The Four Pillars Policy

What Are the Four Pillars of Vancouver’s Drug Policy?

Prevention Treatment Harm Reduction Enforcement
Promoting healthy families and communities, protecting child and youth development, preventing or delaying the start of substance use among young people and reducing harm associated with substance use. Successful prevention efforts aim to improve the health of the general population and reduce differences in health between groups of people. Offering individuals access to services that help people come to terms with problematic substance use and lead healthier lives, including outpatient and peer-based counselling, methadone programs, daytime and residential treatment, housing support and ongoing medical care. Reducing the spread of deadly communicable diseases, preventing drug overdose deaths, increasing substance users’ contact with health care services and drug treatment programs and reducing consumption of drugs in the street. Recognizing the need for peace and quiet, public order and safety in the Downtown Eastside and other Vancouver neighbourhoods by targeting organised crime, drug dealing, drug houses, problem businesses involved in the drug trade, and improving coordination with health services and other agencies that link drug users to withdrawal management (detox), treatment, counselling and prevention services.


Like many cities around the world, the drug trade and the social, health, and criminal ramifications of addiction have challenged Vancouver. The need for Vancouver to find a different way of dealing with its drug problem became apparent in the 1990s when a number of factors converged to cause an explosion in the rates of addiction, overdose deaths, HIV and hepatitis C infections, and the various social and criminal problems that accompany these issues.

Of course, Vancouver wasn’t the first place to grapple with this problem. During the late ’80s and early ’90s, Switzerland and Germany experienced a rise in open drug use accompanied by jumps in overdose deaths and HIV rates. The Swiss and German solution was to deal with addiction as a matter of public health rather than crime. To address the problem, they pioneered a Four Pillars approach, consisting of harm reduction, prevention, treatment and enforcement.

Impressed with the positive results of these countries’ efforts, Vancouver decided to investigate this approach.

In 2000 the City released the Framework for Action: A Four Pillar Approach to Vancouver’s Drug Problems which was a blueprint for change in attitudes as well as policy. The document was presented to citizens at public meetings held in neighbourhoods throughout the city. It outlined how a number of partners, including the City of Vancouver, Vancouver Coastal Health, and the Vancouver Police Department, could deal with the drug problem. Consequently, City Council unanimously adopted the Four Pillars approach as policy in 2001.

The City further engaged the community by bringing together businesses, government agencies, non-profits and advocacy organisations, under the banner of the Four Pillars Coalition, to consult with them about the drug problem and drug-related crime.

Needle Exchanges, NAOMI and InSite

Once the Four Pillars strategy became City policy, those partner organisations rolled out a number of initiatives under the various pillars.

One such initiative was the expansion of the Needle Exchange Program that had been existence in Vancouver since 1989.  Providing new needles prevents the sharing of already used needles and the evidence shows that this contributes to reducing the rates of HIV and Hepatitis C for people who use injection drugs.  The distribution was overhauled and de-centralised so that people could access them easily at any healthcare facility in the city.

Another important step was Vancouver’s participation in the North American Opiate Medication Initiative (NAOMI). The study was trying to determine whether the prescription of heroin, or a combination of heroin and methadone, might offer better treatment for people who have problematic drug use and don’t respond to methadone by itself. Vancouver was one of only three Canadian cities that took part. This study is an important piece of efforts to add to the spectrum of ways to improve the health care of people who use drugs. You can view a copy of the study here.

The most controversial of the Four Pillars experiments was InSite – Canada’s first medically supervised injection site. The facility on East Hastings Street (operated by Vancouver Coastal Health and the Portland Hotel Society) opened its doors in September 2003, allowing people who inject drugs to do so under supervision, thereby preventing overdoses.  There has never been a fatal overdose in InSite.  InSite staff provides first aid as well, treating wounds and abscesses, and give assessments and referrals to primary health care. The facility also provides harm reduction information and counselling, and access to condoms, needles and other injecting equipment.  InSite has led to more people getting into detoxification programs and addiction treatment, and in 2007 the Onsite facility that offers detox and transitional housing services was opened above InSite. Vancouver Coastal Health reports the facility has reduced the number of overdose deaths and hospital visits. Fewer people are injecting in public and the amount of drug litter in the Downtown Eastside has decreased.

The scientific evaluation of InSite has been carried out by researchers at the BC Centre for Excellence in HIV/AIDS and the Department of Medicine at the University of British Columbia. The research has been conducted according to the highest ethical standards, and the results have been published in more than 30 articles in the world’s leading peer-reviewed scientific and medical journals. This means that scientists from around the world have closely examined the researchers’ findings and have accepted their conclusions.

Scientific research has shown that InSite has in many ways improved the health and well-being of individuals and communities in Vancouver’s Downtown Eastside.  As one small health-focused initiative, however, InSite cannot be expected to solve all of the many complex and long-standing problems associated with addiction, disease, mental illness, homelessness, and poverty that are characteristic of so many urban settings today. As part of a larger strategy to address these problems, though, medically supervised injecting facilities such as InSite can play an important role.  For a summary of the results visit InSite summary.  For the most recent findings visit InSite findings.

Donald Macpherson, the City of Vancouver’s former Drug Policy Coordinator, is calling for increased investment in Four Pillars, observing “we’re gonna pay the bill sooner or later.” He says there needs to be more social housing – especially the kind that’s appropriate for people with an active drug problem. Increasing methadone programs and expanding NAOMI are also part of his prescription. And Macpherson says InSite has to be copied so people can have access to safe injection rooms in other neighbourhoods. “We’re heading in the right direction. And it’s an inclusive direction; it’s a compassionate direction. It’s a public health response, not a jail response. So, I think there’s a lot that’s positive. There’s value in that”.

Gillian Maxwell, SafeGames’ 2010 Project Director, says the value of the City’s involvement in Four Pillars goes beyond health. “Vancouver is famous world-wide for being a community that respects its citizens for who they are. The City has paved the way for that respect to be given to people even if they use drugs or are in the sex trade. The programs that are helping these people couldn’t have happened without the City going out and saying, ‘We have to treat people like neighbours.’”

Vancouver Deputy General Manager of Community Services Brenda Prosken agrees. “The holistic approach of Four Pillars – Prevention, Treatment, Enforcement and Harm Reduction – can be used beyond addiction services. The next step for the City will be to integrate mental health supports. Everyone benefits when services come together in a comprehensive approach. Our city becomes healthier, safer and better when we include citizens, rather than marginalising them.”

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