North America’s only safe injection site for drug addicts will remain open. The Canadian government wanted to close Vancouver’s Insite clinic, where addicts can inject under medical supervision. But the Supreme Court of Canada has ruled the government must consider the initiative’s benefits. “The clinic saves lives and improves public order.”

By Frank Kuin in Vancouver

Every day at 10 a.m. in the Downtown Eastside of Vancouver, the doors open at Insite, the only legal safe injection site in North America. The silence in the injection room, a sterile space with twelve shielded stainless steel tables in front of large mirrors, is broken by the noisy arrival of intravenous drug users, mostly homeless, ready for a fix.

A nurse at the desk hands every addict a ‘hit kit’, a package of supplies to inject drugs in a safe manner: a clean needle and syringe, gauze, alcohol swabs, and a small hotplate. Drugs are brought by the user. Supervised by medical staff, addicts can inject safely, without risk of arrest or contracting an infectious disease. When they are done, they move on to a ‘chillout room’, before heading back out onto the street.

It’s been going on like this for eight years, every day from 10 a.m. to 4 a.m. at Insite, the injection clinic in the Downtown Eastside of Vancouver, one of the roughest drug neighbourhoods on the continent. On average, 850 addicts per day come here to use safely – rather than in a back alley with a used needle and water from a puddle.

The goal of the clinic, a pioneering initiative in North America, is so-called ‘harm reduction’: to reduce the spread of infectious diseases such as HIV and hepatitis among the thousands of addicts in the area, and prevent overdose deaths.

Een medewerkster van Insite bereidt 'hit kits' voor in de spuitzaal van de injectiekliniek in de Downtown Eastside van Vancouver.

An Insite worker prepares ‘hit kits’ in the injection room of the clinic in Vancouver’s Downtown Eastside.

“Our main purpose is to keep people alive,” says Liz Evans, a nurse and organizer at Insite and a frontline veteran of the drugs strategy in Vancouver. The city on Canada’s West Coast is sometimes referred to as ‘Vansterdam’ because of its relatively liberal approach to drugs policy. “In addition, we bring users in contact with medical treatment and access to rehab services that they would otherwise not have.”

The pragmatic approach, familiar in Europe but still experimental in North America, will become permanent in Vancouver despite plans by the Canadian government to shut Insite down. The Supreme Court of Canada has rejected a cabinet plan to revoke the clinic’s exemption from Canada’s drug laws.

The Conservative government of Prime Minister Stephen Harper wanted to close Insite, because the initiative goes against its strict drug policy, modeled on the American ‘war on drugs’. It weakens Canada’s prohibition of possessing hard drugs, the government has argued. But the High Court unanimously ordered the government to keep Insite open.

The judges pointed to scientific evidence that Insite has reduced fatal overdoses and the spread of infectious diseases. Abolition of the services provided by the clinic would lead to an “increase in the risk of death and disease to injection drug users,” they ruled. That would not be in proportion to “any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics.”

De ruige Downtown Eastside van Vancouver staat bekend als de armste stadsbuurt van Canada. Foto Astri Sivertsen

Vancouver’s Downtown Eastside is known as the poorest city neighbourhood in Canada. Photo Astri Sivertsen

Evans, who announced the decision to a group of several hundred supporters in front of Insite, called the verdict “a fantastic relief” and “an incredible symbol of hope for drug users in our community.” A banner has been put up on Insite’s façade: “We won!”

The verdict is a painful defeat for the Harper government, which considers the clinic an encouragement of drug use. “We believe that the system should be focused on preventing people from becoming drug addicts,” said Leona Aglukkaq, Canada’s Health Minister. Nevertheless, the government will obey the court, she said in Parliament.

According to Thomas Kerr, a research scientist with the British Columbia Centre for Excellence in HIV/AIDS, the ruling “sends a very clear message that health and science have prevailed over ideology and ignorance.”

Kerr published a study this spring in the medical journal The Lancet, which showed that the number of deaths from drug overdoses in the area has fallen by more than a third since Insite opened in 2003. It is one of over 40 scientific studies that have been done into the effects of the initiative.

“The scientific evidence is clear,” says Kerr. “This facility is saving lives, it’s improving public order, it’s preventing HIV infection, and it’s facilitating entry into addiction treatment. Claims that it is enabling drug use have not been borne out by the data.”

“If Insite had not been there, I would either still be using, or I would be dead”

By contrast, the Harper government’s drugs policy “flies in the face of current scientific evidence,” Kerr argues. “It is driven by ideology, not by science.”

The Supreme Court’s ruling opens the door for similar initiatives in other Canadian cities, observers say. Jean-François Mary, a frontline drugs worker in Montreal, expects to be able to open a safe injection site in his city in 2012. “It has been shown that these types of services actually work, the main aspect that needed to be clarified was the legal issue,” he says. “That has now been cleared up.”

Mary says it’s a breakthrough that the Supreme Court has framed drug addiction as a medical problem. “There’s a recognition that drug addiction is not a criminal issue. The main outcome for us is that drug users require health care, not going to jail.”

In Vancouver, former addict Dean Wilson is delighted about the verdict. He was a regular user of heroin at Insite between 2003 and 2009. “We always knew we were right, and we were vindicated,” he says.

Wilson, who was named as a plaintiff in the court case, has been drugs-free since 2009 after having completed Insite’s rehab program. “They provide gold standard medical interventions for a group of very sick people,” he says. “If Insite had not been there, I would either still be using, or I would be dead.”

Insite: 2 million injections

Vancouver’s Insite injection clinic opened in September 2003 in response to hundreds of fatal overdoses and a high level of HIV infections in the city’s Downtown Eastside, a rough neighbourhood where many drug addicts live, many on the streets.

Canada’s Liberal government at the time granted Insite an exemption from federal drug laws despite sharp criticism from the United States. Washington still believes Insite should be closed, a diplomatic note leaked by Wikileaks recently revealed.

The safe injection site, modeled after similar initiatives in Frankfurt and Bern, among other examples, has since distinguished itself by its sheer size. Although more than 60 cities in the world have various forms of safe injection clinics, few have a daily average of 850 injections – with peaks reaching more than 1,100.

Since 2003, 2 million injections have been performed at Insite. Medical staff can supervise the injections, but not administer them. Since the opening, there have been about 4,000 overdoses where medical staff intervened. None of those was fatal.

In addition to the injection room, the facility also has a detox center on the second floor, and it offers transitional housing for addicts who seek treatment. More than 450 users accessed those services last year. In all, 12,236 individuals used Insite in 2010.

Tafels in de injectiezaal van Insite.

Tables in Insite’s injection room.

Insite under the microscope

Vancouver’s Insite clinic is one of the most studied safe injection sites in the world. More than 40 scientific studies have been done into the impact of the initiative on overdoses, infectious diseases such as HIV, drug use, public order and crime in the neighbourhood.

“We were well aware that these types of facilities have existed in the Netherlands and other countries for many years,” says research scientist Thomas Kerr. “However, they have not been evaluated very vigorously. But because in North America we live in an environment where the ‘war on drugs’ is very dominant, there was much greater pressure to produce high-quality science about the impact of the facility.”

A few examples:

  • Insite has led to an increase of participation in addiction treatment, especially detox programs, according to a study in the New England Journal of Medicine.
  • The clinic has led to a decline in the number of addicts who inject in the streets, and the amount of discarded injection materials in the area, according to a study in the Canadian Medical Association Journal.
  • Insite has not led to a higher rate of return to drug use among former drug addicts, according to a study in the British Medical Journal.

This post is also available in: Dutch

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