As an internal medicine physician who works in Vancouver's Downtown Eastside and as a researcher who was responsible for the evaluation of Vancouver's Insite supervised injecting facility, I have been confused by how entrenched the federal government's opposition to safe-injection programs has become in recent days – despite the clear support of the Canadian Public Health Association and the Canadian Medical Association.
The Conservative government went all the way to the federal Supreme Court in an effort to have Insite shuttered, though they were ultimately unsuccessful when a unanimous 2011 Supreme Court decision stipulated that the facility should remain open. This judgment also described how the federal government must consider applications for future programs. Last week Ottawa responded by announcing its "Respect for Communities Act."
Rather than creating a system for considering applications for new injecting facilities, this bill appears intended to prevent other communities from establishing similar programs. When brought into effect, the act will also threaten the sustainability of Insite, which will need to apply for a renewed permit under new strict guidelines.
Unfortunately, much of the government opposition to injecting facilities stems from the view that these programs result in less control over injection-drug use, when the opposite is actually true. In fact, what is particularly ironic is that Ottawa supports other health interventions for intravenous drug users that are actually less consistent with the law-and-order approach the Conservative Party espouses.
For instance, on the federal stage, few senior Conservative members have opposed Insite more strongly than former health minister Tony Clement. At the 2008 International AIDS Conference, Mr. Clement made clear the Conservative Party's support for needle exchange programs, which involve handing out clean needles to addicts and have proven effective at reducing the spread of infections like HIV. However, in the case of Insite, Mr. Clement made clear his strong opposition to the program, famously calling it an "abomination."
The irony is that the needle exchange programs serve essentially the same function as Insite, but they don't place any "law and order" parameters around how and where the provided needles are used. For instance, individuals using a needle exchange may take a needle and subsequently inject in full view of the public and dispose of the needle in parks or other areas where there is risk of injuring someone.
While needle exchanges have been proven to help cut HIV rates, there is also nothing to prevent a needle obtained at an exchange subsequently being passed from one addicted individual to another – which is how HIV is spread. Most importantly, needle exchanges provide only furtive contact, limiting the potential to meaningfully engage people and offer them an alternative such as addiction treatment.
Reframe the traditional Conservative view of Insite as a loss of control, and consider that it actually imposes rules to establish law and order. For instance, the strict rules at Insite preclude the possibility of a used syringe being passed between users since nurses police the program to ensure clean needles are used in every injection. Not only do injections take place out of public view and away from vulnerable youth who may be curious about injecting, but onsite disposal also ensures used needles cannot find their way into public spaces. Insite further forces its clients to temporarily remain onsite after injecting and where an addiction treatment program is co-located. As a result, a study published in the New England Journal of Medicine demonstrated how the opening of Insite coincided with a 40 per cent increase in addiction treatment admissions among its clients.
The limitations of traditional needle-exchange programs and the desire for greater control over the behavior of intravenous drug users explains why centres of commerce and tourism in Europe have embraced supervised injecting facilities. More than 90 supervised injecting facilities exist in over 60 cities.
Public health and financial constraints are a further consideration, given that each HIV infection costs on average approximately $500,000 in medical costs. Insite has contributed to a 90 per cent reduction in new HIV cases caused by intravenous drug use in British Columbia, which is why the B.C. government has been such a strong supporter of the program.
Of course, regardless of how one's view of Insite is framed, caught in the middle are desperately addicted Canadians just trying to find help and avoid acquiring a life-threatening infectious disease.
Evan Wood MD, PhD, is a professor of medicine at UBC where he holds the university's Canada Research Chair in Inner City Medicine.