A HOME FOR A DRUG PILLAR ORPHAN

Court Ruling Recognizes Harm Reduction As An Important Form Of Health
Care

Strange as it may sound, British Columbia Supreme Court Justice Ian
Pitfield's decision concerning Insite could spell the end of harm
reduction as a separate modality for addressing substance abuse in
Vancouver. Stranger still, that could prove beneficial for both the
city and for people struggling with drug addiction.

Pitfield held that the possession and trafficking sections of the
Controlled Drugs and Substances Act (CDSA) are unjustifiable
infringements of Insite users' rights under s. 7 of the Charter of
Rights and Freedoms, which guarantees "the right to life, liberty and
security of the person and the right not to be deprived thereof except
in accordance with the principles of fundamental justice."

In coming to this conclusion, Pitfield noted that Insite is a form of
health care: "While users do not use Insite to directly treat their
addiction, they receive services and assistance at Insite which reduce
the risk of overdose that is a feature of their illness, they avoid
the risk of being infected or affecting others by injection, and they
gain access to counselling and consultation that may lead to
abstinence and rehabilitation. All of this is health care."

That is an extremely important statement, and I will return to it
shortly.

Pitfield continued by noting that by prohibiting the injection of
controlled drugs at Insite, the CDSA effectively prevents addicts from
accessing this health care service and managing their addictions, and
consequently jeopardizes their well-being and, ultimately, their lives.

Furthermore, while the federal government argued that the law is
designed to prevent the harms associated with drug use, Pitfield
concluded that the law, by being insensitive to the nature of
addiction as an illness, "contributes to the very harm it was meant to
prevent" and is therefore not in accord with the principles of
fundamental justice.

Pitfield consequently declared the law of no force and effect, but
gave the federal government a year to remedy the defects.

The Conservatives' reaction to the judgment was disappointing, if
predictable. Health Minister Tony Clement first said the government
"disagreed" with the decision, and then told the House of Commons that
he would ask Justice Minister Rob Nicholson to appeal the ruling.

The Conservatives are free to do so, of course, but one must wonder
why they wish to spend millions of tax dollars fighting this legal
battle when the money could be better spent on addiction treatment.
After all, Pitfield's decision doesn't require them to do anything,
other than bring their laws into conformity with the
Constitution.

It doesn't, as some people seem to think, create a "positive" right to
health care, or require governments to establish supervised injection
facilities. The ruling only forestalls the government from preventing
highly vulnerable people from accessing health care services that the
provinces have freely chosen to provide.

And this brings me back to Pitfield's comments about health care and
the concept of harm reduction. Given the novelty of measures like
Insite, harm reduction has received a grossly disproportionate amount
of publicity. This has led many people to believe that of Vancouver's
planned four pillar strategy for addressing substance abuse --
prevention, treatment, enforcement and harm reduction -- only one
pillar really exists: Harm reduction.

Now, this is both true and false. There is and has always been only
one pillar, but that pillar is enforcement, which consumes the vast
majority of federal funds -- upwards of 90 per cent, according to the
auditor-general -- directed at combating illicit drug use. Harm
reduction may grab the headlines, but it receives little money.

Even those who are aware that harm reduction is a drug pillar orphan
often tend to think of it as different in kind from the other pillars,
and certainly as different from treatment. This is a natural result of
the four pillars strategy, which causes some people to view the
pillars as separate, discrete modalities.

To be sure, Vancouver drug policy coordinator and four pillars author
Don McPherson has always stressed that the pillars must function as a
unit -- that there must be some level of integration of the services
that each pillar provides.

And there has been some limited success at integrating the pillars --
most notably, perhaps, the building that houses Insite now also
includes Onsite, a detoxification unit for those motivated to stop
using drugs. This represents an integration of services and the people
providing those services, and also involves physical integration as
Insite and Onsite exist in the same building.

Despite these positive developments in integrating modalities, there
has been much less success in integrating the concepts that guide our
thinking on the issue, particularly the concepts of treatment and harm
reduction. In fact, by highlighting these as separate concepts,
treatment and harm reduction are often defined in opposition to each
other, and hence it's no surprise that some people see the modalities
as opposing each other too.

Yet the concepts bleed into each other, and into the concept of
prevention, in both theory and fact. For example, we know that
attendance at Insite is associated with increased uptake of
detoxification and addiction treatment, so it's clear that a harm
reduction measure can lead to treatment.

But there is more to it than that. It's often not possible to even
define where harm reduction ends and treatment begins. The problem
here is that "treatment" is rarely defined, but there is often a
suppressed premise in arguments against harm reduction that treatment
begins and ends with abstinence -- with "curing" the disease.

Yet modern medicine recognizes that some diseases are chronic and will
need lifelong treatment. And that treatment includes various
interventions that improve the health of patients while failing to
cure them.

If we similarly define "addiction treatment" as anything that improves
the health of the addict, then harm reduction measures, including
Insite, would fall under the rubric of treatment.

The United Nations Office on Drugs and Crime, which has not always
been supportive of harm reduction, noted as much in a 2002 report: If
"the purpose of treatment is not only to cure a pathology, but also to
reduce the suffering associated with it (like in severe
pain-management), then reducing IV drug abusers' exposure to pathogen
agents often associated with their abuse patterns (like those causing
HIV-AIDS, or Hepatitis B) should perhaps be considered as treatment."

The mention of pathogens is important because it reveals that there is
no sharp distinction between harm reduction and prevention, either.
For if Insite reduces the transmission of blood-borne infections, then
it is acting as a powerful agent in preventing the spread of disease.
Treatment can also act as a form of prevention, as highly active
anti-retroviral therapy (HAART) renders HIV-AIDS patients less
infectious and thereby helps prevent transmission of the virus.

All of this suggests that by treating prevention, treatment and harm
reduction as separate concepts, we are making false distinctions. It
is now time to move beyond this way of thinking, and to fully
integrate the concepts we use in addressing substance abuse.

And this is why Justice Pitfield's judgment is so important. While
Pitfield did not declare Insite a form of treatment because it didn't
involve "using controlled substances as an antidote for an illness,"
his recognition that Insite is a form of health care should helps us
to move from four pillars to just one -- that which improves the
health of Canada's most vulnerable citizens.