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What is good evidence for safe injection?

The US presidential campaign, while fascinating, tends to overshadow policy debates in other countries.

This week the debate about safe-injection sites in Canada again reared its ugly head. Safe-injection sites, which exist in only a few cities in the world, are health facilities that allow injection drug users to legally use under supervision, with the aim of reducing harm to users’ health and to the public.

As advocates began a cross Canada tour this week to highlight the merits of harm reduction, the country’s leading national newspaper (The Globe and Mail) began a four part series on drug policy. The second part calls into question the evidence on safe-injection sites by stating we do not have “scientific proof” for harm reduction’s success.

But what is “good” evidence for safe injection?

InSite is North America’s only safe-infection site. Established in 2003 in response to high rates of injection drug use and HIV in what is perhaps Canada’s most desperate and vulnerable neighbourhood (the Downtown Eastside of Vancouver), InSite provides a place where drug users can inject under medical supervision and receive clean needles, condoms, counselling, and referral to other medical and social services. InSite operates because it has been given exemption from the federal drug laws. Harm reduction is an established part of drug policy and health promotion in many countries, but unsurprisingly is not without controversy. (When it opened, a White House drug control director called InSite “state-sponsored suicide”).

Since a recent change in national government in Canada, the extension of InSite’s exemption has been cast into doubt. Months of political dodge-ball, passionate debate, and now legal wrangling have ensued. And it all seems to be revolving around evidence.

The federal government claims their heel dragging is because they are still waiting for research that supports the safe injection site. Advocates say there are lots of data, from Vancouver and from Europe and Australia, which show that safe injection sites help people and reduce the spread of disease. Liz Evans, a founder of InSite, has been quoted as saying it “has not increased or prompted drug use, there is less needle sharing, less HIV and there has been no crime increase. People who visit the facility are 33% more likely to receive detox treatment, … and there have been 1 million injections at InSite without a single death.”

And now The Globe and Mail’s columnist has weighed in; charging the research is tainted because it is produced by people who have an interest in InSite continuing. She quotes an “addictions doctor” who says “You can churn out all the research you like if you’ve got a vested interest.”

Tell that to the BMJ, Lancet, New England Journal of Medicine, and Canadian Medical Association Journal, all of whom have peer-reviewed and published research on InSite’s impact. Among the authors are HIV scientists and physicians and the current president of the International AIDS Society—all of whom surely are interested in promoting the health and health care of injection drug users.

Indeed, as Hathaway and Tousaw have argued, scientific arguments alone will not change peoples’ minds about drugs and health promotion. And appreciating the human rights approach that underlies safe-infection sites does not require “evidence.”

In other words, if you have an interest in safe-injection sites not continuing, no evidence will likely ever be good enough.

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