CAST concerns

Issue: BCMJ, Vol. 50, No. 1, January, February 2008, page(s) 14 Letters
Ray Baker, MD, Katie Bertram, MD, Doug Coleman, MD, Patrick Fay, MBBCh, Martin Gerretsen, MD, Carolyn Hall, MD, Donald Hedges, MD, Rob Hewko, MD, Colin Horricks, MD, Shao-Hua Lu, MD, Ramanjot Mangat, MD, Jennifer Melamed, MBBCh, Larina Reyes-Smith, MD, Paul Sobey, MD

The provision of stable safe housing, social supports, coun­seling, and a regular family physician to substance-addicted people on Vancouver’s Downtown Eastside is clearly one of the most exciting and potentially efficacious initiatives to be proposed in recent Vancouver medical care and research. 

What is less clear is the rationale for tying these interventions to pharmacological substitution—the core of the CAST (Chronic Addiction Substitution Treatment Trials) initiative.

Even more troubling to us as physicians is the statement on the CAST web site that “substitution therapy is a means of reducing the users’ impact on public order and public health until durable solutions are reached.” This is not health care, nor is it likely that it represents the goal of addicted patients.

Does this mean that the chances for recovery for addicts is so small that the only option is to be “safely and ethically” managed through the CAST initiative with its stated primary goal being “… to significantly reduce crime and disorder in Vancouver by 2010”?

We believe that the widespread introduction of safe housing, a regular family doctor, and social supports are the cornerstones in the management of patients with addictions. The positive effects of these interventions are well researched and well docu­mented. 

It is equally well supported that homeless, socially unstable, and/or doctorless people are more likely to suffer from addictions (see Vision maga­zine and its citations, summer 2007, The Roots of Addiction in a Free Market Society, 2005 and virtually any text on addictions medicine).

We believe that the CAST initiative is a poorly conceived strategy that has negative consequences. We are concerned that the provision of housing, counseling, or access to a family doctor may be tied to participation in the CAST initiative, and those same services denied to addicts who decline. 

What will happen to study dropouts? Will they lose their doctor/home/social supports? If we begin to base our decisions on social quietude vs. sound medical principle, can we in all good conscience claim to follow the tenets of the Hippocratic Oath and keep our patients free “from harm and injustice”?

—Ray Baker, MD
—Katie Bertrams, MD
—Douglas Coleman, MD
—Patrick Fay, MBBCh
—Martin Gerretsen, MD
—Carolyn Hall, MD
—Donald Hedges, MD
—Rob Hewko, MD
—Colin Horricks, MD
—Shao-Hua Lu, MD
—Ramanjot Mangat, MD
—Jennifer Melamed, MBBCh
—Larina Reyes-Smith, MD
—Paul Sobey, MD

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