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Health Studies
HLTH 323
Stevenson Fergus

FIX: The Story of an Addicted City (Documentary) (October 22, 2013) Synopsis from Website: Dean Wilson used to be an IBM salesman. Now he is possibly the most outspoken drug addict in Canada. As president of the Vancouver Area Network of Drug Users (VANDU) he is a loud and articulate advocate for street addicts from Vancouver's Downtown Eastside, one of Canada’s poorest neighbourhoods, and the site of the highest HIV rate in North America. Ann Livingston is the charismatic organizer of VANDU. She is a non-user, driven by an impatient spirituality and she is as confrontational as hell. Together, Ann and Dean lead an unpredictable crew of street addicts in their fight to open North America's first safe injection site for drug users. Safe injection sites, where users can inject drugs without the danger of overdose or infection, are seen by supporters as the first step in bringing addicts into treatment programs. In 27 cities around the world, safe injection sites have been proven to save lives. Dean loves Ann. But he also is captured by the drugs he uses. Dean Wilson has found a curious ally in Philip Owen, the conservative Mayor of Vancouver who has alarmed members of his own party by championing a daring new drug philosophy called Harm Reduction. The Mayor's plan for dealing with drug and addiction breaks away from the American-style War on Drugs by seriously considering safe injection sites and heroin maintenance programs for long term addicts. Philip Owen is a mayor struggling to transform his city from being North America's most notorious drug port into possibly becoming the first city on the continent to realistically face drug addiction. The Mayor is staking his political career on Harm Reduction. Dean Wilson and Ann Livingston say the drug users are staking their lives on it. But not everyone agrees with the Mayor or the users. Key members of the Mayor's own political party, together with an alliance of business and local residents, say they will do everything they can to stop safe injection sites and the Mayor’s plan. They say their neighbourhoods, their children and their livelihoods are at risk. They are taking to the streets. So are the drug users. Vancouver Police Sergeant Doug Lang is the cop caught in the middle. He is in charge of the corner of Main and Hastings, the heart of North America's largest open drug scene. He wakes up homeless addicts who sleep in the streets, arrests drug dealers and tries to maintain a sense of law and order in the area - he calls it "shoveling water." As the Mayor battles members of his own political party, Dean Wilson dares to face his own addiction. The stories of FIX span over two years as our characters' lives interconnect to reveal a battle for the hearts, minds and streets of a city each one calls home. Reading: Introduction: The search for harm reduction. (p.93-97) (October 22, 2013)  Introduction to a volume of papers presented at the International Conference on the REduction of Drug-Related Harm in Toronto March 1994  Conference first started in Liverpool in 1990, because there was a recognition for the need for more prggmatic strategies for minimizing the risk of HIV transmission among injection drug users, and exploring the success of programs in the Netherlands, Australia and the UK in the 1980s (e.x. syringe-exchange schemes and prescribing of drugs)  Liverpool conference was not a new idea, but it began what formally may be called as the "harm reduction approach"; the coferences stimulated discussion of new perspectives on this approach  In the past there had been three major models to deal with substance use: o 1) Prohibitionish approach: existence of consensus in society that use of drugs is morally corrupt/one that violates the "collective conscience" of the community; control of the "bad" behaviour is best achieved by legal sanctions and a strong law-enforcement approach  Seen with the U.S. "War on Drugs"  Marginilization of druge users putting strain on the criminal-justice system and infringing on the rights of citizens  Reason why new directions/models havebeen sougt out o 2) Legalization: removal of criminal penalties; illicit drugs should eventually be legalized so the black market could be wiped out, supply of drugs could be regulated, and resources and treatment could be increase as money allocated toward law enforcement and processing of criminal offenders is saved  Fear that legalization will promote excessive use, and it is not yet clear how to regulate the supply and distribution of drugs by the government o 3) Medical approach: belief that deviant behaiours, like substance use, are medical problems/sickness, and parentients are no longer held responsible for this sickness, but are obligated to seek medical help to revoer  Drug addict would be perceived as a sick person rather than a criminal, in need of medical attention  However, this field has not come up with a medical remidy that alone can cure the disease; usually, drug usage involves a variety of factors, including psychological, social, cultural, and physiologyical levels  Harm Reduction Model seeks to eliminate constraints ondrug strategies set by existing approaches o Seen with public education on the helath risks of tobacco use, methadone pprograms for opiod users, needle-exchange programs for injection drug users to decrease the risk of HIV...etc. o Model includes three major levels: Concetualization Level, Practical Level, Policy Level o A: At the Conceptualization Level  1) A value-neutral view of drug use: attacheds no moral, leval, or medical- reductioinst strings to drug use  2) A value-neutral view of the user: user of the drug is normal, and not a criminal, morally or medically deviant  3) Focus on the problem rather than the person using it  4) The irrelevance of abstinence: accepts the fact that the user will continue to use drugs while in a drug program or in the community  5) User's role in harm reduction: user is capable of making their own chaoices and places an important role in prevention, treatment, and recovery processes o B: At the Practical Level  1) Prioritization of goals: Harm reduction gives priority to strategies that can achieve more immediate and realizable goals than long-term intervention  2) Pragmatic programs: strategy is exlectic, and achieves any immediate and realizable goal; great flexibility in methods used  3) User-centred programs: solicity cooperation and participation of drug users in determining the most appropriate prevention and invervention tchniques  4) Emphasis of choice: users are encouraged to voluntarily make their own choices regarding prevention and intervention issues o C: At the Policy Level  1) A mosaic of middle-range polciies: generation of policy measures that match a wide spectrum of patterns of drug use; disaggregating drug progblems into manageable components, instead of rigid, bulky rules  2) Accomodation by existing policy: middle range needed to make strategies accepted and incorporated by legal authosities (e.x. needle exchange programs v.s. putting those using in jail)  3) Focus on human rights: rights of citizens protected, and not violated in the 'war on drugs'  Still some issues with this model: definition of harm, the assessment of harm resultign from drug use, the evaluation o such programs and the political issues int eh movements are all areas that have gaps in this model  As more poeple participated in drug use, it became clear that harm reduction needed to step beyond the confines of prevention of HIV infection among injection drug users, and use more methods to decrease harm to drug users (need to do many different things in order to reduce the adverse consequences of substance use)  There is a need to understand and apply this approach and its distinctive features properly; due to its flexibility of programming, these features may be lost; users of this approach shouldr ead the theory and practice before proceeding to do work in harm reduction Harm Reduction as a Health Promotion Strategy (October 25, 2013) Some Approaches to Drug Problems  Prohibition (typical)  Legalization (typical)  Medicalization - look at drug use as a medical problem (having an illness intervened by medical intervention through referrals and treatments/prescriptions)  Harm Reduction Prohibitionist Approach to Illicit Drugs  U.S. - style "War on Drugs" - now being seen in Canada  See people who use drugs as people with moral failings  Realistic? Not realistic to think we can change the views of all those around us  Limited efficacy  Puts a strain on the criminal justice system  Impedes on the rights of those taking drugs Legalization Approach to Illicit Drugs  Different levels of drugs: e.x. Marijuana vs. Heroin and Cocaine  Arguments around Marijuana to be legalized in Canada - evidence that it is a medical treatment; also presents less health issues than tobacco and alcohol.  Criticisms: o Naive? Will problems simply go away, or will usage increase and problems arise o Explicitly condoning? o Increasing use? o Appropriate for all drugs? Do we need to make a distinction between drugs Access to Marijuana  Colorado and Washington State last year allowed Marijuana to be used for recreational processes. State government to regulate production of Marijuana  Could not use and drive; and regulation on Marijuana use and production  California attempted, but it did not pass (Regulation 19) Harm Reduction Approach  Value neutral view of drug use and users  Focus is on ameliorating harms (rather than trying to get people to stop using drugs)  Health promotion may be broadly focused  Recognizes varying stages of change/irrelevance of abstinence to some (some may be at a stage to get off the drugs and to get treatment/detox, while others cannot)  More realistic about Some Harm Reduction Strategies  Supervised injection sites  Needle exchanges  Methadone maintenance (keeps negative side effects away after using Heroin)  Heroin prescription (instead of spending time and money buying Heroin, a pharmacy would provide the Heroin needed to keep yourself steady until you can get off the drug)  Distribution of crack stems  Managed alcohol programs Insite  Vancouver DTA (129 E Hastings St) o Home to 1/3 of city's 12,000 IDUs o IDUs: 30-40% HIV+, >90% Hep. C  Established 12 September 2003  Granted 3-year exemption under Controlled Drugs and Substances Act  Operated by Vancouver Coastal Health and Portland Hotel Society  Evaluation by BC Centre for Excellence in HIV/AIDS  First injection site to this date in North America  Similar to programs in Australia, Switzerland, Germany, Holland, Norway, and Spain  Open 10AM to 4AM, 7 days/week  Funding o Health Canada: $500L/year for evaluation o BC Ministry of Health: $1.2 million to renovate space, plus operating costs  Staffing o 16 registered nurses (2 always on duty) o Physician (on call) o Addictions counsellor (on call) o On-site manager o Program staff, including peer educators Insite Evaluation Results  Over 7,000 unique clients o 26% women o 18% Aboriginal  600 injections/day (18,000/month)  Average client: 11 visits/month  Large numbers of homeless/people who have publicly injected  4,000 referrals/year (40% to addiction treatment)  20% of regular visitors started detox  Over 2 years, 500 overdoses o None fatal o Only 10% transferred to hospital (less cost/burden on ambulances!)  Less needle sharing o Regular clients 70% less likely to share  No worsening of drug use in community  No worsening of crime in community Future of Safe injection sites (SIS) in Canada  September 2006: Extension of Insite exemption through December 2007  August 2007: Insite backers file suit in BC Supreme court  October 2007: Another extension through June  May 2008: B.C. Supreme Court rules in favour of Insite, federal government appeals ruling  January 2010: BC Court of Appeals dismisses appeal  February 2010: Federal government appeals to Supreme Court of Canada  September 2011: Supreme Court of Canada unanimously rules in favour of Insite Currently  10 years of Insite and controversy - Q and A with Jian Ghomeshi, CBC Radio, 18 September 2013  6 June 2013 - Bill C-65 "Respect for Communities Act" Needle Exchange Programs  1980s: Began in the Netherlands  Rationale: o Decrease needle sharing o Provide counselling, testing, referrals, assistance o Distribute sterile needles/syringes, filters cookers, alcohol swabs, sterile water, tourniquets, condoms  Canada o 1989: First program in Vancouver o Today: Over 200  Ontario o Mandated o 2004: 28 programs with >80 locations Kingston Needle Exchange  One of the 2 busiest programs in Ontario  HIV/AIDS Regional Services (844 Princess St.) o More than 50,000 syringes distributed per year  Street Health Centre (253 Wellington St.) Managed Alcohol Programs  Participants o Chronic, heavy, long-term alcoholism (often drink non-beverage alcohol) o Chronically homeless o Little social support o Have failed detox/treatment o Heavy burden on criminal justice and healthcare systems  Participants provided limited amount of alcohol hourly Managed Alcohol Programs (MAP) in Ontario  1997: 3 homeless men freeze in Toronto winter  2001: Shepherds of Good Hope shelter in Ottawa's Lowertown begins MAP  2002: Seaton House Annex homeless shelter in Toronto goes "wet"  2006: Wesley Urban Ministries' Claremont House shelter in Hamilton begins MAP Ottawa MAP  City, U of Ottawa, SGH  15-bed shelter  Up to 5 oz. wine hourly from 7AM to 10PM  Evaluation published: MAP has helped decrease alcohol use, especially use of Listerine/non-drinking alcohol  Also shown less health care and criminal issues (e.x. hospital visits, police reports, intoxication...etc. Harm Reduction II - Reading 1: "The Canadian government's treatment of scientific process and evidence: Inside the evaluation of North America's first supervised injecting facility" By: E. Wood, T. Kerr, M/W/ Tyndall, and JSG Montaner (2008)  Growing concerns raised regarding Canada's federal government's treatment of scientific processes and evidence (relevant to the first SIF, opening in Vancouver in 2003).  This may have been a serious breach to scientific standards, internationally, relating to how the Canadian government handled the SIF's evaluation and what led to a moratorium on SIF trials in other Canadian cities  Hoping that the report will lead to a greater public scrutiny of the Canadian government's handling of addiction research and drug policy  Gap between best evidence and public policy, especially to the illicit drug problem  2003: successful application to the federal government for a legal exemption to place an SIF in Vancouver - granted on the basis of success in international settings; that an SIF promotes safe syringe use and emergency care for overdose events  This application was granted on the basis of a scientific evaluation that would need to be done  Some governments, Canada included, are hesitant to support health strategies that do not fall under the zero-tolerance umbrella, even though drug use interventions are needed ASAP  Illicit drug use and health interventions has been in debate for years: findings specific to HIV prevention interventions have been misrepresented by opponents of these strategies; despite peer-review journals and scientific bodies have endorsed the results  A Canadian federal task force recommended that SIF research be prioritized and that the evaluation (funded by Health Canada)on the Vancouver site occur within a 3-year period  Cohort within the SIF known as the Scientific Evaluation of Supervised Injecting (SEOSI) cohort enrolled 1000 SIF users through randomized recruitment, and were monitored semi-annually for various health indicators and SIF impacts  Scientific safeguards were put in place (evaluation needed to stand up to the highest level of scrutiny): o 1) Regional SIF oversight committee, including members of all stakeholder groups was developed for the project o 2) trend (transparent reporting of evaluations with nonrandomized designs) criteria for observational research was undertaken; required that evaluation be subject to peer review for scientific openness o 3) All findings be subject to external peer review and publication prior to dissemination  Findings: although politicians have implied limited scientific support for Insite, the first 3-year phase showed significant scientific outputs (22 peer-reviewed studies with programme's impacts) o Included in findings were a reduced amount of public injection and HIV risk behaviour and increased uptake of addiction treatment o Found no evidence of negative impacts of the SIF  As a result, an additional 3.5 years was added to the SIF, and funding was submitted to Health Canada in May 2006  Although the program received support from all levels of government, two federal law enforcement organisations put forth statements saying the SIF was unsuccessful and request for a halt  After the CPA (Canadian Police Association) put forth a call to close the SIF did the Health Minister of Canada state that he could not approve the request to extend the Vancouver site, as he needed more answers  Government also decided to prohibit new SIF research in the rest of Canada  Government also stated that grants would be awarded to investigators who agreed to refrain from disseminating findings until 6 months after the completion of research and after the legal expansion had expired - According to UBC, this was against university ethical and legal research guidelines (SOESI investigators were precluded from participating)  Events above brought forward for the following reasons: o 1) Federal government may have interfered with the development of evidence- based health policy by disregarding the scientific results of the evaluation o 2) Health Minister claimed new questions have been raised from the research, yet the Minister has failed to bring those forward; if research must be done the SEOSI cohort had to stay intact - by taking away the cohort, the research was compromised o 3) Vancouver SIF evaluation already demonstrated health and community benefits of the SIF, consistent to those evaluations abroad o 4) Two federal law enforcement organisations spoke out against continued SIF research at the same time as the federal government making an announcement regarding SIF research, before the Health Minister's decision regarding the SIF was announced; RCMP funded the studies, but after the first two reviews endorsed the SEOSI-based evaluation,, saying SIF is a tool to decrease drug- related harm, the RCMP released a press release to distance themselves from he reviews' conclusions  Limitations to the evaluations: scientific reports not accessible to general public and media (lay reports); therefore, greater scrutiny of government's response could have been made with a greater understanding of the results  General public has little understanding about alternatives to the "get tough" drug strategies, and so they will support the government's and law enforcement's plans  However, when peer-reviewed reports and scientific research are ignored by politicians, the scientific community feels undermined  Although the primary focus should be of the health and well-being of people using the SIF, the disregard for the scientific results is a serious breach of international scientific standards  Government's reasoning for going against the results of the evaluation are still unknown  Canadian Institutes of Health Research (Canada's national health research organization, which acts separately from the government) fully funded the SIF in Vancouver Harm Reduction II: Reading 2: "Going soft on evidence and due process: Canada adopts U.S. style harm maximization" By: A. Wodak (2008)  Canadian government recently took a step closer towards the U.S.'s war on drugs  The Federal government took on Canada's provincial and city governments and ignored science due to the public opinion and risk of harming the country's international standing (done in readiness to dump Insite an SIF at a political time)  Lack of transparency and questionable probity of the Canadian government's response to the evaluations of Insite  Federal Minister of Health announced the extension of the legal exemption for SIF for another 6 months to allow for further research, but then announced the funding to conduct the research was cancelled  Now compelling evidence towards benefits, lack of serious unintended negative consequences and cost-effectiveness of medically supervised injection centers, much denied from the evaluation of Insite  This high-level research means more to researchers and clinicians than politicians, likely due to the lack of lay language, especially during controversial drug policy choices; however, researchers must be careful not to cross into advocacy territory from their research non-partisan territory  No current harm-reduction measure, including SIF breached treaties previously brught about by this rigorous evaluation that the SIF was conditional to undergo after receiving exemption  Resisting the introduction to SIF is unethical and breaches Canada' international human rights obligations!  Evaluations in the U.S. that were definitive with the results of SIF sites reducing the number of HIV infections without increasing illicit drug use still did not promote the use of SIF in the government  For the first time, the U.S. is providing funding to a Washington D.C. needle syringe program  In drug policy, often what is effective is unpopular; War on Drugs takes advantage of this appeal  Having the approach of decreasing supply of the drugs is empirically weak; harm- reduction often seems counter-intuitive and weak compared to the War on Drugs though  Belief that it is moral to ignore clear scientific evidence which could protect the public and communities in future - completely wrong take by the government  Politicians want to do well, but they need to realize that they are temporary and must do good, even if it is not the most popular thing to do. Harm Reduction II: Reading 3: "Adrift from the moorings of good public policy: Ignoring evidence and human rights." By: R. Elliott (2008)  With regards to the Canadian government's approach to Insite (North America's first SIF), the government was hostile to evidence and human rights in public policy, as policy involves the health of those who use illicit drugs  Health minister declared he would not facilitate the delivery of health services to some of the most marginalized and at risk communities in Canada through SIF, despite the evidence that supports SIF programming  From the government, failure to show link between Insite and reduction in crime has lead to discontinuation in a legal exemption - despite growing body of evidence that supports the health benefits of the program o Having said this, evaluation has shown that crime has not increased since the program's introduction  Drug Strategy in 2005 focused on ridding society of substance use harms; "four pillars" of the strategy: prevention of problematic drug use, treatment of drug dependence, law enforcement to reduce the supply of drugs, and harm reduction measures to limit possible secondary effects of substance use (like HIV/AIDS and Hepatitis C)  Discussion from Health Canada and Canadian Centre on Substance Abuse released a national framework for reducing the drug-related harms, underscoring the importance of harm reduction measures in Canada's strategy to
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