Four Pillar Approach To Drug Problems
Margit Szermer
In November 2005, Council unanimously endorsed the drug policy prevention plan, Preventing Harm from Psychoactive Substance Use. The plan is the result of extensive research and diverse community consultations.
The plan is also the first of its kind at the municipal level in Canada. It is comprehensive, integrated, and based on the best evidence and research available. It aims to expand awareness, understanding and discourse around prevention.
The recommendations address marijuana grow operations and methamphetamine labs, as well as the need for a syringe recovery system. The plan also calls for increasing limits on the sale of tobacco and a community partnership approach to the development and implementation of a comprehensive alcohol strategy.
Finally, the plan calls for legislative and regulatory changes to create a regulatory system for all currently illegal drugs that would increase our ability to control potentially harmful substances and limit the control that organized criminals have over these drugs.
The prevention of problematic substance use contributes to the public good by reducing costs to society as well as harm to individuals and communities. Important prevention goals include delaying the onset of substance use among youth and addressing the underlying causes of drug use. Prevention acknowledges that individuals usually make the best choices available to them, but that factors such as abuse, poverty or a history of addiction in the family may constrain those choices.
Of the four pillars, prevention requires the greatest amount of commitment and collaboration across all sectors of the community over a sustained period of time to show significant results. In the long-term though, prevention will have the greatest impact in reducing harm from substance use.
Early intervention is a crucial aspect of any treatment system. Treatment seeks to create a continuum of care by recognizing that different drug use patterns must guide treatment strategies. Since there is a chronic relapse pattern with addictions treatment, abstinence is not always the only measure of success.
Currently, there are four levels within withdrawal management ranging from home detox to medical detox. Treatment is most effective when it considers factors unique to each individual and tailors treatment accordingly. Addiction services have been decentralized in Vancouver, with the goals of decreasing acute care demand and improving treatment completion rates.
Currently in Vancouver, alcohol dependence affects over 12,000 people and injection drugs over 9,000 people. Treatment makes sense on both humanitarian as well as economic grounds. According to the March, 2006 Canadian Centre on Substance Abuse report, The Costs of Substance Abuse in Canada 2002, the overall social cost of substance (tobacco, alcohol and illegal drug) abuse in Canada in 2002 was $39.8 billion.
Methadone treatment and counselling has been an area of significant growth in the treatment of heroin addiction in the province. The number of people in BC treated with methadone was 8,319 at the end of 2006.
Vancouver is also one of three Canadian cities that participated in the North American Opiate Medication Initiative (NAOMI). Supported by the City of Vancouver, the study sought to determine whether prescription heroin, or a combination of heroin and methadone, might be a better treatment for those who do not respond to methadone alone. The NAOMI clinical trials took place between 2005 to 2008 and showed that patients treated with injectable heroin were more likely to stay in treatment. After NAOMI, the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) took place to test alternative treatments for people who were using heroin. The SALOME clinical trials concluded in 2015.
Meanwhile, Vancouver Coastal Health has increased its treatment budget by about $2 million per year, over the past five years, adding new addiction services, an increased number of detox beds and the development of addiction housing.
The principles of harm reduction require that we do no harm to those suffering from substance addiction, and that we focus on the harm caused by problematic substance use, rather than substance use per se.
Harm reduction involves establishing a hierarchy of achievable goals which, when taken step by step, can lead to a healthier life for drug users and a healthier community for everyone. It accepts that abstinence may not be a realistic goal for some drug users, particularly in the short term. Harm reduction involves an achievable, pragmatic approach to drug issues.
A 2002 International Narcotics Control Board (INCB) legal opinion on harm reduction approaches noted that the concept of harm reduction had only emerged in the previous decade, but aspects of the existing international drug control treaties addressed harm reduction issues.
Harm reduction interventions have proven successful in decreasing the open drug scene, the spread of HIV/AIDS and hepatitis, overdoses and overdose deaths in countries such as Germany, Switzerland and Australia.
The VPD drug policy sees prevention as the most important of the four pillars, but said there is concern that a lack of resources dedicated to this pillar does not allow for large-scale prevention programs. Success in this pillar, it says, would reduce needs in the other three.
The VPD supports the Supervised Injection Site, located on East Hastings Street. It also supports the North American Opiate Medication Initiative, a clinical trial testing whether medically prescribed heroin can successfully attract and retain heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs. It also supports accessible and immediate treatment for substance abuse on demand, for both adults and youth.
Police officers will continue to work to improve coordination with health services and other agencies that link drug users to immediate medical care, withdrawal management (detox), treatment and other counseling and prevention services. Vancouver police efforts are complemented by Drug Treatment Courts. These provide an alternative to incarceration for non-violent offenders addicted to heroin, cocaine or opiates, to follow treatments such as methadone maintenance.
The City of Vancouver acknowledges that it is situated on the unceded traditional territories of the xʷməθkʷəy̓əm (Musqueam Indian Band), Sḵwx̱w7mesh (Squamish Nation), and səlilwətaɬ (Tsleil-Waututh Nation)
The Federal Commission on Narcotic Drugs expanded the concept of the four pillars to include the dimension of the three use-patterns: low-risk, problematic, and dependent use. In addition, it was also postulated that this model applies to all forms of addiction, not just to illegal drugs.
On the one hand, this area includes measures for general health promotion that intend to strengthen individual health resources and prevent addiction problems. On the other hand, it subsumes measures for behavioral and situational prevention that concern people's health behavior or that are specifically geared towards issues with addiction which aim at preventing the emergence of risk behavior as far as possible. Early detection facilitates the earlier recognition of behavior could lead to health or social problems or addiction.
Health promotion, prevention and early detection (in french)
Measures in the area of treatment are aimed at people who are addicted and who would like to reduce their consumption, as well as measures aimed at their relatives. Counseling or treatment intends to support people in regaining control over their addiction or even to enable them to make a sustainable exit from addiction. The aim of therapy and counseling is to improve the quality of life and the physical and psychological condition of those affected, as well as their social and professional integration.
Measures in the area of harm reduction aim to stabilize the state of health of those affected, maintain their social integration or facilitate reintegration, or offer them survival assistance, for example by switching to less risky or less harmful behaviors. The aim of harm reduction is to preserve the quality of life of those affected, so that they can lead a qualitatively good and, as far as possible, self-determined life despite current risky and addictive behavior, and later pave the way for therapy and withdrawal.
The main goal of regulating alcohol, drugs, tobacco, medicines, or gambling is to protect people's health. In the area of legal substances and behaviors, regulation includes government interventions aimed at limiting the accessibility and availability as well as the attractiveness of psychoactive substances or certain behaviors such as gambling (e.g., advertising restrictions, limiting sales hours, age restrictions). Enforcement refers to the implementation of the existing legal framework.
There was some resistance among some Swiss civil groups. Their push ultimately forced a national referendum in 1997 challenging the four pillars policy. But 70 percent of Swiss citizens voted in favor of the law. The four pillars have withstood other challenges as well, as the majority of Swiss voters continue to support it.
The number of new HIV infections also dropped significantly. In 1986, more than 3,000 people tested positive for HIV in Switzerland. In 2017, there were fewer than 500 new positive tests in a country of 8.4 million.
Harm reduction staff workers make a point not to judge people who come through their doors. And many build relationships with frequent visitors. Resources are available to drug users at these facilities as well to connect them to anything they might need, from a place to sleep, eat, do laundry, or find addiction treatment.
For example, in Geneva, a lot of people gathered and injected near the main train station. So now, around the corner, a drug consumption room is housed in a modern green building that stands out among the backdrop of the traditional Swiss architecture.
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