Prevention in Focus

Fall 2017 

Research Update: Supervised injection facilities in Canada: past present and future

By Zak Knowles

The current opioid epidemic in Canada has led to an increased understanding of the health-related and social harms associated with injection drug use. There is growing acceptance of the need for supervised injection facilities (SIFs) to help reduce these harms and the number of overdose deaths. A recent review1 looks at the history and future of SIFs in Canada and the impact of peers in the history and future of SIFs.

SIFs in Vancouver

In the mid to late 1990s, Vancouver’s health authority declared a public health emergency in response to a high HIV incidence rate (19%) and a large number of fatal overdoses (300). Despite a task group recommending the setting up of SIFs, local health authorities made no plans to implement them. As a result, a peer-led group of people who inject drugs opened and operated the unsanctioned Back Alley SIF in 1995, with over 100 people using this site per night. The site was closed by police after one year. Other unsanctioned SIFs opened, including peer-led models and one at the Dr. Peter Centre where nurses began supervising injections in 2002.

The development of Canada’s first legally sanctioned SIF, Insite, was accelerated by a community organization who quietly built a SIF within an abandoned building. This prompted the health authority to work with them to open Insite in September 2003. It was a vigorously evaluated scientific pilot project with over 40 peer-reviewed studies showing that the facility has many health and social benefits and no negative impacts on public safety and health.

Despite the positive research, the federal Conservative government at the time repeatedly tried to close Insite. This led to several Supreme Court challenges, which ultimately ended with a 9-0 ruling by the Supreme Court justices in favour of the continued operation of Insite. Following the ruling, the Conservative government passed Bill C-2, which outlined 26 conditions that had to be met before a SIF could open.

The election of the Liberal government in October 2015 has changed the narrative, with the new government being actively supportive of SIFs. Health Canada gave a legal exemption to the Dr. Peter Centre a few months after the new government came to power. A new bill, Bill C-37, replaces Bill C-2’s 26 conditions for opening a SIF with five conditions, thus simplifying the path to opening a SIF.

Planning for new SIFs

A number of municipalities are now planning for SIFs. In February 2017, Montreal received federal approval to open three SIFs. The city of Vancouver is seeking approval to open several more SIFs, including one for women only which is expected to open in 2017. Other cities with advanced plans to open SIFs are Victoria (one site) and Surrey (one site) in B.C., Toronto (three sites, which received federal approval to open in June 2017) and Ottawa (one site) in Ontario, and Edmonton (four sites) in Alberta. Support for SIFs has varied considerably, with the mayor and police in Ottawa and citizen groups in Victoria expressing opposition. Similar opposition in Kamloops and Kelowna, B.C., has led the public health authorities to consider mobile rather than fixed-site SIFs. Several other municipalities across Canada have begun to discuss or start to conduct feasibility research, including Thunder Bay, London and Hamilton in Ontario, Chilliwack in B.C., Calgary in Alberta, and Saskatoon in Saskatchewan.

The fentanyl overdose crisis and overdose prevention sites

Concurrent with increasing acceptance of SIFs, there have been increasing epidemics of opioid overdoses across Canada. This has been compounded by the emergence of illicit fentanyl, a powerful opioid that has been found mixed with drugs such as heroin.

In response to the number of overdose deaths in Vancouver’s Downtown Eastside and the inability of the local SIF to meet demand, peers set up a tent where people could inject and smoke with supervision and receive emergency overdose treatment if necessary. This “pop-up” SIF was effective and tolerated by local health officials and police, prompting similar ones to open in other locations across B.C. These pop-up SIFs are well used and have a good record of reversing overdoses.

The B.C. Health Minister also instructed various regional health authorities in B.C. to open “overdose prevention sites” (OPSs). These are indoor facilities where people who inject drugs are given sterile equipment, and non-nursing staff provide emergency response (naloxone) in case of overdoses. There are now around 18 OPSs operating in B.C.

Moving forward

Considerable progress has been made in Canada on SIFs and OPSs thanks to the work of peers, researchers, healthcare professionals and some politicians. There has been an escalation of efforts to open new sites across Canada, spurred on by the ongoing opioid overdose epidemic. In order to ensure adequate coverage of these facilities, new settings and new approaches will need to be explored.

Bill C-37 has made it easier to open a SIF, but the legislation still needs to be amended to make it simpler to scale-up these services. Additionally, there is a need to implement and evaluate models that are more responsive to the needs of people who use drugs, such as assisted injection and peer-run services.

Resources

Best Practice Recommendations for Canadian Harm Reduction Programs

Reference

About the author(s)

Zak Knowles is CATIE’s Web Content Manager. Before coming to CATIE, he worked as an HIV counsellor at Hassle Free Clinic, a sexual health clinic in downtown Toronto.