Professor Catherine Mclaughlin
18 November 2018
Insite Deserves Funds: A Question of Yes or No?
Drugs appeal to us because they deliver a variety of moods and states not immediately available from our surrounding realities. These may take in complete relaxation, ecstatic happiness, the negation of suffering, radically transformed perceptions, or just a sense of being alert and full of potential energy.
· Walton (2002)
As it presents a typical visit in the national TV network, that someone, possibly pseudonymous, walks straight into a site, approaching to a receptionist, and waits until he is called into a large space behind a locked door to pick up fresh and sterile equipment for a drug injection. While he sits at a stainless steel booth getting injected a nurse is implementing her supervision on him. Used equipment is then tossed into a receptacle after use, and the booth is also cleaned up afterwards. Before returning to the street, this drug user rests for a while inside this site’s “chill room”. Moreover, addiction treatment and primary care services are offered if he is interested. This site, as one of the public health interventions, was opened in Vancouver, 2003 – North America's first medically supervised safe injection site (Insite) for illicit injection drug users. Despite the concerns raised by the Canadian opponents about Insite’s potential threat to public safety, alleged encouragement of drug use, and squander of resource, Canadian federal government sanctioned an exemption to Insite under section 56 of Canada’s Controlled Drugs and Substances Act (Boyd 235), authorizing its operation as a harm reduction facility – defending human right (that one gets to live and receive health service), reducing the
risk (of infectious diseases, overdose and mortality) posed by public injection drug use, and generally benefiting healthcare system.
Human rights apply to everyone, so it is unjust to deprive the ones who use drugs of their right to health treatment, to social service, to freedom from cruel inhuman and degrading treatment, and to life. Drug addiction is acknowledged as one of the most resistant illness, which requires infinite willpower and perseverance within the drug users, and certainly thorough treatment and help from the society. Insite not only provides safe injection of illicit drugs but also mainly focuses on helping the drug users who have been marginalized to the alleys, bringing them into the light of healthcare, and eventually making them abstain from drugs by offering standard medical service and mental therapy and consultation. People who use drugs are often experiencing harassment and detainment, being subjected to involuntary and abusive treatment procedures, which foreseeably can turn these addicts into be more vulnerable, aggressive and resentful. Sometimes, as a result, instead of quitting drugs, they proceed to more involvement in drug abuse and even revenge on the society. Facilities and effective individual programs in Insite, on the other hand, aim for ensuring the fulfilment of human rights and ethical obligation by providing the drug addicts with proper access to drug substitution, health service, and detox programs that help them gradually recover. According to a study authored by scientists at the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE), which reveals “Insite’s opening led to a 30% increase in detoxification by facility users, and its new findings suggest Insite users who began detox were more likely to both enrol in longer-term addition treatment and reduce injecting” (Insite Leads to). As a result, drug users, their families and communities could collectively benefit from this facility.
Evidently risks posed by public injection drug use have been reduced when done under the supervision of professional counsellors and medical care in Insite. Approximately 13,000 British Columbians are HIV infected (with close to 350 new cases reported each year) and more than 3,200 cases of AIDS have been reported in the province (Montaner). The fact is, among injection drug users, sharing syringes is one of the primary ways that has led to a high risk of spreading these infectious disease (HIV, AIDS, hepatitis C virus (HCV), etc.). Independently associated with improvements in several measures of public order, Insite includes reduction of both public injection drug use and public syringe disposal. Under supervision, sterile needles, cotton pads, antiseptic are supplied to “those most at risk for overdosing or becoming infected with HIV or HCV”, in addition, “partner restriction” is applied (Insight to Insite). In other words, the drug addicts not only can rely on safe injection but also are less likely to share needles because “they have a chance to learn the least injurious ways of injection . . . [so that] they are less likely to require help from other [drug users] and [then] . . . share needles” (Insight to Insite). After attending safe injection sites, positive outcomes have been showed by several studies – dramatic decline in syringe sharing among drug users (39.6% of drug users reporting syringe borrowing in 1996 but only 1.7% in 2011; the syringe lending had reduced from 39.2% to 1.3% between 1996 to 2011(Urban Health Research Initiative 2)) and overall decrease in infectious disease incidence rates (HIV rates had declined from 8.1 cases per 100 person-years in 1997 to 0.37 cases in 2011; HCV rates had decreased from 37.1 cases per 100 person-years to 1.1 cases during the same period of time (UHRI 3)). Therefore, the expansion of harm reduction programs in the city, including Insite, has appeared to pull people out of the vicious cycle of sharing unsanitary needles and catching disease by leading them into medical programs, reducing
harm, and improving their health and welfare. Moreover, according to BC-CfE, a 2011 paper published in The Lancet reported Insite to be associated with a 35% reduction in overdose death in the surrounding area of supervised injection facility (These 5 Findings). It occurs the cases of overdose requiring medical intervention at Insite almost everyday, yet to this day, no incident of death has been reported (Boyd 236). In other words, these drug users would otherwise had done public drug injection and possibly been found dead in streets. It indicates that the professional supervision in the facility does play an useful and crucial role in managing overdoses and preventing fatality. Last but not least, certain findings have also showed violence linked to exposure to drug scenes, such as robbery, beatings, assaults, etc. (which have generally been associated with a wide array of health-related harms and HIV-related risk behaviours (UHRI 18)) had been cut down. All in all, thus, it would be tremendous helpful and beneficial to drug users and communities if Canadian government can provide various forms of support to Insite and other harm reduction programs, such as funding.
There have been certain concerns from the medical associations and society on the negative impacts of the health care system’s failure to adequately address (drug) addition, to sufficiently supply opioids and specialized treatment (which could lead to poor outcome with frequent co-morbidities, such as HIV and hepatitis) and to greatly improve drug users’ welfare (These 5 Findings). Admittedly, hospitals’ and clinics’workload of receiving and coping with the incidents and accidents due to drug additions has been tremendous. Since fifteen years ago, however, the foundation of Insite and large operation of other harm reduction programs (e.g., needle exchanges) have on some level taken away this associated working burden and stress on these healthcare organizations, by containing programs that fight against HIV/AIDS and protect public
health, and reducing the harms related to illicit drug use. Although Insite as one of health interventions certainly cannot take all the credit of having helped tackle these associated problems and concerns, the efficacy of its operation has been acknowledged by the Canadian government. While it appears Insite has become the flagship component of a comprehensive harm reduction strategy (to tackle drug addiction, to reduce the spread of disease, to improve health and welfare of injection drug users) and afforded society recognized positive outcomes, there has existed a significant opposition to the creation of these health facilities. These particular concerns and crosscurrents evoked in communities around safe injection sites cannot be neglected: safety issues, encouragement of drug abuse, and misallocation of funds.
One of the essential issues has been about safety. Opponents have suggested that crime rate would increase in the neighborhood if these safe injection sites open to public, which would put the community in jeopardy. Understandably, it is not difficult for one to link injection drug addicts to bewilderment and hazard when picturing or witnessing in one’s mind of them gathering into the facility for injections. There has not been, however, any evidence to prove Insite has had a negative impact on either public order and crime rate, or on spatial distribution of criminal activities within the neighborhood (Boyd 236). Two peer reviewed studies (Substance Abuse Treatment, Prevention, and Policy in 2006, and Canadian Medical Association Journal in 2004) also reported that it had not been significant change on the crime rate in the examined neighborhoods directly surrounding Insite – 124 trafficking in 2003 and 116 in 2004; 174 assaults in 2003 and 180 in 2004. There had been “a considerable decrease (25%), however, in car thefts and prowl(302 in 2003 and 227 in 2004)” (Lewis).
Anther suggestion of opponents has been drug abuse would have been largely encouraged after these facilities were in operation, which would have led to drug overdoses and fatality. There is no deny the fact that a large number of drug addicts have been to Insite – 6532 individuals and 263,713 visits by 2016 – and of those there have been 1418 injection drug users overdosed (none of which has been fatal) (Diakiw). It has been no evident, nevertheless, that supported the assumption of an increase in overdoses in general because of Insite. Moreover, Insite has been manifested a significant reduction of the risk for overdose by a BC-CfE’s study – 35% reduction in deaths from drug overdose in the immediate neighborhood, compared to 9% across the rest of Vancouver (These 5 Findings). The main reason of this positive result is nurses are on site attending to stringent supervision and prompt respond to emergencies. These overdosed injection drug users, who would otherwise had injected themselves in public places and destructive consequence would probably had been noticed in the streets around the communities. It is manifest that Insite has made progress in saving lives and making positive impact in the community on a daily basis.
Finally, some of the dissenters have asserted that Canadian government’s funds should not be spent on safe injection facilities and should be instead utilized in a more effective way in treatment and rehabilitation, as opposed to helping addicts to continue using drugs. It is understandable that some people feel the repulsion when giving safe injection to drug addicts constitutes to the daily agenda of Insite, and it seems to be tantamount to encouraging intravenous drug using on the surface. Supervised injection sites in fact, however, are not mutual exclusive with other health projects and institutions, but share the common goal – establish contact with drug users, afford health
services to them, and help them detox. It has been proved Insite is an effective way of meeting this goal: once opened, it led to increased uptake into detoxification programs
and addiction treatment (Insight to Insite). Furthermore, detox is considered the entry point into a long-term addition treatment in Insite, that officers make further referrals to health services and other supports when needed. This facility has explicitly helped the drug addicts recover and equipped them with the means for sustainable recovery. Furthermore, another study done by BC-CfE reported that “809 out of 1082 (75%) injection drug users in the survey (2006) had changed their behaviour as a result of using Insite. Among these individuals, 80% indicated that Insite had resulted in less rush injection and 71% showed the facility had led to less outdoor injection” (Insite Making Positive). As can be seen, all the scientific evaluation and reports have demonstrated safe injection sites have considerably decreased overdose and HIV risk while promoting addition treatment and improving public order.
The only safe injection site in North America – Insite – and all other European facilities (in the early 1970s, supervised injection sites were established in the Netherlands, and since1990s they have dramatically developed in Europe) have consistently reported positive public health outcomes (Lawrence, 1771). These safe injection sites, nonetheless, only play a small role of harm reduction in the society at large, and yet, would not it be encouraging and justified if Canadian government allocate financial support to these sites, help them make imminent improvements and put strategies in place (such as effective follow-up procedures, prevention of mental illness, and greater attention to addition risk factors such as childhood trauma, poverty and homelessness) which ultimately benefit the general public? Even marginal gains for these safe injection sites can be substantially helpful and possibly lead to a big success in
future. Until then, as members of the society, may us drop the preconception and reflect on what roles we could play in healthcare an social service, and what responsibilities we could take on to fulfill the unanimous goal of harm reduction in our country? We can do more than we think and it is never too late for more action and more support.
Diakiw, Kevin. “Safe Injection Sites: Surrey at a Crossroad.” British Columbia Centre for Excellence in HIV/AIDS, 5 August 2016, www.cfenet.ubc.ca/news/in-the-news/safe-injection-sites-surrey-crossroads.
“Insight into Insite.” British Columbia Centre for Excellence in HIV/AIDS, 15 June 2010, www.cfenet.ubc.ca/sites/default/files/uploads/publications/insight_into_insite.pdf.
“Insite leads to Addition Treatment among Users: Study.” British Columbia Centre for Excellence in HIV/AIDS, 24 May 2007, www.cfenet.ubc.ca/news/releases/insite-leads-addiction-treatment-among-users-study.
“Insite Making Positive Changes in Injecting Behaviour, Study Confirms.” British Columbia Centre for Excellence in HIV/AIDS, 25 Aug. 2006, www.cfenet.ubc.ca/news/releases/insite-making-positive-changes-injecting-behaviour-study-confirms.
Lawrence, Thomas B. “High-Stakes Institutional Translation: Establishing North America's First Government-Sanctioned Supervised Injection”. Academy of Management Journal, vol. 60, no. 5, 2017, pp. 1771-1800. Athabasca University Library & Scholarly Resources, 0-eds.a.ebscohost.com.aupac.lib.athabascau.ca/eds/pdfviewer/pdfviewer?vid=3&sid=c79fc6a5-380f-4420-b8cf-b08306285439%40sessionmgr4009.
Lewis, Andrew. “Safe Injection Works in Vancouver, and It Can Here.” British Columbia Centre for Excellence in HIV/AIDS, 25 Jan. 2017, www.cfenet.ubc.ca/news/in-the-news/safe-injection-works-vancouver-and-it-can-here.
Montaner, Julio. “About Us.” British Columbia Centre for Excellence in HIV/AIDS, 2018, www.cfenet.ubc.ca/about-us.
Neil, Boyd. “Lessons from INSITE, Vancouver’s supervised injection facility: 2003-2012.” Drugs: Education, Prevention & Policy, vol. 20, no. 3, 2013, pp. 234-240. Athabasca University Library & Scholarly Resources, doi:10.3109/09687637.2012.755495.
“These 5 BC-CfE Findings Challenge Assumptions on Drug Use and Public Health.” British Columbia Centre for Excellence in HIV/AIDS, 5 October 2015, www.cfenet.ubc.ca/blog/these-5-bc-cfe-findings-challenge-assumptions-drug-use-and-public-health.
Urban Health Research Initiative. Drug Situation in Vancouver. 2nd ed., June 2013. British Columbia Centre for Excellence in HIV/AIDS, www.cfenet.ubc.ca/sites/default/files/uploads/news/releases/war_on_drugs_failing_to_limit_drug_use.pdf.