Canada’s Controlled Drugs and Substances Act (CDSA) makes it a criminal offence to possess or traffic certain controlled substances, including various opioids (such as heroin) and cocaine. Section 56 of the Act gives the federal Minister of Health the authority to issue an exemption to ‘any person or class of persons’ from the application of sections of the Act if, in the Minister’s opinion, ‘the exemption is necessary for a medical or scientific purpose or is otherwise in the public interest’. It is with such an exemption that clients and operators of DCRs are able to operate. Without the exemption, they would face possible criminal prosecution for possession and/or trafficking of controlled substances.
The original exemption for Insite was based on feasibility data suggesting that a DCR could help reduce public drug use, overdose deaths and public disorder in the area. Insite is located in Vancouver’s Downtown Eastside (DTES), a neighbourhood that has a high concentration of poverty, of people affected by drug dependence and mental illness, and an open drug scene, including public injecting.
In September 2003, Vancouver’s regional health authority received a legal exemption from the federal Minister of Health to operate Insite, the first legally approved medically-supervised DCR in North America. PHS Community Services Society operates Insite under contract with the health authority. In 2006, under public pressure, the new Minister of Health granted an extension for the exemption, first until December 2007, and then again until June 2008. However, he rejected requests for a long-term solution permitting Insite to continue operating indefinitely.
Faced with the possibility of Insite’s closure, harm reduction activists began two court actions that sought to keep Insite open. The court cases also challenged both the application of Canada’s drug laws to Insite and the laws themselves as being unconstitutional.
In September 2011, the Canadian Supreme Court issued a unanimous judgment ruling in favour of Insite. The Court was persuaded by evidence that people who use drugs are considerably safer administering their own injections under medical surveillance rather than injecting drugs on the streets. As the Court succinctly declared, ‘Insite saves lives. Its benefits have been proven’. It ruled that shutting Insite would constitute an impermissible violation of the human rights under the Charter of some of those who are most vulnerable. It ordered the Minister to grant an exemption to Insite immediately, in order to respect the constitutional rights of facility users and staff.
Insite and similar facilities seek to reduce the risks of disease and overdose death often associated with injection drug use; connect clients to drug dependence treatment and other health and social services; and to reduce public drug use, injection-related garbage and other related public order problems. All clients can remain anonymous, although client service use and outcomes are tracked at an individual level. There are no admission criteria.
Partly as a condition of its original exemption from Canada’s drug laws, Insite has been subjected to rigorous scientific evaluation. The research has produced more than 30 peer-reviewed studies of the impacts of Insite, which demonstrate that the DCR:
• is being used by those for whom it was intended, including those most at risk for overdosing or becoming infected with HIV or hepatitis C, and those who would otherwise inject drugs in public places
• has reduced HIV risk behaviour: people who use Insite are less likely to share injection equipment, and also have greater access to condoms and safer sex information
• promotes access to drug dependence treatment and other health services. In the first year after it opened, there was more than a 30% increase in the use of detoxification programmes among Insite clients. It also offers care on-site for injection-related infections and frequently connects clients with off-site medical treatment
• has improved public order: near and around the facility, there has been a measurable decrease in the number of injections done in public and the amount of injection-related litter
• has reduced deaths from overdose. Because medical staff are present on-site to respond in emergencies, no overdoses that have occurred at Insite have been fatal; modelling suggests that Insite may have prevented as many as 48 overdose deaths over a four-year period. It has also reduced overdose deaths within the surrounding neighbourhood by 35% in the two years after opening
• provides safety for women who inject drugs by providing a safe space away from the dangers of street-based drug scenes
• prevents more than 80 HIV infections per year and to save CDN $17.6 million in HIV-related medical care.
The Insite staff are a mix of Vancouver Coastal Health and Portland Hotel Society employees, as well as peer-workers who are employed by L.I.N.E.S. (Life Is Not Enough Society). 2 nurses (VCH), 5 program workers (PHS), and 2 peer workers work in the DCR at all times. In the injection room, the staff-to-client ratio is 1:6, and in the chill-out lounge it is 1:10.
In addition, the facility includes Onsite, which consists of 12 rooms with private bathrooms where people can enter detox (including medically-assisted treatment) on a voluntary basis, with support from mental health workers, counsellors, nurses and physicians.