Supervised injection: an intravenous triumph

15 Oct 2011, Posted by Trevor Thomas in Backpages, 0 Comments

This summer Trevor Thomas wrote a series about supervised injection and his experience at a facility in Canada called Insite.

A woman with terrible arthritis came in on May 13 and so she couldn’t prepare her morphine injection—she couldn’t even hold a rig. The track marks on her arm were dark and bumpy. When I lifted her sleeve, I touched them. They felt like the rough spots on a globe that stand for mountains, or the brail underneath men’s room signs. A nurse and I cooked the morphine and pulled it up into a syringe.

After she injected, she fell into a state of deep relaxation. Enlightenment, some might say. Insite was her Bodhi tree and she had been meditating for 49 days—The Dharma in a syringe. But just like Buddha, she eventually got up. She started crying and wanted to call her mom, so I led her to the phone in the chill room. That was the first time they had spoken in years. May 13 was Mother’s Day.

Special to The Chronicle: East Hastings, several blocks from Insite

This was the end of my first week in Vancouver. I was volunteering at North America’s only supervised injection facility, Insite, and this was just another day for me. A supervised injection facility is a type of clinic at which injection drug users can use under the direct supervision of healthcare professionals so that they do not overdose. Additionally, these clinics provide a supply of clean equipment so that users do not share with other users and thus promote the spread of HIV. Insite was opened in 2003 in response to the outrageous HIV/AIDS and overdose death statistics representing the Downtown Eastside. Since its opening, it has been the subject of numerous political debates in Canada, all of which involve the government’s will to shut it down.

There was a monumental Canadian Supreme Court case on the May 12 that was held to decide whether Insite could continue to aid ‘Canada’s Poorest Postal Code,’ or if Downtown Eastsiders would need to find a new method of addiction recovery. On Oct. 7 the decision was released that Insite would indeed continue to operate in Vancouver. The more than 700 people who use Insite daily, the hundreds of staff members who have worked at Insite and the thousands of people who support Insite around the world rejoiced that day.

It was a unanimous decision by the court for the reason that not allowing the facility to remain open would violate the Charter of Rights and Freedoms. Many interpret the unanimity as an embarrassing indication of the how invalid the arguments against Insite really were. As I mentioned in my previous articles, there has been absolutely no scientific evidence presented that shows Insite to be harmful in any way. The fact that this May 12 case is the third case from which Insite has emerged victorious only further supports supervised injection’s success in Vancouver. Stephen Harper and the conservative government have been challenging Insite solely with partisan and ideological arguments, and this was clearly demonstrated with the decision on Friday.

Special to The Chronicle: The nurses’ station, at which there are sterile syringes, cookers, tourniquets, and other equipment for use by Insite participants.

One of the most relevant implications of this ruling is that it yields the opportunity for other supervised injection sites to open across Canada. Officials in both Victoria and Toronto are already considering the option. Obvious and appropriate digression, however, must be used. Injection sites aren’t necessary in areas that do not reflect the needs of the Downtown Eastside—you wouldn’t open a facility in Durham, for example, because there is not an HIV or drug overdose epidemic in the area.

The Supreme Court stated that the ruling “is not a license for injection drug users to possess drugs wherever and whenever they wish,” and “nor is it an invitation for anyone who so chooses to open a facility for drug use under the banner of a ‘safe injection facility.’”

Another item worth notice is the discord created within the Supreme Court because of this case. Because one of the major factors encouraging the Insite decision was the empirical proof behind supervised injection, Canadian legislation now must confront the importance of scientific evidence when it comes laws that may worsen the state of a group of individuals. Academics infer that laws governing prostitution, assisted suicide, and minimum prison sentences might now be subject to change. In fact, the Ontario Court of Appeal says that it wants to reopen a case that significantly changed the country’s prostitution laws in light of the Insite decision.

An anonymous Supreme Court judge reported, “it will force us to look at policies and make difficult qualitative judgments about their effects. That is something that leaves a lot of us uncomfortable.”

With more than 1,400 overdoses having occurred at Insite, there is still yet to be a single death, a sobering reminder of this facility’s necessity in the Downtown Eastside and the importance of this decision.

“The federal government will look back and regret the day they took Insite to the Supreme Court,” said Maxine Davis, executive director of the Dr. Peters AIDS Foundation in Vancouver.

Oct. 7 was that day.

I would like to thank David Noble and the Noble Foundation for providing me with the support I needed to travel to Vancouver and observe at Insite. Additionally, I would like to thank Darwin Fisher and Russell Maynard for welcoming me to the facility in May.

Supervised injection: Insite and the Supreme Court

24 Jun 2011, Posted by Trevor Thomas in Backpages, 0 Comments

With the large amount of scientific support behind Insite, one might wonder why the Canadian federal government would even challenge the facility. Dean Wilson is perhaps one of the most renowned advocates of the Downtown Eastside. At a Harm Reduction Forum held in May, he cited pressure from the United States as a primary cause of the Canadian Federal Government’s attack on Insite. Dean even mentioned that the American government was willing to soften certain taxes if Canada did not open Insite in 2003—a particularly shocking notion. Scientist Will Smalls, a man whose name you can find on many of the articles published about Insite, believes that supervised injection faces so much opposition because of a general “lack of compassion for addicts,” about which he spoke at the same forum. Supervised injection appears to be a method of healthcare that society and law simply haven’t caught up with yet.

Similar to the general attitudes on supervised injection, the Canadians’ opinions about the outlook of the May 12 Supreme Court case vary greatly. At a public showing of footage from the court case in Vancouver, I recall people shouting, “Theatre!” as representatives of the federal government made their arguments, which at times were clumsy and staggered. Many people are clearly confident that Insite will remain open with the decision of the case. This includes Maxine Davis, executive director of the Dr. Peters AIDS Foundation in Vancouver, who believes “the federal government will look back and regret the day they took Insite to the Supreme Court.” Others, however, see this as the end of North America’s only supervised injection facility. The state of the federal government unfortunately makes this an equally convincing prospect.

The alleys of the Downtown Eastside are common places for addicts to use drugs and sleep.

While addiction and poverty are very strong characteristics of the Downtown Eastside, something I noticed even more as I walked down Hastings on my first day was the passion of the residents. While the used syringes on the sidewalks and the open drug use in the streets represent the destitution of “Canada’s Poorest Postal Code,” they also represent activism. The graffiti that covers the alleyways is a petition with thousands of signatures, and each homeless addict is an enthusiastic protestor.

The residents of the Downtown Eastside are stuck in a marvelous limbo of advocacy and pride; never before have I seen such a powerful community! They march the streets and shout, “Insite will never be shut down as long as we’re on the block,” and we must shout with them. Insite must remain open if the Downtown Eastside is to recover.

This is the third and final part of a three-part series about supervised injection and Trevor Thomas’ experience at Insite. Part 1, Supervised injection: “state-sponsored suicide”, gave an overview of Insight and the ideas motivations and successes behind supervised injection, and part 2 of the series, Supervised Injection: injecting the facts, discussed the evidence that supports supervised injection.

I would like to thank David Noble and the Noble Foundation for providing me with the support I needed to travel to Vancouver and observe at Insite. Additionally, I would like to thank Darwin Fisher and Russell Maynard for welcoming me to the facility in May.

Supervised injection: injecting the facts

23 Jun 2011, Posted by Trevor Thomas in Backpages, 0 Comments

Coupled with the exemption to the Controlled Drugs and Substances Act was a requirement that Insite be subject to a variety of rigorous scientific evaluations upon its opening. This was to demonstrate whether such a controversial facility was actually improving the Downtown Eastside or if it was actually promoting drug use, the chief fear of those opposed to supervised injection. The first several years of studies have yielded many different scientific reports, including more than 30 peer-reviewed articles in some of the world’s most prominent journals, all of which support Insite and validate the success of supervised injection. There has not been a single article or empirically based critique of Insite that shows it to be ineffective or hazardous to public sanctity. It is important that people become familiar with the objective data from examinations and judge them in lieu of outrageous political statements and policy-based lobbying.

I’ll begin with the chief fear mentioned above: does Insite promote drug use? An article published in The American Journal of Public Health shows that it does not. Researchers found that the average Insite user has been injecting for 16 years—in fact, only one participant in the study reported performing their first injection at the facility. These results excellently mirror what I experienced while volunteering. None of the users with whom I spoke had begun injecting at Insite, and only one of the nurses mentioned that she once helped an elderly participant as he injected for the first time. A study in the British Medical Journal produced similar results. By examining the drug use behavior of 871 injection drug users one year prior to and one year after the opening of Insite, the study found that there was no statistically significant increase in the rate of relapse among former users after 2003—it was 17 percent before Insite opened and 20 percent after.

The backdrop of all these studies, furthermore, is one exceptional fact about North America’s only SIF: there has never been a fatal overdose at Insite. I was able to witness several overdoses during my time as a volunteer, but during each one, the nurses knew precisely what to do. I recall my first: this middle-aged man had injected a “speedball,” which is slang for an intravenous combination of heroin and cocaine, and he began seizing on his way out of the injection room. The nurses swiftly reacted, giving him oxygen and monitoring his vitals, and the man was eventually resuscitated and moved to the hospital for further observation. I can’t help but wonder what would have happened if he had overdosed in an alley or alone in his home, if he had one. Without Insite as a safe option for injection, he may have become one of the 51 potential fatalities mentioned in the PLoS ONE. In the words of a female Insite client, “Dead people are found in their rooms. They are not found at Insite.”

In addition to providing assistance in the situation of an overdose, the staff at Insite also provides addiction counseling and reference to detoxification programs. While many people feared that an injection facility would actually deter drug users from seeking treatment, a study by the New England Journal of Medicine found that Insite users are significantly more likely to enter a detox program than those who do not use the SIF. Just one year after Insite opened, there was a 33 percent increase in the use of detox services, as reported in the journal, Addiction.

One of the most significant contributors to the HIV rate in the Downtown Eastside is syringe sharing. By providing clean needles and other sterile equipment, Insite is positioned to attack the significant HIV statistics representing the Downtown Eastside—and it has done so quite effectively, as described by another article in the Lancet. Researchers found that Insite users are 70 percent less likely to share syringes than injection drug users who do not utilize the facility. A second article in the American Journal of Infectious Diseases examined the syringe sharing of users in the Downtown Eastside and did not find a single instance of used syringe lending of HIV-positive individuals who reported exclusive use of Insite. The journal, Addiction, compiled another study of SIFs in Spain and Insite in Vancouver and found that regular users of SIFs have a 69 percent less chance of sharing syringes, further supporting these results.

One final topic researched at Insite is its cost effectiveness. With the use of conservative estimates in regard to the number of HIV cases and overdose deaths prevented by the SIF, the International Journal of Drug Policy featured an article that concluded that Insite saves about $6 million of governmental revenue every year. In 2008, an article in the Canadian Medical Association Journal found that decreased needle sharing alone would save approximately $14 million over ten years while increased knowledge of safe injection practices and referral to methadone maintenance through Insite saves $18 million. It is clear that, in addition to being the incredibly beneficial to the recovery of the Downtown Eastside, Insite is also an effective and efficient use of public healthcare resources, especially when compared to other methods of dealing with the injection drug epidemic.

This is the second part of a three-part series about supervised injection and Trevor Thomas’ experience at Insite. Part 1 of the series, Supervised injection: “state-sponsored suicide”, gave an overview of Insight and the motivations behind supervised injection and part 3, Supervised Injection: Insight and the Supreme Court, will discuss Insite’s success in the Supreme Court.

Supervised injection: “state-sponsored suicide”

20 Jun 2011, Posted by Trevor Thomas in Backpages, 3 Comments

I was offered drugs three times during my first walk down Hastings. Homeless men with unkempt beards would ask me for cigarettes and then rescue used butts from the sidewalk, hoping that they might have some tobacco left in them. People openly injected and smoked drugs in public–it reached a point where I was beginning to forget that heroin and cocaine are illegal substances. As I tripped over the used syringes that decorated the sidewalks and alleys, I was beginning to witness the reality of “Canada’s poorest postal code.” This was Vancouver’s Downtown Eastside, today was May 10, and this was my first day volunteering at Insite.

Insite is located in a green building on 139 East Hastings StreetInsite is located in a green building on 139 East Hastings Street–the heart of the Downtown Eastside.the heart of the Downtown Eastside.

Insite is North America’s only medically supervised injection facility, located on 139 East Hastings Street in Vancouver, British Columbia. As the name implies, supervised injection facilities (SIFs) are locations where drug users can inject drugs under the direct supervision of nurses with sterile needles and other equipment provided by the facility. Albeit a very controversial method of remedying the impoverished state of the Downtown Eastside, Insite has been paramount in regard to preventing overdose deaths, improving the health of Downtown Eastside residents, and lowering the costs–health, social, and legal–associated with injection drug use.

Supervised injection is working better than any other available healthcare method to help the residents of the Downtown Eastside, but it has been receiving outrageous political criticisms threating to shut it down. Since Stephen Harper and the Conservative Party of Canada took power in 2006, the federal government has been incessantly challenging the site. Prime Minister Stephen Harper has directly voiced his aversion towards the SIF, saying in February of this year, “We, as a government, will not use taxpayers’ money to fund drug use.” This is a particularly absurd statement considering the cost benefits that Insite provides. Pressure from the United States, which represents a vehement ‘War on Drugs’ perspective, has also not helped the situation. Upon the facility’s opening in 2003, the director of the White House Office of National Drug Control Policy called Insite “state-sponsored suicide,” an equally irrational statement if one simply looks at the number of overdose deaths prevented per year because of Insite. Pressure to shut down the facility has never been stronger and more loosely based on anything factual, which brings me to my intentions for this three-part article.

Canadian SIF conflict reached a culmination on May 12, the date of a Supreme Court case held to determine whether Insite will continue to operate legally. The results of this case will not be released until 2012, February at the latest, as inferred by Insite lawyer Monique Pongracic-Speier. While I’ve found that attitudes regarding the future of Insite vary greatly among the Canadians with whom I have spoken, the fact is that many people–especially those living in the U.S.–have never heard of Insite, let alone the idea of supervised injection. Insite represents one of the most important healthcare issues of our generation and is a potential archetype for other cities plagued by similar drug-abuse problems. In fact, overdose has overtaken homicide as the leading cause of premature death in many North American cities, making it likely that supervised injection will be incorporated into the United States healthcare system. Additionally, political pressure from the U.S. has a significant influence on Canadian debates about Insite, especially with respect to the recent Supreme Court case. This only further highlights the contemporary necessity of increased education about supervised injection. Phrases like “state-sponsored suicide” can no longer be used to describe a healthcare method that saves hundreds of lives each year.

A female participant injecting into her jugular.

A New Third World Country: Vancouver’s Downtown Eastside

An extensive study of the Downtown Eastside commissioned by the city found that 77% of the residents in this community make less than $15,000 a year, with more than half of that coming from government transfer payments. The study also concluded that 79% have health problems and 52% use drugs. Downtown Eastside had 4,700 chronic drug users in 2000, only further contributing to its status as the center of an “injection drug epidemic.” The United Nations conducted a survey that uncovered even more shocking data: 70% of residents are reported to have Hepatitis C, and 30% are reported to have HIV. To emphatically reiterate, 30% of Downtown Eastside residents – that’s almost one in every three people – have HIV. This is absolutely unacceptable. In Botswana, 24.8% of the population has HIV; in Lesotho and Swaziland, two other deeply impoverished African countries, 23.6% and 25.9% are reported to have HIV, respectively. If this didn’t sound bad enough, the release of this survey was delayed due to arguments presented by Downtown Eastside advocates, proclaiming that the government was massaging the data, trying to conceal the true disparity of the situation. Nevertheless, the reality is that these statistics rival those of the Third World, and they’re representing one of the oldest districts of one of the richest countries on the planet.

Even more outstanding, however, are the numbers behind overdose deaths in the Downtown Eastside. In the late 1990s, the yearly overdose death toll in this small ten-block-by-five-block area of Vancouver represented almost half of the total number of overdose deaths in the province of British Columbia. There are sources that document overdoses deaths occurring at rates of almost once a day in the Downtown Eastside in the early 2000s. Something had to be done.

And thus came Insite. In 2003, the regional health authority in Vancouver requested an operational exemption of Section 56 of the Controlled Drugs and Substances Act so that they could pilot North America’s first medically supervised injection facility. The request was granted, and Insite was founded. The idea of supervised injection may appear novel, but there have been clinics of this type in other countries for quite some time. In 2009, there were 92 facilities operating in 61 cities around the world, most of which are in Germany, the Netherlands, and Switzerland. The success of these sites was an important factor in the regional health authority’s allowing the legal operation Vancouver’s SIF in 2003. Several years later, Insite has developed into the busiest SIF in the world and is now serving as a template of improvement for the sites that originally helped open it.

This is the first part of a three-part series about supervised injection and Trevor Thomas’ experience at Insite. Part 2 of the series, Supervised Injection: injecting the facts, will discuss the evidence that supports supervised injection and part 3, Supervised Injection: Insite and the Supreme Court, will discuss Insite’s success in the Canadian Supreme Court.