Strategies for preventing harm from psychoactive substance use

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International Journal of Drug Policy 17 (2006) 127–132. Policy Analysis .... psychoactive substances is a part of our society and that the desire to alter ...
International Journal of Drug Policy 17 (2006) 127–132

Policy Analysis

The evolution of drug policy in Vancouver, Canada: Strategies for preventing harm from psychoactive substance use Donald MacPherson ∗ , Zarina Mulla, Lindsey Richardson Community services, City of Vancouver, 453 West 12th Avenue, Vancouver, BC, Canada V5Y 1V4 Received 6 October 2005; received in revised form 13 October 2005; accepted 16 October 2005

Abstract In December of 2000, the City of Vancouver released its Four Pillars Drug Strategy in response to a serious public health crisis driven by illicit drug use in Vancouver. Following initial actions in the area of harm reduction and enforcement, in June 2005 the City of Vancouver developed its draft prevention plan titled “Preventing Harm from Psychoactive Substance Use”. The plan is based on a synthesis of international research and evaluation, examples of successful programs from other jurisdictions, and a community dialogue process. Its recommendations fall under five key prevention priorities, including reducing risk factors and increasing protective factors across the life course, community centred interventions, addressing impacts on communities, legislative and public policy change and regulated markets. Together, these prevention priorities form an integrated plan to prevent harm from substance use. This article provides a description of the process leading to the development of the plan and seeks to articulate its key strategies. © 2006 Published by Elsevier B.V. Keywords: Prevention; Policy; Drugs; Cities

Introduction Vancouver has always been home to a large proportion of the heroin users in Canada and the Downtown Eastside has a history of having a significant heroin-using population. However, in terms of drug-related harm, the drug that historically was the primary cause of drug-related harm in the community was alcohol. However, something changed during the latter part of the 1980s. There was a significant shift in the marketing and use of heroin and cocaine in the Vancouver region and throughout the Province of British Columbia (BC). By 1990, the Downtown Eastside was home to one of the fastest growing open-air drug markets in Canada, an infrastructure of illegitimate businesses to support this market, and the epicentre of an epidemic of property crime. In 1993 there were 200 overdose deaths in Vancouver and close to 400 in the Province of British Columbia. Highly potent heroin appeared on the market as well as cheap powder cocaine. Something had gone seriously wrong and people were dying in great numbers. The ∗

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conditions for an HIV epidemic among injection drug users were developing, the drug trade was overrunning a community and no one in authority and few in the community really understood what was occurring. A public health disaster was beginning to take place. In 1993 the Chief Coroner of British Columbia, Vince Cain, announced a special task force to look into the rash of overdose deaths. The report he produced after months of public consultations was a hard hitting and comprehensive analysis of a broken system (Cain, 1994). He called for strong action to address the flaws that he saw in our approach to addiction to illegal drugs. He called for society to view addiction as a health issue to be addressed by health care interventions. Cain called for a total overhaul of the drug treatment system and the fashion in which the criminal justice system addressed addicted individuals. He also suggested that the criminalisation of these substances contributed significantly to the harm that we were seeing in our communities and posed the question, “Should we consider decriminalisation or legalisation for some, if not all of illegal substances?” There was no doubt in Cain’s analysis: the status quo was not working

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and urgent action was required to fix it. Unfortunately little action came as a result of the Cain Report. The paper gathered dust on the shelves of government while the drama in the inner City of Vancouver played out with devastating results throughout the decade 1990–2000.

A Four Pillar Approach In December of 2000, the Mayor of Vancouver, Philip Owen, released the City’s drug strategy: “A Framework for Action: A Four Pillar Approach to Drug Problems in Vancouver” (MacPherson, 2000). The release of the Four Pillars Drug Strategy was the municipal contribution to efforts that were being mounted by the local health authority, the Vancouver Police and the provincial and federal governments and the community to respond to a serious public health crisis in Vancouver. The strategy articulated a comprehensive approach to addressing the dire circumstances existing in Vancouver and challenged the status quo by calling for new and innovative interventions such as supervised injection sites and heroin assisted treatment programmes where heroin users receive pharmaceutical grade heroin. The strategy stated clearly that

addiction should be treated as a health issue and that actions across the four pillars of Prevention, Treatment, Harm Reduction and Enforcement be implemented to reduce the negative impact of the sale and use of illegal drugs on individuals and the community. The strategy was inclusive of health and enforcement and had a main goal of public health and public order. The City’s proposed drug strategy was a catalyst for a broad public discussion that took place over the winter of 2001 culminating in the adoption by Vancouver City Council of the Four Pillars Drug Strategy in May 2001. Most importantly though, the development of the drug strategy, lead by then Mayor Philip Owen, brought the issue of addiction into the political arena. The drug strategy became part of a political process that saw civic politicians appealing to other levels of government to work together with the city to fund and implement the plan. The civic election of 2002 saw a new mayor, Larry Campbell sweep to victory promising to implement the Four Pillars Drug Strategy and open North America’s first supervised injection site as soon as possible after being elected. The initial emphasis of the Four Pillars Drug Strategy was a call to action across all four pillars to reduce the drugrelated harm occurring in Vancouver at the time. It focused

Fig. 1. Preventing Harm from Psychoactive Substance Use: prevention priorities, areas of action and recommendations.

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on harm reduction initiatives such as supervised injection sites in the Downtown Eastside, a call for the expansion of addiction treatment interventions and the development of a policing strategy to disrupt the open-air drug market. During the initial phases of the work, there was little emphasis on prevention efforts or much analysis of what prevention activities were taking place in Vancouver. Prevention of problematic drug use was seen as a longer-term proposition and an area that was not well understood by the general public. Simplistic notions of prevention dominated the public discourse. As part of the Four Pillars Drug Strategy, staff began developing a prevention plan in the fall of 2003, holding a symposium that initiated a dialogue on prevention of problematic drug use in Vancouver and considered the best evidence of what works in the field of prevention. In June of 2005, the City of Vancouver released a draft plan: Preventing Harm from Psychoactive Substance Use (MacPherson, Mulla, Richardson, & Beer, 2005). The plan was adopted unanimously by Vancouver City Council on 3 November 2005. This article will articulate the key strategies of this prevention plan (Fig. 1).

The prevention pillar The prevention plan—“Preventing Harm from Psychoactive Substance Use”—is based on a synthesis of international research and evaluation, examples of successful programmes from other jurisdictions, and a community dialogue process. Fifty dialogue sessions were conducted with various stakeholder communities, representing different life stages, sexual orientations, ethnicities, vulnerable populations and service providers. These sessions provided valuable input about the issues, obstacles and visions specific to each of these communities, and their input has been incorporated into the content of the plan. The plan draws on a number of perspectives on prevention—ranging from population health models to community-based, legal and regulatory approaches—and recommends strategies that have shown the strongest evidence for success. The plan acknowledges that the use of psychoactive substances is a part of our society and that the desire to alter consciousness with psychoactive substances is natural. The plan recognizes that drug use can occur across a spectrum of use from beneficial or therapeutic uses to recreational uses moving into problematic drug use. The plan is predominantly concerned with problematic and dependent substance use, or use that has clear harmful effects on individuals and society, and seeks to expand awareness, understanding and discourse around prevention. The intended outcomes for this plan include reduced individual, family, neighbourhood and community harm from substance use, delayed onset of first substance use, reduced incidence and prevalence of problematic substance use, and improved public health, safety and order. The plan identifies significant gaps in local prevention capacity, and recommends institutional support for municipal research and programme delivery, mechanisms

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for collaboration among prevention practicing individuals and organisations, and the establishment of monitoring and evaluation bodies. The creation of a sustainable prevention infrastructure within the Vancouver region is central to, and the first step towards, the implementation of effective prevention initiatives. The plan’s other recommendations fall under five key prevention priorities. These priorities are: reducing risk factors and increasing protective factors across the life course, community centred interventions, addressing impacts on communities, legislative and public policy change and regulated markets. Taken together, these prevention priorities form an integrated plan to prevent harm from substance use. Risk and protection across the life course This prevention priority focuses on risk factors for harmful substance use and protective factors that mediate individual risk across one’s lifetime and at key transition points. It identifies strategies that prevent harm from use through mutually reinforcing change at the individual, family and community levels. These strategies, which include support for non-use and safer substance use, target both the general population and specific groups at increased risk of harm. Recommendations reflect this, and include calls for support for the best early childhood care and learning programs for families, engaging young people in meaningful activities, creating healthy school environments and educating parents and families. Prevention initiatives can also be directed throughout adulthood as individuals move through life transitions. A recommendation to develop a strategy for older adults who are particularly vulnerable to problems from alcohol and pharmaceutical drug use is included. In addition, targeted social marketing and mass media campaigns, combined with a local media advocacy strategy will increase public understanding and bring these issues to the fore. Community-centred prevention This prevention priority focuses on the community as the primary site of intervention. Community centred interventions attempt to build capacity for individuals and organisations to engage at the local level in developing prevention initiatives. It acknowledges that harmful drug use is influenced by broad social determinants of health. The recommendations in this priority call for assistance to vulnerable populations through employment and housing supports as well as methods to strengthen community capacity through information sharing, networks, coalitions and the development of a sustainable youth engagement strategy. Addressing impacts on communities This prevention priority focuses on addressing the impacts from problematic and dependent substance use on the community. It is based on the need to keep community

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neighbourhoods and the environment as safe and healthy as possible within the context of active substance use. This priority outlines initiatives that can reduce the impacts of harmful use in public places, on individuals in potentially high-risk situations, and on neighbourhoods. The focus is on individual well being, public safety and order, the social and economic health of communities, and the environment. The plan recommends implementing a Safer Bars Pilot Program to deal with violence in bars and clubs as well as neighbourhood disorder, addressing the dangers associated with clandestine methamphetamine production labs and developing a city-wide syringe recovery program. Legislative and public policy change The prevention plan takes the position that there is a ceiling to what can be achieved through prevention efforts without considering changes to the legal frameworks within which psychoactive substances exist. The plan states that the historical policy of prohibition of certain drugs has failed in its attempt to eliminate availability of illegal drugs and their consumption. Markets for these substances continue to flourish and street level prices are at an all time low. Preventing Harm from Psychoactive Substance Use explores how prohibition as a policy restricts governments’ ability to stop, influence, administer or regulate the production, sale, and consumption of these substances. A policy of prohibition prevents the possibility of controlling both access to these substances and the circumstances surrounding their use, and as a result, how these substances impact our communities. The plan takes the position that as a society we must move towards considering alternatives to prohibition and that currently illegal psychoactive substances must not be left in the hands of organized criminals and unregulated dealers. To address psychoactive substance use in a proactive, preventative way, it is important to create a legal context that enables a more appropriate and nuanced response than the simple prohibition of these substances. The focus of this section is therefore the reduction of policy-related harm through the creation of public health focused and evidence-based legal responses to substance use. This plan recommends that the Federal Government adopt a legislative framework to deal with currently illegal substances based on population health models, the relative toxicity of each substance and each drug’s potential for creating dependency. It also recommends changes to Canada’s current proposed legislation to depenalize the possession and use of small amounts of cannabis to enable a comprehensive cannabis strategy. Market regulation Legal structures also determine which regulatory mechanisms are available for market intervention. Alcohol, tobacco and pharmaceuticals are legal psychoactive substances that all levels of governments control through regulations and taxes. This priority describes ways in which it is possible

to regulate the production, sale and use of psychoactive substances. It offers regulatory options in anticipation of future changes to the legal structures for some currently prohibited substances. The City of Vancouver does not advocate a free market system for psychoactive substances. Regulatory options instead aim to ensure that drugs are not bought and sold without appropriate controls. The City advocates a regulatory regime based on the particular health and social harms related to each substance. This priority also discusses ways to influence market forces that reduce the efficiency and profitability of illegal drug markets, and explores some substance-specific regulatory strategies. Recommendations include more stringent regulation of premises selling tobacco, the implementation of the British Columbia Provincial Health Officer’s recommendations to mitigate potential harm from new provincial policies that have increased access to alcohol, the development of a municipal alcohol strategy, and stricter control of methamphetamine precursor chemicals. Developing and implementing a plan to prevent harm from substance use is a complex undertaking that will require a coordinated, integrated and sustained effort over many years. The biggest barrier to prevention thus far has been the failure so far to implement a comprehensive and sustainable strategy at any level of government. Preventing Harm from Psychoactive Substance Use highlights the need to put prevention of harmful drug use front and centre in the implementation of the Four Pillars Drug Strategy.

The municipality as the site of action The complexity of implementing a comprehensive prevention plan and the sustained and multi-sectoral efforts it warrants makes it imperative to have a cohesive action strategy in place. As in the original sense of the term government, the Latin and Greek roots of which mean to steer, as in a ship, the prevention plan intends to provide a map to the local government to navigate the waters of prevention by means of a strategy for action encapsulated in the 25 recommendations. Taken together, these recommendations advocate sensible, compassionate, scientific and health-oriented solutions to some of the problems associated with the demand for and supply of psychoactive substances. How the strategy unfolds will ultimately depend on a variety of factors, the most important of which are political commitment, funding and collaboration. While much of the responsibility for prevention initiatives falls outside of the City’s jurisdiction and mandate, municipalities can play a variety of roles in moving towards a more concerted effort to build capacity for prevention in the community. The City of Vancouver has commenced work on some recommendations, especially those directly within its coordinating capacities. They are in the “drawing board phase”, i.e. they have started to coalesce in their respective partnerships

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and begun the process of collaborative planning. Some of the roles that the municipalities can play towards strengthening prevention in their local context are outlined below with, in some cases, corresponding recommendations from the prevention plan. The City as a provider of support to vulnerable populations The City has a key role to play in supporting vulnerable populations through outreach, targeted programmes and initiatives, advocacy and by promoting awareness and action on issues specific to vulnerable populations. Employment is a protective factor that mitigates the risks for problematic substance use. In Vancouver, there are programmes and services that help clients obtain and retain employment. But many of these programmes are inaccessible to most active and recovering users, as these citizens often do not meet the necessary requirements of being on income assistance. Consequently the City of Vancouver is planning a pilot project targeting those recovering drug users willing to explore their potential for job readiness. In Phase I of this project, clients would undergo a job literacy training on topics including work ethics, negotiation skills, anger management and high school completion where applicable. In addition to the training, there would also be one-to-one support from a case coordinator towards employment search and placement. Phase II would involve the actual placement in a working environment under the guidance of a mentor. The City is collaborating on this project with the Vancouver Agreement, an urban development initiative between the federal government, the provincial government and the municipality of Vancouver. The City as a facilitator of services The City facilitates programs and services on a regular and ongoing basis, and in some cases is also involved directly in program delivery. Consideration of the prevention of harm from psychoactive substance use in decisions about services serves to promote a more integrated approach. For example, the City of Vancouver is partnering with Vancouver Coastal Health to develop a plan for collecting and managing discarded syringes in Vancouver. This plan is expected to: establish a clear syringe management structure and plan, including monitoring and evaluation activities; improve awareness among the general public and injection drug using population about syringe recovery efforts; maximize appropriate disposal of syringes in community settings, and collect inappropriately discarded syringes in a timely fashion.

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more informed participants and supporters of preventionbased initiatives. A recent survey has helped identify prevention service providers in Vancouver. The City of Vancouver intends to convene an annual prevention summit on an ongoing basis that invites these organisations to come together with other relevant stakeholders including local community serving organisations, drug users, funders, researchers, members of the public and other levels of government to facilitate dialogue and discussion of prevention of harm from substance use. The City as a facilitator for building capacity The City’s role in capacity building may be as a facilitator, funding source, liaison, coordinator or educator. This is a crucial step in moving towards a community-based and community-driven approach to prevention that is fully supported by local government. The City of Vancouver has partnered with the Vancouver Public Library, Vancouver Coastal Health and Centre for Addictions Research of BC to provide a public education series on drugs and addictions. The purpose of this campaign would include providing information and raising awareness, promoting discussion, dispelling myths, reducing stigma and increasing community resourcefulness. The exact topics for the series will be determined at the end of a survey being conducted through various channels to gauge the kind of issues the public would like to see addressed. Another initiative—for school aged prevention—brings together the Vancouver School Board, Vancouver Coastal Health, Vancouver Police Department, the University of British Columbia and City of Vancouver in planning the development of a comprehensive prevention strategy for school-aged children and youth. Its implementation plan explores the following areas: enhancing the capacity of school staff and administration to address substancerelated incidents; increasing student awareness, knowledge and skills to avoid problematic substance use; and increasing parents’ knowledge and skills to prevent and intervene in substance using situations. The engagement of youth in Vancouver in the strategy for preventing harm from substance use is also a key component. Youth are engaged in the planning and implementation of a youth component of the prevention plan. As a first step, youth are an important part of the consultation process on the plan to get their feedback on it. Funding has been secured for the recommendation advocating the hiring of a youth coordinator for assisting in the planning of a long-term youth engagement strategy. The City as an advocate

The City as a facilitator of communication and dialogue The City often plays a significant role in facilitating communication, dialogue, education and knowledge exchanges with organisations and citizens on significant issues. This prevention plan maintains that an engaged public will be

The development by the City of Vancouver of both the Four Pillars Drug Strategy and the current draft Prevention Plan has placed the City squarely in the position of advocating for a new approach to addressing problematic drug use in Vancouver. This approach is one that: considers alternatives

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to the present system of prohibition; is evidence based and robustly funded by all levels of government; acknowledges the breadth of prevention possibilities across the life course; engages communities in meaningful dialogue on problematic drug use; and builds capacity for healthy responses to substance use. Responsibility for funding health interventions addressing problematic drug use is beyond the mandate of the City of Vancouver as is the ability to draft legislation that could provide the environment for the creation of regulatory schemes for currently illegal substances. The City therefore advocates a collaborative working relationship with senior governments and calls for action by Federal and Provincial governments to create the environment for evidence based strategies to succeed. The City as regulator Cities develop regulations that stem from legislation created by senior levels of government. Land use policies are at the centre of municipal regulatory functions. Cities regulate a wide range of activities that flow from overall land use policies such as the contexts of drug use in the case of alcohol and tobacco. City bylaws help to determine the location of establishments that provide alcohol to the public and direct many operational considerations such as occupancy loads, numbers of seats and hours of operation. Non-compliance with municipal regulations can lead to a loss of business licenses and the closure of problem businesses. Recommendations in the area of regulation include increasing controls on the sale and display of tobacco and developing a municipal alcohol strategy. Regulatory functions of local government are not possible when considering illegal substances. The City as a role model Municipalities can become role models in how to address a wide variety of issues from housing, transportation, cultural life, architecture and liveability to name a few. The Four Pillars Drug Strategy has become a model for other jurisdictions

across Canada. Action at the municipal level on problematic drug use is increasing across Canada. Municipalities have traditionally looked towards provincial and federal authorities to provide policy frameworks and to fund health services and criminal justice interventions that respond to drug use and the drug trade. Increasingly cities are taking the lead in working with other levels of government and their local communities to develop approaches that work best at the local level.

Conclusion The plan “Preventing Harm from Psychoactive Substance Use” was presented to Vancouver City Council on November 3, 2005, and was adopted unanimously. As this article goes to press, a new Mayor and Council have been elected, and will be faced with the significant challenge of implementing this prevention plan for Vancouver. The development of more rational, evidence-based and comprehensive approaches to preventing harm from psychoactive substance use will only come about through a long-term commitment to exploring and understanding our relationship with these substances. The evolution of drug policy in Vancouver continues to broaden the discussion of substance use in our communities and to focus our attention where it belongs, on the prevention of harm from the use of psychoactive substances in whatever form they are taken, and for whatever purposes they may be used.

References Cain, V. (1994). Report on the Task Force into illicit narcotic overdose deaths in BC. Victoria, BC: Government of British Columbia, Ministry of the Attorney General. MacPherson, D. (2000). A framework for action: A Four Pillar Approach to drug problems in Vancouver. Available online: http://www.city. vancouver.bc.ca/fourpillars/pdf/Framework REVISED.pdf. MacPherson, D., Mulla, Z., Richardson, L., & Beer, T. (2005). Preventing harm from psychoactive substance use. Available online: http://www. city.vancouver.bc.ca/fourpillars/pdf/preventingharm report.pdf.