Since 2003, Vancouver has been the only city in North America where drug addicts can shoot heroin into their veins at an officially sanctioned injection site.
Now some of the same voices that lobbied for the site are suggesting supervised inhalation rooms for crack addicts, saying such facilities would help connect users with treatment programs and help fight the spread of HIV/AIDS.
The suggestion, made after a study linked smoking crack to increased risk of HIV, will be controversial but is driven by pressing public health concerns, B.C.'s top health official said yesterday. "I think it's the right time once you've got the evidence, to put the evidence out and say, 'Gee guys, we need to talk about this,' " said Perry Kendall, the provincial health officer. "Which is what we had to do with Insite," the safe injection facility.
Mr. Kendall's support is based on a research paper published yesterday in the Canadian Medical Association Journal.
The study found that people who smoke crack cocaine are at increased risk of becoming infected with HIV, but it did not pinpoint the exact mechanisms behind that link. The study cited risk factors including mouth wounds that could make people more vulnerable to infection when engaging in activities such as sharing pipes or oral sex. People who smoke crack cocaine typically use metal or glass pipes that often leave them with chapped lips or sores in and around their mouths.
Having sex or sharing needles with HIV-positive people could also be a factor, the study found.
The study concluded there is an "urgent need" for public health programs aimed at crack cocaine users, including 'safer crack kits' and supervised inhalation rooms.
A safe inhalation site might be a good first step, but only if it's linked to treatment options, said Brian Conway, an associate professor in University of British Columbia's Anesthesiology, Pharmacology and Therapeutics department who has worked extensively with drug users on the Downtown Eastside.
"The biggest bang for our buck will be taking people who are unengaged in care and getting them engaged in care," Dr. Conway said, adding that the wait for addiction programs is from seven to 10 days.
Supporters of "harm-reduction" programs such as Insite and safe inhalation rooms say such facilities can help connect users to health services.
Several cities are already handing out 'safer crack kits' to help stop the spread of HIV and Hepatitis C. Such kits usually include a glass stem with a mouthpiece, lip balm and hand wipes.
The new study looked at 1,048 injection drug users in Vancouver over a nine-year period. Participants were HIV-negative when they enrolled. At the end of the study, 137 people, or 13.1 per cent, had contracted HIV. The proportion of people who smoked crack cocaine daily increased to 39.7 per cent in the final stage of the study from 11.6 per cent in the first of three periods.
Those results led researchers to conclude that use of crack cocaine was one of the strongest risk factors for contracting HIV.
"We've demonstrated that people who report crack cocaine smoking daily are four times more likely to contract HIV than those that don't," said Evan Wood, a researcher at the B.C. Centre for Excellence in HIV/AIDS and one of the authors of the study. "It's a dramatically high rate of HIV in this group."
A supervised inhalation room would operate along the lines of Vancouver's existing supervised injection site. Insite has a smoking room on site, but it has never operated - largely, Dr. Kendall said, over concerns about whether there was enough evidence to support such an approach and how to handle employee health and safety when it comes to second-hand smoke.
With evidence mounting of a link between crack and HIV infection, it's time to get the room up and running, he said.
Any such room would have meet standards set by bylaws and regulations. Vancouver and neighbouring cities have cracked down on public cigarette smoking. Last year, Vancouver implemented a new bylaw that extended indoor smoking bans to outdoor patios.
Insite has been a lightning rod for controversy since it opened in 2003, generating reams of research papers and a running debate between the harm-reduction and the tough-love schools of drug treatment.
The federal government has appealed a 2008 B.C. Supreme Court ruling that gave Insite a constitutional exemption from Canadian drug laws.