Insite: Canada's landmark safe injecting program at risk

InSite is North Americas first supervised injection site and a landmark public heath initiative operating in Vancouver since 2003. The program is a vital component of that cities internationally recognized harm reduction approach to its serious problems with drugs, crime, homelessness and AIDS. InSite currently operates under a waiver of Federal rules that allow it to provide services as a research project. An extensive evaluation has produced very positive results for thousands of users. Normally such strong evidence documenting the successes of such a program, and the medical and public health significance of these positive outcomes, would be the basis for celebration and moves to expand the model and provide similar services elsewhere in Canada. Instead, there is a distinct possibility that InSite will be closed by the newly elected Canadian Prime Minister Paul Harper – a conservative who has traveled to the US to visit George WQ Bush and come back antagonistic to harm reduction in all its forms. Because InSites federal waiver is expiring and up for renewal in September, the fear is that Mr. Harpers will not renew the approval and that the program will be forced to close down. The risks associated with the potential closure of InSite need to be fully understood. This editorial lays out these public health risks and the associated economic impact if InSite were to be closed. In addition to preventable deaths and disease, InSites closure will cost Vancouver and British Columbia between $3.8 and$ 8.8 million in preventable health care expenses over the next two years

Witch-hunt

Beginning two years ago, the US Dept of Health and Human Services began "special reviews" of all current research grants that involved harm reduction, sex and drugs, and continues its ban on funding of needle exchange. With Bush's second term, the campaign was extended to all US funded international programs that dealt with these issues and populations. And, most recently, the US has again undertaken to dominate the discourse within international organizations charged with drug control and AIDS policies – especially those of the UN. But the international harm reduction and human rights community is fighting back in several important ways, including "An Open Letter to the delegates of the Forty-eighth session of the Commission on Narcotic Drugs (CND) of the UN" prepared by a group of 334 well respected public health experts and human rights advocates, protesting U.S. pressure on the U.N. to withdraw its support from harm reduction. This editorial includes the letter and signatures as well as French, Spanish, and Russian versions of the letter as additional files

Policy makers ignoring science and scientists ignoring policy: the medical ethical challenges of heroin treatment

A decade of research in Switzerland, The Netherlands, Germany, and Spain now constitutes a massive body of work supporting the use of heroin treatment for the most difficult patients addicted to opiates. These trials concur on this method's safety and efficacy and are now serving as a prelude to the institution of heroin treatment in clinical practice throughout Europe. While the different sampling and research protocols for heroin treatment in these studies were important to the academic claims about specific results and conclusions that could be drawn from each study, the overall outcomes were quite clear – and uniformly positive. They all find that the use of prescribed pharmaceutical heroin does exactly what it is intended to do: it reaches a treatment refractory group of addicts by engaging them in a positive healthcare relationship with a physician, it reduces their criminal activity, improves their health status, and increases their social tenure through more stable housing, employment, and contact with family. The Canadian trial (NAOMI), now underway for over a year, but not yet completed, now faces a dilemma about what to do with its patients who have successfully completed 12 months of heroin and must be withdrawn from heroin and transferred to other treatments in accordance with the research protocol approved by Government of Canada, federal granting body and host institutions. The problem is that the principal criterion for acceptance to NAOMI was their history of repeated failure in these very same treatment programs to which they will now be referred. The existence of the results from abroad (some of which were not yet available when NAOMI was designed and initiated) now raises a very important question for Canada: is it ethical to continue to prohibit the medical use of heroin treatment that has already been shown to be feasible and effective in numerous medical studies throughout the world? And while this is being worked out, is it acceptable to require patients who have been successfully treated with heroin in Canada, to be forced to move back to less effective treatments (treatments that failed to be efficacious in the past)? This essay discusses this dilemma and places it in the broader context of ethics, science, and health policy. It makes the case for continuation of the current successful patients in heroin treatment and the institution of heroin treatment to all Canadian patients living with active addictions who qualify

On drug treatment and social control: Russian narcology's great leap backwards

The medical discipline of narcology in Russia is a subspecialty of psychiatry from the Soviet era and it is given warrant to define the scope of health activities with regard to alcohol and other drug use, drug users, and related problems. Narcological practice is in turn constrained by the State. The emergence of widespread injection opiate use and associated HIV morbidities and mortalities during the first decade following the collapse of the Soviet Union has brought the contradictions in Russian narcological discourse into high relief. Narcology officials in the Russian Federation have consistently opposed substitution treatment for opiate dependence – the replacement of a short-acting illegal substance with a longer acting prescribed drug with similar pharmacological action but lower degree of risk. Thus, despite the addition of methadone and buprenorphine to WHO's list of essential medicines in 2005 and multiple position papers by international experts calling for substitution treatment as a critical element in the response to HIV (IOM, 2006; UNODC, UNAIDS, and WHO, 2005), methadone or buprenorphine remain prohibited by law in Russia

Housing for People with Substance Use and Concurrent Disorders: Summary of Literature and Annotated Bibliography

Researchers at the Centre for Applied Research on Mental Health and Addiction (CARMHA) were contracted by Vancouver Coastal Health Authority to compile a brief, annotated bibliography focussing on the provision of housing for people with substance use and co-occurring mental disorders. A comprehensive literature review was completed. The list of publications and search methods are attached. The initial list was culled to extract those manuscripts with the greatest relevance. An expert panel reviewed each of the selected manuscripts and reached consensus on the major conclusions, implications, and quality of each paper. Finally, a brief synopsis of findings was produced

From Punishment to Treatment: A Providers’ Perspective on the Implementation of 2009 Rockefeller Drug Law Reforms in New York

Background: In 2009, New York reformed its “Rockefeller Drug Laws”, terminating mandatory imprisonment for many drug charges and expanding the availability of treatment alternatives to incarceration. The reforms occurred in an environment characterized by high incarceration rates, racial/ethnic disparities in drug convictions and incarceration rates, and expanded use of alternatives to incarceration. Early administrative data show a large impact on the criminal justice system. Few studies have considered the reforms from the providers’ perspective and none have sought to understand how providers are experiencing the reforms in their everyday practice. Methods: To provide a providers’ perspective, we use a qualitative, case-study approach entailing in-depth interviews with drug treatment program leaders and staff in six of the leading New York City drug programs, all with extensive experience treating court-mandated clients. Our goal was to assess treatment providers’ experiences during the reforms’ first years in effect. Results: The providers’ reports indicate that no new administrative structures or processes have been developed to foster a changed relationship between the treatment system and the criminal justice system; that the reforms failed to establish an enhanced role for treatment providers in the courts; and that client assessment, decisions on choice of treatment modalities, and program length for mandated clients continue to be dominated by criminal justice rather than clinical concerns. The providers also report some improvements in their communications and relationships with court employees involved in court-mandated cases. Conclusion: Despite some positive changes, implementation issues are potentially limiting the reforms’ ability to capitalize fully on the potential cost-savings and improvements in public health and safety that can result from the appropriate use of drug treatment as an alternative to incarceration. What appears to be occurring alongside the evolving shift from punishment to treatment under the terms of the reforms is a growing demand for treatment providers to meet the requirements of the powerful criminal justice system

The case of Scott Ortiz: a clash between criminal justice and public health

The criminal justice system creates particular challenges for persons with HIV and Hepatitis C, many of whom have a history of injection drug use. The case of Scott Ortiz, taken from public trial and sentencing transcripts, reveals the manner in which incarceration may delay learning of important health problems such as Hepatitis C infection. In addition, the case of Mr. Ortiz suggests the bias in sentencing that a former injection drug user may face. Collaboration between the Montefiore Medical Center residency in Social Medicine and a Bronx legal services agency, Bronx Defenders, yielded the discovery that a decade after diagnosis with HIV and after long term incarceration, Mr. Ortiz was infected with Hepatitis C. Mr. Ortiz only became aware of his advanced Hepatitis C and liver damage during his trial. The second important aspect of this case centers on the justification for lengthy sentence for a burglary conviction. The presiding Judge in Mr. Ortiz's case acknowledged that because of his advanced illness, Mr. Ortiz posed no threat to society as a burglar (the crime for which he was convicted). But the Judge elected to use his discretion to sentence Mr. Ortiz to a term of 15 years to life (as opposed to a minimum of two to four years) based on the idea that the public health would be served by preventing Mr. Ortiz from returning to the life of a street addict, sharing dirty needles with others. Mr. Ortiz reports distant injection drug use, no evidence of current or recent drug use was presented during Mr. Ortiz's trial and he reports no injection drug use for over a decade. In this case, bias against a former injection drug user, masquerading as concern for public health, is used to justify a lengthier sentence. Mr. Ortiz's lack of awareness of his Hepatitis C infection despite long term incarceration, combined with the justification for his dramatically increased sentence, provide examples of how persons within the criminal justice system may face particular challenges to their health

Years of life lost to prison: racial and gender gradients in the United States of America

© 2008 Hogg et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens