The provision of stable safe housing, social supports, coun-seling, 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.

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