The harm reduction model of drug addiction treatment

Mark Tyndall speaks at TEDMED 2017

I remember the first time that
I saw people injecting drugs.

I had just arrived in Vancouver
to lead a research project

in HIV prevention in the
infamous Downtown East Side.

It was in the lobby
of the Portland Hotel,

a supportive housing
project that gave rooms

to the most marginalized
people in the city,

the so-called
difficult to house.

I'll never forget the
young woman standing

on the stairs repeatedly
jabbing herself with a needle

and screaming I can't find a vein,

as blood splattered on the wall.

In response to the desperate
state of affairs, the drug use,

the poverty, the violence,
the soaring rates of HIV,

Vancouver declared a public
health emergency in 1997.

This opened the door to
expanding harm reduction

services, distributing more needles,

increasing access
to methadone, and, finally,

opening a supervised injection site.

Things that make injecting
drugs less hazardous.

But today, 20 years
later, harm reduction

is still viewed as some
sort of radical concept.

In some places it's
still illegal to carry

a clean needle.

Drug users are far
more likely to be

arrested than to be
offered methadone therapy.

Recent proposals for
supervised injection sites

in cities like Seattle,
Baltimore, and New York

have been met with
stiff opposition.

Opposition that goes
against everything

we know about addiction.

Why is that?

Why are we still
stuck on the idea

that the only option is to stop
using that any drug use will

not be tolerated?

Why do we ignore
countless personal stories

and overwhelming
scientific evidence

that harm reduction works?

Critics say that harm
reduction doesn't stop people

from using illegal drugs.

Well, actually, that
is the whole point.

After every criminal
and societal sanction

that we can come up with
people still use drugs,

and far too many die.

Critics also say that we
are giving up on people

by not focusing our attention
on treatment and recovery.

In fact, it is
just the opposite.

We are not giving up on people.

We know that if recovery
is ever going to happen

we must keep people alive.

Offering someone a clean needle
or a safe place to inject

is the first step to
treatment and recovery.

Critics also claim
that harm reduction

gives the wrong message to
our children about drug users.

The last time I looked, these
drug users are our children.

The message of harm reduction is
that well, drugs can hurt you.

We still must reach out to
people who are addicted.

A needle exchange is not an
advertisement for drug use.

Neither is a methadone clinic
or a supervised injection site.

What you see there are
people sick and hurting,

hardly an endorsement
for drug use.

Let's take supervised
injection sites, for example.

Probably the most misunderstood
health intervention ever.

All we are saying is
that allowing people

to inject in a clean, dry space
with fresh needles surrounded

by people who care
is a lot better

than injecting in a dingy alley
sharing contaminated needles

and hiding out from police.

It's better for everybody.

The first supervised
injection site in Vancouver

was at 327 Carol
Street, a narrow room

with a concrete floor,
a few chairs and a box

of clean needles.

The police would
often lock it down,

but somehow it always
mysteriously reopened, often,

with the aid of a crowbar.

I would go down
there some evenings

to provide medical
care for people

who were injecting drugs.

I was always struck with a
commitment and compassion

of the people who operated
and used this site.

No judgment, no
hassles, no fear,

lots of profound conversation.

I learned that despite
unimaginable trauma,

physical pain, and mental
illness that everyone

there thought that
things would get better.

Most were convinced
that some day they'd

stop using drugs altogether.

That room was the forerunner
to North America's

first government sanctioned
supervised injection

site called INSITE.

It opened in September of
2003 as a three year research

project.

The conservative government
was intent on closing it down

at the end of the study.

After eight years, the
battle to close INSITE

went all the way up to
Canada's Supreme Court.

It pitted the
government of Canada

against two people with a
long history of drug use

who knew the benefits of
INSITE firsthand, Dean

Wilson and Shelley Tomic.

The court ruled in
favor of keeping

INSITE open by nine to zero.

The justices were
scathing in their response

to the government's case.

And I quote, "The effect of
denying the services of INSITE

to the population that it
serves and the correlate have

increased in their risk
of death and disease

to injection drug
users is grossly

disproportionate to
any benefit that Canada

might derive from
presenting a uniform stance

on the possession of narcotics."

This was a hopeful moment
for harm reduction.

Yet, despite this strong
message from the Supreme Court,

it was, until very
recently, impossible

to open up any new
sites in Canada.

There was one
interesting thing that

happened in December
of 2016 when

due to the overdose crisis, the
government of British Columbia

allowed the opening of
overdose prevention sites.

Essentially ignoring the
federal approval process,

community groups
opened up about 22

of these de facto illegal
supervised injection

sites across the province.

Virtually overnight,
thousands of people

could use drugs
under supervision.

Hundreds of overdoses
were reversed

by naloxone and nobody died.

In fact, this is what's happened
at INSITE over the last 14

years.

75,000 different individuals
have injected illegal drugs,

more than 3 and
1/2 million times,

and not one person has died.

Nobody has ever died at INSITE.

So there you have it.

We have scientific
evidence and successes

from needle exchanges, methadone
and supervised injection sites.

These are commonsense,
compassionate approaches

to drug use that improve health,
bring connection, and greatly

reduce suffering and death.

So why haven't harm reduction
programs taking off?

Why do we still think that drug
use is law enforcement issue?

Our disdain for drugs and
drug users goes very deep.

We are bombarded with
images and media stories

about the horrible
impacts of drugs.

We have stigmatized
entire communities.

We applaud military inspired
operations that bring down

drug dealers, and we appear
unfazed by building more jails

to incarcerate people whose
only crime is using drugs.

Virtually millions of
people are caught up

in a hopeless cycle of
incarceration, violence,

and poverty that has been
created by our drug laws

and not the drugs themselves.

How do I explain to people
that drug users deserve

care and support and the
freedom to live their lives when

all we see are images of guns
and handcuffs and jail cells?

Let's be clear,
criminalization is just a way

to institutionalize stigma.

Making drugs
illegal does nothing

to stop people from using them.

Our paralysis to see
things differently

is also based on an entirely
false narrative about drug use.

We have been led to
believe that drug users are

irresponsible people who just
want to get high, and then

through their own
personal failings

spiral down into a life
of crime and poverty,

losing their jobs their families
and, ultimately, their lives.

In reality, most drug
users have a story,

whether it's childhood trauma,
sexual abuse, mental illness,

or a personal tragedy.

The drugs are used
to numb the pain.

We must understand
that as we approach

people with so much trauma.

At its core our drug policies
are really a social justice issue.

While the media may focus on
overdose deaths like Prince

and Michael Jackson, the
majority of the suffering

happens to people who are
living on the margins, the poor

and the dispossessed.

They don't vote,
they are often alone.

They are society's
disposable people.

Even within health care, drug
use is highly stigmatized.

People using drugs avoid
the health care system.

They know that once
engaged in clinical care

or admitted to hospital,
they will be treated poorly,

and their supply line, be it
heroin, cocaine or crystal

meth, will be interrupted.

On top of that,
they will be asked

a barrage of questions that only
serve to expose their losses

and shame.

What drugs do you use?

How long have you been
living on the street?

Where are your children?

When were you last in jail?

Essentially, why the hell
don't you stop using drugs?

In fact, our entire medical
approach to drug use

is upside down.

For some reason we have
decided that abstinence

is the best way to treat this.

If you're lucky enough, you
may get into a detox program.

If you live in a community
with suboxone or methadone,

you may get on a
substitution program.

Hardly ever would we offer
people what they desperately

need to survive, a safe
prescription for opioids.

Starting with abstinence is
like asking a new diabetic

to quit sugar or
a severe asthmatic

to start running marathons
or a depressed person

to just be happy.

For any other
medical condition, we

would never start with
the most extreme option.

What makes us
think that strategy

would work for something
as complex as addiction?

Well, unintentional
overdoses are not new.

The scale of the current
crisis is unprecedented.

The Center for Disease Control
estimated that 64,000 Americans

died of a drug overdose in
2016, far exceeding car crashes

or homicides.

Drug related mortality
is now the leading cause

of death among men and
women between 20 and 50

years old in North America.

Think about that.

How did we get to this
point, and why now?

There is a kind of perfect
storm around opioids.

Drugs like OxyContin,
Percocet, and Dilaudid

have been liberally
distributed for decades

for all kinds of pain.

It is estimated that two
million Americans are daily

opioid users, and
over 60 million people

received at least one
prescription for opioids

last year.

This massive dump of
prescription drugs

into communities has
provided a steady source

for people wanting
to self-medicate.

In response to this
prescription epidemic,

people have been cut
off, and this has greatly

reduced the street supply.

The unintended but
predictable consequences

is an overdose epidemic.

Many people who were reliant on
a steady supply of prescription

drugs turned to heroin and,
now, the illegal drug market

has tragically switched
to synthetic drugs,

mainly fentanyl.

These new drugs are cheap,
potent, and extremely hard to dose.

People are literally
being poisoned.

Can you imagine if
this was any other kind

of poisoning epidemic?

What if thousands
of people started

dying from poisoned meat
or baby formula or coffee?

We would be treating
this as a true emergency.

We would immediately be
supplying safer alternatives.

There would be changes
in legislation,

and we would be supporting the
victims and their families.

But for the drug
overdose epidemic

we have done none of that.

We continue to demonize the
drugs and the people who

use them, and blindly
pour even more resources

into law enforcement.

So where should we go from here?

First, we should
fully embrace, fund,

and scale up harm reduction
programs across North America.

I know that in places
like Vancouver,

harm reduction has been a
lifeline to care and treatment.

I know that the number
of overdose deaths

would be far higher
without harm reduction,

and I personally know hundreds
of people who are alive today

because of harm reduction.

But harm reduction
is just the start.

If we truly want to make an
impact on this drug crisis,

we need to have a serious
conversation about prohibition

and criminal punishment.

We need to recognize that drug
use is, first and foremost,

a public health issue and turn
to comprehensive social and

health solutions.

We already have a model
for how this can work.

In 2001 Portugal was
having its own drug crisis.

Lots of people using
drugs, high crime rates,

and an overdose epidemic.

They defied global conventions
and decriminalized all drug

possession.

Money that was spent
on drug enforcement

was redirected to health
and rehabilitation programs.

The results are in.

Overall drug use is
down dramatically.

Overdoses are uncommon.

Many more people
are in treatment,

and people have been
given their lives back.

We have come so
far down the road

of prohibition, punishment, and
prejudice that we have become

indifferent to the
suffering that we

have inflicted on the
most vulnerable people

in our society.

This year even more
people will get caught up

in the illegal drug trade.

Thousands of children will learn
that their mother or father

has been sent to
jail for using drugs.

And far too many
parents will be notified

that their son or daughter
has died of a drug overdose.

It doesn't have to be this way.

Thank you.