Although Canada's Drug Strategy does indeed start as quoted by Colin Mangham, it explicitly states its long-term goal to be “to reduce the harm associated with alcohol and other drugs to individuals, families and communities.”1
In the CMAJ special issue, Eric Single and colleagues' objective quantification of mortality and morbidity does place illicit drug use in third place after alcohol and tobacco, which are both legal psychoactive substances.2 But their report of 805 deaths and 6940 hospitalizations in 1995 can hardly be said to “downplay the seriousness of illicit drug use.” The role that injection drug use now plays in the transmission of HIV and hepatitis C virus in Canada is further cause for concern. Benedikt Fischer and colleagues and Catherine Hankins argue that our traditional approach to illicit substance use is in part responsible for this tragic metric.3,4
Mangham posits a narrow definition of harm reduction — essentially use-tolerant interventions — yet also raises some of the concerns addressed by Yuet Cheung, who notes that “during its evolution [harm reduction] has been … criticized for sending the wrong message to drug abusers and the public and disparaged as promoting a defeatist position.”5
Eric Single has written about the definitional problems and has called for an empirical definition of harm reduction.6 In this conceptualization one cannot determine a priori whether a policy or program is harm reducing until one examines the evidence of its impact. Any program, be it demand or supply reduction, use tolerance or abstinence, that measurably reduced harm would be deemed harm reduction.
With its present drug strategy Canada spends heavily on law enforcement (more than $400 million annually7); these monies comprise the bulk of dedicated resources, yet there has been virtually no research on its effectiveness in reducing drug use or drug-related harm. Accepting and operationalizing an empirical approach would have advantages. As a nation we could develop and invest in policies and programs that were effective in reducing the prevalence of substance use and misuse, that reduced harm resulting from substance use and misuse and that provided users with effective options for managing or quitting substance use.
Signature
Perry R.W. Kendall
Provincial Health Officer Victoria, BC
References
- 1.Interdepartmental Working Group on Substance Abuse. Canada's drug strategy. Ottawa: Public Works and Government Services Canada; 1998. Available: www.hc-sc.gc.ca/hppb/alcohol-otherdrugs/publications.htm (accessed 24 Nov 2000).
- 2.Single E, Rehm J, Tobson L, Truong MV. The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. CMAJ 2000;162(12):1669-75. [PMC free article] [PubMed]
- 3.Fischer B, Rehm J, Blitz-Miller T. Injection drug use and preventive measures: a comparison of Canadian and Western European jurisdictions over time. CMAJ 2000;162(12):1709-13. [PMC free article] [PubMed]
- 4.Hankins C. Substance use: time for drug law reform [commentary]. CMAJ 2000;162(12):1693-4. [PMC free article] [PubMed]
- 5.Cheung YW. Substance abuse and developments in harm reduction [commentary]. CMAJ 2000;162(12):1697-1700. [PMC free article] [PubMed]
- 6.Single E. A harm reduction framework for British Columbia: a discussion paper prepared for the British Columbia Federal/Provincial Harm Reduction Working Group. Victoria: Office of the Provincial Health Officer, BC Ministry of Health and Ministry Responsible for Seniors; 1999.
- 7.Single E, Robson L, Xie X, Rehm J. The economic costs of alcohol, tobacco and illicit drugs in Canada. Addiction 1998;93(7):991-1006. [DOI] [PubMed]