Insite

Insite is the first legal supervised injection site in North America, located at 139 East Hastings Street, in the Downtown Eastside (DTES) neighbourhood of Vancouver, British Columbia. The DTES had 4700 chronic drug users in 2000 and has been considered to be the centre of an "injection drug epidemic". The site provides a clean, safe location for injection drug use, primarily heroin, cocaine, and morphine. Medical staff are present to provide addiction treatment, mental health assistance, and first aid in the event of an overdose or wound. In 2009, the site recorded 276,178 visits (an average of 702 visits per day) by 5,447 unique users; 484 overdoses occurred with no fatalities, due to intervention by medical staff. Health Canada has provided $500,000 per year to operate the site, and the BC Ministry of Health contributed $1,200,000 to renovate the site and cover operating costs.

Operation
Insite is operated in tandem by Vancouver Coastal Health and the Portland Hotel Society. Between September 2003 and July 2008, the site operated under a special exemption of Section 56 of the Controlled Drugs and Substances Act, granted by the Liberal government via Health Canada. The site was slated to close on September 12, 2006, as the exemption was for a three year pilot project. The new Conservative government granted a temporary extension, then added another six month extension that was to end in mid-2008. A constitutional challenge was heard by B.C. Supreme Court to keep Insite open after Health Minister Tony Clement refused to renew the exemption beyond July 2008. The court ruled that laws prohibiting possession and trafficking of drugs were unconstitutional because they denied drug users access to Insite's health services. The safe injection site currently operates under a constitutional exception to the Controlled Drugs and Substances Act.

Research
When founded, Insite acquired legal exemption under the condition that its impacts be thoroughly evaluated. Consequently, the site has been the focus of more than thirty studies, published in 15 peer-reviewed journals. The research indicates an array of benefits, including reductions in public injecting and syringe sharing and increases in the use of detoxification services and addiction treatment among patients. In addition, studies assessing the potential harms of the site have not observed any adverse effects. Preliminary observations published in 2004 in the journal Harm Reduction indicate that the site successfully attracted injecting drug users and thus decreased public drug use. However, the researchers cautioned that a full assessment of the site will take several years. Additionally, research in the Canadian Medical Association Journal suggests that the site has reduced public injections, neighborhood litter, and needle sharing. A study in the journal Addiction indicates that patients at the site have increased their use of detoxification services and long-term addiction treatment. A study in the New England Journal of Medicine echoed this finding. Furthermore, research in The Lancet indicates that the site substantially reduces the sharing of syringes. A study in the journal Substance Abuse Treatment, Prevention, and Policy revealed that local police facilitate use of Insite, especially among high-risk users. The researchers concluded that the site "provides an opportunity to... resolve some of the existing tensions between public order and health initiatives." A 2008 cost-benefit analysis of the site in the Canadian Medical Association Journal observed net-savings of $18 million and an increase of 1175 life-years over ten years. Another cost-benefit analysis published in the International Journal of Drug Policy in 2010 determined that the site prevents 35 cases of HIV and about 3 deaths per year, indicating a yearly net-societal benefit of more than $6 million. An editorial in the Canadian Medical Association Journal noted that after three years of research "a remarkable consensus that the facility reduces harm to users and the public developed among scientists, criminologists  and even the Vancouver Police Department."

Reception
Insite enjoys strong local support. While Insite is well-liked throughout British Columbia, its popularity is highest inside Vancouver, where some 76% of residents expressed support for the site. Furthermore, according to a 2007 national survey by Mustel Group, some 63% of Canadians believe the federal government should renew the site's mandate while 27% oppose. Support is lowest among Conservatives, only half of whom believe the site should continue operating. Among clients, 95% or greater rated the site's services as excellent or good and its staff as reliable, respectful, and trustworthy.

Partners of Insite include the City of Vancouver, the Vancouver Police Department, and the PHS Community Services Society. The site has the support of Vancouver's mayor Gregor Robertson, former mayor Sam Sullivan, Premier of British Columbia Gordon Campbell, and former Vancouver mayors Larry Campbell, Mike Harcourt, and Philip Owen. The International AIDS Society, B.C. Centre for Excellence in HIV-AIDS, and the Canadian Union of Public Employees have also expressed support for Insite. Though initially opposed to the safe injection site, Chinatown and Gastown merchants associations now support it. International supporters include the UK-based think tank Senlis Council, the Australian Parliamentary Group for Drug Law Reform, and the American Drug Policy Alliance.

The site drew criticism from the Bush administration; the director of the White House Office of National Drug Control Policy called Insite "state-sponsored suicide" on its opening. The Royal Canadian Mounted Police (RCMP), Canada's national police force, has also criticized Insite. This is despite a report commissioned by the RCMP and conducted by two criminologist that concluded in favor of the injection site. In 2006, the Canadian Police Association voted unanimously to encourage the federal government to stop funding Insite and instead invest in a national drug strategy. Moreover, Canadian Health Minister Tony Clement branded Insite an "abomination," telling the Vancouver Sun that "allowing and/or encouraging people to inject heroin into their veins is not harm reduction... it is a form of harm addition."

In 2008 the Canadian Expert Committee evaluating Insite produced an international review of injecting facilities worldwide, and more particularly of Insite. With around 400 opiate injections daily the Expert Advisory Committee calculated that it could statistically save one (1.08) life per year. Drug Free Australia has asserted that the estimate by the Expert Advisory Committee, which did not record its method of calculation, accords well with the method used by the most comprehensive review of injecting facilities worldwide, that of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), to calculate numbers of lives saved in German consumption rooms. Overdoses in the local population have increased each year from 49 in 2002, to 50 in 2003 (the year it opened), to 64 in 2004 and to 77 in 2005.

The Expert Advisory Committee reported that over 8,000 people have visited INSITE to inject drugs. 18% percent, or 1506 of these 8,000 people, account for 80% of the overall visits to INSITE. Less than 10% used INSITE for all injections. The median number of visits is approximately eight. Drug Free Australia has calculated that by taking only the 1,506 injectors who most regularly use the centre, who would cumulatively inject somewhere between 6,000 and 9,000 times daily, the less than 500 injections in Insite daily represents at best one injection in every 12 by these clients inside the facility.

The Expert Advisory Committee reviewed the various journal studies of the impact of Insite on the transmission of HIV which had found positive outcomes, but they were “not convinced that these assumptions were entirely valid.”

The most significant published criticism has been an article by Colin Mangham, the director of research for the Drug Prevention Network of Canada, in the non-peer reviewed and online-only Journal of Global Drug Policy and Practice (JGDPP). In the article Mangham claims that “the published evaluations and especially reports in the popular media overstate findings, downplay or ignore negative findings, report meaningless findings and overall, give an impression the facility is successful, when in fact the research clearly shows a lack of program impact and success.” Based on this article, Tony Clement told an August 2007 meeting of the Canadian Medical Association his belief that Insite should close was reaffirmed. Clement stated that "there has been more research done, and some of it has been questioning of the research that has already taken place and questioning of the methodology of those associated with Insite." The JGDPP is run by the Drug Free America Foundation and received much of its initial funding from a $1.5 million grant from a U.S. Department of Justice agency now under investigation for corruption.

Mangham's article has been questioned because it dismisses more than 20 peer-reviewed studies published in reputable medical journals such as The Lancet, the New England Journal of Medicine, and the British Medical Journal, all of which indicate that Insite has a positive effect. The JGDPP article, which was commissioned and financed by the RCMP, drew further criticism in a commentary in the journal Open Medicine for being "fraught with a host of outright factual inaccuracies and unsubstantiated claims." More than 130 scientists signed a petition endorsing the commentary, which also criticized the government's evaluation of Insite as distortive and politicized. Another commentary in the International Journal of Drug Policy characterized the government's evaluation as "what may be a serious breach of international scientific standards".

Journal studies reporting that Insite did not cause increases in crime were shown by Colin Mangham to have made no mention of the fact that 4 police officers for 22 hours per day were assigned under an Insite-related agreement to patrol the block in which it was located, assisted by another 60 officers deployed across the surrounding 5 block area. Institute of Global Drug Policy interviews with Directors of five area treatment facilities all reported having neither any connection to INSITE nor any clients coming to them from INSITE.

Government and legal controversy
While the Liberal government allowed Insite to open, since 2006 its fate has been the responsibility of the new Conservative government, which has not been as supportive of it. Conservative Prime Minister Stephen Harper has voiced opposition to the injection site in the past, saying that "We as a government will not use taxpayers' money to fund drug use." In mid-July 2006, Conservative Member of Parliament David Fletcher stated that the government would let Insite's special exemption lapse before deciding whether to continue the project. The following week a spokesman for Tony Clement, the Minister of Health, refuted that, saying that a decision had not been made yet. During the XVI International AIDS Conference, held in Toronto, two high-ranking Liberal MPs (Bill Graham and Keith Martin) put their support behind the centre, and criticized the Conservative government for delaying their decision. Insite supporters also demonstrated in Toronto during the conference, prompting the government to further delay any announcement, citing the week's "politicized" nature.

On September 1, 2006, Health Minister Tony Clement deferred the decision of whether to extend the exemption for the site, citing a need for more research. However, on the same day the government cut all funding for future research, amounting to $1.5 million in lost research money. On August 13, 2007, the Portland Hotel Society and two drug addicts filed suit in the BC Supreme Court to keep the centre open, arguing that its closure would be a violation of the Charter right of Insite users to "security of the person." On October 4, 2007, during the announcement of its $64-million drug strategy, the Conservative government announced that Insite will be granted another six month extension, allowing it to operate until June 30, 2008. Minister Clements in that year cited the lack of outcomes by Insite as reason for its closure. He said:


 * " . . . (t)he expert advisory committee was very clear. It found that only 3% of those who attend Insite actually get referred to treatment and that only 10% of those who use Insite use it for all their injections. The expert advisory committee insisted that Insite only saved one life, and that life is important but I want to save more than one life. I want to save hundreds of lives around the downtown eastside, which is why we are focused on treatment and on professionals. Not one life should be lost."

In May 2008, the B.C. Supreme Court struck down sections of the Canadian Criminal Code prohibiting drug trafficking and possession, ruling that they contravened the Canadian Charter of Rights and Freedoms. While this ruling does not take effect until next year, Justice Ian Pettfield also granted Insite an immediate exemption to federal drug laws, giving it legal grounds to continue operating. Several days later the federal government announced plans to appeal the decision to the B.C. Court of Appeal. On 15 January 2010, the B.C. Court of Appeal dismissed the federal government's appeal in a 2-1 ruling. Three weeks later the federal government announced that it will appeal to the Supreme Court of Canada. On 10 February, some 150 people protested the federal government's decision to further appeal. The protesters barred Prime Minister Harper from attending a dress rehearsal for the Vancouver Chinatown Spring Festival Celebration. On February 12, The Canadian Union of Public Employees sent an open letter to Harper, urging him to accept the ruling of the lower courts and allow Insite to remain open.