Insite: ‘Too early to tell’ if it works?

Evidence on the harm-reduction facility is as good as we’ll ever get


“I think it’s just too early to tell.”—Ontario health minister Deb Matthews on whether she opposes safe-injection sites, 11/02/2011

In the 1990s, Vancouver was Canada’s capital of drug-related crime and home to the fastest-growing AIDS epidemic in North America. Back then, drug users injecting were a common sight in the city’s Downtown Eastside. They were doing so against the backdrop of a changing HIV epidemic in Canada, with the concentration of the disease shifting from men who have sex with men to addicts sharing needles.

Thus, the city on Canada’s west coast was a fitting locale for Insite, the first safe-injection site on the continent. Allowing people to use pre-obtained drugs under medical supervision could potentially reduce the harms associated with this type of drug use—namely, the risk of overdose and infectious diseases such as HIV and hepatitis C.

Insite fell into the category of what health policy wonks call “harm reduction,” or policies and programs implemented to reduce the adverse health, social and economic consequences of illegal drugs (and other high-risk activities). International health organizations—such as the WHO and UNAIDS—believe in harm-reduction interventions, and endorse them as a key part of a global HIV-prevention strategy.

Since it opened its doors in September 2003, Insite has been the subject of rigorous scientific scrutiny. Evaluating the impact of Insite, after all, was the reason it was granted legal exemption to operate. Some 30 studies about the project have appeared in peer-reviewed journals, and last September, the Supreme Court made the unanimous decision to allow Insite to stay open.

Politicians across the country are pondering whether to set-up safe-injection sites in their own cities. But does the evidence support the decision to follow Vancouver’s lead?

Mortality reduction

Drug overdose is a major cause of mortality among people who inject opioids like heroin. An April 2011 article published in the Lancet looked at whether the opening of Insite was associated with a reduction in overdose mortality. The researchers reported a 35 per cent drop in overdose fatalities in the area around the facility, when comparing the two-year period before Insite opened in 2003, to the two years immediately after. (During the same five-year run, overdose deaths in other parts of the city also declined, but only by nine per cent.)

It’s important, however, to note that this was an observational trial (a population-based assessment) rather than a randomized trial, therefore—despite what the media reported—it does not prove causation.

But there are a few things to take into account: a randomized trial on access to safe injection was deemed unethical. Scientists could not limit the use of the safe-injection site to only those who agree to participate in research. So we will never see a randomized trial done on the site. As a Lancet editorial on the study noted, “for public health interventions for which randomised trials might be unfeasible, unethical, or otherwise unlikely to take place, findings from well-done implementation science are arguably the highest attainable standard of research that we might achieve.” Also, the research published in the Lancet controlled for other explanations of the drop.

One of the study’s authors, Dr. Thomas Kerr, explained to Science-ish that he and fellow researchers looked into heroin use and methadone provision over the same period to see if they declined and thus caused the reduction in overdose death. There had been no change in those measures. “It’s an observational study so you can’t prove anything,” he said, “but you can rule out the most obvious competing explanations.”

Less needle sharing

There is also good evidence that Insite reduces HIV transmission through needle sharing—a primary driver of the HIV epidemic around the world. (In Canada, injection drug exposure accounted for 17.7 per cent of new HIV infections, according to the most recent Public Health Agency of Canada data.) A  cohort study, published in the American Journal of Infectious Diseases, looked at a group of Insite users between March and October of 2004. The researchers found that while syringe sharing was still widespread among a small group of Insite users, “rates of syringe sharing among this population are substantially lower than the rate observed previously in this community and it is noteworthy that exclusive (Insite) use was associated with reduced syringe sharing.”

As well, another cohort study, published in the Lancet, looked at injection-drug users around Insite between December 2003 and June 2004, and found that “use of the facility was independently associated with reduced syringe sharing after adjustment for relevant sociodemographic and drug-use characteristics.”

What about the costs…

There have been no controlled trials on cost, so the evidence here isn’t great. However, a researcher at St. Michael’s Hospital in Toronto has developed a model to simulate the project and determine its cost-effectiveness. He concluded that Vancouver’s safe-injection site is associated with cost savings—and improved health outcomes—largely because of evaded cases of HIV. (For criticism of the modelling, read here—though the critics also conclude that Insite is cost-effective.)

As for the impact on public order, there was concern that more drug dealers would cluster around Insite, and that the facility would encourage people to increase their drug use. Shortly after the facility was set-up, researchers looked at its impact on community well-being, measuring drug users injecting in public, publicly discarded syringes, and injection-related litter during the six weeks before and the 12 weeks after Insite opened. Their findings were published in the Canadian Medical Association Journal in 2004. In those weeks, Insite was independently associated with reductions on all those measures.

Bottom line

The evidence we have on Insite is as good as we are ever going to get in demonstrating that this type of program is helpful in managing the harms related to illicit drug use as well as the costs associated with treating related infections.

University of Ottawa professor Dr. Mark Tyndall and some of his colleagues are trying to get funding to support a systematic review of the studies on harm-reduction interventions, including supervised-injection sites. Summarizing the research is a worthwhile pursuit. But, as the Supreme Court recognized, we have sound scientific evidence to support the efficacy of the facility. Yet no more Insites have opened, which raises the question of how many systematic reviews and randomized-controlled trials will be needed to satiate politicians whose default is a tough-on-crime agenda—not prevention or harm reduction.

Consider this: Canada does not have a national harm-reduction policy, and the federal government has allocated 70 per cent of its $64 million in funding for the National Anti-Drug Strategy to law enforcement, according to this informal audit. Only 17 per cent is allocated to treatment, and four per cent to prevention.

“This policy,” Dr. Tyndell said,  “has nothing to do with evidence and everything to do with ideology and the war on drugs.”

Hopefully, though, the evidence will win.

Science-ish is a joint project of Maclean’s, The Medical Post, and the McMaster Health Forum. Julia Belluz is the associate editor at The Medical Post. Got a tip? Seen something that’s Science-ish? Message her at or on Twitter @juliaoftoronto


Insite: ‘Too early to tell’ if it works?

  1. I wonder if Vancouver is a special case, in that a large bulk of injected drug users congregated in the one place?  Such that you could build Insite there instead of over there where in other cities there are three or four pockets of smaller drug-using congregations.  I have no idea, but do you think if you had to take two buses to get there, you’d bother?

    • the point of insite is that the streets in this area are littered with people shotting and smoking heroin. The police walk the street and hassle the junkies until they use insite for their fix.

      It takes the junkies off the streets and cleans up the neighbourhood so at least there are less needles around, and less people ODing in back allies because they all know they will go to jail unless they use insite.

      Also they offer clean needles so that people do not share diseases.
      As a final push, nurses try to offer detox and rehab services.

      It does nothing for the removal of the drug from the streets.

      • You are telling the truth, that is also what we can see in our common life. So, how terrible the drug situation in ca now!

    • I work there. Some people will spend 2 hours or more on transit to come and use our facilities and pick up clean needles. There is a huge need for supervised injection sites. Most importantly because they save lives and connect marginalized people with other health care, detox and housing, but also because they drastically cut health care costs.

      • Thanks!  Now I know.




    The producers of this short film are both
    recovering addicts who have both spent time living and indulging with drug
    addiction in Vancouver’s Downtown Eastside. Today they are both clean and sober
    with multiple years of recovery

    Addiction: Chaos in

    • That is quite the film – should show it at the schools.   I’ve had a few friends disappear down there over the years.  Some make it back, others don’t and of course others die.

      Have you watched the ads just done by some Hollywood directors for The Meth Project? 

  3. “This policy,” Dr. Tyndell said, “has nothing to do with evidence and everything to do with ideology and the war on drugs.”

    Why should CPC drug policy be any different than any other CPC policy?

    An extension of this approach is the Harper government’s efforts to reduce the amount of evidence available for evidence-based policy making, by cutting research funding and reducing the long-form census to uselessness (in that case, at increased expense).

    • Don’t you know, All CPC legislation comes down from the mountain top on stone tablets.

      It is not to be questioned as it has come from God himself. The house of commons are the non believers!

      Ironically I just noticed the most offensive of all the bills, the omnibus crime bill is labeled C-10 hehe

    • Provincial governments make the choices of where healthcare dollars get spent.  That is why Insite exists at all in Vancouver.  The federal government could not close it down because the province makes the decisions.   It is the provincal governments that are leary about opening the safe injection sites.  I  think every major city in Canada could  name a neighborhood where they could install a safe injection site and see harm reduction.  I cannot say what happens in other major cities but I know that where I live, nurses go out a hand out clean needles in a certain area outside the downtown.  These safe injection sites could be added on to urgent care centres that already provide emergency services to mostly homeless and high risk populations IF there was a provincial political desire to do so. 

  4. So Dr. Tyndell is looking for more funding for research and supplies an informal audit he did himself on the National Anti-Drug Strategy allocation of monies?

    The Downtown Eastside is unique as I know of no other place where you have 5-6,000 addicts congregated in such a small area.  It is a Mecca for drug users and dealers.  Twice I have had some wacked out fellow fall across the front of my car just as the light was changing at Hastings and Main.

    Incite is a help for the DTES but I wouldn’t go throwing money at setting up in other cities just yet.  No mention of the extra cost for VPD beat cops who patrol all around Insite.

    What about the Mental Health Commission of Canada project?   It also deals with substance use issues.

    In February 2008, the Federal government allocated $110 million to the Mental Health Commission of Canada to find ways to help the growing number of homeless people who live with a mental illness. The MHCC developed the At Home/Chez Soi project. It was officially launched in November of 2009.

    Program founders based the research demonstration project on the Housing First approach. The project specifically involves people who have been homeless and living with a mental health issue.

    The Housing First approach in this case means providing people with housing, along with support services tailored to meet their needs. Projects are underway in Moncton, Montreal, Toronto, Winnipeg and Vancouver, and each site is exploring issues related to various sub-populations.

    Over 2000 homeless people are participating across the country. Approximately half of them are receiving housing and support services and approximately half have access to the regular supports and services available in their communities. The project is providing meaningful and practical support for hundreds of vulnerable people.

    What we learn in these five cities will help inform related planning and policy development across the country. Data from this kind of extensive research does not currently exist in Canada. The research projects will end in 2013, and will collectively develop a body of evidence to help Canada become a world leader in providing services to homeless people living with a mental illness. 

    As of November, 2011 – over 1030 people now have homes.

    The MHCC project is unique and the largest of its kind underway in the world right now.

    • “What we learn in these five cities will help inform related planning and
      policy development across the country. Data from this kind of extensive
      research does not currently exist in Canada. The research projects will
      end in 2013, and will collectively develop a body of evidence to help
      Canada become a world leader in providing services to homeless people
      living with a mental illness.”

      Well, that sounds exemplary. Honestly, and without snark, i would love to see more of this sort of thing in public policy development.

      Unfortunately, Insite seems to be a perfect example of such experimentation and hard data being steadfastly ignored by policymakers. If you really support this program as a worthwhile endeavor, surely you support Insite for exactly the same reasons.

  5. This comment was deleted.

    • So far as I’m aware, the borders haven’t yet been closed. Perhaps you should hie yourself out of here while you still can.

  6. The reason that Deb Matthews won’t get into the debate is because the next step with these insite places would be to provide hard drugs like crack and heroin to these fine drug addicts who are presently robbing other citizens, prostituting themselves and selling drugs in order to feed their very expensive drug habits. Not working though.  Those drug addicts who wish to get rid of their habits should be helped in any way possible, but these insite places just enable drug addicts to be saved over and over again from overdoses, maybe for 20 years. Also if you are drugged out of your mind, maybe you are reusing a needle elsewhere with your friends, not just the onsite place.