New federal rules for supervised injection sites – evidence or ideology?

On June 6, the federal government introduced Bill C-65 entitled the “Respect for Communities Act” which sets out in legislation the requirements for operating supervised injection sites. Such sites are facilities where individuals can consume illicitly obtained drugs under supervision from a health professional and without being prosecuted.

There is currently only one supervised injection site in Canada, known as Insite (located in Vancouver). The evidence for Insite’s effectiveness is extensive. It has been associated with a reduction in public injecting, no increase in drug-related loitering or drug dealing, no changes in crime rates, no evidence of increased relapse among people who had stopped injecting drugs, and decreased fatal overdose in neighbourhoods near Insite. Among people who used the facility, there was an observed increased rate of referrals for drug treatment and a decreased rate of sharing of injection equipment.

Because the drugs remain illegal, facilities need an exemption from the Controlled Drug and Substances Act (CDSA) to operate. While the Minister of Health indicated during her press conference that Bill C-65 was intended to bring needed clarity to the application process for new facilities, the true intent of the bill appears to be to delay or derail the introduction of additional supervised injection facilities.

In September 2011, the Supreme Court of Canada forced the federal Minister of Health to issue an exemption to allow Insite to remain open. The ruling also outlined factors that the Minister should consider for granting exemptions to allow facilities in other Canadian cities, including “crime rates, the local conditions indicating a need for such a supervised injection site, the regulatory structure in place to support the facility, the resources available to support its maintenance, and expressions of community support or opposition.”

But the federal Conservative government has made no secret of its dislike of supervised injection facilities. It has framed the new legislation squarely within its “law and order” agenda – the Minister was joined by the president of the Ottawa Police Association in her press conference and the accompanying press release quoted the Canadian Police Association but no other stakeholder groups. On the same day, the Conservative Party of Canada initiated a literal “Not In My Backyard” campaign. We thus have a surreal situation in which a government is introducing a bill to seemingly advance an objective that the ruling party is actively resisting.

About a year ago, Dr. Carol Strike and I led the TOSCA study that recommended 3 supervised injection sites for Toronto and 2 for Ottawa. We noted that “Implementation plans must be transparent and include effective mechanisms for community stakeholder input. Such consultations are also relevant to considerations of where sites should be established.”

At face value, our call for stakeholder input resembles the government’s call for community consultation. But the government’s approach is problematic because it has the potential to impose an ideological objection to harm reduction on the decision, under the guise of eliciting evidence and values.

There are three reasons to be concerned about the new legislation.

First, it is not clear whether the values of a small group who are opposed to supervised injection facilities would be considered sufficient to deny a new exemption. I am concerned when the president of the Canadian police association publicly rejects evidence published in internationally respected scientific journals in favour of his own anecdotal experience. This is especially troubling, because such small groups reflect minority views, at least in Toronto and Ottawa.  We found that more than 50% of residents in each city strongly agreed with opening a facility if the goals were improving the health and social situation of people who use drugs or on public order. Only about 10 to 15% of respondents were strongly opposed (support was less if the only objective is to encourage safer drug use).

Second, some new criteria are unclear, such as the requirement for scientific evidence of medical or public health benefit. Does this mean citing the Insite evidence, conducting model-based projections, or something else altogether? Will these requirements demand a lot of money or time-consuming freedom of information requests, such as information about crime and public nuisance, public drug use, and the number of people who use drugs? And if some of this information is unavailable for any reason, how will it influence the decision?

Third, the decision making process appears to be both opaque and highly political. The Minister has said that the decision about an exemption would be hers. However, the government could have established an external advisory committee to evaluate the totality of the evidence – epidemiological, health-related, economic, social and ethical. This would have had the potential to somewhat depoliticize the issue of supervised injection sites, but that seems to be precisely what the government did not want.

The government also had other alternatives. It could have consulted broadly with organizations working in harm reduction and addictions and with researchers to ensure that the criteria were meaningful and feasible. It could have learned from the successful experiences with other harm reduction interventions, such as needle and syringe exchange programs, safer crack use kits, or clinics that dispense methadone; the criteria for establishing such programs have never been this onerous. Unfortunately, none of this occurred.

Decisions about supervised injection sites are politically challenging because they require carefully assessing both scientific evidence and potentially conflicting community values. But Bill-65 sets up barriers and puts in place opaque mechanisms that could lead to narrow perspectives dominating the decision. It is a step backwards for informed health policy decision making.

Ahmed Bayoumi is a general internist and health services researcher at the Centre for Research on Inner City Health in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. Follow Ahmed on twitter @AMBayoumi

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  1. Dale Wiebe

    %featured%Thanks for the great response highlighting the lack of clarity from a bill intended for that exact purpose. The dearth of objective criteria for evaluating safe injection sites suggests Bill C-65 would haved benefited from further debate and increased scrutiny at the committee level. Keep up the challenge for evidence based policy on this issue!%featured%

  2. Gerry Goldlist

    %featured%Speaking only as a taxpayer and only for economic reasons, we should have safe injection sites to prevent diseases like hepatitis and aids. These will cost us vastly more as our health care system has to tackle more of these down the road.%featured%

  3. Patrick Fafard

    This is among the best commentaries I have read so far on Bill C-65. I agree with much of the argument. %featured%While I agree that the process for approving new safe injection sites is flawed I remain optimistic that new safe injection sites will be established as long as we learn the two lessons from the Insite experience.%featured% The first lesson is that putting in place a safe injection facility requires a process of community engagement, agenda setting, raising awareness and understanding, and, ultimately, political struggle. Insite was established with the support of local police, city and provincial governments, the regional health authority, etc. And the debate continued for many months as some tried to close it down with disinformation and appeals to emotion. I would expect the same to be true in other cities and indeed, this process has already begun. The second lesson is that Insite was the result of a long process lasting not months but several years and driven by a public health crisis – an explosive increase in rates of HIV in Vancouver. This galvanized public opinion. While we can only hope that a similar crisis does not occur in Ottawa, Montreal, Toronto and other cities, it is reasonable to expect that the political struggle will be lengthy.

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