On Drugs and Evidence
Health minister Tony Clement insists the government's only concern is sound public policy. Does Insite really work? That's all Mr. Clement cares about. If so, the government will allow the Vancouver drug-injection facility to stay open. If not, Insite will have to close when its federal exemption runs out on June 30.
One thing that will not be a factor in the decision, Mr. Clement says, is politics. Not one bit. Science and evidence will settle it.
Some question Mr. Clement's sincerity.
After all, 22 studies examining various facets of Insite's operations have passed the rigorous peer-review process and been published in prestigious scientific journals. Every one of those studies reported positive results. And recently, in the International Journal of Drug Policy, researchers from the British Columbia Centre for Excellence in HIV/AIDS argued that after the government reluctantly granted a temporary extension of Insite's exemption, it had strangled the production of research -- by requiring researchers to agree not to publish any results until after the exemption had expired. The UBC researcher felt this was unethical and refused to co-operate.
"Taking the facts as presented," wrote Robert MacCoun and Peter Reuter, respected American policy experts, in the same journal, "a well-executed piece of policy research on a promising innovation was discontinued for unstated but blatant political reasons."
But who am I to doubt Tony Clement? He's one of the brighter lights in Stephen Harper's cabinet, and, as Ontario's minister of health, he handled the SARS crisis admirably. Besides, drug policy is a matter of life and death. To put politics ahead of evidence in making a decision like this, a politician would have to be callous and ruthless.
I'll assume Mr. Clement is better than that. He wouldn't put politics ahead of lives. The fact that he has balked at declaring Insite a success despite having those 22 peer-reviewed studies on his desk is easily explained: He simply has very demanding evidentiary standards.
That's a good thing. All politicians should.
But I've got terrible news for Mr. Clement, Mr. Harper, and all leaders who base their decisions solely on high-quality scientific evidence: Almost every element of Canada's approach to illicit drugs is unsupported by scientific evidence.
Forget Insite and all the other harm reduction programs such as needle exchanges. They may get all the attention, but they're actually very minor in the big scheme. They cost peanuts. And they don't change the underlying approach to dealing with drugs one iota.
That underlying approach is where the real resources go.
First, there's prevention and treatment. A reasonable person could argue both are underfunded. And yet both get far more money than harm reduction and both are far more important to Canadian drug policy.
Then there's law enforcement. It's an elephant among poodles. A few years ago, the auditor general guesstimated that 90 per cent of all the money spent on the illicit drug problem by Canadian governments goes to law enforcement. That figure is probably a little lower today but there's no question that the lion's share of funding goes to cops, courts and jails.
Harm reduction is fairly new -- to Canada, at least -- but not prevention, treatment, and law enforcement. In one form or another, prevention and treatment have been widely used for many decades. And law enforcement dates back to the criminalization of alcohol and other drugs early in the last century.
Given how long these policies have been kicking around, one might think there's plenty of research on all three. But one would be wrong.
In a 2006 paper published in the journal Addiction, the aforementioned Peter Reuter -- a professor at the University of Maryland whose work is respected by all sides in the drug debate -- surveyed the scientific literature. His results?
"Many studies have found treatment to have large effects on individuals' consumption and harms," he wrote. "However, there is an absence of evidence that even relatively well funded treatment systems have much reduced the number of people in a nation who engage in problematic drug use."
Oh dear. And prevention? "The scientific literature shows useful and modest effects at the individual level but there is little support for substantial aggregate effects."
How unfortunate. But what about the policy that dominates Canada's approach to drugs? "For enforcement, research has almost uniformly failed to show that intensified policing or sanctions have reduced either drug prevalence or drug-related harm. Nor -- outside of the U.K. -- is there more than a modest effort to improve the evidence base for making decisions about the appropriate level of enforcement of drug prohibitions."
Reuter is hardly alone in his assessment. In 2001, a committee of the U.S. National Academy of Sciences -- the world's premier scientific institution -- issued a report examining the state of the evidence on drug policy. In a phrase, the committee said there's very little. Evidence, that is.
"The nation possesses little information about the effectiveness of current drug policy, especially of drug law enforcement," the report concluded. "The central problem is a woeful lack of investment in programs of data collection and empirical research that would enable evaluation of the nation's investment in drug law enforcement."
Incidentally, the state of research is actually worse in Canada than in the U.S. The federal government doesn't even know how much money it spends on drug policy -- which is why the auditor general had to guesstimate.
One might think that the police -- who are in the evidence-gathering business, after all -- would be bothered by the paltry evidence in support of prevention, treatment and law enforcement. But again, one would be wrong.
A spokesperson for the Ontario Association of Chiefs of Police said his organization is opposed to Insite. "We believe this isn't the way to go," said Toronto Police Superintendent Ron Taverner. What the chiefs want, naturally, is a stronger emphasis on prevention, treatment, and enforcement.
And the Harper government agrees. Its drug strategy rejects harm reduction and instead calls for greater efforts in prevention, treatment, and enforcement.
Which is why I am sure the news I have delivered today will devastate Tony Clement. Not even Insite's 22 peer-reviewed scientific studies are enough to satisfy the minister's demanding evidentiary standards. Imagine how he will feel when he learns that Insite is supported by far stronger evidence than almost anything his government is doing about drugs.
Why, he will be shocked senseless. When his aides bring him round with smelling salts, shock will turn to outrage.
Imagine spending all that money and having no idea if it's doing what it's supposed to! Where's the research? Where's the cost-benefit analysis? This is unconscionable!
No doubt Mr. Clement will leap up and rush over to the prime minister's office to share the awful news.
A wholesale review of drug policy will follow. And of course, there will be new money for research -- so politicians will have something other than politics and prejudice to guide their decisions about what does and does not work.
Oh, and in the meantime, Insite will be permitted to keep operating. After all, it would be unconscionable to close a facility supported by evidence while continuing to pour vast sums into policies not supported by evidence.
And as we have agreed, Mr. Clement is better than that.