Pubdate: Fri, 06 Jun 2014
Source: Megaphone (CN BC)
Copyright: 2014 Street Corner Media Foundation
Contact:  http://megaphonemagazine.com/
Details: http://www.mapinc.org/media/5268
Authors: William Damon and Scott Neufeld
Cited: VANDU: http://www.vandu.org/

UNDERGROUND SAFE-INJECTION SITE FORCED TO CLOSE

Vancouver Health Authority Shuts Down Unsanctioned Drug User-Run Site In 
The Downtown Eastside

On a rainy day last December, a delegation from Vancouver Coastal
Health (VCH) delivered a letter to the Vancouver Area Network of Drug
Users (VANDU) ordering the organization to "cease and desist" from
operating an unsanctioned supervised-injection site in the Downtown
Eastside, where members of the drug user group assisted other people
to inject illicit drugs. It was a harm reduction service that was
widely known and used by hundreds in the Downtown Eastside and had
been operating for four years, but flew under the radar of many in the
city, and did not have government approval.

VANDU started its unsanctioned, unfunded, peer-run supervised
injection service out of a repurposed office room in their Hastings
Street storefront "at least four years", says its president Hugh
Lampkin. Unlike the other safe injection sites in the city, Insite and
the Dr. Peter Centre, no nurses were present.

VANDU-a grassroots organization of current and former injection drug
users-began operating the site as a "humanitarian response to an unmet
need," according to Lampkin, specifically the needs of the
approximately 40 per cent of IV drug users who sometimes require
assistance injecting, a service that Insite and other supervised
injection services cannot legally provide.

For four years VANDU quietly offered a safe space, clean supplies, and
the watchful eye and occasional assistance of a trained peer support
worker (current and former drug users) for an estimated 50 to 100
injections a day.

In an interview with Megaphone, VCH Chief Medical Health Officer Dr.
Patricia Daly explained that, as VANDU's funder, "VCH could not
support an operation that was not run according to VCH best practices
and that might put clients at some risk." She did not expand on how
long VCH had known about the peer-run injection service, or why the
health authority ordered it to close when it did. "We found out about
it-we were advised about it by City of Vancouver staff," she says.

Daly added that VANDU's supervised injection site could "jeopardize
[VCH's] application with Insite [Vancouver's supervised injection
facility in the Downtown Eastside] and the Dr. Peter Centre [a
residential care and treatment facility for people with HIV/AIDS in
the West End]," referring to ongoing efforts to obtain legal
recognition from the federal government for existing supervised
injection services.

VCH's decision to close VANDU's unsanctioned supervised injection site
is the latest chapter in long-running tensions between controversial,
but research-tested, peer-run models and more professionally driven
approaches to harm reduction. A peer-run site improves outreach, but
increases other risks. However, unlike past episodes of this ongoing
debate, VCH is in uncertain and politically fraught negotiations with
the federal government to protect the legal standing of existing harm
reduction infrastructure in the city, which puts the future of any
such a program in prolonged purgatory.

To maximize reach, peer-run approaches work According to Lampkin,
VANDU's safe-injection site emerged out of a project called the
Injection Support Team, a Canadian Institute of Health Research funded
project to train peer support workers to find and support injection
drug users in the community, many of whom required assistance
injecting. When funding for the program ended, many of the injection
support team's regular clients began showing up at VANDU's
headquarters. Rather than turn them away, VANDU's staff tried to
support them. A new, unsanctioned, supervised injection site was born.

"Peer-run, low-regulatory kinds of approaches are the best way to
maximize reach, so you can increase the availability of services
rather rapidly in that kind of way," says Dan Reist, the Assistant
Director of the Centre for Addictions Research of BC. "But the
trade-off is there is often less control over quality assurance
issues, and therefore a higher risk of problems emerging. Now the
debate is always about where on that spectrum from quality control to
reach do you want to be?"

Vancouver Coastal Health is acutely aware of the need for expanded
supervised injection services as well as the barriers faced by
injection drug users who require assistance injecting. According to
Daly, VCH is interested in "having a conversation about [assisted
injecting] and finding a way to cover this in the existing law."

But for VCH, the immediate concern is obtaining legal standing for
Vancouver's existing harm reduction infrastructure, an effort that an
unsanctioned injection site operated outside of the medical
establishment is thought to endanger.

Peer-run models are seen as being unable to make it through the
increasingly harsh exemption process, so local health authorities are
forced to quash innovative, research-tested services in an environment
of considerable unmet need.

VCH plans on eventually expanding safe-injection sites in a
"distributed way" by making injection services "just one of the
nursing services that is offered on site" at community clinics that
support injection drug users, wherever they may be. But in the
meantime, drug user run sites, which can build on the success of harm
reduction programs, will have to wait.

Nearly half of IV drug users sometimes require assistance injecting
Research in the prestigious Lancet journal of medicine showed that the
opening of Insite lead to a 35 per cent decrease in overdose deaths
within 500 metres of the facility compared to a 9.3 per cent decrease
in the rest of the city, suggesting that the benefits of
safe-injection sites are significant, but localized.

In addition to a need for more basic supervised injection services,
advocates have also argued that existing regulations around
safe-injection sites do not meet the needs of many IV drug users.

In particular, public health research estimates that some 40 per cent
of injection drug users in the Downtown Eastside sometimes require
assistance injecting. Epidemiological data suggests this group of
injection drug users are twice as likely to acquire HIV when compared
to those able to self-inject and are at significantly elevated risks
for infection, violence, and overdose. A recent study has also shown
that requiring assistance injecting is the strongest predictor of
syringe sharing, a key factor in the spread of HIV/AIDS among people
who use illicit drugs.

In addition, studies show that women are more then twice as likely as
men to require assistance injecting and twice as likely to report not
knowing how to inject as the reason for requiring assistance. Illicit
drug users who require assistance injecting often rely on partners or
so called 'street doctors' to help them use.

The unequal power dynamics of these relationships mean they are often
exploitative, serving to perpetuate the everyday violence many
injection drug users experience.

For some, the difficulty of injecting stems from a lack of knowledge,
while for others physical disabilities and trouble finding a vein can
contribute. However, assisted injection is strictly prohibited by the
operating regulations for supervised injection services at Insite and
at the Dr. Peter Centre, and may incur liability under civil and
criminal law for those who assist.

VANDU's efforts to create a space where drug users could provide
assistance to other drug users who need help injecting is simply the
latest chapter in a long history of peer run organizations identifying
and responding to emergent health care needs of IV drug users.

The harm reduction two-step Since the beginning of the harm reduction
movement, drug user groups have led local politicians and health
authorities in an uncertain dance: peer groups have historically led
the way, raising the alarms of a health crisis among injection drug
users and responding to it directly, while politicians and health
authorities have been slower to respond as they navigated a complex
and shifting legal and political landscape.

While this arrangement has been acrimonious at times, in two decades
it has radically transformed health care planning in Vancouver and
throughout Canada.

As Lampkin recounts, VANDU has been creating and operating
unsanctioned injection sites since as far back as 1993, when an early
incarnation of the group opened an injection room in a rented
storefront on the corner of First and Dunlevy.

These early efforts often placed VANDU, as well as other groups like
the Portland Hotel Society, at odds with police and local politicians.
But by 2003 it contributed to the first major success of Vancouver's
harm reduction movement: the creation of Insite, North America's first
supervised injection site.

According to Dr. Thomas Kerr, co-director of the BC Centre for
Excellence in HIV/AIDS, "VANDU is often at the cutting edge. They
often are one step ahead of the bureaucracy, they know what is going
on with drug users, they start to respond, and eventually they set the
path for public health; public health learns from VANDU either by
example or by their advocacy efforts."

The creation of Insite in 2003, and the 2002 opening of a
safe-injection site at the Dr. Peter Centre, placed Vancouver on the
map as a leader in harm reduction in North America.

It was also the beginning of a legal battle that, in some ways, has
still not run its course 10 years later.

Amidst significant progress, lasting unmet need

In a landmark 2011 ruling, the Supreme Court of Canada prevented
efforts by the Conservative federal government to close Insite and
required the government to create an exemption process to enable
supervised injection services to operate legally.

In response to the Supreme Court ruling, the Conservative federal
government introduced Bill C-65 (now Bill C-2) entitled "the Respect
for Communities Act" which sets forth some 26 criteria for health
authorities seeking to create new supervised injection services.

Organizations like the Canadian Nurses Association have decried the
law, arguing that the criteria emphasizes perceptions of public safety
over public health and do not give evidence the leading role it should
have in public health provision.

While the law has not yet come into effect, VCH's Daly says she is
"concerned about the [proposed] changes" as it is "already quite
difficult to get an exemption".

While the case for supervised injection was taken to the courts and
became the subject of intense political wrangling, the ongoing
healthcare needs of injection drug users and concerns around public
drug use and disorder that motivated the creation of Insite continued
to be a pressing issue.

Since Insite was founded in 2003, a voluminous body of peer-reviewed
research has shown that supervised injection services save lives and
reduce the suffering associated with injection drug use. A 2010
peer-reviewed cost-benefit analysis in the International Journal of
Drug Policy found that Insite prevents approximately 35 cases of HIV
and three deaths per year, leading to a yearly net-societal benefit of
more than $6 million.

According to Kerr, "there has been really amazing progress that has
been made in terms of a massive reduction in fatal overdoses and an
even more impressive decline in HIV infection in terms of new
infections. However, there is still a huge amount of unmet need."

Great expectations for an integrated future A strong example of the
kind of distributed care model that VCH intends to expand upon is at
the Dr. Peter Centre, an internationally renowned health care facility
located in the West End. The centre specializes in providing care for
people living with HIV who also face poverty, homelessness and mental
health and addiction issues.

The Dr. Peter Centre is currently applying for an exemption from
Health Canada to continue offering safe-injection services as part of
its AIDS care program.

According to Maxine Davis, executive director of the Dr. Peter's AIDS
Foundation, supervised injection services are simply one small part of
the nursing care services that the centre provides.

"Individuals who need supervised injection service need far more
health care than supervised injection service," Davis says. Supervised
injection, she adds, "is well within the scope of registered nursing
practice for purposes of preventing illness and promoting health." The
alternative, forcing drug users to use in back alleys or public
restrooms, is irresponsible, according to Davis-especially when the
clientele are HIV positive.

In the Dr. Peter Centre model, supervised injection services are woven
into "an environment of counselling, art therapy, nutritious meals,
the other nursing care," Davis says. "Our data shows that the
individuals who use safe-injection services, about 63 per cent, have
received addiction counselling and about one-third have also gone on
to withdrawal management services and rehab services."

The safe-injection site at the Dr. Peter Centre improves the quality
of AIDs care the centre provides, Davis says. It creates more
therapeutic points of contact to help people work through their
addictions and lead a more full life.

Davis shares Daly's vision for the future of supervised injection
services. They will, as Davis says, be integrated into "services that
already exist, where relationships with injection drug users already
exist."

The future: integrated healthcare alongside community-led supports
While supportive of plans to integrate supervised injection services
into the broader healthcare framework, Donald MacPherson is critical
of VCH's decision to close VANDU's safer injection room. To him,
peer-run models like VANDU's "make so much sense." The veteran harm
reduction advocate, drug policy expert, and architect of Vancouver's
four pillars drug strategy recognizes the need for a wide range in the
kinds of safe injection services offered to user populations. "Where
these sites have been so successful is places like Frankfurt, Zurich
and Amsterdam where there is a diversity of them run by different
outfits," he says.

"Baggage from prohibition and criminalization," MacPherson says, plays
a role in framing the peer-administration of safe-injection services
as untrustworthy and incompetent. "They're not allowed, they're not
full citizens, they're not allowed to have that level of
responsibility," MacPherson says, "even though they may know way more
than some nurse who comes to the Downtown Eastside with very little
training."

For Reist, the question is "how do we help create a community in which
the benefits of medical knowledge and nursing knowledge can be brought
to bear, social knowledge can be brought to bear, and the experience
of peers can be brought to bear to support individuals to take control
of their own life?"

Acknowledging the complex experiences and histories of drug using
communities, Reist is not looking for easy answers. "Nothing is the
magic bullet," he acknowledges. "But if we build towards community,
community can heal itself, and help heal the individuals within it."
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MAP posted-by: Matt