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Canada's highest court unchains injection drug users : implications for harm reduction as standard of… Small, Dan 2012

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COMMENTARY Open AccessCanada’s highest court unrpeheinanrass2to life-saving healthcare. The case began at the SupremeCourt of British Columbia and eventually made its wayhealthcare matter in Canada.As a caveat, I am not a distant academic examiningSmall Harm Reduction Journal 2012, 9:34http://www.harmreductionjournal.com/content/9/1/342Department of Anthropology, University of British Columbia, 6303 NWMarine Drive, Vancouver, British Columbia V6T 1Z1, Canadato the Supreme Court of Canada (SCC). At the centre ofthe case were the personal stories of people who reliedon supervised injection to stay alive together with testi-mony from scientists, physicians, healthcare officials andthe operators of Insite. On 30 September 2011, SupremeCourt of Canada drew a legal line in the sand thatsupervised injection from the point of view of a removedobserver. I am part of the senior management of thenon-profit organization that founded and operates Insite,the PHS Community Services Society (PHS) and, assuch, I have been intricately involved in the develop-ment, set-up, management and advocacy for Insite. I ama participant observer and so this commentary is writtenfrom the point of view of my personal experience.Correspondence: dan@phs.ca1PHS Community Services Society, 20 West Hastings Street, Vancouver, BritishColumbia V6B 1G6, Canada(PHS), the non-profit organization that operates Insite, launched a legal case to protect the program. On 30September 2011, Supreme Court of Canada ruled in favour of Insite and underscored the rights of people withaddictions to the security of their person under section 7 of the Charter of Rights and Freedoms (Charter of Rights).The decision clears the ground for other jurisdictions in Canada, and perhaps North America, to implementsupervised injection and harm reduction where it is epidemiologically indicated. The legal case validates thepersonhood of people with addictions while metaphorically unchaining them from the criminal justice system.“The philosophers have only interpreted the world invarious ways; the point, however, is to change it” [1].After a long legal and cultural battle, North America’sonly supervised injection facility, Insite, is finally safefrom arbitrary political interference. This was a casewhere personal experience, activism, advocacy, medicineand science stood side-by-side to protect the rights ofeven the most marginalized members of the communityhighlights the rights of people with addictions to the se-curity of their person under section 7 of the Charter ofRights and Freedoms (Charter of Rights) [2]. The Char-ter enshrines the values of Canadian culture regardingthe rights of individuals with respect to the provincial,federal and territorial governments. The judges of Canada’shighest court are appointed from a wide variety of politicalbackgrounds. The decision was unanimous and reinforcedthe foundation of our understanding of addiction as ausers; implications for haof healthcareDan Small1,2*AbstractNorth America’s only supervised injection facility, Insite, oexemption as a three-year scientific study. The results of tshowed it to be successful in engaging the target groupinfections while increasing uptake and retention in detoxmedical and scientific journals, also showed that the progDespite the substantial evidence showing the effectivenewith the election of a conservative federal government in© 2012 Small; licensee BioMed Central Ltd. ThCommons Attribution License (http://creativecreproduction in any medium, provided the orchains injection drugm reduction as standardned its doors in September of 2003 with a federalstudy, evaluated by an independent research team,healthcare, preventing overdose death and HIVd treatment. The research, published in peer-reviewedm did not increase public disorder, crime or drug use.of the program, the future of Insite came under threat006. As a result, the PHS Community Services Societyis is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.The journey for Insite has been wrought with chal-lenges because it confronts our inner web of belief abouthow to best approach addiction. Supervised injectionexists in a moral minefield at the very heart of our cul-ture. By culture, I am speaking about what we believe tobe right and wrong, the implicit and explicit values thatare the building blocks of our understanding, practiceand societal approaches to people with addictions [3].As such, it is my belief that this legal victory is aboutsomething much more fundamental than the legal, med-ical or scientific issues that arise from it. It points theway towards a shift in our cultural orientation thatSmall Harm Reduction Journal 2012, 9:34 Page 2 of 11http://www.harmreductionjournal.com/content/9/1/34allows for addiction to be constructed as a social issuebest addressed, metaphorically, by the Chief of Medicinerather than the Chief of Police (Figure 1).This cultural change is best illustrated by a story fromonly a decade ago when harm reduction was not widelyaccepted or understood in Canada. Harm reductioninnovations involve attempting to reduce harms asso-ciated with drugs, such as fatal overdoses, but to do sowithout necessary eliminating the use of drugs (abstin-ence). The Harm Reduction Journal provides the follow-ing definition:“We define 'harm reduction' as 'policies and programswhich aim to reduce the health, social, and economiccosts of legal and illegal psychoactive drug usewithout necessarily reducing drug consumption'” [4].In the year preceding the opening of Insite in 2003, Iwas collaborating on a draft press release in response tolocal opposition to harm reduction. The press releasesimply stated that addiction is, primarily, a healthcarematter. At that time, the notion of publicly stating thataddiction is a healthcare rather than criminal justiceissue was so controversial that I could not convince any-one in the establishment to lend their name to the pressrelease. In the end, two community activists agreed tosign their names to what was, at the time, a provocativeFigure 1 God distributing clean needles. Graphic by Flux Design.public statement. Now, ten years later; this has becomean established legal fact in Canada. Addiction is ahealthcare matter.The PHS initiated the case at the Supreme Court ofBritish Columbia in 2008 to protect the program fromclosure by a conservative federal government. We didso at a time when there was no formal institutionalsupport for a struggle to protect Insite in the courts.The only intervener was the British Columbia CivilLiberties Association. Despite their role in co-managingInsite, Vancouver Coastal Health (VCH) counseled ourorganization not to turn to the courts to protect theprogram and refused to provide any formal assistancefor the PHS to legally defend it. In the initial case,neither Vancouver Health Authority (VCH), nor theAttorney General of British Columbia sought inter-vener status. Fortunately, the PHS was able to obtainpro bono representation by three lawyers: MoniquePongrecic-Speier, F. Andrew (Drew) Schroeder and JosephArvay all of whom nobly took on the case when it felt likeInsite had been backed against the wall. A related andimportant case, entered by the Vancouver Area Networkof Drug Users (Respondent/Appellant on cross appeal)was heard jointly.The PHS case focused on two overarching themes. Thefirst theme related to the division of powers between thefederal and provincial governments and essentially arguedthat the operation of Insite falls under the jurisdiction ofthe Province of British Columbia. The second argumentpertained to the Charter. The Charter is the first part ofthe Constitution of Canada and contains a passage of par-ticular relevance to Insite.2 This portion of the Charter,section 7, is of central importance to Insite and states that:“Everyone has the right to life, liberty and security of theperson and the right not to be deprived thereof except inaccordance with the principles of fundamental justice” [5](p. 4). The PHS argued the federal Health Minister’s with-holding of an exemption from the Controlled Drugs andSubstances Act (CDSA) that was required at that time forInsite’s operation was prejudicial and arbitrary. More so, itjeopardized the life chances of people who need the facil-ity to access life saving healthcare.The case at the BC Supreme Court laid the ground-work for the facts that would later form the foundationfor the landmark ruling at the Supreme Court ofCanada. Given the case’s importance, it is worth examin-ing at a high level. There are, in my view, four key find-ings of fact in this first case.The first key fact pertains to the notion that addictionis a healthcare matter. The Government of Canada con-ceded this as an indisputable fact.The presiding judge at the BC Supreme Court, JusticeIan Pitfield, highlighted this absolutely critical culturaladmission in his Reasons for Judgment when he stated:Small Harm Reduction Journal 2012, 9:34 Page 3 of 11http://www.harmreductionjournal.com/content/9/1/34“drug addiction is an illness” [6] (p. 20). The declarationof addiction as an illness allows for the devotion ofhealthcare resources to addressing it.The second fact that was established was that drugs, inand of themselves, do not necessarily cause serious inter-ruptions in health. Rather, it is the method, mechanism andcontext within which drugs are ingested that brings aboutdanger:“Controlled substances such as heroin or cocaine thatare introduced into the bloodstream by injection donot cause Hepatitis C or HIV/AIDS. Rather, the use ofunsanitary equipment, techniques and procedures forinjection permits the transmission of those infections,illnesses or diseases from one individual to another”[6] (p. 33, para. 87).This is the foundation of supervised injection as anintervention. The point of intervention focuses on redu-cing the harms associated with drug use without forcingabstinence as a precondition for receiving healthcare.The idea that drugs, as substances, are not automatic-ally intrinsically evil or dangerous has been a culturallycontroversial notion. There are, broadly speaking, twocompeting overarching narratives about addiction [3].The first narrative focuses, essentially, on drug use andthe drugs themselves as intrinsically dangerous. The sec-ond does not centre on the drugs themselves, but insteadconcentrates on the way drugs are administered (e.g. cleanversus unclean syringes) and the psycho-socio-culturalcontext of their use (such as criminalization, poverty andmental pain).This distinction can be traced to the work of psychologistBruce K. Alexander who first discussed two orientations forconstructing addiction 30 years ago [7]. The first orienta-tion essentially constructs addiction as follows: first a per-son takes a drug, then, eventually, the drug takes theperson as a result of repeated exposure. Understanding ad-diction in terms of an exposure to drug concentrates on theeradication of drugs as the point of intervention. Followingon from this reasoning, it is the reduction in drug expo-sures that will ultimately reduce or eliminate addiction. Therival narrative about addiction, described in terms of copingor adapting by Alexander and his colleagues constructs theproblem altogether differently. According to this alternativeexplanation, people take drugs; drugs do not take people.This perspective maintains that people misuse drugs due toimpoverished conditions and psychosocial pain that requireextraordinary coping strategies. In turning focus away fromthe dangers of the drugs themselves to the ways in whichthey are being used, the original court decision was alignedwith this latter orientation.The third legal fact pertained to the notion that effect-ive medical interventions are available to measurablyreduce the harms of addiction. The primary healthcareintervention in Insite is the provision of sterile injectionequipment and the supervision of injection:“The risk of morbidity and mortality associatedwith addiction and injection is ameliorated byinjection in the presence of qualified healthprofessionals” [6] (p. 33, para. 87).The finding of this fact, based on the scientific andmedical evidence before the court, established that asupervised injection facility helps to prevent disease anddeath. Contrary to its popular characterization as an iso-lated program, Insite also offers detox and treatment onsite.The final fact is perhaps the most culturally controver-sial because it foregrounds the fact that effective health-care interventions exist for addiction that do notdemand abstinence. Justice Pitfield understood thatwhile Insite is not traditional treatment, it is, nonethe-less, important healthcare:“While users do not use Insite directly to treat addiction,they receive services and assistance at Insite whichreduce the risk of overdose that is a feature of theirillness, they avoid risk of being infected or of infectingothers by injection and they gain access to counsellingand consultation that may lead to abstinence andrehabilitation. All of this is healthcare” [6] (p. 51, para.136).This recognition of this fact feeds into the cultural anxie-ties about somehow enabling or encouraging addiction bynot outlawing it with vehemence. The ruling also addressedthis culturally notorious notion of overlooking addiction:“Society cannot condone addiction, but in the face ofits presence it cannot fail to manage it, hopefully withultimate success reflected in the cure of the addictedindividual and abstinence” [6] (p. 54., para. 144).The rival perspective, abstinence at all cost, wouldpresumably withhold supervised injection as a health-care intervention even if it resulted in preventable fataloverdoses. This was the very reason the PHS enteredthe courts: we believe that harm reduction is a door-way into treatment, detox and abstinence and that thesafeguarding of human life offered by supervised injec-tion is sacrosanct. Without supervised injection,people might perish from fatal overdoses before realiz-ing the opportunity to one day pursue detox, treatmentand abstinence. Instead, all that would be left would bea mortality statistic: a faint reminder that they everlived.Small Harm Reduction Journal 2012, 9:34 Page 4 of 11http://www.harmreductionjournal.com/content/9/1/34In summary, there were four legal facts that go to theheart of a particular cultural understanding of addiction:1. Addiction is a healthcare matter.2. Drugs to do not cause deadly HIV, HCV and fataloverdoses: unclean needles and unsupervisedinjection do.3. Supervised injection is effective at preventingmorbidity and mortality. Harm reduction opens thedoor to a range of healthcare (e.g. detox, treatment).4. Abstinence, though laudable, is not compulsory foreffective healthcare interventions, with measurableoutcomes (e.g. such as saving lives by intervening inotherwise fatal overdoses or preventing HIV) foraddiction. The idea of condoning or enablingaddiction with supervised injection takes secondplace to keeping people alive.The establishment of these four key facts, in my view,laid the groundwork for both a legal and a cultural vic-tory with respect to the notion of supervised injection.As the case advanced, it gathered cultural momentumas part of a growing acceptance of a particular under-standing about addiction as described above. At the finalstage, 14 interveners had joined the proceedings includ-ing: the Vancouver Coastal Health Authority, CanadianNurses Association, British Columbia Nurses’ Union,Registered Nurses’ Association of Ontario, Associationof Registered Nurses of British Columbia, CanadianMedical Association, Canadian Civil Liberties Association,Canadian HIV/AIDS Legal Network, International HarmReduction Association, CACTUS Montreal (a non-profitorganization dedicated to providing non-judgmental as-sistance and risk reduction for at risk individuals includingthose use illicit drugs, street involved youth, sex tradeworkers as well as transvestite and transsexual persons),Canadian Public Health Association, British ColumbiaCivil Liberties Association, Attorney General ofQuebec and Dr. Peter AIDS Foundation. The Attor-ney General of British Columbia was a respondentwith regard to the doctrine of inter-jurisdictional im-munity that was won at the Appeal Court level andargued for localized control over Insite as a provincialinitiative.Sadly, there has always been a psychosocialphenomenon that is culturally expunged or relegated tothe shadows due to the moral anxieties that it creates inthe wider community. This has been true in the case inthe present and past with issues or experiences thatmake people uncomfortable such as death, sexuality,mental illness or addiction which are sequestered in so-cial life and institutional settings [8]. This process ofsequestering, or hiding away of the social phenomenathat alarm or anger us, also takes its shape in the formof cultural erasures and silences, things that are unsaidwhich can, in actuality, be more influential than what issaid [9]. Addiction is just such a phenomenon; peoplewith addictions have been sequestered, silenced anderased from positive social life. Their personhood hasbeen so dramatically undermined that their identities aresometimes socially spoiled [10] leaving them metaphor-ically chained. Throughout the education campaign tosave Insite, we attempted to combat this identity erosionby highlighting the personhood of people living withaddictions by echoing the idea that everyone living withaddictions was someone’s son or daughter (Figure 2).The field of mental health provides an interesting ana-logy with respect to the process of liberation of peoplewith pain from societal shackles of stigma and incarcer-ation. Psychiatry’s approach to people with mental ill-nesses transitioned towards humanistic treatment in the1780’s under the leadership of more humanistic psychia-trists and reforms in the mental health field. PhysicianVincenzo Chiarugi (1759–1820) led a movement espous-ing the humane treatment of the mentally ill which tookits first applied step, in practice, in 1788 with the open-ing of Hospital Bonifacio in Florence, Italy where heserved as the physician director [11]. Chiarugi’s ap-proach was in keeping with the goals of Grand DukePietro Leopold of Tuscany, a socially conscious aristo-crat who ordered the establishment of Bonifazio, andwas predicated on respectful and humane treatment[12]. He is a significant figure in the history of humanis-tic medicine and one of the fathers of compassionatepsychiatry. Chiarugi is thought to be the first figure toforbid the use of chains to restrain the mentally ill (apolicy which he established during his role as physiciandirector of Santa Doretea hospital before 1793) [12].Similarly, Jean-Baptiste Pussin (1746–1811) andMadame Marguerite Pussin (1754-?) helped to infuse com-passion into the practice of mental health [12,13]. Afterhaving been a patient at Bicêtre hospital in the suburbs ofParis, Jean-Baptiste Pussin went on to become the directorof a psychiatric ward from 1785 to 1802 during which timehe implemented a series of compassionate improvementsin the treatment of mentally ill [14]. Pussin outlawed theemployment of chains to imprison the mentally ill in 1797while serving as the governor of Bicêtre [12]. Pussin is animportant forerunner in the history of humanistic mentalhealth services.In popular culture, physician Phillippe Pinel is widelythought of as being the first individual to liberate thementally ill from chains. The renowned painting Mad-women at the Salpêtrière, painted by Tony-RobertFleury, has helped to immortalize this legend. The paint-ing shows Pussin removing the chains of psychiatricpatients while Pinel looks on and symbolizes a transitiontowards more humanistic approaches to the mentally illSmall Harm Reduction Journal 2012, 9:34 Page 5 of 11http://www.harmreductionjournal.com/content/9/1/34in the 18th century. Today the painting hangs in the en-trance to the Library Charcot in the Salpêtrière hospital[14].In fact, it was Pussin who inspired Pinel to ban the useof chains for detaining people living with mental ill-nesses [12,15]. After having worked at Bicêtre between1793 and 1795, Philippe Pinel was so inspired by thework of Pussin that he credited him with the emancipa-tion of the mentally ill and the first actual application ofhumanistic psychiatric treatment. When Pinel moved toFigure 2 This should not be an injection site. Graphic by PHS CommunSalpêtrière, the largest hospital in Paris, he established apost for Pussin who took up the position there from1801 until his death in 1811.14 At Salpêtrière in Paris,Pussin and Pinel worked together to apply humanisticapproaches to psychiatric treatment.There is some humanistic truth at the heart of legend-ary characterization of Pinel as the person that liberatedthe mentally ill from their chains. He did, in fact,showed significant leadership by moving away fromabandonment and brutal imprisonment to a therapeuticity Services Society.Small Harm Reduction Journal 2012, 9:34 Page 6 of 11http://www.harmreductionjournal.com/content/9/1/34approach based on medical science and compassion[12]. Similarly, the Insite legal case helps to make a simi-lar transition from the cruelty of criminalization in ad-diction to a healthcare model where people withaddiction have fundamental rights to life savinghealthcare.The mental health field transitioned from a modelbased on incarceration and neglect of the mentally ill toan approach based on compassion, science and medicaltreatment in the 18th century. In the addiction field, thistransition has taken another two centuries (21st century).The metaphor of chaining of the addicted goes beyond thesymbolic. In 2009, the US incarcerated more than 400,000individuals for non-violent drug offenses (a greater numberthan those incarcerated for all offenses in the 27 nations ofthe European Union combined [16].The incarceration of the addicted has been so dra-matic that, when seen through the lens of epidemi-ology, it can be considered as a catastrophic event thathas resulted in tremendous suffering and death. Theepidemiological tool of years of life lost (YLL) is usefulfor examining the impact of a criminal justice approachto addiction. Drucker defines years of life lost as “thenumber of years between the victim’s age at death andthe age that his or her usual life expectancy would pre-dict. Thus, for the average American with a life expect-ancy of 75years, a child’s death at age ten implies a lossof sixty-five potential years of life [16] (p.69). Buildingon this logic, Drucker notes that 1,513 people diedrepresenting an estimated 47,000 YLL in the Titanicdisaster, 2,819 deaths representing an estimated104,303 YLL died in the World Trade Centre tragedyand reasons that over the past 35years (since the intro-duction of the Rockefeller drug laws in New York),more than 7 million people have been incarcerated.This translates into an estimated 14 million YLL repre-senting 350,000 deaths in a group of the same age [16].In 2009 alone, more than 400,000 individuals wereincarcerated for non-violent drug offenses in the UnitedStates. This represents a greater number than all thoseincarcerated for all offenses in the 27 nations of theEuropean Union combined [16]. The Insite victory isemblematic of a different cultural understanding of ad-diction that is supplanting a traditional one. This newerapproach assumes people living with addictions are inneed of healthcare rather than punishment through thecriminal justice system.By focusing on the federal Health Minister’s refusal toprovide an exemption for Insite under the existing regu-latory framework, the SCC did not have to make anyalterations to existing provincial and federal jurisdictionsover the program. Canada’s federal governmentattempted to argue that the federal minister of healthhad, technically, never “not given” a permit for Vancouver’ssupervised injection site and therefore never formally jeo-pardized its operation. However, the court ruled that it wasself-evident that the federal Health Minister had everyintention to close Insite:“The Minister of Health must be regarded as havingmade a decision whether to grant an exemption, sincehe considered the application before him and decidednot to grant it. The Minister’s decision, but for the trialjudge’s interim order, would have prevented injectiondrug users from accessing the health services offered byInsite, threatening their health and indeed their lives[emphasis added] [2] (p. 9).The SCC concluded that the Minister’s intention toshut Insite would have threatened the lives of the peoplewho rely on the program. It also noted the programwould not have remained open had it not been for pro-tection provided by the Supreme Court of BC (Figure 3).National public policy with respect to supervised injec-tion in Canada began with the establishment of a loca-lized response to a healthcare emergency. Supervisedinjection, in this case, began from the ground up ratherfrom a top down policy. The goals of Insite originatedout of local need, inspired by the idea that people withaddictions deserved something better than death fromoverdose. The goals and outcome measures were simple.The program aimed to provide a doorway to life, sup-ported housing, physicians, healthcare services and sup-ports. The intent of the program was to provide itsinterventions (e.g. clean syringes, supervised injection)in an accessible way without barriers (such as abstinenceor onerous intake procedures).One thing that is clearly demonstrated by the case ofInsite is that science is not enough, on its own, tochange public policy especially in stigmatized areas likeaddiction. The simple existence of a scientific evidencebase does not automatically lead to changes in policiesor practice. Policy makers and elected officials need topay attention to the evidence base. In some disappoint-ing instances, as the case of Insite has shown, policymakers need to be forced to pay attention to the estab-lished facts. Conversely, scientists need to take an activerole in affecting public policy when the evidence indi-cates the need for change [17]. The SIF, for instance, hadmore than three-dozen peer-reviewed papers associatedwith its evaluation [18–47]. Despite the fact that muchof the evaluation was paid for by the Government ofCanada, they chose to ignore the scientific findings. Theevidence base generated by Canada’s supervised injectiontrial should have earned it a medical exemption (thenext stage of operational permit after the scientificauthorization originally granted to Insite) but it was notprovided. Uncompromising advocacy, including publicprotest and legal challenge, was required to obtain thepermit.Small Harm Reduction Journal 2012, 9:34 Page 7 of 11http://www.harmreductionjournal.com/content/9/1/34In this way, science in healthcare and applied researchare not the same [48]. While science in healthcare isportrayed as "objective", applied research is seen asrooted in the context of the community needs. From myperspective, science in healthcare needs to move moretowards clinical application. Yes, it needs to be soundand rigorous, but its main purpose should be to servethe patients, families and the community. Scientificevaluation of the Insite may have been a necessary con-dition but it was certainly not a sufficient condition tobring about a permanent change in public policy or asustainable supervised injection facility.Figure 3 Safe injection site demonstration. Graphic by PHS CommunitySometimes scientists and bureaucrats spend too muchtime worrying about protecting objectivity at the ex-pense of advocacy. Yet, there are, time and time again,instances where advocacy needs to be undertaken andundertaken vigorously. The supervised injection facilitywas one of those times. It demanded public advocacy.Despite the victory, on the day of court announcement, Ifelt relief more than elation. I couldn’t help but wonderwhat would have happened to Insite if things had beendifferent? If we had lost the court case, would the vari-ous stakeholders have chosen the ethically sound courseof action by continuing to operate in spite of an unjustServices Society.political, scientific and moral reactions. While it is forthe relevant governments to make criminal and healthpolicy, when a policy is translated into law or stateaction, those laws and actions are subject to scrutinyunder the Charter” [2] (p.9).The suitability of supervised injection shouldn’t beFigure 4 Safe injection sites now. Graphic by Flux Design.Small Harm Reduction Journal 2012, 9:34 Page 8 of 11http://www.harmreductionjournal.com/content/9/1/34law prohibiting the facility’s operation? There wouldhave been a strong ethical case for breaking the law andkeeping Insite open. There was no scientific uncertaintyabout the effectiveness of Insite at engaging a hard toreach population in healthcare and saving lives. The onlyequipoise was political. Had we lost, would we have beenforced to live through a medical, legal and ethical disas-ter while people died of preventable overdoses because itwas against the law? These are dark questions thathaunted Insite right up until the very moment that thefinal decision was rendered. Thankfully, we never had topublically confront what might have been had we lost.In my view, there are three important cultural ramifi-cations of this case. Firstly, this legal decision says a lotabout what it is to be a person, to have personhood, inCanada. Personhood symbolizes our connection to thewider human family [49]. What it is to be a person existsin the borderland of human relations where personalagency and meaning are psychosocially constructed aspart of an inner and outer conversation. Socially deva-lued features of our selves such as addiction reduce ouropportunities to be on the threshold of a successful life[10]. The personhood of people with addiction is oftenundermined or threatened by policies, programs and im-plicit or explicit exclusion (e.g. drug courts and thera-peutic communities are typically founded on the principlethat addicts must abdicate a portion of their self-deter-mination). The personhood of people with addictions inCanada has been emphasized and their constitutionalrights feature prominently in this legal ruling.The second consequence of this case is that other jur-isdictions may, and should, establish supervised injectionif the epidemiological variables demand it. On this point,I disagree with the overemphasis on obtaining consensusfrom an overly broad collection of stakeholders (e.g. themunicipal government, the local police) who are typic-ally consulted in order to obtain their blessing so thatlives can be saved by supervised injection. A letter ofsupport from the Chief of Police or Mayor of a citywould not be required to establish a cancer treatmentprogram. Correspondingly, one shouldn’t be required inthe case of harm reduction programs. If the evidencebase is there to support an intervention, then we shouldmove past consensus building when it comes to life savinghealthcare. The SCC has ruled that the morality of an ac-tivity, such as drug addiction, isn’t enough to ignore some-one’s rights to security of their person under section 7 ofCanada’s Charter of Rights and Freedoms (the Charter):“Additionally, the morality of the activity the lawregulates is irrelevant at the initial stage ofdetermining whether the law engages a s. 7 right.Finally, the issue of illegal drug use and addiction is acomplex one which attracts a variety of social,debated any longer as though it were on par with a dis-cussion on a sports show about which sports team willSmall Harm Reduction Journal 2012, 9:34 Page 9 of 11http://www.harmreductionjournal.com/content/9/1/34win the championship. Supervised injection is healthcareand whether it is required in a jurisdiction needs to bedetermined by evidence and not arbitrary opinions orfickle political stances in search of votes. If science andmedicine have established the best course of action, thenwe shouldn’t turn to opinion polls to determine the besthealthcare (Figure 4).Finally, it is my opinion that this ruling provides fur-ther affirmation that many healthcare providers know:harm reduction needs to be an explicit part of thestandard of care now. Every single health authority andregion in Canada should have a proactive policy detail-ing best practices in harm reduction when it is epide-miologically indicated. It is simply not acceptable topretend harm reduction doesn’t exist or to let moralopposition rather than evidence based analysis guidedecisions in this area.Any jurisdiction that doesn’t a positive policy on harmreduction is misguided. An example is provided by theCity of Abbotsford in British Columbia. In June 2005,Abbotsford amended their zoning (bylaw no. 1378–2004)in order to overtly exclude harm reduction:“Prohibited uses would include safe injection sites,needle exchanges, mobile dispensing vans, methadoneFigure 5 Church Marquee in Vancouver’s Downtown Eastside. Photogtreatment facilities and other types or similar uses.”The experience of Insite should be an important lessonfor jurisdictions that ignore, or in the case of Abbots-ford, outlaw, harm reduction as part of healthcare. Theydo so at their own peril legally, medically and ethically(Figure 5).This commentary is not meant to be a distant scien-tific paper but, instead, an experience-based and sociallypositioned interpretation of events that I have lived. Asone of the creators of Insite, I had always imagined thatestablishing an injection site would be the most difficulttask to accomplish. In fact, it seems to me that the pro-tection of it, once established, has been an even largerchallenge. The struggle to protect Insite has distractedus from many other important prevention, treatment,enforcement and harm reduction initiatives that need tobe established to comprehensively address addiction.The fact that the program has survived is itself an indi-cator of social change and I believe that this ruling sig-nals that we have reached an important culturalmilestone. We’ve gone so much further than hoping thataddiction will one day be understood as a healthcarematter. The very fact that Insite can exist, with the per-manence of a Supreme Court decision, supports harmraph by Dan Small.Small Harm Reduction Journal 2012, 9:34 Page 10 of 11http://www.harmreductionjournal.com/content/9/1/34reduction as part of the standard of care, with the sus-tainability it deserves. With this ruling, we’ve moved be-yond hopefulness to a point in our history where peoplewith addictions have been unchained. Canada’s highestcourt has spoken. It’s the law.“If you have built castles in the air, your work neednot be lost; that is where they should be. Now put thefoundations under them [50] (p.255).Competing interestsThe author declares that he has no competing interests.Received: 11 November 2011 Accepted: 4 July 2012Published: 20 July 2012References1. Marx K: Selected Works. In Theses on Feuerbach. 1845th edition. Edited byMarx K, Engles F. Moscow: Progress Publishers; 1989:13–15.2. Supreme Court of Canada: Canada (Attorney General) v. PHS communityservices society. In SCC 44 33556. Edited by Canada SC. Ottawa: SupremeCourt of Canada; 2011.3. Small D: Mental illness, addiction and the supervised injection facility.Visions: BC's Mental Health and Addictions Journal 2004, 2(1):37–39.4. Harm Reduction Journal. Definition of Harm Reduction; 2012. [cited 2012 24April]; Available from: http://www.harmreductionjournal.com/.5. 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DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T: Police andpublic health partnerships: Evidence from the evaluation of Vancouver'ssupervised injection facility. Substance Abuse Treatent, Prevention and Policy2008, 3(1):1–5.19. Fairbairn N, Small W, Shannon K, Wood E, Kerr T: Women's experiences inNorth America's First Medically Supervised Safer Injection Facility. Soc SciMed, 67(8):817–823.20. Kerr T, Kimber J, DeBeck K, Wood E: The Role of Safer Injection Facilities inthe Response to HIV/AIDS Among Injection Drug Users. Curr HIV/AIDS Rep2007, 4(4):158–164.21. Kerr T, Small W, Moore D, Wood E: A Micro-Environmental Intervention toReduce Harms Associated with Drug-Related Overdose: Evidence fromthe Evaluation of Vancouver's Safer Injection Facility. Int J Drug Policy2007, 18:37–45.22. Kerr T, Stoltz J, Tyndall M, Li K, Zhang R, Montaner J, Wood E: Impact of aMedically Supervised Safer Injection Facility on Community Drug UsePatterns: A Before and After Study. 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Vermont: Orion Publishing Group; 1995 (1910).doi:10.1186/1477-7517-9-34Cite this article as: Small: Canada’s highest court unchains injectiondrug users; implications for harm reduction as standard of healthcare.Harm Reduction Journal 2012 9:34.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSmall Harm Reduction Journal 2012, 9:34 Page 11 of 11http://www.harmreductionjournal.com/content/9/1/34Submit your manuscript at www.biomedcentral.com/submit


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