Hi everyone and welcome to module 5 video 2.

In the first video, we defined

substance use disorder and talked about how classical conditioning is involved in
some aspects of substance use, such as tolerance, withdrawal, and overdose, to
help explain why some classical conditioning behaviour change strategies can be
helpful for changing substance use behaviours. In this video, I’m going to focus on a
strategy that doesn’t aim to necessarily change the substance use behaviour itself,
but rather focuses on mitigating some of the risks and consequences of the
behaviour. That strategy is harm reduction.

Harm Reduction

LO2: What is
substance use
disorder?
Abstinenceis generally an unrealistic goal
E.g., prohibitionof alcohol
Typically implemented at the community level (esp.
large cities)
E.g., needle exchange programs (e.g.,
Insitein
Vancouver)
70% decrease in needle sharing
35% decrease in overdoses
Harm reduction is described as a public health approach to substance use. The main
goals are to reduce the health, social, and economic harm of the substance use
without necessarily changing the substance use itself, though some goals can also
focus on trying to reduce substance use without necessarily trying to eliminate it
completely. So essentially, trying to reduce the costs of the substance use that we
touched on at the end of video 1. Harm reduction is the approach that guides
Canada’s national drug strategy. The harm reduction approach recognizes that aiming
for totally eliminating substance use in the population is an unrealistic goal. Total
elimination would be similar to some of the US drug campaigns from the past, like
Just Say No, or the harsh criminal penalties for things like smoking or possession of
small amounts of marijuana. A harm reduction approach is more what Canada did in
terms of legalizing marijuana and then controlling its distribution and use to try to
regulate it and make it safer. For example, so people know exactly what it is they are
buying and they know it wasn’t laced with something else.

Another classic example of the abstinence approach to substance use was the
introduction of prohibition (the total banning of alcohol) in the USA in the 1920s. In
Canada, there was a national ban on alcohol as a temporary wartime measure from
1918-1920, and various provinces banned alcohol for different lengths of time in the
early 1900s. In the US though, the national ban on alcohol lasted much longer, from
1920-1933. During that time, the sale, production, importing, and transportation of
alcoholic beverages was prohibited. This brings up some interesting history. I was
born and raised in Windsor, Ontario, which is right across the river from Detroit,
Michigan. The Detroit river is a tiny river and ranges from 0.8-4km wide. When
prohibition hit the US and became nationwide, Windsor became a huge area for
making bootleg liquor and smuggling it over to the US. You can take a Rum Runners
tour in Windsor and go to some of the places where bootleg alcohol used to be made
and hear about how they used to smuggle it across the border into Detroit. Alcohol
smuggling turned out to be pretty beneficial for the Windsor economy during that
time and there are a lot of mansions built in certain neighbourhoods that were built
with money made from rum running.

So, you can already get a sense that prohibition wasn’t really working because people
were still accessing alcohol. However, there are stats to show that prohibition did
have an immediate effect on drinking and drinking levels went down; however, over
time they crept back up again as people figured out how to access illegal liquor.

In addition to prohibition not achieving the goal of total abstinence from alcohol,
there were some unintended consequences that resulted from the strategy of
prohibition. One of these was that crime increased. Often when something is banned

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entirely, it doesn’t just go away, but rather it’s driven underground, like the rum
runners. A profitable and violent black market for alcohol developed that was
controlled by the mafia and gangs. There used to be a bar right on the riverfront in
Windsor that I would go to called Abar’s. It was a speakeasy during the time of US
prohibition and many rich Americans would come there to drink and gamble. That
bar had a bullet hole in the wall from Al Capone that was put there during those rum
running days. This increase in crime subsequently lead to a lot more spending on law
enforcement costs. This is the opposite of the initial intent of prohibition, which was
to try to reduce alcohol-related crime. Prohibition had further costs to the US
economy because they lost out on millions of dollars they would have otherwise
collected from taxes on the sale of alcohol. So, this example of prohibition shows that
there can be unintended consequences to different social engineering strategies for
tackling substance use that must be carefully thought about in terms of what are the
actual goals that one wants to accomplish with those strategies.

Ok, let’s now turn our attention back to harm reduction strategies. Harm reduction
can sometimes be an effective strategy to initially promote safe substance use
before moving to interventions directed at reducing substance use. These are
strategies that are typically implemented at the community level, so not the level of
the individual.

Harm reduction strategies typically take the form of community programs or

resources being put in place. These programs often focus on safe use of substances
to reduce the social and public health costs of things like disease transmission
through dirty needle sharing, or overdose.

A couple examples of harm reduction community programs are methadone

maintenance and needle exchange programs aimed at dealing with illegal injection
drug use, like heroin. Like I mentioned, injection drug use is associated with the
spread of disease from sharing needles. Needle exchange programs offer a way for
injection drug users to reduce some of the harm of that substance use by providing
them with sterile needles and knowledge about how to reduce the spread of disease.
So here the program isn’t targeted at changing the behaviour of injection drug use,
but rather is targeted at reducing some of the additional harm that can come from
that behaviour.

One harm-reduction program (Insite) was launched in 2003 in Vancouver’s

Downtown Eastside, where the concentration of injection drug users was particularly
high, and rates of HIV, hepatitis, and death from drug overdose were rapidly rising.
Insite was Canada’s first safe-injection site. It offered users a disposable injection kit

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(like the image on the top of this slide) and other sterile drug-use tools to prepare
and inject their drugs under the supervision of medical staff. As your text describes,
the initial response to this intervention program was mixed, as many people believed
that it would convey the wrong message and actually increase injection drug use.
However, evaluations of the program showed that people that used Insite were 70
percent less likely to share needles, and needle-sharing rates in the community
decreased after Insite opened. The opening of Insite was also associated with a 35
percent reduction in the number of fatal overdoses in the area surrounding Insite,
whereas there was only a 9 percent reduction in the number of overdoses in the rest
of Vancouver.

Despite these favourable statistics, in 2011 the Conservative government of Canada,

lead to Stephen Harper at the time, sought to shut down Insite because they claimed
the site fostered addictions, encouraged crime, and violated the federal criminal code
by facilitating the use of illegal drugs. This initiative by the Conservative government
was defeated when the Supreme Court of Canada ruled unanimously that Insite
could remain open. The Court even ordered the federal health minister to
immediately issue exemptions at the site from laws prohibiting drug possession and
trafficking to allow the facility to operate.

The Supreme Court judges further found the federal government acted in an
arbitrary manner, in violation of guarantees in the Charter of Rights and Freedoms
protecting life, liberty, and security of the person. Several of the judges emphasized
the point to federal lawyers that the site was, in fact, saving lives.

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 Opioid Crisis

LO2: What is In Canada, use ofprescription opioids

substance use
disorder?
rose 200% from 2000 to 2010.
Additional 70% increase since 2010.
Addiction can start from ‘acceptable
use’
E.g., prescribed for an injury
Death rates increasing during the
pandemic
More toxic supply
Fewer safe consumption spaces
Increased stress

To end video 2, I want to talk a bit about the opioid crisis, some contributing factors,
and how the COVID-19 pandemic has affected harm from opioid substance use.

As mentioned in your text, misuse or non-medical use of prescription opioids is

considered by many experts to be a public health crisis in Canada and throughout the
rest of the world, with between 26 and 36 million individuals misusing prescription
opioids worldwide. Opioid use has been rising in Canada for at least the last 20 years.
It is estimated that between 500,000 and 1.25 million Canadians are misusing
prescription opioids, making non-medical use of prescribed opioids the fourth-most
common type of substance use in Canada, following alcohol, tobacco, and cannabis.

Data from 2018 show that nearly 4,000 Canadians died from apparent opioid
overdoses that year, with men the most likely victims and fentanyl the clear culprit.
The number of apparent opioid-related deaths among 30-39 year olds in 2017 was
greater than the number of deaths due to any of the other leading causes of death
for that age group. The numbers for apparent opioid-related fatalities showed a
national death rate of 10.9 for every 100,000 people in the population in 2017, up
from 8.2 in 2016. These numbers continue to increase, and they are getting worse
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since the COVID-19 pandemic began back in March. Data from Alberta show that
more than 3 Albertans died of opioid overdoses PER DAY between April and June
2020, which is more than double the rate of opioid deaths in Alberta in the three
months before the pandemic, between January and March 2020.

There are many contributing factors to the opioid crisis. One of them is that opioid
use can start from “acceptable use”, which occurs when someone starts using
opioids that were prescribed to them from their doctor for a legitimate reason, like
an injury. You see from the stats on the slide that the amount of opioid prescription
use increased dramatically over the last 20 years. For example, there are many
stories of athletes that get injured, are prescribed opioids, become addicted to them,
then turn to heroin when they can no longer get their prescriptions filled. I’ve
included an optional YouTube video on Blackboard that covers an example of one of
these stories.

Some of the crisis stemmed from a misunderstanding of just how addictive opioid
pain-relieving drugs actually are. So doctors would rely on prescribing them without
considering their addictive properties or potentially considering alternative methods
for pain reduction. Couple these facts with a lack of comprehensive care to respond
to the mental and physical needs of individuals, like mental health counselling
services, and we see opioid use spike because they are accessible and they make
people feel good. But, once people stop being able to get those prescriptions filled,
and have to turn to illegal means to get their opioids, people are exposed to a host of
new risk factors, such as an increasingly toxic supply of opioid drugs laced with
stronger than intended opioids, like fentanyl and carfentanil. Fentanyl is 100 times
more toxic than morphine and carfentanil is 10,000 times more toxic than morphine.
These substances all look like white powder so it’s basically impossible to tell if a
supply of drugs is laced with them.

During the pandemic there are reports that the drug supply is becoming more toxic
due to border closures and restricted ability to move the usual supply of drugs.
People aren’t able to get their drugs from their usual places, so they’re having to turn
to more black-market solutions, which can be very dangerous since they aren’t sure
what they’re getting with each dose. In addition, it is harder for people to access safe
spaces to take their drugs during the pandemic. Further, the stress of the pandemic
in general, and social isolation, can lead people that had been clean to relapse.
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Opioid Crisis:
Harm Reduction

LO2:
What is
substanc
e use
disorder
?

The government of Canada has taken a harm reduction approach to the opioid crisis.
They are making naloxone kits available for free. Naloxone is a substance that
basically kicks the opioid drug off the receptors in the body to reverse the effects.
Administering Naloxone in time can save someone from an overdose. In some areas,
firefighters and police officers now carry Naloxone as they are often the first to arrive
on an overdose scene before paramedics and time can be of the essence to save
someone from an opioid overdose. One of my old friends in Windsor owns a store
downtown and she actually just picked up a Naloxone kit recently in case she’s ever
in the position of coming across someone downtown that is suffering an opioid
overdose she wanted to be equipped to help them.

Another harm reduction strategy is protecting people from criminal drug charges if
they call for help when experiencing an overdose, to make calling for help less risky
for people. Increasing access to treatment for opioid addiction is another harm
reduction measure. Using educational campaigns to increase public awareness of the
signs of overdose and what to do has been implemented. An education campaign like
this is what prompted my friend to get a Naloxone kit. Trying to reduce stigma to
make it more likely that people will seek help and use health care services is another
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harm reduction strategy. And, like we talked about with Insite in Vancouver, another
important strategy is approving supervised consumption sites so people can
consume their drugs in a safe place where Naloxone kits and trained personnel are
available to intervene if someone experiences an overdose.

In addition, Health Canada has also asked provinces and territories to improve access
to safe opioid medications so that people don’t turn as much to street supplies,
which are becoming increasingly more dangerous as they are mixed with substances
like fentanyl and carfentanil. Some doctors and police chiefs are even now calling for
the decriminalization of drug possession for personal use. They argue that
decriminalization would allow for the drug market to be more regulated in a way that
takes profit away from organized crime. In addition, the profits from the sale of
regulated drugs could instead go to things like housing and recovery resources for
people suffering with addiction. They further argue it is a waste of time and money to
arrest people for personal possession, that a small amount of drugs for personal
possession is not a harm to the public, and that those measures don’t work anyway,
similar to prohibition of alcohol that I talked about earlier.

All of these measures are not targeted at totally eliminating the use of opioids, which
is an unrealistic goal. If that where the goal, we might instead see really steep
criminal charges or fines for opioid use or possession. Instead, these measures are
aimed at reducing the harm caused by opioid substance use, such as loss of life due
to overdose.

This brings us to the end of module 5 video 2. I hope you have learned some useful
things about the impact of harm reduction interventions on the overall cost and
harms from substance use disorder and that sometimes aiming for abstinence might
not be the most effective strategy. I’ll see you back here for our last video for module
5, where we’ll focus on a different substance, tobacco smoke, and some
interventions for that type of substance use. See you there.
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