The case for a supervised drug consumption site trial in Victoria, British Columbia

The confluence of a number of factors makes the time right for a supervised drug consumption site in Victoria.

Supervised consumption sites (SCS)—now in existence in some 15 countries—have been one of the most controversial public health interventions targeting high-risk substance use (e.g., injection drug use) over the past 20 years.[1,2] SCS’s main aims are to reduce mortality and morbidity risks among high-risk drug users; to link clients with treatment, social, and health services; and to address public order problems by providing the target population with safe, clean, and designated spaces where pre-obtained street drugs can be consumed.[3,4] Ever since it opened its doors in 2003, the Vancouver SCS (called Insite) has been under intense and controversial scrutiny. A political decision regarding the facility’s continuation—and indirectly the initiation of other SCS programs in Canada—is expected to be made in 2008. In this commentary, we are advancing a strong plea and underlying rationale why an SCS program—in the form of a scientific trial—should be implemented in Victoria, Canada. Our argument is based on the following rationale:

Reducing risk and harm
The specific risk and harm characteristics of street drug use in Victoria would likely be reduced through an SCS intervention. Victoria is home to an estimated population of 1500 to 2000 injection drug users (IDUs).[5] This population is characterized by several key high-risk traits relevant for public health and public order. For example, the recent multisite and Health Canada-facilitated I-Track study documented an HIV prevalence rate of 15.4% and an HCV prevalence rate of 68.5% among Victoria IDUs—rates substantially higher than for most of the other study sites.[6]

Victoria IDUs also reported substantially higher rates of injecting drugs in public or other unsafe places, as well as higher rates of needle, syringe, and other equipment-sharing than IDUs elsewhere in I-Track. Furthermore, most Victoria IDUs reported cocaine, or opioid, and cocaine combinations as their injection drug of choice.[6] 

Taken together, the above behaviors are well documented to represent major risk factors for drug-related morbidity (e.g., infectious disease) as well as mortality (e.g., overdose), and extensive subsequent social cost burden.

Finally, there has been an increasing number of public and business complaints concerning the public order problems—public injecting, discarded needles, littering, loitering—associated with high-risk drug use in the downtown core.[7,8] These are exactly the problems that SCS are designed to address.

Evidence demonstrates beneficial effects
SCS programs in Europe, Australia, and Canada have demonstrated that SCS produce beneficial effects and contribute to a reduction of harms in high-risk drug-user populations. Several dozen SCS programs, including Insite in Vancouver, are now in operation—some of them having been so for two decades. 

These facilities and programs—although heterogeneous in design and practice—have demonstrated that SCS can produce beneficial effects, especially when they are part of a wider continuum of interventions (including other prevention and treatment services) aimed at high-risk drug users. 

Among other outcomes, SCS have been shown to attract especially high-risk and highly marginalized street drug users (often not reached by other mainstream services); to improve key risks relevant for morbidity and mortality (e.g., needle or equipment sharing, unsafe injection practices, and fatal overdose incidence); to increase uptake of detoxification and treatment (e.g., methadone treatment) services among the target population; and to contain public order problems associated with street drug use.[1,2,9,10] 

As such, SCS represent a valuable piece in the puzzle of necessary and effective interventions geared to reduce harms related to high-risk drug use. Their measurable successes, however, do not eliminate the need for additional complementary services such as adequate treatment, mental health services, and community policing. 

Supervised consumption sites cannot solve problems they are not designed to address—namely, curing users of addiction or eliminating drug dealing or drug-related crime.

Everyone’s interests served
It is in the explicit interest of politicians, lawmakers, and key stakeholders at all levels, as well as researchers, to see an SCS study implemented in Victoria. While presumably no friend of the concept of SCS, the current Conservative federal health minister Tony Clement has stated that there is a “need for more facts” in order to assess the value and benefits of SCS interventions before further Section 56 ex­emptions from the Controlled Drugs and Substances Act for the future operations of SCS in Canada can be issued.[11] 

An SCS study in Victoria would provide exactly such an opportunity and add meaningfully to the knowledge base; it would allow for the feasibility and outcomes of an SCS intervention to be assessed in a setting that is considerably different to the rather unique and extreme situation of street drug use in Vancouver’s Downtown Eastside. This would provide additional empirical evidence that would be relevant and generalizable to Canadian cities. 

A Victoria SCS study would allow the testing of different SCS program and delivery models than the Insite model in Vancouver. For example, Victoria might be better served by small, decentralized, multisite supervised consumption sites with a mobile component. In addition, an SCS in Victoria could also provide “safer use” interventions for the sizable population of non-injectors, as well as those IDUs who also smoke crack. 

Such an initiative could also put greater emphasis on key social services—such as shelter, food, and housing—and basic health services than currently featured by the Insite program.[12] The City of Victoria is in the unique situation of having its mayor, city council, chief of police, and the local health authority’s chief medical officer explicitly support a proposal for an SCS intervention. The BC government is supportive of the Vancouver Insite trial and would likely be supportive of conducting an additional study in Victoria.

In sum, a supervised consumption site pilot trial in Victoria offers little possible loss but a great deal of po­tential benefit towards reducing morbidity, mortality, and social costs, as well as key gains in knowledge. The long-term future of such an initiative should hinge on its ability to prove its value, but if it is not tried, its value cannot be assessed. The time has come for an SCS trial in Victoria.

References

1.  Hedrich, D. European report on drug consumption rooms. 2004. Lisbon, European Monitoring Centre on Drugs and Drug Addiction (EMCDDA). 
2.  Independent Working Group. The Report of the Independent Working Group on Drug Consumption Rooms. 2006. United Kingdom, Joseph Rowntree Foundation. 
3.  Fischer B, Rehm J, Kim G, Robins A. Safer injection facilities (SIFs) for injection drug users (IDUs) in Canada: A review and call for an evidence-focused pilot trial. Can J Public Health 2002;93:336-338.
4.  Kimber J, Dolan K, van Beek I, et al. Drug consumption facilities: An update since 2000. Drug Alcohol Rev 2003;22:227-233.
5.  Stajduhar K, Poffenroth L, Wong E. Missed opportunities: Putting a face on injection drug use and HIV/AIDS in the Capital Health Region. 2002. Vancouver: Centre for Health Evaluation & Outcome Sciences (CHEOS). Scientific Monograph 10. 
6.  Health Canada. I-Track: Enhanced surveillance of risk behaviours among in­jecting drug users in Canada—Phase I Report. 2006. Ottawa: Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention, Health Canada. 
7.  Heiman C. Quaint street, mean street. Victoria Times Colonist. 2007. 
8.  Winterhoff T. Drug problem needles North Park. Victoria News. 2007. 
9.  Wood E, Tyndall M, Montaner J, et al. Summary of findings from the evaluation of a pilot medically supervised safer injection facility. CMAJ 2006;175:1399-1404.
10.  Wood E, Tyndall M, Montaner J, et al. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction 2007;102:916-919.
11.  No new injection sites for addicts until questions answered says Minister Clement. 2006. Ottawa, Health Canada. 
12. Fischer B, Allard C. Feasibility study on ‘Supervised Drug Consumption’ options in the City of Victoria. 2007. Victoria: Centre for Addictions Research of BC.

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Dr Fischer is Professor and CIHR chair in Applied Public Health at the Centre for Addictions Research, University of Victoria, Victoria, BC. Dr Kendall is BC’s provincial health officer and a clinical professor in the Department of Health Care and Epidemiology, University of British Columbia. Ms Allard was a Research Assistant at the Centre for Addictions Research, University of Victoria, Victoria, BC.