By M.J. Milloy and Evan Wood
In the wake of the release of a scathing report from international experts declaring their efforts to create a “drug free world” a failure, diplomats from 53 countries including Canada gathered in Vienna, Austria last weekend to plan the next campaign in the so-called war on drugs.
Officially assembled to review the United Nation’s progress towards its 1998 goal of a drug-free world within a decade, the envoys to the Commission on Narcotic Drugs were faced with inconvenient truths in the form of expert data showing that illicit drugs—including cocaine, heroin, and cannabis—are now cheaper and no harder to get despite the untold trillions of dollars spent on drug prohibition and demand reduction.
Spurred by increasing calls from AIDS and human rights groups and public health professionals, a group of 26 countries at the Vienna meeting split with official doctrine and demanded prohibitionist policies be bolstered by harm reduction, a public-health approach that prioritizes pragmatic interventions to reduce the likelihood of drug-related harms such as overdose or infection with HIV.
The efforts of the 26 countries—mostly from Europe and Latin America—to include explicit support for harm reduction in the final declaration were defeated by a group led by the United States, Russia, and Cuba. (Canada’s statement to the Vienna assembly called for, among other things, more drug treatment for young offenders and school-based programs to reduce drug consumption.)
The position of Canada’s diplomats is another result of Prime Minister Stephen Harper’s new anti-drugs policy, which is stripped of all mention of harm reduction, including needle exchange programs and medically-supervised injection facilities (SIFs), such as Vancouver’s Insite. Unfortunately, this stance is not only increasingly out of step with world opinion but, most importantly, inconsistent with the best available medical evidence on the interventions needed to address the global HIV/AIDS pandemic.
Once driven primarily by new cases resulting from sexual contact, the continued growth of the pandemic is now increasingly caused by the sharing of HIV-contaminated needles by individuals who use injection drugs. According to the United Nations Joint Programme on HIV/AIDS, one out of every three new cases outside of sub-Saharan Africa is the result of the use of HIV-contaminated needles. In some of the world’s fastest-spreading and least-controlled outbreaks, such as Eastern Europe and Russia, more than 80 percent of new HIV cases are among injection drug users.
Few places reflect this new reality more clearly than Vancouver’s Downtown Eastside. Starting in the mid-”˜90s, the combination of increased use of cocaine by injection, the deinstitutionalization of psychiatric patients, and sharp cuts to social spending by the federal and provincial governments was fuel for an explosive outbreak of HIV among injection drug users and their sexual partners.
Within months, the rate of new infections topped 15 percent per year, the fastest spread ever observed in a first-world setting; at highest risk were individuals who injected cocaine, were poorly housed, had ever been incarcerated, or were Aboriginal. In addition, the outbreak was accompanied by unprecedented levels of fatal overdose and other forms of drug-related harm, such as hepatitis C and skin infections.
In response, a diverse coalition—including representatives from health bodies, drug users, other Eastside groups, and government and political leaders—responded to the outbreak by establishing Insite, a pilot SIF, in 2003. Despite the wide range of health and social benefits identified during the facility’s evaluation conducted by scientists from the B.C. Centre for Excellence in HIV/AIDS, the continued operation of Insite is strongly opposed by some, including the Canadian Association of Police and the Harper government. Readers of the Georgia Straight know that the federal government has tried a variety of tactics to shut the site in the face of widespread popular and political support.
Just as Mr. Harper’s government has fought Insite at home, Canadian diplomats have opposed international efforts to promote harm reduction. Their actions in Vienna are only the most recent example of the Harper government’s efforts to deny the medical evidence finding that harm reduction is a safe, effective, and scientifically supported strategy to reduce drug-related harm.
At the XVII International AIDS Conference in Mexico City in August 2008, the World Health Organization released a report on evidence-based HIV prevention measures that unequivocally endorsed supervised injection facilities as a “priority intervention” to stem the spread of the virus.
The report noted that SIFs “enable known, WHO-recommended harm reduction interventions to be delivered and used in a safe environment with the aim of reaching the most marginalized and vulnerable” of drug users.
Publicly denounced by then–Conservative Minister of Health Tony Clement, the report was changed to read there “was not enough evidence” regarding the role of supervised injection sites in HIV prevention.
Thus, supporters of Insite and harm reduction should be grateful to read a recently released report from a group of Spanish scientists further supporting these facilities as an effective intervention to reduce syringe sharing. Published in Addiction, a prestigious peer-reviewed medical journal, the study surveyed 249 community-based injection drug users in Spain.
Using standard scientific methods, the team led by Dr. Marí¬a Bravo found that individuals who reported using one of the five SIFs in Barcelona or Madrid were less likely to report borrowing used syringes. This finding persisted when the scientists adjusted their analyses to account for the influence of age, gender, measures of social vulnerability, and other factors.
The conclusion by Dr. Bravo and colleagues that attendance at a supervised injection site has a positive impact on syringe use habits is consistent with preliminary evaluations from other European facilities. Those findings also echo results from two studies conducted in Vancouver.
In a 2005 study, a group led by Dr. Thomas Kerr at the University of British Columbia found that among people participating in the Vancouver Injection Drug User Study, regular Insite users had lower levels of syringe sharing. Notably, the study’s duration spanned the opening of Insite and showed that reductions in syringe sharing coincided with the opening of the facility.
Later, using a group of randomly selected Insite clientele, it was similarly found that HIV-negative injection drug users were less likely to borrow syringes if they were regular users of the facility. These studies suggest an emerging pattern in the medical evidence showing that these harm reduction facilities have a role to play in preventing new infections among drug users. This is bolstered by recent findings from Insite showing that regular users are more likely to use condoms compared to injection drug users who use the facility less often.
Once controversial, needle exchange programs have since been endorsed by virtually all international medical and public health organizations, including the WHO. Opposition to needle exchanges, like opposition to the reality of climate change, is now reserved to individuals who reject the weight of scientific evidence.
The replication of the Insite findings in the Spanish evaluation further reveals how the position of Canada’s federal government against harm reduction is not based on sound medical opinion. Ongoing evaluation of Insite and the experiences of its clientele will hopefully inform public health practice in order to reduce the terrible burden of death and disease borne by individuals who use injection drugs, both in Vancouver and around the world.
M.J. Milloy is a research coordinator for the Urban Health Research Initiative at the British Columbia Centre for Excellence in HIV/AIDS and a doctoral student in the School of Population and Public Health at the University of British Columbia.
Evan Wood is an epidemiologist at the British Columbia Centre for Excellence in HIV/AIDS.