Straight Talk about Harm Reduction: An Open Letter to Margaret Wente

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The following was written by Dr Bruce Alexander and presented as a keynote address to a meeting of the Four Pillars Coalition on 3 October 2008 at the Segal Centre in Vancouver. It is a response to a series of articles by Margaret Wente published in the Globe and Mail in the summer of 2008. Wente has another article in today's Globe and Mail criticizing the North American Opiate Medication Initiative (NAOMI) trial.

Posted with permission of the author.   Dear Margaret,

            I returned home to Vancouver from a long camping trip at the beginning of September to find that, while I was away, you had published some potentially devastating claims about Insite and harm reduction in general.[i] Although I have learned over the years that it is risky to dismiss your Globe and Mail columns without very careful consideration, I have now concluded that you made some important errors this time. I hope that you will be interested in how I reached this conclusion.

    Before I address your claims individually, let me remind you of a few facts of history that you may not have taken into consideration when you wrote those columns about harm reduction in the Globe and Mail.

    Drug addiction has been a major cause of public alarm in Canada since well before the passage of the Opium Act in 1908.[ii] Many techniques have been used in the attempt to control it over this long period. In retrospect, virtually all of these techniques, except for the strictly religious ones, can be seen as belonging to one of the four “pillars” of today’s Four-Pillars Program in Vancouver: treatment, prevention, law enforcement, and harm reduction.[iii] All four pillars have been used, to a greater or lesser degree, at every stage in the effort to control drug addiction and each has helped to ameliorate a different aspect of the problem. But throughout, the advocates of the different pillars have been antagonistic to each other: Inflamed attacks on each of the pillars by the advocates of the other three began scorching the pages of Canadian newspapers long before the television era. Yet all four pillars have endured, because each serves its function.

    Here is one slice of history to illustrate how all four pillars have always been represented. Around 1950 there was relatively little “treatment” for drug addiction in Canada, but a few hospitals did provide counseling to drug addicts along with medical treatment, and a few physicians and ministers attempted secular drug counseling on their own. There was quite a bit of harm reduction, provided by physicians who risked their careers by illegally prescribing morphine or other banned drugs, so that their dependent patients would not have to risk arrest.[iv] There was “prevention”, in the form of sensationalized warnings that drug use could cause personal ruin and social collapse in the popular media like MacLean’s Magazine[v]. However, the biggest “pillar” by far, vastly overshadowing all others in terms of public investment and hope, was law enforcement.

    Successive amendments to Canada’s Opium and Narcotic Drug Act, originally passed in 1920, had created a fearsomely punitive instrument by 1950. The amended law allowed long penitentiary sentences for various drug offences, whipping for convicted offenders at the discretion of judges, and deportation of drug offenders who were not Canadian citizens. This law imposed mandatory minimum sentences for drug offences that were deemed to be particularly onerous. Police powers were much greater then than they are now. Police could legally break into suspected drug users’ homes without warrants[vi] and seriously damage these homes in their search for drugs. Police could legally damage individual suspects too, by choking them or punching them in the stomach hard enough to disgorge any drugs they may have swallowed to avoid detection. Several people were eventually “searched” to death in this way. Beyond these legal practices, routine police brutality towards addicts was not a matter of public revulsion as it is now.[vii]

    By 1950, the failure of this long, extraordinarily punitive regime to achieve its ends had become clear to the majority of Canadians. Panicky headlines in Vancouver and across Canada warned of a growing crime wave that was attributed to drug addicts, of the frequent recruitment of juveniles into the world of heroin addiction, and of the terrible sufferings of addicted drug users. Vancouver’s Downtown Eastside was said to house 2000 addicts, one for every 250 inhabitants of the city. MacLean’s magazine estimated that at the current rate of growth there could soon be 1 junkie for every 16 inhabitants.[viii]  I wonder how Steven Harper reconciles these historical facts with his celebrated tough new measures to control drug addiction.

    The Vancouver Community Chest and Council undertook an investigation which concluded in its 1952 report that punitive enforcement methods did not work well enough and that there should be less imprisonment of addicts -- along with more severe penalties for traffickers -- and a greater emphasis on treatment. This report also strongly advocated providing heroin to addicts who could not be successfully treated.[ix] In other words, the strongest form of harm reduction, provision of heroin to addicts, was needed because the visible failure of the highly punitive enforcement regime! 

    The findings of the Vancouver Community Chest and Council were deemed so important that both daily Vancouver newspapers printed the entire report.[x] Providing heroin to addicts was controversial, but the BC Medical Association, the Metropolitan Health Committee, and the Vancouver City Council all supported the idea publicly, if cautiously, as did some judges.[xi]

    If we slice the historical record again, this time around 1972, we find a different situation. All four pillars were still evident, but their relative importance had changed. Treatment, which was minimal in 1950, had grown into a major pillar by 1972. The psychological and psychiatric professions had flourished in the decades following World War II and virtually all the new treatments they devised were being tried on drug addicts and alcoholics. Alcoholics Anonymous was flourishing as well, and the AA model would come to dominate treatment for addiction by the 1980s. There was so much money for treatment that an entire prison, the Matsqui Institution, had been built in the Fraser Valley in 1966 as a centre for treating convicted drug addicts. The newest group therapy and therapeutic community methods of the day were the centerpiece of treatment at Matsqui.  The Addict/Prisoner/Patients were also given generous exposure to occupational therapists, social workers, and educators. There were even staff members who specialized in teaching hobbies to the prisoners.  The public had pinned its hope on treatment and government funding was generous.[xii] 

    The prevention pillar was also conspicuous around 1972 in the form of dire warnings in the media, supplemented by drug education programs in the schools. Harm reduction was still minimal, despite the 1952 report, although small methadone maintenance programs had already been launched in Vancouver and Toronto and a few medical practitioners were still conscientiously, if illegally, supplying their dependent patients.

    The dominant pillar in terms of public expenditures around 1972, however, was still law enforcement. Although whipping and deportation had disappeared as punishments under the new Narcotic Control Act of 1961, life sentences for trafficking were possible under the new law, and seven-year mandatory minimum sentences were in place for importing and exporting drugs. Brutal law enforcement methods, including warrantless home invasions by police and violent searches were still directed at suspected drug users, although public resistance to them had started to grow.

    Despite the active use of all four pillars in the years around 1972, the drug problem still seemed alarmingly out of control in the era of hippies, speed freaks, and Cheech & Chong. Although enforcement still absorbed the lion’s share of the budget for drug problems, treatment had provided the newest hope and the magnet for new money. However, treatment proved to be the bitterest public disappointment of that day.

    The bottom line result of the experiment in treatment of convicted drug addicts at Matsqui Institution was horrible. Over 90% recidivism of treated addicts who were still alive after 5 years!  Worst of all, the most intense treatment had a higher level of recidivism than the less intense treatment, although this difference, mercifully, did not achieve statistically significance.[xiii] Matsqui, with its well-funded, optimistically-launched program had quickly proven that it could not “treat” convicted drug users out of addiction any more than the police could “enforce” them out of it.[xiv] Many optimistic psychotherapists attempted psychological treatment with drug addicts outside of the prisons  – I was one of them, as a young psychologist and family therapist.[xv] We worked very hard, but the long-term results of our diverse forms of psychotherapy were disappointing. There was no hard evidence that we did much good.

    With this historical refresher course in mind, let’s return to our own year of 2008 and the assertions that you made in your columns on harm reduction in Vancouver.

    The main point in your first article of 12 July, repeated in the subsequent articles in various ways, is that knowledgeable observers can just look at Vancouver’s Downtown Eastside and see that harm reduction doesn’t work. You say, “Just the opposite. It digs the pit of addiction deeper and wider.” You argue that harm reduction is the core philosophy of a “vast enabling industry”. You say that what is needed is for law enforcement to coerce people into treatment. You say, “Treatment should be a part of sentencing.” If addicts need harm reduction, “They also need a far more aggressive push into treatment and recovery.”[xvi]

    Part of what you say on this topic is correct and important. Although harm reduction appears to have reduced overdose deaths and had some other beneficial effects,[xvii] it has not brought the addiction problem under control in Vancouver or anywhere else.[xviii]  On the other hand, it has certainly not increased the problem, as you suggest. The historical record, which I have briefly sampled in 1950 and 1972 above, shows that no matter which of the four pillars is most prominent in the public mind, the problem of drug addiction has continued its long-term upward trend -- with periodic outbreaks of public panic -- for a century or more. In Canada, the biggest pillar by far in terms of public expenditure has always been law enforcement, and that remains so today, despite the publicity given to harm reduction. But it would be simplistic to say that law enforcement has caused the century-long increase in addiction,[xix] and it is just as simplistic to claim that harm reduction (or treatment or prevention) has caused it.

    Margaret, I am guessing that you know as well as I do what is digging the “pit of addiction” to drugs – and a thousand other habits –  “deeper and wider” across the globalized world. I wish you had told your readers about it in your articles. I will re-visit this issue presently.

    Contrary to the hope you expressed in your columns, coercing people into treatment will not bring the problem of drug addiction under control. The historical record shows in Canada and everywhere else shows that coerced treatment has a very low success rate. How is it that the failure of the well-funded, optimistically-undertaken, meticulously-documented Matsqui experiment is completely ignored by the rhetoric of those who pin their hopes on coerced treatment today?

    It is not only coerced, government-run treatment that has a low success rate. Privately-run treatment undertaken with voluntary patients who are alcoholic or addicted to drugs, including treatment based on the AA model, has not been more than marginally successful either. When treatment works at all, it usually requires more than one arduous cycle of recovery, relapse, and then another try at treatment, and another.[xx] As a psychologist, I have conducted treatment with heroin addicts, and many of my friends treat alcohol and drug addicts today, but none of us thinks treatment can control the problem of addiction, no matter how coercively it is forced on addicts. Treatment is just one of our four imperfect pillars of response to a problem that is out of our control at the moment. But this does not mean that treatment caused the spread of addiction, any more than law enforcement, harm reduction, or prevention did.

    Addiction to drugs, and a thousand other habits, like gambling, sex, video games, internet pornography, shopping, overworking and so on, is spreading inexorably around the world. You are right to point out that something effective needs to be done, but you inexplicably ignore the cause of the problem that alarms you so. None of the four pillars and no aspect of drug policy is the cause.

    Addiction is spreading everywhere because we live in a civilization that has become so psychologically fragmented that it is barely tolerable for human habitation without addiction or some other substitute for the psychosocial wholeness that previous human societies have provided as a matter of course. As a people, we lack the identity that comes from secure families, stable communities, and a predictable future; we lack the sense of meaning that comes from shared values and religious beliefs; and we lack the confidence that comes from being part of a nation, a civilization, or an economic system that warrants our deep respect. More and more people are finding that addiction is the most effective way they can find to fill the void and control the anxiety. Addictive lifestyles, whether centered on drugs or anything else provide some kind of a substitute for real identity, meaning, and confidence. Having found a substitute for what they lack in their inner core, people cling to it for all they are worth – addictively. This is as true in enclaves of the educated and rich as it is in the Vancouver’s Downtown Eastside.[xxi]

    The social creation of vulnerability to addiction is nobody’s fault in particular, but rather the outcome of the cultural evolution of a fragmented modernity that most people did not foresee or fully comprehend on a psychological level until fairly recently.

    Margaret, if this explanation for why addiction is ever spreading “deeper and wider” does not ring a bell, just ask your friends in your own social circle if it helps to explain their addictions -- the little manageable ones as well as bigger ones. Then try out the idea on the most socially marginalized drug addicted person you know. I think you will get the same answer. Many, many people, both insiders and outsiders, are eager to confirm that they know this void and recognize that their addictions are filling it in a less than optimal way. Once the cause of addition is understood, it becomes clear that none of the four pillars can ever eliminate it or even stop its growth in a globalizing world that is inexorably growing more and more fragmented.

    Addiction will be controlled only when society learns to domesticate modern technology and the free-market economic system so that it serves us psychologically as well as economically, rather than assaulting us psychologically as it showers us with its dubious economic blessings and intermittent recessions. Ultimately, the lasting solution will be found on the social and political level – the level where many of the people who read your columns in the Globe and Mail exert their influence. Until we get serious about addiction on a political level, our best hope comes from the dedicated proponents of all four of our pillars who strive to ameliorate the problem of addiction as well as they can in the current situation. These are smart, dedicated people who are working on a menacing problem because they genuinely care, even though their successes are generally few and far between. All four pillars are necessary because they can all ameliorate a different aspect of the problem, if they are thoughtfully undertaken.

    If this explanation of the cause of addiction and the remedy still does not seem true after you discuss it with your friends, or if it seems too idealistic to be useful, then, Margaret, do I have a book for you! Of course there are many books that might help, but I am modestly recommending my own, entitled, The Globalisation of Addiction: A Study in Poverty of the Spirit (Oxford University Press, released in Canada September 2008). Apart from natural vanity, I recommend my own book because I sense that you are a tough-minded person with little patience for weak logic and concocted evidence, even if they appear to support your own assumptions. I believe that you are likely to be convinced by the same kinds of extensive, detailed evidence and rigorous logic that have convinced me. (That is also why I have taken the unusual step of extensively footnoting this letter to you.). Here is a picture of the cover of the book: [see above left]

    I believe that it is important to Canada that you re-evaluate the Four-Pillars Approach to drug addiction and use your formidable writing skills to help put us on a better path to dealing with the ever-growing problem of addiction on a social and political level, rather than enlisting in the pointless wars between advocates of the separate pillars that have been usurping out attention for a century.

 Yours sincerely,

  Bruce Alexander   Professor Emeritus   Simon Fraser University

P.S. In your second column[xxii] you make the researchers at the BC Centre of Excellence for HIV/AIDS look foolish. You point out that they are advocates as well as researchers and that there is a certain conflict of interest in being both. As always, there is some substance in what you say, but, by taking it out context, you may have injured the reputations of some excellent scholars and dedicated humanitarians.

            In my long career in the university, I have worked with literally hundred of professional researchers and scientists, some of them famous in their fields. I have never in all these decades met a researcher or scientist who was not passionately committed to his or her point of view and inclined to selectively ignore the evidence against it.[xxiii] (I do not exclude myself from this description). That is why research publications are peer reviewed. None of us can claim to be objective all the time, but we can hope that our biases cancel out if we review each other’s publications, and to a large extent this system works.

            In the field of addiction, passionate commitments run even deeper than in other fields, because beyond the natural pride in one’s own research achievements lie philosophical attachments to underlying ideological and spiritual assumptions. All of us in the field of addiction get labeled as ideologues by colleagues who disagree with our positions, whether we are inclined toward treatment, prevention, enforcement, or harm reduction. I hope that this will make you feel a bond of sympathy with us, since you are quite often labeled as an ideologue yourself, as you surely know.

            Yes, the people who work for the BC Centre for HIV/AIDS may well have an axe to grind, and, yes, their research on the efficacy of harm reduction in Vancouver has been oversold. But no, they do not, as you say, “denounce anyone who even suggests that the value of Insite might still be a matter for legitimate study or debate.” I can testify to this from direct personal experience. And no, no, no, Margaret, their high quality research studies cannot be discounted on the ground that “none of these studies addresses the central issue in the public mind...”

            One of the scholars you criticize so severely recently reviewed an article that I submitted to the International Journal on Drug Policy entitled “Beyond Vancouver’s “Four Pillars”.[xxiv] My article asserted, to use your words, “that the value of Insite [and of harm reduction in general] might still be a matter for legitimate study or debate”. This scholar helped correct minor errors in my article and pointed out a few references that I had overlooked, but then recommended that my critical article be published, and it was. Margaret, these people who you skewer so mercilessly are serious scholars, who, like all researchers and scientists, have passionate commitments to what they believe, but also a capacity for objectivity. In fact, the only point in your four articles where I actually got angry was when you used the phrase, “Could it be that the fix is in?” in relation to them. Ironically, that rude insinuation sounds just like the kind of biased rhetoric that you were attributing to them.

            Actually, the biggest problem with the July 15 article is summed up by your sentence “…none of these studies addresses the central issue in the public mind: Does Insite reduce overall drug use?” Again, you may have temporarily slipped into rhetorical mode when you wrote that. I am sure that you know both that reducing overall drug use is not the function that harm reduction serves, and that there is major support among the public for the true goal of today’s harm reduction programs, which is helping people who have proven unable to give up injection drug use to stay as healthy as possible. In the 1920s, the central issue in the Canadian public mind probably was reducing overall drug use, but now, nearly a century later, a great many members of the public are deeply concerned with saving the lives those people who are unable to eliminate their dependence on drugs. And, to restate the thesis of my new book in the broadest terms, widespread drug use and addiction are not spread by harm reduction, but by a much more complex social evolution that must be drawn into the foreground of public attention, if we are ever to bring addiction under control. You are uniquely qualified to help us to rise above the stale conventional wisdom on this topic, rather than continuing the long, futile tradition of pillar bashing.

P.P.S.

    In your third column, published 17 July, you amplify the theme that harm reduction doesn’t work by comparing the drug addiction rates in two European countries. You point out that Sweden has one of the lowest rates in Europe, whereas Scotland has one of the highest. Sweden has little interest in harm reduction, but favors what you call a “choice between treatment and jail”. Scotland has an advanced harm reduction system. If that were all the information available, it would be reasonable to assert, as you have, that harm reduction policy leads to high rates of drug addiction. But there is much, much more information about the European drug scene that you did not mention. The additional information changes the picture entirely.

    For example, although you did mention that the Netherlands is not as free and easy in its drug policy as some people imagine, you did not mention that the Netherlands was one of the originators of harm reduction in its modern form and still practices harm reduction more widely than most other countries, including Canada. Most important of all, you never mentioned that the Netherlands’ current rate of problematic drug use and deaths due to drug use is as low as Sweden’s! If you had included these facts, the analysis would have become quite a bit more complex and interesting.

    Here, for example, are two directly relevant sets of statistics that you did not include. The UK Drug Policy Commission published these in 2007.[xxv] [see above left]

            These graphs show, as you pointed out in your column, that Scotland (which is included with the UK) has much more serious drug problems on a national level than does Sweden. They also indicate that the Netherlands, which is at least as heavily committed to harm reduction as the UK, has less of a drug problem than Sweden. It is also important to note the position of Canada with respect to the Sweden in the second graph.

    The most interesting question to me is this: Do the Netherlands and Sweden have something in common that makes their drug addiction problems low relative to other European countries and that sets them apart from Scotland whose prevalence of drug addiction is quite high? The “something” cannot be The Dutch and Swedish policies concerning harm reduction, because the Netherlands champions harm reduction whereas Sweden opposes it.[xxvi]

    I believe it will be easy to see what this crucial something is likely to be, as you reflect on the extensive evidence in my book that the root cause of the spread of addiction in the modern world is social fragmentation. Both Sweden and the Netherlands have worked hard to maintain family and community structure and national integrity even as they have moved into modern high technology and high finance in the half-century since World War II. Although both Sweden and the Netherlands are capitalist countries, they have refused to practice the deregulated, take-no-prisoners, free-market capitalism of Milton Freedman, Ronald Reagan, Ayn Rand, Margaret Thatcher, and George Bush. Rather, they keep their countries’ corporations and financial institutions under close control to protect their social fabric. Scotland, as part of the United Kingdom, exercised the same prudent control over its economic system in the early decades after World War II, but then the UK underwent an abrupt change.

    Edward Heath became Conservative Prime Minister of the UK in 1970 in a wave of growing enthusiasm for individualism and free-market capitalism. Margaret Thatcher surfed this wave brilliantly to become head of the Conservative party in 1975 and Prime Minister of England in 1979.[xxvii]

Thatcher’s political skill, iron will-power, and charisma produced a change in British life that was so profound that it is often called the “Thatcher Revolution”. She famously condensed her individualistic philosophy in her 1987 statement that “There is no such thing as society. There are individual men and women, and there are families…”[xxviii]

    Thatcher’s regime led the UK, including Scotland, into massive privatization of public institutions, international free trade, and a national commitment to individualism. Thatcher’s regime turned the UK against labor unions, regulation of finance and industry, social welfare, and public ownership. She changed the tax laws in a way that undermined the previously rock-solid British pension funds for the middle class.[xxix] Her heroes included Ronald Reagan, Milton Friedman, Augusto Pinochet, and our own Conrad Black, whom she proposed for a peerage later in her life.[xxx]  

    When Margaret Thatcher resigned as Prime Minister in 1990, the UK had been transformed from an economically weak welfare state to an individualistic, free-market powerhouse. Although it stagnated as an industrial power during the Thatcher era, the dominance of Britain in the world of finance and banking had been restored, the gap between the rich and the poor had greatly widened, unemployment had increased dramatically, and the social safety net was tattered. The UK had traded-in the economic security of working people and social solidarity built up during World War II and during the welfare state era of the early post-war decades[xxxi] for economic growth. Per capita Gross National Product rose 66% between 1973 and 2001.[xxxii] A new intensely competitive, hypercapitalistic culture – perhaps better called an absence of culture – arose in the UK.

    Thatcher’s policies were continued by her Conservative party successor, John Major, and by her Labour party successor, Tony Blair, following his election as prime minister in 1997. Blair had turned the Labour Party to a philosophy called the “third way”, which is little more than Thatcher’s free-market capitalism gussied up with compassionate rhetoric and some additional welfare spending. Under Blair, the UK became a paradise for super-rich managers and financiers, who found themselves lightly regulated and taxed and in line for political appointments to the House of Lords.[xxxiii] Some so-called ‘non-doms” were hardly taxed at all, further eroding psychosocial integration in the UK by creating a highly visible group of people who made piles of money but perpetually threatened to move away if they had to pay any more tax.[xxxiv] As the financial sector flourished, traditional aspects of the British economy continued to stagnate.[xxxv] Moreover, traditional British society was further depleted as more and more services that used to be performed face-to-face between people and their doctors, lawyers, bankers, and local postmasters have been MacDonaldized and taken over by large corporations.[xxxvi]

    Margaret Thatcher loved Blair’s policies so much that she proclaimed during a Conservative Party leadership contest, “The Conservative Party does not need someone that can beat Mr. Blair, they need someone like Mr. Blair.”[xxxvii] The Thatcher Revolution had become the Thatcher-Blair Revolution and now the Thatcher-Blair-Brown Revolution, as whatever is left of social solidarity is being eroded by the policies of Gordon Brown.[xxxviii]

    Drug addiction had been remarkably low in England up until about 1970. The addiction statistics began to rise significantly only around 1970, accelerated throughout the Thatcher years, and went through the roof in the 21st century. There were 670 registered heroin addicts in the UK in 1968 and over 100,000 by the year 2000, a 150-fold increase.[xxxix] By a different measure, dependent heroin users in England and Scotland increased from 5000 in 1975 to 231,000 in 2007.[xl] Heroin is not the only drug addiction problem that is lurching out of control in the UK. Grotesquely excessive “binge drinking” has become a national scandal among young adults, especially women. The incidence of alcohol-related liver disease has doubled in the last decade.[xli] And, whereas ecstasy and amphetamine appear to be falling out of fashion, “crack” cocaine is coming on strong.

            What caused the enormous increase in addiction during this period? Certainly poverty was not the cause because, although inequality was increasing greatly, the majority of people were getting at least a small cut in the general increase in economic growth, until the credit crisis and recession that began late in 2007 and is exploding in the UK now.[xlii] Moreover, the increase in addiction was by no means restricted to the poor. The typical binge-drinking addict was apparently a well-heeled young lady! Certainly harm reduction cannot be blamed, because during decades of a very low prevalence of addiction prior to about 1970, the UK had the mother of all harm reduction programs, which dated back to the 1920s. Most British doctors were able to prescribe all the heroin and cocaine they thought appropriate to patients whom they believed would benefit from it, including addicted patients. The amount of heroin prescribed in the UK was huge relative to most other countries.[xliii] Prescription of heroin to addicts was known as the “British System” in Canada in the days before real harm reduction was possible here.  

    Could the breakdown of the supportive culture of a post World War II welfare state have caused the huge surge in drug and alcohol addiction that occurred in the Thatcher-Blair era?  It is highly likely. Even people who firmly support the Thatcher-Blair-Brown Revolution agree that it broke down social solidarity in a way that was psychologically damaging. Here is a statement by a strong supporter of the Thatcher Revolution, a financial reporter and business editor for the Financial Times, the Sunday Telegraph, and the BBC:

            These are the conditions in which millions of citizens could ultimately feel dispossessed, alienated, powerless ... The fracturing of our society is no less dangerous simply because it is occurring at a time of prosperity.[xliv]

            Another indication that British society might by badly fractured is the alarming emigration rate of highly educated British people in recent decades. By some measures, more educated professionals emigrate from the UK than from any other country in the world except Mexico![xlv]

Margaret, I imagine you shaking your head in disbelief as you read this. Indeed, my brief summary of the history of the Thatcher-Blair-Brown years is insufficient to prove that hypercapitalism is the cause of the devastating spread of addiction in modern times. Nor is it sufficient to convince a rigorous thinker like yourself that battles for priority among the four pillars cannot solve our drug and addiction problems, but I am hoping it is enough to convince you to review the rest of the evidence in my book. There is plenty.

P.P.S.     This is my final post-script, I promise. I will comment only briefly on your final column published on 19 July and entitled “Legalization in disguise”.[xlvi] You express a fear that harm reduction is the portal to a slippery slope that leads to legalization of drugs and you voice a suspicion that people who support harm reduction are secretly legalizers. Your preferred alternative is arduous abstinence-based treatments based on the Alcoholics Anonymous model.

    The complex debate between the legalizers and the advocates of abstinence has a very long history. The heat of their animosity inflamed the frenzied 19th century prohibition and anti-prohibition movements, but it goes back much farther, at least to the spiritual passions of St. Paul and St. Augustine. It is a deeply personal issue as well as one of great philosophical complexity. This issue cannot be resolved in a short way, either on the emotional or the philosophical level.

    The virtue of the Four-Pillars approach is to call a truce in this endless philosophical war and allow plenty of room both for drugs when they can be used to help suffering people and for abstinence-based treatments when they can be used to help them. This is a truce that has worked quite well in Vancouver. If it is a slippery slope, the slope declines in the direction of humane pragmatism, not legalization.  It is important for you to understand how this truce works and to support it, now that it is under attack by the federal government.

    As for the larger philosophical argument, it is vitally important that it be finally resolved, because it is close to the heart of the addiction issue, and the addiction issue is crucial to the health of modern culture. At the risk of becoming annoyingly repetitive, I would point out that there is an extensive, and I believe definitive, discussion of it in a certain new book on addiction that I have mentioned earlier.

[i] Wente, M. (2008a, 12 July). They’re sick of watching people die. The Globe and Mail, p. 15; Wente, M. (2008b, 15 July). We still await the scientific proof of harm reduction’s success. The Globe and Mail, p. 13; Wente, M. (2008c, 17 July). Europe’s approach to drugs is more enlightened…it’s tougher. The Globe and Mail, p. 17; Wente, M. (2008d, 19 July). Legalization in disguise. The Globe and Mail, p. 17.

[ii] Alexander, B.K. (1990). Peaceful measures: Canada’s way out of the War on Drugs, Toronto: University of Toronto Press, chap. 1. Of course, the most feared drug of the 19th century was alcohol, but morphine and cocaine were sources of alarm and moral panic in the second half of the century as well. Heroin became a matter of concern shortly after its introduction in 1898.

[iii] It would be more accurate to say that there are 5 pillars, the fifth being the spiritual interventions of clergy and religious groups. For simplicity I limit this short letter to the four pillars that are conventionally recognized in the current debate.

[iv] Giffen, Endicott, and Lambert (1991). Panic and indifference: The politics of Canada's drug laws.  Ottawa: Canadian Centre on Substance Abuse, p. 326, 336. Sometimes these doctors had the tacit cooperation of law enforcement agencies, sometimes they were prosecuted, and sometimes their informal harm reduction efforts went unnoticed.

[v]Russwurm, L. (2008a, 13 October) ‘The dope craze that’s terrorizing Vancouver’. The Tyee. Retrieved 1 Oct 2008 at http://thetyee.ca/Views/2008/08/13/DTESHistory/; Murphy, E. (1973). The black candle. Toronto, ON: Coles. (Original work published 1922); Stepler, J. (1949, 29 January). Killer of Men and Morals… The Vancouver Sun; Ex-prisoner No. 104521 (1958, 14 March). My life of terror as a drug addict. The Vancouver Sun Weekend Magazine (vol 9, no 11), p. 2. My thanks to Lani Russwurm for locating these articles in the newspaper files and sharing them with me.

[vi] They were required to have a legal document called a “Writ of Assistance”, but these gave certain police officers the blanket right to search anybody’s house, without having to present evidence of just cause to a judge, as is the case in a normal warrant (See Alexander, 19990, op. cit., chap. 1)

[vii] Alexander, 1990, op. cit., chap. 1.

[viii] Russwurm, L. op. cit.

[ix] Giffen, P.J., Endicott, S., and Lambert, S. op. cit., pp. 356, 360; Russwurm, L. (2008b, 25 August). Harm reduction – 50’s style. Tyee Monday Headlines. (retrieved 15 Sept. 2008 from thetyee_8EBB49B33E56431ED24F19AC7F9F6B928F7D795DAFB9E650@response.thetyee.ca)

[x] Giffen, P.J., Endicott, S., and Lambert, S. op. cit. pp. 356, 360; Russwurm, L. (2008b, op. cit.)

[xi] The Vancouver Sun. (2 December 1952). Doctors approve free dope clinic as an experiment. The Vancouver Sun; The Province (18 December 1952). Health Group Cautious in Drug Plan Approval. The Province; Scott, G.W. (1963, 19 January). All the drugs they want. The Vancouver Sun Weekend Magazine, number 3, p. 3. My thanks to Lani Russwurm for locating these articles in the newspaper files and sharing them with me.

[xii] Holt, S. (1966, 1 March). First prisoners transferred to Matsqui addicts’ jail. The Vancouver Sun; Holt, S. (1966, 2 May). Matsqui officials want addicts to be unhappy. The Vancouver Sun; Moir, N. (1966, 9 July). The big experiment. The Province; My thanks to Lani Russwurm for locating these articles in the newspaper files and sharing them with me. 

[xiii] Ledain, G. (1973). Final report of the commission of inquiry into the non-medical use of drugs in Canada: Appendix I: Treatment of opiate dependents in federal penitentiaries in Canada, pp. 1005-1009. Ottawa: Information Canada.  

[xiv] The Vancouver Sun. (1969, 14 June). Half-empty Drug Centre ‘Can’t Rehabilitate Addicts”. The Vancouver Sun. My thanks to Lani Russwurm for locating this article in the newspaper files and sharing it with me.

[xv] Alexander, B.K. & Dibb, G.S. (1975). Opiate addicts and their parents.  Family Process, 14, 499-514.

[xvi] Wente, M. (2008a, op. cit.)

[xvii] Kendall, P. (2004, September). Public health (sensible) responses to opioid and other injection drug use. Paper presented at the Moving Forward: Improving Treatment for Heroin Addiction meeting, Vancouver, BC, Canada; Stimson, G.V. (2007). “Harm reduction – coming of age”: A local movement with global impact. International Journal of Drug Policy, 18, 67-69.

[xviii] McKeganey, N. (2006). The lure and the loss of harm reduction in U.K. drug policy and practice. Addiction Research and Therapy, 14, 557-588.

[xix] The most obvious reason is that as drug addiction increases, all kind of addictions that do not involve prohibited substances, e.g., addictions to money, sex, video games, shopping, exercise, etc., increase in tandem.

[xx]  I have summarized the evidence for this sweeping conclusion in two books (Alexander, 1990, op.cit., chap. 2 and Alexander, B.K., 2008, The globalisation of addiction: A study in poverty of the spirit. Oxford University Press). Reuter, P., & Stevens, A. (2007, op. cit.) have provided a recent review of evidence for the same conclusion in the UK. This endnote critically analyses some recent studies that are sometimes taken to show that addiction treatment can have a major impact on the prevalence of addiction.

   Treatment for alcoholism has been studied the most intensively. When the decades of results are examined carefully, the best-designed studies generally have negative outcomes, although there are many positive studies as well. Moreover, outcome studies frequently have inconsistent or uninterpretable results. Treatments that cannot be demonstrated to have more than marginal success rates include Alcoholics Anonymous type programs (Miller, W.R., & Hester, R.K.,1995, Treatment for alcohol problems: Toward an informed eclecticism. In R.K. Hester & W.R. Miller, Eds., Handbook of alcoholism treatment approaches: Effective alternatives, 2nd ed., pp. 1-11, Needham Heights, MA: Allyn & Bacon).

   Despite loud claims to the contrary, the enormous American study of alcohol treatment, Project Match, did not provide any real evidence of the efficacy of treatment for alcoholism, as its designers confirm in the context of critical discussion (see Glaser, F.B., Heather, N., Drummond, D.C., Finney, J.W., Lindström, L., Sutton, S., Soyka, M., Stockwell, T., Hall, W., Godfrey, C., San, L., Gordis, E., Fuller, R., Negrete, J.C., Orford, J., Babor, T.F., Miller, W.R., DiClemente, C., & Longabaugh, R. (1999). Comments on Project MATCH: Matching alcohol treatments to client heterogeneity. Addiction, 94, 31-69; Schaler, J.A. (2000). Addiction is a choice. Chicago, IL: Open Court., chap. 9). Critical examination of newer data, including that collected as part of the National Epidemiologic Survey on Alcohol and Related Conditions (Dawson, D.A., Grant, B.F., Stinson, F.S., Chou, P.S., Huang, B., & Ruan, J. (2005). Recovery from DSM-IV alcohol dependence: United States 2001 - 2002. Addiction, 100, 281-292) adds further evidence that treatment cannot solve the problem of addiction.

   Older, large-scale studies of treatment for drug addiction are similarly discouraging (Brecher, E.M., 1972, Licit and illicit drugs. Boston, MA: Little, Brown., chap. 10; revised). New York: Longmans, Green; Ledain, G. (1973). Final report of the Commission of Inquiry into the non-medical use of drugs. Ottawa, ON: Information Canada, pp. 1005-1009; Musto, D.F. (1987). The American disease: Origins of narcotic control (Expanded ed.). New York: Oxford University Press, pp. 85-86; Alexander, 1990 op. cit., chap. 2) although loud claims that “treatment works” are frequently heard.

    The greatest problem with current claims of successful treatment is that the quantitative effects of treatment on a very simple target measure, like number of days without drinking or average number of drinks per day, are usually used to demonstrate success. Such measures do show that well-delivered treatment can have a valuable effect in suppressing drinking or drug use for a time, but they show nothing about the effects of treatment on addiction itself. People who reduce their alcohol or drug consumption are often just as addicted as before, sometimes having switched to a legal or less physically damaging type of addiction. Alcoholics Anonymous and other twelve-step organizations argue, rightly, that even completely eliminating alcohol consumption does not mean that a person is no longer addicted. Many members of AA continue to be alcoholics for the rest of their lives, although they no longer drink at all! The best-known example of ineffectiveness of “successful” treatment might be the founder of Alcoholics Anonymous himself, Bill W. His life and eventual death from emphysema are discussed in detail by Cheever, S. (2004, My name is Bill: Bill Wilson – His life and the creation of Alcoholics Anonymous. New York: Simon and Schuster).

    Leading champions of treatment now argue that addiction is a chronic disease comparable to diabetes, hypertension, and asthma (Leshner, A.I.,1997, 3 October. Addiction is a brain disease, and it matters. Science, 278(5335), 45-47; McLellan, A.T., Lewis, D.C., O’Brien, C.P., & Kleber, H.D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284, 1689-1695). From this point of view, treatment for addiction should not be expect to produce a cure, but should be continued indefinitely, as for other chronic diseases. This position constitutes a reasonable argument for publicly supported addiction treatment. However, in the context of your position on how to handle drug addiction in Vancouver’s Downtown Eastside, it serves as confirmation – from the most prominent authorities – that addiction therapy cannot come close to controlling the problem.

    The newest hope of a quantum jump in the effectiveness of addiction treatment comes from the movement towards “evidence based treatment”. Whereas this administrative innovation may well bring improvements, it cannot change the situation radically. After all, evidence has been collected for a very long time, and most clinicians eagerly use it to improve practice where they can. Imposing “evidence based practice” and “best practices” on clinicians who have other ideas is bound to have mixed results. Prominent advocates of evidence based treatment are properly careful not to raise expectations too much, harkening back to the argument that addiction is like an incurable chronic disease: “In general, our treatment interventions show small to moderate effects and repeated episodes of care are the norm. Substance abuse treatment yields outcomes at least comparable with those for other chronic conditions such as diabetes, asthma, and hypertension… and there are no magic bullets to cure addiction in one acute care episode.” (Miller, W.R., Zweben, J., & Johnson, W.R. (2005). Evidence based treatment: Why, what, where, when, and how? Journal of Substance Abuse Treatment, 29, 267-276.).

   In fact, the global harm reduction movement has provided the most heartening good-news story in the field of addictions for the last two decades (Stimson, 2007, op. cit.). However, unlike treatment, prevention, and law enforcement, harm reduction is not designed to reduce the incidence of addiction. Drug use of all sorts, including addiction, has increased substantially in the UK during a period of high public expenditures on harm reduction measures. Apart from HIV-AIDS, which has successfully been kept under control in the UK during this period, the harms associated with drug use have not been reduced in any dramatic way (McKeganey, 2006, op. cit.). This is not to diminish the fact that harm reduction has provided life-saving benefits and priceless encouragement to countless injection drug addicts and prostitutes, but only to show that harm reduction, like the other three pillars, cannot be expected to co