DRUGS, INSITE, AND HARM REDUCTION: A NEW APPROACH TO PUBLIC HEALTH IN VANCOUVER’S DOWNTOWN EASTSIDE
Introduction
It doesn’t take a scientist to tell you that Vancouver’s Downtown Eastside has a drug problem. Junkies can be seen shooting up in alleys, high on street corners, and selling dope to fellow junkies. In addition the obvious threat of death by drug overdose, drug users face issues of HIV and Hepatitis virus infection along with bacterial infection. These problems were addressed by the opening of Insite—North America’s first supervised safe injection site.
Based on a model of harm reduction implemented successfully in several European nations, Insite provides a safe and clean environment for intravenous drug users to inject their own drugs under clinical supervision. At its time of opening, Insite was given a three-year operating exemption under the Controlled Drugs and Substances Act as a pilot research project, but has recently been given an extension until June of 2008. Despite its successes in clinical research studies, continued operation of Insite beyond 2008 lies in jeopardy
Risks as an Intravenous Drug User in Vancouver’s Downtown Eastside
Life is an intravenous drug user (IVDU) in Vancouver’s Downtown Eastside is full of medical and health risks, as many users resort to using puddle water, and even sewer water for injections. Also, an estimated 1 in 3 IVDU’s are HIV positive and another 90% are estimated to have Hepatitis C—sharing needles represents another major health risk. Due to these risky behaviours, it is no surprise that IVDU’s incur a major cost on our healthcare system. Many users require doctor visits, emergency services, and also visits to the hospital. In many cases, IVDU’s require medical attention for septicemia (blood poisoning) from using contaminated water, and in extreme cases, some may require plastic surgery and even amputation. By implementing a model of harm reduction, many of these costs can be reduced, and even eliminated.
Harm Reduction—A New Philosophy of Public Health
Harm reduction operates under the premise that certain risky behaviours—like intravenous drug use, unsafe sex, and prostitution—are engaged in, and will always be engaged in. However, the dangers to individuals engaging in these risky behaviours can be mitigated by interventions and programs designed to reduce the harm of these behaviours. As you can tell, harm reduction contrasts with the dominant American drug strategy of abstinence, in which interventions are designed to prohibit and stop these risky behaviours from developing to begin with. Some common harm reduction programs include designated driver campaigns, and more controversial topics include provision of condoms in schools, needle exchange programs, and safe injection sites; much like Vancouver’s Insite. Under the harm reduction philosophy, Insite provides a safe injection environment—thus reducing harm to IVDU’s—until they can be helped off drugs.
Vancouver’s Strategy on Drug Use: The Four Pillars
Vancouver has adopted a Four Pillars Drug Strategy to reduce drug related harm in the Downtown Eastside. Harm reduction is featured as one of these four pillars, with the other three including prevention, treatment, and enforcement.
Initiatives under the prevention pillar include promotion of healthy families and communities, and also prevention of or delaying onset of substance use. Successful prevention programs aim to improve the health of the general population.
Under the treatment pillar, individuals are given access to programs that help them come to terms with drug use, and help them lead healthier lives. Programs under this pillar include methadone programs, peer-based counseling, housing support, and daytime residential treatment.
Initiatives under the harm reduction pillar are designed to reduce the spread of communicable diseases, and also help prevent drug overdose deaths. There are also programs designed to increase contact between health care services and IVDU’s and programs to reduce consumption of drugs on the street.
Lastly, the enforcement pillar involves recognizing the need for “peace and quiet”, and preserves public order and safety in the Downtown Eastside. Initiatives target organized crime, drug dealing, and businesses involved in the drug trade.
Separating Fact and Fiction—What is Insite? What Impacts has it Made?
As mentioned earlier, Insite is North America’s first supervised safe injection site, and is located in Vancouver’s Downtown Eastside. Clients using Insite are first greeted at the reception area, and then enter a 12 seated injection room, where they are given a disposable injection kit which includes clean needles and water. Clients are then assigned a stall, where they are able to inject their own self-obtained drugs under medical supervision. Drugs are not provided by the safe injection site, but are obtained by the users themselves. Following injection, they enter a post-injection “chill out room”, where users are able to receive counseling and can also be referred to treatment services. Not only does Insite reduce the risk for IVDU’s, it also refers those seeking addiction help to various treatment programs as well.
Currently, Insite has reached an estimated 7,500 IVDU’s. As a research pilot project, Insite has been the subject of several medical studies, and many findings have been made. Published research in world-class medical journals (including the New England Journal of Medicine and the Canadian Medical Association journal) suggest that Insite has:
– Been leading to increased admissions to detoxification programs and addiction treatment
– Not lead to increased drug-related crime
– Reduced the number of people injecting in public and also reduced injection-related litter
– Attracted highest at-risk individuals for HIV and Hepatitis infection
– Reduced overall rates of needle sharing in the Vancouver Downtown Eastside community
– Not increased rates of relapse among former drug users
– Not negatively influenced those seeking to stop drug use
– Reduced drug overdose mortality rate
Normally, such strong, positive evidence from a pilot research project would result in an extension and implementation of similar initiatives. However, in Insite’s case, these new initiatives have yet to be drafted, yet alone launched; moreover, the future of Insite itself lies in jeopardy.
Arguments Made Against Insite: The Other Side of the Fence
Despite having several positive benefits recognized by the Vancouver Police Department, the International AIDS society, the BC Centre for Excellence in HIV-AIDS, and the Canadian Union of Public and General Employees, arguments have been made against Insite. In particular, the RCMP have released a report (in late 2006) voicing their stance against Insite and the harm reduction model:
“[T]here is considerable evidence to show that when the perceived risks associated to drug use decreases, there is a corresponding increase in the number of people using drugs.”
The report also claims that harm reduction efforts “”by themselves lead to a never-ending cycle of drug use.”
Despite such bold claims made by the RCMP report, no direct evidence was presented, nor were statements made to refute the medical evidence presented earlier. This report was highly criticized as providing mere anecdotal evidence to counter the peer-reviewed, scientific evidence published in world-class medical journals. On one hand you have the RCMP without any evidence arguing that Insite promotes drug use, and on the other hand you have scientists and physicians with scientific evidence published in reputable peer-reviewed journals arguing that Insite reduces drug use. Which do you trust?
Science vs. Politics: Who Will Win in the End?
Despite Insite’s overwhelming success being recognized in the scientific community, the harm reduction initiative is on a crash course with current North American political ideology. When Insite opened in 2003 under the Liberal government, it drew criticism from the Bush administration, and was labeled as “sate-sponsored suicide” by John Walters, director of the White House Office of National Drug Control Policy. Such statements show the lack of insight from our American neighbors—Canada’s safe injection site has in fact lead to a decrease in drug-related overdose death.
Prior to Stephen Harper becoming Prime Minister, federal drug policy was similar to the “Four Pillars” approach described earlier—a holistic model including prevention, treatment, harm reduction, and enforcement. However, the new drug policy put forth by Stephen Harper closely resembles that of our American neighbors’ “War on Drugs”. This “War on Drugs” policy, initially put into action by the Nixon administration in 1971, continues to this day; it views drug use as a crime and calls for harsh penalties and programs promoting prohibition of drug use. Despite its long period of action in the USA, the “War on Drugs” is widely accepted as providing limited success at best.
It has become apparent that our federal government has been delaying its decision on whether to expand Insite’s harm reduction strategy or to continue with the “War on Drugs” approach. At its time of opening, Insite was given a 3 year exemption to operate, and was later given another extension by the federal government to operate until Dec. 31, 2007. In September 2007, Insite was given another extension, this time only 6 months, to continue operating until late June 2008. When our federal government finally decides to make a decision, which direction will it take? Will they choose to follow our current national drug policy where only limited success has been obtained? Or will it choose to revolutionize Canadian drug policy by following one of harm reduction, which has been shown by scientific research to have several profound benefits? I for one believe that it’s time for a change.
References
Drucker, E.. Insite: Canada’s landmark safe injecting program at risk. Harm Reduction Journal 2006, 3:24.
Kerr, T.; Tyndall, M.W.; Li, K.; Montaner, J.S.; Wood, E.. Safer Injecting Facility Use and Syringe Sharing Among Injection Drug Users. Lancet 2005, 366:316-318.
Wood, E; Tyndall, M.W.; Zhang, R.; Stoltz ,J.; Lai, C; Montaner, J.S.G.; and Kerr, T.. Attendance at Supervised Injecting Facilities and Use of Detoxification Services. New England Journal of Medicine 2006, 354:2512-2514.
Wood, E; Tyndall M.W.; Lai, C.; Montaner, J.S.G.; and Kerr, T.. Impact of a Medically Supervised Safer Injecting Facility on Drug Dealing and Other Drug-Related Crime. Substance Abuse Treatment, Prevention and Policy 2006, 1:1-4.
Wood, E.; Kerr, T.; Small, W.; Li, K.; Marsh, D.; Montaner, J.S.; and Tyndall, M.W. Changes In Public Order After The Opening of a Medically Supervised Safer Injection Facility for Injection Drug Users. Canadian Medical Association Journal 2004, 171:731-734.
Wood, E.; Tyndall M.W.; Li, K.; Lloyd-Smith, E.; Small, W.; Montaner, J.S.G.; and Kerr, T.. Do Supervised Injecting Facilities Attract Higher-Risk Injection Drug Users? American Journal of Preventive Medicine 2005, 29:126-130.
“Judge Insite on science, not police anecdotes.” The Vancouver Sun. Dec. 12, 2006. Accessed Nov. 16, 2007. link