Safe-injection site adding detox beds and housing

Safe-injection site adding detox beds and housing
Canadian Press
152 words
27 August 2007
Guelph Mercury
Final
A5
English
Copyright (c) 2007 Guelph Mercury.
VANCOUVER

Addicts who shoot up their own drugs at the city's safe-injection site will soon have a place to start getting clean as the facility expands to include detox beds and short-term housing.

As of mid-September, IV drug users at the supervised injecting facility called Insite won't have to wait for detox beds elsewhere, but can instead go directly into detox on the second floor of the same building where they've been getting their fix.

The detox floor will include 12 rooms, each with its own bathroom, a common area, kitchen and exam room, where professionals will assess users and provide counselling.

Those who are homeless or don't want to go back to living in an unsafe place where people are using can then move up to the third floor for temporary shelter.

Editorial, Globe and Mail, SAFE INJECTION SITES

SAFE INJECTION SITES
Editorial
Renew Insite's licence
626 words
27 August 2007
The Globe and Mail
A14
English
2007 CTVglobemedia Publishing Inc. All Rights Reserved.

Speaking to the Canadian Medical Association last week, federal Health Minister Tony Clement was non-committal on the future of Vancouver's safe injection site. But he seemed to be leaning against extending Insite's licence when it expires at year's end, telling doctors that recent research has cast doubt on the pilot project's usefulness.

Where is Mr. Clement getting his information? He hasn't said. Most likely it is from a well-publicized article published this past spring in the Journal of Global Drug Policy and Practice. The report was authored by Colin Mangham, the director of research for the Drug Prevention Network of Canada, a hard-line organization. Last year, former Reform MP Randy White, the then-head of the network, lauded what he saw as the Conservative government's tough approach on drugs. “A new National Drug Strategy, mandatory minimum prison sentences and large fines for marijuana grow operations, a nationwide awareness campaign, withdrawal of support for injection sites, a crackdown on drug crime and no marijuana decriminalization legislation is a breath of fresh air for Canadians, as well as a reflection of real leadership we have not seen in decades in Canada,” he enthused.

Unsurprisingly, much of the report put out by Mr. White's research director reads more like a rant against the “ideology” of harm-reduction and its alleged infiltration into society than a scientific study. It contains no first-hand research; the bulk of its findings consist of simplistic efforts to poke holes in the litany of more serious studies demonstrating Insite's benefits.
Indeed, virtually all serious research suggests that the program has had considerable benefits with little downside. Reports in reputable medical journals such as The Lancet and the BMJ (British Medical Journal) have shown that Insite reduces needle-sharing in the community, reducing the spread of disease. While 500 users overdosed at Insite over a two-year period, onsite medical assistance prevented a single one from dying – something that would never have been the case on the street.

Far from encouraging drug use, as its opponents claim, Insite has encouraged addicts to kick their habits. Over a one-year period of study, it made 2,000 referrals, 40 per cent of them to addiction counselling. One in five regular visitors to the site enlisted in detoxification programs – resulting, said a recent report in the British medical journal Addictions, in a 30-per-cent rise in the number of local addicts making use of such services. Similar findings were reported last year in the New England Journal of Medicine.

Last week, a group of 134 prominent Canadian doctors and health professionals endorsed a commentary by Dr. Stephen Hwang in the journal Open Medicine calling for Insite to be continued on the basis that it “provide[s] a number of benefits, including reduced needle sharing, decreased public drug use, fewer publicly discarded syringes, and more rapid entry into detoxification services by persons using the facility.” And while the RCMP has been critical of Insite, Vancouver's police department – which is on the ground and thus aware that harm reduction makes the streets safer – has endorsed it.

Unfortunately, it appears that no amount of evidence will convince the Conservatives, skeptical since the project was launched in 2003, of Insite's value. Desperate, local activists and drug users are going to court to argue that closing Insite would violate addicts' Charter rights. That seems a dubious proposition; ultimately the government will likely be free to decide whether or not to keep the program. But if Mr. Clement resists any urge to cherry-pick his information and looks at the overwhelming body of evidence, it should not be a difficult decision.

Illegal drug study says number of deaths high in Downtown Eastside

Illegal drug study says number of deaths high in Downtown Eastside
CP
723 words
23 August 2007
16:42
The Canadian Press
English
(c) 2007 The Canadian Press. All rights reserved.
VANCOUVER (CP) _ Residents of the poverty-riddled Downtown Eastside have seven times the provincial rate of drug-induced deaths, says a report on drug use in Vancouver.
The report from the Canadian Community Epidemiology Network on Drug Use says deaths from illicit drug use were down in Vancouver and the rest of British Columbia for 2006.
Downtown Eastside residents have a 33 per cent higher death rate than the rest of the province.
The report released Thursday says Vancouver's rate of newly diagnosed hepatitis C cases declined from 2006 and new cases of HIV were down from 2005 in connection to intravenous drug use.
The report also says the volume of ecstasy seized by police in 2005 was more than 40 times that seized in 2002.
``This document provides a unique snapshot of the state of drug use in the city,'' Dr. Jane Buxton, Vancouver site co-ordinator, said in a news release.
``Our hope is that we can empower people with a basic understanding of some of the issues involved so that they can begin to do something about it.''
The group says the study was done to provide policy makers and community leaders with better information to help develop harm reduction and prevention techniques to reduce drug use.
The report found the life expectancy for men in the Downtown Eastside, ``the centre of the injection drug use epidemic in Vancouver,'' is nine years less than for Vancouver overall and three years less for women.
In 2006, there were 131 illicit drug deaths in British Columbia, 42 of them in Vancouver, compared with 146 deaths in B.C. and 46 deaths in Vancouver the previous year.
``There has been a dramatic decline in the number of illicit drug deaths in both Vancouver and B.C. since 1998,'' the report said.
Since 2003, the number and proportion of First Nations people to die from illicit drug use has increased to an average of 17 a year or 10 per cent of deaths.
In the 2001 census, 4.4 per cent of B.C. residents identified themselves as aboriginal.
The Downtown Eastside has a higher rate of tuberculosis than Vancouver or British Columbia.
``Challenges to TB control include unstable housing, mobile populations (including populations moving back and forth between the Downtown Eastside and their rural or reserve home communities), and addictions, co-morbidities and non-compliance to TB treatment.''
Studies in top international journals, including the Lancet and British Medical Journal, suggest Vancouver's safe-injection site, where users are given clean needles to inject their drugs, reduces the chance of people passing along infections such as HIV.
But in order to allow the safe-injection site to operate the federal government must grant an exemption from the Controlled Drugs and Substances Act.
The clinic's current exemption lasts until the end of the year and Health Minister Tony Clement has said he wants comprehensive research on the clinic before giving the further operating approval.
The report says between December 2003 and March 2005 4,764 people used the safe injection site.
Insite ordered 1.2 million sterile needles between April 1, 2006, and Feb. 15, 2007.
``It is important that harm reduction programs attract high-risk users, as the contact presents an opportunity to inform users about safer drug use practices and connect them to health services and drug treatment,'' the report says.
Between March 2004 and August 2005 the drugs most often used at Insite were heroin (40 per cent) and cocaine (28 per cent), as well as morphine, dilaudid, oxycodone, crushed crack cocaine, crystal methamphetamine and Talwin-Ritalin.
A study done before and after the site opened found ``significant reductions in the mean number of injection drug users injecting in public and publicly discarded syringes.''
Vancouver police department statistics indicated there was no increase in drug trafficking, assaults or robberies.
The report said said crack cocaine is one of the commonly used drugs in Vancouver's Downtown Eastside.
``While people of all socio-economic backgrounds use crack people who are homeless, street involved or otherwise living in poverty have high rates of use and experience profound negative health consequences.
``There have been few harm reduction initiatives in Vancouver that specifically target the harms associated with crack use.''

130 scientists urge Ottawa to base Insite decision on science, not ideology

130 scientists urge Ottawa to base Insite decision on science, not ideology
CP
228 words
21 August 2007
10:58
The Canadian Press
English
(c) 2007 The Canadian Press. All rights reserved.


TORONTO (CP) _ A group of 130 prominent doctors, scientists and public health professionals is calling on the federal government to use scientific evidence, not political ideology, when deciding whether to extend the life of Vancouver's safe injection site.

The group has endorsed a strongly worded commentary on the issue published by Open Medicine, an online medical journal.

In the commentary, Dr. Stephen Hwang says that if government refuses to accept the scientific evidence backing the Insite program it should be transparent about the basis for its objections.
Hwang says the health of the nation is placed in peril if leaders ignore crucial research findings simply because they run counter to a policy agenda driven by ideology or fixed beliefs.

Hwang, a researcher in the Centre for Research on Inner City Health at Toronto's St. Michael's Hospital, says the federal government seems to be judging the safe injection site program by an entirely different standard than it would other health measures.

An exemption that allows the safe injection site to operate expires at the end of this year.
Signatories to the commentary include Dr. Robert Brunham, head of the British Columbia Centre for Disease Control; Dr. Richard Lessard, Montreal's director of public health; and leading HIV-AIDS researcher Dr. Mark Wainberg

The question of charter rights

Does anyone know the outcome of this court action? It presents an interesting question

Addicts, operator of BC safe-injection site go to court to keep facility open
BY BY CAMILLE BAINS
CP
918 words
17 August 2007
13:30
The Canadian Press
English
(c) 2007 The Canadian Press. All rights reserved.

VANCOUVER (CP) _ Two drug addicts and a group that runs Canada's only safe-injection site have launched court action, saying any effort by the federal government to close the place would violate addicts' Charter rights.

Shelly Tomic and Dean Wilson, along with the Portland Hotel Society which helps operate the facility, filed a statement of claim in B.C. Supreme Court on Friday.

They want the court to declare the operation of Insite, as the facility is known, the exclusive jurisdication of the province and that the federal government shouldn't play any role in its future.

Closing it would be a violation of Tomic's and Wilson's right to ``security of the person,'' the court documents say.

Insite opened four years ago as a pilot project in the Downtown Eastside for IV drug users to inject their own heroin and cocaine with clean needles under the supervision of a nurse.
Addicts who get their fix at the site -- instead of in back alleys and the area's single-room hotels -- can also access referrals to detox and rehabilitation services.

But the future of Insite is currently in Ottawa's hands because in order for the facility to operate, it needs the federal government to grant it an exemption from the Controlled Drugs and Substances Act.

The exemption is set to expire Dec. 31 and federal Health Minister Tony Clement has been noncommital about whether it will be renewed.

``Should Insite close due to the revocation of the exemption. . . Wilson, Tomic and other users will face risk of death or serious harm to their physical and mental health,'' the court documents say.

``In particular, Wilson and Tomic will face increased risks of overdose, infection, decline in their mental and psychological well-being and other health-related complications from drug use.''
The documents go on to say the services provided at Insite are health-care matters and are therefore ``within the exclusive jurisdiction of the province of British Columbia.''

Mark Townsend, director of the Portland Hotel Society, said the ongoing uncertainty is no way to operate a health service for vulnerable people.

``It's not even funded by the federal government, it's 100-per-cent funded by the province, yet they get to give us an extension here and there to create this endless kind of worry,'' Townsend said.

``We'd rather not be in court on this issue but what we really need is just to get the clarification that, really, this is about health care,'' he said.

The site, known as Insite, is the only facility of its kind in North America.

Tomic, a 39-year-old addict with a long history of addiction issues, said she got involved in the legal action because she's seen its positive effects first-hand

``A lot of people will end up dying if they shut it down because with the fear of the police picking them up, they start (injecting) too much just to get it in them before they're caught,'' said Tomic, who was one of the first to use the facility.

Tomic said she's been taking methadone for about 10 months as part of her treatment to withdraw from heroin. And despite staying clean so far, she said she still visits Insite to talk to the staff on days when she feels like relapsing.

Dean Wilson, the other addict named in the statement of claim, credited Insite for keeping him and his two sons alive.

``This is gold-standard medicine,'' Wilson said. ``Addiction is a health issue.

``This is a life-saving measure down here. It may not be a life-saving measure in (Toronto's) Rosedale or Mount Royal in Montreal but in the Downtown Eastside, it is a life-saving measure.''
The court documents note Wilson has been addicted to herion for about 38 years, contracted hepatitis C in 1969 and has had several close calls with overdoses.

The suit says before Tomic and Wilson began getting treatment for their addictions, they stopped in at Insite to inject about six times a day for Tomic and 15 times a day for Wilson.
Dr. Evan Wood, an epidemiologist at the B.C. Centre for Excellence in HIV/AIDS, said 24 studies have pointed to Insite's benefits.

Since 2003, research published in top journals has stated the site reduces public injections, overdose fatalities and the transmission of blood-borne infections like HIV and hepatitis C, Wood said, adding crime hasn't increased in the area despite initial fears by some in the community.

``From a scientific perspective, I believe this is a health issue,'' Wood said, adding he agrees with the court action.

``(Prime Minister) Stephen Harper has failed to show any leadership on this issue and the fact that it's going to the courts now is not surprising,'' he said.

``If the facility closes and somebody contracts HIV or dies of an overdose and has a compelling argument that this wouldn't have happened to them had the federal government not removed this service, then I think that raises legal issues as well.''

Monique Pongracic-Speier, one of three lawyers working on the case for free, said her clients are merely asserting their constitutional rights regarding the use of a facility that's helped them stay alive.

``After all, Insite is about saving lives. That's the bottom line.''

Kerr, Tyndall, Ahang, Lai et al, American Journal of Public Health

Circumstances of First Injection Among Illicit Drug Users Accessing a Medically Supervised Safer Injection Facility
Kerr, Thomas; Tyndall, Mark W; Zhang, Ruth; Lai, Calvin; Et al
2867 words
1 July 2007
American Journal of Public Health
1228
Volume 97; Issue 7; ISSN: 00900036
English
© 2007 American Journal of Public Health. Provided by ProQuest Information and Learning. All Rights Reserved.

There have been concerns that safer injecting facilities may promote initiation into injection drug use. We examined length of injecting career and circumstances surrounding initiation into injection drug use among 1065 users of North America's first safer injecting facility and found that the median years of injection drug use were 15.9 years, and that only 1 individual reported performing a first injection at the safer injecting facility. These findings indicate that the safer injecting facility's benefits have not been offset by a rise in initiation into injection drug use. (Am J Public Health. 2007;97:1228-1230. doi:10.2105/AJPH.2006.086256)

Medically supervised safer injection facilities, where injection drug users can inject preobtained illicit drugs, have been implemented in various cities to reduce the public health effects of illicit drug use.1 Although evidence suggests that safer injecting facilities reduce overdose deaths,2 HIV risk behavior,3 and public disorder,4 this intervention remains highly controversial,5-7 largely because of concerns that the provision of a legal place to inject drugs may encourage initiation into injection drug use.8,9 Preventing initiation into injection drug use is a key public health priority,10 and it is noteworthy that fears regarding potential increased rates of injection drug use were among the reasons for the US federal ban on funding for needle exchange programs.9

In the light of concerns regarding the potential of safer injecting facilities to promote initiation into injection drug use,11 we examined length of injecting career and circumstances surrounding initiation into injection drug use among a cohort of users of a safer injecting facility in Vancouver, British Columbia. The Vancouver safer injecting facility-known as Insite-opened in September 2003 as part of a 3-year pilot study.

The Scientific Evaluation of Supervised Injecting (SEOSI) cohort has been described previously.12 In brief, the SEOSI participants were a representative sample of users of the Insite safer injecting facility derived through random recruitment at the Insite facility. During study visits, blood samples for HIV and hepatitis C virus testing were drawn and a questionnaire was administered to elicit demographic and other information, including drug use and HIV risk-associated behavior.

METHODS
First, we examined length of injecting career. To avoid the potential bias resulting from participants' potential unwillingness to report that their first injection was within the safer injecting facility, we calculated duration of injection drug use by subtracting each participant's age at first injection from the participant's current age rather than asking this question directly. Later in the interview, we assessed the circumstances surrounding initiation into injection drug use among SEOSI participants. Variables of interest included injection by someone else during first injection, injection with a used syringe during first injection, and location of first injection (including within the safer injecting facility). As a subanalysis, we compared the overall rate of initiation into injection drug use among SEOSI participants since the safer injecting facility had opened with the expected rate of initiation among local street youths during a similar follow-up period.

RESULTS
Overall, 1065 participants completed surveys from December 1, 2003, to October 21, 2005 (Table 1). The median age of the participants was 39 years (range= 19-64 years); 312 (29%) participants were women. The median number of years of injection drug use was 15.9 (interquartile range=8.6-25.9). High levels of HIV risk-associated behavior at the time of initiation into injection drug use were reported: 213 (20%) participants reported that their first injection was performed with a used syringe, and 796 (75%) participants reported that they were injected by someone else during their first injection. One man reported performing his first injection within the safer injecting facility. On die basis of the difference between age at first injection and current age, we calculated that an additional 14 individuals had initiated injection drug use since the opening of Insite, all of whom did not report performing their first injection within the facility. When these data were extrapolated to the entire population of safer injecting facility's users (i.e., approximately 5000 individuals),13 the estimated number of injection drug users who may have initiated injection drug use inside and outside the safer injecting facility were 5 (95% confidence interval [CI] =2, 12) and 70 (95% CI= 55, 80), respectively.

For comparison purposes, we estimated the rate of initiation into injection drug use that might be expected among the estimated 1250 Vancouver street youths during a single year.14,15 On the basis of published estimates of the annual incidence of first injection among Canadian street youths (8 per 100 person-years),16 one can estimate that approximately 100 (95% CI=81, 122) Vancouver street youths initiate injection drug use each year. This rate is higher than the rate observed among users of safer injecting facilities overall, and street youths represent only a small fraction of the local population that is at risk for initiating injection drug use on an annual basis. The 14 individuals who initiated injection drug use outside of the safer injecting facility likely did so completely independently of the existence of the safer injecting facility. Thus, the values that are most relevant for comparison are likely the estimated rate of initiation among street youths (100; 95% CI=81, 122) and the estimated rate of initiation within the safer injecting facility (5; 95% CI=2, 12).

DISCUSSION
Our findings indicated that most users of the safer injecting facility were long-time injection drug users, and we found no evidence to suggest that the safer injecting facility prompted elevated rates of initiation into injection drug use in the community. In fact, the median years of injection drug use among users of safer injecting facilities were greater tìian the median years of injection drug use (10; interquartile range=4-20) among participants in another cohort study of local injection drug users (the Vancouver Injection Drug Users Study).17 Although 1 individual reported performing his first injection at the safer injecting facility, even when we included individuals who initiated injection drug use outside the safer injecting facility, the overall rate of recent initiation into injection drug use among users of the safer injecting facility was markedly lower than the estimated background community-level rate of injection initiation.16,18
The negligible number of new injectors observed in the Vancouver safer injecting facility compares favorably with the proportions observed in European safer injecting facilities.11 Our findings also may reflect rules that prevent first-time injectors from using the safer injecting facility. More specifically, the staff members at the safer injecting facility ask all new visitors to the facility to sign a waiver indicating that they have injected previously, and it is known in the community that first-time injectors are prohibited from using the facility.

The findings pertaining to risky behavior during first injections were consistent with those of previous studies19 and indicated the need for interventions to prevent initiation into injection drug use and programs that promote safer injecting practices among new injectors. Given the high rates of syringe borrowing and assisted injection during the first injections reported among participants in this study, rules preventing first-time injectors from using the safer injecting facility should potentially be reevaluated. For example, perhaps first-time injectors could inject at the safer injecting facility if, after a careful assessment, an addiction counselor determined that the individual was unlikely to act on referrals to abstinence-based treatments and remained highly likely to initiate injection drug use.

This study relied on self-reports that may have been susceptible to socially desirable reporting. Although studies indicate that injection drug users may underreport undesirable behaviors, participants were blinded to this eventual use of the data, and therefore, we have no reason to believe that our estimates were biased. This assumption was further supported by the fact that our primary outcome was calculated by subtracting the age at first injection from the participant's current age rather than asking directly about years of injecting. However, we recognize tìiat socially desirable responding may have biased our estimates of the number of first injections performed at the safer injecting facility among the 14 individuals who initiated injection drug use after the safer injecting facility opened. Regardless, even if we assume that all of these individuals initiated injection drug use at the safer injecting facility, the rate of initiation into injection drug use among users of safer injecting facilities still would be lower than the rates that have been reported among similar at-risk populations.

Also, even though we generalized the rates observed in the SEOSI cohort to the overall cohort of users of the safer injecting facility, we thought that this was justifiable because SEOSI was based on a random sample and because previous comparisons between the SEOSI cohort and the overall cohort of users of the safer injecting facility have shown the 2 populations to be statistically similar.12 A further potential limitation of our study pertains to our comparison of rates of initiation into injection drug use from other settings and from previous years. We recognize that contextual and temporal differences may have limited the appropriateness of these comparisons, but local estimates were unavailable.

We found that the Vancouver safer injecting facility is used by individuals with long injecting careers and that users of the safer injecting facility were almost universally long-term injectors. Together, these findings indicate that the reported benefits of the safer injecting facility on HIV risk-associated behavior and public disorder were unlikely to have been offset by negative effects of increased rates of initiation into injection drug use.

References
1. Kimber J, Dolan K, van Beek I, Hedrich D, Zurhold H. Drug consumption facilities: an update since 2000. Drug Alcohol Rev. 2003;22:227-233.
2. Poschade S, Hoger R, Schnitzler J. Evaluation of the Work of the Drug Consumption Rooms in the Federal Republic of Germany [in German]. Final Report on Behalf of the Federal Ministry for Health. Baden-Baden, Germany: Nomos; 2003.
3. Kerr T, Tyndall M, Li K, Montaner J, Wood E. Safer injection facility use and syringe sharing in injection drug users. Lancet. 2005;366:316-318.
4. Wood E, Kerr T, Small W, et al. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ. 2004;171:731-734.
5. Strang J, Fortson R. Supervised fixing rooms, supervised injectable maintenance clinics- understanding the difference. BMJ. 2004;328:102-103.
6. Wright NM, Tompkins CN. Supervised injecting centres. BMJ. 2004;328:100-102.
7. Capozza KL. U.S., Canada spar over anti-drug policies. United Press International. September 16, 2003.
8. Vancouver's heroin users get safe-injection site. Canadian Broadcasting Corporation September 15, 2003.
9. Vlahov D, Des Jarlais DC, Goosby E, et al. Needle exchange programs for the prevention of human immunodeficiency virus infection: epidemiology and policy. Am J Epidemiol. 2001;154(12 suppl):S70-S77.
10. Vlahov D, Fuller CM, Ompad DC, Galea S, Des Jaríais DC. Updating the infection risk reduction hierarchy: preventing transition into injection. J Urban Health. 2004;81:14-19.
11. Hedrich D. European Report on Drug Consumption Rooms. Lisbon, Portugal: European Monitoring Centre for Drugs and Drug Addiction; 2004.
12. Wood E, Kerr T, Lloyd-Smith E, et al. Methodology for evaluating Insite: Canada's first medically supervised safer injection facility for injection drug users. Harm Reduct J. 2004;1:9.
13. Tyndall MW, Kerr T, Zhang R, King E, Montaner JG, Wood E. Attendance, drug use patterns, and referrals made from North America's first supervised injection facility. Drug Alcohol Depend. 2006;83:193-198.
14. Poulin C, Fralick P, Whynot EM, et al. The epidemiology of cocaine and opiate abuse in urban Canada Can J Public Health 1998;89:234-238.
15. Wood E, Stolte J, Montaner J, Kerr T. Evaluating metharnphetamine use and risks of injection initiation among street youth: the ARYS study. Harm Redud J. 2006;3:18.
16. Roy E, Haley N, Ledere P, Cedras L, Biais L, Boivin JE Drug injection among street youths in Montreal: predictors of initiation. J Urban Health. 2003;80:92-105.
17. Kerr T, Marsh D, Li K, Montaner J, Wood E. Factors associated with methadone maintenance therapy use among a cohort of polysubstance using injection drug users in Vancouver. Drug Alcohol Depend 2005;80:329-335.
18. van Ameijden EJ, van den Hoek JA, Hartgers C, Coutinho RA. Risk factors for the transition from noninjection to injection drug use and accompanying AIDS risk behavior in a cohort of drug users. Am J Epidemiol. 1994;139:1153-1163.
19. Fuller CM, Vlahov D, Latkin CA, Ompad DC, Celentano DD, Strathdee SA Social circumstances of initiation of injection drug use and early shooting gallery attendance: implications for HIV intervention among adolescent and young adult injection drug users. J Acquir Immune Defic Syndr. 2003;32:86-93.

Abstract
Medically supervised safer injection facilities, where injection drug users can inject preobtained illicit drugs, have been implemented in various cities to reduce the public health effects of illicit drug use.1 Although evidence suggests that safer injecting facilities reduce overdose deaths,2 HIV risk behavior,3 and public disorder,4 this intervention remains highly controversial,5-7 largely because of concerns that the provision of a legal place to inject drugs may encourage initiation into injection drug use.8,9 Preventing initiation into injection drug use is a key public health priority,10 and it is noteworthy that fears regarding potential increased rates of injection drug use were among the reasons for the US federal ban on funding for needle exchange programs.9 In the light of concerns regarding the potential of safer injecting facilities to promote initiation into injection drug use,11 we examined length of injecting career and circumstances surrounding initiation into injection drug use among a cohort of users of a safer injecting facility in Vancouver, British Columbia. In fact, the median years of injection drug use among users of safer injecting facilities were greater tìian the median years of injection drug use (10; interquartile range=4-20) among participants in another cohort study of local injection drug users (the Vancouver Injection Drug Users Study).17 Although 1 individual reported performing his first injection at the safer injecting facility, even when we included individuals who initiated injection drug use outside the safer injecting facility, the overall rate of recent initiation into injection drug use among users of the safer injecting facility was markedly lower than the estimated background community-level rate of injection initiation.16,18 The negligible number of new injectors observed in the Vancouver safer injecting facility compares favorably with the proportions observed in European safer injecting facilities.11 Our findings also may reflect rules that prevent first-time injectors from using the safer injecting facility.

Copyright American Public Health Association Jul 2007 Thomas Kerr, PhD, Mark W. Tyndall, MD, ScD, Ruth Zhang, MSc, Calvin Lai, MMath, Julio S.G. Montaner, MD, and Evan Wood, PhD About the Authors All authors are with the British Columbia Centre for Excellence in HIV/AIDS, Vancouver. Thomas Kerr, Mark W. Tyndall, fulio S. G. Montaner, and Evan Wood are also with the Faculty of Medicine, University of British Columbia, Vancouver. Requests for reprints should be sent to Thomas Kerr, PhD, BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard St, Vancouver, BC V6Z 1Y6 (e-mail; tkerr@cfenet.ubc.ca). This brief was accepted August 16, 2006. Contributors T. Kerr and E. Wood originated and designed the study, supervised all aspects of study implementation, drafted the article, and incorporated reviewer suggestions. T. Kerr, R. Zhang, and C. Lai conducted the statistical analyses. M. W. Tyndall and J. S. G. Montaner made significant contributions to the formulation and design of the analyses, interpretation of the data, and drafting of the article. All authors helped to interpret findings and review drafts of the article. Acknowledgments The safer injecting facilities evaluation has been made possible through a financial contribution from Health Canada, the Michael Smith Foundation for Health Research, and the Canadian Institutes for Health Research. We wish to thank the staff of the Insite Safer Injecting Facility, the Portland Hotel Society, and Vancouver Coastal Health (Chris Büchner, David Marsh, Heather Hay). We also thank Aaron Eddie, Suzy Coulter, Megan Oleson, Peter Vann, Soni Thindal, Dave lsham, Daniel Miles Kane, Steve Gaspar, Cristy Power, Carl Bognar, Jo-Anne Stolte, and Deborah Graham for their research and administrative assistance. Note. The views expressed in this article are those of the authors and do not represent the offical policies of the study's sponsor. Human Participant Protection The evaluation received ethical approval from the University of British Columbia/Providence Health Care Clinical Research Ethics Board and from Health Canada

Nursing Leader, Liz Evans (Letter to the editor, June 7 National Post)

Counterpoint
Editorials
(Retrieved from Factiva)

The evidence is clear: Harm reduction works
Liz Evans
National Post
587 words
7 June 2007
National Post
National
A24
English
(c) 2007 National Post . All Rights Reserved.

When the National Post comments on harm reduction so glibly (" 'Harm reduction' doesn't work," editorial, May 29), and without any research to back up those comments, it does itself, and its readers, a great disservice.

Addiction is a complex issue, and anyone who thinks a simple solution exists hasn't worked in Vancouver's Downtown Eastside. I am the executive director of the non-profit organization that, together with Vancouver Coastal Health, runs Vancouver's Supervised Injection Site. I am a nurse by training, and a public health advocate by design -- because all of my training as a nurse wasn't enough to make a substantial difference in people's lives.

Just like the author of the Post's editorial, I thought helping those with addiction was simple. We just need to offer treatment. But if it were that easy, the problem would have been solved long ago. I wouldn't have had to call the parents of addicts who had overdosed and tell them their child was dead. I met one mother, at the airport, who had flown across the country to visit her dying son. She arrived too late and fell to the floor screaming in grief when she heard the news. She wanted her addict son alive, addicted or not. Which is what harm reduction does -- it keeps people alive, so that one day, they can enter treatment.

Harm reduction strategies buy time because not everyone is ready to enter treatment. Clean needles and condom distribution prevent the spread of disease. These are basic health interventions that are accepted across the world, from the United Nations to the medical health officers in every jurisdiction of this country.

Vancouver's Supervised Injection Site -- the only one in North America is -- neither the problem nor the solution. It is one measure designed to reduce public disorder, which it has done; reduce the spread of HIV, which it has done; provide a doorway into the health system and into treatment, which it has also done. The Supervised Injection Site receives no federal government money to operate. In the past, the federal government did pay for a group of highly qualified research scientists to conduct a thorough evaluation of Insite and its outcomes, and has proved its success.

I agree that any nation-wide drug strategy desperately needs to incorporate improved enforcement, comprehensive prevention programs and flexible and accessible detox and treatment interventions. But it also needs to include harm reduction -- so people don't die unnecessarily and parents don't continue to lose their children. The most recent piece of research indicates that there has been a 30% increase in the number of people entering detox and methadone therapy as a result of using the injection site -- which strengthens further the argument that harm reduction is a necessary part of the health care continuum.

As Stephen Harper prepares to unveil his new drug strategy, we welcome the much-needed resources to expand addiction treatment. We want Canada to have a drug strategy that Canadians can be proud of. A drug strategy that acknowledges the suffering of our citizens, one that allows access to desperately needed treatment and support and doesn't send addicts back to die alone in Canada's back alleyways.

-Liz Evans is executive director of the PHS Community Services Society, which operates InSite, Vancouver's Supervised Injection Site

UN is Closed to Reason, gives govt ammunition

**"Closed to Reason" document link is in the sidebar**

Narcotics board looks to be 'closed to reason'

WAR ON DRUGS. International panel is dead set against supervised injection sites, even if it can't cogently argue why

Peter McKnight, Vancouver Sun
Published: Saturday, March 10, 2007

Given how the federal Conservatives feel about harm reduction measures, they didn't really need an excuse to shut down Insite, Vancouver's supervised injection facility. But the International Narcotics Control Board recently provided them with one nonetheless.

In its annual report, released last week, the United Nations panel stated that Insite facilitates "the illicit use of internationally controlled substances and violate[s] the provisions of international drug control treaties." Consequently, the board plans to advise Health Minister Tony Clement to shut down the site, possibly at the board's annual meeting next week.

This is certainly not the first time the board has spoken out about supervised injection sites -- SIFs. As the Canadian HIV/AIDS Legal Network and the Open Society Institute document in an excellent expose of the board titled Closed to Reason, the sites, which now exist in Switzerland, Germany, the Netherlands, Australia, Spain, Norway, Luxembourg and Canada, have received significant attention from the board's annual reports for at least six years.

Each year the board has condemned countries that operate SIFs, concluding, without argument, that the sites amount to a violation of international law. A typical example comes from the board's 2002 report, where it said:

"By permitting injection rooms, a government could be considered to be in contravention of the international drug control treaties by facilitating, aiding and/or abetting the commission of crimes involving illegal drug possession and use, as well as other criminal offences, including drug trafficking."

As Closed to Reason documents, board members have been even less accommodating in public speeches. In a 2000 address to the UN, former board president Lourenco Martins described SIFs as "shooting galleries," and said they are places where "drug abusers are allowed to abuse illicit drugs obtained from the illicit market under supervision and under, supposedly, hygienic conditions."

This skepticism about the hygiene of SIFs seems a recurring motif, as the board said last week that it opposed "poorly supervised" injection rooms, which would seem to suggest that hygienic, well supervised rooms are A-OK.

But apparently not, since current president Philip Emafo maintained recently that SIFs violate "the most fundamental principal" of drug control treaties. Exactly how Emafo and the board came to this conclusion is a mystery since the annual report provides no explanation of why SIFs contravene the treaties.

Nevertheless, despite -- or perhaps because of -- the board's apparent inability to construct an argument to support its conclusions, it has engaged in attempts to silence anyone who speaks in favour of SIFs.

Stephen Lewis, former UN Special Envoy for HIV/AIDS in Africa, visited Insite in 2006, spoke about how it could help reduce the transmission of blood-borne diseases, and advised other Canadian cities to consider following Vancouver's lead.

For his trouble, Lewis received a call from board secretary Koli Kouame, who equated SIFs with "opium dens," and threatened to inform then-UN secretary-general Kofi Annan of Lewis's heresy. Kouame made good on his threat, with Emafo demanding in the letter to Annan that Lewis retract his statements. To his credit, Lewis refused to do so.

After all, there is good reason to believe the board is simply wrong in holding that SIFs violate drug control treaties. According to Article 4 of the 1961 UN Single Convention on Narcotic Drugs, parties must "limit exclusively to medical and scientific purposes the ... distribution of, trade in, use and possession of drugs."

The board concluded that Insite violates this article since, in the board's erroneous view, Insite's purpose is to get "public nuisances off the streets." Yet while studies suggest Insite has helped to improve public order, this was never the purpose of the site.

On the contrary, Insite was opened to test the efficacy of such medical interventions in improving the health of addicts and their communities, which suggests that it has both scientific and medical purposes. It's hard to imagine any intervention that would be more in keeping with Article 4.

But don't take my word for it. Lawyers advising Health Canada came to a similar conclusion about the legal status of Insite before its opening, and lawyers in Germany, the Netherlands, Slovenia and Switzerland have all concluded that SIFs don't violate drug control treaties.
But you don't have to take their word for it either, since the UN itself has concluded that SIFs comply with the treaties. In 2002, the board, which apparently doesn't take anyone's word for it, asked lawyers with the UN International Drug Control Program for advice on the legality of SIFs.

Contrary to statements made by board members before -- and since -- 2002, the lawyers said:
"It would be difficult to assert that, in establishing drug-injection rooms, it is the intent of parties to actually incite or induce the illicit use of drugs, or even more so, to associate with, aid, abet or facilitate the possession of drugs." Obviously it's not difficult for board members to make those assertions, but notice how this quote seems a direct rejoinder to the comments board members continue to make.

The lawyers' report continued: "It seems clear that in such cases the intention of governments is to provide healthier conditions for IV drug abusers, thereby reducing their risk of infection with grave transmittable diseases and, at least in some cases, reaching out to them with counselling and other therapeutic options."

The report concludes by saying that permitting SIFs falls "far from the intent of committing an offence" under the treaties. Nevertheless, shortly after receiving the lawyers' report, Emafo said SIFs incite people to use drugs. And every year since receiving the lawyers' advice, the board has maintained that SIFs violate the treaties. All of which makes one wonder why the board asked for the advice in the first place.

Perhaps the board thought the lawyers' report would be more to its liking, more in keeping with its ideology. And make no mistake about it, the board has proven time and again that its positions are the products of its ideology rather than of legal or scientific arguments.

The ideology is, simply put, one of drug prohibitionism, of maintaining the war on drugs at any cost and responding with hostility to any suggestion that harm reduction might play a role in reducing the health and societal costs of drug addiction.

For example, Closed to Reason notes that the board has repeatedly praised countries that have engaged in draconian drug crackdowns, including Bulgaria, Russia, China and Thailand, which recently addressed its drug problems by arresting thousands of people and murdering many others.

In contrast, while the board claims to support harm reduction measures such as opiate substitution treatment and needle exchanges, members have attempted to discredit such interventions, with the board president, as recently as 2002, wrongly claiming that needle exhanges contravene drug treaties.

The board is, of course, free to continue promoting the failed war on drugs, however counterproductive it may be, provided it makes its agenda explicit.

But as a body charged with monitoring countries' compliance with drug control treaties, it should not be free to tell falsehoods about the legal status of harm reduction measures to advance its agenda. And it should certainly not be free to use those falsehoods to try to pressure governments into complying with that agenda.

pmcknight@png.canwest.com

Why start now?

Insite's current exemption is up in Dec. 2007. It's time to start writing letters.

"What?!" I hear you say, "But Jen, that's months away!"

However, read the post below. It looks like things are starting to move on Canada's Drug Policy. It was last updated in 2003 (For a good background on current drug policy go to the Community Insite link and click on "Further reading". Entry #8 refers to the 2003 Federal drug policy update).

Since the current government has a track record of wanting to increase the criminality of everything (particular forms of marriage, age of consent, reducing the age young offenders can be tried as adults-- just 3 quick examples), any new policy is likely to be quite punitive and heavy-handed.

Write to the Prime Minister, your MP, Minister of Health (Tony Clement), the Ministers of Indian & Northern Affairs, Status of Women, Vancouver Olympics, Minister of Human Resources and Social Development and many others. See my post on Aug 31 for reasons to choose one minister or another.

**but fair warning: there has been a cabinet shuffle: check who is the current minister.

Write about Insite specifically or about Canada's Drug Policy in general but write now!

**Nursing students: depending on your community or clinical placements, you could have some unique and worthwhile anecdotes that could really personalize this issue. See the Tips on Letter writing post -- not the next one, but the one after that.

Rumblings in Ottawa

It's time to get active about Insite again.

Here's why: Perhaps in preparation for the Dec '07 deadline on the legislative extension allowing Insite to function, or perhaps in response to the eternal threat of an election (and possible Conservative majority) it looks like action on drug policy is happening here in Ottawa.

At a luncheon here today US "Drug Czar" John Walters was invited by the Canadian Centre on Substance Abuse (a curious move given that the CCSA is a supposedly independant, non-partisan but federally funded agency). Here's the content of an email I recieved at the end of last week from a contact and InSite for Community Safety:

"U.S. Drug Czar John Walters has been invited by the Canadian Center on Substance Abuse to try and rationalize U.S. drug policy to a Canadian audience. Mr. Walters is a reputed zealot, known for an eagerness to drug test every student in America. He is also an infamous purveyor of anti-cannabis propaganda. As Eugene Oscapella from the Canadian Foundation for Drug Policy said: "We in Canada have agreed to take John Walters off your [US] hands for a few hours on February 22. I am more than a little perplexed as to why the Canadian Centre on Substance Abuse, a supposedly independent drug policy agency, is inviting him to speak without using a panel format that would allow his statements to be challenged. There will be a question and answer session after his speech, but that will hardly offer the opportunity for a balanced debate. I wonder if these were the only terms on which he would speak here."

Drug Policy in the United States: A Presentation by John P. Walters Director, White House Office of National Drug Control Policy You are cordially invited to a luncheon event with featured speaker John P. Walters, Director of the White House Office of National Drug Control Policy. Mr. Walters will provide an overview of the U.S. National Drug Control Strategy, its progress and challenges. Opening remarks will be delivered by Michel Perron, Chief Executive Officer, Canadian Centre on Substance Abuse (CCSA), Canada's national addictions organization. An informal question and answer period will follow the presentation.

Date: February 22, 2007 Time: 11:45 am - 1:15 pm (lunch is included)
Location: Fairmont Chateau Laurier, Tudor Room (1 Rideau Street, Ottawa, ON K1N 8S7) Registration: Seating is limited and RSVPs are required.

Since I wasn't the one cordially invited I had no luck finagling my way into the lunch (although it was looking good there for a while...) despite RSVP'ing and talking to the communications person a couple of times.

Here's the official response the press release about the press conference that happened up in Centre Block of the Hill today:

MEDIA ADVISORY: CHALLENGE TO US DRUG CZAR CRITICISMS OF CANADIAN DRUG POLICY

Who: Senator Larry Campbell, Ethan Nadelmann, Line Beauchance, Eugene Oscapella
Where: Charles Lynch Press Theatre, Parliament Hill, Ottawa
When: Thursday, February 22, 2007 at 1:30 p.m.


OTTAWA AND NEW YORK, February 21, 2007: The Canadian Foundation for Drug
Policy (Ottawa) and the Drug Policy Alliance (New York) will be holding a press conference in the Charles Lynch Room, Centre Block, Parliament Hill, Ottawa, at 1:30 pm, Thursday, February 22, 2007. The press conference is being held on the occasion of the visit to Ottawa by the head of the US Office of National Drug Control Policy (the US "drug czar") John Walters. Speakers at the press conference will challenge the continuing criticism of Canada's drug control efforts by Mr. Walters, and discuss pressure by the US Administration on the Government of Canada to follow the American model of drug control, which is based heavily the use of the criminal law, policing and incarceration ("criminal prohibition). Speakers at the press conference will also address the failure of US drug control policies in the United States, the misleading rhetoric by the US Administration about Canada's contribution to US drug problems, and the damaging effects of US drug control policies on Canada, including the risks US poppy eradication policies pose for Canadian soldiers in Afghanistan.

Speaking at the press conference will be:

• The Honourable Larry W. Campbell, Senator, former Mayor of Vancouver, former RCMP Drug Squad member, and former Chief Coroner of British Columbia.
• Ethan Nadelmann, founder and executive director of the Drug Policy Alliance, New York, the leading organization in the United States promoting alternatives to the war on drugs. Mr. Nadelmann is a former Princeton University professor and author of several books and articles on policing, crime control and drug policy.
• Professor Line Beauchesne, Department of Criminology, University of Ottawa,
  the author of several books on drug policy, and co-founder, Canadian Foundation for Drug Policy.
• Eugene Oscapella, Ottawa lawyer, co-founder, Canadian Foundation for Drug
  Policy, and lecturer on drug policy in the Department of Criminology, University of Ottawa.

Canadian Foundation for Drug Policy: http://www.cfdp.ca/
Drug Policy Alliance: www.drugpolicy.org

Time to get the letter-writing started.

Tips on successful letter writing [redux]

According to Elizabeth May, formerly Executive Director of the Sierra Club of Canada, now leader of the Green Party of Canada, in her book "How to save the world in your spare time" (2006), letters to politicians are more effective than emails, post cards or petitions.

"Because so few people take the time to write a letter on an issue that concerns them, politicians count each letter as representative of the views of far more citizens. A letter to a federal politician is seen as representing thousands" (p.90-91).

A handwritten letter is the best, typed is okay, but an email is often only glanced at or automatically discarded by employees.

When the time line on writing to the Health minister and/or the PM in support of Insite is short (as with the exemption last fall) a fax of the letter with the original following in the mail will be the most effective means of contacting a minister and/or your MP regarding Insite.

If you choose to write to one of the other ministers I have listed back in Aug, an email to their office may have some effect as they are likely recieving less/no mail on this issue. If you only have time to send emails, send several and make them unique. Here are some tips gathered from various sources:

Maximize efforts by identifying key players. In this case, Tony Clement, Minster of Health, Prime Minister Harper.

No stamp necessary if you write to their House of Commons address (although some websites say that Constituency offices are more effective, this is only the case if your return address is in that riding).

For MPs: Provide a return address and let them know that you live in their riding. This will provide you with much greater credibility in their eyes.

**Student Nurses: Our voices are super-powerful: We are only writing (on this or any subject) because we have an interest and emotion behind writing. Unlike others who may write, we have no vested interest other than we recognise what is the right thing to do and feel strongly about it.**

It is worth writing to your MP even if s/he or their official party line supports your view. If the issue ever came up for debate or vote in the House your letter would count as the voice and opinion of constituents.

Keep the letter relatively brief—no more than 1 ½ pages – typed or hand written.

Tell them why this issue is important to you, what you think should be done, back it up with facts and/or references and ask for a reply.

Illustrate the key messages by telling your story in your own words—this will have a much greater impact than any pre-written communication they received in the office.

With that in mind, back in August I included other Ministers in the cabinet to whom you may want to write and let them know why this issue matters to you, how you think it relates to their office and that you want to know where they stand on the issue. The cabinet has since been shuffled so you will have to look up who's who in the new zoo. However, Clement and Harper remain the key ones to focus on. The others are just icing.

Be respectful and give the MP the benefit of the doubt. Whatever information you have about an MP's position, it may not be accurate and they may be open to changing their mind. They will respond better to a calm, polite letter — remember passion can be expressed with reason. In this case it can also be supported with peer-reviewed evidence as well.

Don't put down those who oppose extending the exemption. You could be insulting someone close to that person — not an endearing tactic. You'll also just lose credibility.

Ask for their support and request a reply — you can provide them with your phone number and/or email address to make it simple for them to get back to you (See my response from Mr. Clement last fall). When you do hear back, please share the response in the comments section here—we want to know what’s happening.

Feel free to let them know that you were compelled to write based on an email from a concerned indivual and with information from this blog. A grassroots effort by individuals with no vested interests in Insite other than a recognition of Insite's value to the community that it serves, and with compassion for those individuals, could be a powerful message.

Copying a form letter is less powerful. Personalizing it can make it work though.

Clement makes surprise visit to INsite

Ian Bailey, CanWest News ServicePublished: Thursday, January 04, 2007


Font:

VANCOUVER - Canada's health minister made his first-ever visit to a safe-injection site, touring the Insite facility in Vancouver's Downtown Eastside Wednesday.

Tony Clement, accused by critics of having a hidden agenda against such operations, spent about 30 minutes in Insite during his surprise tour.

Clement strolled through the waiting room, injection room and lounge of the operation during his tour, chatting with users and staff while reporters waited outside.

Clement was a tough critic of safe-injection sites as health minister under former Ontario premier Mike Harris about three years ago, vowing to keep them out of that province because he preferred anti-drug education, awareness, treatment and rehab for addicts.

Since entering federal politics, he has been accused of being equally skeptical.

''I had a good chat with the staff there, understood some of their procedures, asked a lot of questions, got a lot of answers,''Clement said after his tour.
But he declined to say whether his views had changed.

''I think I am continuing to get a deeper understanding and this is all part of being the best health minister I can be for the country,''he said.

Insite, which opened in 2003, faced the prospect of closure last fall as Clement tried to decide whether to renew an exemption that allows the use of illegal drugs inside the facility.

He eventually decided to allow Insite to operate through the end of 2007, awaiting studies on supervised injection sites that will help him decide on its long-term fate.

He defended the fact that he did not visit before making that ruling.
''It's important for me to accentuate that I am here now,''he said.

Clement, on the second day of a visit to Vancouver, was previously non-committal about a visit to the operation, which has been praised by B.C. Premier Gordon Campbell and Vancouver Mayor Sam Sullivan as a means of controlling the health risks associated with injection drug use.
But he said the timing was right Wednesday because he was also visiting a nearby Salvation Army detox centre and homeless shelter.

Clement began his tour about 30 minutes after Insite opened for the day so clients entered and left as he was inside.

''A couple of the clients recognized him,''said Chris Buchner, HIV/AIDS and harm-reduction manager with Vancouver Coastal Health.

''(They) were very interested in telling him how important this place was to them,''said Buchner.
Buchner said people were shooting up as Clement had his tour.

''(Clement) was very interested, very attentive,''he said.

Dean Wilson, a board member with the Vancouver Area Network of Drug Users, said he was stunned to see Clement through Insite's front window while passing by.
Wilson said the sight of Clement initially drew his attention because the minister was well dressed, standing out among the regular clients.

''I wanted to see who it was, and then I saw it was honorable member Clement so I went right after him,''said Wilson.

The pair chatted for several minutes.
''I just wanted to tell him that we never promised that this would stop crime,''Wilson said, referring to Insite.
ibailey@png.canwest.com
Vancouver Province

NPR & Insite

Thanks to fellow nurse, Matt for this NPR link to radio commentary on Insite from a couple of years ago.

NPR InSite

Canadian University Press Link

Here's an excellent article hosted at University of Alberta's Gatway newspaper:

The forsight of Insite, Eric Szeto, Oct 25, 2006

VANCOUVER (CUP)—On any given morning on the corner of East Hastings and Columbia in front of the Radio Station Café in Vancouver, a drug dealer can make up to $35 000. Their customers approach them in a nonchalant fashion, do their business and quickly scuttle off in various directions.

Some may venture back to their hotel rooms, rented out at cheap monthly rates. Many will drift into the nearest alley and quickly dose. But these days, most will probably walk into Insite, the city’s highly publicized and contentious safe injection facility, open to all and just eight doors down.

Even on the slowest day, the Vancouver Area Network of Drug Users (VANDU), estimates that nearly 15 000 heroin injections take place in the Downtown Eastside, and Tyrone Caldwell, 39, used to take his fair share.

Caldwell spent the last 14 years of his life dabbling with different drugs, but it was during the last five years that things began to get really heavy. After nearly a decade of drug use, he lost control, and in order to support his $300-a-day cocaine habit, started dealing narcotics himself, including heroin.

It was in May that he went into the facility as he did on any normal day. He proceeded into the injection area to shoot up. The area is the width of a desk, with a mirror in front and two walls, giving an individual the suggestion of privacy. Immediately after dosing, Caldwell had an ominous feeling that something was not right.

“The minute the buzz or rush started coming on, I knew it wasn’t a cocaine rush,” he says. “I knew I was in trouble and that’s the last thing I remember.”

Caldwell was put into an ambulance after the paramedics gave him a shot of Narcan, a drug that reverses the effects of opiates, to revive him. Caldwell later discovered that what he had injected into himself wasn’t just cocaine—it was a nasty trail mix of heroin and cocaine, which led to his overdose. And it was because of the staff at Insite that Caldwell didn’t die that day.

“If Insite wasn’t there and I was in the alley, I’d be dead,” he says.

Caldwell isn’t the only one. Since its inception in 2003, Insite has grown in popularity among drug users in the Downtown Eastside, averaging around 700 visits per day. Section 56 of the Controlled Drugs and Substances Act allows Insite—in addition to doctors prescribing methadone for those in rehab—to have legal possession of controlled substances. Because of this exemption, Insite is currently the only place in Canada where a person can legally carry narcotics.

Before Insite, the number of overdoses and rates of infection for HIV and Hepatitis A, B, and C were soaring in the Downtown Eastside community. According to Anne Livingston, a project coordinator for VANDU, deaths by overdose climbed from 35 in 1989 to 350 in 1994. The 1995 Vancouver Injection Drug User sampled 5000 users in the Downtown Eastside and estimated that the prevalence of HIV/AIDS in the area was around 40 per cent while Hepatitis C hovered around 90 per cent.

The community was dying.

With the alarming rates of infection and death escalating rapidly, the city soon realized traditional drug enforcement and treatment strategies were failing. The city subsequently adopted its “Four Pillars Drug Strategy,” which consists of harm reduction, prevention, treatment and enforcement. Insite was implemented as a progressive step towards increasing harm reduction, though some argue it promotes all four pillars.

Open 18 hours a day, Insite has become one of the busiest safe-injection facilities in the world. There’s no limit to how many times a day a person can use the site. Accounts of its successes have been documented. There are over 7000 registered members and though there have been 500 overdoses, none have resulted in death. Furthermore, Insite has found that users of the site are twice as likely to get into detox.

While there’s no evidence yet to suggest that the rates of HIV/AIDS have gone down since Insite opened, neither have there been any studies investigating this issue. It would be counter-intuitive to think that the facility has been anything less than a bastion of prevention.

In spite of this, at the end of August, the future of the facility was in limbo. The federal exemption that allowed Insite to operate was due to expire on 12 September and Canadian Health Minister Tony Clement, rather than extending it another three years, reluctantly bowed to public pressure and renewed the exemption until December 2007. The scientific evidence, according to Clement, was inconclusive.

“Do safe injection sites contribute to lowering drug use and fighting addiction? Right now the only thing research has proven conclusively is that drug addicts need more help to get off drugs,” says Clement in a media release. “Given the need for more facts, I am unable to approve the current request to extend the Vancouver site for another three-and-a-half years.”

Despite scientific evidence and public support of the facility from all levels of government, the Ministry of Health opted to shy away from granting proponents of the site its full demands—the disconnection between those in Ottawa and the people at the frontlines is unsettling.

Jeff West, a coordinator at Insite, has witnessed first-hand the changes the facility has brought to the Downtown Eastside. He’s seen its successes and its failures. His modus operandi is to dispel the myths circulating in Ottawa and educate people about the many other services that Insite provides.

“We teach people. We never hold or touch the needle—that’s the bottom line,” West says. “[The staff] can tie people off, help them find a vein, [pick] what kind of angle to insert the needle. We also have a prosthetic arm that has veins and use that as a teaching tool.”

West stresses the strictness of these guidelines: if someone dies and they have gone beyond their immediate duties, it’s an automatic charge of manslaughter.

But the big appeal for Insite, West says, is giving a shelter to the people living in squalor. It provides the lost and hopeless a place to go.

“People are complex souls. Addictions are a result of other stuff going on. Ultimately you could really just focus on the addiction and they can go to detox,” West says.

Caldwell and many others attest to the success to this program.

“If Insite wasn’t there ... I really wouldn’t be here,” says Caldwell, who now volunteers at Insite. “I’m living on borrowed time and I’m here to help them. No questions.”

When her sister became a crystal methamphetamine addict, Darcy (who is using only her first name to protect her identity) took custody of her sister’s children. She was only 22. For the next 25 years, she was an operating engineer in northern BC, making an almost six-figure income for many years.

But after injuring her back and losing the pension she spent her entire life working for, everything came crashing down. She eventually moved to the Balmoral Hotel in Vancouver’s Downtown Eastside. She had nowhere else to go.

On welfare for the first time of her life, she started using drugs. From A to Z, she did it all, everything except crystal meth—something she promised herself she would never do after seeing it kill her sister.

“It was from 25 years of being straight, I wanted to experience it all. You name it, I did it. My sister was a junkie; it was like I wanted to experience what she experienced.”

At the height of her drug addiction she was visiting Insite nearly four times a day.

“What I went for was the congeniality and I’d go there because it’s a nice, clean place. I don’t actually inject anymore.”

She can barely describe some of the atrocities she’s seen because they are so egregious. Before Insite, she says, women were contracting HIV at enormous rates, which she attributes to the fact that women are most vulnerable in the Downtown Eastside.

Often times, she says, prostitutes, too messed up to do their own drugs, ask their pimps to shoot them up. But instead of using a clean needle, her pimp uses a “rake,” a needle that has already made the rounds, which is almost inevitably tainted and ridden with disease.

Insite, she says, offers these women an alternative.

“This is a place where women go to control disease,” she says.

Darcy admits there are many misconceptions about Insite, and says given the lack of understanding about addiction in general, it’s not surprising.

This lack of understanding was clearly shown in an online Globe and Mail debate between former mayor of Vancouver and current Senator Larry Campbell and Randy White, the founder of the Drug Prevention Network of Canada held in August, before the extension to the exemption was granted.

During the debate, White, a former Reform-Alliance-Conservative MP and vice-chairman of the parliamentary committee studying the non-medical use of drugs, gave a list of reasons why Insite’s exemption under the Controlled Drugs and Substances Act should not have been renewed and why the site should have been shut down.

Among the reasons:

1) Injection sites do not prevent and treat drug use.

2) Since the opening of the site, Vancouver has become more problematic with crime and addiction, and the injection site has contributed to the problem.

3) Responsible government does not sanction a person walking through a door and getting assistance to shoot up crystal meth.

4) Injection sites are the exception, not the rule, in most countries worldwide.

Campbell retorted. “To be blunt, [White] is a dinosaur and refuses to even consider scientific, peer-reviewed evidence. I suspect that deep in his mind, he believes the earth is flat.”

The inability to get past archaic misconceptions about the realities of drug use is at the root of the problem, says Nathan Allen, an organizer for Insite for Community Safety, which is an advocate group for Insite.

“Federal government doesn’t fund any component. Insite doesn’t provide drugs. They aren’t asking for a single red cent, just for the blessing, just for the exemption to be renewed,” he says.

Libby Davies, a proponent of Insite and an NDP MP, echoed Allen’s concerns.

“The evidence [about] Insite is irrefutable, there’s no research that suggests it’s not working as it should be,” Davies says. “They’re dead wrong with the disputes. You can’t ignore the scientific evidence from incredibly reputable sources. It’s been under a microscope for three years. It’s not a panacea for the drug solution, its part of the solution.”

Echoing Davies’s concerns, Darcy adds a more extreme viewpoint. She believes that Ottawa has given the addiction situation and Insite a lack of attention, and the subsequent drug-related deaths in the Downtown Eastside area is a form of population control.

“[Drug addicts] are seen as a subhuman species here, but they aren’t. It’s tough to make it as a man down here but it’s even tougher to make it as a woman. They’ll stab you, knife you. That’s the element you have to be in,” Darcy says.

According to VANDU and Insite, every ambulance coming into the Downtown Eastside costs $1000. Each case of HIV/AIDS costs the health-care system $320 000. The financial burden the area once carried has decreased significantly.

Surprisingly, one of the strongest messages of support comes from the Chinatown Merchants Association. Before the site opened, the association was among the most vehemently opposed groups to the injection site. Now they are one of Insite’s biggest supporters.

“There aren’t any people shooting up in front of the businesses anymore and Insite has [shown] by example that it works,” Allen says.

Six to eight hours after the last dose of heroin, a person can begin to have withdrawal symptoms that include severe anxiety, depression, diarrhea, convulsions, vomiting and uncontrollable body movements.

Mary Miller used to dose at Insite frequently to avoid these symptoms. “You don’t want to go sleep because when you wake up you’ll be too sick to move,” she says. To alleviate these symptoms she now gets a portion of her welfare check deducted to pay for her methadone.

Months before the creation of Insite, VANDU, which started in 1998 by a group of intravenous drug users that advocated living healthy and productive lives, opened their own de facto safe injection site for people like Mary.

The rogue site could barely operate and their hours were limited (10 pm to 2 am), but according to Ann Livingston, it was what gave the city the gumption to eventually open a legally sanctioned facility in 2003.

Livingston, a project coordinator for VANDU who also ran unsuccessfully for city council in 1996 and 1999, says it was this critical pressure from VANDU that finally started to change minds. The municipal government, she says, had repeatedly dropped the idea for the site for a number of years before Insite came to be.

Even with the cynical outlook, Livingston is still lobbying to open four more government-sanctioned sites. One site, she says, isn’t enough.

“It’s the equivalent of your whole body covered in running sores and one patch is cleared up,” she says. “We know it works but we can’t put it on the rest of our bodies. I said, ‘Fuck you, we can’t.’”

Her plan is to put three more sites on the perimeter of the Downtown Eastside. By surrounding the area with sites it would, in theory, be easier for addicts to get to a nearby site.

But the likelihood of three more sites popping up once the exemption expires in December 2007 seems like a stretch. Livingston knows it, and that’s why VANDU is doing whatever it can to help.

The group has already taken the matter into its own hands. If you know what they look like, you can spot them a block away. A team of ten people in fluorescent vests patrol the streets educating and, in many cases, illegally assisting the injections of addicts in the area who are unable to perform them alone.

These rogue patrols complement the limited services Insite can legally provide. Often, people have to be rejected from Insite because they are not capable of injecting their own drugs—and Insite workers cannot do it for them.

The patrollers look out for these people in particular.

This squadron of injectors, all trained health-care workers certified in CPR, assist in any way they can. If you’re blind and have an amputated arm, for example, they will help you inject.

“It’s considered illegal,” Livingston admits. “But if I inject you with drugs the joke is that you won’t die. You’re much less likely to die with a trained expert who knows CPR and has gloves on.”

There’s no doubt in Livingston’s mind that if the government in Ottawa decides to pull the plug after December 2007, rogue sites will replace Insite. Before Ottawa announced the extension on 1 September, VANDU and other groups were already getting one ready.

The rumour is that the Portland Hotel Society, a Vancouver-based substance abuse advocacy group, has already built a site.

“The only way to find out is if you find one of their workers and literally follow them around until you see them all going to the same place,” Livingston says.

The future of Insite remains uncertain until December 2007, but there’s no doubt that whatever decision is made in Ottawa, it will not sway supporters of Insite from fighting on behalf of their growing and evolving community.

Livingston can attest to that. If Ottawa says no to an exemption beyond 2007, the gloves are going to come off.

“[Ottawa is] going to mud-wrestle with us,” she says. “I don’t think that they want that because we would win.”

Wanna respond? Send your feedback to gateway@gateway.ualberta.ca.

This just in:

Recieved in the mail Oct 13, 2006 in response to my (late) letter of Aug 28, 2006.
From the Hon. Tony Clement, Minister of Health.

Dear Ms. [my name here]

Thank-you for your correspondence concerning Vancouver's supervised injection site, also known as Insite.

The research that has been completed to date on this project is not conclusive. As a result, there are outstanding questions that must be answered before the Government of Canada can make an informed decision about the future of supervised injection sites in Canada. Insite will continue to operate until December 31, 2007, while additional research is conducted to determine how such sites affect crime, and drug prevention and treatment.

Thank you for taking the time to write on this important issue.

Yours sincerely,

[signature: Tony Clement]
Tony Clement

Salon article, Sept 22, 2006

Salon magazine has a good summary of Insite and the background. (You have to watch a bit of an ad to get to the article...)

http://www.salon.com/news/feature/2006/09/22/harm_reduction/index.html

From the Vancouver Sun, Oct 7, 2006

Injection site could save millions: report
A few small sites in Victoria could prevent seven overdose deaths a year, report says

Cindy E. Harnett and Rob Shaw, Times ColonistPublished: Saturday, October 07, 2006

A supervised drug injection site in Victoria would cost $1.2 million to operate, save up to $3 million in health-care costs, and prevent the need for 3,000 hospital visits each year, according to a document obtained by the Times Colonist, the first of two studies to be used to apply in the spring for a downtown pilot project.

Based on about 2,000 intravenous drug users, the creation of a few small safe injection sites could prevent seven overdose deaths annually, divert more than 1,110 emergency room visits for a savings of $444,000, and reduce hospital admissions by 2,000 for a savings of $2.4 million, according to the document obtained through a freedom of information request.

Vancouver Island Health Authority's chief medical health officer Richard Stanwick details the savings in what he calls a "very preliminary" business case to be bolstered by a comprehensive study underway at the Centre for Addictions Research B.C., led by illicit drug researcher Benedikt Fischer.

It is that study that will form the basis of an application to Health Canada in early spring for an exemption to Canada's drug laws to run a pilot research project here, said Victoria Mayor Alan Lowe.

Health Canada put off making a final decision on whether to extend for another 31/2 years Vancouver's supervised injection site called Insite, in early September. Health Minister Tony Clement said at the time additional studies must be conducted into the impact of supervised injection sites.

Victoria's mayor says that tells him the government needs to be convinced of the case for supervised injection sites but he is not overly discouraged by the government's unwillingness to embrace the concept.

"I'm hoping a research project of this kind would give the government more information, the kind of information it needs," Lowe said, in an interview.

If Victoria goes forward with the application, as is the plan, it will likely be for the establishment of more than one drug injection site in downtown Victoria, said Fischer.

Clement had only one big location -- Insite, located in Vancouver's Downtown East Side -- to consider, said Fischer. There have been problems with that site given the high concentration of drug users in the area.

Victoria would propose "something very very different" and therefore its operation could be "attractive to Ottawa" to provide valuable research information for other cities across Canada, Fischer said. Montreal and Toronto are also interested in supervised injection sites.

While the federal Conservative government has not embraced supervised injection sites, "I also know Clement is quite open to the principles of public health,"Fischer said.

The health-care case includes a reduction in overdose deaths, HIV/AIDs and hepatitis C infection and transmission, and the threat of dirty abandoned needles.

Supervised injection sites are part of a broad harm-reduction strategy including a range health, addiction, treatment and social services.

A supervised injection site "will protect our citizens as well as the addicts -- we have to realize these people are sick," Lowe said. "If someone has cancer we want to find treatment. We have to treat drug addiction in the same manner."

ceharnett@tc.canwest.com
© Times Colonist (Victoria) 2006

Retrieved from: http://www.canada.com/vancouversun/news/story.html?id=2616dc10-0f66-41a4-bf44-a076ac0bac84&k=31721 Oct. 14th, 2006

New Article on Insite and Harms Reduction

http://www.visionpositive.ca/e/V8I1/Harm_e.htm

From the Globe and Mail, Sept. 11th, 2006

Setback not stopping injection-site plans
Victoria, Prince George ready proposals despite limited extension in Vancouver
PETTI FONG

VANCOUVER -- Officials in Victoria and Prince George say they still hope to open supervised injection sites in their cities soon, despite the federal government's limited extension for the Vancouver facility.

Victoria Mayor Alan Lowe said it's regrettable that Health Canada will not consider any new applications for injection sites until Ottawa reviews the effectiveness of Vancouver's Insite clinic. But he said his city still intends to submit its proposal by early next year, adding that Victoria would learn from the Vancouver experience.

"The Insite project in Vancouver has proved to be successful, and a facility similar to that will be beneficial to Victoria, but I also agree with the Canadian Police Association that you cannot rely on the supervised injection site alone. In Vancouver, they only focused on the supervised injection site and I think there are fears that the other pillars aren't getting the same focus."

Last week, the Canadian Police Association said the federal government should close Insite and focus on education, enforcement and treatment. A few hours later, federal Health Minister Tony Clement announced he would keep the site open until December, 2007, but was unable to approve a request to keep it open another 3½ years.

More research needs to be done about whether the site is achieving results, he said.

The province provides most of the funds for the injection site but Ottawa must provide an exemption from federal drug laws so that addicts can take drugs inside without fear of being arrested.

Insite, the first such facility in North America, accommodates more than 600 drug users a day.

The main argument in favour of supervised injection sites is that they reduce the number of overdoses and curb the rate of HIV and hepatitis-C infections.

Victoria wants to set up a number of smaller injection sites in its downtown, which is more compact than Vancouver's, rather than a single facility like the one operating in Vancouver's Downtown Eastside.

Prince George would also like to set up a supervised injection site in its downtown core. The city has a big hepatitis-C problem and HIV rates have skyrocketed in recent years.

Lorna Medd, chief medical health officer for the Northern Health Authority, said the immediate concerns are increasing hours and staffing of a needle exchange and getting a mobile van on the road.

"We've been watching what the process has been with the long hard look at the safe injection site in Vancouver and we're feeling if there isn't a long-term solution in Vancouver it will be a difficult thing for Prince George," she said.

Dr. Medd said despite the setback in Vancouver, she and other members of the community in Prince George are still proceeding with developing a plan to open a supervised injection site.

From the Globe and Mail

Drugs and 'consequences'
GABOR MATÉ , MD

Vancouver -- In his column on Insite, Vancouver's safe-injection site, Gary Mason quotes approvingly a British psychiatrist who suggests that reducing the number of overdose deaths is "not our responsibility . . . it's the responsibility of the addicts themselves."

Would Mr. Mason extend the same principle to other groups, such as, say, smokers with lung cancer or emphysema, type-A business executives who work themselves into a heart attack, battered women or people injured in automobile accidents?

As a physician at a clinic that serves drug addicts in the vicinity of Insite, I know who these drug addicts are. Without exception, they are children who were severely abused physically, sexually and emotionally and who endured abandonment and neglect.

Such maltreatment has physiological effects on brain structures and brain functioning and creates an overwhelming craving for self-medication to soothe a suffering most people cannot even imagine. Most addicts began using in adolescence and have since become psychologically and physiologically dependent on their drugs.

To neglect, ostracize, and punish such people when they become adults is shortsighted and inhumane. Insite is a small but necessary step toward helping and, perhaps, rehabilitating drug users.