INSITE WORKS

By Giving Drug Addicts a Sterile Syringe and a Warm Place to Shoot
Up, Are We Saving Lives or Condoning Substance Abuse?

To illuminate the double standard surrounding "harm reduction," Dr.
Stephen Hwang, a medical researcher and associate professor of
medicine at the University of Toronto, offers the following scenario:

Suppose that an innovative but controversial intervention is launched
to reduce complications of Type 2 Diabetes, and 7,000 subjects take
part in a trial. Researchers, funded by Health Canada to study the
intervention's effectiveness, find that while not curing diabetes,
the intervention improves health, reduces infections and prevents
premature deaths -- with no adverse effects. The findings are
published in the world's leading medical journals.

But the federal government deems the findings inconclusive and says
the only acceptable therapies for diabetes are those that either
prevent or cure the condition -- even though no such therapies exist.
Columnists, community leaders and national organizations expound that
the intervention "enables" bad lifestyle choices, and that without
the dire complications of diabetes, people with the condition would
eat more, exercise less and become increasingly obese. And those who
didn't have diabetes would forgo healthy diets and exercise because
they'd no longer fear the disease. The government considers banning
the intervention.

Sound far-fetched? Not, says Hwang, if you replace the word diabetes
with drug addiction, and the word intervention with Insite, the
safe-injection site pilot project that began in Vancouver's Downtown
Eastside in 2003. Insite has allowed addicts to inject drugs under
secure, clean conditions, and all under the supervision of a nurse.

"I wanted people to see how hypocritical we are in the way that we
treat two chronic conditions that have a lot of associated harms,"
says Hwang. A specialist in inner-city medicine, he wrote the
diabetes scenario for the peer-reviewed online journal Open Medicine,
arguing that when it comes to drug abuse, ideology trumps science in
a way that would not be tolerated with other chronic health
conditions. Hwang's treatise was endorsed by more than 130 prominent
Canadian scientists, doctors and public-health professionals.

Think there's a huge difference between drug addiction and diabetes?
There isn't, says Hwang: Both arise through a complex mix of
predisposed genetic and environmental factors -- triggered by
lifestyle choices, behaviour and bad luck -- that result in disorders
of body chemistry. Both have potentially severe complications, such
as infections or premature death, that can be reduced with good
medical care. Just as some addicts can kick their addictions, some
people with diabetes, through weight loss, gastric bypass surgery or
extreme exercise, can eliminate their symptoms and their need for
medication -- though drug-free addicts and insulin-free diabetics
both risk relapse. Yet do we refuse to treat the health complications
of people with diabetes who cannot wean themselves off medication? Never.

"A heroin addict needs heroin as much as a diabetic needs insulin,"
says Norm Stamper, a former chief of the Seattle police department.
"That need is real. It is physiological." After witnessing the
failure of the United States' strict "war on drugs" to stem narcotic
use and its associated problems, Stamper is now a leading advocate of
safe-injection sites, methadone-treatment, needle-exchange and other
harm reduction programs that aim to refocus efforts from policing to
medical management.

Here's what more than 20 studies --all by independent evaluators,
published in prominent journals -- have found: Insite has reduced
instances of needle sharing and drug injecting in public places, and
there has been a decrease in the amount of injection related litter.
In the Insite neighbourhood, there have been no increases in drug
trafficking or assaults, and instances of vehicle break-ins and car
theft have decreased. Despite almost 900 overdose events at Insite --
a common hazard of drug use -- no overdose deaths have occurred at
the facility, compared with an average of 60 a year in Metro
Vancouver. Additionally, since Insite began, the number of drug
addicts who have entered detox programs, addiction counselling and
drug-addiction treatment has increased by over 30%.

Dr. Perry Kendall, the B. C. Health Officer, says opposition to
Insite is not based on evidence of effectiveness but on the notion
that drug addicts have made bad choices and must change or live with
their fate. "The belief," he says, "is that if health providers
remove or lessen the harms of addicts' behaviour, addicts won't hit
bottom and therefore won't have the motivation to go clean."

"The issue is not whether the addict would be better off without his
addiction--of course he would--but whether we are going to abandon
him to illness or death if he is unable to give it up," says Dr.
Gabor Mate, who has served as staff physician at Insite and is the
author of In the Realm of Hungry Ghosts: Close Encounters with
Addiction. Mate's book is a must-read for those who reject harm
reduction as "coddling" drug addicts or who believe "Just Say No" is
a realistic policy. In his book, Mate shows his patients' struggles
and demons, how they became addicts and how they found a way out. The
book illustrates a central premise of HR: accepting those with drug
addictions and trying to move them along the continuum to better
health -- keeping them alive and well long enough to have a chance to
quit later.

Some who were once adamantly against Insite have come to support it.
One such person is George Chow, former president of the Chinese
Benevolent Association of Vancouver. Chow successfully ran for city
councillor on a ticket of rejecting Insite -- the centre was on China
town's doorstep -- gathering some 18,000 signatures from the Chinese
community. Yet, after Insite had been in operation for three years,
he changed his mind. "I am keenly aware of the debate surrounding
[Insite]. But I am pleased to say that the initial fears of the
community -- a potential increase in crime and public disorder --
have not materialized," Chow wrote in a letter to Prime Minister
Stephen Harper in the fall of 2007.

If only more of us were willing to change our positions based on
evidence, we might finally begin to make progress against this
terrible affliction called drug addiction.