Wednesday, December 12, 2007

As Bexar prepares to pilot needle exchange, Vancouver CA models the future of harm reduction

One of the more interesting presentations I saw last week in New Orleans at the Drug Policy Alliance conference centered on implementing ground-level harm reduction strategies, a topic that interests me especially as Bexar County prepares to launch Texas' first legal needle exchange operation in San Antonio. (Last I heard, Bexar officials hoped their county's needle exchange pilot program will begin early next year.)

Vancouver launched its needle exchange programs, said the city's Drug Policy Coordinator Donald MacPherson, because of a spike in overdose deaths in the late 1990s topping 200 per year at its height. Like similar programs elsewhere, Vancouver saw a decline in both overdoses and HIV transmissions among injection drug users after implementing needle exchange, and more addicts referred to treatment.

Observing these successes, MacPherson said, the city took the idea one step further, creating a "supervised injection site" where addicts can use illegal drugs in a clean environment under nurses' supervision. The facility teaches addicts how to protect themselves from disease transmission and encourages them to enter drug treatment. According to this brochure from the Vancouver program, called "insite," more than 7,000 people have used the facility to inject drugs since its inception.
people using insite are more likely to enter withdrawal management (detox) programs, and people using insite who also talk with addiction counselors are even more likely to enter detox. In fact, one in five regular visitors to insite began a detox program, showing that insite is a proven entry-point for the Downtown Eastside’s highest risk injection drug users. Detox programs are an important marker of addiction treatment system use, as most addiction treatment programs first require people to complete a detox program.
This notion may seem radical from where Texas sits now, but from all appearances the idea (which was imported from Switzerland) works surprisingly well at reducing both drug use and the harms associated with it. "It hasn’t been difficult to convince injection drug users that insite offers a safe, clean place to inject drugs," reports the insite brochure. Overall program results were analyzed in a study published in the Canadian Medical Association Journal, reported CBC News, finding that
the three-year-old Supervised Injection Site in the Downtown Eastside has been a great success.

The injection site, which drew about 5,000 users in its first year of operation, is a place where people can safely go to inject illegal drugs while being supervised by nurses.

"By all criteria, the Vancouver facility has both saved lives and contributed toward the decreased use of illicit drugs and the reduced spread of HIV infection and other blood-borne infections," Mark Wainberg, the director of the McGill University AIDS Centre in Montreal, wrote in a commentary published alongside the study.

The study — conducted by Dr. Evan Wood, a professor of epidemiology at the University of British Columbia, and his colleagues — found that drug users who visited the site at least once a week were more willing to enter detoxification programs.

These data make me optimistic about San Antonio's legislatively approved pilot program to exchange clean needles, which I see as an important first step toward implementing policies to reduce drug demand and the harms associated with addiction. Prison, by contrast, does neither of those things.

Vancouver's experience shows that not only do harm reduction principles work but they can be expanded beyond just needle swapping, and indeed may be the best available method for convincing serious addicts to seek treatment.

Vancouver's model demonstrates that its possible to scale up harm reduction strategies to demonstrably reduce deaths and addiction in a major city. Indeed, the idea of a safe injection site strikes me as the epitome of the harm reduction model - a much more civilized, humane, and rights respecting mentality than Texas' current "trail 'em, nail 'em, and jail 'em" approach. Every major Texas city has thousands of addicts who inject illegal drugs, and if all society offers them is prison, they're more likely to remain in the shadows.

In closing, I found these data interesting about the Vancouver supervised injection site, and was especially encouraged to see that 453 overdoses at the site occurred during a two year stretch with no fatalities. By contrast, that many overdoses out on the street or in some run-down shooting gallery would be much more likely to result in morbid outcomes. Here are some other statistics worthy of note for those interested the Vancouver supervised injection site:

Other research results show*:

  • 7,278 unique individuals registered at Insite
  • Women made up 26 per cent of clients
  • Aboriginal people made up 18 per cent of clients
  • Heroin was used in 41 per cent of injections
  • Cocaine was used in 27 per cent of injections
  • Morphine was used in 12 per cent of injections
  • 453 overdoses resulted in no fatalities
  • 4,084 referrals were made with 40 per cent of them made to addiction counselling
  • Referral to withdrawal management: 368
  • Referral to methadone maintenance: 2 per week
  • Daily average visits: 607
  • Average number of visits per month, per person: 11
  • Busiest day: May 25, 2005 (933 visits in 18 hours)
  • Number of nursing care interventions: 6,227
  • Number of nursing interventions for abscess care: 2,055

*All totals or averages are for the two-year period from April 1, 2004 to March 31, 2006.


Anonymous said...

I'm all for making pot legal, but think we should continue to take a harder stance on harder drugs. I'm all for an exchange program, but rooms with nurses seems over the top to me.

Add elements of treatment and therapy, and I could be swayed, however.

Gritsforbreakfast said...

I think the elements of treatment and therapy are the big selling point, rj, that and reduced deaths and HIV rates. IV drug users are a hard group to target bc they're diffused in the community and concealing their habit - this gives public health folks an access point where otherwise one simply doesn't exist.

Besides, these are junkies, not drug kingpins. Is prison a better option? best,

Anonymous said...

If it includes treatment and therapy, absolutely it's a good thing. But that's a bit like going to a Haunted House on Halloween, only to find out that it's the local Baptist church's Horror House, where they try to convert you and show you the evils of abortion, drug use, homosexuality, etc. I wonder how many will see it as a serious bait and switch.

I also wonder how it can be sold to the general public, because even I cringe at the thought of having a safe room, when I know the benefits of having one as an entry point.

However, on the harder drugs, while I understand the difference between users and dealers, they're pretty closely linked. Without the demand (yes, I know the overall goal is to reduce demand), there wouldn't be the dealers and the attendant violence and trafficking issues that are running rampant right now.

It's a tough subject. Until we get more data from Canadian cities, I bet we won't have many US cities try it. It's amazing that San Antonio is.

Is the DA still threatening to prosecute everyone involved?

Gritsforbreakfast said...

I don't think it's seen as a bait and switch, rj, b/c the treatment is optional, not mandatory. If the average person goes there 11 times per month, they develop relationships and when they're ready to quit they have access to help, is the way I think it works. Of course, if the treatment isn't mandatory that might mitigate your (and others) support, but it's the voluntary nature of the program that makes it function in a black market setting, and I think you're right to try to bait and switch them would largely defeat the purpose. best,

Gritsforbreakfast said...

Oh and Bexar is not doing a supervised injection site, just a garden variety needle exchange program which operate in many US cities. best,

Anonymous said...

Did the session provide any information on the site's impact on the neighborhood? I would think that convincing adjacent residents and businesses to accept such a facility would require good data showing no increase in nuisance complaints, criminal activity, etc.

Gritsforbreakfast said...

The presenter said two things related to neighborhood opposition, that I recall - first, that it was built in a downtown commercial section that was already notorious for drug abuse and informal, illegal shooting galleries, and the creation of this legal spot was combined with the crackdown on illegal spots and pitched as a way to increase public safety overall in an unsafe area. Apparently they can now document that that really turned out to be the case.

He also said there was major opposition before the site was approved, with big marches on both sides, and that its creation was extremely controversial, but now it's so popular in Vancouver he said it's almost a "third rail" because it's been effective at helping clean up the area for the reasons described above - funneling illegal activity into a single, safer, supervised spot.

OTOH, given that Travis County just turned its back on state money for drug treatment to respond to ignorant NIMBYism (an item I've been avoiding writing about yet bc it REALLY p&%ses me off), so you're right that may be the biggest obstacle, anywhere, to what otherwise sounds like a pretty good idea.

Anonymous said...

I heard another Federal Lawsuit was filed in Federal Court last month against director: Bill Fitzgerald of the Bexar County Community Supervision & Corrections Department. Can Gritsforbreakfast look into it?