“Harm Reduction” is Killing B.C.’s Addicts – There’s a Better Way

Almost as many Canadians have been lost to drug overdoses in the last seven years as were killed in combat throughout the Second World War. Yet governments, health care professionals […]
Published on January 14, 2024

Almost as many Canadians have been lost to drug overdoses in the last seven years as were killed in combat throughout the Second World War. Yet governments, health care professionals and addiction experts continue to quarrel over virtually every aspect of the opioid crisis – its causes, possible remedies and even whether addicts should be regarded as passive victims or accountable moral agents. And amidst this dithering and experimentation, the horrific death toll mounts. In search of hope, veteran researcher Susan Martinuk takes a close look at life in Vancouver’s notorious Downtown Eastside and compares it to the decidedly different approach taken by Alberta’s UCP government.

Stand at the intersection of Main and East Hastings streets in downtown Vancouver and cast your eyes to the sky. To the north, you will see the majestic Coast Mountains that overlook the city and provide its natural grandeur. Turn to the west and you will see the soaring high rises that define Vancouver’s business district and stand in witness of the city’s global significance.

Drop your eyes to street-level, however, and the iconic vistas of one of the world’s most beautiful cities disappear. Now you find yourself looking at one of the world’s ugliest open-air drug markets. This is Vancouver’s blighted Downtown Eastside, home to an estimated 7,000 addicts. And a complete absence of hope.

Here the streets are covered with trash, needles and human feces. Drugs are publicly bought, sold and consumed. Homeless people sleep in doorways or makeshift tents that crowd the sidewalks and other public spaces. In addition to the scourge of addiction, mental illness is also well-represented. So is poverty. The area is a breeding ground for other anti-social behaviour including crime, violence, prostitution and gangs. The Downtown Eastside is a chaotic, festering, ungovernable neighbourhood that strips human beings of their basic dignity and diminishes all that is civil or presentable.

Jon has been lost to these streets for 15 of his 41 years. He was raised in nearby Surrey but left school before completing Grade 9. Jon’s largely-untreated ADHD made his teenage years a constant struggle for him and his mother, Val (their last name has been withheld to protect their privacy). After leaving school he stopped taking the Ritalin prescribed for his ADHD and began experimenting with street drugs. Jon found work as a warehouse forklift operator, but things quickly fell apart when his drug use became a daily habit. That, says Val, marked “the beginning of the end of any semblance of a normal life for Jon.”

When Jon first disappeared for an extended period, Val had friends search the streets for him. They eventually found him living in a tent in downtown Surrey where, thankfully, police intervened and got Jon into a hospital psychiatric unit for three months. Jon was then admitted to another program for drug addicts with mental illness where, by all accounts, he was doing well. The structure, supervision, medication and separation from the drug culture were exactly what Jon needed – moving him towards sobriety and good health. At that point, Val says, “I was hopeful he would eventually make a full recovery and rejoin his family.”

Then Jon was abruptly released from the treatment centre because his bed was needed for another patient. This, even though his psychosis was not yet fully under control and he still required treatment. Today, Val remains adamant that “releasing him to the streets should never have been an option.”

Abandoned by the system, Jon drifted to Vancouver’s Downtown Eastside where his mother later found him living in a shelter. But this time, the prognosis was no longer favourable. Here Val was confronted with the cruel reality of B.C.’s officially-sanctioned “harm reduction” policy, the centrepiece of the NDP government’s approach to its drug addiction crisis. Rather than recognizing or treating Jon’s mental and physical health needs, shelter staff instead enabled the drug purchases of their “clients.” Such a policy of unfettered access to hard drugs left Val powerless to help her son confront his twin demons of mental illness and addiction.

Today, Val no longer knows where her son is and – with no supports in place to help him make a recovery – she fears how his story will end. “When dealing with drugs, you can’t count on anything to turn out like you expect,” she says, her comment weighted down with equal portions of sadness and anger. “I’m not confident he will ever get the help that he needs.”

Jon’s tale is grimly typical of how drugs, homelessness, unemployment and mental illness have taken over Vancouver’s Downtown Eastside. With addicts generally powerless to resist the siren call of opioids, policies that provide unlimited access to drugs offer little hope they will ever kick their deadly habit. And all of society suffers from the broader confluence of crime, unemployment and homelessness that attends B.C.’s harm-reduction policy. Meanwhile, Val and countless other loved ones of drug addicts plead that there must be a better way.

There is, but you won’t find it on the streets of Vancouver.

Canada’s Opioid Crisis

More than 40,000 Canadians have died from opioid overdoses since 2016. The roots of this crisis lie in the proliferation of the manufactured opioid fentanyl, the culprit in more than 85 percent of these deaths. Cheap to make and hard to detect, fentanyl is far more powerful than many older and more familiar opioids; it is 40-times stronger than heroin and 100-times stronger than morphine. Beyond its addictive properties, fentanyl combined with other drugs can also cause other serious physical impairments, afflicting users with terrible infections, abscesses, strokes or paralysis, the horrific effects of which can sometimes require amputation.

Opioids are painkillers that trigger the release of endorphins in the brain, creating a feeling of euphoria. In doing so, they also reduce the brain’s breathing reflex. This means that during an opioid overdose, the brain is temporarily starved of oxygen. Since each overdose results in some degree of brain injury, multiple overdoses inevitably lead to significant and potentially permanent brain damage. A 2023 study by the BC Centre for Disease Control found that people who experienced at least one overdose were 15 times more likely to have a brain injury than someone who had no history of overdosing.

Despite accounting for only one-quarter of Canada’s population, B.C. and Alberta represent nearly half of this country’s opioid deaths. At 45.2 per 100,000, B.C.’s death rate is more than double the national average and substantially above the U.S. figure.

Beyond causing long-term brain damage, opioid use is also closely linked to pre-existing mental illness. Provincial data reveals that 62 percent of individuals who died from illicit drugs in B.C. between 2017 and 2021 had previously been diagnosed with a mental illness or showed anecdotal evidence of mental health problems.

The Portuguese Connection

Fuelled by the recent flood of fentanyl and other opioids, Canada’s drug overdose death rate stood at 19.3 per 100,000 population in 2022. While this is lower than the U.S. figure of 32.4 per 100,000, it is still shockingly high by international standards. In 2020, the European Union suffered just 1.5 overdose deaths per 100,000.

Canada’s national statistics hide considerable geographic variation. Despite accounting for only one-quarter of Canada’s population, B.C. and Alberta represent nearly half of this country’s opioid deaths. At 45.2 per 100,000, B.C.’s 2022 death rate is more than double the national average and substantially above the U.S. figure; Alberta is close behind at 33.3. In the face of such a deadly toll, Canada’s two western-most provinces have taken sharply divergent approaches to resolving their shared crisis.

Vancouver prides itself in being at the forefront of innovative approaches to treating drug abuse and, for the most part, B.C.’s NDP government has followed its lead. In response to an earlier heroin epidemic, Vancouver established its “Four Pillars” approach to drug policy in 2005. Based on experience in Europe, the four pillars comprise harm reduction, law enforcement, prevention and treatment. In truth, however, Vancouver and, by extension, the entire province has come to emphasize harm reduction as the overwhelmingly dominant pillar. Some international observers have called Vancouver “the gold standard of harm reduction,” noting that “over the past 30 years, Vancouver has implemented the full range of harm reduction strategies.”

Harm reduction seeks to eliminate the damaging effects of illicit drugs without actually removing drugs from the equation. It is generally focused on short-term issues of access and safety. To this end, provincial and municipal policies have promoted measures such as “safe” injection sites, needle exchange programs, crack pipe giveaways and drug-dispensing vending machines for pharmaceutical-grade opiates. In doing so, B.C. is following the path blazed by Portugal, where drug consumption was decriminalized in 2001 and addiction is now treated solely as a medical issue. Vancouver’s political and public health officials repeatedly laud harm reduction as a compassionate approach that defines addicts as patients in need of support rather than criminals in need of sanction.

Crucially, such policies do nothing to discourage drug use. Rather, they actually encourage it by making drugs much easier to obtain. “Safe” supply initiatives distribute hard drugs like heroin and cocaine free of charge to users who ask for them. The hope is that addicts will no longer be tempted by poor-quality street drugs and that the criminality associated with the addict’s need to constantly pay for their drug habit will ease. The same holds for needle exchanges – swapping out dirty street needles for clean government-provided ones. By facilitating the daily needs of drug users, it is assumed that addicts’ health will improve. But it is a policy rife with unintended consequences.

For example, one key element of safe supply policy is to hand out large amounts of the potent and highly-addictive opioid hydromorphone to keep users away from the even-more-deadly fentanyl. But as the National Post has documented, publicly-provided hydromorphone pills distributed to long-time users frequently end up on the streets as well. The original recipients of these pills often sell them to new or relapsed addicts and use the money earned to purchase a street drug that provides a better high – namely, fentanyl.

Stigma Fixation

Harm reduction has many advocates, not only in B.C. but across Canada and throughout the Western world. The politicians and public health officials who promote harm reduction repeatedly emphasize the policy’s role in easing the “stigma” of drug use. Such stigma reduction is supposed to encourage users to seek help and is fiercely defended.

B.C.’s NDP government has taken its fight against the stigma of drug use a step further by pursuing the decriminalization of small amounts of illicit drugs. This was achieved in January 2023 under a special exemption from the federal government.

Last year, when several B.C. municipalities discussed cracking down on public drug use, six B.C. public health officers wrote an open letter expressing their concern that focusing on enforcement “would be perpetuating the harms we are trying to reduce…These harms also include stigma and shame that force people to conceal their substance use and use alone, increasing their risk of dying from substance poisoning.” Carolyn Bennett, until recently the federal minister of mental health and addictions, has similarly claimed that harm reduction is necessary to reduce the “stigma, the fear and shame” that keeps drug users away from seeking help and that this approach “prioritizes the dignity and safety” of users.

B.C.’s NDP government has taken its fight against the stigma of drug use a step further by pursuing the decriminalization of small amounts of illicit drugs. This was achieved in January 2023 under a special exemption from the federal government. It is now no longer illegal to possess up to 2.5 grams of heroin, cocaine, methamphetamines, Ecstasy (also known as MDMA), fentanyl or morphine for ostensibly personal use (B.C. had sought a higher exemption of 4.5 grams). Bonnie Henry, B.C.’s Provincial Health Officer, has long been a proponent of decriminalization; the priority, she claims, is to remove the “stigmatization of drug use as a criminal activity.”

Belief in the curative power of stigma reduction is not universally shared, however. In a lengthy interview with The Epoch Times, recovering B.C. addict Guiseppi Ganci called it “bizarre” to think that stigma is preventing addicts from getting treatment. “It’s not true,” says Ganci, who now works at an inpatient addiction treatment facility in New Westminster. “I’ve never met a person who uses drugs, including myself, that didn’t get help because they felt stigmatized.”

In the 1990s, best-selling author and policy researcher Michael Shellenberger was a keen supporter of the progressive harm-reduction movement in his hometown of San Francisco and participated in the introduction of the city’s first needle exchange. But several decades of officially-encouraged open drug use led Shellenberger to change his mind. As he explains in his 2021 book San Fransicko: Why Progressives Ruin Cities, he now understands that stigmatization of drug use is both necessary and beneficial. Drug use, at its core, is a self-harming behaviour, he observes: “The person requires our compassion. But the behaviour requires our condemnation.”

“Harm Reduction Isn’t Working”

Harm and stigma reduction strategies each rest on the hope that addicts plied with free drugs and other official indulgences will eventually decide on their own to seek treatment. Based on current conditions in the Downtown Eastside, these approaches aren’t working. Vancouver city councillor Brian Montague, a former officer with the Vancouver Police Department, has witnessed first-hand the effects this policy has had on his city. “The stats tell us that harm reduction isn’t working,” Montague says in an interview. He calls B.C.’s decriminalization strategy “a disaster” and one that, he predicts, will be “hard to walk back.”

While harm reduction dominates provincial and municipal drug policy, Montague asserts that, “We need the other three pillars – law enforcement, education/prevention and treatment.” He wants to see significant provincial spending to expand current facilities and create “massive numbers of beds in a treatment facility that deals with both addictions and long-term mental health problems. Alongside detox and treatment centres, we need long-term psychiatric beds, access to free counselling services and housing.” Montague’s envisioned policy would have helped Jon get the treatment he needs since it explicitly recognizes the connection between mental illness and addiction.

With harm reduction the dominant pillar of B.C.’s drug policy, enforcement has become a dead letter. Under B.C.’s current decriminalization policy, police can no longer arrest or ticket individuals carrying small or “personal” amounts of drugs. Instead they hand out wallet-sized “health service referral cards” that provide a list of available health and social services. Since no one is tracking the resource cards, it is difficult to measure the success of the project. Evidence from elsewhere is instructive, however.

In 2020 Oregon decriminalized hard drugs in a similar effort to stem public drug use in its major cities of Portland and Eugene. There police now hand out similar “citations” urging users in public spaces to access health and addiction resources. In two years, approximately 6,000 citations have been handed out; just 92 people have responded by connecting with health services. Beset by problems of rising drug use and crime, Oregon has begun seeking to rein in its decriminalization experiment. Meanwhile, opinion polls show strong public support for a recriminalization proposal backed by the League of Oregon Cities, which represents municipalities across the state as well as police and prosecutors’ associations.

After its own year-long experiment, B.C. has also attempted to tap the brakes on decriminalization. Complaints from citizens, accelerated in-migration of drug users from other provinces and concerns about open drug use around children pushed B.C. to restrict drug use in open areas near parks, playgrounds and businesses. The associated legislation, however, was immediately challenged in court by harm-reduction advocates (in this instance, a tiny lobby group called the Harm Reduction Nurses Association). On December 29, 2023 a B.C. Supreme Court judge declared that the new law could cause “irreparable harm” and imposed a three-month injunction on it coming into force. As it stands now, doing drugs in a playground is effectively a protected right in B.C.

Another of the forgotten pillars of drug policy is prevention. In 1997 a group of Vancouver police officers founded Odd Squad Productions Society to offer youth growing up in Vancouver’s downtown with an alternative to the drugs and criminal behaviour that dominated youth culture there. Today the Odd Squad provides mentoring, sports and video presentations in an effort to keep kids away from drugs. Executive director Mark Steinkampf, a former police officer, says he is frustrated by the resources poured into harm reduction for current addicts while prevention-based organizations are largely ignored by provincial and municipal governments. “So little is given to prevention,” he says. “Programs like Odd Squad struggle to get by.”

As for the much-lauded example of Portugal, it is also showing signs of collapse. An investigation by the Washington Post last summer revealed a heated debate within the country about the wisdom of promoting harm reduction at the expense of the other three pillars of enforcement, prevention and treatment. Illicit drug use is up, overdoses nearly doubled between 2009 and 2023 and police point to a recent crime wave – robbery in public spaces was up by 14 percent last year over 2022 – as the result of increased drug use. As the Post reported, “The state-funded nongovernmental organizations that have largely taken over responding to the people with addiction seem less concerned with treatment than affirming that lifetime drug use should be seen as a human right.”

The Alberta Model

With the election of the United Conservative Party in 2019, Alberta began transforming its drug addiction policy away from the harm-reduction approach pursued by the previous NDP government to one based on publicly-funded treatment and recovery. What is now called the “Alberta Model” is, according to a provincial website, “based on the belief that recovery is possible, and everyone should be supported and face as few barriers as possible in their pursuit of recovery.”

The architect of Alberta’s ambitious program is Marshall Smith, a former addict himself who once lived in Vancouver’s Downtown Eastside and now serves as Alberta Premier Danielle Smith’s chief of staff. His personal story of despair and recovery serves as a template for the province’s entire drug policy.

Rather than providing hydromorphone or other street drugs to addicts, Alberta makes available naloxone (an opioid “antagonist” that, if given in time, can prevent death from overdose and restore normal breathing) along with other medications such as suboxone, sublocade and methadone to help transition opiate users away from drugs as they work through their recovery. And instead of providing safe injection sites and free drugs to addicts, Alberta is building and expanding treatment and detox centres.

Key to this plan are new centres called therapeutic communities. Patients can stay for up to one year, receiving therapy and medical treatment while also developing life skills. To date, new 75-bed facilities have been opened in Lethbridge and Red Deer. The government’s plan calls for 10 such residential treatment centres (four of which will be in partnership with Indigenous organizations) throughout the province. There are currently over 29,000 addiction treatment spaces in the province. And a $40 per day user fee that previously served as a barrier to access for residential treatment beds has been eliminated.

The architect of Alberta’s ambitious drug treatment program is Marshall Smith, a former addict himself who once lived on the streets in Vancouver’s Downtown Eastside and now serves as Alberta Premier Danielle Smith’s chief of staff. His personal story of despair and recovery serves as a template for the province’s entire drug policy. “I slept in doorways, ate out of garbage cans, did all of the things that you would imagine people do as they’re trying to survive that ordeal,” he told CBC in a lengthy and surprisingly positive interview.

Smith stated in the interview that he only escaped Vancouver’s grim drug culture because two police officers convinced him to go into a rehabilitation program. “I went to a 35-day program in British Columbia that was publicly funded,” he said. “I took it seriously, and it was the first time in years that I had that kind of connection and interaction in a very meaningful way with my other fellows who are in pursuit of the same recovery.” With his eyes opened to the importance of treatment, Smith is now bringing the same sense to his home province.

Yet the prospect of free government-provided drugs sans stigma remains an attractive option for most hardcore addicts, who rarely act in a rational fashion. Many can’t be expected to make the same choice as Smith to leave the street for a rigorous if beneficial treatment program. Understanding this, Alberta is now considering “compassionate intervention” legislation that would give police, family members and guardians of drug users the authority to force youth and adults into treatment if they pose a danger to themselves or others. Such a proposal is controversial since it raises the question of whether mandating treatment is a violation of an individual’s liberties under the Canadian Charter of Rights and Freedoms (as well as the Alberta Human Rights Act, which could be amended).

Leaving aside the constitutional implications regarding drug-addicted adults, some medical professionals who work with children see it as a non-issue in the case of minors. Dean Vause is a child psychologist and executive director of the Alberta Adolescent Recovery Centre, a Calgary facility that provides residential-based treatment to drug-addicted youths. “These kids are ill, and it is life-threatening,” Vause notes. “It is up to the parents to save their lives. People should be legally liable if they walk away from a kid who needs help.”

Enforced treatment for adults and minors alike finds favour with others who are critical of B.C.’s indulgent harm-reduction policies. Says Odd Squad leader Steinkampf: “Some people say we should meet addicts where they are at, but no good can come from staying in this lifestyle. Mandating a person to live in a secure environment is better than living on the streets.” Vancouver city councillor Montague adds that what really matters is making sure addicts have accessible treatment, whether mandatory or on-demand. “Denying them an opportunity to recover is unacceptable,” he says.

And writing recently in the National Post, Shellenberger has called the Alberta Model a template for North America, and a truer representation of the European experience than what is on display in Vancouver or his home of San Francisco. “When you look around the world and study approaches to drug epidemics, those with recovery at their core are by far the most successful,” he asserted. “All indications are that Alberta is getting it right.”

The Tale of the Tape

The divergent policies and politics of B.C. and Alberta have played a major role in determining the public perception of Canada’s opioid crisis. Left-leaning media outlets have tended to laud B.C.’s harm reduction as being more compassionate, while conservative voices point to Alberta’s focus on treatment as more practical and realistic. What Canada had lacked until recently was an impartial, data-driven assessment of the two competing systems.

That problem was partially solved last year with the release of a report from the U.S.-based Stanford Network on Addiction Policy. Entitled Canada’s Health Crisis: Profiling Opioid Addiction in Alberta & British Columbia, the document offers an even-handed review of the differing policies of the two provinces, summarizes the latest available data (which it criticizes as inadequate) and cautiously evaluates the results. B.C., the report notes, emphasizes harm reduction, “safe supply” of illicit drugs, decriminalization of possession and reduction of addiction stigma. Alberta, by contrast, is focusing on “investment in rehabilitation beds and spaces, such as therapeutic communities,” while moving away from “safe supply” of opioids and instead providing addicts with medications.

Using these differences as a natural experiment, the Stanford report comes to a few key conclusions. First, it observes “a lack of policy innovation in BC on the issue of drug addiction.” Obsessive attention to harm reduction appears to have blinded politicians and public health officials to the longer-term consequences of their favoured policy. “Enforcement against drug crime has [been] reduced in recent years,” the report notes, “indicating a general lessening of criminal justice enforcement against drug offences in Canada during the escalating health crisis of opioid addiction.”

Second, “Of the two provinces studied for this report, Alberta is currently experiencing a reduction in key addiction-related harms.” The province’s rate of overdose deaths declined by 17 percent from 2021 to 2022 (B.C.’s remained almost unchanged), although it was still Alberta’s second-worst year on record. Using the most recent data available, the Stanford researchers point to B.C.’s higher death rate as suggestive of the two approaches’ relative effectiveness: “Our research indicates that Canada overall, and BC in particular, is not yet showing the progress that the public and those impacted by drug addiction deserve.”

Focusing entirely on harm reduction risks perpetuating subcultures across Canada that look just like Vancouver’s Downtown Eastside, where addicts wander about in a state of ‘pharmaceutical oblivion’ and remain wholly dependent on society for money, food, shelter and more drugs.

The Stanford report is admittedly an early analysis of the two provinces’ newest program innovations. Decriminalization has only been in effect for a year in B.C. and may be partially rolled back if the province can overturn the aforementioned court injunction. Plus, most of Alberta’s planned recovery homes are still under construction. And since the Stanford report was published, opioid death rates have inched higher in both B.C. and Alberta. Nonetheless, the early returns favour Alberta.

Beyond its reliance on concrete evidence, the Stanford report’s conclusions also make moral sense. Society may have an obligation to help drug users as best we can. But surely that duty should extend beyond ensuring their next hit is clean and safe. Offering addicts free drugs does nothing to encourage them to seek treatment or restore their inherent human dignity. Despite all the hand-wringing over the “stigmatization” of drug use, it is an addict’s own decision to use drugs that is the truly stigmatizing act. And focusing entirely on harm reduction risks perpetuating subcultures across Canada that look just like Vancouver’s Downtown Eastside, where addicts wander about in a state of “pharmaceutical oblivion” and remain wholly dependent on society for money, food, shelter and more drugs.

If we want the addicts in Vancouver’s Downtown Eastside and Canada’s many other blighted urban areas to live healthy and meaningful lives, we must offer them something other than free drugs. They need treatment and encouragement – sometimes pointed and uncompromising encouragement – to get clean. Dignity comes from a life of purpose, not a government-funded fix.

 

 

Susan Martinuk is a senior fellow at the Frontier Centre for Public Policy and author of the 2021 book Patients at Risk: Exposing Canada’s Health Care Crisis. She lives in Vancouver. Reprinted with kind permission of the C2C Journal here.

Related Items:

Read: Hard to Find the Moral High Ground in Lawsuit Against Opioid Makers here. December 10, 2023

Read: Safe Supply Programs Creating a Surge in New Opioid Users here. October 22, 2023

Read: The Opioid Crisis Reflects a Failure of Public Policy: It’s Time to Move On here. July 5, 2023

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