INJECTING REASON

Morbidity and mortality associated with drug dependence, especially
drug injecting, constitute major problems for public health.

In the USA intravenous drug use accounts for about one third of all
AIDS and one half of hepatitis C cases.

On page 301 of this issue, Evan Wood and colleagues describe the
rationale behind North America's first medically supervised
safer-injecting facility (SIF), which opened in September 2003, in
Vancouver, Canada. SIFs are professionally supervised health-care
facilities, where high-risk drug users can use drugs in safe, hygienic
conditions. They have been around in Europe for nearly 20 years.

But in North America, where public-health interventions for
intravenous drug users (IDUs) have been controversial and are heavily
politicised, opening of this SIF signifies a radical step forward.

Historically, Europe and North America have diverged in their
public-health response to intravenous drug use. In the mid 1980s
needle-exchange programmes faced fierce opposition in the USA. By
contrast, Europe and Australia quickly adopted them, as did Canada. As
a result, they all experienced a reduction in injection-related HIV
incidence and prevalence, and no further increase in drug abuse and
criminal activity.

But despite the overwhelming scientific evidence, the US view was—and
still is today in many states—opposed to the programmes. The belief is
they promote increased drug use. A federal ban in the USA in 1988 on
funding of needle-exchange programmes, and the research into their
safety and effectiveness, meant that there was a long delay before the
programmes got going in the USA. To this day that ban still exists.

A rational public-health response was also hindered by the AIDS
epidemic in IDUs in the USA coinciding with a crack cocaine epidemic
that generated a lot of public fear about drugs.

The violence associated with the drug-distribution trade generated a
tremendous amount of public anxiety.

And in that atmosphere it was hard to get rational discussion of
measures to reduce HIV infection.

This situation was further compounded by drug use in IDUs being
concentrated in ethnic-minority groups, which made the political
discussions much more difficult.

Over the years one thing has become clear—that the response to the HIV
epidemic among IDUs in North America has become entrenched in law
enforcement and incarceration as the major public-health intervention.
This fact is most evident in the allocation of expenditures in the US
national drug control budget for fiscal year 2004. Of a $12 billion
total, more than $7.2 billion (60%) is devoted to drug law
enforcement, interdiction, and supply reduction in the USA and abroad.

This figure is predicted to rise to more than 70% in 2005. Europe, on
the other hand, has focused more on harm-reduction strategies, with
emphasis on the health and human rights of the individual.

The evolution of SIFS is similar to that of needle-exchange
programmes, since both are surrounded by controversy. According to the
UN's International Narcotics Control Board, SIFs violate the
provisions of the international drug control convention, and countries
that allow the operation of SIFs are guilty of facilitating illicit
drug trafficking. The first SIF opened in 1986 in Berne, Switzerland,
followed by Germany and the Netherlands in the 1990s, and then Spain.
The UK is currently debating whether a pilot project should be set up.
SIFs were seen as a pragmatic approach to a persisting drug problem.

But despite having a medical rationale, they were often run by
community and social workers, and had a history of repeatedly being
shut down and reopened.

Thus the major limitation of SIFs over the years has been the absence
of rigorous scientific evaluation. However, the SIF that opened in
Australia in 2001 as an 18-month scientific trial has demonstrated a
decrease in drug-related deaths, and no reported increase in hepatitis
B and C infections, which has meant that the SIF continues to operate.

The Vancouver SIF has taken 10 years for its doors to open, following
a barrage of political opposition claiming it will encourage increased
drug use, public disorder, and conflict with treatment goals.

But with an explosive HIV epidemic that remains among the most rapidly
spreading in the developed world, it is timely that the Vancouver SIF
has opened now.

What will be invaluable is a rigorous evaluation of the Vancouver
facility. 8 months since opening, there have already been improvements
of public order, a reduction in discarded syringes in the street, and
less injecting in public.

It is very encouraging to hear that Wood and colleagues have embarked
on a prospective cohort study that will provide a scientific evidence
base to support a change in drug policy, and potentially make a strong
case for not allowing public health to get caught up in politics in
the future.