Proponents of needle exchange programs like “Cactus” in Montreal (the first of its kind in North America) say that the Supreme Court decision on InSite will let them “stop being hypocrites” if it means that they will now be able to open a full-service safe injection site.[26] As Cactus community coordinator Jean-François Mary said, “For 22 years, we gave people clean tools, then sent them out into the street. We were doing half the work. Now they’ll be able to shoot up in complete safety.”
Unfortunately, it seems that the current Conservative government is trying to make setting up these safe injection sites in Canada a lot more difficult. Proposed new regulations will make it near-impossible to satisfy all the requirements for opening such a facility. Not only will new sites have difficulty meeting these new requirements, but InSite itself will now find it hard to renew its mandate. The federal health minister will now be able to block safe injection sites based upon his or her assessment of “the local conditions indicating a need,” “the regulatory structure in place to support the facility,” and “expressions of community support or opposition.” The fact that the mayor and police chief in Toronto are both opposed will probably weigh more heavily with the current government than the expressions of support by public health officials.[27]
Other cities in Canada are planning to apply for an InSite-style exemption from criminal law so that they can operate safe injection sites as well. At the end of 2013, Montreal had approved four new supervised injection sites, including one mobile unit.[28] With start-up costs of $3.2 million and operating costs of $2.7 million per year, proponents said the program would pay for itself within four years. They claimed that the health care system would be the winner, with reduced incidences of HIV/AIDS, HCV, overdoses, and problems with dirty needles left in public places. However, nothing can happen until Health Canada provides an exemption from criminal prosecution — something that is by no means guaranteed under the new regulations.
Thousands of prison inmates who inject drugs like heroin are also at risk for disease and death. The government has steadfastly refused to allow for a needle exchange program in prisons despite repeated requests by the prison ombudsman.[29] Prison authorities provide bleach for cleaning needles, but this is not a wholly effective method of killing viruses. The resulting rates of HIV/AIDS and Hepatitis C are ten to twenty times higher in the prison population than in the general population. These are serious and even deadly diseases, which are later spread to the community as prisoners are released from incarceration.
Reasons provided by the correctional services for refusing clean needles have no foundation in fact. Prison needle exchanges do not lead to an increase in drug use, do not result in syringes being used as weapons, and do not result in an increase in accidental needle-stick injuries. These three myths have been rejected by the Public Health Agency of Canada.[30]
Needle exchanges are run inside prisons in many countries, including Spain, Moldova, Iran, and Kyrgyzstan.[31] These regimes are not known for their progressive ideas with regard to incarceration, but they do recognize the facts of life, one of which is that inmates will find ways to obtain drugs and inject them.
NAOMI, the North American Opiate Management Initiative, was a program that operated out of St. Paul’s Hospital in Vancouver. NAOMI supervised the administration of heroin to 350 of the “toughest, most difficult to reach narcotic abusers,” according to Dr. Keith Martin.[32] The randomized trial divided addicts into three groups and provided them with heroin, hydromorphone, or methadone. Hydromorphone is a very potent opioid, a derivative of morphine, used to treat chronic pain. It is anywhere from six to ten times as strong as morphine. Methadone is a synthetic opioid that is legal, has been approved for use as an alternative to heroin, and can be prescribed for addicts. In the remarkable results reported by the NAOMI project, users who were resistant to methadone, and to whom heroin was provided instead, were 62 percent more likely to remain in treatment, used less heroin, and committed fewer crimes.[33] They also showed improved employment satisfaction and social integration — all indicators of a return to some version of a normal lifestyle.
In practice, NAOMI patients attend at a facility like Vancouver’s Crosstown Clinic at set times (two to three times a day) and sign in to receive their prescribed heroin. They are turned away if they have been using alcohol. The clinic provides them with a measured dose of pharmaceutical-grade heroin and sterilized equipment. The patients administer the dose themselves in a mirrored room, and then must sit in the lounge for twenty minutes for monitoring so that staff can deal with any negative reactions.
Dave Murray was one of the addicts who was treated with heroin.[34] He says he is living proof that heroin maintenance works. “After more than 20 years dealing and injecting drugs, Mr. Murray participated in the earlier NAOMI trial, where he regularly received doses of heroin without having to worry about his next fix. This new stability erased the stress from his life and prompted reflection, Mr. Murray said. ‘My brain re-engaged, and I made a conscious decision to try detox. I failed at first, but about three years ago, finally I stopped using.’”
Health Canada sought advice from independent experts on the subject of prescription heroin.[35] These experts told Health Canada that this is the only “next step” available for some addicts, and that prescription heroin is a “promising treatment of last resort.” They also said it decreases harm to individuals and to their families. The Health Minister of British Columbia calls prescription heroin “compassionate use of a medication.”
A follow-up study to NAOMI, “The Study to Assess Longer-term Opioid Medication Effectiveness” (SALOME) has been designed to determine the effectiveness of providing hydromorphone to heroin addicts.[36] It involves 322 patients and will be completed by early 2015. It will attempt to show whether or not hydromorphone is as good as prescription heroin at treating the addicts who do not respond to methadone. Hydromorphone treatment currently costs $39 per day, a not-insignificant amount for patients.
The question then arises: why is the government going to such lengths to find a viable alternative to heroin when prescribed heroin itself appears to provide the best results? We know that methadone does not work for everyone, and that some addicts suffer from pain and craving when they take it.[37] As one pharmacist says, “Most addicts loathe it. It is a highly addictive synthetic opiate, more addictive than heroin and harder to withdraw from, but it survives the digestive system and so does not need to be injected.”[38] In other words, addicts are being required to drink “green gunk” largely because legislators appear to have an aversion to the idea of injection, and especially to providing heroin as the best treatment. As Dr. Perry Kendall, British Columbia Provincial Health Officer, says, “In Switzerland and Germany, they don’t have a problem with treating people with heroin, but here we do.”[39]
Doctors in the SALOME project expressed concerns about an exit strategy for addicts who would be leaving the clinical trials. How would they survive if they could no longer rely upon heroin maintenance? The doctors made an application to Health Canada under its Special Access Program (SAP) to enable them to continue with heroin maintenance and Health Canada duly approved prescription heroin (for ninety days after exiting the program) for 21 of the addicts who would otherwise be facing serious, life-threatening conditions.[40]
When this came to light, the Health minister, Rona Ambrose, was swift in her response. She quickly banned what she called “dangerous drugs like heroin, cocaine, ecstasy, and LSD” from being prescribed to patients.[41] And she followed this up by stating that “the prime minister and I do not believe we are serving the interests of those who are addicted to drugs or those who need our help by giving them the very drugs they are addicted to.”[42] She suggested that addicts try alternative approaches like acupuncture.
Five of the affected addicts, together with their health provider, Providence Health Care, and a legal advocacy group have now filed a lawsuit challenging the federal government.[43] The same arguments will be made as were successfully made in keeping InSite open. In that case, the Supreme Court of Canada found that the government’s attempts to close the site were “grossly disproportionate because the potential