In the CMAJ special issue, Eric Single and colleagues' objective quantification of mortality and morbidity does place illicit drug use in third place after alcohol and tobacco, which are both legal psychoactive substances [Research].² But their report of 805 deaths and 6940 hospitalizations in 1995 can hardly be said to "downplay the seriousness of illicit drug use." The role that injection drug use now plays in the transmission of HIV and hepatitis C virus in Canada is further cause for concern. Benedikt Fischer and colleagues and Catherine Hankins argue that our traditional approach to illicit substance use is in part responsible for this tragic metric [Review],³ [Commentary]⁴

Mangham posits a narrow definition of harm reduction — essentially use-tolerant interventions — yet also raises some of the concerns addressed by Yuet Cheung, who notes that "during its evolution [harm reduction] has been ... criticized for sending the wrong message to drug abusers and the public and disparaged as promoting a defeatist position [Commentary]."⁵

Eric Single has written about the definitional problems and has called for an empirical definition of harm reduction.⁶ In this conceptualization one cannot determine a priori whether a policy or program is harm reducing until one examines the evidence of its impact. Any program, be it demand or supply reduction, use tolerance or abstinence, that measurably reduced harm would be deemed harm reduction.

With its present drug strategy Canada spends heavily on law enforcement (more than $400 million annually⁷); these monies comprise the bulk of dedicated resources, yet there has been virtually no research on its effectiveness in reducing drug use or drug-related harm. Accepting and operationalizing an empirical approach would have advantages. As a nation we could develop and invest in policies and programs that were effective in reducing the prevalence of substance use and misuse, that reduced harm resulting from substance use and misuse and that provided users with effective options for managing or quitting substance use.