SAFER INJECTING FACILITIES IN VANCOUVER: CONSIDERING ISSUES BEYOND POTENTIAL
USE

Craig Fry is Senior Research Fellow, Turning Point Alcohol and Drug Centre
Inc., Fitzroy, and Fellow, Department of Public Health, University of
Melbourne, Melbourne, Victoria, Australia.

In this issue (page 759), Thomas Kerr and colleagues1 report on a
cross-sectional study of the attitudes of Vancouver injection drug users
(IDUs) toward rules for safer injecting facilities proposed by Health
Canada.2 They examine the impact of selected rules (specifically,
prohibition of on-site drug sharing, prohibition of assisted injection and
mandatory client registration) and of police presence on rates of potential
use of such facilities by IDUs. The study is clearly significant for the
Canadian context.

Vancouver's first legal trial of a safer injecting facility will commence in
September 2003 after a protracted debate.

The study adds to what is still a small body of published research on the
feasibility of these facilities and their acceptance by IDUs, despite more
than a decade of experience in Switzerland, Germany and the Netherlands
(and, more recently, Australia and Spain).3,4 Given the large number of
participants in the Vancouver study1 (more than 450) and their demographic
and drug-use characteristics (Kerr and colleagues state that the study
sample was representative of the target population for the new facility),
the results represent valuable baseline data for the coming trial,
particularly if formative process evaluation methods, in which ongoing
consultation with service users about service operations is a key feature,
are to be employed.

From a public health viewpoint, the main findings of interest are the high
levels of reported willingness by IDUs (particularly public injectors) to
use a safer injecting facility, and the extent to which this endorsement
dropped (particularly among women) in the face of prohibition of
drug-sharing, prohibition of assisted injection, mandatory client
registration and proximal policing.

The study replicates findings from similar research that my colleagues and I
have conducted in Melbourne, Australia; in those studies, although most IDUs
supported the establishment of safer injecting facilities, their reported
willingness to use such services varied according to the restrictions in
effect.5,6

Two major weaknesses in the current study deserve comment.

First, the authors do not discuss why the Health Canada rules they targeted
are important for the health and safety of clients of safer injecting
facilities. In this context, rules related to drug-sharing, assisted
injecting and client registration, as well as those related to handwashing
and infection control, violence, on-site dealing and loitering, have
relevance beyond the state's concerns about civil and criminal liability.
Hygienic injecting practices are necessary because of the theoretical risks
of transmission of bloodborne viruses and bacterial infections. In
particular, hepatitis C virus can be efficiently transmitted by injecting
practices that cause blood to be spread on hands, fingers and various
injection items.7,8 The prohibition of on-site drug-sharing is important in
preventing disputes between clients, and client registration is crucial for
purposes of evaluating the facility.

Kerr and colleagues1 rightly conclude that the design of a safer injecting
facility should seek to balance regulatory requirements with accessibility
for high-risk groups.

However, strict service protocols will be necessary for the Vancouver
facility, given that it will be operating in the context of a scientific
research trial, where, for better or worse, the main goal will be to deliver
a reliable and valid evaluation of outcomes.

A second, related weakness (acknowledged by the authors) is that the
researchers considered the possible impact of only 3 Health Canada rules
(and 1 environmental factor, proximal law enforcement) on potential use of
the safer injecting facility.

Furthermore, they do not tell us what strategies Vancouver IDUs might employ
either on site or off site to adapt to the rules they disagree with, or
indeed why they disagree with the rules that are being imposed.

These are critical issues if the goal of the research is to inform the
development of operations protocols for future facilities. The impact of
such guidelines on the extent of use of the facility and on behaviour on
site will of course become clearer when the Vancouver trial commences.

In this regard, it will be important to monitor the attitudes and behaviours
related to safer injecting facilities of both attendee and nonattendee
cohorts of Vancouver IDUs. However, it appears that an important opportunity
may have been missed to gather a comprehensive set of baseline data on IDU
attitudes toward other key components of the Health Canada protocol and
possible adaptive responses before implementation.

Beyond the matter of potential use of the facility, the Vancouver study1
raises an important, broader set of issues that have to date received less
attention, given the focus on outcomes in recent international trials of
safer injecting facilities.4 One such issue is the role of IDU opinions and
expertise in the development of protocols for these facilities. A compelling
case can be made for consulting closely with the intended target group --
street-based IDUs -- about the suitability of recommended models and
operational protocols.

In the recent literature on health program evaluation, the value of
purposive consumer consultation for service design, evaluation quality and
community acceptance has been rated highly.9,10 I join Kerr and colleagues1
in expressing the hope that their latest findings will have some impact on
the Health Canada guidelines.

A related issue is the ethics of trials of such facilities. Macro ethics
issues have emerged in the public debate in Vancouver, where questions of
the moral status and implications of safer injecting facility trials and the
drug policy of which they are a component have figured prominently.11,12 In
the study by Kerr and colleagues,1 micro ethics issues such as privacy and
confidentiality were clearly salient for the IDU sample: the greatest
decline in willingness to use a safer injecting facility occurred in the
face of client registration and proximal policing. Other significant micro
ethics issues that should be considered in the design of any safer injecting
facility trial include: differences in the requirements of facilities
functioning as research projects from those of facilities operating as
treatment sites; decisions about resource allocation; distributive justice
and questions about community representation and consultation (e.g., Are the
benefits and costs of trials of these facilities shared fairly among
different IDU groups?); informed consent in the case of intoxicated clients;
and voluntary consent in the context of dependent relationships (e.g., with
staff of the facility) or inducements for research participation (e.g.,
payment, treatment). Although the protocols for safer injecting facility
trials normally require approval from institutional research ethics
committees, neither the prominent ethical dilemmas that arise nor the
ensuing committee deliberations are typically published.

We have a responsibility to do more than consign these difficult ethical
questions to the veiled processes of ethics committee review. The continuing
debate about safer injecting facilities will benefit from further
explication of these important issues.

Researchers, the Vancouver safer injecting facility trial team, the
community, research ethics committees, the media and government all have
important roles to play here.

The Canadian experience with safer injecting facility trials will be of
substantial interest to international audiences and of value for those
jurisdictions where similar trials have been proposed.

The parties involved in implementing and evaluating this first Vancouver
trial (and perhaps others that follow) have an exciting opportunity to
collect and contribute high-quality data to the growing international
evidence base on the processes and outcomes associated with safer injecting
facilities. In doing so, they might also tackle some of the broader issues
that are important to these trials.

See related articles pages 759 and 825

Footnotes

Fast-tracked article.

Published at www.cmaj.ca on Sept. 12, 2003.

Competing interests: None declared.

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Related articles in eCMAJ:

Potential use of safer injecting facilities among injection drug users in
Vancouver's Downtown Eastside Thomas Kerr, Evan Wood, Dan Small, Anita
Palepu, and Mark W. Tyndall eCMAJ 2003 169: 759-763.