The only officially-sanctioned safe injection site in North America, Vancouver's InSite will have to close its doors June 30 if the Canadian federal government does not extend its exemption from Canada's Controlled Drugs and Substances Act. But while the Conservative government of Prime Minister Stephen Harper has made no secret of its distaste for the program, it has very strong community, local, provincial, and international support, and its supporters are now engaged in a strong campaign to ensure its continued existence.

InSite (courtesy Vancouver Coastal Health)

But now, after five years of monitoring and evaluation, the results are in: According to peer-reviewed scientific studies, InSite increased the use of addiction treatment services, increased the use of detox services, reduced needle sharing, led to improvement in neighborhood public order and quality of life, resulted in no increase in drug-related crime, prevented overdose deaths, and helped reduce the spread of HIV/AIDS among drug injectors.

As if the nearly two-dozen studies of InSite were not enough, the Conservative government last year commissioned its own study, "Vancouver's INSITE service and other Supervised injection sites: What has been learned from research?," which was released in early April. According to Simon Fraser University criminologist Neil Boyd, who was hired by the government to advise the committee overseeing the study, the research shows that InSite has no apparent negative impacts, has resulted in "modest decreases" in drug use, and has not disturbed public order.

In fact, said Boyd at a press conference announcing his findings, InSite should not only be continued, but the program should be expanded to other locations. "I think our data suggests... the building of additional facilities of a similar kind in neighborhoods where they are needed would yield benefits much in excess of the costs required for such projects," he said.

That's unlikely under the Harper government, which is ideologically opposed to such harm reduction practices and in fact removed funding for them from its anti-drug budget. As Harper put it last October: "Because if you remain an addict, I don't care how much harm you reduce, you're going to have a short and miserable life."

Harper has also scoffed at empirical evidence when it conflicts with his agenda. In a January speech to party faithful, he mocked opponents who cited falling crime statistics in challenging his emphasis on law and order. "They try to pacify Canadians with statistics," said the prime minister. "Your personal experiences and impressions are wrong, they say; crime is really not a problem."

More recently, Health Minister Tony Clement and his underlings have sounded similar themes. Science would not be the only factor in determining whether to continue InSite's exemption, Clement's undersecretary, Winnipeg MP Steven Fletcher told The Canadian Press earlier this month. While the government would make a "rational and thoughtful decision based on science," it must also take into account "the realities of the situation," Fletcher explained. "There's multiple sides to this and they all have to be taken into consideration," said Fletcher.

When pressed in parliament by Vancouver East MP Libby Davies, a staunch InSite supporter, Clement vowed to make a decision before June 30 and responded to her criticism about rejecting the science supporting the program: "We are the government that actually wants more research, that actually commissioned more research because we want to make sure this decision is the right decision for Canada, for addicts and for the community in Vancouver," he said. "That is the decision we have made, more research and more consideration. That is because we are open-minded and we want to make the best decision for Canada and Canadians."

Now, as the June 30 deadline looms, InSite's supporters have mobilized. Already this month, the International Journal of Drug Policy published articles by scientists from around the world condemning the federal government for interfering politically with the site's research, Boyd held his Ottawa press conference, advocates held a rally in a Downtown Eastside park featuring 1,000 white crosses to symbolize the people who didn't die from drug overdoses while injecting at InSite, Vancouver street nurses picketed the office of the Vancouver Police Union, whose president is a leading critic of the site, BC Nurses Association president Debra MacPherson held a press conference to tout the health benefits of InSite, and all three BC civic parties have signaled their joint support of the program.

"We're fully behind the effort to keep InSite open," said David Hurford, director of communications for Vancouver Mayor Sam Sullivan. "It is part of the solution, not part of the problem, and it is a bottom-up solution from the grassroots. The federal government has said it supports grassroots decision-making, so why should bureaucrats from 3,000 miles away be making decisions for us here?" he asked.

The mayor's office is "working with local stakeholders to help communicate the benefits of InSite," said Hurford. "We wrote to the health minister last week asking him to keep the site open, and at a minimum, to extend the permits until all pending legal issues are heard."

Hurford is referring to a lawsuit pending in the BC courts that challenges Health Canada's jurisdiction over InSite. That suit argues that since under Canadian law, health care is the domain of the provinces, the federal government should not have control over InSite. But that lawsuit will not be settled by the end of next month.

Opposition politicians have also joined the fight. "This government chooses to view harm reduction as nothing more than dirty words, at the expense of protecting the safety and health of Canadians," said Liberal Party public health spokesperson Dr. Carolyn Bennett.

"The results from the InSite project show measurable evidence that it saves lives," said Liberal MP Dr. Hedy Fry, who played a key role in bringing the agreement that allowed InSite to open. "This has won it widespread support not only from experts in Canada but from the international scientific community, from the Vancouver police and from residents of the Downtown Eastside," said Dr. Fry. "It is simply irresponsible to ignore scientifically-based proof of the efficacy of harm reduction programs like this, and base public policy on ideology alone because real people suffer the consequences."

"The Conservative government must stop its unconscionable interference in scientific research on Vancouver's safe injection site," added New Democratic Party MP Libby Davies, who represents the Downtown Eastside. "Medical researchers from the University of British Columbia have revealed that Harper and his team have been suppressing evidence and denying funding to scientists who are looking objectively at the merits of Insite," she said.

"More than 20 medical and academic studies have been published showing the health and social benefits of InSite. We now have both scientific fact and evidence from users in our community that this facility is helping, not hurting the people of our city. The research record shows that Insite saves lives and increases public safety," Davies continued. "Harper doesn't understand that you can't just hide the facts whenever they don't suit your political agenda. We need a change in direction. It's time for this government to make decisions based on evidence instead of ideology -- InSite needs to be kept open."

"What we want is a 3 ½ year renewal of the exemption from the Controlled Substances Act," said Nathan Allen of InSite for Community Safety. "The fact that the Harper government has not granted this renewal shows they are very reluctant to support the community."

While the Harper government has previously said it needed more research to evaluate InSite's efficacy, that dog won't hunt anymore, said Allen. "They've already spent more than $1.5 million studying InSite, they've produced two dozen academic papers, and they've concluded that it has all kinds of positive impacts. We're wondering what questions the government has left to ask," he scoffed. "InSite has undergone the most thorough and well-funded scrutiny of any health clinic in the country."

In the event the government refuses to grant another exemption, Allen said he hoped it would respect provincial authority and local autonomy. "This has been a regional response to a local crisis here in Vancouver. We need to let the people here on the ground do what they need to do. If not, people will die," he predicted bluntly.

The clock is ticking for InSite, but the pressure is mounting on the Harper government. The next few weeks will determine if that pressure is sufficient to overcome the government's ideological opposition to the safe injection site.

The Idaho Senate voted overwhelmingly Tuesday to override a gubernatorial veto of a bill that would have increased funding for drug treatment and prevention programs. Now, the House must vote to override by a similar "supermajority" to complete the restoration of funding against the wishes of Republican Gov. Butch Otter.

Last week, Otter vetoed line items in two bills that would have provided $16.8 million for Idaho substance abuse programs. The Senate override vote on SB 1458 restores $2.4 million in supplemental funding. But Otter also vetoed $14.4 million in treatment funding for the coming year in HB 608.

The twin vetoes would cut in half the funding for drug courts and treatment for probationers and parolees, as well as some community-based treatment programs. The tussle at the statehouse is the latest round in fighting over how best to continue a three-year, $21 million dollar anti-drug effort originally funded by a federal grant. The federal money ran out last year, and lawmakers replaced it with state funds. Otter complained that the programs were unproven and had been expanded beyond their original scope.

But the state Senate seemed determined to do something other than just pay for more prison cells, and for several senators, Idaho's drug war has hit close to home. "I don't believe there is a family represented in this body who has not been affected by drugs or alcohol or mental health problems at some point," said Sen. Chuck Coiner (R-Twin Falls) in remarks reported by The New West magazine.

Sen. Brent Hill (R-Rexburg), also speaking in support of the override, told of a family member "almost ruined" by methamphetamine. "Her teeth rotted right out of her head," he told his colleagues.

Sen. Lee Heinrich (R-Cascade) said his son had spent two and a half years in prison on drug-related charges. "He could have benefited from this program... I know what these drug-related things can do to families," he added, but then said he would vote against the override because he wasn't sure "we've looked at all the alternatives."

But it was Sen. Dean Cameron (R-Rupert) who was perhaps most perceptive, speaking of a "paradigm shift" among his conservative colleagues. "Doesn't it seem smart to get on the front end of these decisions? Doesn't it seem smart to try to affect them before they become incarcerated, so they don't offend in the first place?" he asked. "Cells alone are not the answer."

At mid-week, the governor was signaling he still sought compromise. "The governor has consistently indicated that he was willing to discuss this issue and reach a compromise as he has on other important issues," he said in a Wednesday statement. But the size of the increase in treatment spending "could not be justified in a year when we are asking so many others agencies, not to mention state workers, to do with less."

Now, the ball is in the House's court.

Phillip S. Smith, Writer/Editor

Like most people interested in drug law reform, I believe that substance use is a constant in human affairs, and that -- as US history over the past few decades demonstrates -- nothing short of totalitarianism can stomp it out, and then, most likely, only temporarily. I also believe that substance use does not automatically equate to substance abuse or addiction.

Nor am I especially comfortable with the "disease model" of addiction championed by the mad scientists of NIDA, as well as too many well-meaning drug reformers and, perhaps, self-interested drug treatment providers. The concomitant to the disease model, which seeks to replace human agency with biopsychopharmacological determinism, is the Alcoholics Anonymous-based drug treatment dogma that people with problematic drug habits are addicts, the victims of a progressive, incurable disease whose only cure is lifelong abstinence.

As the authors of "Over the Influence" note, philosophical objections aside, a major, major problem with abstinence-based drug treatment is that it just doesn't work. Although abstinence-based programs account for more than nine out of ten programs in the US, that appears to be more because of inertia than results: Such programs, which define "success" as abstinence from all drugs, work only between 5% and 39% of the time, and that's for the small minority of users who actually complete them.

Instead of relying on programs and models that rely on the disease model and the insistence that the only success is staying completely straight, the authors of "Over the Influence" suggest that we apply the principles of harm reduction to drug use in our personal lives. While the notion of harm reduction in this context is controversial, it shouldn't be -- because it's only common sense.

Harm reduction accepts that people may do things that pose potential risks or harms to them and -- duh -- seeks to reduce those harms. Some people like to race automobiles. Abstinence says they should never race; harm reduction says they should wear helmets and protective clothing. Some people (like those darned teenagers) like to have sex without waiting for marriage. Abstinence says they should remain virgins until the holy day arrives; harm reduction says provide them with birth control and protection from disease if they're going to be sexually active.

When it comes to substance use, the advocates of abstinence are even more insistent: The only way to cure the disease is to never use any psychoactive substance (except for cigarettes and coffee, as any AA veteran knows). But Denning, Little, and Glickman, all three of whom have long experience in harm reduction and therapy under their belts, dare to suggest what has heretofore been anathema in the treatment community: There are other choices besides quitting. In fact, they take as their mantra a slogan popularized by the Chicago Recovery Alliance: Any Positive Change.

What does that mean? Say you think your cocaine use is getting out of hand. You had been snorting only on weekends, but now you find yourself doing it every day. Can you at least skip Tuesday and Thursdays? If you manage to do that, you have not only reduced the potential harm of chronic cocaine use, you have also proven to yourself that you can control your relationship with your drug of choice, that you are not a helpless victim doomed to a downward spiral of addiction and misery.

Or maybe you like to drink, but you find that your nightly bottle of wine is making you so sluggish the next day that you are not getting your work done and your job could be in jeopardy. Can you make it a half-bottle? If so, once again, you have reduced the harm of your substance use and you have demonstrated your control over your own life. And you have not given up the fruit of the vine, only moderated your use of it.

Of course, not everyone is just going to wake up one day, decide to change their substance use habits, and be successful at it. But even if one does not succeed on the first try, the very act of trying to assess and regulate one's drug use is a step in the direction of harm reduction. One of the elements that makes "Over the Influence" so useful for drug users (and those concerned about them) is that it shows readers how to think critically about their drug use, its benefits, and its potential harms. A little introspection never hurt anybody, and when it comes to potentially lethal substances like alcohol or hard drugs, a little introspection can save lives.

"Over the Influence" is absolutely essential for anyone seeking to come to grips with his or her substance use, and even more so for those friends or family members of people who are having problems with their drug use. Unlike AA-based abstinence programs, which seem to work for only a small percentage of people, applying the principles of harm reduction to substance use is likely to make a difference in the larger world of still-drug-using people.

It seems so sensible. How can this be controversial?

The Bush administration's proposed Fiscal Year 2009 spending for drug treatment, prevention, and recovery includes significant funding cuts for some programs, and that has critics ranging from former federal drug warriors to the treatment and recovery community crying foul. While economic pressures may necessitate a lean budget, say the critics, cutting drug treatment, prevention, and recovery is not the way to do it.

Bush administration drug strategy report and budget

• Funding for the Substance Abuse Prevention and Treatment Block Grant program would see a small increase to $1.779 billion, but that increase would be earmarked for the most effective existing grant recipients.
• The Center for Substance Abuse Treatment (CSAT) would receive $336.7 million, a decrease of $63 million from FY 2008, and a number of programs would be zeroed out, including the Recovery Community Support Program. Other losers include the Treatment Systems for the Homeless program (cut from $42.5 million to $32.6 million) and the Opioid Treatment Program/Regulatory Activities (cut from $8.9 million to $6 million). But funding for the Access to Recovery grant program would remain unchanged at $99.7 million, and drug court funding would increase from $15 million to $37 million.
• The Center for Substance Abuse Prevention (CSAP) would receive $158 million, a decrease of $36 million from FY 2008.
• Funding for the Center for Mental Health Services would be cut by $126 million.
• The Safe and Drug-Free Schools and Communities (SDFSC) State Grants program, which supports community-based prevention programming through the Department of Education, would receive $100 million, a decrease of $194.8 million.
• The National Institute on Drug Abuse (NIDA) would receive $1.002 billion, a nearly $1 million increase over FY 2008.
• The National Institute on Alcohol Abuse and Alcoholism (NIAAA) would receive $436.68 million, a $0.4 million increase over last year's funding.

"We're very concerned about these cuts and looking forward to working with Congress to restore the funding," said Pat Taylor, executive director of Faces and Voices of Recovery, a national organization advocating for those affected by substance abuse problems. "We're especially concerned about the elimination of the Recovery Community Services Program -- it's the only program that funds community recovery services," she said.

Even though the Office of Management and Budget (OMB) report that accompanied the Bush budget claimed such programs are ineffective, thus justifying their being cut, Taylor said that report was wrong. "We know from the government's own data that these programs are highly effective at a relatively low cost," she said. "Funding has gone to organizations that have leveraged tens of thousands of volunteer hours in communities around the country."

"There's not a lot of money for treatment and prevention as it is," said Bill Piper, director of national affairs for the Drug Policy Alliance. "Bush is also cutting law enforcement," Piper said, referring to proposed cuts in the Byrne Justice Action Grants program, "but we know which one Congress is more likely to restore."

"I've argued for years that it's a gross distortion of resources to deny as much funding as necessary for drug treatment, prevention, and education. That is how we stop the link between drugs and crime," said Robert Weiner, who as public affairs director under drug czar Gen. Barry McCaffrey frequently earned reformers' ire (on other issues). Weiner added that two-thirds of arrestees test positive for illegal drugs. "If we prevent it on the front side before forcing them into prison, we save literally billions of dollars and make productive citizens out of these people. The federal drug budget needs to be refigured to change its priorities," he said.

Weiner also had harsh words for the current drug czar, John Walters, for failing to protect his bureaucratic fiefdom. Under Walters, the drug budget under the control of ONDCP has declined from $19 billion to $13 billion.

"That's outrageous," Weiner complained. "Walters has his head in the sand and has been ceding authority. The point of his office was to create an overseer to ride herd on drug policy, but instead, Walters has just been a lackey to this politics of fear and terror and homeland security and has given away the store. It's not just individual programs, but an overall ceding of authority, and that's a shame."

Weiner isn't the only former federal drug warrior taking pot-shots at the Bush administration's drug policy spending priorities. John Carnevale, who served under four different drug czars and helped set federal drug budgets and strategies, ripped into the Bush administration earlier this month with a policy brief charging that it had consistently emphasized the least effective aspects of drug control policy.

According to Carnevale, supply reduction (law enforcement, interdiction, eradication) spending has grown 57% during the Bush years, while demand reduction (treatment, prevention, recovery) spending has increased by only 3%. The ratio between supply reduction and demand reduction spending is about 2:1, near where it has been historically despite repeated claims by federal drug fighters that they are shifting to a more balanced approach.

As Carnevale notes, "Research suggests that treatment and prevention programs are very effective in reducing drug demand, saving lives, and lessening health and crime consequences. It has demonstrated that attacking drugs at their source by focusing on eradication is expensive and not very effective. It has demonstrated that interdiction has little effect on drug traffickers' ability to bring drugs into the United States and on to our street corners where they are sold."

Perversely, however, interdiction funding increased the most during the Bush years, doubling from $1.9 billion in 2002 to $3.8 billion in 2009, while source country funding increased by 50%, law enforcement by 31%, and treatment by only 22%. Spending for drug prevention, on the other hand, actually declined by 25%.

"If research were our guide," wrote Carnevale, "then one would expect the opposite ordering of increases in budgetary resources for drug control. The failure to incorporate research into the budgetary process is a lost opportunity to produce results. The only positive news in this decade is the reduction in youth drug use, a trend which started in the previous decade. Today's discussion of drug policy performance overlooks the fact that adult drug use and rates of addiction remain unchanged in this decade."

The chorus of critics is not just complaining. Led by the treatment and recovery community, moves are afoot in Congress to seek a better mix when it comes to drug policy funding. Look for battles to come in committee hearing rooms and floor votes as advocates seek to restore funding to useful and effective programs.

"These cuts are very shortsighted and I don't think they will stand," said Taylor. "We are working with many allied organizations to support a different budget proposal that we will be distributing on Capitol Hill next week. There is a lot of interest there in moving forward instead of back."