Toronto's top health officer says we should have places where drug users can inject under medical supervision. Should we?
Supervised injection sites—clinics where addicts can get professional help injecting intravenous drugs—are a touchy topic, at the moment, because the City’s top medical officer is urging politicians to open some in Toronto. A Toronto Public Health report, which goes before Toronto’s board of health today, recommends that city council ask the province to fund a few initial clinics on a pilot basis, as a way of preventing the spread of disease.
But would supervised injection sites actually benefit us, or would they only make matters worse?
Toronto Public Health’s report on supervised injection sites says these clinics would reduce overdose deaths and disease transmission—outcomes documented in other jurisdictions by years of research.
But research has never been particularly effective at stopping opposition to supervised injections. Wherever it’s proposed, the idea meets with resistance from residents and politicians. In Canada’s case, Prime Minister Stephen Harper actually fought Vancouver’s Insite, North America’s first supervised injection site, all the way to the Supreme Court.
Research has shown that supervised injection sites like Insite do what they’re supposed to do: they reduce mortality from overdoses and diminish the risks associated with intravenous drug use, both for users and in the community. It’s true that intravenous drug use comes with several potential harmful consequences, including increased risk of diseases like HIV and death from overdose. The purpose of supervised injection sites is to reduce these harmful outcomes by providing a medically supervised location for injections. At the same time, these clinics put drug users in environments where they have regular contact with medical professionals, giving them better access to services like detox, methadone therapy, and rehabilitation, as well as more basic health services and other community supports. “By having a supervised injection site, more drug users will access those kinds of services,” Toronto Public Health spokesperson Dr. Rita Shahin said. “It’s often a good bridge to get people in counselling or treatment.”
There are now more than 90 supervised injection sites worldwide, and the evidence is clear that they decrease public disorder around the sites, public disposal of needles (more than half of Toronto intravenous drug users inject in public spaces), and overdoses. Despite arguments to the contrary, the existence of these sites doesn’t encourage drug use itself. “There isn’t any evidence that users will inject more because they have access to a supervised injection site,” Shahin said.
The reduction of harm for individual drug users also means the reduction of harm for others in the community. Drug users with diseases like hepatitis C and HIV/AIDS don’t only spread them to other drug users; the risk extends to other people, including their sexual partners and healthcare workers.
There’s also an economic benefit to supervised injections, as overdoses and treatment for the serious diseases spread by shared needle use are costly to treat and a burden on the healthcare system. “There’s an economic argument to be made for supervised injection sites based on diseases transmission alone,” Shahin said.
Finally, along with the medical and economic benefits—all well documented by years of research—there’s also an argument to be made on compassionate grounds. Yes, users of intravenous drugs have a problem—one that is both illegal and socially undesirable—but they’re still human beings, many of whom have struggled with some difficult life circumstances. Isn’t our social welfare system a major source of pride for our country? Giving up on those in society who need our help the most is not only foolhardy, it’s also cruel.
Everywhere intravenous drugs are available, some percentage of people are going to use them. We should, of course, support programs that prevent drug use in the first place, and ones that rehabilitate people with addiction problems, but that doesn’t mean that we can’t also implement harm-reduction strategies that help those who are still using drugs avoid disease, for their own health and for the greater health of the community.
Supervised injection sites will not turn Toronto the Good into an amoral wasteland, promote drug use, or increase crime. The 90-odd such sites around the world have already proven that they reduce public drug use, clean up neighbourhoods, and save lives. Even so, this city should not pursue the multiple supervised injection sites that Toronto Public Health has proposed. Ontario’s addiction and mental health strategy can’t support the kind of effective, integrated approach espoused by TPH and achieved by other injection sites in Canada. Nor is this latest proposal developed enough to explain what funding a successful facility would entail. Worse, every dollar diverted to supervised injection sites in Toronto is a dollar badly needed for invaluable addiction and mental health services around the province.
Vancouver’s Insite was the first legal supervised injection facility in North America, and was included in TPH’s proposal as a successful example of a supervised injection site. Its $3 million-per-year budget is funded by the government of British Columbia through Vancouver Coastal Health (VCH), one of six government health authorities in the province. To put Insite’s budget in perspective, VCH has an addiction services budget of $44 million annually, and a general health budget of $3.1 billion annually. “Insite is a very, very small program within Vancouver Coastal Health services,” said VCH Senior Media Relations Officer Anna Marie D’Angelo.
By comparison, what Ontario spends on addiction services is pocket change. The province’s 2013 budget promises to “grow” Ontario’s addiction and mental health strategy to $93 million per year by 2013-2014. And while the budget document also pledges to continue building on the province’s comprehensive strategy in following years, that growth will be directed mainly at extending addiction and mental health services (which until now have been directed mainly at children and youth) to adults. It will also have to cover not just Toronto’s considerable addiction needs, but also the demand for addiction services in other cities and towns, and the continuing addiction issues that plague First Nations communities.
The amount of funding to general addiction services is of paramount importance to the effectiveness of supervised injection sites. Addiction is a holistic, multi-faceted illness, and it requires an equally holistic treatment approach. Last year, Insite referred approximately half of its 9,259 individual visitors to other social and health services. Under the model TPH has endorsed, supervised injection sites would be even more reliant on external healthcare infrastructure. According to TPH spokesperson Dr. Rita Shahin, the plan is for Toronto to have two to three sites, integrated into existing addiction treatment facilities. As Shahin explained, injection sites are a good bridge by which drug users can enter into counselling or treatment. But for that model to work, counselling and treatment have to be reliable, well equipped and, of course, well funded.
All of which is to say that, whatever Toronto’s supervised injection sites end up costing, their effectiveness will be severely hindered by shamefully low funding to addiction and mental health services across the board.
And that’s not the only funding problem related to TPH’s supervised injection site plan. There’s also the fact that nobody knows how much the sites will cost. A City report [PDF] includes hypothetical budgetary needs for the proposed injection sites, but no dollar figures.
And how would allocating funds to supervised injection sites in Toronto impact addiction services in the rest of the province? Supervised injection may represent a very small percentage of spending in British Columbia, but it’s all about proportion. In Ontario, even relatively inexpensive facilities could represent a much larger share of overall addiction spending.
Decreasing the risk of HIV and hepatitis, as supervised injection sites are proven to do, is arguably a priority. But we already have supervised injection programs in place. TPH, in conjunction with 35 community agencies, provides what Shahin describes as “a large needle exchange program” that serves 75,000 client visits, and distributes 1.1 million clean needles, each year.
Supervised injection sites are not wrong. They can be components of holistic addiction treatment strategies. But dedicating an unknown amount of money to multiple injection sites when Ontario is spreading a limited budget across several underfunded addiction and mental health services is not the right move.