HARM REDUCTION: CLOSING THE DISTANCE

Why are harm reduction programs a tough sell? One answer is that they
appear to tolerate social phenomena that are undesirable, hazardous
or, depending on one's perspective, the result of moral turpitude.
Whether the issue is condom dispensers in high school washrooms or
methadone maintenance, for many people harm reduction represents a
capitulation before social ills that we ought to be routing out.

As for teen sex, the genie is out of the bottle. And, as to drug
addiction, the chances of a rout are slim. Roughly 100 000 Canadians
inject cocaine and heroin. Over one-third of new cases of HIV
infection and more than 60% of new cases of hepatitis C result from
injection drug use. [1] As Anita Palepu and colleagues report in this
issue (page 415), [2] emergency department visits for preventable
injection-related complications are common. In British Columbia, drug
overdose is the leading cause of death in people aged 30 to 49.

Harm reduction is not a retreat from the high ground. It is the only
ground on which to meet drug users in the here and now -- a here and
now that may include, in addition to the consuming fire of a chemical
addiction, poverty, limited education, unemployment, a history of
abuse and family dysfunction. Until now, in Canada, that meeting
ground has taken the form of outreach and education, methadone
maintenance and needle exchange. Methadone maintenance, about the only
effective treatment for heroin addiction, [3] has been implemented
only sporadically, mainly because of ideologic opposition. Similarly,
needle exchange has had limited success. As Evan Wood and colleagues
report (page 405), [4] despite needle exchange programs in Vancouver's
Downtown Eastside, a substantial proportion of injection drug users
still share needles.

In response to the growing crisis of drug abuse in many Canadian
communities, a federal task force has called for the establishment of
supervised injection sites, especially in major cities.1 These
facilities would provide a controlled environment where drug users can
obtain sterile needles, naloxone when needed, vaccinations, medical
care, social services and, not least, encouragement to enter
rehabilitation programs.

Safer injecting sites operate in roughly a dozen European cities. In
Canada, we can anticipate objections to taking such an active role in
assisting drug injection, as opposed to merely handing out advice --
or condemnation. There is a symbolic shift here, a closing of the
moral distance between drug addict and public health worker. Drug
injection, an actitivy that has no social legitimacy and hence no
public space, becomes an activity with a publicly sanctioned and
supported venue. It will take a certain sang-froid to see this idea
through. It will require that we face up to the severity of the drug
problem that Canadian communities are experiencing. There is no quick
fix, either for addiction or its risk factors and effects. But we can
make the lives of people with drug addictions a little better and
neighbourhoods a little safer. Supervised injection rooms are a
logical next step, one that combines the merits of realism and
compassion. -- CMAJ

References

1. Advisory Committee on Public Health. Reducing the harm associated with
injection drug use in Canada [working document]. Ottawa: The Committee;
2001 Feb.

2. Palepu A, Tyndall MW, Leon H, Muller J, O'Shaughnessy MV, Schechter
MT, et al. Hospital utilization and costs in a cohort of injection
drug users. CMAJ 2001;165(4):415-20.

3. Connor PG, Fiellin DA. Pharmacologic treatment of heroin-dependent
patients. Ann Intern Med 2000;133(1):40-54. [MEDLINE
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&uid322269&Dopt=r
]

4. Wood E, Tyndall MW, Spittal PM, Li K, Kerr T, Hogg RS, et al. Unsafe
injection practices in a cohort of injection drug users in Vancouver: Could
safer injecting rooms help? CMAJ 2001;165(4):405-10.