Supervised Injection Sites and Needle Exchanges: Why harm reduction matters for public health

By Julia Burpee

“Addiction is a really lonely thing. You think you’re basically the only person on the planet … that’s the way I felt,” says Sean LeBlanc, 37, explaining that five years ago he was homeless and injecting heroin every day.

Harm reduction services helped him recover from his addiction, he says. Safe needle exchanges operated out of community health centres and mobile vans, referrals to addictions treatment, community outreach workers and peer support groups are part of the harm reduction public health model.

Needle exchanges are the traditional approach to harm reduction in Canada, but a supervised injection site, where medical staff supervise injection drug use, is the country’s newest tack to reducing the harm of drug addiction.

These harm reduction services “first and foremost allow people to know that they’re not alone, [giving] a sense of familiarity and family,” LeBlanc says. He would go into Ottawa needle exchanges regularly, receiving love and support from staff, without judgment.

But harm reduction approaches are still questioned, despite the recent Supreme Court of Canada decision blessing Insite, Vancouver’s controversial supervised injection site.

In the face of continuing criticism, one could ask: does harm reduction have a legitimate role in public health for tackling drug addiction in Canada?

Supporters of harm reduction, from Insite‘s management and researchers to registered nurses and outreach workers, argue the public health model saves lives. It reduces the spread of infectious diseases, like HIV and Hepatitis C, and enables medical staff to intervene in drug overdoses at supervised injection sites.

Opponents argue public health should focus on treatment and prevention, rather than harm reduction. They argue harm reduction approaches, particularly supervised injection sites, are the equivalent of drug maintenance and perpetuate, rather than treat or prevent, addiction.

Still, supporters claim harm reduction has the best outcomes for people with drug addictions by building communities for these marginalized members of society. Community, in turn, rekindles a drug user’s self-worth, engaging and empowering them to improve their lives.

But harm reduction is primarily focused on reducing the risks of infectious disease, by providing sterile needles, for injection drug use, at needle exchanges and supervised injection sites, explains registered nurse Lori Jacobson, who has experience at needle exchanges in Ottawa.

Despite Ottawa’s needle exchanges, the city’s injection drug users have the highest rates of HIV in Canada, according to Rob Boyd, director of harm reduction at an Ottawa community health centre.

Eleven per cent of Ottawa drug users are HIV-positive, but the rates have gone as high as 20 per cent in recent years, says Boyd.

The prevalence is comparable to the 30 per cent rate of HIV that initially sparked Vancouver’s Insite initiative, according to Vancouver Coastal Health.

“It would be a pandemic without harm reduction initiatives,” says recovered addict, LeBlanc, who adds that 85 per cent of Ottawa’s drug users have Hepatitis C.

“We used to be able to say we are second highest in the country … behind Vancouver’s HIV rates,” explains Boyd, but the success at Insite has resulted in Ottawa taking over first place.

There are a lot of gaps in harm reduction services across Canada, laments LeBlanc, who started the Drug Users Advocacy League to shine a spotlight on drug use issues.

For example, drug users cannot access safe needles past 11 p.m. in Canadian cities other than Vancouver, where Insite is open 18 hours a day, he says.

Since 2007, Insite has contributed to a 50 per cent decrease, annually, in new HIV infections among Vancouver’s drug users, reports Dr. Thomas Kerr of BC’s Centre for Excellence in HIV/AIDS, lead researcher of Insite. He credits Insite’s accessibility for this impact.

Researchers, like Dr. Kerr, argue supervised injection sites also enable medical staff to intervene when drug overdoses occur on-site.

Since opening in 2003, Insite’s medical staff has intervened in more than 1,400 drug overdoses, with no fatalities; the fatal overdose rate within 500 metres of the facility is down 35 per cent, reports Dr. Kerr.

With as many as 1,000 visits a day, Insite is ten times busier than hospital emergency rooms, yet there have been no overdose deaths, says Russ Maynard, supervisor of Insite.

“Even one [death from overdose] is too many when it could be prevented,” says John Becvar, a needle exchange outreach worker.

By contrast, there were 60 deaths from drug overdoses reported in Ottawa last year, says Becvar, but he suspects there were others, unreported, from the city’s population of 6,000 users.

Becvar belongs to Ottawa’s Coalition for a Safe Consumption Site, a group of outreach workers, medical professionals, and drug users advocating for supervised injection sites.

Supervised injection sites allow medical professionals to intervene in drug overdoses with oxygen or opiate antagonist medication, says Insite supervisor, Maynard.

Harm reduction services in other Canadian cities, operating out of community health centres and mobile vans, do not have the same capacity, Becvar explains.

Despite Insite’s unique capacity, supervised injection sites are controversial. Some opponents argue the sites facilitate drug maintenance instead of focusing on treatment and prevention.

Supervised injection is indefinite, with no clear link to treatment, argues Dr. Tony George, an addictions research scientist at the Centre for Addictions and Mental Health in Toronto.

“I would predict that every person currently using [Insite] will be dead in 10 years,” says Dr. George. “That’s the sober reality of continued drug use that even supporters of Insite would have to admit.”

Treatment, through detox programs and methadone support, for drug withdrawal, and eventual abstinence lead to the best outcomes for people with drug addictions, states Dr. George, who has been treating addictions for 25 years.

Other opponents of harm reduction approaches agree that treatment should be the focus for public health, not harm reduction.

Harm reduction delays treatment and encourages drug use, says Diane Watts of REAL Women of Canada, the organization that challenged Insite supporters at the Supreme Court of Canada.

Dr. George agrees. Environments of permissibility, like supervised injection sites and needle exchanges, are factors that contribute to drug addiction.

“It’s a bit of a desperation kind of thing, the people who support harm reduction assume addict[s] cannot recover or lead normal [lives],” says Watts.
But it is not so simple. People with drug addictions are often not engaged in conventional health care, says Dr. Kerr, Insite researcher.

Supporters of harm reduction argue services specific to people with drug addictions bridge the gap, leading them to health care and treatment – through needle exchange health centres providing drug users referrals to treatment, or by having Onsite detox and methadone treatment located conveniently above Insite’s main floor facilities.

More significantly, some experts argue that the community-building associated with harm reduction approaches addresses the conditions of addiction, stigma and trauma, that deter drug users from conventional care and empowers them to improve their lives.

These conditions can be alleviated by building communities of support for users, explains Allison Lavigne, an outreach worker with harm reduction experience in Vancouver’s Downtown Eastside.

People with drug addictions cannot just stop and go into treatment. “They face trauma, oppression, homelessness, mental illness and infectious disease,” she says.

Addiction is not usually born out of happiness, states LeBlanc, who explains his heroin addiction began after his partner drowned. People do what they have to do to cope, drugs are just a particularly harmful way to deal with trauma, he says.

LeBlanc says stigma is another barrier to treatment for drug users, pointing to nurses in conventional health care who made him feel like he was an “animal” for his addiction.

But harm reduction services are different, says LeBlanc. He never felt he was judged at needle exchanges.

The impact of creating communities for drug users, where they feel safe and are not judged, should not be understated, says Ariel Fuenzalida, addictions expert at Carleton University.
“Being seen as an actual person is powerful for someone who is marginalized by society,” explains Fuenzalida of a quality intrinsic in harm reduction.

“Showing [drug users] we care can translate into them caring for themselves,” says Lavigne, adding that her work is largely about relationship building.

Rebuilding relationships increases the rates of natural recovery, entry into treatment, and abstinence by 75 per cent, and decreases the rates of addiction relapse, says Fuenzalida. This ‘spontaneous remission’ occurs as meaningful relationships empower isolated drug users to overcome addiction.

Though not treatment models, harm reduction is a powerful public health model for drug addiction. Supervised injection sites keep people alive and buy more time, than needle exchanges, to engage and empower users towards treatment.

They bring people out of the cold and allow them to use their drugs safely. Then they can seek support for housing and treatment, all in one spot, says LeBlanc, a recovered addict who wants supervised injection sites opened across Canada.

Harm reduction kept me alive, says LeBlanc. “But, to me, what’s most important is that [harm reduction] meets people where they’re at and provides them opportunities to change. Everyone should have the opportunity to redeem themselves.”

Originally posted to the DUAL website.