Are Safe Injection Sites of any Value?

By Dr David Laing Dawson

Many years ago I attended a presentation on an illicit drug ban conducted in an Asian country. I think all the opium dens were closed. Over the next ten years, presented in graph form, the dramatic fall in Opium use was an almost perfect mirror image of the rise of heroin use. So, in reality, this intervention pushed people to engage in even riskier behaviour.

During those same years in North America, the rise in the numbers of therapists conducting marital therapy, exactly followed the rising number of (newly more acceptable) divorces. It seemed to me then that marital therapy was not an intervention to help people in their relationships, but rather an industry taking advantage of a social trend.

I recently wondered about Insite, the clean needle, safe injection site in Vancouver. After much controversy in the early 2000’s and battles with the Conservative Government of Canada, it has been funded and fully operational for over a dozen years. I understand the rationale, and it makes perfect sense, along with the fact that, on a survey, 75% of addicts said they would be willing to use a safe injection site. Clean needles will prevent the spread of hepatitis and HIV. Staff on hand can intervene with overdoses. Addicts can be referred to programs. Other health needs can be addressed.

So what has happened at Insite between 2012 and January 2019?

2015 stats show:

263,713 visits by 6532 individuals.

722 visits per day

440 injection room visits per day

768 overdose incidents

No overdose deaths.

2017:

175,464 visits by 7,301 individuals

537 visits per day

415 injection room visits per day

2151 overdose incidents

And, overall, deaths by overdose in B.C. have dramatically risen from 270 in 2012 to 1486 in 2017, and then 1510 in 2018.

During this same period death by overdose of prescribed drugs has fallen (and comprises only a small fraction of the total), while illicit fentanyl has flooded the market.

I am not trying to draw any cause and effect conclusion here, but rather to point out that we humans are a puzzling and contrary species. Interventions aimed at bucking trends and changing behaviour, no matter how much they are based on science, numbers, common sense, can be way off the mark, may even produce opposite results and many unintended consequences.

Just looking at the above raw data I would have to wonder A. Without Insite would the deaths by overdose in 2018 have been 2510, a thousand more? B. Has the presence of Insite and all the de- stigmatization/acceptance surrounding it, actually removed psychological barriers that would otherwise prevent people from becoming addicted and engaging in increasingly risky behaviour? and C. Has the tightening of prescription opioid practices simply opened a market for illegal fentanyl and carfentanyl and pushed a whole population toward more dangerous drugs?

Has it been a good intervention broadly speaking or has it actually contributed to or even accelerated a social trend?

Or is it, like marital therapy, good for a few people but absolutely ineffective bucking a complex social evolution?

There has been a bit of a plateau in deaths by overdose in 2018 continuing so far in 2019. So maybe this social trend is peaking, and maybe it has very little to do with any of our well intended interventions.

 

6 thoughts on “Are Safe Injection Sites of any Value?

  1. Shouldn’t we as community demand our government to establish and promote a better education system and provide support for the young and adult people? What I am trying to say is “prevention is always better than cure”. We must become with better “practical ideas” how to PREVENT this desease…never is late to start

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    1. Harm reduction has to be part of the aim (prevention of HIV and hepatitis). I think that quite a lot of other things are likely going on in the safe injection sites. A new area of jobs have clearly been created . Grief councillors and marriage councillors they come out of the woodwork when jobs open up, Peer support jobs for drug users could be complex.

      . When we talk about prevention, we must think about those who have untreated psychotic illnesses who have slipped into drug use. Do they ever get guided to appropriate treatment for their primary problem a psychosis from these places ? One thing that seems evident in the safe drug sites is the general belief that all those users have been victims of abuse of one sort or another. That is a very simple way of interpreting drug abuse in my view.

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      1. “One thing that seems evident in the safe drug sites is the general belief that all those users have been victims of abuse of one sort or another. That is a very simple way of interpreting drug abuse in my view.”

        It’s completely simplistic.

        I’m pretty sure abuse increases the chances of using drugs. But that’s a macro view of things. Individual stories are very much different.

        And moreover, the question of the link between abuse and drug use is one of prevention and trauma treatment. It has no relevance with what should be done on a day to day basis to help drug users.

        Anyhow, I believe policies concerning drug users are almost always completely misguided. Safe injection sites is one of the least worst ideas we have come up with. I wholly support them.

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  2. The fallacy is that there is any one answer to drug addiction. We need to study people who have overcome addiction and learn how it happened for them. I once met a taxi driver who told me he was addicted to opioids in India, and that when he came to Canada he never used again. Why did Vietnam Vets use while at war but stopped when they came home? How does the self help approach of AA work for alcoholics — how important is it to change one’s environment and stay away from friends who use? For chronic pain can we wean someone off the narcotics very slowly while introducing meditation and gentle exercise? We will have to use every tool in the tool box.

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    1. I agree with you up to your last sentence. Since when do people who suffer from chronic pain for a wide variety of reasons get lumped in with addicts. They are not addicts and they do need the medication they get. Meditation and gentle exercise is of little help to anyone in severe pain. What is happening today is that governments are trying to fight the rising number of overdoses by forcing pain patients to give up their meds. Prescriptions are going down but overdoses are going up and many with pain are resorting to suicide or going to street dealers.

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      1. “Since when do people who suffer from chronic pain for a wide variety of reasons get lumped in with addicts.”

        Pain patients who ingest opioids have much in common in addicts.

        What makes you think we should differentiate the two?

        “they do need the medication they get” seems to be your argument. It’s a moral/emotional argument to avoid stigma. It’s not an argument than can be operationalized in anything remotely useful.

        Maybe the drug use patterns of addicts and pain patients really is different. Somehow I have doubts.

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