VANCOUVER'S SAFE INJECTION SITE RECEIVES PASSING GRADE

Vancouver is renowned for many things, a truly cosmopolitan city,
voted by The Economist magazine as the most livable city in the world
in 2005. But Vancouver also has another side to it, a more notorious
side. Vancouver is the heroin capital of North America.

This past week, the Canadian Medical Association Journal (CMAJ)
released a summary of findings related to Vancouver's Insite, North
America's first supervised injection site. Insite is a place where
heroin addicts and other injection drug users can go to inject under
clean, safe, and supervised conditions. The report, led by British
Columbia epidemiologist Mark Wood, found that the site generated "a
large number of health and community benefits, [while] there have
been no indications of community or health-related harms."

Insite was opened in 2003 amidst growing concerns relating to
injection drug use and the problems associated with it. In Vancouver,
the drug of choice has historically been heroin, although there has
been a recent rise in the injection of cocaine and methamphetamine as
well. Advocates for safe injection sites point to repeated studies
that peg Vancouver's Downtown

As with so much of drug policy in Canada -- the most obvious example
is marijuana -- lawmakers must contend with pressure from south of the border.

Eastside addict population, estimated at up to 10,000 people, with an
HIV prevalence of anywhere from 20 to 40 per cent, making the
Eastside home to one of the worst HIV epidemics in the world.

Insite has not come without controversy, however. As with so much of
drug policy in Canada -- the most obvious example is marijuana --
lawmakers must contend with pressure from south of the border. Back
when Insite opened in 2003, John Walters, director of the White House
Office of National Drug Control Policy, called it "state-sponsored
suicide," "immoral," and "a lie." Also, earlier this fall, the
Canadian Police Association voted unanimously on a motion to press
Ottawa to stop financing Vancouver's safeinjection site.

Drugs and prohibition

Underlying the safe injection site issue is the fundamental question
of how to deal with drugs deemed immoral and therefore illegal.

Though, to many, the distinction between acceptable drugs such as
nicotine and alcohol and illegal ones is arbitrary.

The tempest that surrounds discussion over drugs, prohibition and
legalization is by no means new. Alcohol was illegal for a good part
of the 20th century, while, paradoxically, heroin and cocaine, not to
mention marijuana, were quite legal. Products containing opiates (the
broad class of substance of which heroin is a part) and cocaine were
marketed, not to the bad boys on the block, but to housewives for all
sorts of quotidian purposes.

When it comes to heroin today, though, the issue becomes a bit more
pointed, even if the heroin legalization lobby garners much less
support than its softer sister, marijuana.

While marijuana stirs emotions on various sides of the public debate,
from an academically informed public policy-point of view, it isn't a
very complex issue. Throw away its subversive jazz history and our
culture's puritanical trappings and marijuana is sitting in its jar
on the kitchen shelf beside last year's Beaujolais. The same cannot
be said for heroin.

Use and addiction

Heroin is the aging queen of hard drugs.

While it derives from the more benign opium, and while morphine, from
which heroin is synthesized, is one of the most commonly used drugs
in health care worldwide, heroin conjures up nasty images of
addiction and depravity.

The image is not totally undeserved. A walk down East Hastings in
Vancouver's Downtown Eastside is like walking through a Canadian
urban war zone. Boarded-up buildings interspersed with pawn shops and
covered by all manner of garbage sets the backdrop. But it is the
human condition that forms the haunting impression. Vacant eyes and
strung out bodies, the prostitution, the using, the pushing: it all
serves to reveal the violence of heroin addiction.

The battle against addiction is both a personal and a societal one.
In the latter instance, the response falls, in simplest terms, into
two broad paradigms. On the one hand, law-and-order advocates agitate
for a general "get tough on crime" approach.

In that perspective, most famously enshrined in the U.S. "war on
drugs," substances, of which heroin is one of the most notorious, are
criminalized, as are those who use them. By cutting off supply and by
punishing those who generate a demand, the theory goes, society moves
towards ridding itself of the offending substance and problem.

The junk is illegal, and those who possess it and use it are criminals.

On the other hand lies the notion that addiction is a social ill, a
problem that exists and needs to be addressed.

Just how that happens is contentious. Some health professionals argue
for the medicalization of substance abuse and addiction, and
therefore treat the condition as an illness and the addict as a patient.

Others see the problem from a broader societal scope and argue that
its very illegality is what creates so many of the problems.

By making drugs like heroin illegal, the argument goes, the market is
forced underground and prices rise, making it a lucrative trade for
suppliers and compelling (ab)users to resort to other illegal
activities to feed their habit.

Benefits and . . . benefits

Vancouver's experiment falls along medical lines. Medical proponents
of the site refrain from going so far as to calling for legalization
of heroin, but the idea behind the site requires that the space be
granted a "waiver of law," where users can inject without the threat
of being arrested. That "waiver" is now in jeopardy as Stephen
Harper's government did not grant the requested threeand- a-half year
extension, instead only permitting it to remain open until the end of 2007.

Does Insite work? The CMAJ report provides some useful insight.

In a survey of addicts on the Eastside, 42 per cent reported using
the site. Users of Insite also tended to represent some of the most
vulnerable members of an already marginal population; by and large,
patrons were more likely to be younger, to be homeless, to have
previously overdosed, and to be daily users. Heroin was the most
frequently injected substance, followed by cocaine.

The study also reported that those using the facility were less
likely to share needles, a major step in the prevention of the
transmission of HIV and other bloodborne diseases.

The findings related to the Vancouver site mirror the "experience" of
similar facilities that have existed over the past decade in
Australia and Europe. Numerous studies have shown that programs
promoting the use of clean syringes and needles and needle/syringe
exchange have resulted in reduced transmission rates of HIV and other
infectious agents and have saved lives," according to Mark Wainberg,
in a commentary for CMAJ. Wainberg is a professor of medicine at
McGill and a Director of the McGill University AIDS Centre. He has
pushed strongly for more projects like Insite.

Nonetheless, the project still has plenty of detractors. The current
government until now has not had the stomach to support something
that goes against the law-and-order perspective they enthusiastically espouse.

And they are not without support.

Randy White is a former Reform-Alliance-Conservative MP and founder
of the Drug Prevention Network of Canada, which claims a substantial
membership. "Just how does encouraging people to shoot up in a
government-sponsored drug centre break the cycle of addiction?" he
asks in an interview with the Globe and Mail earlier this year. "Harm

The study also reported that those using the facility were less
likely to share needles, a major step in the prevention of the
transmission of HIV and other bloodborne diseases.

reduction initiatives that encourage or facilitate drug use will
inevitably lead to more drug addiction and more despair for our
Canadian citizens."

Another component to the reluctance of policy-makers to espouse the
supervised injection site concept revolves around the concern over
what such a site would do to further compromise the neighbourhood.
Specifically, there are worries that Insite's presence will attract
drug dealers and concentrate criminal activity, as well as act as a
siphon for non-addicts to access and ultimately become addicted to
illicit drugs.

But the CMAJ report, as well as a study commissioned by the RCMP and
led by Ray Corrado and Irwin Cohen, both found that these fears have
not come to fruition.

The site has not exacerbated the drug problem, nor have crime levels increased.

It remains to be seen what effect the CMAJ report will have on policy.

With the threat of funding cuts looming overhead, this latest report
adds to the RCMP-commissioned study and a chorus of other voices,
including Health Canada, that have called for more supervised
injection site initiatives. While the idea may appear radical given
the proximity of this country to its anachronistic neighbour to the
south, safeinjection sites have been implemented and studied in
Europe and Australia for some time. The results have been largely positive.

Time will tell what direction Canada will take in what is very much a
public health issue.