Supervised Injection Sites Research Articles

Harm reduction therapy: a practice-friendly review of research.

Harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behaviors. Although harm reduction was originally and most frequently associated with substance use, it is increasingly being applied to a multitude of other behavioral disorders. This article reviews the state of empirical research on harm reduction practices including alcohol interventions for youth, college students, and a variety of other adult interventions. We also review nicotine replacement and opioid substitution, as well as needle exchanges and safe injection sites for intravenous drug users. Dozens of peer-reviewed controlled trial publications provide support for the effectiveness of harm reduction for a multitude of clients and disorders without indications of iatrogenic effects. Harm reduction interventions provide additional tools for clinicians working with clients who, for whatever reason, may not be ready, willing, or able to pursue full abstinence as a goal.

The cost-effectiveness of Vancouver's supervised injection facility

The cost-effectiveness of Canada's only supervised injection facility has not been rigorously evaluated. We estimated the impact of the facility on survival, rates of HIV and hepatitis C virus infection, referral to methadone maintenance treatment and associated costs. We simulated the population of Vancouver, British Columbia, including injection drug users and persons infected with HIV and hepatitis C virus. The model used a time horizon of 10 years and the perspective of the health care system. We compared the situation of the supervised injection facility with one that had no facility but that had other interventions, such as needle-exchange programs. The effects considered were decreased needle sharing, increased use of safe injection practices and increased referral to methadone maintenance treatment. Outcomes included life-years gained, costs, and incremental cost-effectiveness ratios discounted at 5% per year. Focusing on the base assumption of decreased needle sharing as the only effect of the supervised injection facility, we found that the facility was associated with an incremental net savings of almost $14 million and 920 life-years gained over 10 years. When we also considered the health effect of increased use of safe injection practices, the incremental net savings increased to more than $20 million and the number of life-years gained to 1070. Further increases were estimated when we considered all 3 health benefits: the incremental net savings was more than $18 million and the number of life-years gained 1175. Results were sensitive to assumptions related to injection frequency, the risk of HIV transmission through needle sharing, the frequency of safe injection practices among users of the facility, the costs of HIV-related care and of operating the facility, and the proportion of users who inject in the facility. Vancouver's supervised injection site is associated with improved health and cost savings, even with conservative estimates of efficacy.

Harm Reduction: Keeping the Public’s Health in Sight

The article by Harvard et al. (in this issue of the Journal) on the distribution of harm reduction products in British Columbia provides an opportunity to revisit the recent controversy surrounding Insite, the Vancouver safe injection facility. Started in 2003, Insite is North America’s first legal supervised injection site. Funded by the BC Ministry of Health and operated by Vancouver Coastal Health in partnership with Portland Hotel Society Community services, Insite is one of this country’s important public health successes. Each year, over a quarter of a million visits are registered by over 10,000 individuals for clean and medically supervised drug injection. Insite targets marginalized populations and decreases needle sharing, prevents mortality from overdose, decreases harmful drug-related behaviours and offers both primary health care and addiction counseling and treatment to its clients. In particular, because HIV and hepatitis C infections are endemic among IV drug users (18% and 87%, respectively, of Insite clients), decreasing the risk of transmission is a public health no-brainer. However, the public’s health is at risk of being overtaken by opposition to Insite voiced at the Canadian Medical Association meeting in Montreal last August by the then federal Minister of Health. Although the BC Supreme Court recently extended Insite’s exception to the Controlled Drugs and Substances Act, this decision is being appealed by the federal government which has stated that it would like to see Insite closed. There is strong and consistent evidence that harm reduction strategies have substantial benefits for the health of high-risk, marginalized and hard-to-reach populations. In particular, several independent scientific evaluations by the BC Centre for Excellence in HIV/AIDS have shown not only that Insite has had an important public health impact since its opening, but also that the feared potential increase in crime rates, drug abuse and drug dealing in the community failed to materialize. 1 Quite to the contrary, there was a 30% increase in detoxification service use among Insite clients and no change in drug-related crimes was reported by the police after introduction of the facility. Decision makers sometimes assert that research results are not informative enough to support policy making. In this case, there are ample research results, as well as local community endorsement, in support of a clear-cut, evidence-based policy. Public health must speak loudly and of one voice in support of Insite and for extending this effective intervention model to other high-risk areas in Canada.

For the record at CMA General Council

Doctors and other health professionals who support the Vancouver-based InSite safe injection site are unethical, says federal Health Minister Tony Clement. ![Figure][1]</img> Federal Health Minister Tony Clement says the Vancouver-based supervised injection site “undercuts the ethic of medical

Clement unleashes barrage at safe injection site supporters

Federal Health Minister Tony Clement unleashed a flurry of punches at critics of the federal government’s decision to challenge the operation of the Vancouver-based InSite safe injection site during a 30-minute address to the Canadian Medical Association’s (CMA’s) 141st annual general council

Public injecting among a cohort of injecting drug users in Vancouver, Canada

Despite the implementation of policy interventions to address open drug consumption, public injecting continues to occur in many urban settings. This study sought to examine public injecting among a community-recruited cohort of injecting drug users (IDUs) in Vancouver. The prevalence and correlates of recent public injecting among participants enrolled in the Vancouver Injection Drug User Study during the period of 1 December 2003 to 30 November 2005 were examined prospectively using generalised estimating equations (GEEs). Among the sample of 620 active IDUs, at some point during the study period, 142 (22.9%) individuals reported "usually" or "always" injecting in public in the 6 months prior to their study visit. Factors that were significant and positively associated with recent frequent public injecting in multivariate GEE analysis include homelessness (adjusted OR (AOR) 6.70); frequent crack use (AOR 1.48); and frequent heroin injection (AOR 1.56). Recent frequent public injecting was found to be negatively associated with cooking and filtering drugs prior to injecting (AOR 0.50) and older age (AOR 0.95). The findings indicate that a substantial proportion of local IDUs frequently inject in public, and those who report recently injecting in public spaces appear to be a vulnerable population facing significant health hazards. The provision of secure housing may have the potential to protect the health of IDUs in this setting and significantly decrease the prevalence of public injecting. In addition, the findings support previous work suggesting that removing barriers to the use of Vancouver's existing supervised injection site may serve to further reduce public drug use.

The implicit rules of evidence-based drug policy: A U.S. perspective

w t t e In the classically understated manner of academic pubic health articles, Wood, Kerr, Tyndall, and Montaner (this ssue) describe what others might describe as a policy horror tory. Taking the facts as presented, a well-executed piece of olicy research on a promising innovation was discontinued or unstated but blatant political reasons. Several aspects of his story do suggest a more enlightened political interference han might have been expected in the U.S. The work was in act originally funded. The authors managed to produce 22 eer-reviewed publications without incident. And the authors ell us that the blocked renewal proposal was later funded by he Canadian Institutes of Health Research. On the other hand, the way that the Canadian Minister ramed the goals for safe injecting facilities seemed all too amiliar to U.S. researchers. “Do safe injection sites conribute to lowering drug use and fighting addiction?” This f course completely misses the point of harm reduction, nd illustrates the nearly exclusive reliance on prevalence eduction that stymies innovation in the U.S. We were taken less by the particulars of this Canadian orror story than by the fact that Canadian researchers were hocked by the experience. In the U.S., many seasoned drug olicy researchers have come to take this kind of thing for ranted. The list of high-quality research projects that have een blocked for political reasons is a long one. Both Demoratic and Republican administrations have been assiduous in heir campaigns against projects that challenge such dicta as hat smoked cannabis can have no possible therapeutic value

Review of Essentials of abnormal psychology, first Canadian edition.

Essentials of Abnormal Psychology, First Canadian Edition, by V. Mark Durand, David H. Barlow, and Sherry H. Stewart Thomson Nelson, 2007, 728 pages (ISBN: 0-17-610388-0, CA$99.95 Paperback) Reviewed by MARIA I. MEDVED DOI : 10.1037/0708-5591.49.1.73 This first Canadian edition of Essentials of Abnormal Psychology covers the terrain one might expect of an abnormal psychology textbook. This includes chapters on historical context, approaches to psychopathology, clinical assessment, diagnosis and research methods, anxiety disorders, somatoform and dissociative disorders, mood disorders and suicide, physical disorders and health psychology, eating and sleep disorders, sexual and gender identity disorders, substance-related disorders, personality disorders, schizophrenia and other related disorders, developmental and cognitive disorders, and finally, legal and ethical issues as related to mental health. Although the book initially may look rather dense (it is not), there are numerous organisational aids to facilitate learning. These include concept checks (answers included) embedded throughout the chapters, multiple-choice quizzes, and a visual Cole's Notes summary of the causes, symptoms, and treatments for the different diagnoses. Students should find the accompanying CD with brief clips of therapists interviewing clients with various mental disorders intriguing and thought-provoking. Instructors may appreciate that each clip has an associated question (e.g., What symptoms of depression are evident?). The authors state that their intention for this textbook was to foreground an integrative multidimensional perspective, with emphasis on life-span developmental influences, legal and ethical issues, the scientist-practitioner approach, and treatment options, to name a few. In this review, I will cover each of these; I will begin by examining life-span developmental influences. I find this topic is often given short shrift in many abnormal psychology textbooks, often with coverage limited to a specific chapter on developmental disorders and perhaps mentioning in passing that certain disorders may be related to childhood experiences. In contrast, Essentials of Abnormal Psychology interweaves developmental issues throughout the book. In the chapter on depression, for example, there is a section illustrating how depression might manifest itself in children and adolescents from the ages of 0-36 months to 13-18 years. Rather than recount, summarise, and evaluate the entire book chapter by chapter, I will highlight only certain chapters. One particularly fine chapter is the one on substance-related disorders. Specifically, this section is chock full of Canadian statistics, and to my mind, is especially strong in foregrounding national (and/or provincial) approaches to substance-related disorders. It is also very strong in the presentation of cutting-edge research conducted across Canada. Harm reduction research is illustrated in the context of Vancouver's safe injection sites; it is pointed out that controlled drinking-much of the research having been conducted at what is now the Centre for Addiction and Mental Health in Toronto-as a treatment choice is moderately accepted in Canada (more than in the United States and less than in the United Kingdom); and medical marijuana is discussed in the context of Health Canada's decision to allow its use under certain medical circumstances. I believe that students would also be interested to read the authors' opinions on substance-related disorders in people from First Nations; unfortunately, this topic is not given the reporting it deserves. Given that sleep difficulties plague so many in Western societies, it is surprising how inadequate the coverage of sleep disorders is in abnormal psychology textbooks-it is often completely lacking. Finally we have a textbook that gives sleep its due. In my work as a clinician, it seems as if a large proportion of clients who walk through the door have some sort of sleep complaint. …

Virtue ethics as an alternative to deontological and consequential reasoning in the harm reduction debate

Background There is strong evidence that harm reduction interventions such as Supervised Injection Sites and Needle Exchange Programs prevent many of the negative consequences of problematic substance use. Yet many governments, including the United States and Canada, still do not endorse these interventions, claiming that they do not get people off of drugs and send a mixed message. Methods This paper will analyze objections to harm reduction in light of the ethical theories of John Stuart Mill, Immanuel Kant and Aristotle. Results The most important ethical issue in the abstinence vs. harm reduction debate is whether harm reduction – because it does not require individuals to either reduce their consumption of illicit substances or to abstain from illicit substance use – can be ethically justified. Conclusion Harm reduction interventions are clearly justified on Utilitarian grounds because, based on the evidence, such policies would produce the greatest good for the greatest number. However, Kant would not think that the values guiding harm reduction are ethical because the justification of harm reduction interventions focuses exclusively on examining consequences. Virtue Ethics seeks to find the proper balance between harm reduction and abstinence. We claim that the virtue of compassion would provide a defense of harm reduction.

Harm Reduction and Interdisciplinary HealthCare: North Americas First Safe Injection Site

Harm Reduction and Interdisciplinary HealthCare: North Americas First Safe Injection Site

Clement seeks safe injection site study

In response to Federal Health Minister Tony Clement's demand for proof of the efficacy of safe injection sites, Health Canada has issued a call for research proposals to determine whether there is any validity to the proposition that such sites help to lower drug use and fight addiction. The

Injection site gets 16-month extension

As summer ran its course in Vancouver, a 3-year experiment to provide heroin addicts with a medically supervised injection site neared its scheduled Sept. 12 expiration. Canada's former Liberal government had granted the facility, InSite, a permit exempting it from federal drug laws. To remain open

Insite: Canada's landmark safe injecting program at risk

InSite is North Americas first supervised injection site and a landmark public heath initiative operating in Vancouver since 2003. The program is a vital component of that cities internationally recognized harm reduction approach to its serious problems with drugs, crime, homelessness and AIDS. InSite currently operates under a waiver of Federal rules that allow it to provide services as a research project. An extensive evaluation has produced very positive results for thousands of users. Normally such strong evidence documenting the successes of such a program, and the medical and public health significance of these positive outcomes, would be the basis for celebration and moves to expand the model and provide similar services elsewhere in Canada.Instead, there is a distinct possibility that InSite will be closed by the newly elected Canadian Prime Minister Paul Harper – a conservative who has traveled to the US to visit George WQ Bush and come back antagonistic to harm reduction in all its forms. Because InSites federal waiver is expiring and up for renewal in September, the fear is that Mr. Harpers will not renew the approval and that the program will be forced to close down. The risks associated with the potential closure of InSite need to be fully understood. This editorial lays out these public health risks and the associated economic impact if InSite were to be closed.In addition to preventable deaths and disease, InSites closure will cost Vancouver and British Columbia between $3.8 and $ 8.8 million in preventable health care expenses over the next two years.

A description of a peer-run supervised injection site for injection drug users.

Owing to the ongoing health crisis among injection drug users in Vancouver, Canada, there have been repeated calls for the establishment of supervised injection sites (SIS) since the early 1990s. In April 2003, a group of advocates and drug users opened an unsanctioned SIS in Vancouver's Downtown Eastside. The "327 SIS" operated for 184 days. During the operation of the SIS, volunteers supervised over 3,000 injections by a high-risk injection drug using population. The SIS provided a sterile environment for injection drug use without measured negative consequences and demonstrated the feasibility of a peer-driven low-threshold SIS.

The black market in prescription drugs

A black market is an illicit trading system that avoids government regulation. It operates outside the law and is driven by the opportunity for profit and the needs of consumers. It is subject to the economic rules of supply and demand and can be rapidly subverted by a change in the laws that make possible its existence. Because the legitimate business of selling prescription drugs is very profitable and highly regulated, opportunities for blackmarket entrepreneurship of these drugs exist in both developed and developing countries. Regulations that govern legitimate access to pharmaceuticals are set by state, national, and international bodies. India has circumvented international patent law by creating a national black market, thereby making it legal to copy a medicine that has been patented elsewhere as long as a different and unique manufacturing process is used. This has allowed the Indian people and other foreign buyers to access highquality medications at a fraction of the cost of the same medication in the USA or Europe, but the practice has understandably been criticised vigorously by multinational pharmaceutical firms and the World Trade Organization.

Drug use, risk and urban order: examining supervised injection sites (SISs) as ‘governmentality’

This paper problematises the emergence and functioning of the recent phenomenon of ‘supervised injection sites’ (SISs) as a case study of post-welfarist governmentality. We propose that SISs arose as an unprecedented intervention in the late 20th century to deal with the increasing challenge of ‘urban drug scenes’ towards public order interests ‘entrepreneurial city’. Under predominant discourses of ‘public health’ and ‘harm reduction’, SISs became possible within a wide variety of political interests as a technology for purifying public spaces of ‘disorderly’ drug users to present the ‘new city’ as an attractive consumption space. Thus, SISs can be meaningfully understood as one element of socio-spatial ‘exclusion’ of marginalised populations from urban cores to ghettoised, peripheral spaces, even as they more benignly seek to better meet the unique needs of drug user populations. Further, the inner workings of SISs illustrate these facilities as powerful surveillance and discipline sites, defining the drug user as an agent of omnipresent risk being responsibilized in the care of the self and body, but also multiple aspects of behaviour and lifestyle reaching beyond drug use; thus construing the drug user as a ‘normalised’ citizen/consumer. We suggest that pressures to answer to powerful interests promoting ‘order’ are concretised as practices of ‘risk management’ ‘on the shop floor’, raising serious questions about the extent to which the ability to meet user needs is compromised in the interest of social control, surveillance, ‘management’, ‘education’, and ‘rehabilitation’, particularly in the current socio-political context (characterised as it is by a persistence, and indeed concomitant hardening, of repressive measures ‘on the street’).

A comparison of the new Federal Guidelines regulating supervised injection site research in Canada and the Tri-Council Policy Statement on Ethical Conduct for Research Involving Human Subjects

The Federal Government of Canada has recently published guidelines for researchers interested in studying supervised injection sites (SIS) in Canada. These guidelines articulate the criteria that must be satisfied before the Minister of Health will authorise any such research. The purpose of this paper is to provide a critical analysis of the new Federal Guidelines and compare them to the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans (TCPS). The application of the TCPS ethical principles underscores the ethical probity of SIS research and demonstrates that SIS research qualifies as “minimal risk.” The new Federal Guidelines do not fully appreciate the innocuous nature of SIS research. The level of scrutiny associated with the new guidelines is disproportionate to the level of risk involved in SIS research and these expectations run the risk of limiting the amount of research that can occur. The uncritical acceptance of these guidelines could have the consequence of continuing to deny injection drug users (IDU) the benefits of this promising research on the grounds that there is an inadequate evidence base to establish SIS as the “standard of care.”