Pubdate: Sat, 16 Apr 2016
Source: Globe and Mail (Canada)
Copyright: 2016 The Globe and Mail Company
Contact:  http://www.theglobeandmail.com/
Details: http://www.mapinc.org/media/168
Author: Andrea Woo
Pages: A10-A11

INSIDE INSITE: B.C.'S SUPERVISED INJECTION CLINIC

Supporters of Vancouver Facility Have Faced Many Obstacles but Are 
Seeing Successes

Before there was fentanyl, the highly addictive opioid at the centre 
of an ongoing national crisis, there was OxyContin, another drug that 
took the lives of vulnerable populations. And before Oxy, there was heroin.

In Vancouver's impoverished Downtown Eastside, heroin's ravages 
helped tip the province into a public-health crisis in the late 
1990s. Born of necessity 13 years ago, Insite, a supervised injection 
clinic that remains the only one of its kind of North America, 
persevered under the former Conservative government's tough-on-crime 
anti-drug strategy, which ran counter to such treatment models. After 
successfully battling the government in a series of court cases, the 
facility has emerged as a model in harm reduction, representing a new 
approach to addiction treatment that the federal Liberal government 
has embraced - and one many communities, including Toronto, are 
trying replicate.

Federal Health Minister Jane Philpott has publicly voiced support for 
harm-reduction facilities and, in January, visited Insite, describing 
the experience as "extremely moving." Earlier this month, she further 
distanced her government's approach from that of the Conservatives, 
noting that Health Canada is looking at developing a pan-Canadian 
approach to monitoring prescription drug abuse, as well as projects 
aimed at developing safer opioid prescribing practices.

"We have sent the message out loud and clear that this is a priority 
for us," Dr. Philpott said.

Dean Wilson remembers the day the wheels were set in motion for this 
revolution in the nation's approach to drug policy.

It was 1998, and Mr. Wilson, a long-time heroin user and Downtown 
Eastside advocate, stood in the drizzle at Oppenheimer Park with 
about 500 others - municipal and provincial politicians, the chief 
coroner, a police drug squad, health officials, drug users and 
activists - for a symposium on harm reduction.

B.C., at the time, was in the grip of a public health crisis. At its 
worst, in 1995, the rate of positive HIV tests among adults was about 
18 per 100,000; doctors were diagnosing two new cases of AIDS every 
day. The city's troubled Downtown Eastside had what was described as 
the highest rate of HIV infection in the western world. Meanwhile, a 
study of injection drug users in the province found that up to 90 per 
cent had Hepatitis C, the result of sharing needles and other 
drug-injecting equipment.

It was as good a time as ever to contemplate one of North America's 
most radical public health interventions.

"Before that symposium, a lot of people hadn't even heard of 
supervised injection service," said Mr. Wilson, who would later 
become the president of the Vancouver Area Network of Drug Users 
(VANDU). "A lot of people were aghast, but some of us knew that's 
what we needed here."

Its practices of providing drug users with sterile equipment and 
supervision by trained staff, as well as allowing them to connect 
with health and social services without fear of harassment or arrest, 
were deemed controversial under Conservative leadership, but the 
clinic prevailed.

Harm-reduction programs now provide an advantage in combatting the 
fentanyl crisis that is sweeping the country. The powerful synthetic 
opioid, which is often cut into other drugs and ingested unknowingly, 
was detected in less than 5 per cent of all illicit drug overdose 
deaths in 2012 in B.C.; that figure climbed to 30 per cent last year.

Philip Owen, who served as Vancouver mayor from 1993 to 2002, 
remembers the calls from community groups for the harm-reduction 
service during his tenure.

"As a mayor, I had to understand what it was all about," said Mr. 
Owen, now in his 80s. "I was interested in this subject. It was 
fascinating to me that some people were saying, 'This is terrible, 
encouraging drug use,' and so on, and other people were saying it's a 
health issue. I had to go and figure out which it was."

Some of this research included travelling to Europe to learn about 
the experience in Germany, Switzerland and the Netherlands, where 
numerous consumption sites were already in operation. Some of it had 
the former mayor dressed down in blue jeans, wandering the Downtown 
Eastside at night, asking drug users about their circumstances.

"It was just unbelievable the stories that you hear about some of 
these people. Some of them are just in terrible shape. They convinced 
me that [drug abuse] is a health issue," Mr. Owen said. The 
conservative minded politician with the right wing Non-Partisan 
Association had become an unlikely advocate for harm reduction.

The mayor contacted Ujjal Dosanjh, then attorney-general of B.C., and 
Allan Rock, then federal minister of health, and discussed the idea 
of a supervised injection site in Vancouver. They, too, were 
supportive. Before long, Vancouver secured federal funding to open 
Insite as a pilot project, which the Portland Hotel Society, a 
non-profit advocacy group, and health authority would operate in partnership.

Chris Buchner, who as a 30-year-old in in 2002 had just been hired as 
the health authority's manager for HIV and harm reduction, was 
assigned to the planning for the supervised injection site.

"I remember saying to my boss at the time: 'This is a project that 
could make or break someone's career,' " recalled Mr. Buchner, who 
today is regional director of prevention at Vancouver Coastal Health. 
"I was nervous because it was political. I think part of what caused 
me a lot of anxiety was that to get a lot of the key stakeholders on 
board, we really had to over-promise. ... To get people from their 
initial no to even a qualified yes, we had to tell some of the 
stakeholders that this would cause world peace and there would never 
be another overdose."

Still, the hardest work had been done by the community advocacy 
groups: the PHS, led by cofounders Liz Evans and Mark Townsend; 
VANDU, by cofounder Ann Livingston and Bud Osborn.

"The health authority and the ministry of health were 
Johnny-come-latelies to the picture; we weren't the ones who had to 
do the difficult work of socializing the idea and advocating for it," 
Mr. Buchner said.

Larry Campbell, who attended the 1998 symposium as B.C.'s chief 
coroner, took the reins from Mr. Owen in 2002, winning Vancouver's 
mayoral election on a campaign that promoted harm reduction as part 
of the Four Pillars approach to drug use.

Under Canada's Controlled Drugs and Substances Act, an operator of a 
supervised injection facility must first apply for, and receive, an 
exemption from Section 56 of Canada's Controlled Drugs and Substances 
Act (CDSA). Insite opened its doors in September, 2003, on a 
three-year exemption and received two subsequent extensions, running 
through to June, 2008.

Meanwhile, new HIV/AIDS cases dropped. A report in the Canadian 
Medical Association Journal projected the facility could avert 1,191 
cases of HIV and 54 cases of hepatitis C in a decade, saving 
$14-million health care dollars. A 2008 study by the B.C. Centre for 
Excellence in HIV/ AIDS found that the facility prevented up to a 
dozen overdose deaths a year. Police reported less street disorder 
and public drug use in the area. Evidence seemed to back the 
fledgling harm-reduction initiative.

But in 2006, Stephen Harper's Conservatives formed government, 
promising to change course from the 13 years of Liberal rule before 
it. This included a tough-on-crime approach to drugs that ran counter 
to harm reduction measures; on supervised injection sites, Mr. Harper 
pledged that his government would never use tax dollars to "fund" 
illicit drug use. The federal government said it would not grant 
Insite another Section 56 exemption.

In August, 2007, the PHS, along with Mr. Wilson and another Insite 
client, filed a statement of claim in B.C. Supreme Court, arguing 
that jurisdiction over Insite should be exclusively provincial and 
that federal intervention would be a violation of clients' Charter 
rights. The court sided with the plaintiffs, declaring that sections 
of Canada's drug laws were unconstitutional as they related to the 
supervised injection facility.

The Attorney-General of Canada appealed the decision and lost at the 
B.C. Court of Appeal; the attorney-general filed a further appeal 
with the Supreme Court of Canada.

In September, 2011, the Supreme Court sent a clear message: In a 9-0 
decision, it ruled that the federal government's efforts to shut down 
Insite violated injection drug users' Section 7 Charter rights to 
life, liberty and security of the person. While the federal 
government has the right to restrict illicit drug use under the 
Controlled Drugs and Substances Act, using it to prevent users from 
accessing the health services offered by Insite actually undermined 
the legislation's very purposes: the protection of health and public safety.

"During its eight years of operation, Insite has been proven to save 
lives with no discernable negative impact on the public safety and 
health objectives of Canada," the Court said. "The effect of denying 
the services of Insite to the population it serves and the 
correlative increase in the risk of death and disease to injection 
drug users is grossly disproportionate to any benefit that Canada 
might derive from presenting a uniform stance on the possession of narcotics."

To date, nurses at Insite have supervised more than two million 
injections; there has never been a fatal overdose. Non-fatal overdose 
rates have coincided with public health alerts about fentanyl 
circulating in the local drug supply, suggesting that those who 
overdosed on it at the facility could have seen grim outcomes had it 
not been for the medical intervention of Insite nurses.

Last month, Health Canada, under the new Liberal government, 
voluntarily issued Insite a four-year exemption, green-lighting its 
operations until at least 2020.

Still, even the facility's staunchest supporters acknowledge it is no 
panacea. It won't help users who smoke or swallow their drugs. 
Middle-class recreational drug users will likely never set foot 
inside. It is just one service among a spectrum that is needed in the 
fight against drug abuse and addiction - but a crucial one, says 
Andrew Day, operations director for Vancouver Coastal Health.

"With fentanyl, it's almost like a weather front rolling over the 
[country], where more and more people are being impacted by toxic 
batches of drugs, or people think they're taking one drug and getting 
another," he said. "We can't give people other choices in life, and 
they aren't able to make other choices in life, if they're dead. What 
we always have to remember is that they may be addicts, but at the 
end of the day, that's just one part of who somebody is."
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