Pubdate: Mon, 29 Jan 2007 Source: Peak, The (Simon Fraser U, Edu CN BC) Copyright: 2007 Peak Publications Society Contact: http://www.peak.sfu.ca/ Details: http://www.mapinc.org/media/775 Author: Cindy Lou Bookmark: http://www.mapinc.org/topics/InSite Bookmark: http://www.mapinc.org/find?142 (Supervised Injection Sites) Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction) AN EVALUATION OF INSITE During the last decade, Vancouver has been the national epicentre for drug-related harm. Particularly within the Downtown Eastside (DTES), illicit injection drug use has led to epidemics of overdose-related deaths and infectious diseases such as HIV and hepatitis C. The DTES has an estimated number of 1,400 to 1,900 HIV-positive residents -- approximately one-tenth of its total population. This costs the Canadian health care system roughly $320,000 for each person infected. For years groups in the affected community, such as the Vancouver Area Network of Drug Users, have been advocating for a medically supervised safe injection clinic. In September 2003, amidst much controversy and debate, North America's first safe injection site was opened by the Vancouver Coastal Health Authority on East Hastings Street. Insite was opened as part of the arm reduction branch of Vancouver's Four Pillar Drug policy, with the other branches being enforcement, education, and treatment. Health Canada granted VCH a three-year operater exemption under section 56 of the Controlled Drugs and Substances Act, so that they could operate legally. During these three years an external scientific evaluation of its impact was conducted. When the Conservative party won the election in the spring of 2006, controversy erupted again over the fate of Insite. The federal exemption was due to expire on the 12th of September and despite the positive impact of the site reported by renowned medical journals, the federal government was reluctant to extend the exemption due to "inconclusive scientific evidence." After much public pressure, however, the exemption was extended to December 2007. With only 11 months before we reach another critical crossroad, Canadians must carefully evaluate the impacts that Insite has had thus far. Although the federal government claims that there is insufficient evidence to support extending the site's exemption, there are three people whose work with the site in the past three years offers compelling reasons why Insite should remain open. Jeff West: Vancouver Costal Health Since graduating from UBC, and then studying for a time in India, Jeff West has been working with the people of DTES. Often found standing at the door of the East Hastings facility greeting people and chatting with two or three of the site's users, the Insite coordinator seems to know everyone by name. He knows the story behind many of the faces as well. "Almost everyone I know here has some history of trauma," he said. "The vast majority of these folks are self medicating for physical, emotional, [and psychological] pain. There are other things that people are not grappling with, and [a] drug is a substitution for that." Each day an average of 607 people visit the facility. "The population we want to attract here," says West, "is the people most at risk of unsafely overdosing or contracting blood diseases. The stereotypical person I want to attract is the homeless person who buys his drug, goes behind the dumpster, picks up a needle off the ground, fills it with puddle water, and injects his drugs like that. That is what people do. How can you not get an infection?" Under the exemption, addicts could inject pre-obtained illegal drugs such as heroin, cocaine, and morphine at Insite. The facility provides free clean needles for the 12 injection stalls, and nurses to assist when users overdose. West explains that he and his staff do much more than just ensuring safer injection practices. "Ultimately, I see this site as a health clinic which focuses on a very sick population that isn't accessing the public health care system at all." The site's community transitional care team has been cooperating with hospitals and health care clinics to help addicts complete their course of antibiotics for serious heart and bone infections. They often do not receive much-needed treatment because homelessness, incarceration, and illness interrupt regular hospital visits. The facility also has a referral service for those seeking rehabilitation programs, housing, or health advice. In 2004, 40 per cent of these referrals were for various forms of addiction treatment. West emphasises that the ultimate goal of Insite is to lead people to the road for treatment. "I'm as much abstinence based as the most ideological abstinence person. Our goal is to get people from Insite to detox, and ultimately to abstinence. But people have to be alive to get to detox." In terms of Vancouver's Four Pillar Drug Strategy, West doesn't believe that harm reduction is a pillar in itself. Rather, he sees it as a philosophy from which the other pillars such as treatment are acted upon. "People think of harm reduction as some kind of separate thing, I see it as attached and part of the continuum. The first step in treatment is a place like this, where you can identify these folks, build relationships with them, and connect them to the health care system." Inspector Scott Thompson: Vancouver Police Department Inspector Scott Thompson, presently the drug policy coordinator of the VPD, notes that there initially was some controversy within the department about supporting the Four Pillars and the safe injection site. While the department is supportive of a public health objective that would reduce overdose death and the transmission of fatal diseases, some members have problems with the site from a philosophical perspective. "Are we perpetuating the cycle of drug use and abuse? Are we really helping these people?" he summerises. According to Thompson, the department eventually agreed to support Insite and the Four Pillars because they realised that harm reduction may be the best way to deal with this issue. "The traditional policing approach is to arrest a person X number of times, but we realise that we can't arrest ourselves out of this problem. So why don't we give this a chance to see if it is in fact the best model?" Contrary to some initial fears that the police would be arresting addicts for possession at the entrance of Insite, Thompson reveals that the department isn't really looking to incarcerate people just for possession. "For a number of years we did not charge for possession in that area, but we still maintain our enforcement on trafficking." He believes that trafficking is more of the criminal issue that has to be dealt with. One of the apprehensions people have about the opening of an injection site is that it will draw addicts and drug traffickers from other places to Vancouver. Thompson says, however, that this "honey pot effect" has not been proven to be the case. "Since the opening of the injection site, there has not been an increase in drug trafficking or the open drug market. People who use it are the local population, people who actually live there." Thompson feels it is important to allow Insite to stay open for a longer period of time to properly assess its effect. "It makes great sense to support [Insite] for another couple of years to see if in fact this is the best model. If you're going to have an impact [on HIV transmission rates] you need to do longitudinal studies. Right now you don't have that much data to look at." However, he is adamant that if Insite is to work as well as the models in Europe, the other Four Pillars of Prevention -- enforcement and treatment -- must be up to par. "The injection site is one very small component of an overall approach which would include on-demand treatment, a very robust enforcement arm, and a very robust prevention system. Look at the European models: literally, if you are in an injection site, and want treatment, you've got it. They have made huge investments all across the board. That is not the case in Vancouver and we are going to see these issues become more acute as time goes on. It's a question of how much are we prepared to invest." Dr. Thomas Kerr: B.C. Center for Excellence in HIV/AIDS Dr. Thomas Kerr is a research associate with the B.C. Center for Excellence in HIV/AIDS and a co-principal investigator of the Scientific Evaluation of the Supervised Injection Project. In November, Dr. Kerr and three other scientists from the Center wrote a report summarising the findings from the three-year scientific evaluation of Insite. The article reports the following: * About 7,410 individuals use Insite. The usage indicates that the project is successful in attracting its target users: those prone to overdose, likely to be HIV-positive, and likely to inject publicly. * Public drug use, publicly discarded syringes, and syringe sharing has greatly decreased since the opening of the site. * Use of Insite is associated with more rapid entry into detoxification programs and increased uptake of other addiction treatment amongst injection drug users. * The facility has not caused an increase in drug dealing in the immediate area. The crime rate is stable in the neighbourhood. There is no evidence that the provision of an injection site has resulted in increased rates of relapse into injection drug use or the number of new initiates. * There has been no overdose-related deaths at Insite since its opening. Sixty per cent of overdoses within Insite were successfully managed by facility staff without an ambulance call. When Dr. Kerr reported these findings at the International Aids Conference in Toronto last year, the response was "immensely positive." "When we gave the talk reporting on the results of the three-year evaluation, we got a standing ovation," he said. "A number of policy makers and politicians publicly made comments that this was an important innovation, something that should continue to be supported and evaluated." He feels that any opposition to the site that has been stated thus far "reflects a poor understanding of science." The scientists at the B.C. Center for Excellence in HIV/AIDS have published 15 studies within the three years Insite has been operating in journals around the world such as The Lancet, The New England Medical Journal, and The Canadian Medical Association Journal. "The fact that we have been published by some of the top medical journals in the world shows that the scientific community supports the credibility of these studies," said Kerr. Kerr agrees that although Insite does not necessarily deal with the root of the addiction problem, he asserts that as a tool for harm reduction it is a necessity. "In Switzerland, which has a much more comprehensive addiction treatment than we do here, they have shown that only about 15 to 20 per cent active drug users are engaged in treatment at any time. Meanwhile what will you do about the other 80 per cent who may be dying and transmitting diseases? The reality is, even if we invested very heavily in things like addiction treatment, which we certainly do need more of, the research shows that the problem would never be completely eradicated. There will be people who will continue to engage in illicit drug use, and you need to do something to reduce the harm associated with that behaviour." * * * * * Despite their different backgrounds and roles, West, Thompson, and Kerr concur that while harm reduction, as implanted by Insite, has had positive effects on the community and the drug user population, and for any long-term impact to be made, the other three pillars of the Drug Policy must also be established. According to a recent report on CBC Radio One, federal Liberal leader Stephen Dion agrees, and further, said that he could not understand why the incumbent government has not extended Insite's term. Intertwined with the fate of Insite is the future of Canada's public health programs for combating addictions. Will Insite become a model for other harm reduction facilities to be built throughout Canada? Ironically, at this crucial time when both proponents and opponents alike are demanding more research to be done, the government has cut all funding for further research. With no further funding and an unsupportive government, the fate of Insite remains an uncertainty until December 2007. - --- MAP posted-by: Richard Lake