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The use of knowledge translation and legal proceedings to support evidence-based drug policy in Canada… DeBeck, Kora; Kerr, Thomas Sep 21, 2010

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Analysis and Comment                                                                                                         DeBeck and KerrOpen Medicine 2010;4(3):e167The use of knowledge translation and legal proceedings to support evidence-based drug policy  in Canada: opportunities and ongoing challengesKora DeBecK, Thomas KerrKora DeBeck, MPP, is the knowledge translation program coordina-tor at the Urban Health Research Initiative British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada. Thomas Kerr, PhD, is director, Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, and assistant professor, Department of Medicine, Division of AIDS, Univer-sity of British Columbia, Vancouver.Funding: Kora DeBeck is supported by a Michael Smith Foundation for Health Research (MSFHR) Senior Graduate Trainee Award and a Cana-dian Institutes of Health Research (CIHR) Doctoral Research Award. Thomas Kerr is supported by MSFHR and CIHR. Competing interests: None declared.Correspondence: Thomas Kerr, Department of Medicine, Division of AIDS, University of British Columbia, St. Paul’s Hospital, 608–1081 Bur-rard St., Vancouver BC  V6Z 1Y6  Canada; tel: 604 806-9116; fax: 604 806-9044; uhri-tk@cfenet.ubc.caThe role of evidence-based medicine in improving health services and health outcomes is widely recognized in the realm of health care policy.1,2 However, there is growing recognition, particularly in the areas of illicit drug policy and HIV prevention, that policy-makers are in many instances implementing sub-optimal programs and services because they are not basing their decisions on the best available scientific evi-dence.3–7 The negative impact this has had on the health of marginalized groups, including people who use injec-tion drugs,7 has prompted interest in identifying strat-egies that can support the implementation of evidence-based policies.6 One notable example where a policy-making body has failed to use scientific evidence to inform public policy is the Canadian federal government’s opposition to Van-couver’s supervised injection facility, Insite. This op-position has persisted despite a large body of scientific evidence indicating that the program is associated with a range of health and social benefits.8,9 The government’s position on the supervised injection facility has spurred reactions from a broad range of individuals, organiza-tions and politicians. In particular, two approaches have been pursued in an attempt to shift drug policy toward an evidence-based approach and maintain the operation of this evidence-based health facility. The first approach involved knowledge translation (KT), which rests on the assumption that the gap between research and policy is largely the result of a failure to present research findings in terms that are meaningful and accessible to policy-makers.10,11 However, when the gap between research and policy is the result of ideological conviction taking priority over scientific evidence, as in the case of Insite, KT approaches do not work. Because federal policy-makers disregarded scientific evidence of the benefits of Insite, a second approach was used to support the con-tinued operation of this facility: legal arguments and proceedings. We hope that an overview of these two approaches will offer lessons for the implementation of evidence-based policies in other areas of health and so-cial policy and highlight some of the ongoing challenges to the application of evidence-based policies in contro-versial areas.    The establishment of a supervised injection facility in Vancouver, CanadaIn the wake of a public health disaster characterized by a generalized epidemic of HIV infection among its local injection drug user population and high rates of drug-related overdose deaths, community and public health leaders in Vancouver, Canada, established a supervised injection facility called Insite.12,13 Insite is a place where injection drug users can bring pre-obtained illicit drugs and inject in a sterile environment, with clean injecting equipment, under the supervision of a nurse.8 In order to operate, the injection facility was granted an exemp-tion from Canada’s Controlled Drugs and Substances Act under the premise that it was a medical experiment and would undergo extensive evaluation. When it opened in 2003 the B.C. Centre for Excellence in HIV/AIDS initi-ated an ongoing and rigorous scientific evaluation to de-termine whether there was evidence of benefits or harms to health and to the community.14,15 In the first five years of the scientific evaluation, over 30 studies were pub-lished in peer-reviewed journals demonstrating that the facility was associated with a range of health and social benefits and not associated with adverse effects.8 Al-though this body of evidence would be sufficient to jus-tify the expansion of just about any other public health program, because of the controversial nature of super-vised injection facilities, Insite was held to a much higher standard and continued to be scrutinized by the federal government.9 Knowledge translation to support an evidence-based health facilityTo address this skepticism, researchers involved in Insite’s scientific evaluation developed a multi-pronged KT strategy based on findings from the newly emerging KT field.10,11,16–18 Health researchers in a range of disci-plines are increasingly recognizing that generating high-quality research does not guarantee that the research will be used appropriately to inform policy and practice.16 Within the field of health, efforts are under way to iden-tify the most effective ways that health research findings can be made more accessible, or “translated,” for policy-makers. Key findings of studies of KT methods are that policy-makers and community members generally do not read academic journals and are more receptive to research in the form of plain language summaries and synthesis reports.10,11,16,17 As well, although the scientific rigour and quality of research is an important determin-ing factor in the uptake of research findings, KT research suggests that even with high-quality research, establish-ing communication networks between researchers and policy-makers is a principal facilitator in the adoption of research in public policy.18 Guided by the findings of KT research, the researchers involved in Insite’s scientific evaluation implemented an extensive KT strategy (see Box 1 for highlights of their activities). Public opinion polls19 and endorsements by medical bodies,20 elected officials21 and police22,23 indicated that these KT initiatives were successful and that the evalua-tion results received widespread acceptance; nonethe-less, the federal government remained fiercely opposed to the program, refusing to grant Insite a three-year extension for its operation and imposing a moratorium on trials of safer injection facilities in other Canadian cities.9 It became evident that the basis of its opposition was ideological, that scientific evidence was irrelevant in this policy environment,24 and that KT was not equipped to overcome the systematic disregard of scientific evi-dence by the federal government.9 Legal arguments and proceedings to support an evidence-based health facilityTo prevent the federal government from closing the facil-ity, in 2007 two community-based non-profit organiza-tions representing the interests of injection drug users, along with two individual plaintiffs, sought legal advice. Box 1: Highlights of knowledge translation activities  supporting evidence-based policies and the continued  operation of Insite, Vancouver’s supervised injection facility1Media engagement•	 Educated	media	about	research	findings	through	media	briefs•	 Participated	in	hundreds	of	media	interviews	•	 Wrote	letters	to	the	editor,	op-eds	and	commentaries	for	newspapers	and	magazinesPlain language summaries•	 Synthesized	research	into	reader-friendly	summaries	(both	long	and	short	versions)•	 Distributed	summaries	to	policy-makers	and	other	stakeholders,	including	a	summary	report	sent	to	all	federal	members	of	ParliamentOral presentations•	 Delivered	dozens	of	presentations	to	a	wide	range	of	audiences,	including	the	Canadian	parliament;	provincial	and	municipal	policy-makers	and	advisers;	health	care	providers;	community	groups,	including	Insite’s	local	community;	and	the	general	publicInternet•	 Developed	a	webpage	dedicated	to	posting	research	findings	and	plain	language	summaries	(see	the	Urban	Health	Research	Initiative	website)Political commentaries in academic journals•	 Published	multiple	commentaries	describing	the	political	situation	around	the	evaluation	of	the	supervised	injection	facility	and	the	disregard	of	scientific	evidence	by	the	Canadian	government	6,9,28–33				1	These	knowledge	translation	activities	were	conducted	primarily	by	the	principal	investigators	of	the	scientific	evaluation	of	Insite,		Drs	Thomas	Kerr	and	Evan	Wood.	Relying on a range of legal arguments, this group launched a lawsuit against the Attorney General of Canada and the Minister of Health.25 One of the primary arguments in the case was that people who use injection drugs have a con-stitutional right to access Insite because of its importance as a health care service that reduces the harms of injec-tion drug use. Another argument was based on the doc-trine of interjurisdictional immunity. Specifically, given that the province has constitutional power with respect to health care, and because Insite is a health care service, the facility falls under the jurisdiction of the provincial gov-ernment and its operation should not be subject to federal interference.25 In the process of the court case, KT again came into play when researchers were asked to present their findings in the form of sworn affidavits.After lengthy proceedings, in May 2008 the B.C. Su-preme Court dismissed the plaintiffs’ claims that inter-jurisdictional immunity applied, but it ruled that the current Controlled Drugs and Substances Act, to the extent that it provides the federal government with the power to close the facility, is in violation of the Canadian Charter of Rights and Freedoms,26 and the government was ordered to amend the relevant sections of the Con-trolled Drugs and Substances Act to allow Insite to con-tinue operating. This decision represented an important Open Medicine 2010;4(3):e168Analysis and Comment                                                                                                         DeBeck and KerrOpen Medicine 2010;4(3):e169Analysis and Comment                                                                                                         DeBeck and Kerrstep forward for evidence-based drug policy, and the courts effectively became an arena where scientific evidence and constitutional rights trumped ideology. Although the ruling was not directly concerned with implementing evidence-based drug policy, the decision hinged on scientific evidence to establish that the pro-gram offered health benefits to injection drug users. It is undeniable that the  B.C. Supreme Court decision has already had a significant impact on the course of Insite’s history and prevented its imminent closure; however, the power of the ruling and its implications for the sus-tained advancement of evidence-based drug policy re-main uncertain.  One reason for this uncertainty is that Charter rights have limitations, some of which are embedded in the Charter itself. Specifically, section 1 allows Parliament and provincial legislatures to limit Charter rights if the limitation can be “demonstrably justified in a free and democratic society.” Furthermore, Parliament and prov-incial legislatures can use the notwithstanding clause provided by section 33 to override Charter protections for limited periods of time. Although these provisions are rarely used to reverse judicial rulings, legislative bodies have invoked sections 1 and 33 (Ford v. Quebec, [1988] 2 S.C.R. 712; R. v. Daviault, [1994] 3 S.C.R. 63). Another source of uncertainty regarding the B.C. Su-preme Court decision is that court rulings can be over-turned. Immediately after the 2008 court decision the government appealed the ruling that sections of the Controlled Drugs and Substances Act violated Char-ter rights. Conversely, the plaintiffs in the original case cross-appealed the dismissal of the interjurisdictional immunity claim. In January 2010 justices from the B.C. Supreme Court of Appeals ruled in a 2–1 majority that the doctrine of interjurisdictional immunity did indeed apply in the case; the implication of this ruling was that the Controlled Drugs and Substances Act could not inter-fere with the operations of Insite or hinder its ability to provide health care to people who inject drugs. Although the ruling in favour of applying the doctrine of interjuris-dictional immunity made a ruling on the Charter issue unnecessary, the justices provided their assessment of the arguments pertaining to this aspect of the case. With the same 2–1 majority, the justices concluded that the original ruling on the Charter issue was correct and that aspects of the Controlled Drugs and Substances Act were unconstitutional.27 Despite the positive implications of the rulings from the B.C. Supreme Court of Appeals on Insite’s continued operation, in February of this year the federal government announced that it would appeal this decision to the Supreme Court of Canada.21   ConclusionClearly, implementing evidence-based policies can be particularly challenging in some environments. Al-though gaps between science and policy may at times be the result of a lack of communication between research-ers and decision-makers, there are other instances where understanding scientific data is not the barrier to its use. In these cases other avenues will need to be pursued, and legal proceedings offer potential in this area. However, there are challenges involved in legal proceedings, in-cluding uncertainty regarding the impact and meaning of a ruling owing to its potential to be challenged and re-versed. The case of the supervised injection facility illus-trates that although legal proceedings are a potentially promising vehicle for advancing evidence-based drug policy, as with KT efforts, there are no guarantees that such approaches can effect substantial change. Never-theless, given the health and social harms resulting from persistent gaps between evidence and practice in the areas of illicit drug policy and HIV prevention,7 ac-tions to support even incremental advancements must be pursued. Contributors: Both Kora DeBeck and Thomas Kerr were responsible for determining the concept and content of the analysis. Kora De-Beck prepared the first draft of the analysis and Thomas Kerr provided critical revisions. Both authors have approved the final version. Acknowledgments: We would specifically like to thank Deborah Gra-ham, Tricia Collingham, Sandra Niven, Peter Vann, Caitlin Johnston, Steve Kain, Brandon Marshall and M-J Milloy for their research and administrative assistance. Special thanks to Katrina Pacey for her con-structive comments and suggestions on an earlier draft of this com-mentary.REFERENCES1. White B. Making evidence-based medicine doable in everyday practice. Fam Pract Manag 2004;11(2):51–58. 2. Straus SE, Green ML, Bell DS, Badgett R, Davis D, Gerrity M, et al; Society of General Internal Medicine Evidence-Based Medi-cine Task Force. Evaluating the teaching of evidence based medi-cine: conceptual framework. BMJ 2004;329(7473):1029–1032. 3. MacCoun R, Reuter P. The implicit rules of evidence-based drug policy: a U.S. perspective. Int J Drug Policy 2008;19(3):231–232; discussion 233–234. 4. Reuter P. Why does research have so little impact on American drug policy? Addiction 2001;96(3):373–376. 5. Pearson H. Science and the war on drugs: a hard habit to break. Nature 2004;430(6998):394–395. 6. Kerr T, Wood E. Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy re-search. Int J Drug Policy 2008;19(3):233–234. 7. Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Kaza-tchkine M, Sidibe M, Strathdee SA. Time to act: a call for com-prehensive responses to HIV in people who use drugs. Lancet 2010;376(9740):551–563.8. Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. CMAJ 2006;175(11):1399. 9. Wood E, Kerr T, Tyndall MW, Montaner JSG. The Canadian gov-ernment’s treatment of scientific process and evidence: inside the evaluation of North America’s first supervised injecting facility. Int J Drug Policy 2008;19(3):220–225. 10. Jewell CJ, Bero LA. “Developing good taste in evidence”: facilita-tors of and hindrances to evidence-informed health policymaking in state government. Milbank Q 2008;86(2):177–208. 11. Lawrence R. Research dissemination: actively bringing the re-search and policy worlds together. Evid Policy 2006;2(3):373–384. 12. Strathdee SA, Patrick DM, Currie SL, Cornelisse PG, Rekart ML, Montaner JS, et al. Needle exchange is not enough: lessons from the Vancouver injecting drug use study. AIDS 1997;11(8):F59–F65. 13. Millar JS. HIV, hepatitis, and injection drug use in British Colum-bia: pay now or pay later? Victoria: BC Provincial Health Officer, BC Ministry of Health. June 1998. 14. Wood E, Kerr T, Montaner J, Strathdee S, Wodak A, Hankins C, et al. Rationale for evaluating North America’s first medically super-vised safer-injecting facility. Lancet Infect Dis 2004;4(5):301–306. 15. Wood E, Kerr T, Lloyd-Smith E, Buchner C, Marsh D, Montaner J, et al. Methodology for evaluating Insite: Canada’s first medically supervised safer injection facility for injection drug users. Harm Reduct J 2004;1(9). 16. Graham ID, Tetroe J. How to translate health research knowledge into effective healthcare action. Healthc Q 2007;10(3):20–22. 17. Ritter A. How do drug policy makers access research evidence? Int J Drug Policy 2009;20(1):70–75. 18. Innvaer S, Vist G, Trommald M, Oxman A. Health policy-makers’ perceptions of their use of evidence: a systematic review. J Health Serv Res Policy 2002;7(4):239–244. 19. Decima Research Inc. Record disclosed under the Canadian Ac-cess to Information Act: PCO Corporate Communication. 2006. Table SIS6, p 147. 20. National Specialty Society for Community Medicine. Super-vised drug consumption sites and InSite program [position statement]. 2009. Available at: http://www.nsscm.ca/files/POS-ITION_ON_SUPERVISED_CONSUMPTION_SITES.pdf (ac-cessed 09/09/2010). 21. Bains C. Federal government to take supervised injection site case to Supreme Court. The Record. 2010 Feb 9. Available at: http://news.therecord.com/article/668034 (accessed 13 Aug 2010). 22. Vancouver Police Department. Vancouver police department drug policy. 2006. Available at: http://vancouver.ca/police/assets/pdf/reports-policies/vpd-policy-drug.pdf (accessed 21 Feb 2010). 23. DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T. Po-lice and public health partnerships: evidence from the evaluation of Vancouver’s supervised injection facility. Subst Abuse Treat Prev Policy 2008;3:11. 24. Jones D. Injection site gets 16-month extension. CMAJ 2006;175(8):859. 25.  PHS Community Services Society v. Attorney General of Can-ada, 2008 BCSC 661. 26. Small D. Fighting addiction’s death row: British Columbia Su-preme Court Justice Ian Pitfield shows a measure of legal cour-age. Harm Reduct J 2008;5:31. 27.  PHS Community Services Society v. Canada (Attorney General), 2010 BCCA 15.28. Milloy M, Wood E. Emerging role of supervised injecting facili-ties in human immunodeficiency virus prevention. Addiction 2009;104(4):620–621.29. Kerr T, Montaner J, Wood E. Supervised injecting facilities: time for scale up? Lancet 2008;372(9636):354–355.30. Kerr T, Montaner JS, Wood E. Misrepresentation of science undermines HIV prevention efforts. CMAJ 2008;178(7):964.31. Wood E, Montaner JS, Kerr T. Illicit drug addiction, infectious disease spread and the need for an evidence-based response. Lancet Infect Dis 2008;8(3):142–143.32. Wood E, Kerr T, Tyndall MW, Montaner JSG. The Canadian gov-ernment’s treatment of scientific process and evidence: inside the evaluation of North America’s first supervised injecting facility. Int J Drug Policy 2008;19(3):220–225.33. Kerr T, Kimber J, DeBeck K, Wood E. The role of safer in-jection facilities in the response to HIV/AIDS among injec-tion drug users. Curr HIV/AIDS Rep 2007;4(4):158–164.Citation: DeBeck K, Kerr T. The use of knowledge translation and legal proceedings to support evidence-based drug policy in Canada: opportunities and ongoing challenges. Open Med 2010;4(3):167-170.Published: 21 September 2010Copyright: This article is licenced under the Creative Commons Attibu-tion–ShareAlike 2.5 Canada License, which means that anyone is able to freely copy, download, reprint, reuse, distribute, display or perform this work and that the authors retain copyright of their work. Any derivative use of this work must be distributed only under a license identical to this one and must be attributed to the authors. Any of these conditions can be waived with permission from the copyright holder. These condi-tions do not negate or supersede Fair Use laws in any country. For further information see http://creativecommons.org/licenses/by-sa/2.5/ca.Analysis and Comment                                                                                                         DeBeck and KerrOpen Medicine 2010;4(3):e170

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