotional tug-of-war that underlies drug policy, it is important to draw upon our best capacity for reason. In our endangered civilization in the tumultuous year of 2009, we cannot afford to base important policy decisions entirely on feelings of shock and revulsion. We have to force ourselves to be more rational than that. In the case of supplying heroin to addicts (or capital to failed banks), we must ask what are the overall costs and benefits to the recipient and to society as a whole. We must consult our data bases and our historical records, not just our gut feelings, as we struggle to make our difficult decisions.

All the same, I continue to have a persistent gut feeling that you can be a powerful influence in support of enlightened drug policy in the future, if you are willing to dig a bit deeper into these issues than you have heretofore.

* * *
(Thanks to Curt Shelton, Lani Russwurm, and Seth Klein for their help with this version of the open letter.)

References

Reuter, P., & Stevens, A. (2007). An analysis of UK drug policy: A monograph prepared for the UK Drug Policy Commission. London, UK: UK Drug Policy Commission.

Russwurm, L. (2008a, 13 October) ‘The dope craze that’s terrorizing Vancouver’. The Tyee. Retrieved 1 Oct 2008 at http://thetyee.ca/Views/2008/08/13/DTESHistory/

Russwurm, L. (2008b, 25 August). Harm reduction – 50’s style. Tyee Monday Headlines. (retrieved 15 Sept. 2008 from https://thetyee.ca/Views/2008/08/25/HarmReduction/)

Wente, M. (2008, 12 July). They’re sick of watching people die. The Globe and Mail, p. 15.

Wente, M. (2008, 15 July). We still await the scientific proof of harm reduction’s success. The Globe and Mail, p. 13.

Wente, M. (2008, 17 July). Europe’s approach to drugs is more enlightened…it’s tougher. The Globe and Mail, p. 17.

Wente, M. (2008d, 19 July). Legalization in disguise. The Globe and Mail, p. 17.

Wente, M. (2008, 20 November). Up next: Free heroin for addicts. The Globe and Mail, p. A23.