Three years after the Supreme Court of Canada cleared the way for more supervised injection sites, Canada still only has its original Vancouver facility and proponents for others across the country say an onerous process to get approval is likely to become even more difficult with a new law expected to pass this spring.
Only one new application for a supervised injection site has been forwarded to Health Canada since the ruling in September, 2011.
Public-health officials and advocates are worried that the agency is "dragging its heels" in anticipation of Bill C-2, which will add many more steps for applicants wanting an exemption to Canada's drug laws needed to run such a facility.
The top doctors of Canada's 19 largest cities support supervised injection sites, but only Vancouver's Dr. Peter Centre for the long-term care of AIDS patients has applied to Health Canada for approval of its model.
The centre has been quietly providing supervised injections in a residential facility, a much smaller scale than the InSite facility on the city's Downtown Eastside.
A proposal to open four sites in Montreal is next closest to applying.
It was delayed by Quebec's provincial election last year and is now being evaluated by Quebec's Public Health Minister.
Its proponents are hopeful the proposal will be sent to Health Canada for approval this spring.
Louis Letellier de Saint-Just, a health lawyer, member of the board of the Canadian HIV/AIDS Legal Network and chairman of the Cactus needle exchange, said the Dr. Peter decision will be a bellwether for the Montreal project.
"The worst scenario will be a refusal," Mr. Letellier de Saint-Just said.
He added he wouldn't be surprised at a rejection for Dr. Peter's plan.
"This government does not give any surprises any more. We know what they want and what they don't want, but it would be a disaster. …
"We know it's going to be a battle but I don't want to give them the impression that we're not fighting."
Patricia Daly, head of the Vancouver Coastal Health authority that jointly operates the Dr. Peter facility, is worried that when Bill C-2 becomes law later this year, stringent new rules could make it almost impossible to receive the formal exemption to Canada's Controlled Drugs and Substances Act needed to run such sites.
"The Conservative government has made it very clear that they do not support these kinds of harm-reduction services," Dr. Daly said. "The good news is people in Vancouver support this service."
Dr. Daly's staff filed an "eight-inch thick" application to Health Canada last February so the Dr. Peter model might one day be replicated across the region.
"I could understand that [delay] if we were a brand new facility in a new neighbourhood, but this is something that is supported by the municipal government, the provincial government and health-care providers at St. Paul's Hospital, right next door," Dr. Daly said. "And yet it's taken them a year and they still haven't given us an answer."
A Health Canada spokesperson said the agency would not comment on the ongoing application.
Up to 63 per cent of the Dr. Peter Centre's supervised injection clients have received addiction counselling and about 30 per cent have been referred to withdrawal management or other long-term programs, the centre says.
"Chronically optimistic" advocates such as Ottawa's Rob Boyd say they are watching the Dr. Peter Centre's application closely and want to open sites in their own cities, but the application process is already taking years under the existing laws.
Mr. Boyd is leading Ottawa's campaign for a supervised injection site while directing the Oasis needle exchange at the city's Sandy Hill Community Health Centre. He said he can spend only about six hours a month on an application that is years away as he is too busy running a program that serves about 600 regular users.
Ottawa's mayor and police chief have consistently opposed a supervised injection site in their city, in which Mr. Boyd says 30 people died of overdoses last year.
"You have to be optimistic and at the end of the day it's the right thing to do," Mr. Boyd said. "The default is unsupervised injection and I don't know why anyone would support injection drug use [out] in the community."
In 2013, Toronto's Board of Health asked Ontario to open a supervised-injection site, but the provincial government refused, citing the federal Conservatives' opposition to such harm-reduction practices.
Over the past several years, advocates from Toronto, Edmonton, Ottawa, Victoria and some other cities have met every six weeks as part of a national working group on supervised-injection sites organized by the Canadian Drug Policy Coalition, an organization of harm-reduction NGOs.
During the teleconferences, advocates plan, share data and commiserate as they try to get supervised injection sites up and running in their cities, according to director Donald Macpherson.
Mr. Macpherson said the Dr. Peter Centre application and the forthcoming proposal out of Montreal are backed by public health authorities whose familiarity with consultation processes means both have garnered strong support from the public.
Mr. Macpherson said Health Canada is "dragging its heels" in reviewing the Dr. Peter Centre application and that he "can only surmise that that has to do with political pressure on bureaucracy."
"The Dr. Peter Centre is not rocket science; it's a very straightforward, successful facility."
In the future, Mr. Macpherson said Canada's supervised injection sites will look less like the large and expensive InSite on Vancouver's Downtown Eastside and more like the smaller Dr. Peter Centre model.
"Globally, all of the experience in Europe, Australia and Canada there is really no downside," Mr. Macpherson said. "Injection sites will fade into the background as they have in Europe.
"In Europe, they're just a very small – but important – part of the larger continuum of (harm-reduction) services."
Dr. Daly said her staff plan to file for a one-year renewal of InSite's exemption, which expires in two months.
Editors' Note: An earlier version of this story published in print and online incorrectly stated that Louis Letellier de Saint-Just works for the Canadian HIV/AIDS Legal Network. In fact, he is a board member for that organization but is not on staff. This version has been corrected.