Harm Reduction in Practice

Walter Cavalieri, MSc, MSW

In Canada, we have in operation a number of Harm Reduction services. Needle Exchange is usually one that springs to mind first. Despite the controversy which it has generated - and continues to generate - Needle Exchange, when run in a client-centred way, has proven its worth. That the HIV rate is still below 10% in injection drug users in Toronto, as far as we have been able to determine, can be credited to the Works Program of Public Health and the satellite needle exchanges in the City of Toronto, which made new needles available across the city. On the other hand, Needle Exchange played a major role in the extremely high HIV and hepatitis C infection rates in Vancouver. It all depends on how it is done.

Needle exchange programs in Canada may be framed on a spectrum on which there are three critical loci, which I will refer to as paradigms. In Canada, you can find examples of all three of these paradigms in operation.

The first is conservative. In this paradigm, harm reduction is seen as a temporary strategy, and the ultimate goal is conformity (e.g., abstention). The values which inform this approach are narcophobic, support pejorative labelling and language, and encourage shaming and blaming. The conservative approach accepts the myths about drugs and drug users without question, and reluctantly provides service. This approach is an approach which is rampant in the delivery of medical and social work services. "Undesirable" clients are "othered", diminishing and demeaning them

The approach here is to hold your nose and give them a "clean" hypodermic for a "dirty" one, and perhaps a lecture, if any words at all are exchanged.

The interplay between the worker and the client in this paradigm strongly resembles that prescribed by Mrs. Beeton in her "Book of Household Management" for dealing with an uppity chambermaid: Mrs. B. says you say nothing . . . but "sear her with a withering glance". Observing needle exchange programs run within the conservative paradigm, you witness many a withering glance levelled at the pitiable supplicant who's come begging for a new fit or two.

Within this paradigm, there is extensive denial of access to services and withholding services and information. Doors are not there, or are never really open to the "those people". . . to "others", to people who are "not like us".

In many ways, this has been the Vancouver approach, though the manager of the Exchange would deny it. Vancouver is the largest, busiest needle exchange in the world, but it has been an essentially centralized site which has offered a strict one?for?one exchange, limited, until fairly recently, to two needles per person. This, at the height of the largest cocaine "epidemic" in Canada, when their typical user needs about 35 needles per day! And god forbid the workers should develop any sort of a relationship with the drug user. I believe this approach to Harm Reduction has been the major factor in determining that people in Vancouver who inject drugs have one of the highest HIV rates in the industrialized world.

The second paradigm is liberal. Its aim is to support informed choice and provide a safety net. The worker here may or may not hold his or her nose, but will give the user new rigs and will probably require them to give them used rigs in return; the user will most probably be provided with a "teaching", from a position of social or moral authority.

Most needle exchanges in Canada have been operating on this premise. While this "works", there still are lots of problems and barriers, mostly based on status and judgment - and the limited knowledge of what the person needs. The main danger, however, is that liberalism is fickle and tends to adapt to the dominant ideology in order to survive. We are seeing less than subtle changes in the way exchange programs here in Toronto provide services, as the politics of the local and provincial governments have shifted to neo-conservatism.

The final paradigm is structural.

This approach embraces empowerment, advocacy and emancipation. It is user?driven. Needle exchange becomes needle distribution, and services are typically offered by drug users, usually in concert with professional or paraprofessional staff.

Here, the person accessing service is respected as the expert and, as such, capable of making responsible choices about her or his life, including whether or not to use drugs. Harm from drug use is recognized as having more to do with poverty, oppression or disinformation than with the drugs themselves. The actions taken within this paradigm not only support the individual but challenge social and structural inequalities in order to assist disempowered individuals and groups in gaining access to their legitimate power.

I clearly believe this to be the best approach, true harm reduction, with knowledgeable drug users in leadership roles. It is an approach that affirms that what we do is about life, not death, and it is delivered with love and respect, not disdain, judgment or apology. It is also an approach which is at risk, because it is subversive and is often grounded only in the mission of an agency not in its practice. There are excellent models of this approach in Holland and Denmark, among other places. VANDU in Vancouver - the drug users' union - is working to secure positive change in this direction.

At the Health Centre where I used to work, our program attempted to operate structurally, but it did so within a liberal establishment in a neo?conservative society. It required guile and it generated legitimate insecurity, for us as staff. However, it allowed us, if only for a moment, to do things right . . . until it was disbanded.

The other major harm reduction program which occurs across Canada is methadone maintenance - the substitution of a long-lasting opiate - methadone - for one which satisfies the body's need for only a few hours - namely heroin. There has been a ten-fold increase in the availability of methadone in Ontario over the past six or seven years. And now BC is rapidly moving toward increasing methadone availability. Drug user activists continue to play a very important role in bringing this about.

I have had no experience inside methadone programs, save that I helped facilitate a group of active drug users in designing a model methadone program. This program was granted funds and opened within the urban community health centre where I worked. As I mentioned before, the politics of this centre were "liberal" and power was quickly removed from the founders and their heirs and restored to its proper place, in the hands of administrators. The program operated autonomously, and its clients had limited access to medical services at the health centre. As well, clients of the health centre's needle exchange program and drug user group program had no direct access to it.

Recently the methadone clinic was severed from the health centre. From what I see here in Ontario, most methadone maintenance programs - even those which claim to embrace harm reduction - can only stake that claim on the fact that they prescribe methadone. That and nothing else. Abstinence from any non-prescribed drugs is usually grounds for dismissal.

Just because we have needle exchange and methadone treatment, we tend to think that we have it all. Well we don't. Even within existing needle exchange programs, improvements need to be made. Many of the exchanges supply only needles and alcohol wipes, and nothing more - not even educational materials. Some are incapable of making even the most rudimentary referrals into the healthcare system. Some don't even care.

On the most basic level, exchanges must provide their clients with a supply of any personal injecting materials which might become contaminated with blood. That includes filters, cookers, water, and even tourniquets, as well as needles. With the increase in the injection of crack and powder cocaine, we should officially shift from exchange of needles to the distribution of needles, in whatever quantity the user needs, rather than leave it to the whim of the individual exchange program or the contrivance of the individual worker. As well, we should distribute packets of ascorbic acid, to dissolve the crack - it is less damaging than lemon juice or vinegar - and work to encouraging the people who use our exchanges to pursue safer ways to inject crack (e.g., heating it) and safer ways to use crack - which might be to smoke it rather than to inject it. Some exchanges in Toronto are providing pipe stems for crack smokers, with this in mind. All should. Some activists are providing "state-of-the-art" crack pipes. Another excellent intervention.

Of utmost importance are the quality, attitudes, values and credibility of the workers themselves.

One major harm reduction initiative which is happening all across North America is rave projects. They are doing extraordinary work. Without disparaging the work being done in cities across Canada by local ravers themselves, I commend you to the site of one such project from the United States - RaveSafe - where up-do-date and unbiassed pharmacological information about various raver drugs is made available. The public is way ahead of the politicians and police in dealing with Raves. Recently - as the result of coroner's inquest into the death of a young man here in Toronto - recommendations were made by a jury of ordinary citizens which totally embraced harm reduction as the favoured approach to dealing with this international youth phenomenon.

Unfortunately, it appears doubtful that senior police or political officials will show similar wisdom.

Beyond needle exchange, traditional methadone maintenance and peer-driven rave projects, we do have a few other harm reduction programs, but they are scattered and not coordinated.

We have in Toronto a street-based, "low-threshold" methadone program, run by Public Health, for about 30 people whom most other methadone programs would reject - and who would themselves reject most other programs. It is small and client-centred, managed by an ex-heroin user who is on methadone maintenance himself. It has few hoops to jump through. Alas, its funding is precarious and it appears that a larger program is about to swallow it up, probably to its detriment.

The "wet" hostel at the Seaton House Annex in Toronto has been quite successful at providing housing to some of the most difficult people on the street. There is little hope of getting these folks off their wine, but at The Annex, staff have been able to help them change their intoxicant of choice - cheap sherry instead of Chinese cooking wine - which is less harmful to their health - and to keep them from risking their lives by sleeping on the street in midwinter. The staff are quite imaginative and daring too. I understand that at one time they taught residents how to make their own wine. It gives the residents something to do, and it is less expensive than cheap sherry. Less liver damage; hopefully some money for food. We need more programs like this - and we need them to be as welcoming and supportive of people whose drugs of choice - though no less "hard" than alcohol - are illicit.

We have in Toronto - for the first time in Canada - a drug court, which is attempting to divert people, if they choose, from jail and into treatment and assisting them in making it through the treatment program. It recently celebrated a year of success, and it is seen as a model for other cities to emulate.

People with AIDS who can not or will not give up their use of drugs need safe, supportive housing. Vancouver has the Portland Hotel and other residences, and Montreal has had, for a number of years, Chez ma cousine Evelyn, a hospice for HIV+ drug users.

We are developing in Canada the criteria for clinical trials of heroin prescription. It has been, and continues to be, a painfully slow process which has been underway for several years already. This must be moved forward quickly - especially in light of the enormous number of people who continue to die from overdose - especially but not exclusively in Vancouver.

But it just about ends there . . .

We need to look at prescribing coca leaves or coca paste for people who are unable to control their desire for cocaine. People have chewed the leaf for centuries without deleterious effects. Possibly even cocaine itself.

We need safe shooting rooms - well-lighted and hygienic places where users can come to shoot up, where they can get everything they need except the drugs, where they can get advice, information and support. Safe shooting rooms save lives. Wouldn't it be great if physicians and nurses took the risk and got together to start, as a piece of public health advocacy. Though they are run quite successfully across Europe, none exist in North America. Sites in Australia were started by activists. They were run, briefly, by Catholic nuns . . . when the Pope put a stop to this, the University of Brisbane took over - then changed its mind. More recently they were operated by another Christian church group. Public health is now involved in operating them. Despite the chaos, the safer shooting rooms are still running.

We need methadone detox, not just methadone maintenance. We need it on demand.

We also need user-friendly detox centres; and assistance and support for home detox.

We need more methadone treatment programs - which do more than dispense, but genuinely help people get a life. A full life. Many programs are quite deviant. They simply replicate the culture and atmosphere of the street . . . save that the dealer is a doctor.

As well, the humiliation of having to pee in a bottle in front of a worker must be recognised for what it is - sexual abuse - and stopped immediately.

We could consider adding a small quantity of an amphetamine to the methadone dose, to slake the propensity to supplement methadone with cocaine, which has become increasingly popular and problematic. The amphetamine is to give the methadone a bit of a kick, which people habituated to heroin sorely miss, and which impels them to use crack or cocaine powder.

We could reconsider the type of methadone we are using. A different type of methadone is being distributed by clinics in Europe and Australia. I am told by people who are using it that it is more effective and that it tastes better. We could make methadone available in tablet form or as an injectable drug, giving the client a choice. We could dispense buprenorphine, which many prefer to methadone..

We desperately need comprehensive, co-ordinated community-based harm reduction strategies. Much like Liverpool, Amsterdam and Rotterdam in Holland, and especially Frankfurt. One has been developed for Vancouver. Unfortunately, so far it is still sitting on a shelf.

We need to find ways to prescribe dosages of pain killers to people who use drugs who legitimately need them, in sufficient strength that they work.

We need your help in working to remove the stigma from drug use and drug users - and the fear that many people have of drugs and the people who use them - so that existing health care services, imperfect as they may be at times, are accessible, in opening doors to people who use drugs and providing them with medical services without judging them as losers because they use drugs.

We also need nurses to go out on the street - and to drag doctors and medical students with them - to deliver services where people live, so that they will feel more welcome in your offices and clinics. We need medical professionals you out there too, to teach people how to treat their minor illnesses, such as abscesses, before they become major- because they won't go to hospitals if they can help it. Drug users are not inclined to go to hospitals or health centres because they are unwilling to be abused.

We need nurses and doctors to train people who use drugs how to shoot up properly, those who don't know. And also how to administer narcan to friends in danger of dying from drug overdose, and to advocate that street drug users have a supply of it available.

The list is endless. Endless, because services for people who use illicit drugs are less than basic.

We might look to Europe and Australia for ideas, for leadership - that would be a very good start - but we must also push our own boundaries, be daring and innovative and develop and embrace methodologies and approaches which are humane, respectful and effective. So very much of what we are called upon to do has none of these qualities.

Working with people who use drugs is sometimes exhausting and daunting ... it is also unusually rewarding. It is, in the classic sense, a calling. I challenge you to hear that call - and to answer to it.