THE IDEA THAT DRUG ADDICTS SHOULD BE TREATED, NOT LOCKED UP, IS MAKING WAVES

Hundreds of doctors, politicians, researchers and frontline workers
met with drug users and ex-users in Austin, Texas, in December to
openly talk about drug use. But instead of reaffirming their
commitment to the decades-long war on drugs, the eighth National Harm
Reduction Conference will feature discussions on opening needle
exchanges, legalizing and regulating the drug trade, and overdose
prevention methods.

"What we do in (the United States) is make drugs as unsafe as they
possibly can be, and we do that through laws, which means that, if you
get busted with drugs, you go to prison for a long time. And that's
designed as a deterrent to make people stop using drugs, which
obviously it isn't," said Allan Clear, executive director of the Harm
Reduction Coalition, which runs the national conference. "We do things
like take syringes out of circulation, which has caused epidemics of
hepatitis and HIV. So harm reduction is a way of trying to make drug
use safer for people who use drugs, without demanding that they stop
using drugs."

Harm reduction can include a range of services from needle exchanges
and condom distribution to safe consumption sites and access to
addiction services such as methadone and buprenorphine treatments and
detox facilities.

Supported by the United Nations and over 93 countries worldwide, harm
reduction remains controversial. While over half of the 158 countries
where drug use has been reported say they support harm reduction, only
82 countries have needle exchanges, just 73 provide opiate
substitution therapies like methadone, and a measly eight countries
have safe drug consumption facilities. There are only two safe
consumption facilities in North America, both in Vancouver, British
Columbia, Canada.

"Insite" into Harm Reduction

"We were coming to work and people were overdosing and people were
dying, and at its height it seemed like it was happening every day,
and it just seemed unnecessary. If people were dead, there was no
chance of detoxing," said Mark Townsend, executive director of the
Portland Hotel Society, which runs Insite, one of the two safe
consumption sites in North America, open since 2003.

"(Insite opened) because lots of people worked hard to make it happen,
including the mayor - all the different mayors - and (Premier) Gordon
Campbell."

Insite is located in the city's Downtown Eastside, often referred to
as Canada's Poorest Postal Code. Injection drug users in that area
have a mortality rate 14 times higher than the rest of B.C., with an
HIV rate of 4 in 10, and a hepatitis C rate of 9 out of 10 users.

The facility consists of 12 safe-injection booths, monitored by
nurses, where clients are provided with clean syringes, cookers,
filters, water, and tourniquets, as well as education on safe
injection practices that limit the spread of diseases like HIV and
hepatitis C. Injection drug use is illegal in Canada, but Insite
applied for and received an exemption from the federal government to
run the site, though the current government is trying to shut the
facility down.

There are approximately 12,000 registered clients at Insite, but in
2009 only 5,447 used the clinic, with an average 491 injections per
day. Four-hundred-and-eighty-four overdose interventions were
performed that year, with no fatalities - in fact, no one has died at
Insite since it opened, but the long lines mean some people walk away
without injecting.

Because the local health authority funds it, Insite acts as a gateway
to other medical services, such as treating infections and diseases
and referrals to mental health treatment. In its second year alone,
Insite made 2,000 referrals to outside services, including 800 to
addiction counseling. There is also a detox center called Onsite
located upstairs if people want to quit.

Vancouver's second safe injection site is less well known, likely
because its clientele is limited to people living with HIV/AIDS.
Located in the nursing clinic of the Dr. Peter Centre West End, safe
injection is only one of the services offered, including access to
medication, counseling, and art and music therapy. Unlike Insite, the
Dr. Peter Centre has not applied for a government exemption for its
safe injection room.

"The College (of Registered Nurses of British Columbia) confirmed for
us that it was within the scope of registered nursing practice to
supervise injections for two purposes: for the purposes of promoting
health and preventing illness. And they went on to say that this is
particularly so with a high-risk population," said Maxine Davis,
executive director of the Dr. Peter Centre.

Davis estimates there are 50 people out of the clinic's 325 registered
patients who inject drugs at the Center. The clinic is only open from
9 a.m. to 3:30 p.m., however, so they also provide people with clean
needles to take home, as well as providing a place to have their
methadone delivered.

a Different Story on the Island

The Canadian federal government opposes safe injection on moral and
ethical grounds, and this stance has prevented other Canadian cities
from opening their own safe injection sites, including B.C.'s capital
city Victoria. While drug users in Vancouver have access to needle
exchanges all over the city, Victoria lost its only fixed-site needle
exchange in 2008 after complaints about noise, crimes, garbage and
human waste in the area.

The Vancouver Island Health Authority secured another location for the
needle exchange in March 2008, but complaints from neighbours resulted
in an indefinite hold on a fixed-site needle exchange. Volunteers
drive mobile exchange vans in the city, but they have also been banned
from that neighbourhood, commonly referred to as the "no-go zone."

"Not having a space where people can be and to feel like they can meet
their peers in a safe location is huge. So you have people being very
spread out and finding spaces where they can congregate, in spaces
that aren't that safe," said Kim Toombs, a member of Harm Reduction
Victoria. "People don't want to be using drugs on the street, in front
of other people. This is a private thing, and they'd rather be doing
it indoors on their own terms, whether it be in their house or whether
it be in a safe space. But they're in a position where they don't have
any other options."

A study released by the city's Centre for Addictions Research this
year found that in 2009, 23 per cent of Victoria's drug users reported
sharing needles, compared to eight per cent of Vancouver's; 89 per
cent of Victoria's users injected daily, compared to 29 per cent of
Vancouver's.

Despite the sharp reduction in services to Victoria's drug users, the
City of Victoria adopted a harm-reduction policy framework in 2004 and
is working on a harm-reduction strategy. The public at large also
supports it, with 74 per cent of residents from Victoria and 12
surrounding communities agreeing with harm reduction in Victoria.

No Needles in Nashville

The story is different in the United States, however, where the first
needle exchange opened in 1987 in New Haven, Connecticut, but it was
only last year that a ban was lifted on federal funding for needle
exchanges, introduced by former Republican Sen. Jesse Helms in 1989.
The government has yet to provide any guidelines for funding the
programs, however, and many states are unwilling to move forward
without knowing if their programs will receive funding. In addition,
needle exchanges are only legal in 36 states, leaving 14 states, such
as Tennessee, without one.

Nashville, Tennessee's capital city, runs harm-reduction programs on
both sides of the law. The city's Annual Vulnerability Index, released
in October, interviewed 885 homeless people (out of an estimated
4,000) and found 64 per cent abused substances at some point, while 44
per cent had received addiction treatment.

There was a tolerated needle-exchange program in 2001-2002, recognized
by City Hall as well as the local law enforcement, but for reasons
unknown the exchange died off, and now clean needle distribution has
gone underground. Legal harm reduction comes in the form of mobile
outreach vans run by groups such as Street Works, which offers free
HIV testing, condoms and lubricant to drug users, sex workers, and the
homeless.

Leslie Davis, outreach team leader for Street Works, has been doing
harm reduction work with the organization for 10 years. Davis says
needle use is actually down in the city, likely because the grade of
heroin has improved and can be snorted or smoked instead, which
decreases the chance of contracting HIV/AIDS.

Davis wants more than clean supplies to pass out, though. He also
wants to see drug use decriminalized and treatment focused on lifting
users out of poverty, as well as counseling for the personal traumas
that led them to drug use in the first place.

"There are success stories around. At Street Works, we have several
success stories people celebrating five or six years clean. (But) the
odds of turning your life around are not good," he said. "I've seen
'em die in this town and never get clean."

Conservative Cincinnati

Like Tennessee, needle exchanges are illegal in Ohio unless they are
sanctioned by a city's health commissioner under an emergency order.
Such an order was issued in Cleveland, where a needle exchange has
been operating since 1995. At that time, according to the Centers for
Disease Control and Prevention, 17 per cent of the city's new HIV
infections were among IV drug users. Today that number has dropped to
3.4 per cent.

But it's a different story in Cincinnati, where it's a crime to
possess a dirty syringe, regardless of whether you're the user or a
volunteer at a needle exchange. While both the city's mayor and health
commissioner say they support a needle exchange in theory, STOP AIDS
Cincinnati, a local AIDS prevention and support group that operates on
a harm-reduction model, must make the case for a needle exchange to
the entire city council and health board.

"Cincinnati is notably a fairly conservative city, and we have some
groups in the city who kind of coalesce around what they identify as
being family and community values, that are a little further out there
than most of the community. But they do a good job rallying their
forces," said Amy McMahon, CEO of STOP AIDS.

HIV/AIDS levels among IV drug users in the city are five to 10 per
cent for HIV, while hepatitis C is much higher at 35-38 per cent. It's
numbers like these that drive McMahon to push for needle exchange on
top of the condoms, lube, and testing STOP AIDS Cincinnati already
supplies.

"While there are certainly statistically high-risk groups, (IV drug
use) crosses all socio-economic groups, racial and age boundaries,"
she said. "People with hepatitis C, people who contract HIV do also.
Statistically, is it everybody equally? No. But the risk exists
because it's your behavior that puts you at risk, not the color of
your skin or your gender or your income."

Methadone Not Covered in Midwest State

Needle exchanges are legal in Chicago, Illinois, but since the federal
ban has been repealed, Dan Biggs hasn't seen a flood of government
money coming in. Instead, the Chicago Recovery Alliance (CRA), of
which Biggs is founder and director, is funded by the Chicago Health
Department and the Illinois Department of Health and has become one of
the largest harm-reduction outreach programs in the country.

CRA provides the clean rigs and condoms common to harm reduction in
other parts of the world, but also offers free vaccines for hepatitis
A, B, and C, as well as the flu and pneumococcal pneumonia, through
their mobile van and their office. But thanks to federal law that
limits distribution of opiate substitutes to specialized clinics, CRA
can't provide methadone or buprienorphine to marginalized drug users.

"(Treatment is) not available to most people who want it. We are in
juggernaut to most brutal, ineffective approach. Right now I can't get
you into methadone treatment unless you have good resources - money.
Most insurance don't pay for it. (It costs) $60 a week," Biggs said.
"But I can get you a cell and court date for $50,000 a year. What kind
of insanity is that?" The Centers for Disease Control and Prevention
estimates there are 60,000 to 90,000 injection drug users in Chicago,
but only 7,000 to 8,000 use CRA's services per year. Biggs says some
areas of the city see no service at all, particularly the southwest
side, which has high rates of injection drug use.

Rocky Mountain High

Colorado became the 36th state to gain a legal syringe exchange
program this year, but each county's public health board has to opt
into the program, and only after that can a harm-reduction
organization apply to become a needle exchange. Nor will users be
fully exempted from state paraphernalia laws once the exchange
opens?volunteers will be exempted, but it's a class II misdemeanor for
a user to be caught with a needle, dirty or clean.

Denver, Colo., has an illegal needle exchange program, however, that's
been running since 2007, although previous exchanges operated in the
late 1990s and in 2003-2004. Unlike some other illegal exchanges, the
Underground Syringe Exchange of Denver actually has funding from the
North American Syringe Exchange Network, the only group that will fund
underground exchange programs.

"We average probably, on one day of exchanging, seeing 5-10 people and
exchanging 200-800 syringes in a three-hour block," said Andrew, one
of the founding members of the exchange, who requested his last name
be withheld. Andrew assumes the large numbers of needles per user is
people doing secondary exchanges, where they take dirty needles for
friends and exchange them, giving their friends clean rigs in return.

Denver faces other challenges in getting a needle exchange, stemming
from previous attempts to set up the service. A city ordinance on
syringe exchanges was actually passed in the late 1990s, though no
exchange was ever established. However the ordinance remains and
restricts the number of needle exchanges to a maximum of three, they
must be one-for-one exchanges, and they cannot be within 50 feet of a
dwelling. With an estimated 10,000-15,000 IV drug users in the city,
the ordinance needs to be changed in order for the program to be effective.

"The fact that there's still nothing happening is why we still have an
underground syringe exchange. And it's going to continue until we have
an effective exchange running in Denver," Andrew said.

Support for Harm Reduction

The fight for harm-reduction services, particularly needle exchanges
and safe consumption sites, has gained ground in both Canada and the
United States, but there are still hurdles to overcome.

Despite being the subject of 30 peer-reviewed studies by the BC Centre
for Excellence in HIV/AIDS, which showed a significant reduction in
public injections and in HIV and hepatitis C infections, as well as an
increase in the number of users seeking treatment, Insite is in danger
of being shut down by the Canadian federal government, which cites
moral and ethical issues with safe injection. After two separate cases
before the B.C. Supreme Court and Court of Appeal, which ruled in
Insite's favour, the decision now lies with the Supreme Court of Canada.

"The Canadian Medical Association, normally a very conservative body,
has stepped in twice to defend Insite, and they will be intervening in
the Supreme Court to say, 'This is ridiculous. (Prime Minister)
Stephen Harper needs to give his head a shake,'" Townsend said. "You
can find an opinion from a fool, but ultimately the information is in
and the evidence is utterly clear."

It's not just the government that stands in the way, however. Members
of the public who don't experience the realities of drug addiction in
their lives often do not understand the reason for harm-reduction
services, particularly because illicit drug use is illegal in North
America.

"We live in a society that doesn't often turn its thoughts to those
who are least among us," said Andrew of the Underground Syringe
Exchange of Denver. "And injection drug use affects a very small
portion of the population, so, since it's not on their radar, and it's
one of those icky topics that they're not interested in delving into
because it challenges their moral boundaries. They just kind of look
at it and say, 'You know, let 'em die off,' basically."

But Clear of the Harm Reduction Coalition believes it is the
politicians, not the public, who are holding back harm reduction, and
with the retraction of funding bans on needle exchanges in the United
States and the support of safe injection sites by the provincial
courts of British Columbia, the future of harm reduction in North
America is one of growth.

"The funny thing is that topic opinion polls, the few that exist, have
always been pretty consistent that the general public actually
supports them. It's not overwhelming, but they are pretty consistent.
It's something like 55 to 45, or 52 to 48 in favor of syringe exchange
programs. The general public has always been fairly supportive,
especially if it's explained what they are for," Clear said.

"And I think that the changing in the legislation around the federal
ban on the funding on needle exchange means that some of those
programs that have been around for a while, but have not strictly been
legal, will be tolerated a lot more by their local health departments.
Hopefully we can build upon that, and then they can get funding and be
legal and everything."