Issue #41 November 2024
Some people are not immediately successful at navigating the potentially perilous journey of maturation in our complex, demanding, inequitable excuse for a caring society. Some of them will use drugs to cope, and some of them will become dependent or otherwise engage in high-risk drug use. Drug industries chronically fail to operate, and governments chronically fail to regulate, in ways that help to prevent drug problems. As in the regulation of all industries, market expansion and increased revenues are the priorities. The captains of industry and enabling legislators are rarely held accountable. People with drug problems should not be punished for that.
In recent issues, I have written about the importance of preventing drug problems, especially through evidence-based policy. A good policy can, over time, prevent millions of drug-related deaths and much suffering. While prevention initiatives are important, they are insufficient – because they can fail. If prevention efforts were entirely successful, we would have no drug problems and no need for other kinds of interventions.
Some people require other kinds of interventions to help them get their lives back on track. Drug treatment programs act as one of two safety nets for those who do not receive, or respond favourably to, prevention efforts. The other is harm reduction initiatives. Both types of interventions save lives and reduce suffering.
Canadian provinces offer drug treatment programs at no charge to the user. That is an admirable alternative to other jurisdictions where profit-driven corporations dominate the drug treatment sector. In such a regime, corporations profit by creating the problem and by selling a solution. Not good. Neither is treatment a panacea for our societal drug problem. For a variety of reasons, including stigma, people may resist getting help for many years, even in the face of considerable harm to themselves and to those around them. We have known this for a long time. Some data I collected in the early 1990s from addiction treatment programs in Hamilton, Ontario showed that, on average, twelve years passed between an individual’s perceived onset of a problem and their entry into a treatment program. Imagine the amount of harm that can occur over twelve years. When people try to get help, many find the system difficult to access and navigate. Many will face long waiting lists. The same Hamilton data set suggested that, within a one-year period, only 7% of those who might benefit from help received that help from an addiction treatment program.
There is limited capacity for follow-up support after treatment, and accordingly, substantial risk for relapse. Relapse is fueled by the same cultural forces that contribute to the onset of drug problems in the first place. That would be almost perpetual exposure to stimuli that encourages drug use. Decades of research has shown that treatment success rates are highly variable. Our treatment system will continue to struggle to keep up with the population prevalence of drug problems. Under the prevailing conditions, it is a tribute to the people working in our drug treatment system that they manage to help as many people as they do. It is unreasonable to expect much more from them.
If our treatment programs were easy to access and had a 100% success rate, there would be much less need for the other safety net – harm reduction. Harm reduction is for individuals for whom treatment programs, for whatever reason, are unattractive or ineffective. Harm reduction does not typically try to curtail or even reduce the person’s drug use. The primary intent is to minimize the harm associated with the person’s ongoing drug use.
One of the first harm reduction/treatment hybrid approaches for drug problems was, unsurprisingly, a controversial one referred to as “controlled drinking.” The controversy arose in the early 1960s – a time when it was near universally believed that alcohol dependence was an inherited disease and abstinence was the only viable intervention. Proponents of controlled drinking were sometimes accused of “killing alcoholics”. This was directed at me on more than one occasion. Over the ensuing years, research studies repeatedly supported controlled drinking goals as a treatment option. Treatment goals other than abstinence are now supported in many treatment programs.
This is not to say that abstinence should not be supported as a treatment goal. For some people it is the best approach. I was once dependent on nicotine. After several failed attempts at controlled smoking, abstinence was ultimately the approach that worked for me. There were no nicotine replacement products available at that time. Yeah, it was tough.
A different type of harm reduction is naloxone – a medication that can be administered to a person in peril of opioid overdose. It prevents an opioid from attaching to a cell’s receptors, thus preventing the drug’s potentially lethal effects. Naloxone is now carried by many first responders and has been increasing in public availability. This is helping to prevent fatal opioid overdoses. Many of those saved by naloxone continue to use opioids and remain dependent upon them.
Another approach is safe injection sites. Over a quarter century ago, I collaborated on a report with the Hamilton Department of Public Health Services to support the development of needle exchange services. The service allowed needle users to exchange damaged and/or potentially contaminated needles for new, sterile ones, and a safe place to inject. The public health objective was to prevent the spread of infectious disease trough needle sharing. These services were not an easy sell in communities at that time. Today, public health advocates are still fighting to have such services established and protected from uninformed and unsympathetic legislators. Progress on such matters is painfully slow.
Another type of harm reduction program that has been around for over a half century is methadone maintenance. Administration of methadone prevents withdrawal from opiates without producing intoxication. This allows the person to function more productively without engaging in criminal and high-risk activities to support their drug use, and without the risk of using a potentially contaminated street supply of a drug.
Safe supply programs dispense uncontaminated supplies of the drugs being used, for example, hydromorphone for those dependent on opioids. Again, these interventions are not intended to help the person to stop using drugs – only to save them from some, perhaps the worst, of the harm. Safe supply has become perhaps the most controversial drug policy issue of our time. The clinical, policy, and philosophical complexities are daunting. Some advocates focus their attention on the importance of saving lives by providing drugs of assured integrity. Others worry about diversion of these drugs to the illegal trade which potentially fuels increases in prevalence of drug use and dependence.
Some of the debate is based principally upon ideology and cherry-picked evidence, and thus remains polarized. A small group of extremists on both sides refuse to listen carefully to what the other has to say. They appear to be less committed to the needs of people with drug problems than to sustaining their anger-mediated dopamine rushes. A detente does not appear imminent. That is unfortunate and ultimately counter-productive. Government regulators continue to flail about like a weathervane in a hurricane, typically yielding to the loudest gust of the day.
This is a prominent dynamic of our times, extending far beyond drug use, drug problems and their solutions. Ultimately, the solution may lie, at least partly, outside the drug policy silo.
Mike DeVillaer
Hamilton Ontario Canada
November 25 2024
This issue is a modified and updated excerpt from “Buzz Kill: The Corporatization of Cannabis”. You can order it from:
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