The great safe-inject debate

New Quebec Health Minister shoots down plans for safe-injection sites around the province, local groups come out in protest

Early this summer, plans for a safe inject site (SIS) pilot program seemed to be getting serious in Quebec. Though no concrete plans had been laid down, tentative pilots were proposed for Quebec City and Montreal. However, Quebec’s incoming Health Minister Yves Bolduc scrapped the plans shortly after they began unfolding.

Bolduc’s predecessor Philippe Couillard, who stepped down from his post in late June, had been considering setting up a safe injection site project in Quebec, but Bolduc’s office announced a turnaround in their stance towards SISs.

Quebec’s Ministry of Health and Social Services under Bolduc held that there was not enough direct evidence in support of safe injection sites for the project to go on. The announcement came less than a week after Canadian Health Minister Tony Clement delivered a speech at the Canadian Medical Association’s Annual Conference (CMAAC) attacking the merits of safe injection sites, and citing “profoundly disturbing” ethical concerns.

Most recently, a number of community health organizations, including the Coalition des organismes communautaires québécois de lutte contre le SIDA (COCQ-Sida), an umbrella organization consisting of over a dozen local activist groups, have come out in direct opposition to the new decision to scrap the SIS project.

Where to draw the line?

Currently, North America’s only safe injection site, Insite, is located in Vancouver, British Columbia, but even this site’s continued existence came into Health Minister Clement’s line of fire.

Clement’s office provided a transcript of the CMAAC speech, which particularly expressed great moral concern over government’s role in establishing safe injection sites. He stated that this type of service really provides “palliative care” rather than a road to “full recovery.”

While he did not call for a full-out closure of Insite, he outlined funding cuts for the safe injection services at the facility in favor of detox and classical rehab expansion.

“I believe we have to draw the line somewhere with regard to these kinds of measures,” stated Clement, calling it a “slippery slope.”

“Already there are people saying injection sites are not enough, that government should give out heroin for free,” he stated.

While most Canadians are not calling for government drug handouts, the idea of “inhalation rooms for people who smoke their drugs” is a less far-fetched concern in Clement’s slippery slope argument. Even so, drug inhalation cannot be directly compared to injection. Clement seems to miss that it is the nature of injecting drugs which is problematic – unlike inhalation, injection carries with it more ominous risks, such as facilitating the spread of infections and disease.

The issue is further complicated by the absence of comprehensive statistics on the impacts of safe

injection sites on target populations. For instance, few concrete numbers exists on the role of safe injection sites in reducing new HIV/AIDS and hepatitis C infections, as well as other injection-related diseases.

Clement cited an Expert Advisory Committee commissioned by his office as having found no sure evidence of supervised injection – such as that offered at Insite – making “any difference at all in the transmission of blood-borne infections, including HIV/AIDS.”

Despite the lack of statistics on infection transmission, there is evidence that safe injection sites can be beneficial to users. A study published on behalf of the Society for the Study of Addiction found that “the SIF’s [safe injection facility’s] opening was associated independently with a 30 per cent increase in detoxification service use, and this behavior was associated with increased rates of long-term addiction treatment initiation and reduced injecting at the SIF.”

Health Canada’s web site offered a similar assessment, stating that although the evidence is inconclusive on the impact that safe injection services have on rates of blood-borne

disease or injection-related infections, the sites “positively impact many at-risk behaviors,” such as decreasing needle sharing and increasing the regular use of condoms.

Contradictory ethics

While Clement’s concern stems, in part, from the questionable ethics of allowing illicit drug use under government watch, he also sees SISs as an inappropriate form of patient care. In his speech, he characterized safe injection facilities as offering “palliative care,” not “full recovery,” asserting that rather than addressing the problem of addiction directly, they only “slow the death spiral of a deadly drug habit.”

Others, however, would rather call safe injection a philosophy of harm reduction.

Quebec director of public health Alain Poirier shares the latter opinion. He has been a steadfast voice of support for the plan for Quebec safe injection sites, even as the Health Ministry’s stance has shifted with the change in administration.

“We have evidence that they could be part of a solution – even if not the solution – to the consequences of drug use,” said Poirier.

He views these sites in a more positive light than Bolduc or Clement. “They have given good results where they have already been implemented,” Poirier said. “I’ve been to Geneva. I went to visit the sites they have. There is a big difference from what we have here.”

Starting with the Netherlands in the 1970s, many countries around the world, including Germany, Switzerland, several northern European nations, and Australia have implemented safe injection programs as a tool in their fight against drug abuse. Poirier sees Quebec as being able to gradually integrate a similar system.

“In Quebec we have 820 sites where you can exchange old syringes for new ones – sterile materials. There are exchanges in most pharmacies, hospitals, and some community organizations. This is the next step,” he said.

What Poirier noted as the problem is a lack of consensus. “It is feasible [to have safe injection sites around Montreal and Quebec] but we first need consensus…. We need a group of citizens [to back the sites].”

Still, he concedes that people don’t know what to think about these types of facilities, and have nowhere to turn for answers. “Do these sites increase the number of drug users? The number of people on the streets? The answer is no, but people wonder,” Poirier said.

Meanwhile, local community groups are openly calling for a re-evaluation of the stance against safe injection sites by the Ministry of Health and Social Services .

Members of COCQ-Sida are among those coming out against the decision. One such group, Anonyme, is a Montreal-based organization aimed at helping young people with drug addictions, health problems, and other issues leading to social exclusion.

Julien Montreuil, Anonyme’s Coordinateur à l’Intervention, asserted that safe injection sites can be an integral part of the fight against drug addiction, and the range of negative consequences that can accompany intravenous drug use. To him, Clement and Bolduc’s stances against the expansion of these facilities are counter-productive to the war on drug abuse.

“When we give people who inject drugs clean materials to use, we give them advice about their proper use, general health, and other issues. But I feel like I then have to say ‘now go to a very dirty place and shoot yourself up.’ However, with safe injection, we could continue to help these people and offer other services. The sites would be a good door to come to for people in need, for people who wouldn’t otherwise go to clinics,” he said.

Montreuil also expressed concern over the moral considerations touted by Clement. “Tony Clement said that the ethics of doctors are at question [with regards to] safe injection sites. But what is more ethical – letting the people shoot up in back streets?” asked Montreuil.

Instead, Anonyme sees safe injection facilities playing a positive role in the battle against drug abuse, especially as a transitional step towards full recovery.

Montreuil is another believer in the harm reduction approach. Much like Poirier – who has called SIS’s a “complementary service,” not one necessarily in opposition to that of classical detox and traditional rehabilitation – Montreuil sees safe injection sites as a good intermediate level of care, specifically for those who are not ready to go into detox or who have tried it and failed.

“A lot of people aren’t able to quit right now, but the motivation from inside is better than from out,” said Montreuil. “If the government sends you to detox, it’s not the same as if the person is ready to work on it themselves, to quit the lifestyle of drug abuse. It’s society’s responsibility to help these people even when they can’t quit. We need to help them be as safe as possible in this situation so that they can eventually make the choice to go to detox of their own will.” He holds that safe injection sites can play an integral role in this.

So far, community groups have spoken out against the decision to halt plans for the safe injection sites at a press conference denouncing the Quebec Health Ministry’s stance. But Montreuil promised that “we will continue to fight this.”

“The government doesn’t need any more delays,” he said. “Mr. Bolduc just needs the population to stand up and say ‘hey, this is a good thing.’”