Walk to the back of North America's only supervised drug injection facility - past the tables numbered one through 12, beyond the people shooting heroin into their veins - and you'll spy a room that appears to be nothing more than crowded storage space.
But this room inside Vancouver's Insite clinic is more than just a keeper of filing cabinets. Built when the facility opened in the city's drug-ridden Downtown Eastside eight years ago, the space is designed for supervised inhalation and outfitted with special ventilation equipment.
Insite's operators have twice applied for a federal health exemption to allow crack cocaine smokers to use the room - the request was rejected in 2006, ignored in 2009. Proponents say the room would allow health officials to reach a fast-growing segment of drug users, a group prone to viruses because of dirty crack pipes. Critics say scientific evidence for the benefits of supervised inhalation rooms is scant, and such a facility would hurt addicts by allowing them a space to continue their habit.
Lawyers for Insite and the federal government, among others, were in the Supreme Court of Canada this week to argue about the facility's future. While the high court ruling will deal with Insite's injection component, a favourable decision could clear the path for the facility to attempt to launch an inhalation space.
Lorna Bird is hoping that happens. Her 20-year-old daughter died in 2008 after overdosing on crack cocaine while smoking by herself. Deanna wasn't an injector, and though overdoses among smokers are rare, Ms. Bird said the case highlights the danger inhalers can face. "I believe if there had been a safe inhalation site, she'd be alive today," Ms. Bird said through tears.
Ms. Bird, 54, is president of the Western Aboriginal Harm Reduction Society, a group dedicated to improving the quality of life for native people who use illicit drugs. She said she smokes crack every day and would use an inhalation room if one were to open. "There are things that would have to be ironed out. I would not like to see a crack shack, where everybody's sitting there and everybody's smoking up."
Insite's inhalation room was built to mirror those established in Europe. More than 40 facilities with both injection and inhalation areas were operating in the Netherlands, Germany and Switzerland by late 2003. Insite opened in September, 2003, six years after Vancouver Coastal Health declared a public health emergency in the Downtown Eastside.
Vancouver Coastal Health finances the facility, but it's operated by the non-profit Portland Hotel Society. In August, 2005, PHS wrote to the federal Liberal government requesting authorization to open the supervised inhalation room. After failing to get a response, PHS sent a follow-up letter on Jan. 2, 2006. A federal election was held on Jan. 23 and the Conservatives won a minority government. On Feb. 1, PHS received a letter stating its exemption request had been denied.
"Health Canada would only consider granting an exemption to allow such a facility to operate on a scientific research basis to gather evidence to demonstrate its effectiveness on the health needs of users or as a public health approach," the rejection letter said.
"To date, a strong case addressing all of the previously mentioned elements has yet to be made to Health Canada. As a result, we are not in a position to take action on your request at this time."
A more detailed exemption request was sent to Ottawa in November, 2009. The federal government did not respond, but with the legal questions surrounding Insite, a PHS spokesman said, the society didn't really expect an answer. The spokesman said an inhalation room would be part of the next stage, along with a second injection facility.
Liz Evans, executive director of PHS, said the goal of the inhalation room is clear - bringing addicts into a safe space where they can obtain clean pipes, and where detox services are at hand. "People don't have a gateway into support if they're smoking in alleys and being marginalized," she said.
The argument for an inhalation space is similar to that for an injection site, with a couple of notable differences. The evidence on HIV and hepatitis C being transmitted through crack sharing is not definitive. A 2009 study by the British Columbia Centre for Excellence in HIV/AIDS found people who smoke crack cocaine are at increased risk of contracting HIV, although it was unclear whether the virus was contracted through smoking or other risky behaviour associated with drug use, such as needle sharing or unprotected sex.
Insite's proponents say an inhalation room would also reduce public disorder because fewer people would be smoking on the streets.
Gwen Landolt, president of the Drug Prevention Network of Canada, a group that advocates for abstinence-based alcohol recovery and treatment, questioned the need for a supervised inhalation room.
"This is detrimental to the drug addict, to families, to the community. It doesn't serve any purpose, apart from those people who want to liberalize drug use," she said.
"You want to cure them of addiction and you do that by treatment and you give them hope."
Patricia Daly, Vancouver Coastal Health's chief medical health officer, said officials need to evaluate whether current harm-reduction strategies for crack cocaine users are sufficient - and get an accurate count of the number of crack smokers. And a thorough scrutiny of the merits of a supervised inhalation site is needed before one is added to any harm reduction approach, she said.
"The question of a supervised inhalation site is one that people have asked about, because we do wonder if we could achieve some benefits with that that we've seen with a supervised injection facility. Being able to engage people, get them into treatment, but it still needs to be studied."