When the Supreme Court of Canada convenes Thursday to consider Vancouver's supervised injection site, it will hear detailed arguments that hinge on the fine print of the Canadian Constitution.
But besides being a landmark showdown between federal and provincial powers, the hearing also sets the stage for a ruling expected to affect not only the daily lives of injection drug users on Vancouver's Downtown Eastside but drug policy across the country and potentially farther afield.
In cities including Victoria and Montreal, groups that have lobbied for supervised injection sites along the lines of Vancouver's Insite facility will be waiting to see whether their proposals could proceed without breaking the law.
Across the country, researchers and health-care workers are looking to the Supreme Court decision as a signal that could shape future health care policy, ranging from needle exchange programs in prisons to inhalation rooms for crack-cocaine smokers.
Internationally, health researchers will be monitoring the case as a bare-knuckle brawl between political ideology and evidence-based research, of which a small mountain has accumulated to back Insite and which supporters repeatedly cite in their long-running fight to keep the clinic open.
At home and abroad, policy makers are watching the case in the context of Prime Minister Stephen Harper's newly-minted majority and tough-on-crime agenda.
A lightning rod for controversy, Insite attracts support and detractors along several main lines.
It saves lives:
There have been no overdose deaths at Insite since it opened in 2003. On average, nearly 600 injections occur daily at the site and last year alone there were more than 200 "overdose interventions" by Insite staff who provide oxygen or drugs to users who are in danger of overdosing. A paper published in the Lancet in April of this year found fatal overdoses within 500 metres of Insite decreased by 35 per cent after the facility opened compared to a decrease of nine per cent in the rest of Vancouver.
Earlier this month, the B.C. Coroners' Service warned of a spike in overdose deaths resulting from potent heroin being sold throughout the province and urged drug users to use community services such as Insite "where possible." B.C. public-health officials and the British Columbia Nurses' Union support the facility.
It serves as a bridge to detox and treatment:
Insite was conceived of as part of a four-pillars approach – those being harm reduction, prevention, treatment and enforcement – modelled on similar programs that jurisdictions such as Switzerland and Germany pursued in the 1990s.
By offering a clean, safe, non-judgmental environment to shoot up, the reasoning goes, Insite allows drug users to connect with other services, whether that be treatment for a drug-related abscess or dental care.
Last year, Insite staff made more than 5,000 referrals to other social and health agencies, including 458 admissions to Onsite, a neighbouring detox facility that opened in 2007 and recorded a "program completion rate" of 43 per cent in 2010.
Supporters say supervised injection facilities should be seen as just one piece of a bigger puzzle in treating drug addiction and its related toll on society.
It benefits public health and the broader community:
Among the many studies published on Insite are papers that conclude the clinic has not led to an increase in drug-related crime, is not a negative influence of those seeking to stop drug use and has resulted in a drop in public injections in back alleys and doorways.
Studies have also reported declines in dangerous behaviour, such as sharing needles, and a related decrease in HIV infections. The Vancouver Police Department supports the facility, which studies have shown has resulted in fewer discarded needles in neighbourhood streets.
In fighting to keep Insite open, the provincial government argues that the health benefits of the facility should trump jurisdictional issues, saying in written submissions to the court that British Columbians have a "visceral" memory of hundreds of addicts dying needlessly in flophouses and on the street before Insite was opened.
Those who want to see the site closed maintain:
Insite's operation is an affront to federal control:
When Insite opened, it obtained a three-year exemption from Canada's Controlled Drugs and Substances Act from Health Canada. That exemption was extended twice, until June 30, 2008. When the federal government declined to extend the exemption, Insite supporters launched a court challenge. The B.C. Supreme Court and the B.C. Court of Appeal supported B.C.'s right to run the clinic on health grounds. The federal government appealed.
Federal prosecutors say Ottawa needs to maintain control over drug policy and that giving B.C. control over Insite would open the door to a fragmented, patchwork of rules and regulations across the country.
The legal wrangle will zero in on the constitutional conundrum posed by Insite – the federal government has authority over criminal law and the promotion of health and safety, but provinces decide how health care can be delivered.
Governments should not facilitate drug use:
Despite the research studies backing Insite and its harm-reduction approach, there is still profound discomfort for many with any facility that gives addicts a green light to inject illegal drugs and flout the law. Governments, they argue, should not be facilitating illegal, dangerous activities. "The state has no constitutional obligation to facilitate drug use at a specific location by hardcore addicts, the mildly addicted, frequent users or occasional users," federal prosecutors Robert Frater and W. Paul Riley said in written submissions to the court.
There have been arguments that money spent on Insite would be better spent on services such as treatment and that government's support of supervised injection sites sends a mixed message to young people who might be considering illicit drug use.
Supervised injection sites do nothing to deter drug use or help drug addicts:
Part of the federal government's argument is that drug laws are not an unreasonable restriction on individuals' liberty. "Unsafe injection or, for that matter, consumption by injection at all, is a choice made by the consumer," the federal prosecutors say in their brief to the Supreme Court.
There are also arguments that supervised injection sites are a magnet for drug dealers and predators, and that public safety demands that illegal drugs be tightly controlled.