Injecting reason

Abstract

Morbidity and mortality associated with drug dependence, especially drug injecting, constitute major problems for public health. In the USA intravenous drug use accounts for about one third of all AIDS and one half of hepatitis C cases. On page 301 of this issue, Evan Wood and colleagues describe the rationale behind North America's first medically supervised saferinjecting facility (SIF), which opened in September 2003, in Vancouver, Canada. SIFs are professionally supervised health-care facilities, where high-risk drug users can use drugs in safe, hygienic conditions. They have been around in Europe for nearly 20 years. But in North America, where public-health interventions for intravenous drug users (IDUs) have been controversial and are heavily politicised, opening of this SIF signifies a radical step forward. Historically, Europe and North America have diverged in their public-health response to intravenous drug use. In the mid 1980s needle-exchange programmes faced fierce opposition in the USA. By contrast, Europe and Australia quickly adopted them, as did Canada. As a result, they all experienced a reduction in injection-related HIV incidence and prevalence, and no further increase in drug abuse and criminal activity. But despite the overwhelming scientific evidence, the US view was—and still is today in many states—opposed to the programmes. The belief is they promote increased drug use. A federal ban in the USA in 1988 on funding of needle-exchange programmes, and the research into their safety and effectiveness, meant that there was a long delay before the programmes got going in the USA. To this day that ban still exists. A rational public-health response was also hindered by the AIDS epidemic in IDUs in the USA coinciding with a crack cocaine epidemic that generated a lot of public fear about drugs. The violence associated with the drug-distribution trade generated a tremendous amount of public anxiety. And in that atmosphere it was hard to get rational discussion of measures to reduce HIV infection. This situation was further compounded by drug use in IDUs being concentrated in ethnicminority groups, which made the political discussions much more difficult. Over the years one thing has become clear—that the response to the HIV epidemic among IDUs in North America has become entrenched in law enforcement and incarceration as the major public-health intervention. This fact is most evident in the allocation of expenditures in the US national drug control budget for fiscal year 2004. Of a $12 billion total, more than $7.2 billion (60%) is devoted to drug law enforcement, interdiction, and supply reduction in the USA and abroad. This figure is predicted to rise to more than 70% in 2005. Europe, on the other hand, has focused more on harm-reduction strategies, with emphasis on the health and human rights of the individual. The evolution of SIFS is similar to that of needle-exchange programmes, since both are surrounded by controversy. According to the UN's International Narcotics Control Board, SIFs violate the provisions of the international drug control convention, and countries that allow the operation of SIFs are guilty of facilitating illicit drug trafficking. The first SIF opened in 1986 in Berne, Switzerland, followed by Germany and the Netherlands in the 1990s, and then Spain. The UK is currently debating whether a pilot project should be set up. SIFs were seen as a pragmatic approach to a persisting drug problem. But despite having a medical rationale, they were often run by community and social workers, and had a history of repeatedly being shut down and reopened. Thus the major limitation of SIFs over the years has been the absence of rigorous scientific evaluation. However, the SIF that opened in Australia in 2001 as an 18-month scientific trial has demonstrated a decrease in drug-related deaths, and no reported increase in hepatitis B and C infections, which has meant that the SIF continues to operate. The Vancouver SIF has taken 10 years for its doors to open, following a barrage of political opposition claiming it will encourage increased drug use, public disorder, and conflict with treatment goals. But with an explosive HIV epidemic that remains among the most rapidly spreading in the developed world, it is timely that the Vancouver SIF has opened now. What will be invaluable is a rigorous evaluation of the Vancouver facility. 8 months since opening, there have already been improvements of public order, a reduction in discarded syringes in the street, and less injecting in public. It is very encouraging to hear that Wood and colleagues have embarked on a prospective cohort study that will provide a scientific evidence base to support a change in drug policy, and potentially make a strong case for not allowing public health to get caught up in politics in the future.