SUPERVISED INJECTION FACILITY WINS LEGAL BATTLE IN CANADA

PREAMBLE: Harm Reduction for People Addicted to Injection Drug Use
The purpose of supervised injection facilities is to reduce the harms associated with injection drug use. This said, the way forward is decidedly uphill for any society that pits the perceived interests of “law and order” against public health interests. Insite, a supervised injection facility in British Columbia, Canada’s western most province, illustrates this struggle.

When opened in September 2003, Insite was awarded a three-year exemption from Section 56 of the Controlled Drugs and Substances Act, for scientific and research purposes. In September 2006, the Federal Health Minister announced an extension to the facility’s exemption that allowed Insite to operate for another 15 months. In October 2007 the exemption was extended until June 30, 2008. In August 2007, the PHS Community Services Society, the two Insite clients and Vancouver Area Network of Drug Users (VANDU) filed a statement of claim in BC Supreme Court seeking to have the court declare Insite the exclusive jurisdiction of the province and for the federal government not to play any role in its future. In May 2008, the BC Supreme Court struck down the provisions of the Controlled Drugs and Substances Act that deal with possession and trafficking but suspended the declarations of invalidity for one year to allow Parliament to bring the law into compliance with the Constitution, and the Court’s reasons, which ensure Insite a permanent constitutional exemption. The Attorney General of Canada appealed the decision. On January 15, 2010, the BC Court of Appeal dismissed the appeal by the Attorney General of Canada, allowing Insite to continue operations. The Attorney General filed a further appeal with the Supreme Court of Canada. Early in 2011, it was announced that the Supreme Court of Canada would hear the appeal from Attorney General of Canada.

Note: The position of Attorney General is a Cabinet post awarded to an elected member of the governing party; its central role is to advocate and act on the policies and views of the government of the day.

The Outcome: On September 30, 2011, the Supreme Court of Canada ordered the federal Minister of Health to grant an exemption to Vancouver’s supervised injection facility under the Controlled Drugs and Substances Act.

By ruling that addiction-related drug use is a health issue and not simply a criminal justice issue, the Supreme Court decision upheld Canada’s constitutional rights to life, liberty and security of the person and the role of public health interventions of this nature.

Under Canada’s Conservative government, an unremitting effort had been made to close the facility down, despite support from the provincial government of British Columbia. Their objections were based on reasons of political ideology. In stark contrast, the decision made by the Supreme Court, was based on a careful reading of Canada’s Charter of Rights, and scientific evidence that the facility was saving lives, and not promoting the drug culture as the federal Conservatives had claimed. It is relevant to note also that several European countries have similar established facilities in major urban centers, as does Australia.


BACKGROUND: ROLE OF HARM REDUCTION
Supervised Injection as a Public Health Approach to Drug Addiction - the Evidence

Instead of responding to drug addiction primarily as a matter for law enforcement as many nations do, a public health approach to this condition can offer positive alternatives. That superior health and social outcomes can be achieved is illustrated by Insite. Operating under an exemption from provisions under federal legislation, Insite is North America’s first legal supervised site for injection drug use (IDU). Located in a disadvantaged area of Vancouver, Canada, about half of the people who use Insite are marginalized: homeless or living in shelters or have significant mental health issues. Many are older and have been using drugs for many years. Their long-term drug use and chaotic lives have seriously compromised their health. Through Insite, clients develop trusting relationships with health and social workers, making them more likely to pursue withdrawal management (detox) and other addiction services.

Since 2003, Insite has offered a safe place where people may inject drugs and connect with diagnosis and treatment of infection and disease, addiction counselling and treatment, access to housing and community support. The provincial Ministry of Health provides funding, while Vancouver’s public health agency operates the facility in collaboration with community organizations. Insite represents a “harm-reduction” model: it strives to decrease the adverse health, social and economic consequences of drug use without requiring abstinence from drug use. This embodies prevention: reducing the incidence of primary infections through safe injection itself, and reducing HIV and TB transmission by expanding highly active antiretroviral therapy (HAART) coverage among HIV infected persons.

Insite’s front line team includes nurses, counsellors, mental health workers and peer support personnel. The operation has 12 injection booths where clients inject pre-obtained illicit drugs under supervision. It supplies clean injection equipment such as syringes, cookers, filters, water and tourniquets. If an overdose occurs, the team, led by a nurse, is available to intervene immediately. Nurses also provide other health services, like wound care and immunizations. Although there have been 1,418 overdoses at InSite between 2004 and 2010, staff were able to successfully intervene each time. There has never been a fatality at InSite since opening.

Not designed to be a stand-alone facility, Insite is part of a continuum of care for people with addiction, mental illness and HIV/AIDS. It was designed to be accessible to injection drug users who are not well connected to health care services. For people with chronic drug addiction, this is the first step towards possible recovery. When clients are ready to access withdrawal management, they can be immediately accommodated at Onsite, a partner program where people have access to 12 rooms with private bathrooms where they can detox. Mental health workers, counsellors, nurses and doctors work together to help people stabilize and plan their next steps. People can then move up to transitional recovery housing for further stabilization and connection to community support, treatment programs and housing.

Insite is supported by The Urban Health Research Initiative (UHRI), established in 2007 as a program of the British Columbia Centre for Excellence in HIV/AIDS at St Paul’s Hospital in Vancouver, affiliated with the University of British Columbia. The UHRI comprises a network of studies developed to help identify and understand the many factors that affect the health of urban populations, focusing on substance use, infectious diseases, the urban environment and homelessness. For example, UHRI research has produced evidence of reduction of overdose mortality after the opening of Insite: this retrospective population-based study found that fatal overdoses within 500 metres of Insite decreased by 35% after the facility opened compared to a decrease of 9% in the rest of Vancouver.[1] Details of this and other studies are available online.[2]

An initial evaluation focused on the first three years of Insite (2003-6).[3] This revealed that the facility attracted IDUs who were hard to reach through conventional public health programs. Its opening coincided with a significant reduction of public injection drug use and publicly discarded syringes, suggesting that the facility has also contributed to an increase in public order. Among its clientele, Insite significantly reduced the rate of syringe sharing, a practice that is identified as a primary mode of HIV transmission. Individuals who used Insite were also significantly more likely to enter into addiction treatment services. Finally, the opening of Insite was not associated with an increase in levels of drug- dealing or other drug related crime in the area in which the facility is located. The paper concluded that Insite was associated with an array of community and public health benefits and, despite rigorous evaluation, no identified adverse impacts. These findings should be useful to other cities considering opening supervised injecting facilities, and to governments considering regulating their use.

A study of user perspectives revealed that, Of 1,082 Insite users surveyed, 809 (75%) said that they injected more safely as a result of visiting Insite.[4] Of individuals reporting safer injecting, 80% reported rushing less during injecting, 71% reported less outdoor injecting, and 56% reported less unsafe syringe disposal. When asked to list any obstacles or barriers to using Insite, study participants most commonly reported travel time to Insite, the facility’s limited operating hours, and the waiting time to use the facility. When asked in what ways Insite might be improved, the three most common suggestions were longer hours of operation, the addition of a washroom, and reduced wait times. Clearly there is wide demand for Insite’s services.

Insite as a refuge for women who inject drugs has also been studied.[5] Violence is common within open drug scenes, especially for women who spend time in such environments. There is often a sense of danger on the streets, and women who inject illegal drugs live with the constant threat of arrest, robbery, physical abuse, sexual assault, partner violence and even murder. Struggling to avoid these dangers, women are less able to exercise choice in protecting themselves against other threats such as HIV and hepatitis C. In-depth interviews with women have revealed that Insite has provided temporary refuge from the dangers of the street-based drug scene. Women also have learned the correct way to perform an injection. In many cases, the first time a woman uses an injection drug, someone else—usually an older male drug user—injects the drug for her. By learning how to inject themselves, women rely less on men and gain more control over the circumstances of their own drug use. They are then more likely to practise safer habits when injecting, such as using clean needles. This, in turn, reduces their risk of becoming infected with HIV or hepatitis C.

References: 1. Marshall BDL, Milloy MJ, Wood E, Montaner JSG, Kerr T. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: A retrospective population-based study. Lancet. Published online April 18, 2011. DOI: 10.1016/S0140-6736(10)62353-7.
2. BC Centre for Excellence in HIV/AIDS. http://www.cfenet.ubc.ca/ Accessed September 2, 2011.
3. Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian Medical Association Journal, 2006; 175(11): 1399‑1404.
4. Petrar S, Kerr T, Tyndall MW, Zhang R, Montaner JS, Wood E. Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility. Addictive Behaviors, 2006; 32(5): 1088-1093.
5. Fairbairn N, Small W, Shannon K, Wood E, Kerr T. Seeking refuge from violence in street-based drug
scenes: Women’s experiences in North America’s first supervised injection facility. Social Science & Medicine, 2008; 67(5): 817-823.

Envoi: We at Pacific Health & Development Sciences Inc. congratulate Insite for winning this landmark legal battle. It is to be hoped, now that the Supreme Court of Canada has held sway, that Insite will move forward without the constant threat of political harassment, and thereby more able to focus on its mission of harm reduction, one of the main pillars of a coherent prevention and control strategy for drug abuse. The others pillars are primary prevention, treatment and enforcement.