THE NEED TO PROMOTE PUBLIC HEALTH IN THE FIELD OF ILLICIT DRUG USE

Correspondence to: Dr. Mark A. Wainberg, McGill University AIDS
Centre, Jewish General Hospital, 3755 chemin de la Cote Ste-Catherine,
Montreal QC H3T 1E2; mark.wainberg@mcgill.ca

In this issue of the CMAJ, 2 important articles shed light on policies
that Canada should adopt to stem the spread of HIV infection among
users of illicit drugs. In the first article, Evan Wood and colleagues
of the BC Centre for Excellence in HIV/AIDS provide a summary of the
findings from the evaluation of the supervised safer injecting
facility established in Vancouver in September 2003 (page 1399).1
Individuals who use this site inject pre-obtained illicit drugs under
medical supervision in conditions that assure safer use of clean
needles and syringes than might otherwise be expected.

Recently, the federal government announced a limited extension of the
waiver of law that will enable the Vancouver safer injecting facility
to remain open only until the end of 2007 instead of the additional
3 1/2 years that had been requested. This waiver of law is necessary
because both the injection drug users (IDUs) and the medical
supervisors at the facility are theoretically engaged in the abuse of
illicit substances and could otherwise be charged with a criminal
offence. Although Health Minister Tony Clement stated that further
evaluation of the site was necessary,2 the government cancelled a
grant that would have permitted further evaluation. Funding for the
facility itself is provided by Vancouver Coastal Health, an agency of
the BC provincial government.

The Vancouver safer injecting facility follows on 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 rates of transmission of HIV and other infectious
agents and have saved lives.3--6

According to the findings summarized by Wood and colleagues, the
Vancouver safer injecting facility has been a great success. About
5000 unique IDUs used the facility during its first year of operation.
Heroin and cocaine were used in about 40% and 30% of injections
respectively. Virtually all of the facility users expressed
satisfaction with the site and its staff.

Advocates of the Vancouver facility hoped that it might play an
important role in promoting public health by both discouraging the
continued use of illicit drugs and providing education about safer
injecting and prevention of HIV infection and other bloodborne
diseases. The program appears to have been successful in this role.
The rate of syringe sharing decreased after the facility opened, and
only among facility users. In addition, use of the facility was
associated with reduced syringe lending by HIV-positive IDUs and
reduced syringe borrowing by HIV-negative IDUs. It was also associated
with other safe injection practices, including decreased reuse of
syringes, increased use of sterile water for formulation of injected
drugs and increased alcohol swabbing of injection sites. The facility
also proved to be a valuable referral centre for addiction counselling
and other community resources. Individuals who visited the facility at
least once per week reported an increased willingness to enter a
detoxification program. Hence, existence of the safer injecting
facility may ultimately lead to decreased use of illicit drugs. No
negative consequences, such as increased rates of crime, were reported.

In another article in this issue, Fischer and colleagues report on
their assessment of opioid use patterns and related social and health
indicators in the multisite OPICAN cohort (page 1385).7 The cohort was
established in 2001 and continues to enroll regular illicit opioid
users who were not receiving methadone maintenance treatment at the
time of recruitment. Fischer and colleagues found that, as of the 2005
follow-up assessment of the cohort, there was an important shift away
from heroin use in most of the 7 study sites and that use of other
opioids, including hydromorphone (Dilaudid), morphine (e.g., Ms
Contin) and oxycodone (OxyContin, Percocet, Percodan), has become the
predominant form of opioid abuse. Their findings are substantiated by
recent findings from the United States. Their data indicate that a
substantial proportion of prescription opioids were reportedly
obtained directly or indirectly from hospitals and other medical
sources. A common conclusion that can be drawn from the studies by
Wood and Fischer and their colleagues is that the risk of drug
overdose and transmission of HIV infection and other viral infections
will, of course, be increased if drug injections are carried out under
conditions of syringe and needle sharing.8--10

The findings reported by Wood and Fischer and their colleagues
highlight the fact that Canada continues to be plagued by problems of
illicit drug use that not only threaten the health of individuals but
also the general public health through the transmission of HIV and
other infectious agents. By all accounts, the Vancouver safer
injecting facility has reached its goal of reducing the risk of
overdose among IDUs who use the facility at least once a week.
Existence of the facility has also resulted in substantial increases
in the number of facility users who have entered detoxification
programs and have modified their HIV risk behaviours. The study by
Fischer and colleagues on changes in illicit opioid use away from
heroin toward prescription opioids indicates a need for constant
vigilance and possible adjustments to opioid addiction treatment programs.

The success of the Vancouver safer injecting facility indicates that
the facility should not be shut down. Instead, the federal government
should draft legislation to allow other such facilities to operate
elsewhere in Canada. Also, it should support the evaluation of a safer
injecting facility in the context of a "wet shelter," which provides
alcohol and shelter to homeless alcoholic people.

Why would the government on the one hand announce that additional time
is needed to study the potential success of the Vancouver safer
injecting facility and on the other hand eliminate the funding needed
for such evaluations? Government policies regarding safer injecting
facilities should be driven by consideration of evidence-based
medicine and social policy and of findings indicating whether such
programs are successful. By all criteria, the Vancouver facility has
both saved lives and contributed toward the decreased use of illicit
drugs and the reduced spread of HIV infection and other bloodborne
infections. One hopes that the current government under Stephen
Harper, which has been in office since only February 2006, will be
willing to learn and to revisit this issue in the interest of public
health. Government leaders should understand that allowing safer
injecting facilities to operate in other Canadian cities is consistent
with conservative values aimed at diminishing illicit drug use and HIV
transmission. Moreover, studies conducted by Health Canada scientists
advocate harm reduction strategies as important means of preventing
HIV transmission.11

FOOTNOTES

This article has been peer reviewed.

Competing interests: None declared.

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