Harm reduction or reducing harm?

I am concerned that readers of the June 13, 2000, special issue of CMAJ on substance abuse may think that harm reduction is the central tenet of Canadian drug policy. While aspects of harm reduction have merit under specific conditions, I am deeply concerned that some truths are missing from the articles in this issue.

Although Canada's Drug Strategy1 does advocate reducing the “harm associated with alcohol and other drugs to individuals, families, and communities,” its first sentence states that “Canada's drug strategy reflects a balance between reducing the supply of drugs and reducing the demand for drugs.”1 Neither of these 2 chief aims of Canada's drug strategy can be called harm reduction as defined in the CMAJ articles. Reducing harm should not be confused with harm reduction.

The articles also neglect to point out that demand reduction — preventing use in the first place and reducing the number of users — not only is central to the strategy but in fact constitutes the most cost-effective intervention.1 Instead, the articles give the impression that harm reduction — reducing harms without focusing on consumption —should form the crux of drug policy. Adopting harm reduction as the flagship for drug policy is neither compassionate nor visionary. It is simply a classic case of cop-out realism.

The articles tend to downplay the seriousness of illicit drug use, citing low incidences and the relatively greater economic costs of tobacco and alcohol. Low incidence does not necessarily mean a lesser problem. Harm reduction, adopted as an umbrella strategy, would simply widen the envelope of what drug use is considered acceptable. The message this strategy would send future generations alone cancels any benefits that I could envision.

Small ‘h’ harm reduction, in the form of specific strategies to help specific groups avoid harm while working toward abstinence or nonproblematic use (if such exists), does need to be considered. However, we should continue to concentrate on preventing drug use, making treatment much more comprehensive and accessible and sticking with drug users over the long haul of rehabilitation.