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"The use of illegal drugs is a serious health and social problem in Canada," Rebecca Jesseman, a research and policy analyst with the Canadian Centre on Substance Abuse, writes today in her Comment Page article Beyond harm reduction

Ms. Jesseman argues that Globe columnist Margaret Wente's recent four-column series "demonstrated that 'harm reduction' has become a polarizing term that divides those with a common interest — the reduction of harm associated with drug use.

"Rather than being guided by evidence, the debate over harm reduction is often based on ideology, with opposing sides seeing harm reduction as either a way to help those who continue to use drugs to minimize the associated harms, or as an approach that encourages use and implicitly supports more liberal drug policy.

"These polarized interpretations of harm reduction create a false dichotomy: in truth, interventions such as needle exchange programs and supervised injection facilities do not preclude abstinence-based programs or interventions . . . "

Although debate tends to focus on individual, high-profile programs, the evidence clearly illustrates that no single intervention can be relied on to address the broad spectrum of risks and harms associated with substance use.

"What we need is a broad continuum of services and supports that encompasses the abstinence-based programs highlighted in Ms. Wente's final article as well as harm reduction programs such as needle exchange and methadone maintenance."

Ms. Jesseman concludes by urging: "Perhaps those involved in Canada's debate on drug policy can . . . agree to set ideology aside in favour of advancing evidence-based programs, policies and interventions regardless of the label applied to them, and to work together toward a common goal of providing a comprehensive approach to substance use."

Whether you agree or not, it's a provocative argument, so we're pleased that Ms. Jesseman was online earlier today to take your questions on her Comment article and the broader issues it raises.

Your questions and Ms. Jesseman's answers appear at the bottom of this page.

Rebecca Jesseman is a research and policy analyst at the Canadian Centre on Substance Abuse, where she is currently involved in monitoring harm-reduction initiatives, and in the ongoing development of a national treatment strategy under the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada.

Ms. Jesseman obtained her MA in criminology from the University of Ottawa, where she continues as a sessional lecturer.

Editor's Note: globeandmail.com editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. HTML is not allowed. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Jim Sheppard, Executive Editor, globeandmail.com: Welcome, Ms. Jesseman, and thanks for joining us today to take questions from the readers of globeandmail.com.

You made a strong argument in your Comment Page article today for a "common goal of providing a comprehensive approach to substance use." But as you and Ms. Wente also noted separately, ideology often gets in the way of this goal.

How practical do you think this is? What are the first steps that should be taken toward this goal?

Rebecca Jesseman: I think that reaching common ground on the need for a comprehensive approach to substance use is a very practical goal. As I mentioned in my column, the precedent for consensus exists on the international stage.

I think that the first step to be taken is creating dialogue — which is already happening through venues such as the media, public forums, and both online and print publications. We — as an organization and as a field — need to continue to create and promote these opportunities to bring people together and to exchange knowledge and ideas.

I think that the starting point for advancing dialogue is finding common ground. Most people will agree that there are harms associated with substance use. Most people will also agree that there is no silver bullet that will resolve all of these harms.

Most people will agree that if people want help to address harms that they are experiencing, they should have access to effective services.

The evidence base supports that the best way to provide effective services is through a comprehensive approach that provides a range of integrated services and supports respecting culture, gender, and diversity.

One excellent example of co-operation here in Canada is the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada.

This initiative brought together over 100 representatives from, for example, governments, enforcement, service providers, aboriginal organizations, people who use drugs, the medical community, and non-governmental organizations. This diverse group came to consensus on 13 strategic priorities to guide actions to address substance use in Canada.

I realize that I keep coming back to highlight consensus achievements but I believe, for one thing, that they are worth celebrating and, for another, that they demonstrate that achieving common goals is both practical and already under way.

When it comes down to finer points of disagreement, there is nothing wrong with agreeing to disagree, and continuing to move the dialogue ahead.

That is also where it's important to address evidence versus ideology. Rather than getting caught up in categorizations, we can sit down and discuss the merits of individual interventions based on evaluation evidence.

Don Grant, Bowmanville, Ont.: Ms. Jesseman, I have witnessed the results of harm reduction and I believe that when someone suffers from the disease of addiction, they will seek out the easier and softer way to deal, or so they think, receive treatment.

Without harm-reduction practices in place, the professional field would have no statistics on the exact number or location of these people addicted to drugs. When areas like Vancouver's Downtown Eastside became notorious for safe houses, it actually drew the attention of users.

People are not going to an abstinence-based program when all their peers are located at the local methadone facility. At least once they are in the harm-reduction program, they are given the choice to follow up with the help of another agency, and that is where the client should be well-informed of the treatment options offered in their area by the health professional.

Would you agree that people who are clean and sober be employed to relay this message to those still undecided either by literature or in person?

Rebecca Jesseman: I believe that people need to be able to access help from "where they're at."

People with substance-use problems have a diverse range of needs, wants, and backgrounds, and should have access to a range of options that is responsive to that diversity.

I completely agree that people should have access to information about the full range of options available. But I think that they should have access to this information from any point in the system, not necessarily just from a health professional.

There are, for example, many peer-based agencies and organizations that are able to reach out to and connect with people who may not have access to, or may not be receptive to, information from a medical professional.

Roman Spears, St. Catharines, Ont.: Is there room in Canadian society to tolerate drug use, provide treatment options and criminalize those actively using or trying to quit substance abuse? Should users of addictive/abused substances be dealt with in the same way regardless of their being illegal or legal substances?

Rebecca Jesseman: I am not sure I entirely understand the question, but I do believe that we need to provide evidence-based treatment options across all contexts in which treatment is offered — whether in the community or in a correctional institution.

All people involved in substance use should have access to an integrated continuum of options should they decide to seek services — regardless of whether they are active users seeking to minimize the harms associated with use or former users seeking to maintain abstinence.

Adrian Powell, Burnaby, B.C.: Ms. Jesseman, to what extent are Canadians helped or harmed by criminalizing drug use rather than legalizing and regulating it?

Alcohol is harmful and addictive but we repealed Prohibition in the 1920s, we prevented minors from accessing it, eliminated toxic impurities and explosions in covert distilling, and eliminated the violence that came from criminal gangs.

If we adopted a similar approach with drugs, how would the health benefits to our communities as a whole and individual drug users compare to possible increases in usage?

Rebecca Jesseman: Unfortunately, Adrian, the best answer I can provide you with is to admit that I don't know.

The debate over legalization and regulated distribution is even more polarizing than the debate over harm-reduction, and therefore often more strongly couched in ideology.

There are certainly many factors to take into account on either side of the discussion, including social and political context, regulatory control options, impacts on use, and impacts on the illicit market.

Thank you for putting some of these considerations in concrete terms in your question, and I look forward to continuing to follow emerging knowledge on this issue at both the national and international levels.

Lemmy Nothor: When an article based on substance abuse mentions only illegal drugs, it is going in the wrong direction.

Illegal drug abuse — and we are talking only about abuse, not controlled use — is indeed a problem for a few people. They are the tip of the iceberg, the visible part.

There are a lot more people abusing prescription drugs, but no one seems to want to take on the pharmaceutical companies who are making a lot more money than the Medellin Cartel ever made, and who don't want to curb the flow, simply because they make so much money from the clean-looking crowd, who drive Lexus, Beemers and Mercs, wear ties, and donate generously to charitable organisations.

Please write an article on these people instead of the eternal street junky, the one stuck in the gutter with no way out except steeling hubcaps and ripping off little old ladies. I've known hundreds of those for every street junkie you can name.

As for injection sites, the same can be said. 99% of users crank up in their living rooms, with a good sound system playing in the background, a fridge full of food, and all their bills paid, stacked neatly on their desks. The ones who use injection sites, are in hell, but they are the minority.

Rebecca Jesseman: Thank you, Lemmy. You are correct — the health and social costs associated with the abuse of legal drugs in Canada far outweighs those associated with illegal drugs.

We have fairly good information about the health and social impacts of alcohol and tobacco, but we are still in the early stages of getting a better grasp on the impacts of the misuse of pharmaceutical drugs.

The use of prescription opiates has clearly been identified as one of concern through the problems associated with OxyContin in the Atlantic Provinces, and the U.S. legal settlement against its manufacturer for misrepresenting its addictive potential.

Preventing the misuse of pharmaceuticals is one of 13 priorities identified under the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada. Hopefully, as this priority moves forward, you will see more information and discussion on this important topic.

Zavie Kucer, Montreal: Is there any hard data on the proportion of addictive hard drug users who are suffering from mental illness? I have seen a significant increase of drug users in my neighbourhood and it seems to me that many of them are bipolar or schizophrenic.

I think that any sort of action on their drug use would be complicated by their mental illness. Is there any evidence on the effectiveness of treatment vs. incarceration for mentally ill addiction sufferers?

Rebecca Jesseman: We don't have exact statistics on the rate of people with concurrent disorders — those with both substance use and psychiatric disorders — in Canada.

However, we do know that there is an association between substance use and mental illness, and that individuals with concurrent disorders present more complex treatment needs as well as increased levels of stigma and discrimination.

There are evidence-based best practices for providing services and supports to those with concurrent disorders, based on providing integrated treatment that addresses both substance use and mental health rather than trying to isolate one or the other.

In terms of your question about treatment vs. incarceration, I think it is important to recognize and address substance use as primarily a health and social issue rather than just as a criminal justice issue.

However, we also need to recognize that many people who are involved with the criminal justice system have or have had problems with substance use. Therefore, we need to make sure that they have access to evidence-based services within the criminal justice context.

By providing an integrated continuum of care, we can ensure that people within the criminal justice system have the tools that they need to connect an individual with a concurrent disorder to the specialized treatment system in cases where such a referral is sought or appropriate.

Just to clarify — I am not advocating a system of mandated treatment, but rather a system that ensures people have access to effective services through as many doors as possible.

Karen Leith, Toronto: After my sister's overdose death in 1991, I have travelled a rollercoaster of guilt. What else could I have done? Why her and not me? What about her children?

I also felt partly responsible because I could no longer bear to listen to her lies and watch her sad physical decline, so I withdrew myself completely and we didn't speak for the last three years of her "life."

I now believe that, while I did everything by the book that was fashionable at the time, (let her go, she has to hit bottom, blah blah blah) part of what contributed to her death was the isolation of her addiction.

I support onsite facilities like the one in Vancouver because I would like to think that addicts have at least one place to go where they don't have to hide and the opportunity to find out about available resources — a place to be treated like a human being.

Harm-reduction programs are difficult for a lot of people to rationalize, if only because most of us will never have to witness the long slow death of addiction. Harm-reduction programs are a hard sell because of over-simplification and misunderstanding of drug addiction.

Remember the "just say no" nonsense? How successful was that in the U.S.? As if anything were that simple!

I cannot even guess whether my sister would have chosen any alternative other than the one she chose, but someone else will and it will make the difference between life and death to them.

I thank you and your colleagues for your brave work and I hope it continues until it is no longer necessary.

Rebecca Jesseman: Thank you for sharing your story, Karen. Stigma and isolation are certainly barriers to seeking services and supports for substance use problems.

The irony is that most of us have in fact been impacted by substance use on a personal level. Yet as a society, we do not recognize this issue as a health and social priority.

Your story also draws attention to the importance of ensuring that services and supports are available not only for individuals with substance use problems, but for their families, loved ones, and other carers as well.

Jasmine Francis, Halifax: Rebecca, you express yourself very articulately but it seems to me that you are dancing around the elephant in the room.

How can there ever be a national consensus on how to treat illegal drug abuse when such a sizable number of Canadians — many of whom are in or support the Harper government — adamantly oppose any approach other than the maximum jail time for everyone caught by police?

Rebecca Jesseman: I think we have to go back to the starting points I identified earlier, beginning with evidence-based dialogue. I think you'll find that when people are presented with evidence rather than rhetoric, they are willing to consider a wider range of options to deal with illicit drug use.

Public opinion polls can be deceiving, and often reflect the wording of the question rather than an informed opinion of the issue.

Alan Ogborne, London, Ont.: Excellent article, Rebecca.

I think debates about the merits and limitations of interventions in the substance abuse field would be better-informed, and perhaps less acrimonious, if there was a greater investment in evaluation research.

In the case of Insite, research has shown that it provides high-quality services and that it is used by large numbers of marginalized injection drug users with significant health and other problems. Further it is clear that the staff make an effort to refer clients to detoxification and other services.

However, a significant investment in research will be needed to show if it reduces overdose deaths and HIV transmission rates and to establish its cost effectiveness when compared with outreach service, enhanced needle exchange service, drug courts, and opening more detoxification and treatment services.

This is not to say that research will be easy or that the results will be clear-cut. Controlled studies of Supervised Injection Services (SIS) such as Insite are very difficult to mount due to the nature of these services and the contexts in which they operate.

Nonetheless, good longitudinal research could reduce some of the uncertainties about the benefits of Insite and move us beyond the unsubstantiated claims and counter-claims of the true believers and the sceptics. The same applies to other types of intervention including prevention, treatment and law enforcement.

Research would also be more useful if the objectives of new interventions were always clear and measurable, and if there was a consensus as to the appropriate indicators of success. This was not the case with Insite where the objectives were laudable but not very specific and no specific indicators of success were stated up front.

Rebecca Jesseman: Thank you for contributing to the discussion. Research in this field certainly faces a range of ethical and resourcing challenges that will hopefully be taken up by the field and by the academic community in order to further advance the evidence base.

Matthew Elrod, Victoria: Dear Rebecca, some some commentators were not impressed that the NGOs in Vienna reached a consensus on the definition of harm reduction, perhaps not realizing that a single objection would have prevented it. Can you elaborate on the full resolution to emerge from those meetings and its significance?

Rebecca Jesseman: The full Beyond 2008 resolution and declarations are actually 12 pages long, but I will share the definition of harm reduction that emerged from the Beyond 2008 Forum.

It reads: "Recognizing the important contributions made by NGOs since 1998, as reported through the NGO questionnaire and the Beyond 2008 regional consultations, including, inter alia: iv. harm reduction, meaning efforts primarily to address and prevent the adverse health and social consequences of illicit/harmful drug use, including reducing HIV and other blood-borne infections."

The challenge to reach consensus on this definition alone could have altered the course of the entire forum. However, obtaining consensus on this key point lowered the rhetoric in the room, allowing delegates to move forward and agree to the declaration and its three resolutions.

What's most significant coming out of these meetings is that it represents the first time that non-governmental organizations representing those who work most closely with those affected by substance use were able to advise the United Nations on international drug policy.

Its declaration and resolutions represented many different voices — individuals, families, and communities — from around the globe and will bring a fundamental understanding on how to achieve demonstrable progress to reduce illicit/harmful drug use and its adverse health, social and economic consequences.

The Beyond 2008 declaration and resolutions are just the start. Participants made a commitment to build upon the achievements in Vienna by engaging their governments. For more information, please visit www.vngoc.org

Jim Sheppard: Thank you again, Ms. Jesseman. I'm sure our readers appreciated your insight and analysis. Any last thoughts?

Rebecca Jesseman: I'd just like to thank everyone who provided questions and comments for this discussion.

I hope that we can continue to work toward increased understanding of one another's perspectives and support the development of a comprehensive approach to substance use in Canada.