Safe Injection Sites-1

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1 Harm Reduction of Safe Injection Sites Harm Reduction of Safe Injection Sites: Comparisons between Vancouver’s InSite and the closure of Victoria’s needle exchange Matt Cook – Social Work 417 Yukon College Instructor – Brooke Alsbury Winter 2014

2 Harm Reduction of Safe Injection Sites Matt, I would suggest a brief introductory paragraph that introduces the overall purpose and plan for your paper prior to getting into the details about SIS. Safe injection sites (SIS) also known as Safe Injection Facilities (SIF) are professionally run clinics within cities or communities with the intent of promoting harm reduction within the intravenous drug user communities (Weekes et al., 2005). SIFs are a “low threshold” (i.e., easily accessible) service typically run by nurses, social and public health workers or other medical staff who provide sterilized injection equipment and counselling to users, but are not allowed to provide drugs or directly assist in the process of injection (Weekes , et al., 2005). Safe injection facilities also help direct drug users to treatment and rehabilitation programs, and can operate as a primary healthcare unit (Elliott , et al., 2002). Facilities provide free equipment, including syringes, alcohol, dry swabs, water, spoons/cookers, and tourniquets (Elliott et al., 2002). The facilities are intended to reduce incidents of unsafe use of injection drugs and to prevent the negative consequences that too often result from unsafe injection (Elliott et al., 2002). A famous Canadian example, and the core basis of this paper, is Vancouver’s infamous downtown eastside where addiction is visibly prevalent and injection drug users face serious potential health risks, including fatal and non-fatal overdoses and blood borne diseases such as HIV/AIDS and hepatitis C (Elliott et al., 2002). In a 2005 frequently asked questions publication, The Canadian Centre on Substance Abuse clearly summarized their mandate and the three main goals of SIFs: a) To reduce acute mortality and morbidity risks among intravenous drug users b) To bring intravenous drug users in contact with social, health and treatment services,

3 Harm Reduction of Safe Injection Sites c) To reduce public order problems (drug use in public, discarded needles) related to intravenous drug use With the intention of reducing the community, public health and fiscal impacts of injection drug use, the supervised injection facility, known as ‘InSite’, opened its doors September 22, 2003 in Vancouver’s Downtown Eastside (Jozaghi et al., 2013). In order to ensure that clients would utilize InSite and the available resources, The Government of Canada agreed to exempt the Vancouver Coastal Health Authority from the Controlled Drugs and Substances Act, to allow for a medically supervised safe injection facility (Fafard, 2012). InSite was granted a 3-year exemption linked to a rigorous evaluation of what was styled as a pilot project (Fafard, 2012). InSite drew from similar models of previously established by health service providers in the Netherlands during the 1970s, Switzerland in the 1980s, and Germany in the 1990s, in order to minimize the public nuisance associated with injection drug use and to provide a clean and protected environment for IDUs in order to reduce the transmission of blood-borne viruses, risk of overdose and public disorder (Weekes et al., 2005). In Switzerland, the first government authorized SIF (1986) was established in direct response to increasing rates of HIV infection and public nuisance factors (Weekes et al., 2005). In Hamburg and Rotterdam, Germany, certain SIFs have been established that specifically aim at assisting drug-using sex workers (Weekes et al., 2005). Currently, there are approximately 40–50 legal SIFs in operation throughout the world in places such as Australia, Luxembourg, Spain, Austria, Germany, Netherlands and Switzerland (Weekes et al., 2005).

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4 Harm Reduction of Safe Injection Sites The first key fact to t T he Government of Canada granting leniency toward InSite pertained to the notion that addiction is a healthcare matter (Small, 2012). The Government of Canada conceded this as an indisputable fact (Small, 2012). The presiding judge at the BC Supreme Court, Justice Ian Pitfield, highlighted this absolutely critical cultural admission in his reasons for Judgment when he stated: “drug addiction is an illness” (Small, 2012). The declaration of addiction as an illness allows for the devotion of healthcare resources to addressing it (Small, 2012). While the users do not use InSite directly to treat addiction, they receive services and assistance at InSite which reduces the risk of overdose that is a feature of their illness, they avoid risk of being infected or of infecting others by injection and they gain access to counselling and consultation that may lead to abstinence and rehabilitation (Small, 2012). All of this reasonably falls under the healthcare moniker (Small, 2012). Since the launch of InSite, there are an estimated 700 to 800 injections per day for InSite clients (Jozaghi et al., 2013). A Vancouver IDU Study (VIDUS) found that 28% of the InSite intravenous drug users, who agreed to participate in the study, were HIV-positive and 86% tested positive for Hepatitis C (Weekes et al., 2005). A greater frequency of back alley injections, prior to InSite being launched and the incentive to inject quickly to avoid legal consequences increased the likelihood that individuals would share needles and other equipment, putting themselves at risk for HIV and Hep C infection in the East Hastings area of Vancouver (Elliott et al., 2002). Further studies with IDU drug users across Canada have indicated that approximately 40 percent had shared needles within the past six months thereby increasing the risk of spreading blood borne STI’s (Elliott et al., 2002). Public injectors without access to clean injection sites

5 Harm Reduction of Safe Injection Sites and needle exchange programs were also more likely to report injecting behaviors that put them at elevated risk for blood borne viruses, such as using needles or injecting equipment already used by another IDU (Green et al., 2003). When presented with different rationales for their reported reuse of another injector’s needle (more than one response was permitted), 91% of public injectors affirmed that they “didn’t have a syringe,” 57% said they did so because they “were jonesing” (i.e., experiencing cravings for drugs), and 50% felt they could reuse someone else’s needle because they select the people with whom they share needles and therefore feel confident that there is no real risk (Green et al., 2003). Of public injectors who reported needle sharing, 34% rationalized doing so because they “are dying from AIDS or otherwise; so who cares.” (Green et al., 2003) Evaluations by the BC Centre for Excellence in HIV/AIDS indicate that InSite did directly result in the intended harm reduction to users and other members of the community, reducing drug-trade litter and increased intake into intervention and addiction treatment programs (CMAJ, 2007). One analysis estimated that two to twelve deaths due to overdose have been averted annually by the facility, and in another mathematical modelling study, it was estimated that InSite prevents an average of 35 cases of HIV infection and three deaths per year (Laupland et al., 2012). In addition, these investigators found that after program costs were taken into account, InSite provided a saved estimated net societal benefit of $6,000,000 per year (Laupland et al., 2012). Although other investigators have modelled infection rates and associated costs with varying results, the common conclusion is that infections and societal costs are greatly reduced by InSite and the focus on harm reduction (Laupland et al., 2012).

6 Harm Reduction of Safe Injection Sites To put this in perspective, a lifetime of HIV-related medical care can be approximately $210,555 in 2008 Canadian dollars (Pinkerton, 2010). Consequently, by preventing 5–6 HIV infections per year, the InSite SIF averts more than $1,000,000 in future HIV-related medical care costs (Pinkerton, 2010). This makes an estimate that the SIF generates $660,000 in additional cost savings by preventing 1.08 overdose deaths per year (Pinkerton, 2010). The total savings due to averted HIV-related medical care costs and prevented overdose deaths (approximately $1.7 to $1.9 million per year), in and of itself, is just slightly greater than the estimated $1.5 million annual operating cost of InSite (Pinkerton, 2010). Despite the fact that InSite has saved lives, prevented infections, promoted and facilitated addictions treatment, and saved public dollars, it has remained a source of public controversy due to the illegal activities of the clients (Laupland et al., 2012). InSite’s continual ability to remain open has been uncertain and is continually at risk with governmental challenges of the legality to continue operation (Laupland et al., 2012). Conservative opposition largely relates to objections to the ‘permissive’ use of controlled substances at InSite on a daily occurrence (Laupland et al., 2012). In addition, a number of potential moral, ethical and political issues have been raised, including the use of tax payer funds to support this ultimately illegal activity, and unfounded concerns that such a facility may be condoning or legitimizing intravenous drug use (Laupland et al., 2012). Regardless of the evidenced harm reduction, and InSite having shown the ability to reduce tax-payers cost in longevity, the counterpart to InSite, Victoria’s fixed-site needle exchange, closed doors on May 31, 2008, due to a lawsuit from neighbours and was evicted

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7 Harm Reduction of Safe Injection Sites (Ivsins et al., 2010). Attempts from the Vancouver Island Health Authority to find another fixed- site location were unsuccessful due to neighbourhood pressure and a lack of available rental spaces (Ivsins et al., 2010). Since June 2008, needle exchange services in Victoria have been offered through a mobile outreach program (Ivsins et al., 2010). Mobile needle exchanges are typically used as an alternative to fixed site services to reach clients who may not feel comfortable accessing fixed sites (Ivsins et al., 2010). However, best practice documents recommend that in cities with large populations of injection drug use, more than one model of needle exchange service delivery is necessary and that a fixed site needle exchange is an essential component (Ivsins et al., 2010). Another factor that impacts the mobile service is a “no- go zone” in an area of downtown Victoria, where street outreach workers are not permitted to hand out clean needles or any other harm reduction supplies, but where a significant number of people who use injection drugs are located (Ivsins et al., 2010). The result has been a substantial reduction in the level of health service provided for intravenous drug users and of clean needles, and has impacted their ability to meet the provincial policy of providing drug users with one clean needle for every injection (Ivsins et al., 2010). Before InSite was opened, there were concerns that it would result in increased crime rates in the neighbourhood as a result of the migration of drug dealers and drug users toward the facility and subsequent increases in drug dealing and drug acquisition crime (Wood et al., 2006). The analysis of public order indicators described above showed that suspected drug dealing did not increase in the vicinity of the facility and that public drug use declined (Wood et al., 2006). In addition, police statistics during the year before versus the year after the facility opened

8 Harm Reduction of Safe Injection Sites showed that crime rates remained stable in the neighbourhood where the facility is located (Wood et al., 2006). Specifically, the facility’s opening has not been associated with increases in charges for drug dealing or several markers of drug-related crime, including assaults, robbery and vehicle break-ins (Wood et al., 2006). Ironically, these publicly documented parallels did little to help the Victoria Needle Exchange in regard to their doors closing. In early 2009 a lengthily titled report by the Centers of Addiction Research BC was published under the title: Drug use trends in Victoria and Vancouver, and changes in injection drug use after the closure of Victoria’s fixed site needle exchange. The results were reported from 464 interviews with intravenous drug users in the Victoria area and focused on how to assess the closure of the fixed-site needle exchange had impacted drug use and injection drug users (Ivsins et al., 2010). Common themes emerging from the responses included: • More open and public drug use. • An increase in improper disposal of used needles (i.e., on the street). • More people sharing and re-using syringes. • More difficult to get clean needles. The qualitative data collected in early 2009 shows that the numbers of clean needles distributed in Victoria since the closure fell by over 15,000 per month (Ivsins et al., 2010). Needle sharing rates increased up to an estimated 23% and participants also frequently spoke about re-using needles on a weekly basis (Ivsins et al., 2010). Some other changes noted after the closure of the fixed site needle exchange in Victoria were that although there was a substantial

9 Harm Reduction of Safe Injection Sites reduction in the number of clean needles distributed in Victoria, daily drug injection increased significantly over time (Ivsins et al., 2010). Conversely, in Vancouver, where clean needles were more accessible, daily drug injection significantly decreased (Ivsins et al., 2010). These results may underscore the importance of educational supports provided by needle exchange personnel that promote healthier lifestyles (Ivsins et al., 2010). Conclusively, when reviewing the facts and taking in consideration the controversial aspects of safe injection sites, it is easy to understand the initial reservations made by the public. The idea of creating a safe haven for addicts to get high would appear to condone and encourage addiction, not actively trying to minimize it through treatment or RCMP law enforcement. Additionally, the logical conclusion would be that a safe injection site would be a lure for not just the addicted clientele; but drug dealers seeking to capitalize on the practicality of having their customers frequent the same location. This would all appear to be a recipe for increased crime, violence and deviance within the particular neighborhood of the site or facility. Despite this, the statistical evidence shown throughout this paper has indicated the contrary. Crime rates remained mostly stable as indicated earlier in the paper (Wood, 2006). Location would also play an important part of a successful safe injection facility, such as InSite being located within East Hastings. Understandably, the most home owners would want to keep a distance from safe injection sites and addicts could theoretically want to keep a low profile from the general public’s eyes. Additional stereotyped problems such as stray needles would be a worry to parents with young children, despite the irony of a safe injection facility having a secure needle disposal program. The stigma of HIV and Hep C being connected to

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10 Harm Reduction of Safe Injection Sites injection addiction would increase paranoia concerning stray needles around safe injection site neighborhoods. Sadly, as mentioned before, a safe injection facility decreases these risks. One of the most essential services that these facilities provide society is the previously mentioned decrease in blood borne infections, HIV and Hep C being the most prevalent. While providing a safe and comfortable environment for an addict, the safe injection sites and needle exchange programs prevent the sharing of previously used needles and provide safe disposal. Taking this into consideration, the health benefits to the client and the harm reduction done more than validates the necessity of these programs. In my personal opinion, every major Canadian city would benefit from having a safe injection site. The benefits to healthcare alone from decreased HIV and Hep C infections should be enough to persuade anyone of the importance they play in societal harm reduction. While abstinence may be too much to hope for in the case of some IDU addicts, personal management and ethical humane treatment concerning their addiction is integral in respecting their rights as Canadian citizens.

11 Harm Reduction of Safe Injection Sites References Elliott, Richard. Malkin, Ian. Gold, Jennifer. Establishing Safe Injection Facilities in Canada: Legal and Ethical Issues Canadian HIV/AIDS Legal Network 2002 Fafard, Patrick. Public Health Understandings of Policy and Power: Lessons from INSITE. Journal of Urban Health Vol. 89, No. 6, 2012 the New York Academy of Medicine Green, Traci. Hankins, Catherine. Palmer, Darlène. Boivin, Jean-François. Platt, Robert. Ascertaining the Need for a Supervised Injecting Facility: The Burdon of Public Injecting in Montreal Canada. Journal of Drug Issues 2003 33: 713 http://www.sagepublications.com Ivsins, A., Chow, C., Marsh, D., Macdonald, S., Stockwell, T. & Vallance, K. (2010). Drug use trends in Victoria and Vancouver, and changes in injection drug use after the closure of Victoria’s fixed site needle exchange (CARBC Statistical Bulletin) Victoria, British Columbia: University of Victoria. Jozaghi, Ehsan. Andresen, Martin A. Should North America’s first and only supervised Injection Facility (InSite) be expanded in British Columbia, Canada? Harm Reduction Journal 2013, 10:1 http://www.harmreductionjournal.com/content/10/1/1 Laupland, Kevin B. MD. Embil, John M. MD. Reducing the Adverse Impact of Injection Drug use in Canada. 2012 - Departments of Medicine, Critical Care Medicine, Pathology and Laboratory Medicine, and Community Health Sciences, Peter Lougheed Centre University of Calgary, Calgary, Alberta.

12 Harm Reduction of Safe Injection Sites Pinkerton, Steven D. How many HIV infections are prevented by Vancouver Canada’s supervised injection facility? International Journal of Drug Policy. Center for AIDS Intervention Research, College of Wisconsin 2011 Rynor, Becky. Clement seeks safe injection site study Canadian Medical Association Journal 176 (13). • June 19, 2007 Weekes, John. MD, Percy, Leah. Cumberland, Karen. Supervised Injection Facilities (SIFs) FAQs Canadian Centre on Substance Abuse 2005. ISBN 1-896323-17-0 Wood, Evan. Tyndall, Mark W. Montaner, Julio S. Kerr, Thomas. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian International Review of Law November 21, 2006 • 175(11)

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