It is known that programs like Vancouver's Insite reduce the spread of HIV/AIDS and of hepatitis C and reduce drug overdose. No evidence exists to support its spreading drug abuse.
This week on American television, as part of its coverage of the 2010 Vancouver Winter Olympic Games, particularly on the CNN Network each morning at the gym were I exercise, the morning news was astir with discussions of Insite, a Vancouver-based project that provides addicts with a safe site to inject, including clean needles. The American TV was awash with criticisms of this policy, the primary one being that it promoted drug abuse and caused people to abuse drugs even more than they otherwise would. What amazed me was the complete lack of attention to data in the American media. Substantial research has been conducted on Insite and on harm reduction models. It is known that programs like Insite reduce the spread of HIV/AIDS and of hepatitis C and reduce drug overdose. No evidence exists to support its spreading drug abuse.
Why do the American media avoid discussing these research findings? Why are the opinions of unknowledgeable people in towns like Decatur, Georgia, and Cumberland, Maryland, more meaningful than the results of carefully conducted scientific research? Why is evidence-based medicine abandoned when it comes to drugs? Why is the existence of credible research not even mentioned? The best that was done was to mention that the director of the Insite Program believed that lives were being saved. Not mentioned was the hard scientific evidence amassed to back his position. Why does science not matter when it comes to drug policies?
CNN implied that Insite was operating under the legal radar and that the Vancouver Police Department were pretending not to notice its existence. In fact, in 2003, the regional health authority in Vancouver successfully applied to the federal government for a legal operating exemption to pilot Insite.3 This exemption was granted following the release of feasibility data which suggested that Insite had the potential to reduce public drug use and overdose deaths.4,5 Insite was established following prior experience of similar facilties in European and Australian settings. Corresponding research suggested that these facilities had unique potentials to reduce public illicit drug use while promoting the use of sterile syringes and providing emergency care in the event of overdose.6-9 Since opening in 2003, Insite has been a place where people could inject drugs and connect to health care services from primary care to treating disease and infection, to addiction counselling and treatment. Few areas suffer more from the lack of response to research than illicit drug use.1,2
Dr. Evan Wood, Director of the University of British Columbia's Center for Excellence in HIV/AIDS research reported in The Calgary Herald on January 31, 2010, that despite criticisms levied by Conservatives (and the American media), the benefits that Insite provides are real and verified.
Dr. Wood pointed out that drug prohibition has created a massive global revenue stream for organized crime, worth an estimated $320 billion US annually. These enormous proceeds threaten the political stability of entire regions, including Mexico and Afghanistan. In the U.S., where the war on drugs has been fought most vigorously, the incarceration of drug offenders has placed a huge burden on the taxpayer and contributed to the world's highest incarceration rate. Primarily as a result of drug-law enforcement and mandatory minimum sentences, one-in-eight African-American males in the age group 25 to 29 is incarcerated on any given day, despite the fact that ethnic minorities consume illicit drugs at the same rate as white and other subpopulations. Paradoxically, ever-increasing drug enforcement expenditures and incarceration levels have not prevented the drug market from becoming more efficient.
The association between drug prohibition and increased inner-city violence is consistent. A recent international example is the upsurge in severe drug-related violence in Mexico subsequent to Mexican President Felipe Calderon's escalation in the fight against Mexican drug traffickers. Increasing gun violence in Canadian cities has been directly linked to clashes between organized crime groups over the enormous drug market profits.
HIV and overdose death rates are highest in areas where law enforcement is prioritized over evidence-based public health strategies. These harms are significant given HIVs spread beyond its traditional risk groups and its burden on the health system. Each and every case of HIV is estimated to cost $250,000 in medical expenses. For the above reasons, conservative economists like Nobel Prize winner Milton Friedman have long argued that the "war on drugs" does much more harm than good.
Due to their effectiveness, harm reduction policies are now endorsed by all evidence-based scientific consensus bodies, including the U.S. Institutes of Medicine and the World Health Organization. This consensus is based on rigorous reviews of the large volume of international scientific evidence indicating that harm-reduction programs save tax dollars and improve public health by reducing HIV rates while increasing uptake of addiction treatment. To read more from Dr. Evan, see click here
In Europe, more than 65 programs like Insite bring street-based drug addicts indoors where they can be prevented from sharing needles and overdosing while increasing enrolment into addiction treatment. Insite has replicated the European experience, and is undoubtedly the most highly studied health clinic in Canadian history. More than 30 peer-reviewed studies show that Insite reduces public injecting, reduces HIV risk behaviours (e.g., needle sharing), and increases rates of addiction treatment. Studies seeking to identify potential harms of the facility found no evidence of negative impacts. Studies were independently peer-reviewed and published in top scientific periodicals, including the New England Journal of Medicine, The Lancet and the British Medical Journal.
During the period from March 10, 2004 to April 30, 2005, 4,764 individuals registered to use Insite. Heroin was used in nearly half of all injections, and cocaine was injected 37% of the time. There were 273 witnessed overdoses, none of which resulted in a fatality. There were also 2,171 referrals to addiction counselling and other support services. These early results indicated that Insite was being successfully integrated into the community. The facility was attracting a wide cross-section of injection drug users, and staff were successfully intervening in overdose events on site and actively referring drug users to addiction treatment and other services.10
A 2006 study showed that Insite was attracting a large number of hard-to-reach intravenous drug users and that the existence of the facility presented an excellent opportunity to enhance HIV prevention through education, the provision of clean injecting equipment, and the availability of a supervised and sterile environment to self-inject. Finally, the facility was also an important point of contact for HIV-positive individuals who were not yet participating in HIV care and treatment.11
One concern prior to the opening of Insite was whether the facility would encourage injection drug use by making drug injection easier and more comfortable for intravenous drug users. Therefore a study was made to determine whether or not the opening of the facility would be accompanied by a worsening of community drug use patterns. The drug use behaviours of 871 intravenous drug users were observed in the one year period before the opening of Insite and in the one-year period after. The drug use behaviours studied included the rates of relapse into injection drug use among former users and the cessation of injection drug use among current users. The study found that after Insite opened there was no substantial increase in the rate of relapse into injection drug use among former users (the rate of relapse was 17% prior to the opening and 20% after). There was also no substantial decrease in the rate of injection drug use cessation among current users (the rate was 17% prior to Insite's opening and 15% after). This research showed that the benefits of Insite on reducing the high-risk behaviours of intravenous drug userss and on increasing public order were not offset by negative effects on drug use patterns among Vancouver's intravenous drug using population.12
Critics suggested that the availability of a supervised injection facility might discourage drug users from seeking treatment for their addiction. A study was conducted to examine the effect of Insite on the use of detoxification services, which is the entry point into the addiction treatment continuum in Vancouver. The study followed more than 1,000 Insite users between December 1, 2003 and March 1, 2005. Of this group, 185 (18%) began a detoxification program at some point during the study period. Individuals who used Insite at least weekly were 1.7 times more likely to enroll in a detox program than those who visited the centre less frequently. The study also found that contact with Insite's addictions counsellor significantly increased a person's chances of enrolling in detox. Contrary to fears that Insite might be deterring drug users from seeking treatment, these findings strongly suggested that Insite was facilitating entry into detoxification services among its clients.13
In another study, researchers measured the effect of Insite on the use of detoxification services by comparing rates of detox service use among injection drug users in Vancouver in the year before Insite opened and in the year after it opened. The researchers also investigated whether those individuals who attended Insite and enrolled in detox were subsequently more likely to enroll in methadone maintenance or other drug treatment programs. They learned that, in the year after Insite opened, there was a 33% increase in detoxification service use, compared to the year prior to the opening of the facility. The study also showed that Insite clients who entered detox were 1.6 times more likely to enroll in methadone treatment and 3.7 times more likely to enroll in other forms of addiction treatment. As well, individuals who entered detox visited Insite less frequently in the month after enrolling in detox services than in the month prior to enrolment. This research indicated that Insite encouraged intravenous drug users to enter detox. It also suggested that drug users who enrolled in detox were more likely to remain in subsequent treatment programs and reduce their use of Insite.14
I don't have an answer for why ideology trumps scientific evidence in the United States and its media. Why are the opinions of ordinary people in ctiies across the United States considered more valid than three dozen rigorous scientific studies? Is this just the American way?
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11. Tyndall MW, Wood E, Zhang R, Lai C, Montaner JSG, Kerr T. HIV seroprevalence among participants at a supervised injection facility in Vancouver, Canada: Implications for prevention, care and treatment. Harm Reduction Journal, 2006; 3(1): 36.
12. Kerr T, Stoltz JA, Tyndall M, Li K, Zhang R, Montaner J, Wood E. Impact of a medically supervised safer injection facility on community drug use patterns: A before and after study. British Medical Journal, 2006; 332(7535): 220-222.
13. Wood E, Tyndall MW, Zhang R, Stoltz J, Lai C, Montaner JSG, Kerr T. Attendance at supervised injecting facilities and use of detoxification services. New England Journal of Medicine, 2006; 354(23): 2512-2514.
14. Wood E, Tyndall MW, Zhang R, Montaner JS, Kerr T. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction, 2007; 102(6): 916-919.
Authors Bio:Lewis Mehl-Madrona
graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and Narrative Medicine.