Addiction, Bicycle Helmets, and Leaky Boats
Good intentions do not prevent unintended consequences
I write this sitting here at my office window overlooking the harbour in Canso, Nova Scotia. Fishing boats come in and out every few hours harvesting lobster, bluefin tuna, halibut, or crab depending on the season.
The ocean is dangerous and working on a boat leaves little room for error. Fishermen are tough, and smart. They know how to stay alive while making a living on the cold Atlantic.
One of the expressions I heard growing up was “you can’t drill a hole in the bottom of your boat to let the water out”. Even if you write “OUT” beside the hole, and even if you fervently believe that the water will move in that direction, the water doesn’t go where you want it to just because you wish it to. Drilling a hole can only seem like a good idea if you don’t understand hydrostatic pressure and gravity.
(Aside: Dr. Julian Somers - a thoughtful and heterodox voice on the issue of “Safe Supply”, will be one of our speakers at this year’s Free Speech in Medicine conference in Baddeck, Oct 27th-29th, for which registration is now open. He will be speaking on harm reduction policy and safe supply. You can read some of his thoughts in the National Post here.)
We have ourselves a BIG problem
Our society has a major drug problem. Currently the USA is losing around 100,000 people per year (mostly young men) to drug overdoses. In comparison, about 58,000 Americans (mostly young men) died during the entire Vietnam war. Canada has a similar overdose death toll per-capita.
The reasons why so many people are dying “deaths of despair” are varied, complex, and interwoven. The “death of God” and the loss of community. Pernicious effects of the internet and social media. A decadent society that allows and encourages disability and sloth. Cheap and available drugs. The death of shame. Moral relativism. Entire books have been written each of these issues, so I’ll stop at one paragraph, particularly because what I want to talk about are solutions. Or more specifically things that APPEAR to be solutions, but aren’t, like drilling a hole in the bottom of your boat.
Making things safer doesn’t necessarily make things safer - the paradox of the Peltzman effect
There is a concept in behavioural economics called “The Peltzman Effect”, also known as “Risk Compensation”. Here’s a good example.
It’s been observed that kids (and probably adults) take more chances and drive their bicycles more aggressively after putting a helmet on. As well, drivers are less careful around cyclists wearing helmets than bare-headed cyclists (interestingly, drivers also allow more space for female cyclists than male.) So the beneficial effects of helmet-wearing are somewhat mitigated by the behaviour of both the rider and nearby motorists. This change in behaviour in response to safety (or perceived safety) is called the Peltzman Effect.
I’ve heard this effect described in a humorous way in the converse: The most effective safety device to install in a car would actually be a 4-inch metal spike protruding from the centre of the steering wheel, pointed at the driver. There would be no speeding, no tailgating. Drivers wouldn’t run red lights or drive drunk (or at least not for long). People would self-police their driving habits.
The Peltzman effect is an example of a “second-order effect” - an effect that is not intended or necessarily desired, but is a logical outflow or consequence of an intervention or policy. Actions have more than just their INTENDED consequences.
How might this Peltzman effect apply to “Harm-Reduction” drug policies?
All public health measures have complex second-order effects
During my ER work I meet a lot of addicted people (and far more people who are recovered addicts). Two stories have stuck with me through the last number of years, as they were stark examples of the downsides of public policy.
Clean Needles
Whether shooting up to get high or taking your insulin, clean needles are clearly better than dirty, shared needles. A generation ago we started giving them out for free to drug users as a way to prevent diseases in that population.
One young man I met arrived in ER late at night, essentially because he had nowhere to sleep, having burned all his bridges. His friend had just evicted him from his latest adventure in couch-surfing. He was estranged from his parents. He had no job, no hopes or dreams for the future. We chatted a bit. I could tell he was very smart. I asked how a guy as bright as him first tried injection drugs. Wasn’t he scared to try it? Didn’t he know the risk of addiction? Of catching diseases?
Yes, he knew the risk of addiction but (stupidly, he acknowledged) didn’t think he would be susceptible. That’s standard. Most of us have that hubris, especially when we’re young.
But the second part of his answer was notable. “I wasn’t stupid enough to use a dirty needle!”, he told me somewhat proudly. And he said that he never had used a dirty needle during his several years of being an injection narcotic addict. His first time “shooting up” had been at a party at the end of grade 12. Some folks were out in the garage “partying”. He had been drinking. He had smoked some weed and tried some cocaine in the past, so was keen to go and see what was happening out back. A few of the party-goers were injecting narcotics. They offered him some. They had lots of clean needles from our local support centre, that (proudly, according to newspaper articles) gives out well north of 100,000 clean needles per year. I asked if he would have shot up had their not been a fresh needle. “No way”, he said. Having clean needles available had made injection narcotic use seem “safe” enough to try. It had lowered the bar that people hurdle over the first time they use drugs. It had allowed him to take the first step down the path to addiction that had absolutely shattered his life.
Is Peltzman at play here? Do more people start using drugs in the first place, because clean needles make the activity “safer”?
Narcan
Narcan is the brand name for naltrexone, an injectable drug that temporarily reverses the effects of a narcotic overdose so that the person restarts breathing (long enough to get to hospital - if you ever are in a situation where it’s used, you still have to call an ambulance!). Previously confined to use in hospital or by paramedics, 10 or more years ago we started to give out Narcan kits to drug users, so that they could self-administer or give to a fellow user in the event of an overdose. There is no question that these save lives in specific circumstances.
Another young man (also late at night, because that’s when most of this happens in ER) came in because he had decided enough is enough. He told me he wanted to get off drugs, because he knew that if he didn’t stop injecting he would end up dead. (I had to explain to him that his only publicly-funded options were methadone or suboxone - also called “opioid replacement programs”, but that’s another story). I asked him what stimulated him to come in at that particular time
He told me that several days earlier, his best friend had died from an OD. They had been using together. He remembers passing out. He regained consciousness hours later, but his friend didn’t. It was too late to revive him. They had been doing all the things the local harm reduction centre had told them to do to stay “safe”. They didn’t use alone. They had been given Narcan kits. I asked him if he would have used as big a dose if he didn’t have the Narcan, if a friend wasn’t there. He didn’t think so. Having safety mechanisms had given him an illusion of safety, but not true safety. Addicts chasing the dragon push their limits. When an illusion of safety is created, they take more chances; they literally push the needle too far.
Not long after meeting this patient, I read a story in the media. It featured an addict talking about a friend who had died of an overdose. His friend had actually OD’ed on a half-dozen or so previous occasions, but each time had been rescued by a Narcan kit. He wasn’t so lucky with his last overdose. Yes Narcan had saved his life, sort-of…
Peltzman would ask the question: does giving out Narcan kits decrease the overall overdose death rate?
Back to Bike Helmets
There is some interesting research about bicycle helmet laws and their affect on community health. This is a subject that is near and dear to my heart (and head) that I’ve spent a lot of time immersed in over the years. You can read some details here if you are interested. To summarize:
-Yes, helmets help a bit if you do crash your bicycle
-Serious bicycle crashes are, thankfully, rare. Fatal crashes occur at a rate somewhere around 1 in a million kilometres travelled (depending on the country, the city, and what kind of a cyclist you are). The odds that your helmet will save your life is very low.
-Cycling is a great form of exercise, and pretty much 100% of us need more exercise. Exercise decreases cardiovascular disease risk. Rather than 1 in 1 million, CV disease is the leading cause of death for us in North America. When we force riders to wear helmets, some people stop cycling. Data shows that if even 10% of people quit bicycling because of helmet hair, then helmet laws are killing more people from heart attacks than they are saving from head injuries.
The problem here is that it is easy to identify a person with a head injury due to a bicycle crash. He is the dude lying bleeding on the road next to his twisted bicycle, beside the car with the spidered windshield. But the 52 year old with the heart attack is just another person with a heart attack. He doesn’t have “THIS HEART ATTACK CAME 15 YEARS EARLY FROM NOT BICYCLING” emblazoned on his chest as we do CPR.
What does this have to do with drug policy?
Similarly, those we save with Narcan kits are obvious. Those who overdose and die in part because their Narcan kit gave them an artificial sense of security are impossible to identify.
It is striking that “Harm Reduction” as a practice is about a quarter century old. The same quarter-century where overdose deaths have skyrocketed (graph below). If these things worked so well, shouldn’t deaths be decreasing? Although deaths appear to be levelling out somewhat in certain regions in the last few years, in my opinion this is happening for similar reasons to why obesity has levelled out. There are only so many people who will become obese, and most already are. We have “maxed out”. There are only so many people at risk of becoming addicted to drugs, and since not an insignificant number of them die every year, the growth of the “pool” of at-risk addicts is slowed. At some point, a steady-state is reached.
We have provided a seemingly limitless supply of clean needles, outreach programs, housing programs, free Narcan kits, safe injection sites, and now the latest in the line “Safe Supply” (ie: your tax dollars are now paying for addicts’ drugs). Vancouver, for instance, now spends over 1 million dollars per DAY on social spending in the downtown east side. And yet OD death rates have increased or stayed steady.
Yeah, but it would be even worse if…
Proponents of harm reduction are reduced to the highly unscientific argument “It would be even worse if we weren’t doing this!”. This has always struck me as being similar to a long-ago patient of mine who had refused standard therapy for her rheumatoid arthritis. She was very much into natural treatments, and anti-pharma (both of which I admire), but had taken this to mean that EVERY modern medicine was dangerous and unfit to put in her body. She was extremely crippled and limited by her joints. She wore copper bracelets which she explained to me kept the joints from being affected. When I pointed out that her joints WERE in fact quite bad, and getting worse over time, she said something along the lines of “They’d be even worse if I didn’t wear my bracelets!”. This thinking is magical, not logical. I respect an individual right to make personal decisions based on this thinking, but I don’t support using it to take large amounts of tax money and spend it on programs of dubious value.
We don’t have a homelessness problem, we have a drug problem
As an aside, I am bothered when the argument is made in 2023 that we have a “homelessness problem”. We do not. We have a drug problem.
I can’t recall the last time I met someone homeless for any length of time who was not addicted. Would you give a spare bedroom or couch to a family member in need if they suddenly became homeless? I sure would, and so would most of us. Now, what if that person was a mess: injecting drugs, high much of the time, and involved with crime to feed their habit. Would that change your calculation?
Someone who finds himself homeless can get help through a myriad of social programs that we fund through our tax dollars. But housing programs and homeless shelters have rules around drug and alcohol use. For obvious reasons it is not fair to the others who share these services and facilities to have people who are often disruptive and potentially dangerous (not to mention presenting a temptation to others with addiction who are trying to kick their habit) in the shelter with them.
Misdiagnosing a problem leads to mistreating that problem.
And finally, we arrive at “Safe Supply”
The ultimate end of the slippery slope that is “harm reduction” is what proponents have labelled “Safe Supply”. Much like the “MAID” acronym (Medical Assistance in Dying) I find the term obfuscatory. MAID should be called what it really is: euthanasia, or medically-assisted suicide. More sober (excuse the pun) scientists and doctors call “Safe Supply” PSAD: Public Supply of Addictive Drugs.
I highly recommend Aaron Gunn’s documentary “Canada is Dying” which delves fearlessly into the issues of drug use, homelessness, crime, and “Safe Supply”.
SPOILER ALERT. Safe supply has not worked out. What actually happens when “experts” use our tax dollars to provide large amounts of narcotics to addicts?
The basic law of supply and demand says that when there is much more of a product available, the price goes down. If there is a bumper turnip crop this fall, the price of a turnip falls. Put a bunch of “free” drugs onto the street, the price falls.
The addicts being given this supply of drugs (typically Dilaudid, or hydromorphone, a narcotic about 7 times stronger than morphine) don’t actually want the drug they are being given. In most areas, addicts are now using fentanyl. Fentanyl is 100 times stronger than morphine, so more than 10 times stronger than the Dilaudid they are supplied for free. Giving hydromorphone to people addicted to fentanyl is like giving Mario Andretti (sorry to show my age with that choice of example) a K-Car (OK, that dates me even more) to race. It just feels so, so slow!!!
Creating a new crop of addicts with “Safe Supply”
Those who are given hydromorphone don’t use it “safely”. Instead they very often sell it to help finance their fentanyl habit. And all of that hydromorphone released onto the streets means the price has plummeted. So now a high-schooler looking to get freaky on a Friday evening can decide between popping (or snorting or injecting it for a better high) some cheap hydromorphone, or opting for much more expensive alcohol or marijuana. Thereby a fresh supply of addicts is being created with “Safe Supply” drugs - a new demographic that harm reduction “experts” can use to argue for more funding for their programs.
Where is the line between helping and enabling?
Safe supply and other harm-reduction strategies are attractive ideas. Supporting them feels compassionate. It feels like we are “doing something” to fight addiction. But reality is reality. Our actions don’t always produce the effects that we envision, despite our best intentions, and despite “experts” who tell us that they will.
Over the years I have met many patients - and have friends and family - who are recovered addicts. Many still call themselves “addicts” and refer to themselves as “in recovery” even if they have been sober for decades. As I understand it, this is a reminder to themselves that they need to stay forever vigilant against relapse.
Hitting rock bottom is often the only thing that makes an addict change. Is harm reduction a cushion that keeps people from hitting that rock bottom?
At some point in our attempt to help addicted people we cross a line from reducing harm into enabling continued drug use. Exactly where that line is is debatable. But what is certain is that for those who are addicted, continuing to use drugs means many things. Continued misery, poor health, lack of fulfillment, low self-esteem, and lack of hope and plans for the future - things that can’t be put on a spreadsheet or quantified, like the number of clean needles and Narcan kits distributed.
Continued drug use also means continued risk of overdose and death. Has our focus on harm reduction increased or decreased the overall harms of drugs to our society? How is it possible to tell?
Is this the government’s problem to solve?
I am all for helping others. I think it is moral. And Christian. Even from a selfish, pragmatic sense, it makes society better as a whole if we can help those who are, because of their current lifestyle and behaviours, harmful to their communities. It seems to be our current default that when we walk by someone like the man pictured above on the sidewalk, our automatic reaction is “the government needs to do something about this issue!” rather than “What is it about this individual that has led him to this circumstance, and what can I personally do to help him”.
One thing I’ve always taught students and medical residents is that if a decision you are making seems easy, you are doing something wrong and need to think harder.
If only we could just drill a hole in the bottom of our boat to let the water out. Even if an expert with a PhD in marine engineering tells me it’s a good idea, I think I’ll listen to the fishermen. If only free needles, Narcan kits, safe injection sites, and free, “safe” drugs would result in FEWER drug problems instead of more. Again, people with PhD’s can preach, but forgive me if I remain skeptical.
What a great article you have written! It is spot on in how I look at these problems we are facing today. So often I say, "Look at all the marijuana shops". There are numerous ones even in small towns. Who is funding these? And the safe injection sites and safe this and that -- all put there to dumb us down. Look at the covid scam, small shops were forced to close but the alcohol and drug shops were left open. That should make us all think. I think government (federal, provincial and city/town) is largely responsible for enabling this addiction. If one town/city promotes it, then others follow. Brain cells have shrunk, honestly. All these things that 'catch on' including helmets are there to make you dumber and not think for yourself. As soon as you speak out about the obvious, you are called names as many of us can testify to.
I spent much of the ‘90s between the edge of Vancouver’s downtown Eastside and Halifax. The poverty industry had already assumed control of Hastings St and things were getting visibly worse every year. Petty crime was out of control of course but the real disaster was the division of the city into two camps; the disposable and the prosperous. You could hear the educated classes speak of the need to “do something” about the despair and rot in their city core. Their guilt of living in million dollar homes while all around them junkies lived in alleys and doorways was a recipe for disaster. They wanted to throw money at the problem and any poverty professional with a “solution” was more than happy to receive it. In about ‘01 I asked a doctor friend here in Halifax if her ER saw many opioid ODs and she said no. I said she would soon enough. Much like the capital flow of Chinese money from West to East, Vancouver through Ontario and onwards to the Eastcoast, driving up asset prices and perceived prosperity in its wake, the opioids were sure to follow. And the “solutions” would follow as well. I’m hearing the same prosperous, guilty classes discussing the same easy solutions and I imagine they’ll get the same inevitable results. Halifax will become a city divided, a poverty industrial complex will grow to service it, and the change will become a permanent feature of the city. As the saying goes, Any bureaucracy created to solve a problem will evolve to perpetuate it. People on the peninsula will install more and advanced security systems while they become accustomed to the crime and homelessness. The police will receive more funding and the hospitals will demand more capacity to deal with the victims of addiction. It will become normalized.