Downtown Eastside

Four Pillars drug strategy

About the four pillars approach 

The four pillars approach to drug addiction was first implemented in Europe in the 1990s, and is based on four principals:

  • Harm reduction
  • Prevention
  • Treatment
  • Enforcement  

Successfully used in such cities as Geneva, Zurich, Frankfurt, and Sydney, this four pillars approach has resulted in a:

  • Dramatic reduction in the number of drug users consuming drugs on the street
  • Significant drop in overdose deaths
  • Reduction in the infection rates for HIV and hepatitis.


Learn more about the four principles

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BC211's "Redbook" is a complete online directory of programs and services in Vancouver for residents with alcohol or drug misuse issues.

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The prevention pillar includes strategies and interventions that help prevent harmful use of alcohol, tobacco, and both illegal and prescription drugs.

In November 2005, Council unanimously endorsed the drug policy prevention plan, Preventing Harm from Psychoactive Substance Use. The plan is the result of extensive research and diverse community consultations.

The plan is also the first of its kind at the municipal level in Canada. It is comprehensive, integrated, and based on the best evidence and research available. It aims to expand awareness, understanding and discourse around prevention.

Goals of the drug policy prevention plan

The plan will:

  • Reduce individual, family, neighbourhood and community harm from substance use
  • Delay onset of first substance use
  • Reduce incidence (rate of new cases over a period of time) and prevalence (number of current cases at one time in a population) of problematic substance use and substance dependence
  • Improve public health, safety and order.

Recommendations of the drug policy prevention plan

There are 27 recommendations in the plan. They map out a comprehensive strategy for reaching the goals.

They call for public education, employment training and jobs, supportive and transitional housing and easily accessible healthcare. They also call for prevention efforts tailored to Vancouver’s youth and its diverse ethno-cultural and Indigenous communities.

The recommendations address marijuana grow operations and methamphetamine labs, as well as the need for a syringe recovery system. The plan also calls for increasing limits on the sale of tobacco and a community partnership approach to the development and implementation of a comprehensive alcohol strategy.

Finally, the plan calls for legislative and regulatory changes to create a regulatory system for all currently illegal drugs that would increase our ability to control potentially harmful substances and limit the control that organized criminals have over these drugs.

Benefits of the plan

The prevention of problematic substance use contributes to the public good by reducing costs to society as well as harm to individuals and communities. Important prevention goals include delaying the onset of substance use among youth and addressing the underlying causes of drug use. Prevention acknowledges that individuals usually make the best choices available to them, but that factors such as abuse, poverty or a history of addiction in the family may constrain those choices.

Of the four pillars, prevention requires the greatest amount of commitment and collaboration across all sectors of the community over a sustained period of time to show significant results. In the long-term though, prevention will have the greatest impact in reducing harm from substance use.


The treatment pillar includes a range of interventions and support programs that encourage people with addiction problems to make healthier decisions about their lives.

Treatment improves health by decreasing preventable deaths, illnesses and injuries, while improving social integration.

Early intervention

Early intervention is a crucial aspect of any treatment system. Treatment seeks to create a continuum of care by recognizing that different drug use patterns must guide treatment strategies. Since there is a chronic relapse pattern with addictions treatment, abstinence is not always the only measure of success.

Treatment interventions must also respond to multiple individual needs as well as particular needs of specific populations.

Treatment services

Treatment services, delivered by Vancouver Coastal health, include:

  • Core services at community health centres
  • Withdrawal management
  • Residential and non-residential services.

 Currently, there are four levels within withdrawal management ranging from home detox to medical detox. Treatment is most effective when it considers factors unique to each individual and tailors treatment accordingly. Addiction services have been decentralized in Vancouver, with the goals of decreasing acute care demand and improving treatment completion rates.

Currently in Vancouver, alcohol dependence affects over 12,000 people and injection drugs over 9,000 people. Treatment makes sense on both humanitarian as well as economic grounds. According to the March, 2006 Canadian Centre on Substance Abuse report, The Costs of Substance Abuse in Canada 2002, the overall social cost of substance (tobacco, alcohol and illegal drug) abuse in Canada in 2002 was $39.8 billion.

Methadone treatment and counselling has been an area of significant growth in the treatment of heroin addiction in the province. The number of people in BC treated with methadone was 8,319 at the end of 2006.

Vancouver is also one of three Canadian cities that participated in the North American Opiate Medication Initiative (NAOMI). Supported by the City of Vancouver, the study sought to determine whether prescription heroin, or a combination of heroin and methadone, might be a better treatment for those who do not respond to methadone alone. The NAOMI clinical trials took place between 2005 to 2008 and showed that patients treated with injectable heroin were more likely to stay in treatment. After NAOMI, the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) took place to test alternative treatments for people who were using heroin. The SALOME clinical trials concluded in 2015.

Meanwhile, Vancouver Coastal Health has increased its treatment budget by about $2 million per year, over the past five years, adding new addiction services, an increased number of detox beds and the development of addiction housing.

Harm reduction

The goal of the Four Pillars Drug Strategy is to reduce harm to individuals and communities from the sale and use of both legal and illegal substances.

The principles of harm reduction require that we do no harm to those suffering from substance addiction, and that we focus on the harm caused by problematic substance use, rather than substance use per se.

Harm reduction involves establishing a hierarchy of achievable goals which, when taken step by step, can lead to a healthier life for drug users and a healthier community for everyone. It accepts that abstinence may not be a realistic goal for some drug users, particularly in the short term. Harm reduction involves an achievable, pragmatic approach to drug issues.

A 2002 International Narcotics Control Board (INCB) legal opinion on harm reduction approaches noted that the concept of harm reduction had only emerged in the previous decade, but aspects of the existing international drug control treaties addressed harm reduction issues.

It pointed to a provision in the 1988 Convention: “Demand reduction policies shall: (i) Aim at preventing the use of drugs and at reducing the adverse consequences of drug abuse.” The legal opinion said it could be argued that this provision provides a mandate for harm reduction.

Harm reduction interventions have proven successful in decreasing the open drug scene, the spread of HIV/AIDS and hepatitis, overdoses and overdose deaths in countries such as Germany, Switzerland and Australia.

Supervised injection sites and needle exchanges

Vancouver’s harm reduction programs include the supervised injection site (SIS), needle exchanges and low-threshold community health services. Vancouver has 24-hour-a-day access to needles through low-threshold, peer-based needle exchanges, to mobile exchanges and needle exchanges attached to primary health care services.

North America’s first Supervised Injection Site (SIS), InSite, opened in Vancouver in September 2003.


The enforcement pillar of Vancouver’s four pillars strategy recognizes the need for peace, public order and safety in the Downtown Eastside and other Vancouver neighbourhoods. History tells us, however, that policing alone is not a solution to Vancouver’s drug problem and that an integrated approach including prevention, treatment, harm reduction and policing has proven to be effective. The Vancouver Police Department (VPD) has formally endorsed the four pillars strategy and its principles.

In 2006, the VPD published its drug policy. It says that the VPD’s mission, as related to drug policy, is to reduce crime, fear of crime, and street disorder while protecting the vulnerable and preserving and protecting life.

The VPD drug policy sees prevention as the most important of the four pillars, but said there is concern that a lack of resources dedicated to this pillar does not allow for large-scale prevention programs. Success in this pillar, it says, would reduce needs in the other three.

The policy says that the VPD will continue to target street and middle-level drug traffickers and producers. Police will be guided by an individual’s behaviour in determining whether or not to lay drug or alcohol possession charges. Police will also target areas frequented by children, such as schools and parks, and other areas where possession or use of drugs could interfere with lawful use of the public areas by members of the community.

The VPD supports the Supervised Injection Site, located on East Hastings Street. It also supports the North American Opiate Medication Initiative, a clinical trial testing whether medically prescribed heroin can successfully attract and retain heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs. It also supports accessible and immediate treatment for substance abuse on demand, for both adults and youth.

Police officers will continue to work to improve coordination with health services and other agencies that link drug users to immediate medical care, withdrawal management (detox), treatment and other counseling and prevention services. Vancouver police efforts are complemented by Drug Treatment Courts. These provide an alternative to incarceration for non-violent offenders addicted to heroin, cocaine or opiates, to follow treatments such as methadone maintenance.