Canada and the U.S. are making significant strides toward mainstreaming harm reduction, but there are still walls to knock down
Hundreds of doctors, politicians, researchers and frontline workers will get together with drug users and ex-users in Austin, Texas, this month to openly talk about drug use. But instead of reaffirming their commitment to the decades-long war on drugs, the eighth National Harm Reduction Conference will feature discussions on opening needle exchanges, legalizing and regulating the drug trade, and overdose prevention methods.
“What we do in (the United States) is make drugs as unsafe as they possibly can be, and we do that through laws, which means that, if you get busted with drugs, you go to prison for a long time. And that’s designed as a deterrent to make people stop using drugs, which obviously it isn’t,” said Allan Clear, executive director of the Harm Reduction Coalition, which runs the national conference. “We do things like take syringes out of circulation, which has caused epidemics of hepatitis and HIV. So harm reduction is a way of trying to make drug use safer for people who use drugs, without demanding that they stop using drugs.”
Harm reduction can include a range of services from needle exchanges and condom distribution to safe consumption sites and access to addiction services such as methadone and buprenorphine treatments and detox facilities.
Supported by the United Nations and over 93 countries worldwide, harm reduction remains controversial. More than half of the 158 countries where drug use has been reported say they support harm reduction, and 82 countries have needle exchanges, but only 73 provide opiate substitution therapies such methadone, and only eight countries have safe drug consumption facilities. There are only two safe consumption facilities in North America, both in Vancouver, British Columbia, Canada.
Progress in Portland : In the late 1980s Portland, Oregon became one of the first U.S. cities to establish Syringe Exchange Programs, or SEPs. The city was dealing with rampant drug abuse that continued through the 1990s, and reached 250 reported heroin-related deaths in 1999.
Portland now offers three fixed sites for syringe exchange, along with the mobile Multnomah County Exchange Van. A drug paraphernalia law remains on the books in Oregon, though the possession of needles and syringes is exempted.
Outside In provides a majority of local needle exchanges. The organization offer one-for-one exchanges of up to 30 syringes along with HIV and hepatitis C counseling. Kelly Anderson of Outside In observes a clear need for their services in the community, their needle exchange clients alone having doubled in recent years. Nevertheless, she says that their funding “has not increased in over five years.”
Despite the relative availability of services, drug-related deaths themselves have returned to alarming levels in Portland — the state’s main site for overdoses. Oregon’s Alcohol & Drug Policy Commission delivered a report to Governor Ted Kulongoski identifying 229 overdose deaths in Oregon is 2008. The Associated Press reports that in 2009, 127 Oregonians’ lives were claimed by heroin alone.
Dr. Rachel Solotaroff is the medical director at Central City Concern, one of Portland’s oldest service providers. She acknowledges the city’s heroin problems but then expands the purview onto the ubiquity of prescription opiates. Oxycotin, suboxone, and methadone — the latter two prescribed as anti-addictives — can lead to their own addictions, black market street distribution, and even deaths.
“Not many of the prescription opiates on the streets come from people breaking into pharmacies,” Dr. Solotaroff says. “That’s the onus on us as prescribers. Not having sufficient regulation around prescription opiates is a huge contributor to drug-related death in Oregon.”
Solotaroff also identifies structural strains on providers. “With the unemployment and rising uninsurance in the country as well as in the state we just can’t see everybody. We just couldn’t keep our doors open. One issue is the rising uninsurance rate and the other is the increasing complexity of the individuals.”
Often cited social determinants of health include poverty, homelessness, addiction, social isolation, criminal history, and a lack of employment.
But Solotaroff doesn’t believe the issue is strictly a monetary one. “We need the flexibility to give better care to our patients. We need to support them in so many ways. We need to have supportive housing for individuals. And we need to have supportive housing for people still in their addiction. That’s often the first step to getting them out of their addiction. It’s something that may not take a lot of money, just an act of will and understanding and compassion.”
Central City Concern’s own Community Engagement Program (CEP) utilizes aspects of such a multidisciplinary approach. They attempt to address issues of drug addiction simultaneously with issues of chronic homelessness. “Housing is the really critical thing,” says Sara Goforth, Director of Addictions and Chemical Dependencies and Mental Health Services.
Goforth mentions that the majority of their clients have been homeless for a long time, averaging 8.6 years. “If you can’t find housing then all the medical treatment and counseling in the world is not going to be very helpful.” Whereas CEP offers Portland residents a variety of support, including HUD vouchers and Section 8 in a slough of zip codes, there remains a housing bottleneck. Long waiting periods usually precede available housing for individuals and families.
The harm reduction measures in Portland — including needle exchanges, housing, and health services — may also be undercut by the criminalization of drug use and addiction. For along with a rise in reported heroin- and opiate-related deaths, Multnomah County has seen a concomitant rise in drug arrests for heroin possession. (See “Oregon’s Budding Future,” October 15, 2010 for one state lawmaker interested in drug legalization as a means of saving money and increasing public health.)
“Insite” into harm reduction : “We were coming to work and people were overdosing and people were dying, and at its height it seemed like it was happening every day, and it just seemed unnecessary. If people were dead, there was no chance of detoxing,” said Mark Townshead, executive director of Vancouver’s Portland Hotel Society, which runs Insite, one of only two safe consumption sites in North America, open since 2003.
“[Insite opened] because lots of people worked hard to make it happen, including the mayor – all the different mayors – and [Premier] Gordon Campbell.”
Insite is located in the city’s Downtown Eastside, often referred to as Canada’s poorest postal code. Injection drug users in that area have a mortality rate 14 times higher than the rest of B.C., with an HIV rate of 4 in 10, and a hepatitis C rate of 9 out of 10 users.
The facility consists of 12 safe-injection booths, monitored by nurses, where clients are provided with clean syringes, cookers, filters, water and tourniquets, as well as education on safe injection practices that limit the spread of diseases like HIV and hepatitis C. Injection drug use is illegal in Canada, but Insite applied for and received an exemption from the federal government to run the site, though the current government is trying to shut the facility down.
There are approximately 12,000 registered clients at Insite, and in 2009, nearly 5,500 used the clinic, with an average 491 injections per day. Nearly 500 overdose interventions were performed that year, with no fatalities. In fact, no one has died at Insite since it opened, but the long lines mean some people walk away without injecting.
Because the local health authority funds it, Insite acts as a gateway to other medical services, such as treating infections and diseases and referrals to mental health treatment. In its second year alone, Insite made 2,000 referrals to outside services, including 800 to addiction counseling. There is also a detox center called Onsite located upstairs if people want to quit.
Vancouver’s second safe injection site is less well known, likely because its clientele is limited to people living with HIV/AIDS. Located in the nursing clinic of the Dr. Peter Centre West End, safe injection is only one of the services offered, including access to medication, counseling, and art and music therapy. Unlike Insite, the Dr. Peter Centre has not applied for a government exemption for its safe injection room.
“The College (of Registered Nurses of British Columbia) confirmed for us that it was within the scope of registered nursing practice to supervise injections for two purposes: promoting health and preventing illness. This is particularly so with a high-risk population,” said Maxine Davis, executive director of the Dr. Peter Centre.
A different story on the island : The Canadian federal government opposes safe injection on moral and ethical grounds, and this stance has prevented other Canadian cities from opening their own safe injection sites, including B.C.’s capital city Victoria. While drug users in Vancouver have access to needle exchanges all over the city, Victoria lost its only fixed-site needle exchange in 2008 after complaints about noise, crimes, garbage and human waste in the area.
The Vancouver Island Health Authority secured another location for the needle exchange in March 2008, but complaints from neighbors resulted in an indefinite hold on a fixed-site needle exchange. Volunteers drive mobile exchange vans in the city, but they have also been banned from that neighborhood, commonly referred to as the “no-go zone.”
“Not having a space where people can be and to feel like they can meet their peers in a safe location is huge. So you have people being very spread out and finding spaces where they can congregate, in spaces that aren’t that safe,” said Kim Toombs, a member of Harm Reduction Victoria. “People don’t want to be using drugs on the street, in front of other people. This is a private thing, and they’d rather be doing it indoors on their own terms, whether it be in their house or whether it be in a safe space. But they’re in a position where they don’t have any other options.”
A study released by the city’s Centre for Addictions Research this year found that in 2009, 23 percent of Victoria’s drug users reported sharing needles, compared to eight per cent of Vancouver’s; 89 percent of Victoria’s users injected daily, compared to 29 per cent of Vancouver’s.
Despite the sharp reduction in services to Victoria’s drug users, the City of Victoria adopted a harm-reduction policy framework in 2004 and is working on a harm-reduction strategy. The public at large also supports it, with 74 percent of residents from Victoria and 12 surrounding communities agreeing with harm reduction in Victoria.
No needles in Nashville : The story is different in the United States, however, where the first needle exchange opened in 1987 in New Haven, Connecticut, but it was only recently that a ban was lifted on federal funding for needle exchanges. The government has yet to provide any guidelines for funding the programs, however, and many states are unwilling to move forward without knowing if their programs will receive funding. In addition, needle exchanges are only legal in 36 states, leaving 14 states, including Tennessee, without one.
In Nashville, there was a tolerated needle-exchange program in 2001-2002, recognized by City Hall as well as the local law enforcement, but for reasons unknown the exchange died off, and now clean needle distribution has gone underground. Legal harm reduction comes in the form of mobile outreach vans run by groups such as Street Works, which offers free HIV testing, condoms and lubricant to drug users, sex workers, and the homeless.
Davis wants more than clean supplies to pass out, though. He also wants to see drug use decriminalized and treatment focused on lifting users out of poverty, as well as counseling for the personal traumas that led them to drug use in the first place.
“There are success stories around. At Street Works, we have several success stories … people celebrating five or six years clean. … (But) the odds of turning your life around are not good,” he said. “I’ve seen ’em die in this town and never get clean.”
Conservative Cincinnati : Like Tennessee, needle exchanges are illegal in Ohio unless they are sanctioned by a city’s health commissioner under an emergency order. Such an order was issued in Cleveland, where a needle exchange has been operating since 1995. At that time, according to the Centers for Disease Control and Prevention, 17 percent of the city’s new HIV infections were among IV drug users. Today that number has dropped to 3.4 percent.
But it’s a different story in Cincinnati, where it’s a crime to possess a dirty syringe, regardless of whether you’re the user or a volunteer at a needle exchange. While both the city’s mayor and health commissioner say they support a needle exchange in theory, STOP AIDS Cincinnati, a local AIDS prevention and support group that operates on a harm-reduction model, must make the case for a needle exchange to the entire city council and health board.
HIV/AIDS levels among IV drug users in the city are five to 10 percent for HIV, while hepatitis C is much higher at 35-38 percent. It’s numbers like these that drive McMahon to push for needle exchange on top of the condoms, lube, and testing STOP AIDS Cincinnati already supplies.
“While there are certainly statistically high-risk groups, (IV drug use) crosses all socio-economic groups, racial and age boundaries,” said Amy McMahon, CEO of STOP AIDS. “It’s your behavior that puts you at risk, not the color of your skin or your gender or your income.”
Methadone in the Midwest : Needle exchanges are legal in Chicago, Illinois, but since the federal ban has been repealed, Dan Biggs hasn’t seen a flood of government money coming in. Instead, the Chicago Recovery Alliance of which Biggs is founder and director, is funded by the Chicago Health Department and the Illinois Department of Health and has become one of the largest harm-reduction outreach programs in the country.
The Chicago Health Department provides clean rigs and condoms, and also offers free vaccines for hepatitis A, B, and C, as well as the flu and pneumococcal pneumonia, through their mobile van and their office. But thanks to federal law that limits distribution of opiate substitutes to specialized clinics, the department can’t provide methadone or buprienorphine to marginalized drug users.
“(Treatment is) not available to most people who want it. We are in juggernaut to the most brutal, ineffective approach. Right now I can’t get you into methadone treatment unless you have good resources — money. Most insurance don’t pay for it. (It costs) $60 a week,” Biggs said. “But I can get you a cell and court date for $50,000 a year. What kind of insanity is that?”
The Centers for Disease Control and Prevention estimates there are 60,000 to 90,000 injection drug users in Chicago, but only 7,000 to 8,000 use CRA’s services per year. Biggs says some areas of the city see no service at all, particularly the southwest side, which has high rates of injection drug use.
Rocky Mountain attitude : Colorado became the 36th state to gain a legal syringe exchange program this year, but each county’s public health board has to opt into the program, and only after that can a harm-reduction organization apply to become a needle exchange. Nor will users be fully exempted from state paraphernalia laws once the exchange opens — volunteers will be exempted, but it’s a class II misdemeanor for a user to be caught with a needle, dirty or clean.
Denver has an illegal needle exchange program, however, that’s been running since 2007, although previous exchanges operated in the late 1990s and in 2003-2004. Unlike some other illegal exchanges, the Underground Syringe Exchange of Denver actually has funding from the North American Syringe Exchange Network, the only group that will fund underground exchange programs.
“We average probably, on one day of exchanging, seeing five to 10 people and exchanging 200-800 syringes in a three-hour block,” said Andrew, one of the founding members of the exchange, who requested his last name be withheld. Andrew assumes the large numbers of needles per user is people doing secondary exchanges, where they take dirty needles for friends and exchange them, giving their friends clean rigs in return.
Denver restricts the number of needle exchanges to a maximum of three, they must be one-for-one exchanges, and they cannot be within 50 feet of a dwelling. With an estimated 10,000-15,000 IV drug users in the city, the ordinance falls short of addressing the demand.
“The fact that there’s still nothing happening is why we still have an underground syringe exchange. And it’s going to continue until we have an effective exchange running in Denver,” Andrew said.
Support for Harm Reduction : The fight for harm-reduction services, particularly needle exchanges and safe consumption sites, has gained ground in both Canada and the United States, but there are still hurdles to overcome.
Despite being the subject of 30 peer-reviewed studies by the British Columbia Centre for Excellence in HIV/AIDS, which showed a significant reduction in public injections and in HIV and hepatitis C infections, as well as an increase in the number of users seeking treatment, Insite is in danger of being shut down by the Canadian federal government, which cites moral and ethical issues with safe injection. After two separate cases before the B.C. Supreme Court and Court of Appeal, which ruled in Insite’s favor, the decision now lies with the Supreme Court of Canada.
“The Canadian Medical Association, normally a very conservative body, has stepped in twice to defend Insite, and they will be intervening in the Supreme Court to say, ‘This is ridiculous. (Prime Minister) Stephen Harper needs to give his head a shake,’” Townshead said. “You can find an opinion from a fool, but ultimately the information is in and the evidence is utterly clear.”
It’s not just the government that stands in the way, however. Members of the public who don’t experience the realities of drug addiction in their lives often do not understand the reason for harm-reduction services, particularly because of the drug laws in North America.
“We live in a society that doesn’t often turn its thoughts to those who are least among us,” said Andrew of the Underground Syringe Exchange of Denver. “And injection drug use affects a very small portion of the population, so, since it’s not on their radar, and it’s one of those icky topics that they’re not interested in delving into because it challenges their moral boundaries. They just kind of look at it and say, ‘You know, let ’em die off,’ basically.”
But Clear of the Harm Reduction Coalition believes it is the politicians, not the public, who are holding back harm reduction, and with the retraction of funding bans on needle exchanges in the United States and the support of safe injection sites by the provincial courts of British Columbia, the future of harm reduction in North America is one of growth.
“The funny thing is that topic opinion polls, the few that exist, have always been pretty consistent that the general public actually supports them. It’s not overwhelming, but they are pretty consistent. It’s something like 55 to 45, or 52 to 48 in favor of syringe exchange programs. The general public has always been fairly supportive, especially if it’s explained what they are for,” Clear said.
This is a collaborative report by members of The North American Street Newspaper Association.
