VANDU started its unsanctioned, unfunded, peer-run supervised injection service out of a repurposed office room in their Hastings Street storefront “at least four years”, says its president Hugh Lampkin. Unlike the other safe injection sites in the city, Insite and the Dr. Peter Centre, no nurses were present.
VANDU—a grassroots organization of current and former injection drug users—began operating the site as a “humanitarian response to an unmet need,” according to Lampkin, specifically the needs of the approximately 40 per cent of IV drug users who sometimes require assistance injecting, a service that Insite and other supervised injection services cannot legally provide.
For four years VANDU quietly offered a safe space, clean supplies, and the watchful eye and occasional assistance of a trained peer support worker (current and former drug users) for an estimated 50 to 100 injections a day.
In an interview with Megaphone, VCH Chief Medical Health Officer Dr. Patricia Daly explained that, as VANDU’s funder, “VCH could not support an operation that was not run according to VCH best practices and that might put clients at some risk.” She did not expand on how long VCH had known about the peer-run injection service, or why the health authority ordered it to close when it did. "We found out about it—we were advised about it by City of Vancouver staff," she says.
Daly added that VANDU’s supervised injection site could “jeopardize [VCH’s] application with Insite [Vancouver’s supervised injection facility in the Downtown Eastside] and the Dr. Peter Centre [a residential care and treatment facility for people with HIV/AIDS in the West End],” referring to ongoing efforts to obtain legal recognition from the federal government for existing supervised injection services.
VCH’s decision to close VANDU’s unsanctioned supervised injection site is the latest chapter in long-running tensions between controversial, but research-tested, peer-run models and more professionally driven approaches to harm reduction. A peer-run site improves outreach, but increases other risks. However, unlike past episodes of this ongoing debate, VCH is in uncertain and politically fraught negotiations with the federal government to protect the legal standing of existing harm reduction infrastructure in the city, which puts the future of any such a program in prolonged purgatory.
To maximize reach, peer-run approaches work
According to Lampkin, VANDU’s safe-injection site emerged out of a project called the Injection Support Team, a Canadian Institute of Health Research funded project to train peer support workers to find and support injection drug users in the community, many of whom required assistance injecting. When funding for the program ended, many of the injection support team’s regular clients began showing up at VANDU’s headquarters. Rather than turn them away, VANDU’s staff tried to support them. A new, unsanctioned, supervised injection site was born.
“Peer-run, low-regulatory kinds of approaches are the best way to maximize reach, so you can increase the availability of services rather rapidly in that kind of way,” says Dan Reist, the Assistant Director of the Centre for Addictions Research of BC. “But the trade-off is there is often less control over quality assurance issues, and therefore a higher risk of problems emerging. Now the debate is always about where on that spectrum from quality control to reach do you want to be?”
For four years, the Vancouver Area Network of Drug Users (VANDU) offered a safe space, clean supplies, and the watchful eye and occasional assistance of a trained peer support worker for an estimated 50 to 100 injections a day. The assisted injections offered at VANDU are not offered at Vancouver’s official supervised injection facility, Insite, pictured here. Photo: Jay Black
Vancouver Coastal Health is acutely aware of the need for expanded supervised injection services as well as the barriers faced by injection drug users who require assistance injecting. According to Daly, VCH is interested in “having a conversation about [assisted injecting] and finding a way to cover this in the existing law.”
But for VCH, the immediate concern is obtaining legal standing for Vancouver’s existing harm reduction infrastructure, an effort that an unsanctioned injection site operated outside of the medical establishment is thought to endanger.
Peer-run models are seen as being unable to make it through the increasingly harsh exemption process, so local health authorities are forced to quash innovative, research-tested services in an environment of considerable unmet need.
The Downtown Eastside has lost a safe-injection facility with the closure of VANDU’s peer-run safe-injection room, leaving Insite, pictured here, as the only supervised injection facility in the neighbourhood. Photo: Jay Black
VCH plans on eventually expanding safe-injection sites in a “distributed way” by making injection services “just one of the nursing services that is offered on site” at community clinics that support injection drug users, wherever they may be. But in the meantime, drug user run sites, which can build on the success of harm reduction programs, will have to wait.
Nearly half of IV drug users sometimes require assistance injecting
Research in the prestigious Lancet journal of medicine showed that the opening of Insite lead to a 35 per cent decrease in overdose deaths within 500 metres of the facility compared to a 9.3 per cent decrease in the rest of the city, suggesting that the benefits of safe-injection sites are significant, but localized.
In addition to a need for more basic supervised injection services, advocates have also argued that existing regulations around safe-injection sites do not meet the needs of many IV drug users.
In particular, public health research estimates that some 40 per cent of injection drug users in the Downtown Eastside sometimes require assistance injecting. Epidemiological data suggests this group of injection drug users are twice as likely to acquire HIV when compared to those able to self-inject and are at significantly elevated risks for infection, violence, and overdose. A recent study has also shown that requiring assistance injecting is the strongest predictor of syringe sharing, a key factor in the spread of HIV/AIDS among people who use illicit drugs.
In addition, studies show that women are more then twice as likely as men to require assistance injecting and twice as likely to report not knowing how to inject as the reason for requiring assistance. Illicit drug users who require assistance injecting often rely on partners or so called ‘street doctors’ to help them use.
The unequal power dynamics of these relationships mean they are often exploitative, serving to perpetuate the everyday violence many injection drug users experience.
For some, the difficulty of injecting stems from a lack of knowledge, while for others physical disabilities and trouble finding a vein can contribute. However, assisted injection is strictly prohibited by the operating regulations for supervised injection services at Insite and at the Dr. Peter Centre, and may incur liability under civil and criminal law for those who assist.
VANDU’s efforts to create a space where drug users could provide assistance to other drug users who need help injecting is simply the latest chapter in a long history of peer run organizations identifying and responding to emergent health care needs of IV drug users.
The harm reduction two-step
Since the beginning of the harm reduction movement, drug user groups have led local politicians and health authorities in an uncertain dance: peer groups have historically led the way, raising the alarms of a health crisis among injection drug users and responding to it directly, while politicians and health authorities have been slower to respond as they navigated a complex and shifting legal and political landscape.
While this arrangement has been acrimonious at times, in two decades it has radically transformed health care planning in Vancouver and throughout Canada.
As Lampkin recounts, VANDU has been creating and operating unsanctioned injection sites since as far back as 1993, when an early incarnation of the group opened an injection room in a rented storefront on the corner of First and Dunlevy.
These early efforts often placed VANDU, as well as other groups like the Portland Hotel Society, at odds with police and local politicians. But by 2003 it contributed to the first major success of Vancouver’s harm reduction movement: the creation of Insite, North America’s first supervised injection site.
According to Dr. Thomas Kerr, co-director of the BC Centre for Excellence in HIV/AIDS, “VANDU is often at the cutting edge. They often are one step ahead of the bureaucracy, they know what is going on with drug users, they start to respond, and eventually they set the path for public health; public health learns from VANDU either by example or by their advocacy efforts.”
The creation of Insite in 2003, and the 2002 opening of a safe-injection site at the Dr. Peter Centre, placed Vancouver on the map as a leader in harm reduction in North America.
It was also the beginning of a legal battle that, in some ways, has still not run its course 10 years later.
Amidst significant progress, lasting unmet need
On September 30, 2011, Vancouver Coastal Health confirmed that it will continue to operate Insiite following a unanimous Supreme Court of Canada ruling that the court supporting the ongoing operation of North America’s only safe-injection facility. Pictured here at a news conference dissecting the results of the hearing are (from left to right): Liz Evans of the Portland Hotel Society; Dr. Patricia Daly, Chief Medical Health Officer of Vancouver Coastal Health; Dr. Julio Monanter, director of the BC Centre for Excellence in HIV/AIDS; and Dr. Thomas Kerr of the BC Centre for Excellence in HIV/Aids. Photo: Vancouver Coastal Health
In a landmark 2011 ruling, the Supreme Court of Canada prevented efforts by the Conservative federal government to close Insite and required the government to create an exemption process to enable supervised injection services to operate legally.
In response to the Supreme Court ruling, the Conservative federal government introduced Bill C-65 (now Bill C-2) entitled “the Respect for Communities Act” which sets forth some 26 criteria for health authorities seeking to create new supervised injection services.
Organizations like the Canadian Nurses Association have decried the law, arguing that the criteria emphasizes perceptions of public safety over public health and do not give evidence the leading role it should have in public health provision.
While the law has not yet come into effect, VCH’s Daly says she is “concerned about the [proposed] changes” as it is “already quite difficult to get an exemption”.
While the case for supervised injection was taken to the courts and became the subject of intense political wrangling, the ongoing healthcare needs of injection drug users and concerns around public drug use and disorder that motivated the creation of Insite continued to be a pressing issue.
Since Insite was founded in 2003, a voluminous body of peer-reviewed research has shown that supervised injection services save lives and reduce the suffering associated with injection drug use. A 2010 peer-reviewed cost-benefit analysis in the International Journal of Drug Policy found that Insite prevents approximately 35 cases of HIV and three deaths per year, leading to a yearly net-societal benefit of more than $6 million.
According to Kerr, “there has been really amazing progress that has been made in terms of a massive reduction in fatal overdoses and an even more impressive decline in HIV infection in terms of new infections. However, there is still a huge amount of unmet need.”
Great expectations for an integrated future
A strong example of the kind of distributed care model that VCH intends to expand upon is at the Dr. Peter Centre, an internationally renowned health care facility located in the West End. The centre specializes in providing care for people living with HIV who also face poverty, homelessness and mental health and addiction issues.
The Dr. Peter Centre is currently applying for an exemption from Health Canada to continue offering safe-injection services as part of its AIDS care program.
According to Maxine Davis, executive director of the Dr. Peter’s AIDS Foundation, supervised injection services are simply one small part of the nursing care services that the centre provides.
“Individuals who need supervised injection service need far more health care than supervised injection service,” Davis says. Supervised injection, she adds, “is well within the scope of registered nursing practice for purposes of preventing illness and promoting health.”
The alternative, forcing drug users to use in back alleys or public restrooms, is irresponsible, according to Davis—especially when the clientele are HIV positive.
In the Dr. Peter Centre model, supervised injection services are woven into “an environment of counselling, art therapy, nutritious meals, the other nursing care,” Davis says. “Our data shows that the individuals who use safe-injection services, about 63 per cent, have received addiction counselling and about one-third have also gone on to withdrawal management services and rehab services.”
The safe-injection site at the Dr. Peter Centre improves the quality of AIDs care the centre provides, Davis says. It creates more therapeutic points of contact to help people work through their addictions and lead a more full life.
Davis shares Daly’s vision for the future of supervised injection services. They will, as Davis says, be integrated into “services that already exist, where relationships with injection drug users already exist.”
The future: integrated healthcare alongside community-led supports
While supportive of plans to integrate supervised injection services into the broader healthcare framework, Donald MacPherson is critical of VCH’s decision to close VANDU’s safer injection room. To him, peer-run models like VANDU’s “make so much sense.” The veteran harm reduction advocate, drug policy expert, and architect of Vancouver’s four pillars drug strategy recognizes the need for a wide range in the kinds of safe injection services offered to user populations. “Where these sites have been so successful is places like Frankfurt, Zurich and Amsterdam where there is a diversity of them run by different outfits,” he says.
“Baggage from prohibition and criminalization,” MacPherson says, plays a role in framing the peer-administration of safe-injection services as untrustworthy and incompetent. “They’re not allowed, they’re not full citizens, they’re not allowed to have that level of responsibility,” MacPherson says, “even though they may know way more than some nurse who comes to the Downtown Eastside with very little training.”
For Reist, the question is “how do we help create a community in which the benefits of medical knowledge and nursing knowledge can be brought to bear, social knowledge can be brought to bear, and the experience of peers can be brought to bear to support individuals to take control of their own life?”
Acknowledging the complex experiences and histories of drug using communities, Reist is not looking for easy answers. “Nothing is the magic bullet,” he acknowledges. “But if we build towards community, community can heal itself, and help heal the individuals within it.”