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Insite is the first legal supervised injection site in North America, located at 139 East Hastings Street, in the Downtown Eastside (DTES) neighbourhood of Vancouver, British Columbia. The DTES had 4700 chronic drug users in 2000 and has been considered to be the centre of an "injection drug epidemic". The site provides a safe and heath-focused location for injection drug use, primarily heroin, cocaine, and morphine. Medical staff are present to provide addiction treatment, mental health assistance, and first aid in the event of an overdose or wound. In 2009, the site recorded 276,178 visits (an average of 702 visits per day) by 5,447 unique users; 484 overdoses occurred with no fatalities, due to intervention by medical staff. Health Canada has provided $500,000 per year to operate the site, and the BC Ministry of Health contributed $1,200,000 to renovate the site and cover operating costs.

Operation

Insite is operated in tandem by Vancouver Coastal Health and the Portland Hotel Society. Between September 2003 and July 2008, the site operated under a special exemption of Section 56 of the Controlled Drugs and Substances Act, granted by the Liberal government via Health Canada. The site was slated to close on September 12, 2006, as the exemption was for a three year pilot project. The Conservative minority government granted a temporary extension, then added another six month extension that was to end in mid-2008. A constitutional challenge was heard by the Supreme Court of British Columbia to keep Insite open after Federal Health Minister Tony Clement refused to renew the exemption beyond July 2008. The court ruled that laws prohibiting possession and trafficking of drugs were unconstitutional because they denied drug users access to Insite's health services. Justice Ian Pitfield gave Ottawa until 30 June 2009 to amend the Controlled Drugs and Substances Act and bring it in line with the constitutional principle of fundamental justice (section seven of the Canadian Charter). The House of Commons did not amend the law meaning Insite currently operates under a constitutional exception to the Controlled Drugs and Substances Act.

Research

When founded, Insite acquired legal exemption under the condition that its impacts be thoroughly evaluated. Consequently, the site has been the focus of more than thirty studies, published in 15 peer-reviewed journals. The research indicates an array of benefits, including reductions in public injecting and syringe sharing and increases in the use of detoxification services and addiction treatment among patients. In addition, studies assessing the potential harms of the site have not observed any adverse effects. Preliminary observations published in 2004 in the journal Harm Reduction indicate that the site successfully attracted injecting drug users and thus decreased public drug use. However, the researchers cautioned that a full assessment of the site will take several years. Additionally, research in the Canadian Medical Association Journal suggests that the site has reduced public injections, neighbourhood litter, and needle sharing. A study in the journal Addiction indicates that patients at the site have increased their use of detoxification services and long-term addiction treatment. A study in the New England Journal of Medicine echoed this finding. Furthermore, research in The Lancet indicates that the site substantially reduces the sharing of syringes. A study in the journal Substance Abuse Treatment, Prevention, and Policy revealed that local police facilitate use of Insite, especially among high-risk users. The researchers concluded that the site "provides an opportunity to... resolve some of the existing tensions between public order and health initiatives." A 2008 cost-benefit analysis of the site in the Canadian Medical Association Journal observed net-savings of $18 million and an increase of 1175 life-years over ten years. Another cost-benefit analysis published in the International Journal of Drug Policy in 2010 determined that the site prevents 35 cases of HIV and about 3 deaths per year, indicating a yearly net-societal benefit of more than $6 million. A 2011 study in The Lancet found overdose deaths have dropped 35% in the Insite area since it opened, much more than 9% drop elsewhere in Vancouver. An editorial in the Canadian Medical Association Journal noted that after three years of research "a remarkable consensus that the facility reduces harm to users and the public developed among scientists, criminologists and even the Vancouver Police Department."

The most significant published criticism of this research has been an article by Colin Mangham, the director of research for the Drug Prevention Network of Canada, in the Journal of Global Drug Policy and Practice (JGDPP), which has incorrectly been described by the criticized researchers to be "posing as open-access, peer-reviewed scientific journal." In the article Mangham claims that “the published evaluations and especially reports in the popular media overstate findings, downplay or ignore negative findings, report meaningless findings and overall, give an impression the facility is successful, when in fact the research clearly shows a lack of program impact and success.” Based on this article, Tony Clement told an August 2007 meeting of the Canadian Medical Association his belief that Insite should close was reaffirmed. Clement stated that "there has been more research done, and some of it has been questioning of the research that has already taken place and questioning of the methodology of those associated with Insite." The JGDPP is run by the Drug Free America Foundation and received much of its initial funding from a $1.5 million grant from a U.S. Department of Justice agency.

Journal studies reporting that Insite did not cause increases in crime were shown by Colin Mangham to have made no mention of the fact that 4 police officers for 22 hours per day were assigned under an Insite-related agreement to patrol the block in which it was located, assisted by another 60 officers deployed across the surrounding 5 block area. Institute of Global Drug Policy interviews with Directors of five area treatment facilities all reported having neither any connection to INSITE nor any clients coming to them from INSITE.

In turn, the Journal of Global Drug Policy and Practice (JGDPP) article, which was commissioned and financed by the RCMP, drew criticism in the journal Open Medicine, where a commentary by researchers criticized by the journal described it as being "fraught with a host of outright factual inaccuracies and unsubstantiated claims." More than 130 scientists signed a petition endorsing the commentary, which also criticized the government's evaluation of Insite as distortive and politicized. Another commentary in the International Journal of Drug Policy characterized the government's evaluation as "what may be a serious breach of international scientific standards".

Government Expert Advisory Committee

In 2008 an Expert Advisory Committee (EAC) appointed by Health Canada produced an international review of injecting facilities, focusing on studies of Insite and a comparable facility in Sydney, Australia. With around 400 opiate injections daily mathematical models indicated it could statistically save one (1.08) life per year. Drug Free Australia has asserted that the estimate by the EAC, which did not record its method of calculation, accords well with the method used by the most comprehensive review of injecting facilities worldwide, that of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), to calculate numbers of lives saved in German consumption rooms.

The Expert Advisory Committee reported that over 8,000 people have visited INSITE to inject drugs. 18% percent, or 1506 of these 8,000 people, account for 80% of the overall visits to Insite. Less than 10% used Insite for all injections. The median number of visits is approximately eight. Drug Free Australia has calculated that by taking only the 1,506 injectors who most regularly use the centre, who would cumulatively inject somewhere between 6,000 and 9,000 times daily, the less than 500 injections in Insite daily represents at best one injection in every 12 by these clients inside the facility.

The Expert Advisory Committee reviewed various journal studies analyzing the impact of injection facilities on the transmission of HIV which had found positive outcomes, but they were not convinced that the assumptions made in the mathematical models were entirely valid. Regarding the financial benefit of Insite, as calculated in various journal studies, the EAC noted, "While some longitudinal studies have been conducted, the results have yet to be published and may never be published given the overlapping design of the cohorts. Until these studies have been undertaken it will not be possible to show with any certainty that INSITE is cost- effective or to show that the economic benefits exceed the costs."

Reception

Letters of support and surveys show that health professionals, local police, the local community and the general public have positive or neutral views of INSITE services and the majority wish to see the service continue.

— Final Report of the Expert Advisory Committee for Tony Clement

Insite enjoys strong local support. While Insite is well liked throughout British Columbia, its popularity is highest inside Vancouver, where some 76% of residents expressed support for the facility. Furthermore, according to a 2007 national survey by Mustel Group, some 63% of Canadians believe the federal government should renew the Insite's mandate while 27% oppose. Support is lowest among Conservatives, only half of whom believe the site should continue operating. Among clients, 95% or greater rated the facility's services as excellent or good, and its staff as reliable, respectful, and trustworthy.

Partners of Insite include the City of Vancouver, the Vancouver Police Department, and the PHS Community Services Society. The site has the support of Vancouver's mayor Gregor Robertson, former mayor Sam Sullivan, Premier of British Columbia Gordon Campbell, and former Vancouver mayors Larry Campbell, Mike Harcourt, and Philip Owen. The International AIDS Society, B.C. Centre for Excellence in HIV-AIDS, and the Canadian Union of Public Employees have also expressed support for Insite. Though initially opposed to the safe injection site, the Chinatown and Gastown merchants associations now support it. International supporters include the UK-based think tank Senlis Council, the Australian Parliamentary Group for Drug Law Reform, and the American Drug Policy Alliance.

The site drew criticism from the Bush administration; the director of the White House Office of National Drug Control Policy called Insite "state-sponsored suicide" on its opening. In 2006, the Canadian Police Association voted unanimously to encourage the federal government to stop funding Insite and instead invest in a national drug strategy. Moreover, Federal Health Minister Tony Clement branded Insite an "abomination," telling the Vancouver Sun that "allowing and/or encouraging people to inject heroin into their veins is not harm reduction... it is a form of harm addition."

The Royal Canadian Mounted Police (RCMP) has also criticized Insite. This is despite a report commissioned by the RCMP and conducted by two criminologists that concluded in favour of the injection site. The RCMP in British Columbia had agreed to announce their support for Insite in 2009 at a joint news conference with the BC Centre for Excellence in HIV/AIDS; they planned to note "an extensive body of Canadian and international peer-reviewed research reporting the benefits of supervised injection sites and no objective peer-reviewed studies demonstrating harms", and they were to admit that reports commissioned by the RCMP criticizing Insite "did not meet conventional academic standards." However, the RCMP in British Columbia were ordered by headquarters in Ottawa to cancel the news conference days before the event.

Gwendolyn Landolt, President for Drug Prevention Network of Canada, has criticized Insite's research, noting that "(Thomas Kerr) lobbied for the establishment of the drug injection site a decade ago, and he and his co-researchers have published over two dozen studies on the facility – all positive. It is no coincidence that all these studies have been peer reviewed only by those (as is Mr. Kerr) who support a harm reduction policy i.e. a policy that presupposes that the addict will continue to use drugs and the only solution is to reduce the “harm” to the drug addict." Landolt also states that there are other data, not produced by Thomas Kerr and his co-researchers, that show (with one exception) that the number of drug related deaths have increased each year in the site area.

Government and legal controversy

While the Liberal government allowed Insite to open, since 2006 its fate has been the responsibility of the Conservative government, which has not been as supportive of it. Conservative Prime Minister Stephen Harper has voiced opposition to the injection site in the past, saying that "We as a government will not use taxpayers' money to fund drug use." In mid-July 2006, Conservative Member of Parliament David Fletcher stated that the government would let Insite's special exemption lapse before deciding whether to continue the project. The following week a spokesman for Tony Clement, the Minister of Health, refuted that, saying that a decision had not been made yet. During the XVI International AIDS Conference, held in Toronto, two high-ranking Liberal MPs (Bill Graham and Keith Martin) put their support behind the centre, and criticized the Conservative government for delaying their decision. Insite supporters also demonstrated in Toronto during the conference, prompting the government to further delay any announcement, citing the week's "politicized" nature.

On September 1, 2006, Federal Health Minister Tony Clement deferred the decision of whether to extend the exemption for the site, citing a need for more research. However, on the same day the government cut all funding for future research, amounting to $1.5 million in lost research money. On August 13, 2007, the Portland Hotel Society and two drug addicts filed suit in the BC Supreme Court to keep the centre open, arguing that its closure would be a violation of the Charter right of Insite users to "security of the person." On October 4, 2007, during the announcement of its $64-million drug strategy, the Conservative government announced that Insite will be granted another six month extension, allowing it to operate until June 30, 2008. In 2008 Minister Clement explained his position during a House of Commons debate period:

" . . . (t)he expert advisory committee was very clear. It found that only 3% of those who attend Insite actually get referred to treatment and that only 10% of those who use Insite use it for all their injections. The expert advisory committee insisted that Insite only saved one life, and that life is important but I want to save more than one life. I want to save hundreds of lives around the downtown eastside, which is why we are focused on treatment and on professionals. Not one life should be lost."

In May 2008, the B.C. Supreme Court struck down sections of the Canadian Criminal Code prohibiting drug trafficking and possession, ruling that they contravened the Canadian Charter of Rights and Freedoms. While this ruling does not take effect until next year, Justice Ian Pitfield also granted Insite an immediate exemption to federal drug laws, giving it legal grounds to continue operating. Several days later the federal government announced plans to appeal the decision to the B.C. Court of Appeal. On 15 January 2010, the B.C. Court of Appeal dismissed the federal government's appeal in a 2-1 ruling. Three weeks later the federal government announced that it will appeal to the Supreme Court of Canada. On 10 February, some 150 people protested the federal government's decision to further appeal. The protesters barred Prime Minister Harper from attending a dress rehearsal for the Vancouver Chinatown Spring Festival Celebration. On February 12, The Canadian Union of Public Employees sent an open letter to Harper, urging him to accept the ruling of the lower courts and allow Insite to remain open.

The only one of nine interveners that will support the conservative government's case to close the injection is REAL Women of Canada, a social conservative organization The other eight, including the Canadian Medical Association will argue against the case for closure of the facility. The REAL Woman of Canada group argues that the site will discourage drug users from ceasing their habit, get "worse and worse until they die" while their families and communities are suffering.

Notes

Citations

1. Vancouver site report for the Canadian Community Epidemiology Network on Drug Use (CCENDU), 2005
2. Insite - Supervised injection site Official webpage
3. Staff Writer. "User Statistics." Vancouver Coastal Health: Insite. Retrieved May 5, 2010.
4. "Timeline: Insite". CBC.ca. Canadian Broadcasting Corporation. 2009-03-13. Retrieved 12 February 2010.
5. "Safe injection site will continue, with or without [[Ottawa]], supporters vow". CBC.ca. Canadian Broadcasting Corporation. August 11, 2006. Retrieved 12 February 2010. {{cite news}}: URL–wikilink conflict (help)
6. "B.C. injection site to continue operating, for now". CBC.ca. Canadian Broadcasting Corporation. 2006-09-01. Retrieved 12 February 2010.
7. "Safe-injection site mounts constitutional challenge". CBC.ca. Canadian Broadcasting Corporation. 2008-04-28. Retrieved 12 February 2010.
8. "Drug laws unconstitutional: B.C. Supreme Court". CBC.ca. Canadian Broadcasting Corporation. 2008-05-27. Retrieved 12 February 2010.
9. "Legal status". Insite. Vancouver Coastal Health. 2010-01-15. Retrieved 12 February 2010.
10. ^ Wood E, Kerr T, Lloyd-Smith E; et al. (2004). "Methodology for evaluating Insite: Canada's first medically supervised safer injection facility for injection drug users". Harm Reduction Journal. 1 (1): 9. doi:10.1186/1477-7517-1-9. PMC 535533. PMID 15535885. {{cite journal}}: Cite has empty unknown parameter: |month= (help); Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
11. Findings from the Evaluation of Vancouver’s Pilot Medically Supervised Safer Injection Facility – Insite, pg 5
12. ^ Deborah Jones (2006). "Injection site gets 16-month extension". CMAJ. 175 (8): 859. doi:10.1503/cmaj.061209. PMC 1586084. PMID 17030931. {{cite journal}}: Unknown parameter |month= ignored (help)
13. Findings from the Evaluation of Vancouver’s Pilot Medically Supervised Safer Injection Facility – Insite, pg 5
14. Wood E, Tyndall MW, Montaner JS, Kerr T (2006). "Summary of findings from the evaluation of a pilot medically supervised safer injecting facility". CMAJ. 175 (11): 1399–404. doi:10.1503/cmaj.060863. PMC 1635777. PMID 17116909. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
15. Wood E, Kerr T, Small W; et al. (2004). "Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users". CMAJ. 171 (7): 731–4. doi:10.1503/cmaj.1040774. PMC 517857. PMID 15451834. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
16. Wood E, Tyndall MW, Zhang R, Montaner JS, Kerr T (2007). "Rate of detoxification service use and its impact among a cohort of supervised injecting facility users". Addiction. 102 (6): 916–9. doi:10.1111/j.1360-0443.2007.01818.x. PMID 17523986. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
17. Findings from the Evaluation of Vancouver’s Pilot Medically Supervised Safer Injection Facility – Insite, pg 26
18. Findings from the Evaluation of Vancouver’s Pilot Medically Supervised Safer Injection Facility – Insite, pg 37
19. DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T (2008). "Police and public health partnerships: evidence from the evaluation of Vancouver's supervised injection facility". Substance Abuse Treatment, Prevention, and Policy. 3 (1): 11. doi:10.1186/1747-597X-3-11. PMC 2396609. PMID 18462491.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
20. Bayoumi AM, Zaric GS (2008). "The cost-effectiveness of Vancouver's supervised injection facility". CMAJ. 179 (11): 1143–51. doi:10.1503/cmaj.080808. PMC 2582765. PMID 19015565. {{cite journal}}: Unknown parameter |month= ignored (help)
21. Andresen MA, Boyd N (2010). "A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility". The International Journal on Drug Policy. 21 (1): 70–6. doi:10.1016/j.drugpo.2009.03.004. PMID 19423324. {{cite journal}}: Unknown parameter |month= ignored (help)
22. Marshall BDL, Milloy M-J, Wood E, Montaner JSG, Kerr T. "Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study". The Lancet. doi:10.1016/S0140-6736(10)62353-7.{{cite journal}}: CS1 maint: multiple names: authors list (link)
23. ^ Power, Matthew (2010-02-01). "The Vancouver Experiment". Slate. Retrieved 15 February 2010.
24. ^ Solomon, Sam (2007-09-15). "Doctors, get tough on drugs': Tony Clement : Minister's mind made up on safe injection site, warn experts". National Review of Medicine. Parkhurst Publishing Ltd. Retrieved 16 February 2010.
25. Kerr, Thomas; Wood, Evan (2008). "Misrepresentation of science undermines HIV prevention". Canadian Medical Association Journal. 178 (7). Canadian Medical Association: 964. doi:10.1503/cmaj.080257. PMC 2267848. PMID 18362390. Retrieved 2011-03-11.
26. Mangham, Colin (2007-01-17). "A Critique of Canada's INSITE Injection Site and its Parent Philosophy: Implications and Recommendations for Policy Planning". The Journal of Global Drug Policy And Practice. Retrieved 2011-02-09.
27. ^ Mangham C. "A Critique of Canada's INSITE Injection Site and its Parent Philosophy: Implications and Recommendations for Policy Planning". Retrieved 2010-01-09.
28. Woods, Evan "Readers Comments : Time for Reasoned Academic Debate on Safer Injection Facilities" Open Medicine September 7, 2007
29. Wood E, Kerr T, Tyndall MW, Montaner JS (2008). "The Canadian government's treatment of scientific process and evidence: inside the evaluation of North America's first supervised injecting facility". The International Journal on Drug Policy. 19 (3): 220–5. doi:10.1016/j.drugpo.2007.11.001. PMID 18551754. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
30. ^ see the Executive Summary "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008 Cite error: The named reference "hc-sc.gc.ca" was defined multiple times with different content (see the help page).
31. see Executive Summary – Cost Benefit/Effectiveness section "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
32. "Drug Free Australia Analysis of the KPMG Injecting Room Evaluation" (PDF). Drug Free Australia. 2010. Retrieved 2010-10-23.p 8
33. Drug Free Australia "The Case For Closure – 2010 Update" (PDF). Drug Free Australia. 2010. Retrieved 2010-10-23.p 2
34. ^ Ogborne, Alan (2008-03-31). "Final report of the Expert Advisory Committee". Health Canada. Retrieved 15 February 2010. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
35. Staff Writer. "About Insite." Vancouver Coastal Health: Insite. Retrieved August 1, 2006.
36. Mike Howel Canada.com Gregor Robertson and Peter Ladner square off in first public debate
37. ^ Staff Writer. "Support grows for Vancouver's safe-injection site." CTV/Canadian Press. July 18, 2006.
38. ^ Bailey, Ian. "Fate of safe-injection site remains up in the air." The Globe and Mail. October 3, 2007.
39. ^ Mickleburgh, Mike. "Vancouver ex-mayors speak up for injection site." The Globe and Mail. August 22, 2006.
40. Branswell, Helen. "Supporters of Vancouver's safe injection site turn up the heat on Ottawa." CBC/Canadian Press. August 15, 2006.
41. Staff Writer. "Tories asked to keep Vancouver's safe injection site open." NUPGE.ca. Retrieved August 1, 2006.
42. Hainsworth, Jeremy. "U.K. think-tank supports continuing B.C. safe-injection site for heroin users." CBC. July 28, 2006.
43. Howell, Mike (2010-02-24). "U.S. advocate lauds supervised injection site". Vancouver Courier. Canada.com. Retrieved 9 March 2010.
44. ^ Staff Writer. "B.C. injection site to continue operating, for now." CBC. September 1, 2006.
45. Geddes, John (2010-08-20). "RCMP and the truth about safe injection sites". Maclean's Magazine. Retrieved 2011-02-09.
46. DPNC PRESIDENT’S LETTER TO THE NATIONAL POST, May 30, 2011
47. ^ Staff Writer. "No AIDS announcement during 'politicized' week: Ottawa." CBC. August 17, 2006.
48. Salinas, Eva. "Safe injection site's fate debated anew." The Globe and Mail. July 26, 2006.
49. Gohier, Philippe. "Unwelcome Insite." Macleans.ca. December 11, 2006.
50. Staff Writer. "Advocates of B.C. safe-injection site go to court to keep it open." CBC. August 17, 2007.
51. "Canadian Parliament Hansard". 2008. Retrieved 2010-10-23.
52. Staff Writer. Drug laws unconstitutional: B.C. Supreme Court. CBC News (The Canadian Press), 27 May 2008.
53. Staff Writer. Federal government to appeal B.C. court ruling on supervised injection sites. CBC News (The Canadian Press), 29 May 2008.
54. Staff Writer.B.C. court affirms injection site's right to exist. CBC News (The Canadian Press), 15 January 2010.
55. Staff Writer. Ottawa to appeal injection site ruling. CBC News (The Canadian Press), 9 February 2010.
56. Canadian Union of Public Employees (2010-02-12). "Supporters rally to defend Insite from Feds". Canadaviews.ca. Retrieved 13 February 2010.
57. "Harper protesters bar doors at Chinese cultural centre". Vancouver Sun. The Victoria Times Colonist. 2010-02-11. Retrieved 13 February 2010.
58. "Federal government's Supreme Court Appeal to close Insite, Vancouver's supervised injection site" (PDF). Canadian Union of Public Employees. 2010-02-12. Retrieved 13 February 2010.
59. ^ Gyapong, Deborah (2011-03-22). "REAL Women to intervene in Vancouver drug injection site case". The B.C. Catholic Paper. Retrieved 2011-03-22.

References

• "Findings from the Evaluation of Vancouver's Pilot Medically Supervised Safer Injection Facility – Insite". Urban Health Research Initiative. British Columbia Centre for Excellence in HIV/AIDS. June 2009. p. 54. Retrieved 14 February 2010.

External links

• Insite website
• Vancouver Coastal Health website

49°16′52″N 123°06′04″W / 49.28111°N 123.10111°W / 49.28111; -123.10111

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