TORONTO - Toronto and Ottawa would benefit from having supervised drug injection facilities, but reaction to the report making that recommendation suggests the process of translating advice to reality may not be swift.
Four years in the making, the report recommended three safe injection sites for Toronto and two for Ottawa, saying injection drug use in both cities isn't focused in one area, as it is in Vancouver's Downtown Eastside, home to Canada's first safe injection facility, Insite.
Asked about the recommendation, Ontario's Health Minister Deb Matthews said the province is not planning to pursue supervised injection sites at this time.
Zita Astravas, Matthews's press secretary, said in an email that the province doesn't have the power to block supervised injection sites, if a group trying to open one receives the necessary legal exemption from the federal government.
But the reality is that unless alternative funding sources can be found, provincial backing would probably be needed to get — and keep — these facilities up and running. However, if funding can be found, one expert in the field suggested it is unlikely Ontario would get in the way.
"Knowing the situation in Ontario with the deficit and the financial challenges, I think were the private sector to enter into the discussion and allow something like this to go forward, it would be very interesting to see what the province would do," said Dr. Evan Wood, co-director of the Urban Health Research Initiative at the B.C. Centre for Excellence in HIV-AIDS.
"Because in many cases it's a question of health-funding priorities and I can't imagine how, with resources on the table to do something like this ... any government would impede a public health initiative like this."
One of the authors of the new report said it isn't clear what the path is for translating recommendation into reality.
"Somebody would need to apply for an exemption from Section 56 of the Controlled Drug and Substances Act," Dr. Ahmed Bayoumi said via email. Bayoumi is a scientist in the Centre for Research on Inner City Health at the Keenan Research Centre at St. Michael's Hospital.
"In Vancouver this was led by an independent community group (The Portland Hotel Society). Who would lead such an initiative in Toronto or Ottawa is an open question."
Still, his co-author, Dr. Carol Strike, said she and Bayoumi hope Ottawa and Toronto will act on the advice in the report.
"I think we have strong evidence to suggest that there's a benefit for both cities and we hope that both cities use the evidence to move forward," said Strike, an associate professor at the Dalla Lana School of Public Health at the University of Toronto.
Vancouver is currently the only city in Canada that has supervised drug injection facilities. But other cities — including Victoria, Montreal and Quebec City — have expressed interest in setting up similar sites. Vancouver has Insite, a stand-alone facility, and the Dr. Peter AIDS Foundation, which offers a safe injection service for clients of the agency.
The report estimated opening facilities in Toronto and Ottawa would reduce new HIV and hepatitis C infections, though the numbers of potentially averted infections per year are not enormous.
Mathematical modelling suggests each site in Toronto would avert two to three HIV infections per year and between 15 to 20 new hepatitis C infections would be prevented per facility over the course of 20 years.
In Ottawa — which has the highest rate of new HIV infections among injection drug users in Ontario — the report anticipated the effect would be greater. It estimated each facility would avert six to 10 HIV infections a year and 20 to 35 hepatitis C infections per year.
While those numbers are not huge, they would translate into lives — and health-care dollars — saved. It is estimated that each HIV infection costs the health-care system about $500,000 over the lifetime of the infected person, said Wood, who was involved in the scientific evaluation of Insite, which started as a research program.
The report said demand for injection facilities is high in the two cities, which have an estimated 9,000 (Toronto) and 3,000 (Ottawa) injection drug users.
And it suggested there is backing for the facilities among the public, though it admitted that even those who are supportive of the concept raise concerns about where the facilities would be located.
"It seems to me there is a shift — movement towards acceptance. And I think there's a broader understanding in the public that addiction problems are complicated. And the model that we currently have addresses some needs but not all and perhaps we need to explore other options," Strike said.
She acknowledged that the police departments in both cities object to the idea, but said that shouldn't stand in the way.
"These are public health facilities. And the police are one stakeholder among many. And I think not implementing because the police are opposed, it does not make sense in terms of public health policy," Strike said.
The current federal government is philosophically opposed to supervised injection sites. It tried repeatedly to shut down Insite until the Supreme Court of Canada ruled in 2011 that the exemption the site needed to operate could not be denied if there was a demonstrated need for the facility.
Toronto Mayor Rob Ford is also on the record opposing the idea.
The researchers were not asked to recommend specific neighbourhoods in which to locate the facilities and the report did not make suggestions. Selecting appropriate locations will be a challenge, the authors suggested.
Other tough discussions would include whether there should be an age limit on people who can use supervised injection facilities and whether the facilities should agree to help drug users inject, if they want or need help.
The researchers looked into but did not recommend a supervised drug smoking facility. There isn't enough evidence to say whether such a facility would be used by people who smoke drugs or whether it would have public health benefits, they said, suggesting a pilot study should be done to look into the question.
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