The science is in. And Insite works.

Top researchers gather to learn how Vancouver’s safe injection site has made B.C. a medical world-beater—and a political pariah


 
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Marc Townsend, manager of the Portland Hotel Society, enters Insite, Canada's only safe injection site for intravenous drug addicts in Vancouver, Tuesday, October 2, 2007. The society along with Vancouver Coastal Health Authority operates the site which was given a six-month operating extension by the federal government Tuesday. Richard Lam/CP

Marc Townsend, manager of the Portland Hotel Society, enters Insite, Canada’s only safe injection site for intravenous drug addicts in Vancouver, Tuesday, October 2, 2007. The society along with Vancouver Coastal Health Authority operates the site which was given a six-month operating extension by the federal government Tuesday. Richard Lam/CP

With his steel-grey hair and spectacles, he looks more like a country doctor than a troublemaker, yet here is Dr. Julio Montaner cracking open what Health Minister Rona Ambrose and indeed the entire federal Conservative government consider the very gates of hell. It is the inner door to Vancouver’s Insite safe injection facility, the only such site in all of North America. All 13 mirrored booths are in use by addicts injecting illegal street drugs into their veins. There’s an old man with a motorized scooter, a young guy with a mountain bike parked behind his chair, and all ages in between. There’s a nurse and care attendants watching over the predominantly male group. It is spotless and bright in here, there’s a ready supply of clean syringes, sterilized water, alcohol swabs and rubber tourniquets to bring drug-battered veins to the surface.

There will be 600 injections in here over the course of the day. No one will die of an overdose this day; no one has ever died of an overdose here since this opened in 2003. The hundreds of overdose deaths over the years happened outside in the streets, urine-soaked alleys and the fetid single-room occupancy hotels of Vancouver’s Downtown Eastside. Sometimes the dead are found with needles still jammed in their arms. It is sad that such a place is needed, but not as pathetic as watching someone inject in a Vancouver alley and then offer the syringe to a companion. Montaner, director of the B.C. Centre for Excellence in HIV/AIDS, watches respectfully from the door for a couple of minutes, then ushers a group of international journalists outside, through a waiting room of drug-sick addicts waiting their turn.

Over the course of the next several days more than 6,000 world-leading researchers, clinicians and public health officials will gather in Vancouver for a conference of the International AIDS Society (IAS). They will learn all there is to know about this storefront facility and its role as part of a harm reduction strategy that has made B.C. a world-beater in the fight against the deadly infection—and a pariah in the eyes of Stephen Harper’s Conservative government.

Insite was opened, following extensive consultation, after a public health emergency was declared in Vancouver in 1997 in an attempt to counter more than 1,000 overdose deaths in the preceding years and a spike in HIV and hepatitis C infections caused by shared needles. Dr. Thomas Kerr of the B.C. Centre for Excellence in HIV/AIDS called the outbreak “the most explosive epidemic of HIV infection that had been observed outside of sub-Saharan Africa.” Since then, B.C. has gone from having the highest infection rate in Canada to among the lowest. “In the immediate area around Insite, the 40-block area around the facility, there’s been a 35-per-cent decline in overdose deaths,” says Kerr. “And people who use Insite on a regular basis are 30 per cent more likely to enter addiction treatment.”

The supervised injection site, the only one of its kind in North America but one of about 90 around the world, has been a target of the federal Conservative government since it came to power in 2006. In 2008, then federal health minister Tony Clement called Insite, “a failure of public policy, indeed of ethical judgment.” Since then a succession of ministers, including current Health Minister Rona Ambrose, have been consistent in their opposition, saying it diverts finances from treatment, legitimizes illegal drug use, encourages others to inject drugs, is a magnet for crime and threatens neighbourhoods.

Kerr and Montaner are using the conference to make the case to delegates and the international media that ideology and the stigma of HIV and drug use are blinding governments, including Canada’s, to the building on the substantial advances in anti-viral therapies that have reduced HIV in B.C. to the level of a chronic disease—as well as the harm-reduction strategies that have contributed to a plunging rate of new infections.

While Insite has the full backing of the city of Vancouver, its police department, public health officials and the B.C. government, the constant federal attacks resulted in the facility becoming one of the most studied health initiatives in Canadian history. More than 40 peer-reviewed studies have been published in The Lancet, the New England Journal of Medicine, and the British Medical Journal among others, concluding that the facility and other harm-reduction strategies like free needle exchanges have slashed HIV infections and overdose death rates, and have increased the number of people seeking treatment without contributing to an increase in crime, notes Kerr, one of the lead researchers.

The federal government’s determination to close Insite by refusing to renew its exemption from existing drug laws was fought all the way to the Supreme Court of Canada, only to lose  in a unanimous 2011 decision. The high court’s conclusion in ordering the federal government to allow the continued operation of the facility: “Insite has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada.”

Plans to use the high court ruling as a precedent to add other supervised injection sites in B.C., and to open one in Montreal, however, are stymied by new federal legislation. The so-called Respect for Communities Act received royal assent this June. Ambrose said the law brings “greater clarity and transparency” to the application process. Critics say the law requires such a high level of public approval, research and consultation that it is all but impossible to open new facilities.

Any doubts about the government’s intentions were largely erased after the Supreme Court ruling by a petition and fundraising appeal the party sent to its base under the headline: “Keep heroin out of our backyards. Add your name if you demand a say before a supervised drug consumption site is opened close to your family.”

The campaign, under the signature of Jenni Byrne, national campaign manager, states “special interests are trying to open up these supervised drug consumption sites in cities and towns across Canada—over the objections of local residents and law enforcement. We’ve had enough—that’s why I am pleased the Harper government is acting to put the safety of our communities first,” she said, referencing the new legislation.

The issue of stigma and ideology trumping science is a constant theme among researchers here. Canada is hardly the worst offender. HIV infection rages out of control in eastern Europe and parts of Asia and Africa. There are also alarming new HIV outbreaks in Indiana and Appalachia among poor, white rural residents known to share needles, says Chris Beyrer, president of the IAS, and director of the Johns Hopkins Center for Public Health and Human Rights in Baltimore. In much of the U.S., and until it was largely too late to curb the outbreak in Indiana, there are laws against allowing even needle exchanges. “We are an evidence-based organization,” he says of the IAS. “The evidence is overwhelming that needle-syringe exchange and safe injection facilities work, save lives, are cost-effective, and prevent new infections. So, of course, we are vigorously working on trying to move the bar from saying this can only be done in an emergency to saying this is a part of basic public health.”

Dr. Nora Volkow, director of the U.S. National Institute on Drug Abuse, also holds open the possibility that supervised injection sites are not beyond the possibility in the conservative United States. The fact that the Republican governor of Indiana relented and allowed needle exchanges in the face of the HIV and hepatitis C outbreak is a case in point. “You should never say that it is unlikely,” she said in an interview at the conference. “If you had asked me that same question about would they approve the needle and syringe exchange programs in Indiana, I would have said ‘no, I don’t think so.’ Sometimes reality forces the issue.”

Montaner, however, is not optimistic under the current government in Canada. “Look, the only hope for us to have a constructive approach to HIV/AIDS and everything else that needs to be done in order to address the needs of this epidemic is to make this an election issue. I don’t see the Conservatives doing that.”

In fact, they already have. It’s called the Respect for Communities Act.


 

The science is in. And Insite works.

  1. Quick comment – Marc Townsend is no longer manager of the Portland Hotel Society.

  2. If you consider this from a drug addicts point of view…yes, INSITE has been a success. Sort of like having a place for drunks and alcoholics to drink to the point of vomiting on their clothes without anyone seeing it.

    If however, you happen to live near this place; or a place with similar goals in mind, the matter is different entirely. I owned a home in BC, and one of these places (drop in centre, social outreach centre..etc..etc..) opened up just prior to my moving to Ontario. Within the first week, there were used needles in the kids park, druggies passed out on my front yard, used condoms littering the sidewalks, and constant harrassment by these losers and deadbeats when my wife left for work. The three stores nearest the place were all robbed within the first week, and theft, burglary, and assault increased tenfold.

    Yeah…..Insite is successful all right. It enables junkies to keep doing what they have always done, without having to worry about the cops stopping them.

    For all of the fans of insite……..I can’t wait until they put one beside your house, or your kid’s school. See what a fan you are after living with societies detrius for a few months. Bet you will change your mind.

    • “In the immediate area around Insite, the 40-block area around the facility, there’s been a 35-per-cent decline in overdose deaths,” says Kerr. “And people who use Insite on a regular basis are 30 per cent more likely to enter addiction treatment.”

      So what’s been the impact on overdose death rates outside that 40 block area? And how successful in actually kicking their addictions are the Insite users that are 30% more likely to enter treatment? And what is the baseline for the 30% increase in likelihood of treatment, i.e. “13% of Insite users seek addiction treatment v. 10% of non-Insite users”.

      In the absence of more data, this is all just spin and, furthermore, it’s spin based on the flawed premise that “harm reduction” is to be measured in a way that doesn’t take into account prolonging an addiction and the broader social harm that entails. Perhaps these things shouldn’t be taken into account, but surely that’s a point worthy of debate, especially since the SCC wasn’t so inclined.

      • So, a basic Google Scholar search brings up this:
        Insite did not increase crime (but appeared to reduce crime):
        http://www.substanceabusepolicy.com/content/1/1/13

        A review of the evidence brought to the Supreme Court:
        http://www.tandfonline.com/doi/abs/10.3109/09687637.2012.755495#

        You claim that ‘in the absence of data, this is just spin’, but it is, in fact, you who is ignoring the data. I don’t doubt your anecdote, but it’s intellectually lazy of you to cry foul over no data when the article itself points to the fact that there is an overwhelming amount of data. This is further supported by the fact that the Supreme Court, after examining that data (and the best data the Government of Canada lawyers could muster against InSite’s existence), comes to a unanimous conclusion that the data supports the existence of these facilities.

        Where is your data?

        In the absence of more data, your comment is just spin, based on the flawed premise that addiction can be cured by incarceration and other ‘tough on crime’ social conservative ideology. Perhaps dozens of peer reviewed articles (ie: data) from multiple internationally recognized journals shouldn’t be taken into account, but surely that’s a point worthy of debate, isn’t it?

        I wish we didn’t have drug addicts draining societal resources that could be better used elsewhere, but I haven’t seen a better or cheaper solution offered by anyone lately. Prison is expensive, after all and no one is going to leap up to offer an unreliable drug addict a job.

      • It doesn’t take into account prolonging an addiction, because is doesn’t prolong an addiction.
        So no, no more data is needed know that Insite saves lives.

        • So making it easier for addicts to feed their addiction doesn’t keep them addicts for longer – who knew! My kids are addicted to TV, I guess I’ll now buy them a big screen one and put in a cozier couch to wean them off of it. Best part? The SCC will order Harper to pay for it!

          • Except that it doesn’t make it easier for addicts to feed their addiction. It neither provides their heroin nor comfy couches as your failed analogy would suggest.

            Have you got a shred of evidence that Insite prolongs addiction?
            ‘In the absence of data’, you’re just spouting BS.

          • So shooting up in a clean, sterile environment staffed with medical personnel isn’t easier than shooting up in a filthy alley behind a dumpster! Your “InSite” is peerless! Keep posting- the world is in your thrall. Meantime, I’ll scurry off looking for data that will convince you if you make bars nicer and keep them open longer, alcoholics will keep drinking and if you let people smoke in restaurants, movie theatres and offices instead of banishing them to the loading dock, they’ll take you up on it.

          • No, it’s not easier.
            It’s easier to shoot up wherever you happen to be when you score your fix.

            You seem to have trouble with analogies. Insite isn’t a ‘bar’ – it doesn’t provide heroin. Nor is it a theatre, restaurant or workplace.
            Addicts actually has to leave the theatre, restaurant or work access safe injection.

          • The hope is that some addicts will stop using. The reality of insite is that clean needles are available so addicts who have infectious diseases won’t be spreading their diseases by sharing with other addicts. It is what it says it is …harm reduction. Not a cure. Also, it keeps addicts out of prison so it saves you and me tax dollars because an out patient clinic is far cheaper than a prison. Insite is just like meth treatment for heroin addicts. It isn’t a cure. It is a bandaid that means less deaths and less hospitalizations plus less crime.

          • How does it keep addicts out of prison?

      • Great Walls Of Fire…you are looking for miracles. The experts are looking for baby steps.

    • Shorter jameshalifax:

      I didn’t bother to read the story I’m commenting on, but let me share some of my fiction with you.

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