19 Oct 2007 Safe Injection Sites: Are they the Answer?
By Jamie Hellewell (for the Surrey/Cloverdale ARPA Alert)
On September 15, Vancouver became the first city in North America to open a legal ‘safe injection site’ for heroine users. The site – called “Insite” – is a small clinic located in Vancouver’s Downtown Eastside district near the corner of Main and Hastings. Inside there are 12 private cubicles where needle drug users can inject between the hours of 10:00am-4:00am, seven days a week. The site provides a clean environment, spoons, water and sterile needles for users to prepare and inject heroine. There are also registered nurses on staff to supervise injections in case of an overdose or medical emergency. The site does not provide any drugs and prohibits certain types of injection behaviors: Sharing of drugs is not allowed, all users must self-inject, and there is a mandatory registration for anyone wanting to use the site.
This is not the first ‘safe injection site’ to operate in the Downtown Eastside (D.E.S.) – however, it is the first one to do so legally. That’s because Health Canada has given the Vancouver Health Authority a special exemption – one that authorizes them to operate ‘Insite’ as a sanctioned medical pilot project. So, while there has been no legal changes regarding the criminal status of heroine possession and trafficking, ‘Insite’ has legal legitimacy as a medical outreach. Whether Health Canada allows ‘Insite’ to operate indefinitely will depend on how successful it is. If it is deemed a success, it is very likely similar sites will open up in other Canadian cities – especially cities with large drug using populations, such as Toronto, Montreal, Hamilton and Winnipeg.
It is no surprise that health officials chose the neighbourhood they did for this pilot project. The D.E.S. – which is Canada’s poorest neighbourhood – has an enormous drug-using population, and a more-or-less open drug market on many of its sidewalks and parks. There are an estimated 4000 injection drug users living in the area. But as startling as that number is, it does not really indicate the true extent of the problem – injection drug users are not even in the majority! “Crack cocaine,” which is generally inhaled through a pipe, is easily the drug of choice in the neighbourhood, not to mention a range of “uppers” and “downers” available on the street that would put many pharmacies to shame.
In the 1990s, it had become clear that the D.E.S. was in a state of medical emergency. The widespread unsafe needle using practices (sharing needles, re-using non-sterilizing needles) had resulted in a rapid spread of HIV and other diseases. Today at least one-third of injection drug users have HIV or AIDS, and 90% have contracted Hepititus C. Moreover, because many drug users are also involved in prostitution, infection is not easily contained within the drug-using community or even within the neighbourhood (most “Johns” come from the suburbs). In addition, the high number of deaths due to overdose – 147 per year since 1993 – has proven impossible for medical community to respond to using traditional medical delivery models.
All this brings us back to the issue of safe injection sites. In the mid-1990’s, groups from within the D.E.S. community began calling for a variety of measures to cope with the effects of the widespread drug and alcohol problems. Many people also advocated the implementation of “harm reduction” practices. “Harm Reduction” is a term used to describe medical services intended to reduce negative consequences of drug use, rather than the drug use itself. It accepts as inevitable that drug use is a part of our world, and seeks to minimize its harmful effects rather then simply ignore or condemn it.
Some harm reduction practices have been in place in Vancouver for several years already. For example, there is a needle exchange program operating out of various permanent and mobile locations. At the needle exchange, users can bring in their used needles and get new ones at no charge. This aim of this project is to reduce the level of needle-sharing and re-using.
The most controversial of the harm reduction proposals has been the idea of a ‘safe injection site.’ In 2000, the idea got its first real push when then-Vancouver mayor Phillip Owen included the establishment of safe injection sites in his “Four-Pillar” plan to deal with the drug and alcohol problems of the D.E.S. The plan was modeled after similar strategies operating elsewhere in the world – including Germany, Australia, the Netherlands, and especially Switzerland. In Europe, there are currently 47 safe injection sites in operation, many have been doing so for over a decade. Vancouver’s new mayor Larry Campbell continued this support for the safe injection sites, and over the past year won the support of the federal Ministry of Health. This brings us to the present day and the establishment of the ‘Insite’ pilot project.
Proponents of the project hope that the site will improve the health of injection drug users in the community, reduce the number of overdose deaths, reduce the level of HIV and Hep C risk behaviors, reduce the improper disposal of needles, and reduce the level of public drug injection. This hope is based on the European experience, where cities with safe injection sites have recorded success in all of these categories. ‘Insite’ also offers access to detox programs, recovery programs and free onsite counseling. Again, this is modeled after the European experiments, which have recorded increases in referrals for detox and recovery programs among the site users.
There have been a number of objections to the establishment of safe injection sites here in Canada. Some focus on the practicality of the plan. For example, many people wonder if users will actually use the sites. The Canadian Medical Association Journal recently published a report that surveyed 458 D.E.S. needle drug users and asked them about their willingness to use the site. 92% indicated that they would use the site. However, when asked if they would still be willing to use the site if there were prohibitions on sharing drugs, on assisted injection, and a mandatory registration, only 31% said they would still be willing. Moreover, only 13% indicated that they would use the site if there was a police presence outside. This doesn’t sound promising for ‘Insite,’ since the above restrictions are in place; and so far the Vancouver Police Department has been keeping a regular presence outside the site. Other practical objections center on concerns about the site actually increasing the level of drug use or reducing the motivations to overcome addiction.
However, I think the place for Christians to begin is to consider the idea of safe injection sites at the level of principle. I have tried to describe the main perspectives operating in the debate at present in what follows; though I should note that most people involved in the issue do not fit neatly into a single category.
Libertarian perspective – The issue of safe injection sites is a question of individual freedom. Freedom is a matter of being able to live as you choose. We should not interfere with individuals who want to use drugs, nor should we prevent them from doing so in as safe and healthy a manner as they see fit. Our own moral convictions should not be imposed on others.
Medical perspective – The issue of safe injection sites is simply a medical issue. Drug addiction is a medical problem not a moral problem. Addicts are the victims of a sickness that is outside of their control, and should be treated as patients. Safe injection sites are just like other kinds of medical practices where we try to keep patients as healthy and comfortable as possible during the time of their sickness until they recover or pass away. Moreover, they are just like other kinds of medical practices in that they attempt to prevent spread of infection not only by developing cures but also by discouraging infection-risk behaviors. We should not allow moral convictions to stand in the way of maximizing public health.
Moralistic perspective – Drug use is immoral. No one is forced into a drug addiction; individuals choose to start using drugs and choose to continue to use drugs even after they become addicted. Thus, drug users are morally responsible for their behavior and must live with the consequences of their choices. Safe injection sites are a way of condoning immoral behavior; in fact, we are ourselves participating in sinful behavior by enabling it. We should not sacrifice moral rightness even for the sake of greater public health.
I don’t think any of these perspectives operates out of principles consistent with Christian faith. Against the libertarians, we hold that humans are not free to live however they choose. Instead we are responsible to the one who created us and are called to live lives of obedience to him. In this we find true freedom. It is particularly ironic to defend drug use on the grounds of freedom, when the reality of drug addiction is the opposite of freedom. My own experience living in the D.E.S. over the past two years seeing lives of friends and neighbours completely consumed by the demands of their addictions has brought this home. Freedom in the Christian sense is not about being able to choose to do whatever your desires urge, but in being liberating from the enslaving and life-destroying effects of sin and the desires of sinful nature. Against the medical perspective, we hold that humans are not mere victims but are responsible for their behavior to both God and their neighbours.
I believe the moralistic perspective is also inconsistent with Christianity, not so much in what it says but in what it doesn’t say. It is true that humans are responsible for their sinful behavior and habits, but this should not lead us to an uncaring condemnation of people addicted to drugs. If we simply condemn and wash our hands of the problem, we are actually disciples of the Pharisees, not of Jesus.
A Christian perspective must involve a combination of righteousness and compassion. We can not agree to condone or to cooperate with sinful ways of living. However, we must at the same time reach out in compassion and love to sinners, even as Christ reaches out to us. Having compassion involves recognizing the difficulty of overcoming sin. Most people involved in drug use in this neighbourhood have experienced a great deal of pain in their lives, and the little moments of pleasure they receive from being high are the closest thing they have encountered to real contentment. Many people have tried to quit numerous times, but on the other end of detox or recovery program there remains little to hold onto and for which to resist falling back into using.
Those in the D.E.S. come from a variety of backgrounds. Almost without exception, they have experienced abuse as children. Many of the women became involved in the prostitution-drug addiction cycle between the age of 12-15 already. There is also a very high number of users who have serious mental health problems like schizophrenia and who have been abandoned by their families.
Drug addiction in this neighbourhood is lonely, painful, chaotic, violent, and destroys both body and mind.
What does all this mean for the issue of safe injection sites? I believe we must oppose the plan, on grounds that it involves us in a social condoning and cooperation with sin – and with it self-destroying misery. However, I think we need to do this with integrity, and that means committing to reaching out in supporting and loving ways to those addicted to drugs. So I would recommend the following political actions for ARPA readers:
(1) Write to your local federal MP expressing your concerns about allowing the establishment of safe injection sites. You could also write directly to the Ministry of Health. If your local municipal government is considering the option, write them.
(2) There is a serious shortage of decent recovery programs in this province. Get involved in supporting efforts to establish the needed programs. If you do not think this should be done through government funding, then support efforts by privately-funded groups.
(3) We need to find ways to reach out to those on the social margins of our cities and welcome them into our church community. Ultimately it is this kind of communal support and love rooted in faith that is needed to overcome addiction. If we are content to be a church of stable middle-class families sealed off from the problems of the world, it should not be surprising if the world resorts to desperate measures like safe injection sites.
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