THE CASE FOR A SUPERVISED DRUG CONSUMPTION SITE TRIAL IN VICTORIA,
BRITISH COLUMBIA

The Confluence of a Number of Factors Makes the Time Right for a
Supervised Drug Consumption Site in Victoria.

Abstract:

Supervised consumption sites (SCS)-now in existence in some 15
countries-have been one of the most controversial public health
interventions targeting high-risk substance use (e.g., injection drug
use) over the past 20 years.[1,2] SCS's main aims are to reduce
mortality and morbidity risks among high-risk drug users; to link
clients with treatment, social, and health services; and to address
public order problems by providing the target population with safe,
clean, and designated spaces where pre-obtained street drugs can be
consumed.[3,4] Ever since it opened its doors in 2003, the Vancouver
SCS (called Insite) has been under intense and controversial
scrutiny. A political decision regarding the facility's
continuation-and indirectly the initiation of other SCS programs in
Canada-is expected to be made in 2008. In this commentary, we are
advancing a strong plea and underlying rationale why an SCS
program-in the form of a scientific trial-should be implemented in
Victoria, Canada. Our argument is based on the following rationale:

Reducing Risk and Harm

The specific risk and harm characteristics of street drug use in
Victoria would likely be reduced through an SCS intervention.
Victoria is home to an estimated population of 1500 to 2000 injection
drug users (IDUs).[5] This population is characterized by several key
high-risk traits relevant for public health and public order. For
example, the recent multisite and Health Canada-facilitated I-Track
study documented an HIV prevalence rate of 15.4% and an HCV
prevalence rate of 68.5% among Victoria IDUs-rates substantially
higher than for most of the other study sites.[6]

Victoria IDUs also reported substantially higher rates of injecting
drugs in public or other unsafe places, as well as higher rates of
needle, syringe, and other equipment-sharing than IDUs elsewhere in
I-Track. Furthermore, most Victoria IDUs reported cocaine, or opioid,
and cocaine combinations as their injection drug of choice.[6]

Taken together, the above behaviors are well documented to represent
major risk factors for drug-related morbidity (e.g., infectious
disease) as well as mortality (e.g., overdose), and extensive
subsequent social cost burden.

Finally, there has been an increasing number of public and business
complaints concerning the public order problems-public injecting,
discarded needles, littering, loitering-associated with high-risk
drug use in the downtown core.[7,8] These are exactly the problems
that SCS are designed to address.

Evidence Demonstrates Beneficial Effects

SCS programs in Europe, Australia, and Canada have demonstrated that
SCS produce beneficial effects and contribute to a reduction of harms
in high-risk drug-user populations. Several dozen SCS programs,
including Insite in Vancouver, are now in operation-some of them
having been so for two decades.

These facilities and programs-although heterogeneous in design and
practice-have demonstrated that SCS can produce beneficial effects,
especially when they are part of a wider continuum of interventions
(including other prevention and treatment services) aimed at
high-risk drug users.

Among other outcomes, SCS have been shown to attract especially
high-risk and highly marginalized street drug users (often not
reached by other mainstream services); to improve key risks relevant
for morbidity and mortality (e.g., needle or equipment sharing,
unsafe injection practices, and fatal overdose incidence); to
increase uptake of detoxification and treatment (e.g., methadone
treatment) services among the target population; and to contain
public order problems associated with street drug use.[1,2,9,10]

As such, SCS represent a valuable piece in the puzzle of necessary
and effective interventions geared to reduce harms related to
high-risk drug use. Their measurable successes, however, do not
eliminate the need for additional complementary services such as
adequate treatment, mental health services, and community policing.

Supervised consumption sites cannot solve problems they are not
designed to address-namely, curing users of addiction or eliminating
drug dealing or drug-related crime.

Everyone's Interests Served

It is in the explicit interest of politicians, lawmakers, and key
stakeholders at all levels, as well as researchers, to see an SCS
study implemented in Victoria. While presumably no friend of the
concept of SCS, the current Conservative federal health minister Tony
Clement has stated that there is a "need for more facts" in order to
assess the value and benefits of SCS interventions before further
Section 56 ex-emptions from the Controlled Drugs and Substances Act
for the future operations of SCS in Canada can be issued.[11]

An SCS study in Victoria would provide exactly such an opportunity
and add meaningfully to the knowledge base; it would allow for the
feasibility and outcomes of an SCS intervention to be assessed in a
setting that is considerably different to the rather unique and
extreme situation of street drug use in Vancouver's Downtown
Eastside. This would provide additional empirical evidence that would
be relevant and generalizable to Canadian cities.

A Victoria SCS study would allow the testing of different SCS program
and delivery models than the Insite model in Vancouver. For example,
Victoria might be better served by small, decentralized, multisite
supervised consumption sites with a mobile component. In addition, an
SCS in Victoria could also provide "safer use" interventions for the
sizable population of non-injectors, as well as those IDUs who also
smoke crack.

Such an initiative could also put greater emphasis on key social
services-such as shelter, food, and housing-and basic health services
than currently featured by the Insite program.[12] The City of
Victoria is in the unique situation of having its mayor, city
council, chief of police, and the local health authority's chief
medical officer explicitly support a proposal for an SCS
intervention. The BC government is supportive of the Vancouver Insite
trial and would likely be supportive of conducting an additional
study in Victoria.

In sum, a supervised consumption site pilot trial in Victoria offers
little possible loss but a great deal of po-tential benefit towards
reducing morbidity, mortality, and social costs, as well as key gains
in knowledge. The long-term future of such an initiative should hinge
on its ability to prove its value, but if it is not tried, its value
cannot be assessed. The time has come for an SCS trial in Victoria.

References

1. Hedrich, D. European report on drug consumption rooms. 2004.
Lisbon, European Monitoring Centre on Drugs and Drug Addiction (EMCDDA).

2. Independent Working Group. The Report of the Independent Working
Group on Drug Consumption Rooms. 2006. United Kingdom, Joseph
Rowntree Foundation.

3. Fischer B, Rehm J, Kim G, Robins A. Safer injection facilities
(SIFs) for injection drug users (IDUs) in Canada: A review and call
for an evidence-focused pilot trial. Can J Public Health 2002;93:336-338.

4. Kimber J, Dolan K, van Beek I, et al. Drug consumption
facilities: An update since 2000. Drug Alcohol Rev 2003;22:227-233.

5. Stajduhar K, Poffenroth L, Wong E. Missed opportunities: Putting
a face on injection drug use and HIV/AIDS in the Capital Health
Region. 2002. Vancouver: Centre for Health Evaluation & Outcome
Sciences (CHEOS). Scientific Monograph 10.

6. Health Canada. I-Track: Enhanced surveillance of risk behaviours
among in-jecting drug users in Canada-Phase I Report. 2006. Ottawa:
Surveillance and Risk Assessment Division, Centre for Infectious
Disease Prevention, Health Canada.

7. Heiman C. Quaint street, mean street. Victoria Times Colonist. 2007.

8. Winterhoff T. Drug problem needles North Park. Victoria News. 2007.

9. Wood E, Tyndall M, Montaner J, et al. Summary of findings from
the evaluation of a pilot medically supervised safer injection
facility. CMAJ 2006;175:1399-1404.

10. Wood E, Tyndall M, Montaner J, et al. Rate of detoxification
service use and its impact among a cohort of supervised injecting
facility users. Addiction 2007;102:916-919.

11. No new injection sites for addicts until questions answered says
Minister Clement. 2006. Ottawa, Health Canada.

12. Fischer B, Allard C. Feasibility study on 'Supervised Drug
Consumption' options in the City of Victoria. 2007. Victoria: Centre
for Addictions Research of BC.

Dr Fischer is Professor and CIHR chair in Applied Public Health at
the Centre for Addictions Research, University of Victoria, Victoria,
BC. Dr Kendall is BC's provincial health officer and a clinical
professor in the Department of Health Care and Epidemiology,
University of British Columbia. Ms Allard was a Research Assistant at
the Centre for Addictions Research, University of Victoria, Victoria, BC.