Date: April 16, 1998
Author/Local: J. Brooks/6043
CC File No. 4113
TO: Vancouver City Council FROM: Director of Community Services, Social Planning SUBJECT: Information on Needle Exchange Programs in Vancouver
The Director of Community Services, Social Planning Department, presents this report for information.
GENERAL MANAGER'S COMMENTS
The General Manager of Community Services submits the foregoing for Council's INFORMATION.
While there is no explicit Council policy on needle exchange programs, Council has consistently taken the position that the City will not fund programs that come within the funding mandates of senior levels of government.
The purpose of this report is to inform Council about the current needle exchange programs in Vancouver.
On January 19, 1989 Council approved funding for the creation of a needle exchange program in Vancouver. The Downtown Eastside Youth Activities Society (DEYAS) was granted $100,000 to provide this service, with grant disbursements to be made upon the approval of the Medical Health Officer. Subsequent grants to cover the needle exchange program's operating costs were provided in 1990 ($170,000), 1991 ($226,000) and 1992 ($82,000 for 4 months). The City ceased funding the needle exchange program when the Provincial government took over responsibility for it later in 1992.
At the Council meeting of March 23, 1998, Council requested staff to report back on needle exchange programs in Vancouver, including information on needle distribution, locations, concentrations, program accountability and public health policies.
What is a Needle Exchange Program and Who Provides It
First it is important to explain what a needle exchange program is. It is a service for intravenous drug users that provides them with clean needles, a bleach kit and education in exchange for used or dirty needles. The goal of a needle exchange program is to have injection drug users always using a clean needle, reducing the risk of spreading HIV and hepatitis. The recovery of needles is an essential element in these programs to control the unsafe disposal of used needles in streets, playgrounds, etc. All exchange programs provide needles on a one-for-one basis - for every clean needle given a used needle must be returned. In Vancouver, needle exchange programs are delivered by the Vancouver/Richmond Health Board, the B.C. Centre for Disease Control Society-AIDS/STD Prevention Street Nurse Program, DEYAS and some pharmacies. Outside of Vancouver, there are only two Lower Mainland municipalities that have needle exchange programs. These are New Westminster and Surrey.
Public Health Policies for Needle Exchange Programs
Needle exchange programs are one part of a Provincial harm reduction approach to decrease the negative consequences of addictive drug use. At this time, the primary focus of the approach is to reduce the spread of HIV/AIDS and other infectious diseases among people who inject drugs and who work in the sex trade.
The Vancouver/Richmond Health Board endorses this approach and has incorporated it into a continuum of care model that includes needle exchanges, information and education about safe sex practises (including condom distribution), vein maintenance, testing for HIV and other diseases, and pre and post-test counselling. They also refer clients to other services such as drug and alcohol treatment and disease management programs for communicable diseases. The Health Board describes their harm reduction strategy as "an opportunity to increase client contact, improve relations with clients and make Health staff more accessible when a client is ready for healthier lifestyle changes".
The current needle exchange programs operate within a framework of Provincial Ministry of Health policies. These policies cover values and principles about how clients are to be treated. The objectives of the program are preventing the transmission of HIV and other related diseases, promoting safer injection drug use and sex practises, and maximizing the safe recovery and disposal of used needles. The policies require that all agencies receiving free needle exchange supplies from the Ministry of Health must develop written policies to cover the exchange of needles and syringes, safe disposal of needles, distribution of condoms, health education, referral to other health and social services, tracking and monitoring systems. The agencies are also required to participate in quarterly meetings of the Needle Exchange Providers Group for the Province facilitated by the Ministry's AIDS Strategy HIV/AIDS Policy, Program and Support Branch.
Copies of the needle exchange policies for the B.C. Ministry of Health are attached as Appendix A. The Vancouver/Richmond Health Board, DEYAS and the B.C. Centre for Disease Control Society are also available.
There is no Provincial legislation governing who can sell needles. At one time the Pharmacy Act prohibited the sale of syringes for the use of illicit, narcotic drugs. This prohibition is no longer in the Act.
The Vancouver/Richmond Health Board's community health clinic programs and the B.C. Centre for Disease Control Society - AIDS/STD Prevention Street Nurse Program are all accountable to the Vancouver/Richmond Regional Heath Board. DEYAS is accountable to the Ministry of Health for their needle exchange program. These governmental and non-profit service providers deliver their programs within policies and guidelines developed in partnership with the Ministry Health and Needle Exchange Programs. As of September 1997, the B.C. Centre for Disease Control became a society changing its direct reporting relationship from the Ministry of Health to the Vancouver/Richmond Health Board. Broader community involvement is a component in the planning, development, evaluation and support of needle exchange programs. The Ministry of Health has an advisory body that
reviews the policies and practises of needle exchange agencies. In Vancouver, the group is called the Lower Mainland Needle Exchange Advisory Committee and has been meeting for the last three years.
New Westminster's needle exchange program is accountable to the Simon Fraser Health Region. Surrey's program reports to the Ministry of Health and the Boundary Health Region's Chief Medical Health Officer.
Accountability for the retail sale of needles is limited. There is no Provincial policy that addresses who can sell needles or how they are to be sold. The College of Pharmacists is fulfilling a Ministry request to distribute needles from pharmacy dispensaries instead of on store shelves. There is no such agreement with other retailers such as grocery stores. At present, no retail outlets are required to handle the return of used needles.
Needle Exchanges and Sales
This section covers how the various needle exchange providers go about delivering needle exchange services. Details on fixed needle exchange locations and mobile services are noted along with hours of service, needle recovery statistics, client profile and numbers served.
Vancouver/Richmond Health Board Programs
The Vancouver/Richmond Health Board programs currently provides needle exchanges as one of a number of health services. Needle exchanges are conducted in community health clinics by Health Office nurses and physicians. Currently six Health Board locations provide this service and there are plans to integrate needle exchange into all of the community health delivery sites. The Downtown Community Health Clinic has been providing their regular clients with needle exchanges many years. Since December 1997, a number of other clinics have begun to offer this service. The latest additions are the Downtown South Community Health Centre, the Pine Free Clinic, the Mt. Pleasant Youth Clinic, the North Health Office, and the North Health Office's Youth Clinic at the Reach Community Health Centre. The number of exchanges that occur in Health clinics are low. For example, the Pine Free Clinic had 12 needle exchanges in March 1998. This is typical of the other clinics as well. Needles can be exchanged at a variety of times throughout the week. Service hours vary from clinic to clinic but generally they occur throughout the week during the hours of 8:30 a.m. to 5:00 p.m. Some clinics offer later hours up to 7:30 p.m. but the Downtown South Clinic is the only clinic offering daily service until 11:00 p.m.
The Vancouver Needle Exchange run by DEYAS is a 24 hour service. Their fixed location at 221 Main Street is open from 8:00 a.m to 8:30 p.m.. Mobile outreach is done by vans seven days a week from 1:00 p.m. to 8:30 a.m., as well as by foot during the day. DEYAS recovers used needles on a 1:1 trade basis. One needle is returned for every one given. Clients can do bulk trades of up to 50 needles per day at the fixed site and the van will accept bulk trades to a limited extent. DEYAS uses a manual counting method to determine their needle recovery results. In 1997, the Needle Exchange Program exchanged over 2.5 million needles. For the last two years DEYAS has had a 101 percent needle return rate. The majority of the clients are Caucasians and Aboriginals in their thirties or forties. Seventy-three percent are male, 26 percent are female and less than 1% are transgendered.
DEYAS provides Sharp's containers to community businesses, organizations, facilities and residents to safely store used syringes until they can be returned to the Exchange's office. The society has hired a worker to pick-up needles, condoms and other paraphernalia from community streets, lanes, parks and schoolyards. This worker also coordinates distribution and collection of Sharp's containers.
Street Nurse Program
The AIDS/STD Prevention Street Nurse Program provides a range of health programs. They conduct needle exchanges in street clinics as well as on a one to one basis in homes, hotels and on the street. They operate a mobile van to do outreach work and they make on-foot street contact with clients. A full time staff of twelve nurses and 2 health care workers work flexible hours Monday to Saturday from 7:00 a.m. - 11 p.m.. Their fixed site locations include 3 street clinics: 219 Main Street, 1170 Bute Street and 1058 Seymour Street. They regularly visit 13 other locations to provide services and education. These other locations are: the overnight holding jail on Main Street, the Burnaby Correctional Facility for Women, the 2 Vancouver Detox Centres, the Dusk to Dawn Resource Centre, the Adolescent Service Unit, the Gathering Place, Bridge Clinic and the youth safe houses.
In 1997, the AIDS/STD Street Nurse Program handed out 431,626 needles and received 434,498 in return: a rate of return of 101%. Needles are collected in Sharps containers and returns are measured using an approximation method based on what the containers can hold. Manual checks are done periodically to test the counts. The Street Nurses do not have a formal pick-up program for discarded needles, however, they do provide Sharps containers to some centres that do not have a relationship with any of the needle exchange programs. The program does not keep statistics on clients accessing needle exchange services.
New Westminster and Surrey Programs
As a part of providing health services closer to home, the New Westminster's Health Services is providing needle exchanges along with baby weighing and other typical health services at their health unit. They provide this service Monday to Friday during the hours of 8:30 a.m. to 4:30 p.m. In 1997, the health nurses at this clinic served 472 people for needle exchanges and they exchanged 13,660 needles. Similarly, the South Fraser Community Services has operated a fixed site needle exchange program in Whalley since 1990. Their service operates seven days a week from 1:00 p.m. to 6:00 p.m. with a late opening until 8:00 p.m. on Wednesdays. On average they exchange 25,000 needles per month with a 99 percent return rate.
Pharmacies and Retail Outlets
Needles are sold by pharmacies and other retail outlets. The College of Pharmacists supports the sale of needles in pharmacies but there are differing points of view among pharmacists about selling needles for non-medical drug use. Individual pharmacies establish their own store policies around the sale of needles. Not all pharmacies provide the service. Other retail outlets can and do sell this product. There are no limitations to the quantity they can sell or the cost they can charge. They are under no obligation to accept returns of used needles. A sub-committee of the Needle Exchange Advisory Committee has recommended that needle sales and collection be expanded to all pharmacies. They also suggest that retailers selling needles take responsibility for handling returns. Shoppers Drug Mart is one of the retailers that do accept used needles in some store locations.
Needle exchange programs have become the lightening rod for public concerns about HIV/AIDS, drug abuse and crime and safety issues. The major issue behind these concerns is a drug epidemic in Vancouver which has been going on in the Downtown Eastside since the early 1990s. The drug situation is being fuelled by the following factors:
a) Cheap and available cocaine and heroin;
b) Lack of accessible treatment programs for addicts;
c) Proliferation of "2nd hand stores" and pawn shops where stolen goods are being sold, to give addicts money to buy drugs; and
d) Continued proliferation of 24 hour grocery stores where the drug sales occur around the clock.
There are few public health issues as emotionally charged as the debate about programs that provide clean needles to drug addicts to help reduce the spread of HIV. This harm reduction policy aims to lessen the health and social consequences of drug use among addicts, their families and communities. The program's goal is to act as a bridge to treatment and general medical care for addicts.
Support for these programs varies. Residents in some communities believe that needle exchange programs will negatively impact their neighbourhoods by bringing in new addicts into their communities. In addition to fears about crime and safety, finding used needles littered in the neighbourhood is a major health issue and concern for all. Others say the programs save lives, curb the spread of HIV and do not boost drug use. If needle exchange programs are to be located in other neighbourhoods than the Downtown Eastside and in other municipalities, communities want consultation with the Health Boards to take place before expansion occurs. In addition, the issue of discarded needles in communities needs to be addressed. Currently, DEYAS is the only needle exchange program that regularly does community collection of discarded needles and will provide this service upon request. The City's Engineering Department will dispatch a foreman to pick-up discarded needles.
What does the scientific literature have to say about needle exchange programs? Last December, a panel of the White House Office of National AIDS Policy presented a report that concluded there was "scientific evidence of the efficacy of such programs in preventing new HIV infections without increasing substance abuse". Numerous studies have concluded needle exchange programs reduce the spread of HIV and do not encourage drug use. A consensus panel convened by the U.S. National Institute of Health found that "an impressive body of evidence suggests powerful effects from needle exchange programmes...there is no longer doubt that these programs work". A recent study published in The Lancet, a British medical journal, found that where needle exchanges are in place worldwide, HIV infection dropped.
Despite these studies from a variety of government agencies, that have shown clean needle programs are effective, the debate over their utility is likely to continue.
The authors of the Vancouver and Montreal needle exchange studies wrote in the April 9, 1998 New York Times that "clean needles are only part of the solution. A comprehensive approach that includes needle exchange, health care, treatment, social support and counselling is also needed".
Addiction is a phenomenon that has long been debated. Many people continue to think of addiction - particularly to illicit drugs - as primarily a moral issue or character problem, or a lack of willpower. Scientific research into addiction however, has led experts to conclude that addiction is actually a disease - a disease that causes changes in the brain, which then drives compulsive drug-taking behaviour. However, addicts can learn to change that behaviour, only doing so is difficult and often requires treatment and major lifestyle changes. Treatment and recovery from addiction are possible. Drug abuse treatment can have a significant effect on reducing drug use. The National Institute on Drug Abuse study tracking 10,000 drug abusers found that methadone treatment cut heroin use by 70 percent. The study also found that long-term abstinence-based treatment resulted in 50 percent reductions in weekly or more frequent cocaine use after one year of follow-up. Reductions were greatest for those in treatment for at least 3 months.
In April 1998, a U.S. study sponsored by Physician Leadership on National Drug Policy was released comparing more than 600 research articles, plus original data analysis, show conclusively that drug addiction treatment is very effective and that it works as well as other established medical treatments for illnesses such as diabetes, asthma and hypertension. The study also compares the outcome of treatment with imprisonment and found treatment is an effective anti-crime measure and less costly than prison. Improved outcomes include greatly reduced medical costs to society, returning many more addicts to normal, healthy lifestyles and gainful employment, major crime reductions and savings that would otherwise be spent on new prisons and law enforcement. While reduced health costs are impressive, the most dramatic return is the effectiveness of treatment in reducing the occurrence and costs relating to crime. From a business perspective the study found that drug treatment reduces crime by 80 percent; for every dollar spent in drug treatment, seven dollars is saved in societal and medical costs; and drug treatment helps society's health, reducing the spread of AIDS and hepatitis.
In Vancouver, we are missing the most vital piece of our strategy - accessible drug treatment for addicts. The use of the criminal justice system to reduce illegal drug use and its harmful effects is not adequate to address these problems. A new emphasis utilizing effective criminal justice procedures with the creation of more prevention and treatment programs, with effective community partnerships will be a more likely cost-effective approach.
Scientific research indicates that addiction treatment programs are effective anti-crime measures and that needle exchange programs prevent new HIV infections without increasing substance abuse. At the same time, there is a segment of the public which supports more spending on incarceration and increased police resources as the direction to take in response to drug addiction.
In Vancouver, the situation is complicated by the fact we have some but not all the elements of a comprehensive strategy on HIV/AIDS and on drug addiction. We lack the necessary treatment programs which would be significant in reducing drug use and crime.
There needs to be a bridge between public concerns, research findings and public policy, a broader understanding of addiction and treatment options, more clarity from the Province about their overall strategy which then needs broader public discussion. Without the discussions, the public support and Provincial commitment to develop treatment facilities will continue to be lacking.
Staff will monitor these issues, and continue to work with the Vancouver /Richmond Health Board and the Ministry for Children and Families and their Vancouver Alcohol and Drug Management Advisory Committee.
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