What do you do when you hit rock bottom? Responding to drugs in the city of Vancouver

Transcription

1 International Journal of Drug Policy 17 (2006) Editorial What do you do when you hit rock bottom? Responding to drugs in the city of Vancouver Introduction For most of the last decade, the city of Vancouver has ranked near the top of the United Nations indices of the world s most livable cities. With a mild climate by Canadian standards, clean air, beautiful mountains and beaches, the city s economy has been fuelled by a booming tourism industry. As a gateway to the rest of Canada, and with links to the ports of Asia, the city has a growing business culture centered in the city s Downtown core. Like most modern cities, Vancouver also has a concentrated lower income neighbourhood, which borders both the central business district and a bustling tourist area known as Gastown. This neighbourhood, known as the Downtown Eastside (DTES), is characterised by a concentration of lowincome single room occupancy (SRO) hotels that originally provided accessible and inexpensive accommodations for seasonal workers who would come to Vancouver to work in the salmon cannaries and other resource-based industries that sprung up along the port of Vancouver during the turn of the century. Many of these same hotels that served seasonal workers also operated taverns at street level. As resource-based economies began to slow down during recent decades, the DTES soon became the epicenter of Vancouver s illicit drug and sex-trade economies. In fact, the neighbourhood, with its mix of marginally housed individuals, low-income workers, and high rates of alcoholism and drug use, is like many of the low-income neighbourhoods that exist in other large urban areas in the western world. As was observed throughout most of North America, intravenous heroin injection was documented in the neighbourhood in the late 1960s, and in 1989 the city s first needle exchange opened to respond to the growing number of injection drug users (IDU) (Bardsley, Turvey, & Blatherwick, 1990). Hitting rock bottom However, in the mid-1990s, a series of factors culminated in the small neighbourhood becoming a vortex of drug-related harm that brought international attention to the community. Some of these factors have been described previously (O Shaughnessy, Montaner, Strathdee, & Schechter, 1998) and included a marked decrease in social housing budgets and the mass deinstitutionalisation of individuals living with mental illnesses. This in turn led to a concentration of the city s low income and mentally ill population into the most central low-income neighbourhood in the city. Most of these individuals remained homeless or sought refuge in the DTES SROs, many of which had evening $10 re-entry fees, which dissuaded individuals from going out on the street at night, but also dissuaded individuals from seeking sources of sterile syringes. The impact of this unstable housing environment on HIV risk was recently documented in a prospective cohort study of Vancouver IDU known as the Vancouver Injection Drug Users Study (VIDUS), and is shown in Fig. 1. The concentration of individuals with low incomes and mental illnesses in the DTES coincided with a dramatic shift in the local illicit drug supply that resulted in a major increase in the availability of powder cocaine injection. As has been well described, the short half-life of cocaine, in comparison to heroin is such that cocaine injectors can inject more than 20 times per day, whereas the long half-life of heroin is such that most local heroin injectors inject only 2 4 times per day (Tyndall et al., 2003). The severe impacts of increased cocaine injection was also documented in VIDUS, and Strathdee et al. (1997) demonstrated an explosive outbreak of HIV among the city s IDU which culminated in an annual HIV incidence rate of 18%, the highest incidence rate ever documented among IDU in the developed world. Updated data showing the impact of daily cocaine injection versus daily heroin injection among local IDU is shown in Fig. 2. Much has been made about the fact that Vancouver had in place a large needle exchange programme (NEP) at the time that the HIV epidemic emerged, and the fact that those using the NEP more frequently experienced elevated HIV rates (Moss, 2000). While the latter finding has been explained by the fact that more frequent users of the NEP were higher risk individuals (particularly, homeless and cocaine injectors), the character of the risk environment that led to the /$ see front matter 2006 Elsevier B.V. All rights reserved. doi: /j.drugpo

2 56 Editorial / International Journal of Drug Policy 17 (2006) Fig. 1. HIV incidence among Vancouver IDU stratified by stable (home, apartment) vs. unstable (SRO, homeless) housing (Vancouver Injection Drug Users Study). Reproduced with permission from Corneil et al. (2006). explosive HIV epidemic remains poorly understood in many circles (Schechter et al., 1999). In recent years, however, local epidemiological studies have provided much insight into the causes of the Vancouver HIV epidemic. In addition to the impact of high-risk network formation that resulted from unstable housing environments and the high prevalence of mental illness noted above, when the city s IDU increasingly shifted towards cocaine injection, the supply of sterile syringes were severely limited (Corneil et al., 2006). Specifically, when the Vancouver HIV outbreak occurred, the NEP operated on a strict one-for-one syringe exchange policy, and hours of operation were restricted to daytime in an effort to reduce drug use in the vicinity of the exchange at night (Spittal et al., 2003; Wood, Tyndall, Spittal, Li, Hogg, O Shaughnessy et al., 2002; Wood, Tyndall, Spittal, Li, Hogg, Montaner et al., 2002). Furthermore, the NEP operator faced funding constraints and significant pressure to maximise returns of used syringes. These dynamics resulted in the concentration of a population of closely networked high-intensity cocaine injectors whose access to sterile syringes was restricted throughout the hours of the evening that the drug and sex-trade economies were at their peak. The documentation of the explosive HIV epidemic by Strathdee et al. (1997) resulted in the local health authority declaring a public health emergency in Also coinciding with the emergence of the HIV epidemic are the periodic police sweeps that have characterised the neighbourhood for over a decade (Wood, Kerr, Small et al., 2003; Wood, Kerr, Spittal et al., 2003). Early police crackdowns are credited with driving IDU off of the streets, deep into the recesses of the SROs where sources of sterile syringes were absent, and where syringe sharing become common place (O Shaughnessy et al., 1998). Despite the lack of sustained positive impact, policy-makers persisted in sending police into the neighbourhood in an attempt to address the health and social harms plaguing the community (Small, Fig. 2. HIV incidence among Vancouver IDU stratified by daily cocaine and heroin injection (Vancouver Injection Drug Users Study). Reproduced with permission from Tyndall et al. (2003).

3 Editorial / International Journal of Drug Policy 17 (2006) Fig. 3. Changes in safe syringe disposal in the core area where the public illicit drug market was traditionally located before and after a police crackdown. (a) Unsafe disposal in the core, (b) unsafe disposal outside the core, and (c) use of outdoor safe-disposal boxes. Reprinted from Wood et al. (2004) by permission of the publisher CMA Media Inc. Kerr, Charrette, Schechter, & Spittal et al., 2006; Wood et al., 2004). Unfortunately, these efforts have only succeeded in displacing the drug problem to other neighbourhoods as was shown in one evaluation of their efforts (Fig. 3). Other evaluations have quantified reduced sterile syringe access during periods of elevated police presence (Wood Tyndall et al., 2003; Wood Schechter et al., 2003). Ongoing police efforts to clean up the neighbourhood have resulted in large numbers of local IDU spending periods of time in prison. As has been documented in both qualitative and quantitative analyses, this resulted in large numbers of IDU reporting syringe sharing in prison (Small et al., 2005; Wood et al., 2005). Elevated HIV incidence has been associated with periods of incarceration among local IDU (Tyndall et al., 2003), and it has been estimated that 21% of HIV infections among Vancouver IDU may be attributable to this risk factor (Hagan, 2003). Despite the shift towards increased cocaine injection, throughout this time, heroin injection continued to have a horrible impact on the morbidity and mortality of the local community with over 1200 overdoses documented during As a whole, the province experienced one overdose per day during the mid-1990s, and many of these deaths were not restricted to the local community (Miller et al., 2001; Tyndall et al., 2001). As in most urban areas with unchecked illegal drug economies, the DTES also become home to a bustling sextrade economy. The health-related harms associated with

4 58 Editorial / International Journal of Drug Policy 17 (2006) the local illicit sex market have been previously described (Kuyper, Lampinen et al., 2004; Kuyper et al., 2005), and to this day community concerns continually erupt whenever the industry spills over into neighbouring areas as a result of police crackdowns in the neighbourhood (Wood et al., 2004). Vancouver, dependent on its tourist economy, was increasingly being overrun by a growing public drug market while its hospitals were groaning under the strain of infectious diseases and other health-related harms (Kuyper, Hogg, Montaner, Schechter, & Wood, 2004; Palepu et al., 1999). A city that prided itself on being one of the world s best places to live, was gaining increased notoriety for the high rates of death and disease that were occurring among its citizens. In short, the city had hit rock bottom and conventional approaches were only worsening the problem. Cities and drugs: Vancouver as a case study Given the horrible health and social consequences resulting from the city s drug problem, and the persistent failure of conventional drug control approaches, it is in some ways no surprise that the city had to initiate plans to address the drug problem in an evidence-based fashion. However, many cities throughout the western world are facing similar challenges as Vancouver, and yet evidence-based drug policies often remain unimplemented. Using Vancouver as a case example, this issue of the International Journal of Drug Policy is devoted to examining drug policy issues affecting cities and explores the role municipalities can play in addressing the health and social consequences resulting from illegal drug use. Attention is also given to some of the factors that culminated in Vancouver City Council adopting its policy document A Framework for Action: A Four Pillar Approach to Drug Problems in Vancouver, and critical analyses of this attempt at an evidenced-based municipal drug policy are also presented. Among the contributions to the special issue are a series of articles related to the activities of the Vancouver Area Network of Drug Users (VANDU). This organization of drug users played an instrumental role in advocating for and eventually bringing about meaningful drug policy change in Vancouver (Kerr, Small, Peeace, Pierre, & Wood, 2006). These articles describe the essential and powerful role that drug users play in contributing to drug policy advancement at the municipal level. In addition, Small, Palepu, and Tyndall (2006) document the cultural shift that culminated in the opening of North America s first medically supervised safer injecting facility. This paper seeks to capture the injection site mania that literally took over the media and civic debate prior to the election of Mayor Larry Campbell in the fall of In the accompanying commentary by Wodak (2006), parallels to the establishment of the Sydney supervised injection facility are noted, and it is suggested that many instances, some threat of civil disobedience may be required to move policy-makers to initiate meaningful drug policy change. Small, Kerr et al. (2006) demonstrate the major health and social harms resulting from the Enforcement Pillar s first effort since the establishment of the Four Pillars experiment. A series of articles from local and international commentators demonstrate how far the city s Four Pillar approach must move before it can purport to be truly evidence-based. A related commentary by Cohen and Csete points to the internal inconsistencies inherent drug policy approaches that attempt to balance enforcement and harm reduction activities. These authors argue forcefully for a human rights approach to drug policy that more fully considers the rights of drug users and also places limits on the powers of police (Cohen & Csete, 2006). Police-crackdowns against illicit drug users have recently been described as a public health menace (Fitzgerald, 2005), and in this issue local lawyer Eby (2006) discusses some deeply concerning aspects of the Enforcement Pillar and argues that effective police oversight is the only way to ensure appropriate use of policing resources. In light of the well-known harms associated with enforcement activities in the DTES, it is concerning to note that these activities have also failed to produce benefits in terms of supply reduction, as noted in the article by former Head of Vice and Drugs for Vancouver which states: Enforcement everywhere ought to have effects on the supply of drugs: it should drive up the price, reduce the competition and restrict the supply. However, the increased efforts that we have made to stem the flow do not appear to have raised the price, lowered the purity or discouraged the purchase or use of drugs (Heed, 2006). The last pillar to be implemented in Vancouver is the prevention pillar, and in this issue Donald MacPherson, the architect of the Four Pillar approach, and co-workers outline the proposed plan to prevent harmful substance use in the City (MacPherson, Mulla, & Richarson, 2006). Many of the recommendations contained in the paper, including regulating drug markets, are indeed revolutionary. However, as the authors admit, many of the boldest recommendations can only be implemented by the federal government, and yet the authors argue rather convincingly that this should not deter municipalities from adopting such policy positions as cities can work to incite change by playing an advocacy role in the broader policy context. In this, issue, additional shortcomings of the city s prevention strategy are discussed by Friedman and Touze (2006) and Room (2006). Shannon, Ishida, Lai, Palepu, and Tyndall (2006) provide a glimpse into the current health and social conditions associated with SRO housing in the DTES and argue that aspects of the Four Pillar approach are destined to fail unless the housing conditions for IDU are improved in the city. Evans and Strathdee (2006) outline one of the successes of the neighbourhood, the Portland Hotel, which has succeeded in providing housing to individuals with an array of needs. However, the reality is that thousands of people who reside in the many SROs of the neighbourhood cannot be expected to live 24 h a day inside their rooms, and unless suitable off-street venues are created for all public drug users, major public

5 Editorial / International Journal of Drug Policy 17 (2006) order problems will persist in the city (Collins et al., 2005). As such, we believe that, despite the progress made by the Portland Hotel Society, the streets of the DTES will continue to be characterised by large numbers of low-income individuals using illicit drugs in the alleys and street corners unless pragmatic strategies are implemented to address the neighborhood s public order problems (Collins et al., 2005). The special issue concludes with Bruce Alexander s article that points to the need to move beyond the Four Pillars as well as the need to address some of the larger social and cultural issues driving drug use in a free market society (Alexander, 2006). In his critique of this analysis, Haden (2006) argues that Alexander misses an important aspect of the current debate in Vancouver. Specifically, that moving beyond the Four Pillars will require a rational discussion of the health and social problems stemming from drug prohibition. Haden alludes to a recently released Health Officers Council of British Columbia report which is intended to promote public discussion of the issues that need to be considered to end drug prohibition. In this context, Marsh and Fair (2006) discuss the strengths and weaknesses of the city s addiction treatment strategies. Moving forward should be an urgent priority since the reality on the streets of the DTES is that the fledgling Four Pillar experiment still has a long way to go before it can be truly recognised as evidence-based drug policy. Local and international politics continue to shape the decisions and the expectations associated with various interventions. For example, the city s supervised injecting facility was implemented as a tightly controlled 3-year pilot and remains subject to rigorous public health evaluations, whereas massive police efforts that have profound effects on the drug market go largely unevaluated and unmodified when evidence of harm is clearly demonstrated. Nevertheless, Vancouver is currently and will likely remain a hotbed of drug policy activity and debate. This debate has resulted in a commitment on the part of the city to pursue an evidence-based drug strategy, the opening of North America s first supervised injecting facility, and the in initiation of North America s first heroin prescription trial. If these efforts are successful, the city will likely continue in its pursuit of the goal that all rationally minded cities should be seeking if they hope to avoid hitting rock bottom: a truly evidence-based illicit drug strategy. References Alexander, C. S. (2006). 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