8 years of local research & recommendations: no action

Evidence for Action:

A review of the evidence supporting safe consumption facilities and
comprehensive harm reduction services in Victoria BC

May 2010

1/ Best practices supporting SCS according to BC’s medical professionals:

The Health Officers Council of BC has resolved that “supervised injection services have been studied enough as research projects, and that it is time to move them into the mainstream of health service provision” (Health Officers Council of BC, 2008).

The College of Registered Nurses of BC and the Canadian Nursing Association have interpreted their Professional Standards for Registered Nurses and Nurse Practitioners in BC and Code of Ethics for Registered Nurses to encompass and support the supervision of drug consumption by clients (McCall, Pauly, Goldstone, Gold & Payne, 2007; Adlersberg, 2007).

2/ Reports concerning fixed-site NEX & Supervised Consumption Sites in Victoria:

September 2010: City of Victoria presents resolution to Union of BC Municipalities to lobby the province to “legislate that base levels of harm reduction services, including needle exchange and access to safe substance use equipment and detox and treatment beds, be made available in every local government in British Columbia in order to ensure that political pressure does not limit access to necessary health services for those affected by problematic substance use and addiction problems, including adequate funding to support these services”

September 2010: Centre for Addictions Research of BC (CARBC) releases its study of the effects of fixed-site closure in Victoria. This study finds an increase in needle sharing in Victoria, and explains this increase by the combination of Victoria’s offering less access to clean needles and offering less access to educational supports:
> Needle-sharing rates increased to 23%, up from 10% before the fixed site needle exchange closure—“a concern highlighted by qualitative data suggesting this increase was directly linked to the closure” (1)
> Clean needles distributed since the closure fell by over 15,000 per month (1)
> Daily drug injection in Victoria “increased significantly over time” at the same that injection rates were falling in Vancouver—this increase of drug use was associated with the lack of “educational supports provided by needle exchange personnel that promote healthier lifestyles” that are provided by fixed-site services (6).

This study recommends the abolishment of the no-go zone & opening of fixed-sites:
“We recommend an immediate abolishment of the “no-go zone” in downtown Victoria, to enable outreach workers and health service providers to adequately respond to the health needs of injection and other drug users. We further strongly recommend that, in accordance with optimal best practice put forward elsewhere (Strike et al., 2006), one or more fixed site needle exchanges be reintroduced in Victoria as part of a comprehensive plan to attend to the health needs of injecting drug users and preventing the spread of HIV and Hepatitis C” (7)

March/April 2010: VIHA completes its most recent I-Track survey (an ongoing research initiative designed to track changes in the prevalence of HIV and hepatitis C and associated risk behaviours among people who inject drugs). These statistics have yet to be released to the public.

May 2009: VIHA releases needle distribution and recovery statistics showing an average drop of 40% in needles being distributed, and of 18% in needle recovery rates, since the closure of the Cormorant needle exchange (VIHA, 2009).

March 2009: City of Victoria identifies harm reduction as one of seven strategic priorities.
These were to include--
> Pursue distributed needle exchange model to address immediate health risks
> Consider findings of VIHA-led committees on locations for fixed sites
> Advocate for increased detox and treatment services in the Region

December 2008: University of Victoria researchers Dr. Bernie Pauly and Dr. Joan MacNeil conduct the first evaluation of Victoria' Fixed-Site Needle Exchange on Cormorant street (Pauly & MacNeil, 2008). This study took place before and after the closure of the fixed-site, finding:

Decrease in clients: “The number of clients accessing the AVI needle exchange dropped dramatically after the closure of the fixed site, from 373 in May [2008] to 273 in June and 277 in July [2008]” (Pauly & MacNeil, 2008: 23)

Significant decrease in distribution and recovery of needles: “after the closure of the fixed site, the numbers of needles distributed and collected by AVI dramatically decreased (see Table 2 below). AVI needle distribution in June was down 46% and intake decreased by 69% compared to May. AVI distribution and collection in July increased over June, but was still significantly below the April and May numbers. Needle distribution and collection by others increased in June and July, however, the overall total distributed in July was still over 4,000 less than in May, and the total collected was over 17, 000 less than in May. The numbers for August reveal an increase in the numbers of needles distributed (27,000) but only 10,000 collected which is disturbing. The decrease in numbers of clients and in needles distributed and collected directly relates to the closure of the fixed site” (2008: 24)

Reduced access to associated health services: “Results from the Victoria site revealed that the closure of the fixed site decreased access to not only the needle exchange services but also decreased access to other services, thus exposing already vulnerable clients to increased health risks” (2008: 3)

Note: AVI reports that the Cormorant NEX program served 1560 clients in 2005-2006, on approximately 25, 000 separate occasions (AVI, 2008).

April 2008: University of Victoria addictions researcher Dr. Benedikt Fischer and BC’s Provincial Health Officer Dr. Perry Kendall call on relevant authorities to implement a supervised consumption site trial for high-risk street drug users in Victoria. Their argument would be the basis for an editorial to be published in the BC Medical Journal on April 1, 2008. “Victoria provides a perfect platform to implement a distinct and scientifically evaluated supervised consumption site program that is uniquely tailored to reflect the local characteristics of street drug use and associated public health needs,” says Fischer, the director of the Illicit Drugs, Public Health and Policy Unit at UVic’s Centre for Addictions Research. “The time has come to take the necessary steps forward towards bringing a SCS program to Victoria,” says Kendall who also notes that the SCS concept already has the support of Victoria City Council and the Victoria Police Chief.

April 2007:Feasibility Study on ‘Supervised Drug Consumption’ Options in the City of Victoria is released. The report was commissioned by the Vancouver Island Health Authority (VIHA) and the City of Victoria and written by Benedikt Fischer and Christiane Allard of the Centre for Addictions Research of British Columbia (CARBC) at the University of Victoria. The recommendation to the Health Authority and City are clear: “That the City of Victoria, the Vancouver Island Health Authority and other local key stakeholders and partners undertake the necessary steps to move forward on the planning and implementing of a Supervised Consumption Site (SCS) initiative in Victoria with the main objective of improving the health and safety of drug users, as well as that of the community at large.”

The authors make a further recommendation on the process that VIHA and the City should follow: “That the specific parameters of an SCS program – e.g., operations and facility design – are developed in active cooperation with key stakeholders and representatives of the drug user target population.”

The feasibility study also included a stakeholder survey of 45 social and health service providers, business, community and tourism representatives, political and government representatives, law enforcement representatives; and 23 drug user informants. The study found that “stakeholders expressed strong support for the implementation of an SCS intervention in Victoria as a measure to tackle problems associated with street drug use in Victoria, and that such a step needs to be initiated now, as much talk and little tangible action has occurred to date.”

The report recognizes the political challenges to following through with their recommendation to implement a SCS intervention, specifically further s.56 exemptions under the Controlled Drugs and Substances Act (CDSA) for SCS initiatives. They therefore makes an addition recommendation “that the efforts toward an SCS initiative in Victoria ideally go forward under the umbrella of an s.56 exemption under the CDSA obtained from the federal government. However, if such an exemption cannot be obtained, that alternative ways are considered for an SCS initiative in Victoria to go forward outside this umbrella while within socially, ethically and legally defensible parameters.”

The 2007 Victoria Homeless Needs Survey finds at least 1,200 people, many with mental health or addiction issues are homeless in Victoria. A third of those residents are both mentally ill and addicted. Those reporting drug and alcohol use were more likely to sleep on the street, go to a hospital emergency room, be admitted to hospital and stay in jail. The report includes six “basic” recommendations for Victoria, including “provide a range of harm reduction and treatment services” and specifically mentions that “VIHA and community-based health services should work together more closely to deliver everything from clinical, professional supports to community-based services (2007:56).”

In October 2007, the Mayor’s Task Force on Breaking the Cycle of Mental Illness, Addictions and Homelessness report determines that “there is a need for small, properly staffed, supervised consumption sites to reduce the spread of disease, provide a sable point of contact for referrals and reduce the public disorder associated with public injection of drugs on our sidewalks (2007:10).” The Task Force recommends “strengthen[ing] harm reduction services to help mitigate public health and public order issues; in particular, investigate the use of substitution therapies and indoor supervised consumption sites and services (2007:15).”

The Steering Committee established an “Action Plan” that was committed to the outcomes of reducing open drug use, reducing individual drug use, improving health outcomes, fewer client visits to ER and fewer interactions with Police and the expanded availability of key services and treatment supports. The commitments included; within six months (May, 2008) a Section 56 application for supervised consumption service delivery (2007:27).”

The “Victoria Model” recommends “a best practice, evidence-based mental health and addictions strategy to meet the needs of the homeless SAMI population” and that “funders need to meet to review the model and determine how to support its implementation (2007:15).”

Costs related to homelessness and addictions in Victoria is calculated, including the cost of “cleaning up the refuse of 1,200 people living and using drugs on the streets. (2007:8)” By September 2007, the City of Victoria has already spent “$1.4 million spent on clean-up costs.

The Victoria Police Department reports that a group of 324 homeless individuals, many of whom are mentally ill, suffering from substance use disorders, or co-occurring disorders, are responsible for 23,033 police encounters over a period of 40 months at an estimated cost of over $9 million (2007:8).

VIHA hospitalization records indicate that 162 people were discharged to the streets from Capital Region hospitals in fiscal 2007 after being hospitalized for mental illness. Drug psychosis was the primary reason for hospital admission for this population… (2007:9).

The “Expert Panel” developed an integrated and comprehensive model of care that lists as a “basic needs’ support for homeless residents in Victoria a needle exchange and supervised consumption service (2007:37) – these are described as services “to address the most basic needs of homeless residents.”

In 2006, VIHA and the Public Health Agency of Canada release their report from the I-TRACK Surveys , an ongoing research initiative designed to track changes in the prevalence of HIV and hepatitis C and associated risk behaviours among people who inject drugs. The report presents the research from surveys of hundreds of IDU participants – 150 surveyed in 2003, then 254 surveyed in 2003 and 250 in 2005.

Overall the report found that injecting drug users in the surveys are engaging in multiple risk behaviours that put them at risk of transmitting and/or acquiring infections, with a high proportion of respondents injecting drugs on the street and a high proportion of respondents sharing needles and crack pipes. The report concludes that “results indicate strong support for both a safe injection site and a crack pipe distribution program among persons who use injection drugs in Victoria who participated in the I-TRACK survey (2006:27).”

The I-Track study found that a high proportion of drug users reporting that the street is the most common place for them to inject, with 68 percent had injected in a public place in the last six months – the highest proportions among Canadian cities surveyed .

The studies show an overall increase in high risk, needle sharing behaviours in Victoria, documenting 42 percent reporting needle sharing and 91 percent of crack smokers reported sharing pipes.

Approximately 85% of respondents reported using the SOS Needle Exchange in both phases of the research.

Researchers asked whether participants would use a safe injection site in Victoria, and a high proportion (72%) said yes, with those most likely to use a safe site being those people currently reporting to be using in the street.

In 2006, VIHA releases Closing the Gap , a strategic directions document “to articulate and guide the sustainable delivery of effective HIV and hepatitis C (HCV) services in the health authority over the next three years (VIHA, 2006:1).” VIHA’s service plan describe its role as ensuring comprehensive needle exchange services are provided in collaboration with drug users and community, public and private partners in health, social services, law enforcement, corrections and other relevant sectors.

The service plan set out targets including HIV prevention goals established by the province. VIHA’s funding was to achieve the goal of reducing the number of new HIV infections by 50%. At street level, VIHA set the target of reducing the 2004 rate of new HIV infections among South Island IDU’s (N=22) in half, meaning this year, in 2008, there should be no more than 11 new cases of HIV infection among the IDU population on the South Island .

In the spring and summer of 2005 the City of Victoria and VIHA held a series of public consultations on harm reduction, including safe consumption sites.

In July 2005, the City of Victoria releases the report Fitting the Pieces Together: Towards an Integrated Harm Reduction Response to Illicit Intravenous Drug Use in Victoria, BC. The report, developed in consultation with VIHA, the Victoria Police Department, service providers and drug users, proposes a “comprehensive continuum of harm reduction services … based on the policy directions of the City of Victoria and Vancouver Island Health Authority (2005:4).”

The report recommendations a continuum of harm reduction services include:
• Increase availability and accessibility of harm reduction supplies to meet provincial policy guidelines. For example, ensure that there is 24/7 access to needle exchange services and supplies through multiple venues across the City
• Pilot distribution of free crack pipes …
• Develop business case and research proposal for supervised consumption environments in Victoria…

In April 2004 the City of Victoria formally endorses a harm reduction policy framework.

In January 2003, the City of Victoria, VIHA and the Victoria Police Department launch the Downtown Health Initiative Action Plan to “intensify law enforcement of drug trafficking and provide additional supports to address addiction and mental health problems within the City.” The Action Plan lists ten actions, including “an investigation of the feasibility and effectiveness of a supervised safe injection site in our community.”

In September 2003, the Downtown Service Providers Group releases their report reviewing the gaps, resources and solutions to address homelessness in the Victoria downtown. The report lists five primary issues in downtown Victoria, including lack of addictions treatment and support services, including safe injection site” among other critical issues such as affordable housing and employment.

The 2002 report Missed Opportunities: Putting a Face on Injection Drug Use and HIV/AIDS in the Capital Health Region provides the estimate that there are 1,500 to 2,000 current injection drug users in the CHR. Research for this report included 98 people participating in interviews or focus groups, almost half of participants being injection drug users, as well as 70 hours of observations in drug hot spots. At that time, it is reported that approximately 800 injection drug users access Street Outreach Services (the Needle Exchange) each quarter and exchange over 400,000 needles annually.

The research indicated that “There is a lack of services for drug users who do want to protect themselves. The single fixed Needle Exchange site with its limited hours of operation cannot meet the needs of its clients.”

The study recommends a comprehensive harm reduction service for the region that would include:
fixed site needle exchange --- with expanded hours of operation and access to injecting equipment including needles, spoons, filters, sterile water, and bleach;
street outreach component --- including youth and adult outreach workers, and expanded social work and street nursing services;
mobile component --- including a van offering nursing/medical services, needle exchange, counseling support, referral, etc.; and
satellite needle exchange sites
The report specifically names the Health Authority in the recommendation to ensure improvements to access to clean needles and expanded hours of operation for the Street Outreach Service and fixed needle exchange (2002:67).

The researchers insist that a mobile exchange enhance – not replace – a fixed site needle exchange:
“Based on this evidence, some might conclude that a mobile rather than a fixed site harm reduction service should exist. However, a fixed site provides drug users with a consistent location to receive care, treatment and support. For some, it is their main source of support. At the same time, not all drug users can access the fixed site and other models of service delivery may be required for certain populations. … Both a fixed site harm reduction service and a mobile component are needed. Having a mobile component would, according to the participants, greatly reduce the risk behaviors/situations associated with drug use. The absence of such a service represents another missed opportunity to reduce the harm associated with drug use (2002: 35).”

A safe consumption site is recommended for Victoria in this 2002 research report.
“Recommendation 12: “That consideration be given to the establishment of a safe injection facility in the Capital Health Region. Planning for and development of a safe injection facility should include active participation by the community and by injection drug users (2002:69).”
The researchers note that “establishing a safe injection facility in the CHR is a partial solution to the public health problems associated with drug use” and note that participants suggest “that the planning and development of such a facility must include active participation from the community, including those with drug addictions.”

In 2001, the provincial government transferred responsibility for HIV services to the regional health authorities, with VIHA managing a $1.5 million budget for HIV services on Vancouver Island (VIHA, 2005). Approximately 30% of the budget has been allocated for needle exchange services .

Health Officers Council of BC (2008). Resolution 2008: Supervised Injection Services. Retrieved November 15, 2009.

McCall, Pauly, Goldstone, Gold & Payne (2007). The Ethical, Legal & Social Context of Harm Reduction. Canadian Nurse. October 2007; Adlersberg, Mary. Correspondence on Scope of Nursing Practices. Dec, 2007.

VIHA (2009). Needle Exchange Data. VIHA Information Bulletin. May 1, 2009. Retrieved November 15, 2009.

Pauly, Bernie & Joan MacNeil (2008). Reaching Out: Evaluating Outreach and Needle Exchange Services on Vancouver Island. School of Nursing, University of Victoria.

Aids Vancouver Island (2008). Research Report: Needle Distribution Through Secondary Outlets. Feb 28, 2008.

Fisher, B., Kendall, P. & Allard, C. (2008). The case for a supervised drug consumption site trial in Victoria, British Columbia. BC Medical Journal. Vol. 50, # 3, pp. 130-131. University of Victoria (2008). Media Release: Victoria needs to study supervised consumption sites. Retrieved on June 24, 2008 from http://communications.uvic.ca/releases/release.php?display=release&id=904

Fischer, B. & Allard, C. (2007). Feasibility Study on ‘Supervised Drug Consumption’ Options in the City of Victoria. Victoria, BC: Centre for Addictions Research of British Columbia.

Victoria Cool Aid Society (2007). Housing first – plus supports. Homeless needs survey 2007. Victoria, BC: Victoria Cool Aid Society.

City of Victoria (2007). Mayor’s task force on breaking the cycle of mental illness, addictions and homelessness: A Victoria model. Victoria, BC. For each set of outcomes, goals and actions, there is an “Accountability” section that describes VIHA as the lead agency for these actions.

VIHA (2006). I-TRACK: Enhanced surveillance of risk behaviours and prevalence of HIV and Hepatitis C among people who inject drugs. Victoria, BC: Epidemiology and Disease Control and Population Health Surveillance Unit, Vancouver Island Health Authority.

Health Canada (2006). I-Track: Enhanced surveillance of risk behaviours among injection drug users in Canada - Phase I Report. Ottawa: Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention, Health Canada.

VIHA (2006). Closing the Gap: Integrated HIV/AIDS and Hepatitis C Strategic Directions for Vancouver Island Health Authority 2006/07 – 2008/09. Victoria, BC: VIHA. Statistic from an earlier “Circulation Draft”, dated July 18, 2005.

Jones, B. & Hagen, K. (2005). A report on the City of Victoria’s harm reduction information sessions. Victoria, BC. Retrieved on June 25, 2008 from http://www.victoria.ca/cityhall/pdfs/hrmrdc_rprt0506.pdf.

City of Victoria (2005). Fitting the pieces together: Towards an integrated harm reduction response to illicit intravenous drug use in Victoria, BC. Victoria, BC: City of Victoria.

City of Victoria (2003). Media Release: Downtown Action Plan Announced. Victoria, BC: City of Victoria.

Downtown Service Providers Group (2003). Serving the homeless: Social agencies in “the red zone”. Victoria, BC.

Stajduhar, Kelli et al (2002). Missed Opportunities: Putting a face on injection drug use and HIV/AIDS in the Capital Health Region. Vancouver, BC: Centre for Health Evaluation and Outcome Services. Monograph 10. http://www.cheos.ubc.ca/monographs/Monograph10.pdf

VIHA (2006). Closing the Gap: Integrated HIV/AIDS and Hepatitis C Strategic Directions for Vancouver Island Health Authority 2006/07 – 2008/09. Victoria, BC: VIHA.