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Canada's decision on reducing illicit drug harm
Leading Edge
In May 2004 this journal published a Personal View article by Evan Woods and colleagues describing the rationale for evaluating prospectively a medically supervised safer-injecting facility (SIF) in Vancouver, Canada. Various aspects of the evaluation have been reported, with encouraging results. However, the Vancouver SIF now faces the possibility of closure. A SIF (known also by other names such as supervised injection site and drug consumption room) is a place where injecting drug users are allowed to bring their illegally obtained drugs and take them in supervised, hygienic conditions. The purpose of SIFs is to reduce the community and public-health impacts of illicit injection drug use such as drug-related litter, hepatitis B and C and HIV infections, and overdoses. The Vancouver SIF, known as Insite, opened in September 2003, and in a Leading Edge editorial in the May 2004 issue we welcomed the decision to do a prospective cohort study of the impact of the site, because it would provide a scientific evidence base for drugpolicy decision making. There are now about 65 SIFs in operation in Germany, Switzerland, the Netherlands, Spain, Norway, Luxembourg, Australia, and Canada. The first was established in Berne, Switzerland, in 1986, but the Vancouver facility was the first in North America. Before it could open, Insite was given a 3-year exemption from Canadian drug laws by the federal government. That exemption will expire this month (ie, September 2006) and must be renewed for the Vancouver SIF to remain in operation. In the election of February this year, Canadians voted out the Liberal government that originally granted the exemption and replaced it with a Conservative-led alliance under Prime Minister Stephen Harper. At the time of writing, the Harper administration had not announced whether or not it would allow an extension to the exemption. We urge the Canadian government to consider the evidence that has accumulated regarding the efficacy of Insite before reaching a decision. The Vancouver SIF has, by most measures, reduced the impact of injecting drug use, and has certainly not worsened it. For example, concerns have been raised that SIFs will lessen the likelihood that drug users will seek addiction treatment. However, in Vancouver, use http://infection.thelancet.com Vol 6 September 2006
of the SIF weekly or more often, and contact with the facility’s addiction counsellors were both associated with more rapid entry into detoxification programmes. In surveys done before and after the opening of Insite, the facility was not associated with increased drugrelated crime, but was associated with reduced public injection of drugs and public syringe disposal. A further before and after analysis showed no substantial increase in the rate of relapse into injecting drug use and no substantial decrease in the rate of stopping injecting drug use. Attendance at the Vancouver facility by drug users was also independently associated with reduced syringe sharing. Furthermore, during 18 months from March 1, 2004, there were 336 overdose events at Insite, none of which resulted in a fatality. This finding compares favourably with an expected rate of four in every 100 overdoses resulting in death. Examining the effects of the Vancouver SIF on the incidence of blood-borne infections is difficult because there have been too few HIV and hepatitis C virus seroconversions among clients of the centre to draw conclusions. Nevertheless, it is reasonable to conclude that the facility has reduced the local public nuisance associated with injecting drug use and the burden on health services of serious overdoses, while not encouraging increased drug use. Billions of dollars are spent worldwide every year on enforcement-based drug-control strategies designed to limit drug supply and imprison offenders. These approaches have had negligible impact on the supply of drugs—for example, US prisons contain around half a million non-violent drug offenders, while the price of heroin has fallen three-fold since the late 1980s—and done nothing to reduce the harm caused by illicit drug taking. By contrast, harm-reduction policies such as establishing SIFs seem to offer a rational and evidence-based approach to limiting the impact of illicit drug use. An announcement on the future of the Vancouver SIF is expected during the International AIDS Conference, which was scheduled to start in Toronto, Canada, as we went to press. Closure of the site would be a clear retrograde step. We trust that scientific evidence rather than wishful thinking will have informed the Canadian government’s decision. ■ The Lancet Infectious Diseases
Christoph Papsch/Still Pictures
Canada’s decision on reducing illicit drug harm
See Lancet Infect Dis 2004; 4: 301–06.
See Lancet Infect Dis 2004; 4: 253.
537
In May 2004 this journal published a Personal View article by Evan Woods and colleagues describing the rationale for evaluating prospectively a medically supervised safer-injecting facility (SIF) in Vancouver, Canada. Various aspects of the evaluation have been reported, with encouraging results. However, the Vancouver SIF now faces the possibility of closure. A SIF (known also by other names such as supervised injection site and drug consumption room) is a place where injecting drug users are allowed to bring their illegally obtained drugs and take them in supervised, hygienic conditions. The purpose of SIFs is to reduce the community and public-health impacts of illicit injection drug use such as drug-related litter, hepatitis B and C and HIV infections, and overdoses. The Vancouver SIF, known as Insite, opened in September 2003, and in a Leading Edge editorial in the May 2004 issue we welcomed the decision to do a prospective cohort study of the impact of the site, because it would provide a scientific evidence base for drugpolicy decision making. There are now about 65 SIFs in operation in Germany, Switzerland, the Netherlands, Spain, Norway, Luxembourg, Australia, and Canada. The first was established in Berne, Switzerland, in 1986, but the Vancouver facility was the first in North America. Before it could open, Insite was given a 3-year exemption from Canadian drug laws by the federal government. That exemption will expire this month (ie, September 2006) and must be renewed for the Vancouver SIF to remain in operation. In the election of February this year, Canadians voted out the Liberal government that originally granted the exemption and replaced it with a Conservative-led alliance under Prime Minister Stephen Harper. At the time of writing, the Harper administration had not announced whether or not it would allow an extension to the exemption. We urge the Canadian government to consider the evidence that has accumulated regarding the efficacy of Insite before reaching a decision. The Vancouver SIF has, by most measures, reduced the impact of injecting drug use, and has certainly not worsened it. For example, concerns have been raised that SIFs will lessen the likelihood that drug users will seek addiction treatment. However, in Vancouver, use http://infection.thelancet.com Vol 6 September 2006
of the SIF weekly or more often, and contact with the facility’s addiction counsellors were both associated with more rapid entry into detoxification programmes. In surveys done before and after the opening of Insite, the facility was not associated with increased drugrelated crime, but was associated with reduced public injection of drugs and public syringe disposal. A further before and after analysis showed no substantial increase in the rate of relapse into injecting drug use and no substantial decrease in the rate of stopping injecting drug use. Attendance at the Vancouver facility by drug users was also independently associated with reduced syringe sharing. Furthermore, during 18 months from March 1, 2004, there were 336 overdose events at Insite, none of which resulted in a fatality. This finding compares favourably with an expected rate of four in every 100 overdoses resulting in death. Examining the effects of the Vancouver SIF on the incidence of blood-borne infections is difficult because there have been too few HIV and hepatitis C virus seroconversions among clients of the centre to draw conclusions. Nevertheless, it is reasonable to conclude that the facility has reduced the local public nuisance associated with injecting drug use and the burden on health services of serious overdoses, while not encouraging increased drug use. Billions of dollars are spent worldwide every year on enforcement-based drug-control strategies designed to limit drug supply and imprison offenders. These approaches have had negligible impact on the supply of drugs—for example, US prisons contain around half a million non-violent drug offenders, while the price of heroin has fallen three-fold since the late 1980s—and done nothing to reduce the harm caused by illicit drug taking. By contrast, harm-reduction policies such as establishing SIFs seem to offer a rational and evidence-based approach to limiting the impact of illicit drug use. An announcement on the future of the Vancouver SIF is expected during the International AIDS Conference, which was scheduled to start in Toronto, Canada, as we went to press. Closure of the site would be a clear retrograde step. We trust that scientific evidence rather than wishful thinking will have informed the Canadian government’s decision. ■ The Lancet Infectious Diseases
Christoph Papsch/Still Pictures
Canada’s decision on reducing illicit drug harm
See Lancet Infect Dis 2004; 4: 301–06.
See Lancet Infect Dis 2004; 4: 253.
537