Reducing the Harm Associated with Injection Drug Use in Canada
Appendix B - National And International Experiences (continued)
Needle Exchange Programs
Needle exchange programs are well established in the United Kingdom, the Netherlands, Australia and Switzerland.171 In the United Kingdom, needle exchange programs saw a rapid expansion during the late 80s and early 90s. At the same time, there was an increase in pharmacies which would sell injecting equipment to drug users. The rapid expansion was part of an overall harm reduction strategy that included an "active promotion of safer drug use for injectors".172
In an increasing number of prisons in Switzerland, Germany, and Spain, sterile syringes are provided to prisoners.173 These programs have demonstrated successful outcomes including reduced rates of occupational exposure to used needles by correctional services personnel and the removal of used needles from circulation. An evaluation of needle exchange programs in Swiss prisons indicated the following: consumption of drugs did not increase; syringes were not used as weapons; there were no incidents of needle stick injuries; sharing of syringes among prisoners greatly decreased; there were no new cases of HIV or hepatitis C; injection site abscesses did not increase; there was a decrease in drug related sanctions; a decrease in overdoses and suicides; and staff acceptance of the program increased.174
Needle exchange programs are well established in some parts of Canada and are one of the important strategies in a harm reduction approach to injection drug use, but it is necessary to improve them, expand them, particularly in rural communities and consider pilot projects in correctional facilities. Needle exchange programs have never been tried in a Canadian prison. Needle exchange programs should be part of a comprehensive outreach program which conveys educational messages about the health risks of injecting, and provides bleach kits, condoms, safe disposal of used needles, addiction and HIV counseling, HIV testing, referral and support and other services.
Supervised Injection Sites
Some countries are establishing sites where drug users can bring their own drugs and inject them in a supervised, safer environment, and other countries are considering this option. The desirability of supervised injection sites has been raised in many countries. The main purpose stated is to prevent fatal incidents by providing a hygienic setting and supervision. There are also opportunities to link supervised injection sites with adjunct services, such as needle exchange programs.
For example, injection rooms have existed in Germany for several years in some large cities. Frankfurt, has incorporated supervised injection sites into its harm reduction services, which include day or night rest areas and needle exchange programs.
The Frankfurt program has been evaluated and found to meet both the objectives of improving public health and increasing public order in the central city district as well as significantly reducing the number of homeless drug users, incidents of drug-related crime and violence, and drug-related deaths.175 In Luxembourg, a parliamentary bill has been introduced which proposes hygienic injecting rooms linked to medical assistance.
Switzerland has also incorporated supervised injection sites into its comprehensive strategy to assist drug users, including heroin maintenance, needle exchange programs, and methadone maintenance treatment. Swiss officials report that, given their comprehensive strategy and capacity to assist drug users, supervised injection sites were seen as the next logical step to help people with drug problems.
Discussions on supervised injection sites have also taken place in Denmark.176
Member States of the United Nations and the International Narcotics Control Board discussed supervised injection sites during the Forty-third Session of the Commission on Narcotic Drugs. The Board expressed the view "…that Governments, by permitting drug injection rooms and thus condoning such abuse, could be viewed as contravening the international drug control treaties by facilitating, aiding and/or abetting the commission of crimes…{and violating} the spirit, if not the letter of the international drug control treaties."
Other representatives, however, expressed a dissenting view, stating that drug injection rooms were not in contradiction with the international drug control treaties, and elaborated some practical benefits of injecting rooms involving enhanced assistance to long-term drug abusers not yet reached by existing services.177
As such, there was no consensus at the meeting of the Commission on Narcotic Drugs in March 2000 regarding whether or not supervised injection sites were in contravention of international drug control treaties.
Drug User Groups and Networks
Several countries have recognized the importance of involving drug users in developing and implementing strategies, policies, programs, and initiatives intended for them. As a result, groups and networks of drug users have been formed to provide these individuals with a stronger voice to affect change. Formal groups exist in some major cities in Canada such as Vancouver, Montreal, Regina and Toronto, and informal groups and networks are emerging across the country.
A major contributor to the success of Australia's response has been the partnerships between injecting drug user groups, government, and health professionals. Since the late 1980s, the Australian government has funded a number of user groups. They are managed and staffed by people who are strongly linked to the injection drug use community and are often former injection drug users. Funding is provided, specifically, for user groups to provide needle provision, peer-education on issues such as HIV/AIDS, hepatitis B and C, safer injecting methods, overdose, and adverse drug interactions. They are seen as a source of credible and easily accessible primary information and referral and provide valuable links between users and services such as alcohol and other drug treatment, counseling, and general health or social services.
Provision of Harm Reduction Information and Education to Drug Users
Drug education materials with a harm reduction focus aimed at high-risk populations are readily available in some countries while, in others, they are extremely controversial and often unavailable. The intention of these materials is not to promote use, but to explain to people who use how to reduce the risk associated with using drugs, especially overdose, transmission of HIV, the hepatitis C virus, and other blood-borne pathogens. In many countries, outreach workers distribute education material, syringes, condoms and bleach kits as well as help users contact other services.178
The United Kingdom provides harm reduction education to young people, acknowledging that taking risks and experimenting with drugs are common adolescent behaviours. The educational materials provide accurate information to youth about how to minimize health and other risks if they use or are going to use drugs.
In Canada, harm reduction information and education materials are often provided through community based needle exchange programs and drug user groups and networks.
Diversion Programs
Diversion programs provide a mechanism to divert people with drug problems away from the traditional justice system. In drug treatment courts, offenders accused of less serious (summary) drug offences are directed to a specialized court where a personalized treatment and rehabilitation plan can be designed using a combination of intense judicial supervision, comprehensive substance misuse treatment, random and frequent drug testing, incentives and sanctions, clinical case management, and ancillary services.
Drug treatment courts have existed in the United-States for over ten years; the over-riding goal is abstinence and law-abiding behaviour. They have demonstrated good retention rates (60% with adults, 70% with youth), and results indicate drug use and criminal activity are substantially reduced during treatment and up to one-year follow-up.179 To date approximately 200,000 persons have entered US drug treatment courts. Per person, drug treatment courts cost about $2,000 (US) annually, compared to $20,000 to $50,000 for incarceration.180
The European Union is trying to put in place a drug treatment court system. However, some member states lack sufficient judicial infrastructure or resources for such alternative measures. Australia and Ireland have set up pilot programs; evaluation results are expected soon.181
In early 1999, the Commonwealth Government of Australia gave assent and has set aside over $110 million in order to implement, evaluate and pursue drug diversion programs182. These programs are aimed at individuals who have little or no past criminal history and are apprehended for use or possession of small quantities of illicit drugs. Violent offenders are not eligible. The program in New South Wales consists of a special drug court to which eligible offenders are referred from other courts183. Participants have their sentence suspended while they undertake individualised drug treatment. Participants who do not comply may be sanctioned by a fine or up to fourteen days imprisonment. Victoria implements a cautionary process; drug offenders are referred by police for assessment and treatment within five days of arrest184. The funding for the Australian diversion programs is being provided by both health and law enforcement Ministries at federal, state and territory levels185.
In Canada, a drug treatment court was established in Toronto on December 1, 1998 as a four-year pilot project for Canada.186 It is targeted specifically at non-violent offenders who are addicted to crack, heroin or cocaine. Voluntary participants complete the program when they establish social stability in terms of housing, education and/or employment, and eliminate their use of cocaine and/or opiates. At the completion of the program, participants receive a non-custodial sentence, or may have their charges withdrawn.
In Canada, drug treatment courts are being positioned as a more humane approach to addressing minor drug crimes than incarceration. They are a means of supporting entry into treatment for those with a long history of incarceration. Early evaluation results of Toronto's drug treatment court indicate high rates of retention and program participation.187 Participant comments suggest that the drug court was a real alternative to traditional sentencing and offered them hope for a better life.
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