Posts Tagged 'politics'

Addiction programs in Manitoba: support is flat in the great flatlands

As a have-less province with a significant fraction of the population that is poorly educated and un- or underemployed, Manitoba has its share of drug-related problems. Manitobans with addictions (many of whom have mental health issues) do not have ready access to treatment. Resources are inadequate and there are long waits. Take the case of methadone intervention programs.

Manitoba has only one-quarter of the methadone spaces per capita as compared to neighbouring Saskatchewan, and it is a sad fact that some programs currently operating in Winnipeg are feeling oxygen-deprived. Two Ten on Maryland, in Winnipeg’s inner city, is a non-profit post-treatment program for recovering addicts run by a former meth addict, Ian Rabb. He has been requesting more support from the provincial government for years, claiming that additional funding is required to provide round-the-clock supervision of clients and improve safety.

Manitoba spends $22 million a year on addiction services. Not surprisingly, belt-tightening is going on throughout government – the province faces a projected $592-million deficit this year – but officials claim this hasn’t prevented the funding of vital programs.

In a recent Winnipeg Free Press article [1] Rabb accuses the government of foot-dragging and insincerity when it claims that money is tight. In his view the programs offered at the facilities save the government money. Clients stay out of hospital and jail, and most of them eventually get off welfare.

By coincidence, in a letter to the editor on the same day a local representative of the Canadian Mental Health Association, Nicole Chammartin, pleads for improved harm-reduction programs for those with addictions, specifically mentioning methadone treatment. “We require a comprehensive and responsive addictions system that serves everyone,” concludes Chammartin.

Existing research provides some evidence for the value of harm-reduction programs for addicts. A Lancet study published last October found that psychosocial interventions used in England are associated with reduced use of heroin and crack cocaine [2]. Outreach programs can lead to high levels of compliance, general improvement, and treatment satisfaction [3]. Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement [4].

However, it is difficult to demonstrate conclusively the effectiveness of programs and successful treatment outcomes. A recent Cochrane Review went so far as to say that “there is no good available research to guide the clinician about the outcomes or cost-effectiveness of inpatient or outpatient approaches to opioid detoxification” [5].

Although Manitoba’s left-of-centre NDP government makes the appropriate clucking noises when it comes to addiction problems, its record is not looking good. The Addiction Foundation of Manitoba’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [6] has shown itself to be effective, but insufficient funds are being directed at this serious problem. People with intractable addictions are waiting for help and inner-city programs are stalled, while money earned from government-run casinos is lavished on developing yet more affluent suburbs and on purchasing law-and-order fetishes like police helicopters to make suburbanites feel safer.

References

1. Owen B. Cuts at addictions centres? Director may trim services without new provincial funding. Winnipeg Free Press. 2010 Jan 23;Sect. A:8 (col. 3).

2. Marsden J, Eastwood B, Bradbury C, Dale-Perera A, Farrell M, Hammond P, Knight J, Randhawa K, Wright C; National Drug Treatment Monitoring System Outcomes Study Group. Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study. Lancet. 2009 Oct 10;374(9697):1262-70. PubMed PMID: 19800681.

3. Henskens R, Garretsen H, Bongers I, Van Dijk A, Sturmans F. Effectiveness of an outreach treatment program for inner city crack abusers: compliance, outcome, and client satisfaction. Subst Use Misuse. 2008;43(10):1464-75. PubMed PMID: 18615321.

4. Morris ZS, Gannon M. Drug misuse treatment services in Scotland: predicting outcomes. Int J Qual Health Care. 2008 Aug;20(4):271-6. PubMed PMID: 18492708.

5. Day E, Ison J, Strang J. Inpatient versus other settings for detoxification for opioid dependence. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004580. PubMed PMID: 15846721.

6. Bodnarchuk J, Patton D, Broszeit B. Evaluation of the AFM’s Methadone Intervention & Needle Exchange Program (m.i.n.e.) [Internet]. Winnipeg: Addiction Foundation of Manitoba; 2005 July [cited 24 Jan 2010]. Available from: http://www.afm.mb.ca/pdf/MINE_report_final.pdf

Photo credit: cc licensed flickr photo by wysiwtf

A victory for common sense around harm reduction: Vancouver’s injection site wins a court battle

Insite supporters can breathe a sigh of relief. On January 15, 2010, the B.C. appeal court upheld a 2008 ruling by the province’s Supreme Court that allows the supervised injection site in Vancouver’s Downtown Eastside to stay open.

Liz Evans, the executive director of the Portland Hotel Society, which runs Insite, told The Globe and Mail: “Let’s hope [Prime Minister] Stephen Harper doesn’t waste any more taxpayers’ money by taking this to the Supreme Court.”

The debate over the future of Insite has been passionate in the two years since the Canadian government, in the face of convincing research, began questioning the validity of a harm reduction approach to injection drug use.

Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accused the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite’s work with drug users. “This government may already have garnered a reputation for being the most antiscience government in Canadian history,” they wrote in a sharply worded article published online in April 2008.

Doing exactly what it was set up to do

Kerr and Wood charge the government with attempting to “cloud science” and “manufacture uncertainty.” In the Tories’ get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including more than 20 studies by the authors which have appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

  • contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
  • helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
  • achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
  • not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to “deviant behaviour” is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite’s articulate defenders — not even the largely positive conclusions of the government’s own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

Ideological warfare

Given the significant disagreement on this issue, perhaps the very term “harm reduction” is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have “sufficiently inflamed … drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented.” Leshner advocates the avoidance of ideological intensity. “Let’s get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense.” This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one’s-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

Scientific arguments are insufficient in themselves

In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as “legalizers” in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction’s muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science. The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, “Without commitment to ‘strong rights’ and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really ‘legalizers’ harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention.”

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. The decision of the BC Appeal Court in favour of Insite is a victory in what has become a culture war waged on the backs of people who have the least power in this country.

References

1. Leshner AI. By now, “harm reduction” harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

Photo credit: cc licensed flickr photo by audreyjm529


Will Smitherman clean up Toronto’s soggy bottom? The man with the incontinence product runs for mayor

The Globe and Mail reported today on the official entry of George Smitherman into the race for mayor of Toronto.

A former health minister and deputy premier, Smitherman is renowned for much more than merely having been Ontario’s first openly gay MPP. Over the years the aggressive politician dubbed “Furious George” left a trail of arched eyebrows and stares of incredulity as he blundered into modest notoriety.

Two years ago, in what will surely be remembered as the nadir of his public career, Smitherman demonstrated appalling, cringe-making insensitivity as he made a bad mess worse in responding to criticism of the treatment of the elderly in the province’s largely private nursing homes. He told the media that he was prepared to don an adult diaper — and use it — to justify his government’s policies. Not surprisingly, this deranged outburst did not sit well with an outraged public.

The criticisms Smitherman’s health ministry received were justified. The Ontario Association of Non-Profit Homes and Services for Seniors claimed that seniors in nursing homes should be getting at least three hours of personal care; it said the average in the province is about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, called for a standard of 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, 2008, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn’t only critics of the Liberal government who were angry. There were loud calls for the minister’s resignation, even within his own caucus.

Wags and cynics sharpened their quills. In March the National Post published an imaginary Smitherman diary entry, with entries like this:

TUESDAY
Major confession, diary. I tried out an incontinence diaper today. It was so … freeing. I had three large coffees … and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won’t make that mistake again! I think this will really help in my discussion with the nurses’ union. Five hours seems to be the limit before things get a little soggy. I think I’ll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.

Of course, an apology followed immediately. “I wasn’t trivializing the matter,” Smitherman said. “I take it really, really seriously.” The minister could not be reached for comment for a long time after that; but his “diary” entry gives us some insight into why:

FRIDAY
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper “stunt.” I explained that I only thought it would gain a better understanding of the issue, but he wouldn’t listen. “Also, George,” he said, “please tell me you weren’t wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift.” I told him my cellphone was cutting out and I hung up.

Sam Solomon, writing in his blog Canadian Medicine, addsed that this wasn’t the first time that “Furious George” has run off at the mouth:

Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as “Taj Ma-hospitals.”Another classic outburst was featured on Stephen Colbert’s American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists “a bunch of terrorists, and I don’t negotiate with terrorists.” “Bravo, sir,” Mr Colbert said. “Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs.”


During the “incontinence product” controversy in 2008 Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE’s Ontario chapter, who said the minister completely missed the point. The problem wasn’t the products, but the cruel reality that residents in long-term care facilities were forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario’s health minister possibly be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should have tried absorbing some of those important statistics and the advice of experts. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.

From Eyeweekly.com here is a a taste of what to expect when Smitherman hits the Toronto campaign trail – a few Diaper George gems:

On announcing his candidacy intent: “A native son is coming home to serve.”

On wearing adult diapers to ensure nursing home residents are getting adequate care: “I’ve got one of these incontinence products … on my desk and I’m really giving this matter very serious contemplation.”

On controversial energy audits for homebuyers: “They taught me in some Grade 10 course — which was almost at the end of my stream of education — the notion of caveat emptor, buyer beware.”

On music: “I’ve been working out to the new Whitney Houston. I’m a gay man, so I love Whitney.”

On working with others: “Nobody should associate me with the status quo.”


References:

1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.



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