Dr. Lisa Lefebvre of Canada’s Centre for Addiction and Mental Health (CAMH) made an educational video in response to the Hoffman overdose. In it she addresses the issue of an addict’s ability to choose to use or not use heroin. “One of the biggest misconceptions is that it is a choice someone makes, and unfortunately that’s not the case…. Heroin addiction is an illness.… Thinking of this as a sort of disease of choice has not been helpful in the past because it has put the onus entirely on that person to, with their willpower, treat what is really a medical illness that needs medical and psychosocial treatments in order to improve the outcomes.”[13]
In a seminal ruling allowing the drug injection clinic InSite to continue operating in Vancouver, the Supreme Court of Canada (in a unanimous 9:0 ruling) said that “serious drug addiction is not a moral choice; it is an illness which essentially negates the notion of ‘choice’ altogether.”[14] Chief Justice McLachlin said many addicts “use multiple substances, and suffer from alcoholism.… [T]hese people are not engaged in recreational drug use: they are addicted.”
American jazz legend Billie Holiday’s riff on heroin explains it this way: “If you think dope is for kicks and thrills you’re out of your mind. There are more kicks to be had in a good case of paralytic polio and living in an iron lung. If you think you need stuff to play music or sing, you’re crazy. It can fix you so you can’t play nothing or sing nothing.” She went on to say that in Britain the authorities at least had the decency to treat addiction as a public health problem, but in America, “if you go to the doctor, he’s liable to slam the door in your face and call the cops.”[15]
Negative Effects of Criminalization
A number of negative health effects are also caused by the fact that heroin has been criminalized. These effects can be profound, sometimes life-threatening, and all-but-impossible to alleviate because of the fear of prosecution. The suppression efforts of law enforcement drive the trade underground, where there are no controls over the quality of the drug or its potency. Users are thus consuming dangerously adulterated and dangerously potent heroin, both of which can kill. Users also inject in unhygienic conditions because of a fear of being arrested. Forced to hide from the law, heroin users may inject with dirty, shared needles, using water from puddles, in cold back alleys that make it more difficult to inject into constricted veins. These conditions encourage the spread of deadly diseases like HIV/AIDS and HCV.
One heroin addict in Moscow described the fear occasioned by aggressive drug law enforcement, and the negative effects it produces: “Fear. Fear.… And not only fear of being caught, but fear that you will be caught and you won’t be able to get a fix. So on top of being pressured and robbed [by police], there’s the risk you’ll also end up being sick [from withdrawal]. And that’s why you’ll use whatever syringe is available right then and there.”[16]
Safe injection sites are one way of providing a safe place and safe conditions for heroin addicts to use their drugs. These are places staffed by trained nurses and doctors. Users must buy their drugs from their usual illegal source, but are provided with sterile syringes and clean surroundings in which to inject safely. Should the heroin prove to be so pure that the user begins to show signs of overdose, medical personnel step in to help. Similarly, should the heroin be adulterated with a dangerous substance,[17] they are available to deal with the consequences. The spread of HIV/AIDS and HCV is substantially reduced by safe injection sites because of the hygienic conditions in which the injections take place. As well, used needles must be left at the location, and so are not discarded in public places where they can cause harm to the public.
In Canada, the only safe injection site (InSite) is located in Vancouver. It was established in 2003 in response to the epidemic of illness and death associated with large numbers of heroin-addicted people living in the Downtown Eastside neighbourhood. It was able to operate due to an exemption from criminal prosecution provided by the federal Liberal government. Despite the proven success of InSite, the subsequent Conservative government spent three years and substantial funds to oppose its continuation. Only a direct order from the Supreme Court of Canada in 2011 compelled the Harper government to continue providing the site with its exemption from prosecution.
This case represented a direct confrontation between the hard-line criminal justice approach of the Conservative government and the public health approach represented by InSite. In assessing the evidence presented by both sides of this argument, the Supreme Court concluded that “InSite has saved lives and improved health. And it did those things without increasing the incidence of drug use and crime in the surrounding area. The Vancouver police support InSite. The city and provincial government want it to stay open.”[18] Chief Justice McLachlin noted that this tiny area of Vancouver is home to 4,600 intravenous drug users whose lives are on the line.
InSite said its staff had intervened in 336 overdoses since 2006, and that no deaths had occurred at the facility. It had supervised more than 1.8 million injections since it opened, and oversees an average of 587 injections daily.[19] In 1993, before InSite was opened, two hundred people were dying annually in the Downtown Eastside.[20] A recent peer-reviewed study reported in The Lancet showed that fatal overdoses dropped by 35 percent in the vicinity of InSite in the two years after it opened (from fifty-six deaths to thirty-three), compared to 9 percent in the rest of Vancouver during that same period. In 2011, there were sixty-six overdose deaths in the entire city.[21] Many others were contracting AIDS/HIV, Hepatitis C, and other serious illnesses. Today, British Columbia is the only Canadian province in which the rate of HIV infection is going down.
Importantly, InSite does more than just provide a safe place to inject drugs. Nurses attend to wounds, abscesses, and vein and skin conditions. Clients are treated like human beings and not like criminals. For some, it is the only place they can go where no one is judging them. And it is critical that the clinic provides a point of entry for treatment. There is a detox centre on its premises that claims a 43 percent completion rate for addicts who seek treatment — something addicts are otherwise reluctant to do because it means risking exposure to law enforcement. InSite also provides transitional housing for addicts who finish detox.
Critics of InSite say that “safe injection” is an oxymoron, and that programs like InSite “enable addictions.”[22] Because the emphasis of such a program is on maintenance and disease prevention rather than abstention, many are unwilling to see its value. “Arguably, places like InSite are actually making addictions worse by enabling the drug use and sending the message that its ‘okay’ to use drugs, so long as it’s done ‘safely,’” says one critic. This statement flies in the face of evidence that clearly shows the number of addicts to be falling substantially from harm-reduction programs such as the one in Switzerland.
Critics often fall back on inflammatory language in rejecting the idea of harm reduction. For example, one says that InSite is a “spit-shined flophouse of momentary sobriety” where, “despite any lofty claims, for most addicts, InSite’s just another place to get high.”[23] This critic claims that there has never been an independent analysis of InSite, choosing to ignore the extensive analysis done by the Supreme Court of Canada, among others. He appears to be unaware that even the Vancouver Police Department approves of the program and urges addicts to use the location.[24] Police say that “injecting drugs without close supervision compounds the problem. InSite has been established to reduce that risk.” Opened in 2003, InSite has been visited 1.9 million times and there have been no overdose deaths as a result of its services.
The Urban Health Research Initiative in Vancouver has recently reported some other remarkable improvements that can be largely attributed to harm-reduction programs.[25] For example, in 1996, 39.6 percent of drug users were borrowing needles. In 2011, only 1.7 percent were engaging in this risky behaviour. There have also been dramatic decreases in