The harm reduction model of drug addiction treatment | Mark Tyndall

The harm reduction model of drug addiction treatment | Mark Tyndall


I remember the first time
that I saw people injecting drugs. I had just arrived in Vancouver
to lead a research project in HIV prevention in the
infamous Downtown East Side. It was in the lobby of the Portland Hotel, a supportive housing
project that gave rooms to the most marginalized
people in the city, the so-called “difficult to house.” I’ll never forget the young woman
standing on the stairs repeatedly jabbing herself with a needle,
and screaming, “I can’t find a vein,” as blood splattered on the wall. In response to the desperate
state of affairs, the drug use, the poverty, the violence,
the soaring rates of HIV, Vancouver declared a public
health emergency in 1997. This opened the door to
expanding harm reduction services, distributing more needles, increasing access to methadone, and, finally, opening
a supervised injection site. Things that make injecting
drugs less hazardous. But today, 20 years later, harm reduction is still viewed
as some sort of radical concept. In some places, it’s still illegal
to carry a clean needle. Drug users are far more likely
to be arrested than to be offered methadone therapy. Recent proposals for
supervised injection sites in cities like Seattle,
Baltimore and New York have been met with stiff opposition: opposition that goes against
everything we know about addiction. Why is that? Why are we still stuck on the idea that the only option is to stop using —
that any drug use will not be tolerated? Why do we ignore
countless personal stories and overwhelming scientific evidence that harm reduction works? Critics say that harm
reduction doesn’t stop people from using illegal drugs. Well, actually, that is the whole point. After every criminal and societal sanction that we can come up with, people still use drugs,
and far too many die. Critics also say that
we are giving up on people by not focusing our attention
on treatment and recovery. In fact, it is just the opposite. We are not giving up on people. We know that if recovery
is ever going to happen we must keep people alive. Offering someone a clean needle
or a safe place to inject is the first step to
treatment and recovery. Critics also claim that harm reduction gives the wrong message to
our children about drug users. The last time I looked,
these drug users are our children. The message of harm reduction
is that while drugs can hurt you, we still must reach out to
people who are addicted. A needle exchange is not an
advertisement for drug use. Neither is a methadone clinic
or a supervised injection site. What you see there are
people sick and hurting, hardly an endorsement for drug use. Let’s take supervised
injection sites, for example. Probably the most misunderstood
health intervention ever. All we are saying is that allowing people to inject in a clean, dry space
with fresh needles, surrounded by people who care is a lot better than
injecting in a dingy alley, sharing contaminated needles
and hiding out from police. It’s better for everybody. The first supervised injection site
in Vancouver was at 327 Carol Street, a narrow room with a concrete floor,
a few chairs and a box of clean needles. The police would often lock it down, but somehow it always
mysteriously reopened, often with the aid of a crowbar. I would go down there some evenings to provide medical care
for people who were injecting drugs. I was always struck with the
commitment and compassion of the people who operated
and used the site. No judgment, no hassles, no fear, lots of profound conversation. I learned that despite
unimaginable trauma, physical pain and mental illness, that everyone there thought
that things would get better. Most were convinced that, someday,
they’d stop using drugs altogether. That room was the forerunner
to North America’s first government-sanctioned
supervised injection site, called INSITE. It opened in September of 2003
as a three-year research project. The conservative government was intent on
closing it down at the end of the study. After eight years,
the battle to close INSITE went all the way up to
Canada’s Supreme Court. It pitted the government of Canada against two people with a
long history of drug use who knew the benefits of INSITE firsthand: Dean Wilson and Shelley Tomic. The court ruled in favor
of keeping INSITE open by nine to zero. The justices were scathing in
their response to the government’s case. And I quote: “The effect of denying the services
of INSITE to the population that it serves and the correlative increase in the risk
of death and disease to injection drug users
is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance
on the possession of narcotics.” This was a hopeful moment
for harm reduction. Yet, despite this strong message
from the Supreme Court, it was, until very recently, impossible to open up
any new sites in Canada. There was one interesting thing
that happened in December of 2016, when due to the overdose crisis, the government of British Columbia allowed
the opening of overdose prevention sites. Essentially ignoring the
federal approval process, community groups opened up
about 22 of these de facto illegal supervised injection sites
across the province. Virtually overnight, thousands of people could
use drugs under supervision. Hundreds of overdoses were reversed
by Naloxone, and nobody died. In fact, this is what’s happened
at INSITE over the last 14 years: 75,000 different individuals
have injected illegal drugs more than three and a half million times, and not one person has died. Nobody has ever died at INSITE. So there you have it. We have scientific evidence
and successes from needle exchanges methadone and supervised injection sites. These are common-sense,
compassionate approaches to drug use that improve health, bring connection and greatly reduce suffering and death. So why haven’t harm reduction
programs taken off? Why do we still think
that drug use is law enforcement issue? Our disdain for drugs and
drug users goes very deep. We are bombarded with
images and media stories about the horrible impacts of drugs. We have stigmatized entire communities. We applaud military-inspired operations
that bring down drug dealers. And we appear unfazed
by building more jails to incarcerate people whose
only crime is using drugs. Virtually millions of people are caught up in a hopeless cycle
of incarceration, violence and poverty that has been created by our drug laws
and not the drugs themselves. How do I explain to people
that drug users deserve care and support and the freedom to live their lives when all we see are images of guns
and handcuffs and jail cells? Let’s be clear: criminalization is just a way
to institutionalize stigma. Making drugs illegal does nothing
to stop people from using them. Our paralysis to see things differently is also based on an entirely
false narrative about drug use. We have been led to believe
that drug users are irresponsible people who just
want to get high, and then through their
own personal failings spiral down into a life
of crime and poverty, losing their jobs, their families
and, ultimately, their lives. In reality, most drug users have a story, whether it’s childhood trauma,
sexual abuse, mental illness or a personal tragedy. The drugs are used to numb the pain. We must understand that
as we approach people with so much trauma. At its core, our drug policies
are really a social justice issue. While the media may focus on overdose
deaths like Prince and Michael Jackson, the majority of the suffering happens to people who are
living on the margins, the poor and the dispossessed. They don’t vote; they are often alone. They are society’s disposable people. Even within health care,
drug use is highly stigmatized. People using drugs avoid
the health care system. They know that once
engaged in clinical care or admitted to hospital,
they will be treated poorly. And their supply line, be it heroin,
cocaine or crystal meth will be interrupted. On top of that, they will be asked
a barrage of questions that only serve
to expose their losses and shame. “What drugs do you use?” “How long have you been
living on the street?” “Where are your children?” “When were you last in jail?” Essentially: “Why the hell
don’t you stop using drugs?” In fact, our entire medical
approach to drug use is upside down. For some reason, we have decided that abstinence
is the best way to treat this. If you’re lucky enough,
you may get into a detox program. If you live in a community
with Suboxone or methadone, you may get on a substitution program. Hardly ever would we offer people
what they desperately need to survive: a safe prescription for opioids. Starting with abstinence is
like asking a new diabetic to quit sugar or a severe asthmatic
to start running marathons or a depressed person to just be happy. For any other medical condition, we would never start with
the most extreme option. What makes us think that strategy would work for something
as complex as addiction? While unintentional overdoses are not new, the scale of the current
crisis is unprecedented. The Center for Disease Control estimated that 64,000 Americans died
of a drug overdose in 2016, far exceeding car crashes or homicides. Drug-related mortality is now
the leading cause of death among men and women between
20 and 50 years old in North America Think about that. How did we get to this point, and why now? There is a kind of perfect
storm around opioids. Drugs like Oxycontin,
Percocet and Dilaudid have been liberally distributed
for decades for all kinds of pain. It is estimated that two million
Americans are daily opioid users, and over 60 million people received at least one prescription
for opioids last year. This massive dump of
prescription drugs into communities has provided a steady source
for people wanting to self-medicate. In response to this prescription epidemic, people have been cut off, and this
has greatly reduced the street supply The unintended but predictable consequence is an overdose epidemic. Many people who were reliant on
a steady supply of prescription drugs turned to heroin. And now the illegal drug market
has tragically switched to synthetic drugs, mainly fentanyl. These new drugs are cheap,
potent and extremely hard to dose. People are literally being poisoned. Can you imagine if this was
any other kind of poisoning epidemic? What if thousands of people started dying from poisoned meat
or baby formula or coffee? We would be treating
this as a true emergency. We would immediately be
supplying safer alternatives. There would be changes in legislation, and we would be supporting
the victims and their families. But for the drug overdose epidemic, we have done none of that. We continue to demonize the drugs
and the people who use them and blindly pour even more resources
into law enforcement. So where should we go from here? First, we should fully embrace,
fund and scale up harm reduction programs
across North America. I know that in places like Vancouver, harm reduction has been a
lifeline to care and treatment. I know that the number of overdose deaths would be far higher
without harm reduction. And I personally know hundreds
of people who are alive today because of harm reduction. But harm reduction is just the start. If we truly want to make
an impact on this drug crisis, we need to have a serious
conversation about prohibition and criminal punishment. We need to recognize that drug use is
first and foremost a public health issue and turn to comprehensive social
and health solutions. We already have a model
for how this can work. In 2001, Portugal was
having its own drug crisis. Lots of people using
drugs, high crime rates and an overdose epidemic. They defied global conventions
and decriminalized all drug possession. Money that was spent on drug enforcement was redirected to health
and rehabilitation programs. The results are in. Overall drug use is down dramatically. Overdoses are uncommon. Many more people are in treatment. And people have been
given their lives back. We have come so far down the road
of prohibition, punishment and prejudice that we have become
indifferent to the suffering that we have inflicted on the
most vulnerable people in our society. This year even more
people will get caught up in the illegal drug trade. Thousands of children will learn
that their mother or father has been sent to jail for using drugs. And far too many parents will be notified that their son or daughter
has died of a drug overdose. It doesn’t have to be this way. Thank you. (Applause)

93 comments

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  2. It's better to take a steady dose of methadone every day than to take different doses of different drugs until you suddenly OD and expire.

  3. What is happening in the comment section? I guess the upload-time…

    The Idea is great, but i think that we (expecially children) also need better education in drugs (maybe wrong grammar, what i mean is that people should know what they are doing before they do it).

  4. ITS ABOUT TIME THAT PSYCHIATRISTS REALISED THAT THE MEDICATIONS THEY SUPPLY ARE DESTROYING PEOPLES LIVES, FROM CHILDREN RIGHT UP TO PENSIONERS, THIS IS THE BIGGEST CULL OF THE CENTURY, BARRING ANIMAL EXTINCTION NOW IM NOT SAYING THAT THE PSYCHIATRISTS ARE DELIBERATELY CULLING THE PATIENTS BUT'" FOOD"' IS A CHEMICAL AND A SCHOOL OF THOUGHT FOR PSYCHIATRIC DRS TO USE FOR THE MENTALY ILL SHOULD BE THE RIGHT TYPE OF FOODS FOR THE RIGHT TYPE OF PERSON AND NOT ORWELLIAN MEDICATIONS

  5. There won't be any progress with the for-profit prison lobby being as strong as it is. Decriminalizing drug users and focusing on therapy would directly cut their income considering that the largest part of inmates are serving time for drug related crimes.

  6. As a former heroin addict I would have died from who knows what without the local needle exchange. I now have over 5 years clean. I'm going back to school, I have a 2 year old. I'm so grateful for those people who worked there.

  7. I can think of a thousands ways you are correct.The only hurdle I see is profiting of of the drug war being an obstacle of the highest concern. Great Ideas Thanks!

  8. Thank you for this passionate and concise discourse. I am also grateful to Canada for showing us another way. Doing something over and over again even when it doesn't work but expecting a different result… isn't that the definition of insanity? I do, however, confess to a distrust in pharmaceutical intervention as that industry seems to put money before people, effectively creating a 'better' or 'safer' addiction? If it is designed to ease the pain of detox, I am all for it but when it is used without an intention for eventual freedom from all drugs I am suspicious. Adding a practice like yoga to the treatment side of addiction has proven to repair the brain. A yoga practice also addresses the physical, emotional, mental and spiritual aspects of drug addiction. As you noted, there is nearly always a story and as Bessel Von der Kulk reports in his book, The Body Keeps the Score – well, the body keeps the score! Thank you again for keeping the disenfranchised part of our consciousness.

  9. Prescription addiction is equally harmful as illicit drug addiction, but far more overlooked!

  10. We shouldn't make policy based simply based on what we believe. We should make policy what works, what's true… Ultimately, what we can justifiably prove will get us to where we believe we should be.

  11. The stupid thing is that schools told us that marijuana is the "gateway drug" to harder substances. In truth, the prescriptions provided by doctors is what mainly leads people to those hard substances.

  12. Here in the U.S. the so called "War on Drugs" is an abysmal failure. This is why I see some progress – for example where I live all first responder vehicles have Naloxone to stop overdoses. And I'd love to see the focus on drugs change from a law enforcement issue to a public health issue. That would change everything. And I wouldn't want to be a police officer because I can see drugs being completely legal and safe and autonomous vehicles that never break the law. So you don't need as many police at that point.

    And the trauma – most people in my family that used drugs were either physically abused as kids or grew up in the extreme suburbs.

  13. Weed 😂😂😜it comes in oils with enough thc to calm ya down if it is grown properly ✅✅✅

  14. Fantastic message. Stop Shaming addicts. Judging, demonising and criticising people in pain increases the stigma and self hatred which is driving the need to numb out.

  15. This is one of those very thought provoking talks, that should be advertised by the government, so everybody would be aware of what really goes on in the world. Big Pharma creates these painkillers and the people get addicted to them and when the supply is cut off, they look elsewhere to kill the pain. Fortunately cannabis is being legalized and that substance has proven itself to be a superior painkiller among other benefits. It is common knowledge, that the big pharmaceutical companies make billions on the suffering of the most vulnerable among us. They are reputed to reward MD`s for prescribing their brands. In my book this is corruption, which is costing the taxpayers a fortune. I can`t help but think of Lord Acton`s quote: "Power corrupts and absolute power corrupts absolutely. And all powerful men are almost always bad men". And in this respect women are not much different,

  16. Excellent talk, great ideas. I really hope that some day the harm reduction can be discussed in some global institution, and used as a international standard of dealing with drug addiction worldwide.

  17. Some of the most common and deadly drugs, are alcohol and cigarettes.. Look at a smoker and every time they take a sif, imagine its not a cigarette but a syringe.. And now, take yourselves together! 😉 Its funny how we only point fingers at others, if they break the so-called "law".. You drive to fast, you are not allowed to park there . . . on and on and on!

  18. Need education in schools at an early age and information about the effects of drugs and more detox facilities made available and more research

  19. I say try it in California. If that place is at least 90% cleaner with no junkies in walkways shooting up then I'll say it's a success.

  20. People say oh you're wasting money on drug users. No, providing things like clean needle exchanges helps prevent the transmission of diseases like Hep C and HIV. By preventing users from getting it, you're saving tons of money in the long run that would be for hospital costs and treatments for these diseases.

  21. while i do agree that we should help addicts and care for them, but decriminalize drugs.. thats a step too far..
    if u rly need to fix the drug addiction problems u need to look for the reason why ppl become addicts.

  22. Drug prohibition started because the guy who was responsible for alcohol prohibition lost his job after everybody noticed that alcohol prohibition didn't work so he created the demonized image of drugs and added a little racism to it and a couple decades later people deny any arguments against prohibition.

  23. My favorite is the people who have heard all of the data and still say something stupid and blindly propose a naive and ineffective solution like "Just Don't Do Drugs."

  24. SIS don't stop addiction.Get private funding,why should taxpayers pay to enable people? We need rehab centers and opiate education. Live with an addict and have an addict for a child before you preach.

  25. Saying a needle exchange/injection site is an endorsement for drugs is like saying a hospital is an endorsement for sickness or a Chemotherapy Clinic is an endorsement for cancer. These are all places you go to treat illness.
    Addiction IS an illness and an effective and proven treatment for it is harm reduction.

  26. Maybe potentially the Elon Musk of the medical field. He thinks ambitiously and basically solves a problem in some peoples lives.

  27. I want to thank you sir for this talk because you see the people that use drugs as people and not as the drug that they consume to try to self-medicate the problems they are dealing with that we can't see because the problem lies in their brain.

  28. We NEED these places in the USA. I nearly got raped trying to find a hidden safe place to get well.
    I stabbed the dude w/a needle & ran
    I found out I was lucky..
    Others got sexually assaulted
    🙁
    A disease, even as ugly as addiction, we are not awful ppl-we May do desperate things, we don’t deserve to die or be raped.

  29. I'm so glad I can get clean needles where I live. I always said I'd never share a needle. But if the option for clean needles wasn't easily available….idk if I'd have been able to keep that promise to myself x

  30. "Dont do drugs,if you do,you deserve to go to jail."
    Procceds to injest vast ammounts of alcohol,coffe,sugar and prescription drugs.

    The hypocracy of today's society…

  31. I've found that the people who shame the most are those with the greatest/worse to be shamed 4 ex. "Look at him…not me".

  32. I am a recovery heroin addict. If it wasn't for methadone I wouldn't have the life that I have now. I am back in school and I am an advocate for all the people on methadone in my area. Methadone is recovering if you allow it.

  33. problem with harm reduction is that addicts all deal drugs and they hurt others. forced naltrexone injections are a better strategy. a better strategy is to force long acting vivitrol ie naltrexone

  34. We have to ask ourselves then is the needle exchange that is the issue or is it the political and ideological use of these programs. Personally, I believe that narcotics should be made legal and it should be the individuals choice. As a free people one should choose their path but when we look at examples in America where these programs are allowed to exist a city like Seattle, where I grew up by, has gone from a thriving metropolis to a cesspool of crime, disease, and drug use. The West Coast is facing real problems that are secondary and tertiary effects of such programs. San Fransisco is in a full-blown epidemic because of such programs. So I ask to put ideology aside, my life and childhood were turned upside down to addiction because of my parents' decisions to use drugs and alcohol, so my compassion has limitations. The approach should be more empirical and logistical and less ideological. Compassion is a constant, but these sites need to be strictly regulated and the condoning of behaviors that are a result of such use should also be strictly enforced.

  35. What a great video that pretty much covers everything… we need more open-mindedness and willingness to try something new. What’s the harm in trying something new?

  36. Where I live, drug users murder their children, cause accidents, harm others, etc…we do needs laws against using drugs. And I think there would be great benefit to offering recovery programs for free ( including inpatient) as part of the needle exchange, so they can elect to do that. Many may not know how to get help.

  37. If the big pharma cartel weren't profiting from harm reduction "treatment" they wouldn't care two craps abt addicts. It's like saying vaccines may kill and injure but it's worth the risk bc it protects the herd. Yrs down the road addicts are still addicts when using replacement therapy, they're just paying doctors and big pharma cartel instead of joe at the corner. Now sub is being sold on the street and ppl are selling their govt funded semi synthetic heroin ao they can br on sub and meth. Govt is retarded imo

  38. I would be more on board if these sites also provided nutritional support. A good warm meal and a multi vitamin with extra B Complex…

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