Canadian literature

Noam Katz, Lynne Leonard, Lorne Wiesenfeld and al., Support of supervised injection facilities by emergency physicians in Canada, International Journal of Drug Policy 2017.

The findings from our study demonstrate that the majority of emergency physician respondents in Canada support the implementation of such sites (74.5%) while 84.6% of respondents would refer patients from the emergency department to such sites if they did exist. Given that many Canadian cities are actively pursuing the creation of SIFs or imminently opening such sites, it appears that our sample population of emergency physicians would both support this approach and would utilize such facilities in an effort to improve patient-centered outcomes for this often marginalized population.

Supervised Consumption Service Operational Guidance, BC Centre on Substance Use, August 2017.
Supervised consumption services (SCSs) vary immensely in their operation and design. However, despite differences in populations of people who inject drugs (PWID) and settings where SCSs are implemented, the following minimum set of recommendations are offered as being essential to the establishment of any SCS in British Columbia.
Sanjana Mitra, Beth Rachlis, Ayden Scheim and al., Acceptability and design preferences of supervised injection services among people who inject drugs in a mid-sized Canadian City, Harm Reduction Journal 2017.
High levels of willingness to use SIS were found among PWID in this setting, suggesting that these services may play a role in addressing the harms associated with injection drug use. To maximize the uptake of SIS, programme planners and policy makers should consider the effects of gender and views of PWID regarding SIS design and operational preferences.
Geoff Bardwell and al., Assessing support for supervised injection services among community stakeholders in London, Canada, International Journal of Drug Policy 2017.
The results of this study challenge the assumptions that smaller cities like London may be unlikely to support SIS. Community stakeholders were supportive of the implementation of SIS with some preferences or conditions. Interview participants had differing perspectives, but ultimately supported similar end goals of accessibility and reducing community harms associated with injection drug use. Future research and SIS programming should consider these factors when determining optimal service delivery in ways that increase support from a diversity of community stakeholders.
Thomas Kerr and al., Supervised injection facilities in Canada: past, present, and future, Harm Reduction Journal 2017.
Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.
Ayden Scheim BA, Beth Rachlis PhD, Thomas Kerr PhD and al., Public drug injecting in London, Ontario: a cross-sectional survey, CMAJ Open, April 2017.
Background: Harms associated with public drug injection in large cities are well-established, but little is known about challenges that public injecting may pose for smaller municipalities. We evaluated the prevalence and correlates of public injecting among a sample of people who inject drugs in London, a mid-sized city in southwestern Ontario. Methods: Between March and April 2016, a sample of people who injected drugs participated in a quantitative survey as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models estimated associations of sociodemographic characteristics, sociostructural exposures and drug use behaviours with regular public injecting (injecting in public ≥ 25% of the time over the previous 6 mo). We also described the locations and rationales provided for public injecting. Results: A total of 196 participants (38.3% female, median age 39 yr) provided complete data. Of the 196, 141 (71.9%) reported any public injecting in the previous 6 months, and 91 (46.4%) injected in public regularly. Homelessness or unstable housing (adjusted odds ratio [OR] 2.04, 95% confidence interval [CI] 1.01–4.12) and frequently injecting opioids (adjusted OR 2.27, 95% CI 1.17–4.42) or crystal methamphetamine (adjusted OR 2.38, 95% CI 1.18–4.79) daily were independently associated with regular public injection. Convenience (98 participants [69.5%]) and homelessness (56 [39.7%]) were the most commonly reported reasons for public injecting. Interpretation: As in large cities in Canada, public injecting in London is common and appears to be associated with unstable housing and high-intensity injecting. These results indicate an urgent need to create safer environments for people who inject drugs in London, including supervised injection, to reduce the negative individual and community impacts of public injecting.

Les faits en bref : Dissiper les mythes sur les sites de consommation supervisés, Association des infirmières et infirmiers du Canada, Mars 2017. [English version]

The Ontario Supervised Injection Services Feasibility Study, Ontario HIV Treatment Network, February 2017.

The Ontario HIV Treatment Network (OHTN), supported by the Regional HIV/AIDS Connection and the Thunder Bay Drug Strategy, undertook research to assess the feasibility of supervised injection services in London and Thunder Bay, Ontario. Supervised injection services allow people to inject drugs under safe conditions and provide access to sterile injecting equipment:

Study Report: London, ON      OISIS London Fact Sheet      Study Report: Thunder Bay, ON      OISIS Thunder Bay Fact Sheet

OISIS Study FAQ      Recommendation Middlesex-London Health Unit

Paul C Webster, Calls for medically safe heroin mount in Canada, The Lancet, Volume 389, No. 10066, p239, 21 January 2017.

Canada is rapidly scaling up supervised injection facilities to tackle a surge in heroin overdoses. The move is welcomed by experts but several are calling for further measures.

Overdose Prevention Site Manual, Vancouver Coastal Health, January 2017 (V2).

Overdose Prevention Sites (OPS) opened as part of the provincial response to the opioid overdose (OD) emergency on December 8, 2016 as ordered by the BC Minister of Health. OPS are fixed sites to which VCH provides clinical protocols, training and supplies to enable teams of peers, lay staff and in some instances clinical providers, to observe injections in a room that is integrated into an already existing social services setting. The primary goal is to provide a space for people to inject their previously obtained illicit substances, with sterile equipment, in a setting where trained OPS staff can observe and intervene in overdoses as needed. The OPS will last for the duration of the public health emergency.

Evin Jones, Mona Lee, Janet Madsen and al., Canadian Drug Policy, Supervised Consumption Sites & Provincial Response to the Public Health Crisis of Overdose Deaths, PAN, December 22, 2016.

Sandy Hill CHC, Community Consultation Report on proposed model to add a small scale supervised injection service at 221 Nelson street, September 2016. [Version française]

Bruce Wallace, Bernie Pauly, Katrina Barbe and al., Every Washroom: De facto consumption sites in the epicenter of an overdose public health emergency, University of Victoria, Centre for Addictions Research of B.C., Bulletin 15, August 2016.

Supervised Injection Sites and Nursing Practice, Coalition of Nurses and Nursing Students for Supervised Injection Services, July 2016. [Version française]

Carol Strike, Ahmed M. Bayoumi, Tara Marie Watson and al., Public opinions about supervised smoking facilities for crack cocaine and other stimulants, Substance Abuse Treatment, Prevention, and Policy (2016) 11:8.

The purpose of this study was to estimate awareness and opinions about supervised smoking facilities(SSFs) for smoking crack cocaine and other stimulants and make comparisons with awareness and opinions aboutsupervised injection facilities (SIFs) in Ontario, Canada.

Resultats of the Independently Facilitated Public Consultations Regarding the Addiction of Supervised Injection Services in Toronto, Toronto Public Health, June 13, 2016

Jonathan Glendenning, Espace disciplinaire et normativité sociale contemporaine. L’exemple du site d’injection supervisée Insite dans le Downtown East Side à Vancouver, Nouvelles pratiques sociales, Volume 28, Numéro 1, Printemps 2016, p.195–210.

Insite est un site d’injection supervisée destiné à la population d’usagers de drogues injectables du Downtown Eastside à Vancouver. Dans une perspective foucaldienne, cet article analyse le processus de régulation des conduites de ses usagers par la mise en oeuvre de « pratiques divisantes » et par l’implantation d’un « espace disciplinaire ». Il propose de déterminer comment Insite relaie dans leurs conduites concrètes la normativité sociale associée à la philosophie de réduction des méfaits par l’intériorisation des normes d’autonomie et de responsabilité individuelle de même que par la surveillance de l’appropriation d’une technique d’injection médicalement conforme. 

Brief to the Toronto Board of Health regarding Supervised Injection Services in Toronto, Canadian HIV/AIDS Legal Network, HALCO and ARCH, March 21, 2016.

Following 35 deputations, the Toronto Board of Health voted unanimously in favour of moving forward with consultations for three supervised injection sites in Toronto. Read the brief submitted jointly by the Legal Network, HIV & AIDS Legal Clinic Ontario and ARCH Disability Law Centre to the Board of Health on the importance of integrating supervised injection services into existing clinical health services.

Medical Officer of Health, STAFF REPORT - ACTION REQUIRED, Supervised Injection Services for Toronto: Next Steps, March 7, 2016.

This report outlines the process for SIS implementation and seeks BOH support to begin stakeholder consultations, to meet federal requirements. Results of the consultations and next steps for this initiative will be reported to the BOH in July 2016.

Alex Berrymann, The Merits of Supervised Injection Facilities: A case for Sudbury and Northern Ontario, Northern Policy Institute, March 2016. [Version française]

Sudbury and other communities in Northern Ontario should take steps to determine the viability of a supervised injection facility says new report.

Eva A. Enns, Gregory S. Zaric,  Ahmed M. Bayoumi and al., Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada, Journal of Addiction online,  DOI: 10.1111/add.13195, November 2015.

Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. 

Ashley Shaw, Lisa Lazarus, Tyler Pantalone, Sean LeBlanc and al., Risk environments facing potential users of a supervised injection site in Ottawa, Canada, Harm Reduction Journal, 22 October 2015.

Supervised injection sites (SISs) have been effective in reducing health risks among people who inject drugs (PWID), including those who face issues of homelessness, mental health illness, interactions with local policing practices, and HIV infection. We investigate the risk behaviours and risk environments currently faced by potential users of an SIS in Ottawa to establish the need for such a service and to contribute to the design of an SIS that can address current health risks and reduce harm. 

Ehsan Jozaghi and VANDU, Exploring the role of an unsanctioned, supervised peer driven injection facility in reducing HIV and hepatitis C infections in people that require assistance during injection, Health and Justice, 2015.

Supervised consumption rooms or supervised injection facilities (SIFs) are venues that have reduced the risk of needle sharing and deaths caused by drug overdose among people who inject drugs (PWID). As a result of such a decline in the mortality rate, numerous studies have been able to illustrate its cost-effectiveness. However, studies have neglected to examine the same phenomena for unsanctioned SIFs that are run by peer drug users and provide assisted injections.

Ehsan Jozaghi and Andrew A. Reid, The Potential Role for Supervised Injection Facilities in Canada’s Largest City, Toronto, International Criminal Justice Review,  vol. 25 no. 3 233-246, September 2015.

Supervised injection facilities (SIFs) or supervised consumption rooms are a component of harm reduction strategies that attempt to reduce drug overdoses and risky injection behaviors among injection drug users. The purpose of this study is to determine whether expanding SIFs into the City of Toronto, Ontario, would be a fiscally responsible decision. By analyzing secondary data gathered in 2013, this article relies on mathematical models to estimate the number of new HIV and hepatitis C virus infections prevented as a result of SIF locations in Toronto. After factoring in the costs associated with SIFs, the models produce cost–benefit and cost-effectiveness outputs. With very conservative estimates, it is predicted that establishing SIF locations in Toronto is cost effective with an average benefit–cost ratio of 1:1.2 for the first two facilities based on the sensitivity analysis at 30% sharing rate. Consequently, funding SIFs in Canada’s largest city appears to be an efficient and effective use of financial resources in the public health domain with cost savings in excess of CAN$728,620 per year for the first two facilities. 

Carol Strik, Tara Marie Watson, Gillian Kolla and al., Ambivalence about supervised injection facilities among community stakeholders, Harm Reduction Journal, 2015.

We used purposive sampling methods to recruit various stakeholder representatives (n = 141) for key informant interviews or focus group discussions. Data were analyzed using a thematic process. We identified seven reasons for ambivalence about SIFs: lack of personal knowledge of evidence about SIFs; concern that SIF goals are too narrow and the need for a comprehensive response to drug use; uncertainty that the community drug problem is large enough to warrant a SIF(s); the need to know more about the “right” places to locate a SIF(s) to avoid damaging communities or businesses; worry that a SIF(s) will renew problems that existed prior to gentrification; concern that resources for drug use prevention and treatment efforts will be diverted to pay for a SIF(s); and concern that SIF implementation must include evaluation, community consultation, and an explicit commitment to discontinue a SIF(s) in the event of adverse outcomes.

Ehsan Jozaghia, Tarah Hodgkinsona & Martin A. AndresenaIs, Is there a role for potential supervised injection facilities in Victoria, British Columbia, Canada? Urban Geography, 03 Jul 2015.

Supervised injection facilities (SIFs) are medical facilities where injection drug users can inject their illicit drugs under the supervision of nurses and doctors. Currently, there is only one legal SIF in operation in North America and it has been operating in Vancouver, British Columbia for over a decade. The purpose of this study is to determine whether the current facility needs to be expanded to other locations in British Columbia, Canada. We employ mathematical modeling to estimate the number of new human immunodeficiency virus (HIV) and hepatitis C infections prevented based on the available secondary data. Additionally, we also estimate the number of prevented overdose deaths attributable to the SIF. With very conservative estimates, it is predicted that establishing two SIFs locations outside Vancouver in British Columbia’s capital city, Victoria, is cost-effective, with a benefit-cost ratio of 1.25:1. It appears that expanding SIFs to Victoria could offer significant savings for local health care institutions.

Donna Harati, Inside Insite: How a Localized Social Movement Led the Way for North America’s First Legal Supervised Injection Site, Harvard Law School, Irving Oberman Memorial Student Writing Prize: Law and Social Change, June 2015.

This paper explores the connection between law and social change by looking at Insite, North America’s first legal supervised injection site, as a case study. The paper focuses on how the Canadian Supreme Court was primed to grant legal status to the site. By examining the deep, grassroots, addict-led movement that set the foundation for the site to exist, the paper looks at how local movements coupled with evidence-based statistics can help inform judges in making decisions that affect social change. The paper looks closely at how advocates drew on both the social movement and the law in defending the legality of Insite.

Ehsan Jozaghi and Asheka Jackson, Examining the potential role of a supervised injection facility in Saskatoon, Saskatchewan, to avert HIV among people who inject drugs, International Journal of Health Policy and Management, 2015, 4(6), 373–379, May 2015.

Based on cumulative cost-effectiveness results, SIF establishment is cost-effective. The benefit to cost ratio was conservatively estimated to be 1.35 for the first two potential facilities. The study relied on 34% and 14% needle sharing rates for sensitivity analyses. The result for both sensitivity analyses and the base line estimates indicated positive prospects for the establishment of a SIF in Saskatoon.

David-Martin Milot, Évaluation de la pertinence d'un service d'injection supervisée en Montérégie (Québec), Editions universitaires europeennes, Mai 2015.

Les usagers de drogues par injection (UDI) présentent des taux de morbidité et de mortalité élevés, en plus d’une importante précarité psychosociale. Pourtant, leur utilisation des services en place est sous-optimale. Dans ce projet de recherche, nous avons dressé un portrait de cette population, des services et de la pertinence d’un service d’injection supervisée (SIS) en Montérégie. À l’aube de l’implantation possible d’un SIS à Montréal, ce projet explorait l’impact d’une telle mesure dans une région de grande superficie comportant des zones autant rurales qu’urbaines. Un devis transversal combinant une approche quantitative et qualitative a été utilisé. Les résultats indiquent que bien que similaire aux populations UDI montréalaise et du Québec, celle de la Montérégie s’en distingue par le fait qu’elle s’injecte moins souvent dans des lieux publics, qu’elle soit sans domicile fixe à moindre proportion et par ses taux inférieurs d’infection au VIH et à l’hépatite C. Par ailleurs, les participants interrogés ont noté une appréciation sous-optimale, ainsi que plusieurs obstacles à l’accessibilité et à la continuité de l’offre de services dédiés aux UDI en Montérégie.

Lianping Ti, Jane Buxton, Scott Harrison, Sabina Dobrer, Julio Montaner, Evan Wood and Thomas Kerr, Willingness to access an in-hospital ‪‎Supervised Injection‬ facility among hospitalized people who use illicit drugs, Journal of Hospital Medicine, Volume 10, Issue 5, pages 301–306, May 2015.

Our findings highlight the potential of in-hospital SIFs to complement existing harm reduction programs that serve PWUD. Moreover, an in-hospital SIF may minimize the harms associated with high-risk illicit drug use in the hospital.

Ryan McNeil, Thomas Kerr, Hugh Lampkin and Will Small, “We need somewhere to smoke crack”: an ethnographic study of an unsanctioned safer smoking room in vancouver, canada, The International Journal of Drug Policy, January 2015.

Many cities around the globe have experienced substantial increases in crack cocaine use. Public health programmes have begun to address crack smoking, primarily through the distribution of safer crack use equipment, but their impacts have been limited. More comprehensive safer environmental interventions, specifically safer smoking rooms (SSR), have been implemented only in select European cities. However, none have been subjected to rigorous evaluation. This ethnographic study was undertaken at an ‘unsanctioned’ SSR operated by a drug user-led organization in Vancouver, Canada, to explore how this intervention shaped crack smoking practices, public crack smoking, and related harms.

Rapport sur la situation de la consommation de drogue par injection à Québec et sur la pertinence d’offrir des services d’injection supervisée, Centre de santé et de services sociaux de la Vieille-Capitale, Décembre 2014.

Le 2 février 2015, le CSSS de la Vieille-Capitale a présenté le Rapport sur la situation de la consommation de drogue par injection à Québec et sur la pertinence d’offrir des services d’injection supervisé à l’Agence de la santé et des services sociaux de la Capitale-Nationale. Depuis 2012, un comité de travail mène des travaux, notamment pour évaluer la pertinence de mettre en place des services d’injection supervisé (SIS) à Québec.

Cécile Kazatchkine, Richard Elliott and Donald MacPherson, An Injection of Reason: Critical Analysis of Bill C-2, Canadian HIV/AIDS Legal Network and Canadian Drug Policy Coalition, 2014. [Version française]

Bill C-2 (An Act to amend the Controlled Drugs and Substances Act) undermines the rights of people who use drugs to access lifesaving and health-protecting services. Read more about supervised consumption services in Canada and internationally, and their positive impact on individuals and communities. (Submission to Parliament) 

Projet de loi C-2 : Loi modifiant la Loi réglementant certaines drogues et autres substances afin de permettre des exemptions pour les sites (et services) d’injection supervisée. Mémoire, Comité permanent de la sécurité publique et nationale, ACIIS, 2014. [English version]

Denielle Elliotte, Debating safe injecting sites in Vancouver’s inner city: Advocacy, conservatism and neoliberalis, Contemporary Drug Problems 41, Spring 2014.

North America’s first and only legal, supervised injection site is located in Vancouver and has been one of Canada’s most controversial biomedical interventions. Emerging from a progressive harm reduction model, and adopted in many cities around the globe from Sydney to Paris, safe injection facilities are considered by many to be the hallmark of innovative programming for the urban poor. In Vancouver, an intense public debate resulted, focusing attention on addictions, the rights of drug users, and the politics of knowledge. Drawing on the work of Nikolas Rose and Michel Foucault, this ethnographic article suggests that the politics of activism and care that have emerged from the Insite controversy among scientists, researchers, and advocates are characterized by a neoliberal logic, which limits the full potential of this health care intervention. This article considers the specific ways in which scientists and advocates inadvertently adopted neoliberal techniques of governing and conservative politics. 

Ehsan Jozaghi, Andrew A Reid, Martin A Andresen and Alexandre Junea, A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Ottawa, Canada, Substance Abuse Treatment, Prevention, and Policy 2014 (4 August), 9:31.

The sensitivity analyses conducted with the models reveals the potential for SIFs in Ottawa to be a fiscally responsible harm reduction strategy for the prevention of HCV cases - when considered independently. With a baseline sharing rate of 19%, the cumulative annual cost model supported the establishment of two SIFs and the marginal annual cost model supported the establishment of a single SIF. More often, the prevention of HIV or HCV alone were not sufficient to justify the establishment cost-effectiveness; rather, only when both HIV and HCV are considered does sufficient economic support became apparent. Funded supervised injection facilities in Ottawa appear to be an efficient and effective use of financial resources in the public health domain. 

Recommendations from the Toronto Residents’ Reference Panel on Supervised Injection Services, Final Report, St. Christopher House, July 2014.

The Residents Panel was an exemplary group of citizens who voluntarily took responsibility to address a complex public policy issue. Supervised injection services are locations where drug users can intravenously inject drugs under the eye of medically-trained staff. Supervised injection services are intended to reduce harm to people with severe drug addictions. Harm reduction is a part of a comprehensive drug strategy that also includes addiction prevention, drug addiction treatment, and law enforcement. The Residents Panel was asked to recommend how to meaningfully involve local people if a supervised injection service is proposed. They were not judging whether supervised injection services are good or bad. Rather the Residents Panel provides policy-makers with guidance about how to involve the broader public in a controversial issue. The Residents Panel members volunteered their time over the course of 4 Saturdays to learn from researchers, people with lived experience of addictions, and other informed stakeholders such as retail businesses, service-providers, advocates, and police representatives. We witnessed the powerful effect that information had on the Residents Panel in this process. Becoming well-informed, even when some of the information is contradictory, provided a good base for finding common agreements. Being well-informed also allowed discussions and debates to be more focused on facts instead of irreconcilable emotion or values.

Hadland SE, DeBeck K, Kerr T and al., Use of a Medically Supervised Injection Facility Among Street Youth, Journal of Adolescent Health, 10 June 2014.

This study, the first to examine SIF use among street youth in North America, demonstrated that the facility attracted high-frequency young drug users most at risk of blood-borne infection and overdose and those who otherwise inject in public spaces.

McNeil R et al, Impact of supervised drug consumption services on access to and engagement with care at a palliative and supportive care facility for people living with HIV/AIDS: a qualitative study, Journal of the International AIDS Society 2014, 17:18855.

This study highlights how adopting comprehensive harm reduction services can serve to improve access and equity in palliative and supportive care for drug-using populations.

Strike C., Jairam J., Kolla G. and al., Increasing public support for supervised injection facilities in Ontario, Canada, Addiction, 2014 February 12, doi: 10.1111/add.12506.

Determine the level and changes in public opinion between 2003 and 2009 among adult Canadians about implementation of supervised injection facilities (SIFs) in Canada.

Ryan McNeil, Will Small, Hugh Lampk and al., ‘‘People Knew They Could Come Here to Get Help’’: An Ethnographic Study of Assisted Injection Practices at a Peer-Run ‘Unsanctioned’ Supervised Drug Consumption Room in a Canadian Setting, Springer, AIDS and Behavior, June 2013.

People who require help injecting are disproportionately vulnerable to drug-related harm, including HIV transmission. North America’s only sanctioned SIF operates in Vancouver, Canada under an exemption to federal drug laws, which imposes operating regulations prohibiting assisted injections. In response, the Vancouver Area Network of Drug Users (VANDU) launched a peer-run unsanctioned SIF in which trained peer volunteers provide assisted injections to increase the coverage of supervised injection services and minimize drug-related harm. We undertook qualitative interviews (n = 23) and ethnographic observation (50 h) to explore how this facility shaped assisted injection practices. Findings indicated that VANDU reshaped the social, structural, and spatial contexts of assisted injection practices in a manner that minimized HIV and other health risks, while allowing people who require help injecting to escape drug scene violence. Findings underscore the need for changes to regulatory frameworks governing SIFs to ensure that they accommodate people who require help injecting.

Toronto Drug Strategy, Supervised Injection Services Toolkit, June 2013.

The purpose of this toolkit is to provide information and resources to assist when considering whether to provide supervised injection services (SIS) in Toronto. A SIS is a health service that provides a safe and hygienic environment where people can inject pre-obtained drugs under the supervision of trained staff. In Canada, nurses provide this supervision. This toolkit is intended for use by decision makers, potential service providers, and other community stakeholders. A working group of the Toronto Drug Strategy Implementation Panel developed the toolkit. The content draws on relevant policy and research, input from diverse stakeholders in Toronto, expertise from SIS operators and stakeholders in Vancouver, and input from external reviewers. While this toolkit is focused on the Toronto context, it is anticipated that much of the content will be relevant for other communities.

Ehsan Jozaghi, Andrew A Reid and Martin A Andresen, A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Montreal, Canada, Substance Abuse Treatment, Prevention, and Policy 2013, 8:25.

With very conservative estimates, it is predicted that the addition of each supervised injection  facility (up-to a maximum of three) in Montreal will on average prevent 11 cases of HIV and 65 cases of HCV each year. As a result, there is a net cost saving of CDN$0.686 million (HIV) and CDN$0.8 million (HCV) for each additional supervised injection site each year. This translates into a net average benefit-cost ratio of 1.21: 1 for both HIV and HCV.

Toronto Public Health, Supervised Injection Services, June, 2013.

Medical Officer of Health, Supervised Injection Services in Toronto, Report, June 21, 2013.

The Toronto Drug Strategy Implementation Panel has developed a comprehensive toolkit to assist with effective implementation of SISs in Toronto.  The toolkit supports a reasonable process that reflects the conditions outlined in the Supreme Court of Canada ruling, and recognizes the importance of community engagement.  It is therefore recommended that the Board of Health urge the provincial government to fund the integration of supervised injection services, on a pilot basis, into existing provincially-funded clinical health services in Toronto, and fund the evaluation of this pilot.

BOOK : Insite. The role of supervised injection facility in transforming the Downtown Eastside of Vancouver

Jozaghi Ehsa, Insite. The role of supervised injection facility in transforming the Downtown Eastside of Vancouver, LAP Lambert Academic Publishing, June 2, 2013.

While numerous studies on InSite (North America's first and only supervised injection facility (SIF)) have been published in leading international journals, little attention has been given to the potential role that InSite has played in transforming the landscape and culture of drug use in the Downtown Eastside (DTES) of Vancouver, British Columbia (BC). The present research was conducted on the premise of assessing the transformative role of InSite in the lives of injection drug users (IDUs) who are caught in a vicious cycle of substance abuse, poverty and homelessness. Semi-structured qualitative interviews were conducted with a purposively chosen sample of IDUs in Vancouver, Surrey, and Victoria, BC. Audio recorded interviews were transcribed verbatim and analyzed thematically using NVivo 8 software. Findings suggest attending InSite has numerous positive effects on the lives of IDUs. Furthermore, attending InSite has contributed to landscape and drug use transformation in the DTES. There is also an urgent need to expand the current facility to cities where injection drug use is prevalent (Download).

Richard Cloutier, Balises pour les établissements de santé et de services sociaux et les organismes communautaires désirant offrir des services d'injection supervisée aux personnes qui font usage de drogues par injection, Ministère de la Santé et des Services sociaux, Gouvernement du Québec, 2013.

Ehsan EJ Jozaghi and Martin MA Andresen, Should North America's first and only supervised injection facility (InSite) be expanded in British Columbia, Canada?, Harm Reduction Journal 2013, 10:1.

This article reports qualitative findings from a sample of 31 purposively chosen injection drug users (IDUs) from Vancouver, Surrey and Victoria, British Columbia interviewed to examine the context of safe injection site in transforming their lives. Further, the purpose is to determine whether the first and only supervised injection facility (SIF) in North America, InSite, needs to be expanded to other cities.

Neil Boyd, Lessons from INSITE, Vancouver's supervised injection facility: 2003–2012, School of Criminology, Simon Fraser University, Bunby, BC, Canada, Janv 2013.

This paper focuses on the evolution of INSITE, North America's first supervised injection site, first opened in 2003, and subjected to continuous empirical and political scrutiny from that date to the present. This analysis considers the relevant global history of supervised injection sites, and key events in the Canadian timeline. The article canvasses the origins of INSITE and its support by the Liberal government of Canada from 2003 to 2006, the change of federal government in 2006 and the decision of the Harper Conservatives to refuse to grant a continuing exemption to INSITE. The paper considers three court decisions, one by the B.C. Supreme Court in 2008, followed by a B.C. Court of Appeal decision in 2010, and, ultimately, the Supreme Court of Canada's decision in the fall 0f 2011, a decision that ordered the federal government to grant an operating exemption to INSITE. The paper examines how empirical evidence was presented to governments and to the courts, and how both governments and the judiciary interpreted the relevance of empirical evidence in the formulation of law and policy. The paper concludes by comparing the parallel experiences of Vancouver's INSITE with the MSIC in Sydney, Australia.

Martin A. Andresen and Ehsan Jozaghi, The Point of Diminishing Returns: An Examination of Expanding Vancouver's Insite, Urban Stud December 2012, vol. 49, no. 16, 3531-3544.

North America's only government-sanctioned supervised injection facility, Insite, has been subjected to substantial research. This research has found evidence for numerous public health benefits: decreased risky injection behaviour, decreased fatal overdoses, increased probability of initiating and maintaining addiction treatment, and cost-effectiveness. To date, a small number of costing studies have emerged with none of them investigating Insite expansions. Such an analysis is reported in this paper and it is found that, based on benefit–cost ratios, Insite should be expanded. However, this expansion is dependent on altering injection drug user behaviour outside Insite.

Tara Marie Watson, Ahmed Bayoumi, Gillian Kolla and al., Police Perceptions of Supervised Consumption Sites (SCSs): A Qualitative Study, Substance Use & Misuse, 47:364–374, 2012.

Police are key stakeholders in cities considering supervised consumption site (SCS) implementation. We examine police perceptions of SCSs using data collected between 2008 and 2010. Data from interviews and focus groups conducted with police officers of varied ranks (n = 18) in Ottawa and Toronto, Canada, were analyzed using thematic analyses. Participants opposed SCS implementation in their respective cities. The police views we heard invoke values and perspectives on evidence that differ from those used in research. Whether these divergent frameworks are reconcilable is a question for future research. Study limitations are noted. The Ontario HIV Treatment Network funded the study.

Professor Suzanne Bouclin and Priyanka Vittal, The Insite Decision and the Case for Supervised Consumption Facilities in Ottawa, (December 2012) 1:1 C.J. Poverty Law 91.

Professor Suzanne Bouclin of the Ottawa University Faculty of Law and Priyanka Vittal, a law student & CSCS volunteer, have co-authored a paper on the 2011 Supreme Court decision in favour of Insite remaining open, and what the decision means for the possibility of similar sites opening in Ottawa. The article is available in the December issue of the Canadian Journal of Poverty Law, and offers a valuable analysis of the legal aspects of this issue. On September 29, 2011, the Supreme Court of Canada unanimously ruled to allow a safer supervised consumption facility (SCF) to remain open under a section 56 exemption of the Controlled Drugs and Substances Act. The decision has lent additional legitimacy to SCFs as a necessary health care service that is part of a comprehensive and holistic drug and addiction strategy. In part one of this comment, we describe the context in which Insite emerged in Vancouver, British Columbia. In part two, we discuss the legal mobilization that led to the Supreme Court decision and the framework under which Insite currently operates. In part three, we explore the decision's implications for another jurisdiction – Ottawa, Ontario.

ADDICQ, Les Services d'Injection Supervisée démystifiés... par les personnes qui vont les utiliser!, AQPSUD, 30 août 2012.

Centre canadien de lutte contre l'alcoolisme et les toxicomanies. Sites d'injection supervisée : Une bibliographie, Ottawa (Ontario), Centre canadien de lutte contre l'alcoolisme et les toxicomanies, 2012.

Insp. Thompson S., L'équilibre entre santé et sécurité in La Gazette Gendarmerie Royale du Canada, Vol.74, N°1, 2012, p.17-18.

Bayoumi AM, Strike C and al., Report of the Toronto and Ottawa Supervised Consumption Assessment Study, St. Michael's and University of Toronto, April 2012.

Cette étude, dirigée par Dr Amhed Bayoumi de l'Hôpital St. Michael et Dre Carol Strike de l'Université de Toronto, indique que ces sites pourraient améliorer la santé des usagers de drogues et réduire les méfaits dans cette population ainsi que l'usage de drogues en public. Après quatre ans de recherche indépendante, les Drs Bayoumi et Strike recommandent de créer trois sites d'injection supervisée à Toronto et deux à Ottawa.

E. Wood and al., Improving community health and safety in Canada through evidence-based policies on illegal drugs, Open Medicine, Mars 2012.

L'étude avance notamment que le gouvernement fédéral devrait ouvrir des centres d'injection supervisée pour les consommateurs de drogues injectables où les besoins se font sentir. Les médecins-chefs de 18 grandes villes canadiennes, dont Québec, appuient les conclusions de cette étude.

Questions-réponses. Questions les plus souvent posées au sujet des services d'injection supervisée à Montréal, Direction de santé publique, Agence de la santé et des services sociaux de Montréal, 16 décembre 2011.

Richard Lessard, Carole Morissette, Vers un service d'injection supervisée, Rapport de l'étude de faisabilité sur l'implantation d'une offre régionale de services d'injection supervisée à Montréal, Agence de la santé et des services sociaux de Montréal, Décembre 2011.

L'implantation de services d'injection supervisée à Montréal est incontournable, affirme le Directeur de santé publique dans son rapport qui vient d'être dévoilé. Le docteur Richard Lessard propose en fait des sites fixes localisés à l'intérieur d'établissements de santé et de services sociaux et d'organismes communautaires. S'y ajouterait une unité mobile qui serait déployée dans des secteurs jugés prioritaires, avec la présence d'infirmières. Le Dr Lessard justifie sa recommandation d'implanter de tels sites par le taux élevé de mortalité chez les utilisateurs de drogues intraveineuses et par une épidémie d'infections causées par le VIH et l'hépatite C.


Sébastien Harvey et Mariane Fradet, Contreverse - Les centres d'injection supervisée en débat. L'ouverture de tels centres est une question de respect des droits fondamentaux in Revue Relations n°752, Nov. 2011.

Amélie Descheneau-Guay, Contreverse - Les centres d'injection supervisée en débat. La mise en place de CIS ne remet pas en cause les structures d'exploitation au fondement du commerce de la drogue, ni l'approche gestionnaire de la toxicomanie in Revue Relations n°752, Nov. 2011.

Ligue des droits et libertés – section de Québec, Un SIS au centre-ville de Québec du point de vue de la Charte canadienne des droits et libertés : une question de santé et de sécurité, Avril 2011.

Mémoire sur l'ouverture d'un service d'injection supervisée. À l'attention du conseil d'administration du conseil de quartier de Saint-Roch.

B. D. L. Marshall, M-J. Milloy, E. Wood, J. S. G. Montaner and T. Kerr, (2011), Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study, The Lancet, Volume 377, Issue 9775, Pages 1429 - 1437, 23 April 2011.

Overdose from illicit drugs is a leading cause of premature mortality in North America. Internationally, more than 65 supervised injecting facilities (SIFs), where drug users can inject pre-obtained illicit drugs, have been opened as part of various strategies to reduce the harms associated with drug use. We sought to determine whether the opening of an SIF in Vancouver, BC, Canada, was associated with a reduction in overdose mortality.

-  Greg Pike, Joe Santamaria, Stuart Reece and al., Analysis of the 2011 Lancet study on deaths from overdose in the vicinity of Vancouver’s Insite Supervised Injection Facility, 2011.

Gary Christian, Greg Pike, Joe Santamaria and al., Overdose deaths and Vancouver's supervised injection facility, The Lancet, Volume 379, Issue 9811, Pages 118 - 119, 14 January 2012.

B. D. L. Marshall, M-J. Milloy, E. Wood, J. S. G. Montaner and T. Kerr, Overdose deaths and Vancouver's supervised injection facility — Authors' reply, The Lancet, Volume 379, Issue 9811, Pages 118 - 119, 14 January 2012.

Alexandra Robitaille, Perspectives juridiques de l'implantation des centres d'injections supervisés au Canada, 21 avril 2011.

Travail présenté à Mme Julie Desrosiers, Professeure à la Faculté de Droit de l'Université Laval, Dans le cadre du cours : Service juridique (Ligue des droits et libertés, section de Québec).

Centres de consommation et d’injection sous surveillance in La réduction des méfaits et les drogues actuellement illicites : Implications pour les politiques, la pratique, la formation et la recherche en soins infirmiers. Document de travail, Association des infirmières et infirmiers du Canada, Mars 2011, p.39.

Kathleen Dooling MD MPH, Michael Rachlis MD LLD, Vancouver’s supervised injection facility challenges Canada’s drug laws, CMAJ, Sept. 2010, 182(13).

Pinkerton, S. D., Is Vancouver Canada's supervised injection facility cost-saving?, Addiction, 2010, 105: 1429–1436. doi: 10.1111/j.1360-0443.2010.02977.

François Gagnon, Autour d'Insite : un événement discursif in Drogues, santé et société, vol. 8, n°2, p. 267-302, Décembre 2009.

Cet article effectue un retour sur l'hypothèse de renforcement des logiques prohibitionniste et thérapeutique par la logique de "périllisation". Cette hypothèse a été émise pour expliquer l'apparent succès politique des pratiques et politiques de réduction des méfaits, celles-ci étant animées par la logique de "périllisation". Cette réflexion s'effectue à travers un examen des énoncés produits autour d'Insite, un des deux services d'injection supervisée de Vancouver. S'inspirant de l'approche foucaldienne de l'analyse du discours, il montre comment des énoncés ont problématisé les logiques thérapeutique et prohibitionniste même s'ils les ont reconduites en partie. En conclusion, une discussion exploratoire de certains possibles ouverts par cet "événement discursif " est amorcée.

CMAJ, Smoking of crack cocaine as a risk factor for HIV infection among people who use injection drugs, Octobre 2009.

Smoking of crack cocaine was found to be an independent risk factor for HIV seroconversion among people who were injection drug users. This finding points to the urgent need for evidence-based public health initiatives targeted at people who smoke crack cocaine. Innovative interventions that have the potential to reduce HIV transmission in this population, including the distribution of safer crack kits and medically supervised inhalation rooms, need to be evaluated.


Lina Noel et al., Avis sur la pertinence des services d'injection supervisée : analyse critique de la littérature, INSP Québec, Juin 2009.

Urban Health Research Initiative du British Columbia Centre for Excellence in HIV/AIDS, Résultats de l'évaluation du Centre d'injection supervisé de Vancouver – projet pilote Insite, Juin 2009.

Urban Health Research Initiative of British Columbia Centre for Excellence in HIV/AIDS, Findings from the evaluation of Vancouver's Pilot Medically Supervised Safer Injecting Facility - Insite, June 2009.

En 2003, la régie régionale de la santé à Vancouver, au Canada, a demandé au gouvernement fédéral une exception juridique en vue de mettre sur pied le projet pilote Insite, le premier centre d'injection supervisé (CIS) par un personnel médical en Amérique du Nord. L'exception a été accordée à condition que le programme se soumette à une évaluation scientifique rigoureuse. Étant donné la nature controversée des CIS, comme le décrit ce rapport, l'évaluation d'Insite a été conçue selon les normes scientifiques les plus strictes. Les quelques premières années d'évaluation ont produit un ensemble de données scientifiques, dont plus de 30 études examinées par les pairs sur les impacts du programme. Ces publications indiquent que le centre Insite offre une gamme d'avantages à sa clientèle et à la collectivité, dont la baisse du nombre d'injections dans des lieux publics, la réduction des comportements à risque pour le VIH (p. ex., le partage de seringues) et une hausse des taux d'inscription à des programmes de traitement de la toxicomanie parmi la clientèle du centre. De plus, les études visant à cerner les éventuels effets nuisibles du centre n'ont trouvé aucune preuve d'impacts négatifs. Les études, soumises à des examens indépendants par les pairs, sont parues dans les revues scientifiques les plus prestigieuses, dont le New England Journal of Medicine, The Lancet et le British Medical Journal. On reconnaît que le manque de compréhension parmi les intervenants clés par rapport aux résultats de l'évaluation d'Insite se doit en partie à des lacunes dans la présentation et le partage des résultats du projet d'évaluation. Plus précisément, il est devenu de plus en plus clair dans les cercles scientifiques que les publications universitaires ne sont pas suffisamment accessibles aux politiciens et au grand public. Ce rapport aborde cette question en offrant une description en langage clair de l'évaluation scientifique d'Insite, ainsi que des résumés des résultats de la recherche sur son impact. Nous espérons qu'en rendant ces renseignements plus accessibles au grand public, au gouvernement fédéral et aux médias, ce rapport offrira de la clarté à l'ensemble de la population canadienne sur la question des centres d'injection supervisés comme Insite.

Andrea Krüsi, Will Small, Evan Wood and Thomas Kerr, An integrated supervised injecting program within a care facility for HIV-positive individuals: a qualitative evaluation, AIDS Care, 21:5, May 2009, 638-644.

While there has been growing interest in comprehensive models of treatment and care for individuals living with HIV/AIDS, little attention has been given to the potential role that supervised injecting programs could play in increasing access to prevention and care services for HIV-positive injection drug users (IDU). We conducted 22 semi-structured interviews with HIV-positive IDU regarding a supervised injection program integrated in an HIV focused care facility known as the Dr. Peter Centre (DPC). We also interviewed seven staff members who supervise injections within the facility. All interviews were audio recorded, transcribed verbatim, and a thematic analysis was conducted. Participant and staff reports indicated that the integrated supervised injection program influenced IDUs' access to care by building more open and trusting relationships with staff, facilitating engagement in safer injection education and improving the management of injection-related infections. Participants and staff viewed the program as facilitating the delivery of care through mediating overdose risks, reducing the need to punitively manage drug use onsite and reducing the risks of encountering used syringes on the premises. For some participants, however, feelings of shame and fear of judgment in relation to their drug use limited initial uptake of the program. Our findings identify mechanisms through which integrated supervised injection programs may serve to better facilitate access and delivery of comprehensive care for HIV-positive IDU and highlight the benefits of addressing HIV-positive IDUs' drug use in the context of comprehensive models of healthcare.

Beverly Lightfoot, Ciro Panessa, Sargent Hayden, Meaghan Thumath, Irene Goldstone et Bernadette Pauly, Gaining Insite: Harm Reduction in Nursing Pratice, Canadian Nurses, April 2009.

Insite, a supervised injection facility in Vancouver, British Columbia, is an evidence-based response to the ongoing health and social crisis in the city's Downtown Eastside. It has been shown that Insite's services increase treatment referrals, mitigate the spread and impact of blood-borne diseases and prevent overdose deaths. One of the goals of this facility is to improve the health of those who use injection drugs. Nurses contribute to this goal by building trusting relationships with clients and delivering health services in a harm reduction setting. The authors describe nursing practice at Insite and its alignment with professional and ethical standards of registered nursing practice. Harm reduction is consistent with accepted standards for nursing practice as set out by the College of Registered Nurses of British Columbia and the Canadian Nurses Association and with World Health Organization guidelines. Texte françaisUn centre d’injection « insite » à la réduction des méfaits.

Centre canadien de lutte contre l'alcoolisme et les toxicomanies, Forum de discussion: recherche évaluative sur le centre d'injection supervisé. Rapport sommaire sur le forum, Centre canadien de lutte contre l'alcoolisme et les toxicomanies, Mars 2009.

En 2002, le CCLAT a collaboré avec Santé Canada à l'élaboration de directives pour appliquer une exemption à l'article 56 à un projet pilote de centre d'injection supervisé (Insite). En 2007-2008, le CCLAT a siégé au Comité fédéral de coordination chargé de passer en revue la recherche pour voir s'il fallait prolonger l'exemption. Le CCLAT a organisé un forum en novembre 2008 pour encourager la discussion sur le dossier des centres d'injection supervisés au Canada.

Andresen M. A., and Boyd N., A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility. International Journal of Drug Policy, 2009.

Don C. Des Jarlais Ph.D., Kamyar Arasteh Ph.D., Holly Hagan Ph.D. Evaluating Vancouver's supervised injection facility data and dollars, symbols and ethics. CMAJ 179 (11), 18 novembre 2008.

Ahmed M. Bayoumi MD MSc, Gregory S. Zaric Ph.D. The cost-effectiveness of Vancouver's supervised injection facility. CMAJ 179 (11), 18 novembre 2008.

Milloy MJS, Kerr T, Tyndall M, Montaner J and Wood E, Estimated Drug Overdose Deaths Averted by North America’s First Medically-Supervised Safer Injection Facility. PLoS ONE 3(10): e3351. doi:10.1371/journal.pone.0003351, 2008.

Danya Fast and al., The perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facility. Harm Reduction Journal, vol. 5(1), 2008.

J-F. Mary, Salle de consommation supervisée - Une mesure nécessaire, un contexte à consolider, CACTUS Montréal, Septembre 2008.

Kora DeBeck and al., Police and public health partnerships-Evidence from the evaluation of Vancouver's supervised injection facility. Substance Abuse Treatment, Prevention, and Policy, vol3, 2008.

J-F. Mary, La pertinence des salles de consommation supervisée dans le contecte montréalais, CACTUS Montréal, Avril 2008.

The Hon. Tony Clement, Minister of Health, Government of Canada, INSITE de Vancouver et autres sites d'injection supervisés : Observations tirées de la recherche. Rapport final du Comité consultatif d'experts sur la recherche sur les sites d'injection supervisés, 1 mars 2008.

Santé Canada a nommé un Comité consultatif d'experts (CCE) de la recherche sur le site d'injection supervisé (INSITE) situé dans la partie est du centre-ville de Vancouver (Downtown Eastside [DTE]) afin qu'il rende compte à un comité fédéral de coordination et au Ministre de la Santé. Ce comité était composé d'experts en matière de maladie transmissible par le sang, de toxicomanie, d'évaluation de programmes et de criminalité. Les sites d'injection supervisés (SIS) sont des instances de santé contrôlés où les consommateurs de drogue peuvent sous surveillance s'injecter la drogue illicite qu'ils se sont procuré personnellement et recevoir des soins médicaux, être conseillés et orientés vers des services sociaux, de santé et de traitement de la toxicomanie. Il en existe à présent 70 dans six pays. La recherche étudiée et discutée dans le présent rapport porte sur INSITE et sur un SIS à Sydney (Australie). INSITE a été établi en 2003, quand une exemption a été accordée à la Vancouver Coastal Health Authority (VCH) aux termes de l'article 56 de la Loi réglementant certaines drogues et autres substances. Santé Canada à versés des fonds à la VCH, qui elle ensuite a engagé le B.C. Centre for Excellence in HIV/AIDS pour l'évaluation du service. Le centre a terminé des parties de l'évaluation initiale, mais a indiqué qu'il lui faudrait une deuxième demande d'exemption et plus de temps pour terminer l'évaluation. Santé Canada a accordé l'exemption pour une période additionnelle sans toutefois accorder de crédits pour l'évaluation proposé. Ce financement a été obtenu auprès d'autres sources. Le CCE a structuré en tableaux la recherche dont il disposait selon les questions majeures et les objectifs déclarés d'INSITE (voir l'annexe B). Chaque tableau présente des aperçus i) de la recherche publiée et non publiée sur INSITE, des données sur l'utilisation fournit par la VCH et de trois recherches supplémentaires demandées par le CCE ; ii) de la recherche sur le SIS de Sydney (Australie) ; iii) de la recherche sur des SIS établis dans d'autres pays. La recherche analysée porte sur les objectifs officiellement déclarés par INSITE, soit i) accroître l'accès aux soins de santé et à ceux de la toxicomanie, ii) réduire les décès par surdose, iii) réduire la transmission des infections virales transmissibles par le sang et de celles liées aux injections, iv) améliorer l'ordre public (Santé Canada).

Stephen W. Hwang, Science et idéologie, Open Medicine, vol.1, no2, 2007.

Ce commentaire interroge sur la précarité de la continuité du lieu d'injection supervisé Insite à Vancouver. La question posée est si l'idéologie passe avant les données probantes et appelle à l'action les médecins, scientifiques et professionnels de la santé.

David Garmaise, Le gouvernement conservateur abolit le financement de la recherche sur l'Insite, Revue VIH/sida, droit et politiques, vol. 12, n°1, mai 2007, p.19.

Sommaire concernant l'abolition du financement pour l'évaluation d'Insite à Vancouver, seul lieu d'injection supervisé au Canada. Description des actions incohérentes en dépit des preuves scientifiques démontrées qu'Insite aide à réduire les méfaits associés à l'injection de drogues.

Benedikt Fischer and Christiane Allard, Feasibility Study on ‘Supervised Drug Consumption’ Options in the City of Victoria, CARBC, University of Victoria, 30 April 2007.

Richard Pearshouse et Richard Elliott, Une main secourable : questions juridiques entourant l'assistance à l'injection dans les lieux supervisés pour l'injection, Réseau juridique canadien VIH/sida, Mars 2007.

Selon le cadre juridique et les lignes directrices pour les professionnels qui sont en vigueur au Canada, les employés de lieux sécuritaires pour l'injection (LSI) ne peuvent pas aider les clients à s'administrer leur drogue et ces clients ne peuvent pas s'entraider dans l'injection. Cependant, de récentes évaluations ont démontré, parmi les personnes qui ont besoin d'assistance pour l'injection de drogues illégales, des taux de prévalence du VIH deux fois plus élevés que parmi les personnes qui n'ont pas besoin d'une telle assistance; ce constat soulève de sérieuses préoccupations de santé publique. Les femmes sont deux fois plus susceptibles que les hommes d'avoir besoin d'assistance à l'injection, et deux fois plus susceptibles de déclarer que la raison de ce besoin est qu'elles ne savent pas comment se faire une injection elles-mêmes. Dans le présent document, nous nous penchons sur la prohibition de l'assistance à l'injection dans ls LSI, dans la perspective de la Charte canadienne des droits et libertés, et nous avançons que cette interdiction est susceptible de porter atteinte aux dispositions de la Charte qui garantissent le droit de ne pas subir de discrimination, ainsi qu'aux droits à la vie, à la liberté et à la sécurité de la personne.

Colin Mangham, PhD, A Critique of Canada's INSITE Injection Site and its Parent Philosophy: Implications and Recommendations for Policy Planning, The Journal of Global Drug Policy and Pratice, January 17, 2007.

This report provides a critical analysis of the evaluations done on INSITE, the drug injection site in operation in Vancouver, British Columbia, and billed as North America's first medically supervised injection facility. In doing so, it provides a documented historical discussion laying out INSITE's context within a national drug strategy that has been driven increasingly toward an ideology of harm reduction, as distinct from specific adjunct harm reduction strategies in support of a broader policy. An informed critique is made of the specific published INSITE evaluations. Serious problems are noted in the evaluations' reporting and interpretation of findings. Specifically, 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. The published findings actually reveal little or no reductions in transmission of blood-borne diseases or public disorder, no impact on overdose deaths in Vancouver, very sporadic individual use of the facility by individual clients, a failure to reach persons earlier in their injecting careers and very little or no movement of drug users into long-term treatment and recovery. The fact that the evaluators and the funders of INSITE nonetheless have hailed the program as successful reveals a serious problem in drug policy today. It is argued that harm reduction has so permeated governments and the civil service and so politicized drug policy that evidence against the philosophy and its practice are being ignored, information is being managed in support of it, voices in opposition are decreasingly being included in drug policy dialogue and a culture of defensiveness has taken hold. This can only harm efforts to reduce drug problems and produce negative impacts on prevention and treatment, which are discussed along with other implications and recommendations for future policy directions. This paper offers an independent critique of the evaluations of the INSITE supervised injection site in Vancouver, British Columbia and of the broader ideology of harm reduction that has given rise to such programs. To do so effectively, it provides first a historical context with an informed critique of harm reduction ideology as it has emerged in Canadian drug policy over the past decade. It then examines the published evaluations of INSITE, pointing out clear problems in how the findings have been reported and interpreted. Finally, it provides a discussion of the effects harm reduction ideology has dealt on treatment and prevention in British Columbia and in Canada and offers suggestions for reforms and rebalancing of drug policies to refocus on prevention and treatment. INSITE refers to the supervised injection facility opened in Vancouver's Downtown Eastside, an area defined by high drug use, crime, public disorder and homelessness.

Mark W Tyndall and al., HIV seroprevalence among participants at a Supervised Injection Facility in Vancouver, Canada: implications for prevention, care and treatment, Harm Reduction Journal 2006, 3:36, December 2006.

North America's first government sanctioned medically supervised injection facility (SIF) was opened during September 2003 in Vancouver, Canada. This was in response to a large open public drug scene, high rates of HIV and hepatitis C transmission, fatal drug overdoses, and poor health outcomes among the city's injection drug users. Between December 2003 and April 2005, a representative sample of 1,035 SIF participants were enrolled in a prospective cohort that required completing an interviewer-administered questionnaire and providing a blood sample for HIV testing. HIV infection was detected in 170/1007 (17%) participants and was associated with Aboriginal ethnicity (adjusted Odds Ratio [aOR], 2.70, 95% Confidence Interval [95% CI], 1.84–3.97), a history of borrowing used needles/syringes (aOR, 2.0, 95% CI, 1.37–2.93), previous incarceration (aOR, 1.87, 95% CI, 1.11–3.14), and daily injection cocaine use (aOR, 1.42, 95% CI, 1.00–2.03). The SIF has attracted a large number of marginalized injection drug users and presents an excellent opportunity to enhance HIV prevention through education, the provision of sterile injecting equipment, and a supervised environment to self-inject. In addition, the SIF is an important point of contact for HIV positive individuals who may not be participating in HIV care and treatment.

David Marsh, First Supervised Injection Site in North America, Evaluating Effectiveness from a range of perspectives, 2006.

Evan Wood, Mark W. Tyndall, Julio S. Montaner and Thomas Kerr, Summary of findings from the evaluation of a pilot medically supervised safer injecting facility, CMAJ, November 21, 2006, 175(11), p.1395.

In many cities, infectious disease and overdose epidemics are occurring among illicit injection drug users (IDUs). To reduce these concerns, Vancouver opened a supervised safer injecting facility in September 2003. Within the facility, people inject pre-obtained illicit drugs under the supervision of medical staff. The program was granted a legal exemption by the Canadian government on the condition that a 3-year scientific evaluation of its impacts be conducted. In this review, we summarize the findings from evaluations in those 3 years, including characteristics of IDUs at the facility, public injection drug use and publicly discarded syringes, HIV risk behaviour, use of addiction treatment services and other community resources, and drug-related crime rates. Vancouver's safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts. These findings should be useful to other cities considering supervised injecting facilities and to governments considering regulating their use.

Evan Wood, Ruth Zhang, Julio S.G. Montaner and Thomas Kerr, Attendance at Supervised Injecting Facilities and Use of Detoxification Services, The News England Journal of Medicine, June 8, 2006.

Evan Wood, Mark W Tyndall, Calvin Lai, Julio SG Montaner and Thomas Kerr, Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime, Substance Abuse Treatment, Prevention, and Policy, May 2006.

North America's first medically supervised safer injecting facility (SIF) recently opened in Vancouver, Canada. One of the concerns prior to the SIF's opening was that the facility might lead to a migration of drug activity and an increase in drug-related crime. Therefore, we examined crime rates in the neighborhood where the SIF is located in the year before versus the year after the SIF opened. No increases were seen with respect to drug trafficking (124 vs. 116) or assaults/robbery (174 vs. 180), although a decline in vehicle break-ins/vehicle theft was observed (302 vs. 227). The SIF was not associated with increased drug trafficking or crimes commonly linked to drug use.

Racine P. et Grégoire L. (collaborateur), Facteurs de réussite de l'implantation d'un programme de services à bas seuil - Revue de littérature, Agence de développement de réseaux locaux de services de santé et de services sociaux de la capitale nationale, Direction régionale de santé publique, Beauport (Québec), 2005.

Evan Wood et al., Do Supervised Injecting Facilities Attract Higher-Risk Injection Drug Users, American Journal of Preventive Medicine, Vol.29, N°2, 2005.

In Western Europe and elsewhere, medically supervised safer injection facilities (SIFs) are increasingly being implemented for the prevention of health- and community-related harms among injection drug users (IDUs), although few evaluations have been conducted, and there have been questions regarding SIFs' ability to attract high-risk IDUs. We examined whether North America's first SIF was attracting IDUs who were at greatest risk of overdose and blood-borne disease infection.

Thomas Kerr, Megan Oleson, Mark W. Tyndall and al., A Description of a Peer-Run Supervised Injection Site for Injection Drug Users, Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 82, No. 2, 2005.

Owing to the ongoing health crisis among injection drug users in Vancouver, Canada, there have been repeated calls for the establishment of supervised injection sites (SIS) since the early 1990s. In April 2003, a group of advocates and drug users opened an unsanctioned SIS in Vancouver’s Downtown Eastside. The “327 SIS” operated for 184 days. During the operation of the SIS, volunteers supervised over 3,000 injections by a high-risk injection drug using population. The SIS provided a sterile environment for injection drug use without measured negative consequences and demonstrated the feasibility of a peer-driven low-threshold SIS.

Wood E, Kerr T, Stoltz J, Qui Z and al., Prevalence and correlates of hepatitis C infection among users of North America’s first medically supervised safer injection facility, Public Health, 2005; 119(12): 1111-1115.

The SIF has attracted injection drug users with a high burden of HCV infection and a substantial proportion of uninfected individuals. Although crosssectional, this study provides some insight into historical risks for HCV infection among this population, and prospective follow-up of this cohort will be useful to determine if use of the SIF is associated with reduced risk behaviour and HCV incidence.

Evan Wood and al., Methodology for evaluating Insite - Canada's first medically supervised safer injection facility for injection drug users. Harm Reduction Journal, November 2004.

Evan Wood and al., Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users, CMAJ, Sept. 28, 2004; 171 (7).

Thomas Kerr, Megan Oleson and Evan Wood, Activisme pour la réduction des méfaits : étude de cas d'un lieu sécuritaire pour l'injection non autorisé, dirigé par des utilisateurs – Revue VIH/sida, droits et politiques 9(2), août 2004.

Devant la perpétuelle crise de santé qui sévit parmi les utilisateurs de drogue par injection (UDI) de Vancouver (Canada), plusieurs appels à l'introduction de lieux sécuritaires pour l'injection (LSI) ont été lancés depuis le début des années 1990. En avril 2003, en réponse à une vaste intervention policière et à l'inaction gouvernementale, un groupe de militants a ouvert un LSI non autorisé dans le quartier Downtown Eastside de Vancouver. Dans cet article, Thomas Kerr, Megan Oleson et Evan Wood relatent les événements entourant la création, l'opération et la fermeture du LSI non autorisé, puis décrivent les leçons que l'on peut tirer.

City of Vancouver, Supervised injection sites (SISs), Frequently asked questions. November 12, 2003.

Nadine Pederson, Vancouver ose la différence. Journal Alternatives, 27 avril 2003.

Nicolas Carrier, Une dépolitisation hygiénique : les lieux d'injection de drogues illicites comme stratégie de réduction des méfaits, Déviance et Société, 2003/1 (Vol. 27), P.59 à 76.

Au Canada, depuis la fin des années 1990, la mise en place de lieux où il serait possible de s’injecter des drogues interdites sans craindre d’autre intervention étatique que le contrôle médical est revendiquée par plusieurs acteurs sociaux. Le fait qu’il n’aura fallu que quelques années pour que cette stratégie de « réduction des méfaits» soit envisagée politiquement dans un Canada pourtant toujours attaché à son régime prohibitif appelle une interprétation sociologique. Examinant les motifs utilisés pour justifier la mise en place éventuelle de tels lieux par les acteurs des champs universitaire, journalistique et politique, on constate que ces motifs prennent pour axe majeur la dimension socio-sanitaire de l’usage. Une dépolitisation hygiénique: la tension prohibition-légalisation a disparue.

Projet de recherche sur un site pilote d'injection supervisé - Demande d'exemption en vertu de l'Article 56 de la Loi réglementant certaines drogues et autres substances, à des fins scientifiques. Décembre 2002.

Le présent document a pour but d'offrir des conseils aux demandeurs qui désirent obtenir une exemption en vertu de l'article 56 de la Loi réglementant certaines drogues et autres substances, à des fins scientifiques, pour un projet de recherche sur un site pilote d'injection supervisé au Canada.

Réseau juridique canadien VIH-sida, Les lieux sécuritaires pour l'injection. Feuillet d'information 10. 2002.

Broadhead and al., Safer injection facilities in North America: Their place in public policy and health initiatives. The Journal of Drug issues, 2002.

Réseau juridique canadien VIH-sida, Un nouveau rapport exhorte à mettre à l'essai des sites sécuritaires pour l'injection dès que possible. 11 avril 2002.

Ralf Jürgens, Les sites d'injection supervisés. Enjeux éthiques et légaux. Réseau juridique canadien VIH-sida, Montréal, 23 novembre 2001.

Denis Hamel, Perception de la population québécoise en lien avec les programmes de prévention de la toxicomanie et du VIH, INSP Québec, 2001.

Thomas Kerr, Safe Injection Facilities, Proposal for a Vancouver Pilot Project. Novembre 2000.

Video - SIS (Site d'Injection Supervisé)

Traduction française - Video SIS