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Should North America’s first and only supervised injection facility (InSite) be expanded in British Columbia,… Jozaghi, Ehsan; Andresen, Martin A. Feb 16, 2013

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RESEARCHireaiaeThe situation has been particularly bad in Vancouver,Canada with one of the highest outbreaks of HIV in thewhose lives are further marked by extreme poverty,mental illness and homelessness [7-9].Jozaghi and Andresen Harm Reduction Journal 2013, 10:1http://www.harmreductionjournal.com/content/10/1/1InSite provides a range of benefits to its clients and society.School of Criminology, Simon Fraser University, 8888 University Drive,Burnaby B.C. V5A 1S6, Canadadeveloped world [3]. In addition to the spread of infectiousdiseases, British Columbia, Canada has a drug overdoseepidemic, with up to one death per day being documentedin recent years [3,4].Though mortality (overdose) and blood bornepathogens epidemics (such as HIV and HCV) arecentered in the Downtown Eastside of Vancouver, theyIn order to reduce the community, public health andfiscal impacts of injection drug use, North America’sfirst and only supervised injection facility (SIF), knownas ‘InSite’, opened its doors September 22, 2003 inVancouver’s Downtown Eastside [7]. To date, there havebeen 1.5 million visits to InSite with 700 to 800 injectionsper day [10-13]. The first several years of evaluation haveyielded an array of scientific output, including more than30 peer-reviewed studies. These publications indicate that* Correspondence: eja2@sfu.cafacility (SIF) in North America, InSite, needs to be expanded to other cities.Methods: Semi-structured qualitative interviews were conducted in a classical anthropological strategy ofconversational format as drug users were actively involved in their routine activities. Purposive sampling combinedwith snowball sampling techniques was employed to recruit the participants. Audio recorded interviews weretranscribed verbatim and analyzed thematically using NVivo 9 software.Results: Attending InSite has numerous positive effects on the lives of IDUs including: saving lives, reducing HIVand HCV risk behavior, decreasing injection in public, reducing public syringe disposal, reducing use of variousmedical resources and increasing access to nursing and other primary health services.Conclusions: There is an urgent need to expand the current facility to cities where injection drug use is prevalentto reduce overdose deaths, reduce needle sharing, reduce hospital emergency care, and increase safety. In addition,InSite’s positive changes have contributed to a cultural transformation in drug use within the Downtown Eastsideand neighboring communities.Keywords: Supervised injection facility, Harm reduction, Drug policyBackgroundPeople infected today with HIV/AIDS are increasinglyintravenous drug users (IDUs) who are involved in sharinginjection equipment [1]. In Canada for example, one infour new cases of HIV is attributed to sharing needles [2].are national and provincial problems requiring immedi-ate action. Conservative estimates suggest that there arenow more than 125,000 people who inject illicit drugsin Canada [5,6]. In British Columbia, it is estimated thatthere are approximately 20,000 injection drug usersShould North America’s finjection facility (InSite) bColumbia, Canada?Ehsan Jozaghi* and Martin A AndresenAbstractBackground: This article reports qualitative findings from(IDUs) from Vancouver, Surrey and Victoria, British Columbsite in transforming their lives. Further, the purpose is to d© 2013 Jozaghi and Andresen; licensee BioMeCreative Commons Attribution License (http:/distribution, and reproduction in any mediumOpen Accessst and only supervisedexpanded in Britishsample of 31 purposively chosen injection drug usersinterviewed to examine the context of safe injectiontermine whether the first and only Supervised injectiond Central Ltd. This is an Open Access article distributed under the terms of the/creativecommons.org/licenses/by/2.0), which permits unrestricted use,, provided the original work is properly cited.Therefore, if North America’s only supervised injectionfacility has numerous positive benefits (operating at fullcapacity with potentially a few thousand injection drugusers who reside in the vicinity of the facility alone), thequestion of whether or not the program should beexpanded is topical [14]. In fact, HIV, HCV infectionsand illicit drug overdose deaths are documented in virtu-ally all settings in British Columbia, Canada where injec-tion drug use is prevalent [15]. Furthermore, improvingaccess to, and availability of supervised injection throughexpansion may help reduce persistent risk behaviouramong IDUs [16,17]. As a result, this study explores thepotential of expanding InSite to more locations through-out British Columbia. In addition, this study exploresthe current status of injection drug users who reside incities that have no access to supervised injection facil-ities such as, Surrey and Victoria, British Columbia.MethodsBeginning in October 2009, participants living in Surrey,Vancouver and Victoria, who had injected illicit drugs inthe previous month were recruited to participate in thestudy. The participants were eligible for the study if theyhad injected illicit drugs at least once in the previousmonth, were 19 years or older and provided informedoral consent. They received CAD$10 reimbursementfor their participation at the end of a semi-structuredinterview. The study was approved by Simon FraserUniversity’s Research Ethics Board.The city of Vancouver’ Downtown Eastside neighbor-hood was chosen as one of the recruitment locations be-cause it is home to North America’s only supervisedinjection facility (see Figure 1).The city of Surrey’s Whalley/City Centre neighbor-hood was chosen as another recruitment location be-cause the neighborhood is home to a needle exchangedepot, a health center and a homeless shelter that attracta large number of IDUs. It is also estimated that theFraser health authority region that includes Surrey hasthe second highest population of IDUs in BC with ap-proximately 16,000 [18] (See Figure 2).The city’s proximity to Vancouver’s DTES is uniquebecause many IDUs can access InSite by travelling onthe train for 45–60 minutes. Finally, Victoria, is a smallcity located on the southern tip of Vancouver Island.The city’s Downtown neighborhood was chosen as aJozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 2 of 9http://www.harmreductionjournal.com/content/10/1/1Figure 1 Map of the Downtown Eastside of Vancouver.bJozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 3 of 9http://www.harmreductionjournal.com/content/10/1/1recruitment location because the city’s fixed needle ex-change depot was recently forced to shut down.Figure 2 Fraser health location within the Province of British ColumIn Vancouver, 16 interview participants were recruitedthrough key informants in the city’s Downtown Eastsideneighborhood. The key informants helped to establish arapport and trust among IDUs. In order to maintain confi-dentiality, all names used in this paper are pseudonyms.Table 1 Characteristics of the sample of IDUs of VancouverName Gender Age Ethnicity Drug of choiceTania Woman 46 White Heroin & CrackJoe Man 60 White HeroinMaxim Man 50 White Heroin & CrackMichelle Woman 30 White Heroin & CrackAshley Woman 43 First Nation Cocaine, Heroin & CMartin Man 46 White Cocaine & HeroJack Man 46 First Nation Heroin & CrackCatherine Woman 53 White Heroin & CrackGeorge Man 53 White Cocaine & HeroSam Man 37 First Nation HeroinAlex Male 47 Caucasian Heroin & CrackAyatollah Male 50 Middle Eastern HeroinDan Male 37 First Nation HeroinLisa Female 39 First Nation Cocaine & CracNiki Female 30 Caucasian Cocaine & CracShane Male 29 Caucasian HeroinThe key informants also proved to be instrumental inguiding the sampling selection based on participants’ drugia.of choice, years of injection, ethnicity and gender asoutlined in Table 1.In Surrey, nine participants were recruited in areaswhere most IDUs congregate. Snowball sampling provedto be instrumental in guiding the selection process. ThereYears of injection Medical condition Year selected27 HCV & HIV 201145 HCV 201135 HCV & HIV 201112 HCV 2011rack 20 HCV 2011in 10 Bipolar Disorder 201130 HCV & HIV 201123 HCV 2011in 2 HCV & Diabetic 201110 HCV & Abscesses 201130 HCV 200920 HCV 200910 HCV & Abscesses 2009k 15 Bipolar Disorder 2009k 14 HCV & HIV 200913 HCV & HIV 2009were no refusals of invitations to participate in the study.All the participants were only interviewed once. Based onTable 2, a variety of participants were selected.In Victoria, six participants were recruited in neigh-borhoods where most IDUs are known to congregate.Recruitment of participants was facilitated by a key in-formant (Table 3).The open ended, semi-structured interviews werefacilitated through the use of an interview guide. The inter-view guide encouraged discussion about SIF, the impact ofSIF upon their behavior, and elicited suggestions relatedValidity is an important concept in both quantitativeand qualitative research that was considered in this ana-lysis. Validity is defined as, “truth: interpreted as the ex-tent to which an account accurately represents the socialphenomena to which it refers” [21]. In order to maintainvalidity in this research and avoid “anecdotalism”a,quotes were considered both in the context of the inter-view and as standalone representations of a theme.ResultsOverdosececkoinckoininoinkJozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 4 of 9http://www.harmreductionjournal.com/content/10/1/1to the ways it can be improved. The themes followedthroughout the interview in Vancouver were along thefollowing four dimensions: 1-experience prior to openingof InSite, 2-experince after opening of InSite, 3-changesthat they have noticed in their behavior and 4-an open dis-cussion about anything raised during the interview. Thethemes followed in Surrey and Victoria was along thefollowing three paradigms: 1-experience on the street2-what is the difference between injecting at InSite or onthe street (if they have attended a SIF) 3-should InSite beexpanded in their community. To reduce distortion ofdata due to social desirability responses, interviews wereconducted in a conversational format as drug users wereactively involved in their routine activities. This classical an-thropological strategy of participants’ observation allowed atriangulation of responses to conversational prompts [19].The qualitative data were reviewed, and all textsegments were subsequently subjected to a thematic ana-lysis using NVivo 9 software. Initially an open codingmethod of searching for similar words or repeatingphrases was employed. Twenty coding categories emerged.Researchers warn of the tendency for coding schemes tobecome powerful conceptual grids from which it is diffi-cult to escape [20]. Therefore, each coding category wasreviewed again at a later date, this time using the keythemes as coding categories. Each coding category wasreviewed independently for latent meanings and commonideas. The main thematic analysis focused on the socialprocesses and experiences of injecting on the street.Table 2 Characteristics of the sample of IDUs of SurreyName Gender Age Ethnicity Drug of choiCindy Woman 42 White Cocaine & CraGary Man 56 White Cocaine & HerBrian Man 47 White Cocaine & CraScott Man 42 White Cocaine & HerChris Man 49 White Speed & HeroDaniel Man 41 First Nation Cocaine & HerHolly Woman 50 White Speed & CracJenny Woman 47 White Cocaine & HeroinKayleigh Woman 28 White Heroin & CrackThe most common narrative offered by the studyparticipants—who have used InSite—was that InSite issaving lives. In fact, most participants such as George,can recall the dire situation of the Downtown Eastsideprior to the opening of North America’s first supervisedinjection site:After they opened InSite, It was like a warm hug fromGod . . . I mean people used to die here from overdosealmost every day . . . Almost everyday people werehauled out of an alley, behind dumpsters byparamedics after they went blue.bThis notion of fear and death associated with overdosewhen injecting outside reinforces the safety and securitythat many participants have come to associate withInSite. In fact, all the participants who have used InSitehave seen an overdose or have experienced an overdoseat InSite and all of them agree that InSite has reducedoverdose deaths.The notion that InSite saves lives is echoed by otherusers who have seen a reduction in overdose in the alliesin the vicinity of InSite because most IDUs prefer tocome to InSite. In effect, IDUs who used InSite havecome to associate outside injection with a substantialrisk of death that they are simply not willing to take. Asa result of InSite, there are fewer public injections. InSitehas also reduced public syringe disposal and substan-tially reduced the use of various medical resources suchYears of injection Medical condition Year selected18 Nil 201144 HCV & Abscesses 201117 HCV & HIV 201130 HCV 201115 HCV 201115 HCV 201120 Bipolar & Cancer 201130 HCV 201110 HCV 2011Jozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 5 of 9http://www.harmreductionjournal.com/content/10/1/1as ambulances and hospital emergency care. In essence,according to Joe:If it wasn’t for InSite you would see 150 people sittingdown in the alley with rigs [needles] sticking out oftheir arms, flagging blood in their needle, Y’know,ODing left and right every day and leaving their rigsaround . . . They needed ambulances up in the alleysconstantly . . . Today you rarely see people fixingoutside, especially in and around InSite.However, in cities that have no access to a safe injec-tion site, such as Surrey, regular overdose death is thereality. All the participants in Surrey have known a per-son who has died of overdose. For example according toKayleigh:I know of at least three to four people a year that Iknew personally that ODed and eventually died as aresult. You see ambulances coming to the front room[homeless shelter] all the time. At least twice a weekpeople are ODing down here.In most cases, an overdose in both Surrey and Victoriais accompanied by death. IDUs do not have the know-ledge or expertise to help someone in an overdose case.Further, IDUs don’t have access to a cell phone or a pub-lic phone to call 911.SharingNot having access to a supervised injection facility cando more damage than a simple overdose; it can help toTable 3 Characteristics of the sample of IDUs of VictoriaName Gender Age Ethnicity Drug of choiceHenri Man 50 White Heroin & CrackFraser Man 49 White Heroin & CrackKila Woman 30 White Cocaine, & HeroinLoren Woman 29 White Heroin & MethMelanie Woman 44 White HeroinThomas Man 35 White Heroin & Methspread infectious diseases such as HIV and HCV.According to Ashley, “before InSite, people would’vebeen fixing everywhere in public. HIV and Hep C waseverywhere ‘cause junkies where sharing rigs or didn’thave access to clean ones”. But the opening of NorthAmerica’s first supervised injection site has changedsharing behavior and public injection scenes in theDowntown Eastside of Vancouver where IDUs wouldnot share again or inject outside. Moreover, because theyperform all of their injections at InSite, they curb thespread of infectious diseases like HIV/HCV and injectionrelated illnesses such as abscesses. Furthermore, theparticipants report that the provision of sterile syringes,the ancillary injecting equipment and safer injecting ad-vice by nurses serve to reinforce the permanent adoptionof safer injecting practices. As Maxim explained,Because of InSite, I don’t like to do it outside anymore,I don’t want people seeing me fixing . . . But beforeInSite we were fixing in the shooting galleries. It was sounhealthy, Y’know, I ended up with HIV because of thearea. And now the only reason I come to InSite is toslow down the spread. Not only that, InSite is such aclean experience . . . You don’t have to use puddlewater for injection. There are nurses on staff there thathave taught us about diseases and shit like that we’dbe scared not to use a clean needle . . . Also, I havetaken upon myself to give shit to junkies who are fixingoutside, I usually tell them: have little respect forpeople for God’s sake. We have a place, why don’t youdo it at InSite. And I’ve convinced few people to do itat InSite.This dramatic advocacy for InSite and on behalf ofother users by participants who once injected and sharedoutside is something unique to the Downtown Eastsidecommunity. Unfortunately, no such advocacy or healthconsciousness was observed in Victoria or Surrey. Infact, sharing needles is still prevalent in cities that don’thave access to a supervised injection site. For example,as Gary explained:I have seen people picking needles off the ground andusing them. My wife picked one up down here coupleYears of injection Medical condition Year selected33 HCV, HIV, Cancer & Diabetes 201135 HCV & HIV 201110 Abscesses & MRSA 201112 HCV 20112 Bipolar & HCV 201118 HCV 2011of years ago and she wanted to return it to the needleexchange depot so she could get a credit. The rig wasfull of blood, and this junkie bug her so he could trywhat was in there. He didn’t know what was in thereor who has used it, but he wanted that rig so bad sohe could get high.In effect, sharing behaviors within the IDU populationis an established factor that is thought to lead to asubstantially higher risk of HIV infection, even if prac-ticed relatively infrequently [22]. Participants in Surreyand Victoria attribute sharing and reusing needles toJozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 6 of 9http://www.harmreductionjournal.com/content/10/1/1inaccessibility of needles in both cities. In fact, closingthe recent needle exchange depot in Victoria hasresulted in more sharing within the IDU population.SafetyIn addition to the improved changes in behavior andshared health concerns described above, InSite hashelped to bring safety and security to participants whouse the facility. Before opening of InSite, according toCatherine, fixing outside was accompanied by variousrisks including the risk of theft:When I was going to the alley to do my fix, I gotrobbed so many times. For example, you do your fix,and somebody takes off with your purse, Y’know.Hands are busy and you can’t run after them. I lostmy welfare cheque more than once . . . At least atInSite you know you’re not getting robbed.In addition to risk of theft, participants who have usedInSite have come to associate outside injection with sig-nificant risk of bodily harm or even death. As a result,most of those who describe injecting at InSite are notwilling to inject outside. In other words, once saferinjecting habits and feelings of safety are establishedwithin InSite, it becomes more likely that IDUs willcome to InSite for every injection, reducing the risk ofsharing or getting attacked. For instance, according toMartin:Junkies would do anything for the money, they willfucking stab you for it. That’s why fixing outside is notsafe. I saw somebody getting stabbed in one of thesealleys few years ago. He was trying to fix, thensomebody jump on him, trying to steal his bag. Thepoor guy tried to fight the mob and they fucking killedhim. They stabbed him in the neck. No fucking lie, Ithink about that every single day, that’s why I alwaystry to fix at InSite.Furthermore, IDUs who come to InSite escape policearrest because they will not be questioned by police forhaving an illegal substance. Injecting in public brings asignificant risk of arrest and questioning by police if theyare caught in the act. According to Joe, InSite has be-come a refugee camp for IDUs of the DowntownEastside who want to escape, disease, theft, arrest anddeath:First of all you’ve got a clean, safe place; nobody isgonna bother you or you don’t have people trying tosteal from you. You don’t have police coming andhassling you . . . That’s why people are always hidingfrom cops and fixing in washrooms or behinddumpsters. But then you’re facing over dose ‘cause youmight do a bigger whack. But InSite is such a stressfree, cop free, disease free, OD free environment that Icall it the refugee camp for junkies.Although InSite mitigates the risk of violence and ar-rest for IDUs who are using the facility and many maydescribe it as a ‘refugee camp for junkies’, the daily real-ity for IDUs who don’t have access to the site is formid-able. IDUs that live in Surrey, according Scott, have toendure risk of violence and theft everyday when they fix:Everyday there is a few fights. You can bump into thewrong person and have three guys jump on you and robyou . . . A lot of girls get robbed. They just walk up andtake their money when they have the chance, and thebest fucking time to rob someone is when their fixing.In addition to the risk of violence and theft that seemsto be the daily reality of street life for many IDUs whodon’t have access to InSite, according to the participants,the risk of police arrest is another factor in their dailylives.ServicesParticipants’ accounts indicate that availability of servicesand equipment at InSite has made a huge difference intheir lives. In effect, according Tania, accessibility of injec-tion equipment and ancillary services provided at InSitereduces sharing behavior in the vicinity of InSite:There used be a lot of sharing down here before InSite.Today, you don’t see that anymore. People seem tounderstand the risk. There are enough clean rigs goingaround. I used to see people using water from drainpipes and things. But at InSite you can get all yoursupplies.In addition to accessibility of injection equipment, an-cillary services, and available nurses, counselors andstaff, InSite helps transform the public injection scene ofthe greater Vancouver area. This is particularly true forthose who are the most marginalized, such as Maxim:The staff are so helpful, anything you need, all youhave to do is ask, if you need housing, or you need toget off the street, Y’know. For example, when I was firstdiagnosed at VGH [Vancouver General Hospital], theDr said: you have Hep C and you’re HIV positive andhe walked out of the room. I wasn’t told where to go. . . It wasn’t till I came to InSite for my injection thatone of the counselors told me about going to St. Paul’sand he set up the appointment . . . The staffs genuinelydo care about us.Jozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 7 of 9http://www.harmreductionjournal.com/content/10/1/1Moreover, participants’ accounts indicate that staff andnurses at InSite gain awareness holistic strategies andapproaches that go beyond simply providing care. In ef-fect, the staff has been able to create dignified, caringand trusting bonds that build foundations for changethrough personal empowerment. According to Ashley:I’ve had the chance to talk to nurses, in fact, I had askin rash . . . and they changed my bandages . . . theyalso paid for my transportation so I could see a doctor. . . Also when my son died I was really hurting and Iwas gonna OD myself, and when I got there, I talkedto one of the staff and they gave me hope to stay alive. . . Just because of the programs at InSite, my drug useis now the third of what it was. They gave me positivethinking and stuff, and I realized I can do it.The relationship that exists between the staff and IDUsat InSite facilitated more than 2,000 referrals to addictionservices, with 800 of these referrals to addiction coun-seling [23]. Furthermore, the services provided by nursesat InSite, such as changing bandages for bites or abscessesreduces emergency care utilization significantly. However,IDUs in municipalities with no supervised injection siteare having difficulty meeting their most basic need: findinga clean needle. In effect, in both Surrey and Victoria themost common narrative was associated with inaccessibilityof clean needles. According to Daniel:It’s hard to get a needle down here, [the needle depot]closes at six o’clock and they don’t open till noon. So alot of people go without a clean one. And that happensall the time. . . . I remember . . . this fellow asking me ifI had a syringe. I looked in my bag: All I had was aused one. And I told him that I don’t want to sell youa used one . . . But he still insisted . . . So I told himagain that I don’t have bleach and I have Hep C. But. . . he didn’t care. He bought the syringe.Clean needle accessibility is a major problem in Victoriawith the number of clean needles distributed in Victoriafalling by 15,000 per month since the closure of the needleexchange office in the Downtown Victoria [24].Changes in behaviorThose IDUs who use InSite have come to associate InSiteas their ‘community center’. Many feel right at home atInSite because staff and nurses are non-judgmental andrespectful toward everyone who uses the facility. InSite isa place where all IDUs gather for support and acknow-ledgment. For example, as Sam describes:InSite has helped junkies to feel a sense of belonging, Icall it the community center for junkies ‘cause we arewelcomed there, we can stay in for a coffee or juice, seeour buddies, watch TV in the chill room or talk tocounselors. We are not judged for who we are, or whatwe do. Staff gives us respect and they don’t judge us.At InSite we actually feel like that we exists.The influence of InSite goes beyond changing sharingbehavior and reducing overdose death, enhancing safetyor enhancing a positive image within IDUs. Servicesprovided by nurses and staff at InSite inspire many IDUsto become safety and educational ambassadors withintheir own community. According to Sam:I always carry extra rigs in my pocket to give out toother junkies. We try to promote InSite at every chancewe get . . . If we see somebody new in town, we try totake him to InSite. We are tired of seeing people OD inalleys; we are tired of seeing rigs on the ground. I alsogo around in alleys and pick up rigs and bring emback to InSite or the needle depot.Furthermore, participants who have been coming toInSite for a few years felt empowered to help others.Many of them had seen the transformative power ofInSite (either through counseling, social support, oroverdose emergency care) and craved for change withintheir own community. This empowering change is evenobserved in people who travelled from surrounding mu-nicipalities such as Surrey. For example, according toBrian:I travel to InSite at least twice a week . . . Every time Icome here I grab few boxes of needles, water, alcoholwipes to take it to Surrey. I give those out to otherjunkies. It’s harsh when you need a rig and you can’tfind one. The needle depot in here has limited hours. . . I’ve also told about InSite to few people.Their new roles as a result of self-empowerment havethe potential to mediate patterns of infectious diseaseand mortality, and eventually change lives amongst themost marginalized IDUs.AccessThe most common problem associated with InSiteaccording to participants is related to the lineup and ac-cess to the site. In essence, participants believe that the12 booths that are currently in operation should beexpanded so fewer users would have to substitute InSitefor the alleys. InSite seems to be inaccessible during wel-fare week in particular when IDUs are issued their dis-ability or social assistance cheques. During that week,the only alternative for many IDUs is to use the alleysthat involve risking arrest, theft, violence or overdose. Ifthey would use a supervised injection facility for safetyJozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 8 of 9http://www.harmreductionjournal.com/content/10/1/1reasons, others emphasized the need to avoid hazardsof the street, while many stated they would use asupervised injection facility to stay alive. For instance,according to Jenny:I know for a fact that if they open an InSite, a lotpeople would go and use it. Right now people arefixing in alleys, crack shacks or drug houses . . . Also, ifyou OD nobody is gonna care . . . they’ll take you andthrow you outside. That’s . . . why an injection sitewould be good ‘cause there would be people there thatcan help you. You would feel safe in there. There is norisk of . . . sharing.DiscussionThe present study was conducted on the premise ofassessing the transformative role of InSite in the lives ofIDUs. In addition, this study explored the current status ofinjection drug users who reside in cities that have noaccess to supervised injection facilities such as, Surrey andVictoria, British Columbia. The ultimate objective of thisstudy was to determine whether the current supervisedinjection facility needs to be expanded to other cities. Theresults reveal a positive change in many aspects of IDUswho are increasingly relying on the services offered atInSite. In fact, the findings of the present study suggestthat InSite prevents drug overdose deaths and reducesoverdose deaths in surrounding areas. InSite has alsoreduced HIV and HCV risk behavior (e.g., sharingneedles), decreases injection in public, reduces public syr-inge disposal and substantially reduces use of variousmedical resources such as ambulances and hospital emer-they are not homeless, they still risk overdose if they in-ject at their single occupancy units. This is particularlytrue according to Martin, if they are ‘dope sick’:There are times when there is long waiting list inthere, such as welfare week. You basically have 60people ahead of you . . . Long waiting list at InSite isn’tlike waiting for a hockey game, but when you’rewaiting to put a needle in your arm and you haven’thad a hit for a day and a half, even five minutes is toofucking long.The underlying message that InSite needs to beexpanded is echoed by other users who believe that in-accessibility is acutely felt during morning hours whenInSite is closed. IDUs who live in Surrey and Victoria in-dicate they would use a supervised injection facilityif such a site ever opened. Many participants statedgency care. In addition, InSite has increased access tonursing and other primary health services crucial forcurbing the spread of infectious disease and injection-related illnesses.Aside from the numerous positive accounts of InSitereinforced by peer reviewed studies, the current studyreports four new findings not previously discussed. First,InSite has created a ‘refugee camp’ for IDUs by allowingthem to escape the theft, violence, and murder theywould normally face on the streets. Furthermore, IDUswho come to InSite escape police arrest and questioning.The new sense of safety that many IDUs have come toassociate with InSite reinforces their reliance on the fa-cility for all their injection needs.Second, the most prominent finding in this paper isrelated to the significant transformation in IDUs’ rolesand behaviors. InSite’s positive changes mentioned above(such as not sharing, improved health, less overdosedeath, plus changes in enhanced safety, helping othersand collective identity) have contributed to a culturaltransformation in drug use within the DowntownEastside and neighboring communities. Those who in-creasingly rely on InSite have gradually become activewithin their community, trying to alleviate misery andimprove lives in the Downtown Eastside. This paperidentifies participants who strive to better their peers’health and their communities’ self image as educationaland safety ambassadors.Third, there is a need to expand the program in theDowntown Eastside of Vancouver to reduce the waitingtime. This finding is not surprising because it isestimated that the pilot program with only 12 injectionsseats is located in a neighborhood that contains 5000IDUs [17]. A similar study also suggests waiting timesand travel distance to the facility as significant barriersto InSite use [25]. Finally, results in this study depict thelives, stories and circumstances of IDUs who live inmunicipalities that do not have access to a supervisedinjection facility. InSite is the only supervised injec-tion facility in North America, so their stories andcircumstances have relevance to other Canadian andAmerican cities. Based on the results, IDUs in such cit-ies are faced by over dose death, disease, violence, theftand arrest on a daily basis. As a result, there is an urgentneed to open similar supervised injection facilities in cit-ies with significant IDU populations. Further, the resultssuggest that a high proportion of IDUs in Surrey andVictoria would attend a supervised injection facility ifone were available.ConclusionIn summary, the supervised injection facility in Vancouvernot only saves lives and reduces HIV and HCV transmis-sion, but it is a life raft in a sea of misery for the people inthe Downtown Eastside. The findings in this study are inkeeping with more than 30 peer reviewed studies thatwith public injecting among users of Vancouver’s supervised injectionfacility. Amer J Drug and Alcohol Abuse 2007, 33(2):319–325.17. Marshall BDL, Milloy MJ, Wood E, Montaner JSG, Kerr T: Reduction inoverdose mortality after the opening of North America’s first medicallysupervised safer injection facility: a retrospective population-basedJozaghi and Andresen Harm Reduction Journal 2013, 10:1 Page 9 of 9http://www.harmreductionjournal.com/content/10/1/1show InSite has numerous positive provisions. Further-more, this study’s qualitative data indicates that after yearsof operation, InSite has become a refugee camp for manyof its users who escape death, violence and theft. Inaddition, InSite’s positive changes have contributed to acultural transformation in drug use within the DowntownEastside and neighboring communities. This studysuggests there is an urgent need to expand InSite not onlyin the Downtown Eastside, but in other cities that havesignificant IDU populations. Opening more SIF in BritishColumbia could ultimately be a life raft in a sea of miseryfor the most vulnerable and marginalized people in oursociety.EndnotesaAnecdotalism is defined as taking “lone entertaininginstances” to be representative of a consistent theme [19].bAll quotes in this paper are verbatim to accurately re-flect language usage by IDUs.AbbreviationsHCV: Hepatitis; HIV: Human Immunodeficiency Virus; SIF: Supervised injectionfacility; IDU: Injection drug user.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAll authors contributed to the design of this study. All authors read andapproved the final manuscript.Received: 15 April 2012 Accepted: 11 February 2013Published: 16 February 2013References1. Picard A: A changing epidemic: Canada’s AIDS rate on the rise. The Globeand Mail 2010, 23:A1–A8.2. Wood E, Montaner JSG, Li K, Zhang R, Barney L, Strathdee SA, et al: Burdenof HIV infection among Aboriginal injection drug users in Vancouver,British Columbia. Amer J of Public Health 2008, 98(3):515–519.3. Urban Health Research Initiative: Drug situation in Vancouver, British ColumbiaCenter for Excellence in HIV/AIDS: Vancouver. http://uhri.cfenet.ubc.ca/.4. Miller JS: HIV, Hepatitis, and injection drug use in British Columbia: Pay now orpay later? Victoria: BC: B.C. Ministry of Health; 1998:1–39.5. Fischer B, Rehm J, Kim G, Robins A: Safer injection facilities (SIFs) forinjection drug users (IDUs) in Canada: a review and call for an evidence-focused pilot trial. Can J Public Health 2002, 93(5):336–338.6. Remis RS, Strathdee SA, Millson M, Leclerc L, Degani N, Palmer RWH:Consortium to characterize injection drug users in Montreal, Toronto, andVancouver, Canada. Ottawa: Health Canada; 1998.7. Kerr T, Wood E, Palepu A, Wilson D, Schechter MT, Tyndall MW: Responding toan explosive HIV epidemic driven by frequently cocaine injection: Is there arole for safe injecting facilities? J Drug Issues 2003, 22(426):579–608.8. Martin RE, Gold F, Murphy W, Remple V, Berkowitz J, Money D: Drug useand risk of blood born infections: a survey of female prisoners in BritishColumbia. Can J Public Health 2005, 96(2):97–101.9. Mass B, Fairbairn N, Kerr T, Li K, Montaner JSG, Wood E: Neighborhood andHIV infection among IDU: place of residence independently predicts HIVinfection among a cohort of injection drug users. Health Place 2007,13:432–439.10. Andresen MA, Boyd N: A cost-benefit and cost-effectiveness analysis ofVancouver’s supervised injection facility. Int J Drug Policy 2010,21(1):70–76.11. Hunter J: No decision on InSite, court told. The Globe and Mail 2011,13:S1–S2.study. Lancet 2011, 377(9775):1429–1437.18. McKnight J: Reducing the harms from illegal drug use in Fraser Health: Can FHAallow municipal bylaws to spread disease? Vancouver: Fraser Health Authority;2009. http://www.fraserhealth.ca/media/boardmtg_druguse_110210.pdf.19. Bourgois P, Martinez A, Kral A, Edlin BR, Schonberg J, Ciccarone D:Reinterpreting ethnic patterns among white and African American menwho inject heroin: a social science of medicine approach. PLoS Med 2006,10(3):1805–1815.20. Silverman D, Marvasti A: Doing qualitative research: a comprehensive guide.Los Angeles, CA: Sage Publications; 2008.21. Hammersley M: Reading ethnographic research: A critical guide. London:Longmans; 1990.22. Des Jarlais DC, Semaan S: HIV prevention research: cumulative knowledgeor accumulating studies? an introduction to the HIV/AIDS preventionresearch synthesis project supplement. J Acquired Immune DeficiencySyndromes 2002, 30(S1):S1–S7.23. Vancouver Coastal Health: From the ground up: Insite’s role in accessingtreatment and care. 2007. http://www.vch.ca.24. Ivsins A, Chow C, Marsh D, Macdonald S, Stockwell T, Vallance K: Drug usetrends in Victoria and Vancouver, and changes in injection drug use after theclosure of Victoria’s fixed site needle exchange. Victoria, BC: University ofVictoria; 2010. http://www.carbc.ca/Portals/0/PropertyAgent/2111/Files/299/CARBC_Bulletin6.pdf.25. Petrar S, Kerr T, Tyndall MW, Zhang R, Montaner JSG, Wood E: Injectiondrug users’ perceptions regarding use of a medically supervised saferinjecting facility. Addict Behav 2007, 32:1088–1093.doi:10.1186/1477-7517-10-1Cite this article as: Jozaghi and Andresen: Should North America’s firstand only supervised injection facility (InSite) be expanded in BritishColumbia, Canada? Harm Reduction Journal 2013 10:1.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 redistribution12. Kerr T, Small W, Moore D, Wood E: A micro-environmental intervention toreduce the harms associated with drug-related overdose: evidence fromthe evaluation of Vancouver’s safer injection facility. Int J Drug Policy2007, 18:37–45.13. Smith C: InSite parties for the right to fight Harper. http://www.straight.com/article-173337/insite-parties-its-right-fight-harper.14. Health Canada: Vancouver’s Insite service and other supervised injection sites:What has been learned from research? Final report of the export advisorycommittee. Ottawa (ON): Health Canada; 2008. http://www.hc-sc.gc.ca/ahc-asc/pubs/_site-lieux/insite/index-eng.php.15. Hogg RS, Strathdee S, Kerr T, Wood E, Remis R: HIV Prevalence amongaboriginal British Columbians. Harm Reduction J 2005, 2(26):1–6.16. McKnight I, Mass B, Wood E, Tyndall MW, Small W, Lai C: Factors associatedSubmit your manuscript at www.biomedcentral.com/submit

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