Dear Minister Dosanjh:

Transcription

1 Minister Ujjal Dosanjh 3 August, 2005 Minister's Office - Health Canada Brooke Claxton Bldg., Tunney's Pasture P.L. 0906C Ottawa, Ontario, Canada K1A 0K9 Dear Minister Dosanjh: I am writing to you in order to formally request authorization to open a safe inhalation room (SIR) to be operated by the PHS Community Services Society. Our organization, in partnership with the Vancouver Coastal Health Authority and the City of Vancouver, has previously been granted an exemption under Section 56 of the Controlled Drug and Substances Act (CDSA) to operate a Supervised Injection Facility (SIF). While the SIF provides a desperately needed entry level of health engagement for people with active addictions who inject drugs, there are still several thousand people in Vancouver s Downtown Eastside that are addicted to narcotics that are smoked. Currently, this group of people is still forced to use drugs in open public spaces and unsafe environments where their access to housing, health and treatment services are minimal. The aim of the supervised inhalation pilot would be to match the positive effects of the supervised injection initiative by reaching a target group that is otherwise unengaged in any form of medical or support services in order to reduce the harms associated with smoking crack cocaine and crystal methamphetamine while dramatically reducing public disorder and open drug use. In the present circumstance, we have established a standard of care for one group with serious needs (those who inject drugs), but inadvertently excluded the needs of an equally needy target group (those who inhale or smoke drugs). We believe that a supervised inhalation room needs to be opened as soon as possible to resolve this disparity by reaching the equally marginal group of people living with active additions who smoke drugs such as crack cocaine or crystal methamphetamine. We have identified an ideal location in the Downtown Eastside of Vancouver for this program where it could work in conjunction with the Supervised Injection Facility, a pilot program that we currently operate in partnership with the Vancouver Coastal Health Authority. In fact, the international standard of practice for safer consumption rooms is to operate supervised injection initiatives together with supervised inhalation programs. By way of example, there are 12 safe consumption facilities in Switzerland. Of these, eight have spaces for injection and inhalation. Similarly, there are 22 safe consumption facilities in the Netherlands. All of them have space for both injection and inhalation. In Germany, there are 25 consumption rooms with 13 providing space for inhalation as well as injection. The European Report on Drug Consumption Rooms (Hedrich, 2004) that outlines this standard of practice is attached for your files.

2 In many jurisdictions including Canada, the distribution of people with serious addictions who inject is roughly the same as those who inhale. In some settings, the numbers of those who inhale drugs are overtaking those who inject. To truly evaluate the efficacy and effectiveness of a supervised consumption pilot in Canada, we need to offer services for those people with serious addictions who inject as well those who inhale. We would be pleased to meet to discuss the scientific and medical evidence base for supervised inhalation rooms and our plan to operate a supervised inhalation room pilot in detail with you or your representative at any time. I can be reached on my direct line at: For your convenience, our original Section 56 Exemption (CDSA) is attached. If federal sanction is required to operate a SIR, then please commence our formal application immediately. If, in your opinion, we do not require federal permission to operate a SIR, then we will make plans to open one next year. On Behalf of the PHS Community Services Society, Dr. R. Dan Small Cc Libby Davis, MP Vancouver East Jenny Kwan, MLA Vancouver Mt. Pleasant Larry Campbell, Mayor, City of Vancouver Philip Owen, Mayor (retired), City of Vancouver Steven Owen, Minister of Public Works and Government Services and Receiver General for Canada Suzanne Desjardins, Health Canada Nathan Lockhart, Health Canada John Reid Bibby, President PHSCSS Arn Berry, Schroeder and Company, PHSCSS Legal Counsel

3 Minister Ujjal Dosanjh 2 January 2006 Minister's Office - Health Canada Brooke Claxton Bldg., Tunney's Pasture P.L. 0906C Ottawa, Ontario, Canada K1A 0K9 Dear Minister Dosanjh: Re: Second Request and Follow-up Letter Thank you for your recent public support of the Supervised Injection Facility when you challenged Mr. Harper s comments in the media about harm reduction. I have not yet received a response from you to my letter of last year requesting your authorization to open a safe inhalation room (SIR) to be operated by the PHS Community Services Society. I enclose a copy of the letter sent to you in August of By way of review, our organization presently operates North America s first Supervised Injection Facility in partnership with the Vancouver Coastal Health Authority and we are permitted to do so based on an exemption under Section 56 of the Controlled Drug and Substances Act (CDSA). I was heartened by your recent public endorsement of Supervised Injection Facilities as a health initiative. Although I had invited you shortly before you were first elected, I do not believe that you have not had a chance to tour the program. Particularly as you are the Health Minister, I would like to extend another invitation to you to visit the Supervised Injection Facility so that we can provide you with an in depth look at this important health care initiative. As I said in my earlier letter, while the SIF provides a desperately needed entry level of health engagement for people with active addictions who inject drugs, there are still several thousand people in Vancouver s Downtown Eastside that are addicted to narcotics that are smoked. The international standard of practice for safer consumption rooms is to operate supervised injection initiatives together with supervised inhalation programs. For example, there are 12 safe consumption facilities in Switzerland. Of these, eight have spaces for injection and inhalation. Similarly, there are 22 safe consumption facilities in the Netherlands. All of them have space for both injection and inhalation. In Germany, there are 25 consumption rooms with 13 providing space for inhalation as well as injection (European Report on Drug Consumption Rooms). In the Canadian setting, we have established a standard of care for one group with serious needs (those who inject drugs), but inadvertently excluded the needs of an equally needy target group (those who inhale or smoke drugs). We believe that a supervised inhalation room needs to be opened as soon as possible to resolve this disparity by reaching the equally marginal group of people living with active additions who smoke drugs such as crack

4 cocaine or crystal methamphetamine. We would like to initiate a second research pilot examined supervised inhalation aimed at reaching a target group that is otherwise unengaged in any form of medical or support services in order to reduce the harms associated with smoking crack cocaine and crystal methamphetamine while dramatically reducing public disorder and open drug use. We would be pleased to meet to discuss the scientific and medical evidence base for supervised inhalation rooms and our plan to operate a supervised inhalation room pilot in detail with you or your representative at any time. I can be reached on my direct line at: If, in your opinion, a federal sanction is required to operate a SIR, then please commence our formal application immediately. If we have still not heard from your office soon, then we will make the assumption that it is your opinion that federal permission is not required to operate a SIR, and we will proceed accordingly with our plans to initiate a pilot project in the next year. On Behalf of the PHS Community Services Society, Dr. R. Dan Small Cc Libby Davis, MP Vancouver East Jenny Kwan, MLA Vancouver Mt. Pleasant The Honorable, Larry Campbell, Senate of Canada Philip Owen, Mayor (retired), City of Vancouver Sam Sullivan, Mayor, City of Vancouver Steven Owen, Minister of Public Works and Government Services and Receiver General for Canada Suzanne Desjardins, Health Canada Nathan Lockhart, Health Canada John Reid Bibby, President PHSCSS Arn Berry, Schroeder and Company, PHSCSS Legal Counsel Enclosures: European Report on Drug Consumption Rooms Original Request Letter 3 August, 2005 (Original by Registered Mail)

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7 Director General 10 November 2009 Drug Strategy and Controlled Substances Programme Canada's Drug Strategy Division 123 Slater Street, Room D286 Address Locator 3502D1 Ottawa, Ontario K1A 1B9 Telephone: Facsimile: Dear Director General: Re: request to operate a Supervised Consumption Room I am writing, once again, on behalf of the PHS Community Services Society to request the support of Health Canada for our plan to open a supervised consumption room (SCR) for people who inhale or smoke dangerous drugs. There are serious dangers from drugs that are used by inhalation-including the potential transmission of deadly infectious diseases- HIV and HCV. The fact remains that no matter how much we may wish it not to be, there is a pandemic of smoking and snorting illicit drugs, such as crack cocaine and crystal methamphetamine, and that this activity rivals injection drug use in many countries. The sharing of implements for smoking or inhaling illicit drugs is also now known to be a risk factor for HCV or HIV [1] [2]. Furthermore, it may be the case that sharing of inhalation equipment may link intravenous drug using and non-injecting drug using populations. One of primary risks associated with crack and crystal methamphetamine smoking is posed by the use of inadequate pipes. Most crack and methamphetamine users cannot afford commercially purchased pipes so they make use of metal tubing such as car antennas that transmit heat when a flame is applied to the end to vaporize the drug [3]. This technique can result in burned or blistered lips. Crack pipes are frequently shared; the pipes are passed from one person to the other with each individual smoking some of the drug [3]. When this paraphernalia is shared, bodily fluids such as saliva or blood carrying HCV can travel between persons [1]. The Hepatitis C (HCV) virus is a significant cause of liver damage in the world and the related disease processes including fibrosis, cirrhosis and hepatocellular carcinoma [4]. Of those individuals affected with HCV, between sixty and eighty percent develop chronic hepatitis leading to significant morbidity and mortality. The smoking of crack cocaine causes blisters, sores and cuts in the mouth which may also lead to the transmission of HIV [2]. Once blisters or cuts are created by inadequate pipes or filters, then a further risk may also be posed through the transmission of infected blood through oral sexual activity and the sharing of pipes [3]. A second risk is created by the utilization of fragile glass pipes as these present risks in that they crack when heated or dropped [3]. A jagged glass pipe can cut the lips of a drug user thereby presenting a risk for infection through exposure to blood when crack pipes are shared between persons. As a harm

8 reduction measure, a safer pipe, made of heat resistant material such as Pyrex, can be substituted to reduce likelihood of cuts from an inferior glass pipe that is prone to cracking under heat. A third risk is posed by the use of inadequate filters used by crack smokers [3]. Furthermore, drug users use copper or steel wool, such as brillo pads, as filters for the pipes. These compact pieces of steel wool are designed for cleaning pots and pans and often contain detergents. At times, particles of steel wool break off from these makeshift filters and, at times, are inhaled and cut or burn the drug users lips. Smoking stimulants such as crystal meth-amphetamine or crack cocaine may also effect the pulmonary system leading to lung damage, infection, pulmonary edema or respiratory failure [5-12]. The filter presents an obvious place to intervene with a harm minimization strategy by providing a safer replacement. While the risk of death due to injection of heroin is well established, fatal overdoses are not limited to injection [13]. Snorting (intranasal ingestion) or smoking (pulmonary inhalation) of heroin can be lethal [14]. Methods of inhaling drugs can also introduce hazardous concentrations of opiate in the blood stream. Risk of death from inhalation (snorting or smoking) may be further increased when other drugs, such as alcohol, are simultaneously ingested [13, 14]. Lethality may be further amplified by compromised physical health such as decreased organ function. There are practical population health responses to the risks outlined above that can be implemented through a supervised consumption room to mitigate the dangers of snorting and smoking illicit drugs. First, flexible and durable mouthpieces need to be provided to cover the tip of the pipes so that drug users lips are not blistered or cut. Secondly, particularly dangerous pipes, such as those made out of metal or glass, need to be replaced so that the harms posed by cuts or burns are reduced and in turn reduce risk of the transmission of hepatitis or HIV. Thirdly, the primitive steel wool filters need to be replaced with a durable and safe substitute that can be inserted into the end of the pipe without danger of breaking down and posing risks of inhaling chemical detergents and metal or being cut by shards. Fourth, the potential overdoses from intranasal or ingestion of stimulants (e.g. heroin, crack cocaine, crystal methamphetamine) could be mitigated through the provision of a supervised inhalation facility. A supervised consumption facility would provide the opportunity for a highly marginalized group of drug users to be brought into the doorway of healthcare where they can have access to harm reduction, preventive population based health innovations, treatment, detox and supported housing. While Insite, the supervised injection facility operated by our organization, provides a desperately needed entry level of health engagement for people with active addictions who inject drugs, there are still several thousand people in Vancouver s Downtown Eastside that are addicted to narcotics that are smoked. The international standard of practice for safer consumption rooms is to operate supervised injection initiatives together with supervised inhalation programs. For example, there are 12 safe consumption facilities in Switzerland. Of these, eight have spaces for injection and inhalation. Similarly, there are 22 safe consumption facilities in the Netherlands. All of them have space for both injection and inhalation. In Germany, there are 25 consumption rooms with 13 providing space for inhalation as well as injection (European Report on Drug Consumption Rooms).

9 In the Canadian setting, we have established a standard of care for one group with serious needs (those who inject drugs), but inadvertently excluded the needs of an equally needy target group (those who inhale or smoke drugs). We believe that a supervised consumption room needs to be opened as soon as possible to resolve this disparity by reaching the equally marginal group of people living with active additions who smoke drugs such as crack cocaine or crystal methamphetamine. We would like to initiate a supervised inhalation as a pilot project aimed at reaching a target group that is otherwise unengaged in any form of medical or support services in order to reduce the harms associated with smoking crack cocaine and crystal methamphetamine while dramatically reducing public disorder and open drug use. Our organization has the expertise to operate a SIR aimed at reaching vulnerable drug users with healthcare based on our established experience in implementing and managing Insite, Vancouver s supervised injection facility, in partnership with the provincial government of BC. We have been requesting federal permission from Health Canada and the Minister of Health to operate this essential health program since August We re hoping that the ever increasing scientific and medical evidence base for supervised consumption rooms will encourage Health Canada to provide us with a scientific exemption under Section 56 of the Controlled Drug and Substances Act (CDSA) so that we can commence a supervised consumption room with the support of the Federal Government as a lawful healthcare intervention for people living with serious and persistent inhalation addictions to narcotics. Our organization has secured a location and engaged consultants to complete initial design and municipal permitting for a facility located in Vancouver. It may be the position of the federal government, and Health Canada, that we do not require permission to operate a SIR especially in light of the overwhelming support in the medical and scientific community for population approaches as part of a comprehensive approach to addiction. If this is indeed the case, then we will commence operation without a scientific or medical permit. We intend to operate the SCR in accordance with the same operational protocols that have already been developed for Insite in partnership with Health Canada and the Vancouver Coastal Health Authority. We can meet you and your representative at any time to discuss our plans to open a supervised consumption room. I can be reached on my direct line at: On Behalf of the PHS Community Services Society, Dr. R. Dan Small, Ph.D., M.Phil. Cantab., BA Soc./Anth., BA Psych. References 1. Tortu S, McMahon JM, Pouget ER, Hamid R: Sharing of Noninjection Drug-Use Implements as a Risk Factor for Hepatitis C. Substance Use and Misuse 2004, 39: Faruque S, Edlin BR, McCoy CB, Word CO, Larsen SA, Schmid SD, Bargen JCV, Serrano Y: Crack Cocaine Smoking and Oral Sores in Three-Inner City Neighborhoods. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 1996, 13:87-92.

10 3. Porter J, Bonilla L: Crack Users' Cracked Lips: An Additional HIV Risk Factor. American Journal of Public Health 1993, 83: Amarapurkar D: Towards Control of Hepatis C in the Asia-Pacific Region: Natural History of Hepatitis C Virus Infecdtion. Journal of Gastroenterology and Hepatology 2000, 15:E101-E Chang W-C, Hsu H-H, Tzao C, Chen C-Y: Pneumomediastinum following crack cocaine. Injury Extra 2005, 36: Toronto SCUCo: Fact Sheet: Health Issues Affecting Crack Smokers. Toronto, Ontario: Safer Crack Coalition of Toronto; Network ONE: Reducing the Risks of Hepatitis C for People Who Use Crack or Crystal Methamphetamine Reference Manual. (Network ONE ed. Toronto, Ontario: Ontario Needle Exchange Network; Wolff AJ, O'Donnell AE: Pulmonary effects of illicity drug use. Clinics in Chest Medicine 2004, 25: (CCSA) CCoSA: Crack Cocaine Fact Sheet. (Firestone-Cruz M, Kalousek K, Fischer B eds.). Ottawa: Canadian Centre on Substance Abuse (CCSA); Butters J, Erickson PG: Meeting the Health Care Needs of Female Crack Users: A Canadian Example. Women and Health 2003, 37: Hoffman CK, Goodman PC: Pulmonary Edema in Cocaine Smokers. Radiology 1989: Goodman D: Toronto Crack Users Perspectives: Inside, Outside, Updside Down. Toronto: Safer Crack Use Coalition; Darke S, Ross J: Fatal heroin overdoses resulting from non-injecting routes of administration, NSW, Australia, Addiction 2000, 95: Thiblin I, Eksborg S, Petersoon A, Fugelstad A, Rajs J: Fatal intoxification as a consequence of intranasal administration (snorting) or pulmonary inhalation (smoking) heroin. Forensic Science International 2004, 139: