Hundreds of doctors, politicians, researchers and frontline workers gathered with drug users and ex-users in Austin, Texas, last month to openly talk about drug use. But instead of reaffirming their commitment to the decades-long war on drugs, the eighth National Harm Reduction Conference featured discussions on opening needle exchanges, legalizing and regulating the drug trade, and overdose prevention methods.
"What we do in [the United States] is make drugs as unsafe as they possibly can be, and we do that through laws, which means that, if you get busted with drugs, you go to prison for a long time. And that's designed as a deterrent to make people stop using drugs, which obviously it isn't," said Allan Clear, executive director of the Harm Reduction Coalition, which runs the national conference.
"We do things like take syringes out of circulation, which has caused epidemics of hepatitis and HIV. So harm reduction is a way of trying to make drug use safer for people who use drugs, without demanding that they stop using drugs," Clear added.
Harm reduction can include a range of services from needle exchanges and condom distribution to safe consumption sites and access to addiction services such as methadone and buprenorphine treatments and detox facilities.
Supported by the United Nations and over 93 countries worldwide, harm reduction remains controversial. While over half of the 158 countries where drug use has been reported say they support harm reduction, only 82 countries have needle exchanges, just 73 provide opiate substitution therapies like methadone, and a measly eight countries have safe drug consumption facilities. There are only two safe consumption facilities in North America, both in Vancouver, British Columbia, Canada.
'Insite' into harm reduction
"We were coming to work and people were overdosing and people were dying, and at its height it seemed like it was happening every day, and it just seemed unnecessary. If people were dead, there was no chance of detoxing," said Mark Townsend, executive director of the Portland Hotel Society, which runs Insite, one of the two safe consumption sites in North America, open since 2003.
"[Insite opened] because lots of people worked hard to make it happen, including the mayor -- all the different mayors -- and [Premier] Gordon Campbell."
Insite is located in the city's Downtown Eastside, often referred to as Canada's Poorest Postal Code. Injection drug users in that area have a mortality rate 14 times higher than the rest of B.C., with an HIV rate of four in 10, and a hepatitis C rate of nine out of 10 users.
The facility consists of 12 safe-injection booths, monitored by nurses, where clients are provided with clean syringes, cookers, filters, water, and tourniquets, as well as education on safe injection practices that limit the spread of diseases like HIV and hepatitis C. Injection drug use is illegal in Canada, but Insite applied for and received an exemption from the federal government to run the site, though the current government is trying to shut the facility down.
There are approximately 12,000 registered clients at Insite, but in 2009 only 5,447 used the clinic, with an average 491 injections per day. That year 484 overdose interventions were performed, with no fatalities -- in fact, no one has died at Insite since it opened, but the long lines mean some people walk away without injecting.
Because the local health authority funds it, Insite acts as a gateway to other medical services, such as treating infections and diseases and referrals to mental health treatment. In its second year alone, Insite made 2,000 referrals to outside services, including 800 to addiction counseling. There is also a detox centre called Onsite located upstairs if people want to quit.
Vancouver's second safe injection site is less well known, likely because its clientele is limited to people living with HIV/AIDS. Located in the nursing clinic of the Dr. Peter Centre West End, safe injection is only one of the services offered, including access to medication, counseling and art and music therapy. Unlike Insite, the Dr. Peter Centre has not applied for a government exemption for its safe injection room.
"The College [of Registered Nurses of British Columbia] confirmed for us that it was within the scope of registered nursing practice to supervise injections for two purposes: for the purposes of promoting health and preventing illness. And they went on to say that this is particularly so with a high-risk population," said Maxine Davis, executive director of the Dr. Peter Centre.
Davis estimates there are 50 people out of the clinic's 325 registered patients who inject drugs at the centre. The clinic is only open from 9 a.m. to 3:30 p.m., however, so they also provide people with clean needles to take home, as well as providing a place to have their methadone delivered.
A different story on the Island
The Canadian federal government opposes safe injection on moral and ethical grounds, and this stance has prevented other Canadian cities from opening their own safe injection sites, including B.C.'s capital city Victoria. While drug users in Vancouver have access to needle exchanges all over the city, Victoria lost its only fixed-site needle exchange in 2008 after complaints about noise, crimes, garbage and human waste in the area.
The Vancouver Island Health Authority secured another location for the needle exchange in March 2008, but complaints from neighbours resulted in an indefinite hold on a fixed-site needle exchange. Volunteers drive mobile exchange vans in the city, but they have also been banned from that neighbourhood, commonly referred to as the "no-go zone."
A study released by the city's Centre for Addictions Research this year found that in 2009, 23 per cent of Victoria's drug users reported sharing needles, compared to eight per cent of Vancouver's; 89 per cent of Victoria's users injected daily, compared to 29 per cent of Vancouver's.
Despite the sharp reduction in services to Victoria's drug users, the City of Victoria adopted a harm-reduction policy framework in 2004 and is working on a harm-reduction strategy. The public at large also supports it, with 74 per cent of residents from Victoria and 12 surrounding communities agreeing with harm reduction in Victoria.
No needles in Nashville
Just last year in the United States a ban was lifted on federal funding for needle exchanges, introduced by former Republican senator Jesse Helms in 1989. The government has yet to provide any guidelines for funding the programs, however, and many states are unwilling to move forward without knowing if their programs will receive funding. In addition, needle exchanges are only legal in 36 states, leaving 14 states, such as Tennessee, without one.
Nashville, Tennessee's capital city, runs harm-reduction programs on both sides of the law. There was a tolerated needle-exchange program in 2001-2002, recognized by city hall as well as the local law enforcement, but the exchange died off, and now clean needle distribution has gone underground. Legal harm reduction comes in the form of mobile outreach vans run by groups such as Street Works, which offers free HIV testing, condoms and lubricant to drug users, sex workers and the homeless.
Leslie Davis, outreach team leader for Street Works, has been doing harm reduction work with the organization for 10 years. Davis says needle use is actually down in the city, likely because the grade of heroin has improved and can be snorted or smoked instead, which decreases the chance of contracting HIV/AIDS.
Davis wants more than clean supplies to pass out, though. He also wants to see drug use decriminalized and treatment focused on lifting users out of poverty, as well as counseling for the personal traumas that led them to drug use in the first place.
Like Tennessee, needle exchanges are illegal in Ohio unless they are sanctioned by a city's health commissioner under an emergency order. Such an order was issued in Cleveland, where a needle exchange has been operating since 1995. At that time, according to the Centers for Disease Control and Prevention, 17 per cent of the city's new HIV infections were among IV drug users. Today that number has dropped to 3.4 per cent.
Needle exchanges are legal in Chicago, Illinois, but since the federal ban has been repealed, Dan Biggs hasn't seen a flood of government money coming in. Instead, the Chicago Recovery Alliance (CRA), of which Biggs is founder and director, is funded by the Chicago Health Department and the Illinois Department of Health and has become one of the largest harm-reduction outreach programs in the country.
CRA provides the clean rigs and condoms common to harm reduction in other parts of the world, but also offers free vaccines for hepatitis A, B and C, as well as the flu and pneumococcal pneumonia, through their mobile van and their office. But thanks to federal law that limits distribution of opiate substitutes to specialized clinics, CRA can't provide methadone or buprienorphine to marginalized drug users.
"[Treatment is] not available to most people who want it. Right now I can't get you into methadone treatment unless you have good resources -- money. Most insurance don't pay for it. [It costs] $60 a week," Biggs said. "But I can get you a cell and court date for $50,000 a year. What kind of insanity is that?"
The Centers for Disease Control and Prevention estimates there are 60,000 to 90,000 injection drug users in Chicago, but only 7,000 to 8,000 use CRA's services per year. Biggs says some areas of the city see no service at all, particularly the southwest side, which has high rates of injection drug use.
Rocky Mountain high
Colorado became the 36th state to gain a legal syringe exchange program this year, but each county's public health board has to opt into the program, and only after that can a harm-reduction organization apply to become a needle exchange. Nor will users be fully exempted from state paraphernalia laws once the exchange opens -- volunteers will be exempted, but it's a class II misdemeanor for a user to be caught with a needle, dirty or clean.
Denver, Colo., has an illegal needle exchange program, however, that's been running since 2007, although previous exchanges operated in the late 1990s and in 2003-2004. Unlike some other illegal exchanges, the Underground Syringe Exchange of Denver actually has funding from the North American Syringe Exchange Network, the only group that will fund underground exchange programs.
"We average probably, on one day of exchanging, seeing 5-10 people and exchanging 200-800 syringes in a three-hour block," said Andrew, one of the founding members of the exchange, who requested his last name be withheld. Andrew assumes the large numbers of needles per user is people doing secondary exchanges, where they take dirty needles for friends and exchange them, giving their friends clean rigs in return.
Denver faces other challenges in getting a needle exchange, stemming from previous attempts to set up the service. A city ordinance on syringe exchanges was actually passed in the late 1990s, though no exchange was ever established. However the ordinance remains and restricts the number of needle exchanges to a maximum of three, they must be one-for-one exchanges, and they cannot be within 50 feet of a dwelling. With an estimated 10,000-15,000 IV drug users in the city, the ordinance needs to be changed in order for the program to be effective, said Andrew.
"The fact that there's still nothing happening is why we still have an underground syringe exchange. And it's going to continue until we have an effective exchange running in Denver," Andrew said.
Support for harm reduction
The fight for harm-reduction services, particularly needle exchanges and safe consumption sites, has gained ground in both Canada and the United States, but there are still hurdles to overcome.
Despite being the subject of 30 peer-reviewed studies by the BC Centre for Excellence in HIV/AIDS, which showed a significant reduction in public injections and in HIV and hepatitis C infections, as well as an increase in the number of users seeking treatment, Insite is in danger of being shut down by the Canadian federal government, which cites moral and ethical issues with safe injection. After two separate cases before the B.C. Supreme Court and Court of Appeal, which ruled in Insite's favour, the decision now lies with the Supreme Court of Canada.
"The Canadian Medical Association, normally a very conservative body, has stepped in twice to defend Insite, and they will be intervening in the Supreme Court to say, 'This is ridiculous. [Prime Minister] Stephen Harper needs to give his head a shake,'" Townshead said. "You can find an opinion from a fool, but ultimately the information is in and the evidence is utterly clear."
Allan Clear of the U.S. Harm Reduction Coalition believes it is the politicians, not the public, who are holding back harm reduction. Most opinion polls show more than half support syringe exchanges, he said, and with the retraction of funding bans on needle exchanges in the United States and the support of safe injection sites by the provincial courts of British Columbia, the future of harm reduction in North America is one of growth.
I'm a bit of a fangirl for harm reduction. Can we get a "harm reduction" tag?