Four Pillars Drug Strategy Vancouver

[Baldomero Prado]

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)

Non-Partisan Association (NPA) Coun. Melissa De Genova is putting a motion before council this week asking for a comprehensive review of the city's Four Pillars Drug Strategy. The motion also calls for more resources to tackle drug issues, which De Genova says should pay for a full-time staff member dedicated to drug strategy.

The Four Pillars strategy, which is based on the principles of harm reduction, prevention, treatment and enforcement, was first implemented in Vancouver in the late 1990s. De Genova said she supports the strategy, but worries some pillars are being underutilized.

De Genova said decriminalization would fall under the enforcement pillar of the city's strategy and allow authorities to focus their resources on organized crime operations and large-scale traffickers, rather than drug users.

City council approved the 85-page document, A Framework for Action: A Four-Pillar Approach to Drug Problems in Vancouver, in April 2001. It included almost 40 recommendations on how to tackle drug issues in the city and marked a shift toward categorizing addiction more as a health problem than a criminal issue.

Donald MacPherson, author of the framework and current director of the Canadian Drug Policy Coalition, told CBC's The Early Edition in August the strategy was "never really implemented" and addicts are not getting the help they need.

"We keep propping up this failed drug policy that we have in Canada that continues to criminalize vulnerable people, push them into the shadows and make them the target of the problem," said MacPherson.

In her motion to council, De Genova is asking the city "to organize staff and resources to increase the capacity of Arts, Culture and Community Service to research new drug policy to further achieve the goals of the Four Pillars Drug Strategy."

"It is my understanding that we only have one drug policy staff member that is dedicated to drug policy, who also has a number of other files," said De Genova, who would like to see another staff member put on the payroll.

According to the B.C. Coroners Service, Vancouver Coastal Health Authority had the highest number of illicit drug deaths in B.C. between January and August, with 208 deaths out of 690 province-wide. The City of Vancouver's website says the overdose death rate in the city has increased every year since 2014.

Canada is facing an urgent challenge to reduce the harms associated with opioids: from January 2016 to December of 2018, more than 11,500 individuals lost their lives due to opioid related harms. This review examines responses to the opioid crisis thus far, the lessons learned from these initiatives and the knowledge gaps that still need to be addressed across the four pillar model adopted by the CDSS.

A search of peer-reviewed literature was conducted in PubMed and PsycNet, and grey literature was retrieved from reputable substance use and health organizations to determine responses to the opioid crisis and related outcomes between 2013 and 2019. Findings related to actions, outcomes and unintended consequences across the categories of prevention, treatment, harm reduction, enforcement and the evidence base were included and synthesized into a narrative review on lessons learned.

The opioid crisis is a result of multiple, complex interrelated factors. Many physicians may not feel competent to appropriately treat pain and/or addiction. Pushes for opioid deprescribing have resulted in some individuals using illicit opioids as treatment. A range of effective and accessible pharmacological and psychological treatments are still required. When regulations are barriers, unsanctioned actions, such as overdose prevention sites, may be enacted by individuals to respond to urgent public health needs. A nimble response with evolving enforcement perspectives can aid individuals experiencing harms from opioid use.

c80f0f1006