An interesting commentary this week from Canada – The Canadian Centre on Substance Abuse actually – on the meaning of “Harm Reduction” as a strategy for dealing with drug use
Harm Reduction: What’s in a name?
It’s true that prohibition campaigners have long been suspicious of harm reduction as being what they claim is a “back door” argument for legislation and this discussion paper tries to counter this argument, it could be argued to paper over the cracks.
At the root of this is the fact that harm reduction seeks to reduce the potential for harm amongst drug users. In assuming people will use drugs of course, the golden eyed dream of prohibitionists is undermined as policy can no longer have a pure abstentionist agenda. Of course, they are right, true harm reduction does demand legalisation and it is an argument against prohibition. The Canadian Centre on Substance Abuse however, try to argue the opposite.
The paper starts by offering two definitions of Harm Reduction, a lose one and a more specific one:
In its most general sense, “harm reduction” refers to any program, policy or intervention that seeks to reduce or minimize the adverse health and social consequences associated with drug use.
This seems a fine definition, but the report argues that:
This broad perspective would include virtually any drug policy, program or intervention since at some level, the objective of all such measures—including enforcement and abstinence-oriented programs—is to reduce the harmful consequences of drug use in some manner.
And with that this paper avoids discussion of the core issues because of course, that statement is in theory true: If prohibition could work, it would mean no-one used drugs and thus there was no harm from them. Of course, that would be the ultimate in harm reduction if it succeeded. It isn’t real world though.
Prohibition campaigners make two huge leaps of logic which The Canadian Centre on Substance Abuse doesn’t challenge. They claim prohibition leads to the lowest level of drug use and that the lowest level of drug use automatically leads to the least harm.
The essential debate to be had is can enforcement and abstinence-oriented programs actually produce the desired result in practice and – perhaps importantly – prove that it’s doing so? Is the assumption that the lowest level of drug use automatically leads to the lowest levels of harm in fact true? The experience of the past 30-odd years of enforcement lead prohibition flies in the face of these claims. Indeed prohibition has created a vast underground economy and illegal drug use is still very much with us and there are many dangers associated with illegal drug use which are created uniquely by the prohibition policy.
The way prohibition works is to prevent any supply side controls and worse, to disrupt the supply side so as to create highly variable doses and unknown levels of purity. So it may be that the level of use is lower under prohibitionist regime than it would be under some other system, but the use that happens is deliberately made more dangerous as a result.
There’s is yet another twist of the screw though, in that it can’t even be proven that the levels of use under prohibition are the lowest it’s possible to achieve, this is an assumption, no more. Because of the way prohibition works it isn’t possible to study the user group in a statistically reliable way. No-one will admit to illegal behaviour and encouraging people to do is considered to be undermining the effectiveness of the policy. So we have to rely on uncertain sampling methods and yet more assumptions to gauge what’s really going on. We are expected to accept without question the claim that prohibition produces the lowest levels of drug use without question.
We are also expected to accept the simplistic assumption that the lowest levels of use automatically mean the lowest level of harm. Drugs are bad – m’kay? Is that always true? Of course it isn’t. Consider an everyday example: 1000 adults drinking beer in a pub or 10 kids drinking vodka straight from the bottle, which causes the most harm? The method and social setting of drug use is at least if not more important than the simple level of use.
So in truth enforcement lead abstentionist policies are not forms of harm reduction and never can be. They are built on an assumption which hasn’t been tested and cannot be measured and other assumptions which are simply untrue.
The true value of real harm reduction is that it is based on policies which can be measured, not assumptions based on ideology. Harm reduction is evidence based, not belief based.
The Canadian paper avoids this discussion altogether and proposes a narrower definition of harm reduction:
A narrower definition of “harm reduction” focuses on those policies, programs and interventions that seek to reduce or minimize the adverse health and social consequences of drug use without requiring an individual to discontinue drug use.
By doing that of course it accepts the myths of prohibition without question and ditches the most important harm reduction tool – control of the supply side. This is not mentioned in the paper as even being an option, never mind an essential part of any real harm reduction strategy.
By way of illustration for a moment, let us consider what the Canadian Centre on Substance Abuse idea of “harm reduction” would have meant for alcohol during the prohibition years of the 1930’s. Would it indeed have meant anything worth having? There would have been no controls over manufacture of spirits, so drinkers would still have been slugging moonshine containing unknown levels of wood alcohol, the moonshine would still have been made by the mob, there would still have been no regulation of the supply side, no licensing of the speakeasies. But the drinkers would have had clean glasses to drink out of.
This report from Canadian Centre on Substance Abuse backs away form challenging any of the assumptions of prohibition in its defence of harm reduction and by doing so neuters the whole concept.
True harm reduction must include control and regulation of the supply side. Drugs should be sold in known doses and be pure. They shouldn’t be sold by people who’s only qualification is unaccountability from venues who’s location is secret. Moreover the aim of the policy should be to ensure the supply side is of a high standard and not seek to introduce extra dangers entirely of the making of the policy.
Harm reduction – true harm reduction – is about legalisation. It’s about control and regulation of the trade as well as encouraging safer methods of use. It’s about treating potentially dangerous substances as potentially dangerous. But more importantly it’s about being honest, by developing policies based on real, quantifiable science and not assumptions based on what is often claimed to be no more than “common sense”. We have, in short, to be able to measure and quantify what’s going on.
To claim as the Canadian Centre on Substance Abuse seems to be doing that prohibition can be a part of a serious harm reduction strategy is little short of deception.
Interestingly no mention of harm reduction as it applies to cannabis was made in this report. Despite being by far the most popular illegal drug, cannabis didn’t get a look in. It seems in Canada, there is no scope for cannabis harm reduction. Really? There is here in the UK.
To be fair, in Canada they don’t usually mix cannabis with a deadly addictive carcinogen drug like we do this side of the pond. The single most effective bit of harm reduction we could have in this country is a safer use campaign, aimed primarily at separating the use of cannabis and tobacco. Even now most cannabis users still smoke joints packed full of tobacco and with no filter. Interestingly in Holland this whole idea has been given an unexpected and unplanned boost with the introduction of a tobacco ban in the famous coffeeshops.
Some 8 years ago, UKCIA launched it’s “Tokepure” campaign, which is online here. This could and should have been taken up by the wider legalisation effort, but wasn’t – probably because most law reform campaigners were themselves heavy tobacco users, but we missed a trick there. It’s a mark of pure hypocrasy on the part of some campaigners to rally against alcohol as they stand there tobacco stuffed joint in hand. In terms of PR it’s a disaster and a reality check is urgently needed in some quarters.
Such measures have to be a part of any future law reform effort. It’s all about preventing harm, making people aware of thir actions.
But of course it goes further than that, it’s about wanting to see a properly regulated commercial supply side providing a consistent product of a high standard. Cannabis is unlike almost every other drug in that it isn’t a single drug, but a combination of at least two important chemicals THC and CBD. A proper regulated supply side would thus reduce if not eliminate the dangers of cannabis with super high THC content, because you’d know what you’re buying, it wouldn’t be the unknown risk it is now.
The future for the law reform movement is harm reduction, not just to reduce the immediate harm from using cannabis badly, but also to reduce the harm done to the rest of society by a rampant illegal trade. It’s important that we make it clear what harm reduction means really and that prohibition has no role in it. Indeed, prohibition is harm maximisation, the polar opposite.
It should not really be a discussion about harm reduction since it will always return to the assertion that no use at all is is no harm at all. It should be more to do with supporting the individual in their life choices.
We all need to compromise between benefit and risk in our lives – we do it all the time but do not think about it. If we need something or enjoy something then we take precautions to do that thing as safely and unobtrusively as possible. In every other aspect of life we would never consider a measure or regulation that would make a dangerous activity more dangerous.
I have enjoyed rock climbing and motor racing in my life but everything is done to make these activities as safe as possible. I have risked serious injury (with a possible burden on friends, family and the NHS that may ensue) but that has been my choice. Others may choose not to take these risks – that is there choice. No one would ever suggest prohibiting these activities or that making them more dangerous is an effective deterrent to participation. In fact any measure (however well-meaning) that served to add danger would be seen as criminal. Some one needs to explain to me just why substance use (other than alcohol) is a special case.
I am not a slave to the state they work for me and should support me in my life choices not attempt to control me. Why do people not complain – well the powers that be are careful to only pick on minorities in society in the hope that they can rally the majority on their side.
I would like perhaps if it works to apply an analogy to the simple idea that things which are desirable (even if not necessary in the strict sense) are made safer both as a result of the voluntary work of users and providers alike and through regulation.
Good example would be something perhaps like a roller coaster, not actually necessary, purely recreational and in early primitive generations of them had a horrendous safety record (perhaps comparable to the unregulated illegal drugs market) mainly from lack of knowledge and evidence what worked, lack of regulation etc.
Over the years studies were made that enabled quantifiable evidence on the risks (quantifying the problem) and methods to minimize such risks (assessing solutions) and through a combination of demand from users (who just like drug users really didn’t want to die or suffer horrific injury) and regulation by various authorities the choices of those who wished to use roller coasters was supported and now they are despite all the risk factors (high speed etc) the statistical safety record is exceedingly impressive compared to how it began.
This process could easily be applied to drugs by first working to quantify the real problem (use itself is not the problem, risky use/abuse, lack of quality control etc is the problem) once those unknowns are quantified we can study and analyze possible solutions, it may indeed take some decades to reach the level of safety as roller coasters have, or indeed or any other technology which presents risk to have true harm minimization but it will happen, but only if we accept the situation and decide to take that action, we have the knowledge and experience in advance to help minimize the risks of drugs somewhat already though, they have been quantified and analyzed as a natural evolution of the field of medicine.