The City of Vancouver's Four Pillar Drug Strategy: An analysis of how each of the four pillars positively impacts substance use in Vancouver
Le Nguyen (Mark) Dao - NaloxHome Youth Educator
Introduction
In May of 2021, the City of Vancouver enacted the Four Pillars Drug Strategy (McCann, 2008, p. 1). This approach was started in Europe in the 1990s and was based on four pillars: Harm Reduction, Prevention, Treatment, and Enforcement (City of Vancouver, n.d.). Harm reduction focuses on reducing the harm associated with substance use itself (City of Vancouver, n.d.). Prevention focuses on strategies to reduce the harmful use of alcohol, tobacco, and drugs (City of Vancouver, n.d.). Treatment focuses on interventions and programs that help individuals with addiction to reduce and eliminate their cravings (City of Vancouver, n.d.). Enforcement focuses on integrating the first three pillars into current policing practices (City of Vancouver, n.d.ff). The Four Pillars Drug Strategy differs greatly from the approaches to substance use and addiction by other Canadian jurisdictions and the United States, which emphasize enforcement and substance abstinence (McCann, 2008, p. 2). However, the Four Pillars Drug Strategy has led to a “dramatic reduction in the number of drug users consuming drugs on the street”, “significant drop in overdose deaths”, as well as “[a] reduction in the infection rate for HIV and hepatitis” (City of Vancouver).
The purpose of this paper is to examine each of the four pillars in the City of Vancouver’s Four Pillars Drug Strategy and list some ways in which the pillars have positively impacted substance use and addiction in Vancouver. This paper is important because substance use is a serious problem that affects a large number of people. This problem requires an appropriate drug strategy in order to conserve human lives and improve communities.
Discussion
Harm Reduction
Vancouver’s Four Pillars Drug Strategy has allowed for an increase in harm-reduction services, both in number and variety. Harm reduction is defined as “policies and programs that reduce individual and societal harm, without requiring abstinence or reduction in addictive behaviour” (Driedger & Wiercigroch, 2018, pp. 4-5). Even though it is the newest of the four pillars (Alexander, 2005, p. 1), harm reduction has already taken many forms such as widespread availability of Naloxone (Taha & Buxton, 2019, pp. 4-5), overdose prevention sites (OPS) and safer consumption site (SCS), the “Don’t Use Alone” campaign (Taha & Buxton, 2019, p. 6), as well as the provision of clean needles (Longhurst & McCann, 2016, p. 109). Naloxone is a drug that can reverse an opioid overdose while not causing an additional risk to the patient nor increase drug use. (HealthLink BC). It is widely available across Canada and a prescription is not needed (Taha & Buxton, 2019, pp. 4-5). Taha & Buxton et al (2019) state that “a recent study estimated that one death was averted for every 11 take-home naloxone kits used in British Columbia” (pp. 4-5). OPSs and SCSs allow individuals to use substances safely by providing them with clean needles and other substance use equipment (Taha & Buxton, 2019, p. 4). OPSs and SCSs also prevent overdose deaths with supervision and rapid intervention (Fraser Health), as well as connect individuals to appropriate resources (Taha & Buxton, 2019, p. 4). One such example of an SCS is Insite on Hasting Street, right in the heart of Vancouver’s Downtown Eastside (Vancouver Coastal Health, n.d.). Insite was founded in 2003 (Longhurst & McCann, 2016, p. 109). It is the first and only facility of its kind in North America (Fischer, Murphy, Rudzinski, & MacPherson, 2015, p. 4). The “Don’t Use Alone” campaign was introduced to reduce overdose deaths caused by people using substances alone, without anyone to call for help should an overdose happen (Taha & Buxton, 2019, p. 6). The wide variety and number of harm reduction services across Vancouver have allowed for lower health impacts and increased safety without requiring individuals to reduce or fully eliminate their substance usage. Certain concepts of harm reduction also help destigmatize substance use and addiction. Thus, more support and understanding from the public could be gained. However, because of its very definition, a limitation of harm reduction is that it doesn’t address the underlying cause of substance addiction itself, but rather reduces the proximate effects.
Prevention
Vancouver’s Four Pillars Drug Strategy has allowed for more appropriate pain management prescribed by physicians. The Association of Faculties of Medicine reports that there are “inconsistencies in time allocation across Canadian medical school curriculums with regards to education on substance use and pain management” (Driedger & Wiercigroch, 2018, p. 5). A way that Vancouver’s Four Pillars Drug Strategy address this issue is by using Prescription Monitoring Programs (PMPs). PMPs collect and monitor data on the prescription and distribution of substances which have the potential for abuse (Driedger & Wiercigroch, 2018, p. 3). In B.C, the PMP is called the Prescription Review Program and it is regulated by the College of Physicians and Surgeons of British Columbia (College of Physician and Surgeons of British Columbia, n.d.). PMPs would help reduce the overprescribing of opioids by physicians, which both reduce the risk of opioid dependence and the supply of illicit opioids. By extension, it would also reduce the supply of opioids that is mixed with other substances such as fentanyl and thus, reduce overdose deaths. Furthermore, medical education curricula should put more emphasis on substance use and pain management content. Curricula should also be uniformed across institutions. However, putting more emphasis on substance use and pain management content would mean either reducing other contents, which might bring problems of their own, or increasing the duration of medical education programs, which results in higher costs and time commitments to students.
Treatment
Vancouver’s Four Pillars Drug Strategy has allowed for more effective treatment of drug addiction by improving accessibility to current treatment options and introducing new treatment options. Improving accessibility to current treatment options is done through telemedicine, Rapid Action Addiction Medicine (RAAM) clinics, and assertive community treatment (Taha & Buxton, 2019, p. 4). Taha and Buxton (2019) state that “the use of these programs in North America has contributed to reduced emergency department visits, reduced wait times and lessened stigma, and greater engagement in treatment” (p. 4). As for new treatment options, an example would be Opioid Agonist Therapy (OAT). OAT involves taking the opioid agonists methadone or buprenorphine, which are long-acting opioids that prevent withdrawal and reduce cravings for opioid drugs (Centre for Addiction and Mental Health, n.d.). Improving accessibility allows more people to acquire the treatment they need. This is extremely relevant to marginalized populations such as immigrants and Indigenous communities. Improving accessibility to current treatment options also help foster communication between different members of the healthcare system or even between members of the health care system and external organizations (such as the case of telehealth). A limitation of improving accessibility to current treatment options is the financial costs associated with it. Examples of costs would be equipment and internet service for telehealth, as well as the operating cost for clinics. The added financial cost could fall on the health authority or the general public in the form of tax. In the case of the latter, increased tax might reduce the public’s support of initiatives to improve accessibility. OAT is effective because it offers a way for individuals to slowly reduce and ultimately eliminate their cravings for opioids. A limitation, as pointed out by the Centre for Addiction and Mental Health (2016), is that both methadone and buprenorphine are powerful drugs and could be dangerous if used by someone other than the individual that was prescribed them (p. 3).
Enforcement
Vancouver’s Four Pillars Drug Strategy has shifted the paradigm of law enforcement agencies and society. Taha and Buxton (2019) report that some law enforcement agencies are “increasingly acknowledging harmful substance use as a chronic health issue rather than a criminal justice one” (p. 5). McCann (2007) states that “[intravenous drug users] are now officially regarded as a primarily sick, rather than primarily criminal, population” (p. 8). As a result, the Good Samaritan Drug Overdose Act was passed by the Canadian federal government in 2017. According to the Act, “any person who seek emergency medical or law enforcement assistance for themselves or another person following overdosing on a controlled substance” is “exempt from charges for possession or charges related to the violation of certain conditions or orders.” (Government of Canada, 2017). The paradigm shift among law enforcement agencies and society at large would reduce stigma around substance use and addiction, thus allowing more individuals to come forward and acquire the treatment they need. The paradigm shifts among law enforcement agencies and society at large would also reduce incidences of law enforcement violence towards substance users and therefore improve the relationship between law enforcement officers and the community. A limitation of this paradigm shift is that it is a double-edged sword. Law enforcement officers should not consider substance users as criminals, but they should also not ignore the upper levels of the chain, which are substance dealers and drug enterprises. Law enforcement agencies will need to find a balance between maintaining their relationship with the community and remaining vigilant on drug enforcement.
Conclusion
This paper has examined each of the pillars in the city of Vancouver’s Four Pillars Drug Strategy, identifying ways the pillars have positively affected substance use and addiction in Vancouver. This paper’s limitation is that it does not include all the ways each of the pillars has positively impacted substance use and addiction in Vancouver, but rather focuses on significant ways among the four pillars. Another limitation of this paper is that some of its references are not recent (within the last five years). This paper calls for more emphasis on substance use and pain management in medical education curricula as well as uniformity across medical education institutions. This paper also calls for continued observation and data recording of the impact each of the pillars will have on substance use and addiction in Vancouver as the Four Pillars Drug Strategy is still relatively new. This paper is important because substance use and addiction is a serious problem that affects many people. Thus, an effective drug strategy will help conserve human lives and improve communities.
References
Alexander, B.K. (2005). Beyond Vancouver’s “Four Pillars”. International Journal of Drug Policy, 17(2), 118-123. DOI: https://doi.org.ezproxy.library.ubc.ca/10.1016/j.drugpo.2005.12.009
Centre for Addiction and Mental Health. Opioid agonist therapy. (2016) Retrieved from https://www.camh.ca/-/media/files/oat-info-for-clients.pdf
City of Vancouver. (n.d.). Four Pillars drug strategy. Retrieved May 17, 2020, from https://vancouver.ca/people-programs/four-pillars-drug-strategy.aspx
College of Physicians and Surgeons of British Columbia. (n.d.). Prescription Review Program. Retrieved May 27, 2020, from https://www.cpsbc.ca/programs/drug-programs/prp
Driedger, M., Wiercigroch, D. (2018). Responding to Canada’s opioid crisis. Retrieved from the Canadian Federation of Medical Students website: https://www.cfms.org/meetings/sgm2018-halifax
Fischer, B., Murphy, Y., Rudzinski, K., MacPherson, D. (2015). Illicit drug use and harms, and related interventions and policy in Canada: A narrative review of select key indicators and developments since 2000. International Journal of Drug Policy, 27, 23-35. DOI: http://dx.doi.org/10.1016/j.drugpo.2015.08.007
Fraser Health. (n.d.). Overdose Prevention Site. Retrieved May 27, 2020, from https://www.fraserhealth.ca/Service-Directory/Services/mental-health-and-substanceuse/substance-use/overdose-prevention-site#.Xs6n2GhKhPZ
Government of Canada’s Justice Laws Website. Good Samaritan Drug Overdose Act. (2017, May 4th). Retrieved from https://laws.justice.gc.ca/eng/AnnualStatutes/2017_4/page1.html IMPACTS OF VANCOUVER’S FOUR PILLARS DRUG STRATEGY 9 HealthLinkBC. (n.d.). Naloxone: Treating Opioid Overdose. Retrieved May 27, 2020, from https://www.healthlinkbc.ca/healthlinkbc-files/naloxone
Longhurst, A., & McCann, E. (2016). Political struggles on a frontier of harm reduction drug policy: Geographies of constrained policy mobility. Space and Polity, 20(1), 109-123. DOI: http://dx.doi.org/10.1080/13562576.2016.1140403
McCann, E.J. (2007). Expertise, truth, and urban policy mobilities: Global circuits of knowledge in the development of Vancouver, Canada's `four pillar' drug strategy. Environment and Planning, 40, 885-904. DOI: 10.1068/a38456
Taha, S., Maloney-Hall, B., & Buxton, J. (2019). Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy. Substance Abuse Treatment, Prevention, and Policy, 14(1), 1-10. DOI: http://dx.doi.org.ezproxy.library.ubc.ca/10.1186/s13011-019-0220-7
Vancouver Coastal Health. (n.d.). Insite - Supervised Consumption Site. Retrieved May 27, 2020, from http://www.vch.ca/locations-services/result?res_id=964