In April 2011 the Lancet published an article written by authors from the British Columbia Centre for Excellence in HIV/AIDS, the UBC Faculty of Medicine, the UBC School of Population and Public Health and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
The title was Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study, by Brandon D L Marshall, M-J Milloy, Evan Wood, Julio S G Montaner, Thomas Kerr was followed by a media release from The University of British Columbia which included:
Researchers compared nearly 300 case reports from the British Columbia Coroners Service documenting all illicit drug overdose deaths in Vancouver between January 1, 2001 and December 31, 2005.
Compared to the 35 per cent reduction in overdose deaths in the immediate vicinity of Insite following its opening in September 2003, overdose deaths in the rest of Vancouver declined only nine per cent over the same period. No overdose deaths have been recorded at Insite since the facility’s opening. The researchers also noted that there was no evidence of significant changes in drug supply or purity during the study period.
“This study provides the first unequivocal scientific evidence of the benefits of supervised injection facilities, and clearly demonstrates that facilities such as Insite are saving lives and playing a vital role in reducing the harms associated with illicit drug use,” says co-author Dr. Julio Montaner, director of the BC-CfE and Chair of AIDS Research at the UBC Faculty of Medicine.
The Abstract can be read here. Insite which opened in September 2003 has also been the subject of more than 30 studies in 15 peer reviewed journals. These have cited a number of benefits including increased access to rehabilitation services, detoxification, reduced syringe litter, reduced public injecting and most importantly reduced needle sharing which serves to reduce blood borne virus spread.
In 2006 the new Conservative government which did not support the initiative threatened to let the site’s legal exemption lapse before the project was complete. On September 1st 2006, Health Minister Tony Clement cited a need for more research as he deferred his decision to extend the site’s legal exemption. On the same day the Government cut all funding for future research. In August 2007 two addicts and the Portland Hotel Society filed suit in the B.C. Supreme Court arguing violation of rights – “security to the person”. What followed was from a legal and human rights perspective remarkable including the May 2008 strike down of sections of the Canadian criminal code on drug trafficking and possession as a breach of the Canadian Charter of Rights and Freedoms.
The struggle between progression and conservatism continued with the federal government appealing this legal advance in human rights. The B.C. Court of Appeal dismissed this in a 2-1 ruling. The government announced a further appeal to the Supreme Court of Canada. There were nine interveners in the Supreme Court Case. Only one supported the stance of the conservative government to close Insite. That group was the socially conservative, anti-women’s rights lobby group REAL Women of Canada.
National vice president of REAL Women…, Gwen Landolt, argued against the Canadian Medical Association and other supporters. She claimed that Insite would allow users to get “worse and worse until they die” and that such facilities “are assisting in the suicide of drug addicts.” The government had to admit it had no credible research to show Insite was not working. There were no valid data to show Insite was not reducing drug related harm. In essence the government and REAL Women of Canada were mounting non evidence based claims.
The Supreme Court of Canada ruled unanimously on September 29th, 2011 to uphold Insite’s exemption from the Controlled Drugs and Substances Act. This allowed the site to stay open indefinitely. The ruling was highly critical of Health Minister Tony Clement’s application of the CDSA to Insite stating it was grossly disproportionate and undermined “the very purposes of the CDSA, which include public health and safety”.
Drug Free Australia’s Bogus Critique
Drug Free Australia (DFA) is a conservative right wing prohibitionist lobby group of loosely affiliated extremists masquerading as a quasi-official body critical of Australia’s illicit drug policy. Regarding Injecting Facilities they have a discredited history (indeed presence) in maintaining the highly flawed opinion piece Case For Closure attacking Sydney’s Medically Supervised Injecting Centre. The Drug Misuse and Trafficking Amendment (MSIC Bill) was passed in October 2010 with considerable support from then Premier Kristina Keneally, The Australia Medical Association and the Royal Australasian College of Physicians. All three along with countless other individuals, MPs and organisations rejected the efforts of Drug Free Australia under the auspices of Secretary Mr. Gary Christian to sabotage over a decade of trial success.
On September 17th 2011, perhaps in a final effort to sway the Supreme Court of Canada (at that time yet to hand down it’s decision) DFA presented a media release claiming to have “exposed major, inexcusable errors” alleging “research fraud and professional misconduct” in the Lancet paper by Marshall et al. They cited an article headed Analysis of the 2010 Lancet study on deaths from overdose in the vicinity of Vancouver’s Insite Supervised Injection Facility published in the Journal of Global Drug Policy and Practice (JGDPP).
The authors were familiar names. Dr. Greg Pike co-author of the Case for Closure, and already profiled here. Dr. Stuart Reece and Dr. Joe Santamaria, also both co-authors of the Case for Closure of the Sydney MSIC. Prohibitionist Robert DuPont, former “White House Drug War Czar” under Richard Nixon and present board member of Drug Free America Foundation and finally Dr Colin Mangham, Director of Research, Drug Prevention Network of Canada. Their coordinator was anti-Harm Reduction campaigner Gary Christian.
In a comprehensive response the Lancet authors note their methodology and data was subjected to extensive scientific peer review and that this independent process “confirmed the appropriateness of the data and methods that we employed”. They further note Mr. Christian’s source has not been subject to peer review nor published in any scientific journal.
Nevertheless this formed the basis of a complaint by “research coordinator”, DFA Secretary Mr. Gary Christian to the University of British Columbia. The media release included:
The international team’s analysis has been sent by the Drug Prevention Network of Canada to the Ethics Committee of the agency which funded the Lancet study with questions regarding research fraud and professional misconduct.
Mark Wainberg, professor of medicine and director of the McGill University AIDS Centre was called upon to independently review the matter. Wainberg reviewed DFA’s analysis, the Lancet paper and the author’s response. He concluded in part:
In my view, the allegations that have been made by ‘Drug Free Australia’ are without merit and are not based on scientific fact. In contrast, it is my view that the work that has been carried out by the team of Thomas Kerr et al is scientifically well-founded and has contributed to reducing the extent of mortality and morbidity in association with the existence of the safer injection facility. . . . The University of British of British Columbia should be proud of the contributions of its faculty members to the important goal of diminishing deaths due to intravenous drug abuse.
The JGDPP analysis and complaint were found to be entirely without merit and the complaint was dismissed.
Drug Free Dishonesty
Along with the Lancet author’s response and the independent review there are a number of elements which render this amateurish attack particularly offensive. As noted above the “analysis” is not peer reviewed nor published in any recognised scientific journal. It was published in the JGDPP which is a collection of non peer reviewed articles and opinion pieces. Described as a “glorified blog” by The Media Awareness Project, the JGDPP is run by DFA’s parent body Drug Free America Foundation (on whose board sits DuPont). It was initially funded by the US Department of Justice which is presently under investigation for corruption. It has an international reputation for hosting articles seeking to sabotage human rights oriented policy initiatives successful in controlling the spread of blood borne viruses. Many authors hold extreme and archaic religious and/or anti-science views.
Essentially the JGDPP piece argues that the 35% reduction in overdose deaths in a delineated area following the opening of Insite and documented in the Lancet by Marshall et al. is flawed. Tactics by which this is done obfuscate context and manipulate the import of data in such a way as to misrepresent it to the reader. By using flawed population analysis and failing to state the nature of deaths across a much larger area it seeks to claim overdose deaths increased. The JGDPP team also suggest the Lancet authors should have dismissed an entire year as irrelevant because doing so decreases the overall decline in mortality. Thus it was, in their minds, only included by Marshall et al. to skew results.
The Lancet authors note the JGDPP report:
[U]ses crude Vital Statistics data, which included all accidental poisonings to define its estimate of overdose deaths, and it did not exclude deaths unlikely to be affected by a supervised injecting facility (e.g., suicides, adverse effects of drugs in therapeutic use). We note that the REAL Women/DPNC (JGDPP) critique seeks to call into question the Lancet paper’s findings using these crude data, and then goes on to argue that the Lancet paper’s findings cannot be relied upon because they use similarly unrefined death counts. We would argue that you cannot have it both ways.
The JGDPP article also fails to admit it used crude death counts and not population-adjusted mortality rates. This fails to account the relevance of death rates in a changing population. The Lancet study used annual population estimates from Statistics Canada to conclude on overdose mortality. Most shocking however was the increase by the JGDPP authors in area consulted by around a factor of 10. The Lancet studied mortality in 41 city blocks. The JGDPP article refers to mortality in a 400 block area. This further obscures the fact that the greatest reduction in overdose is within 4 blocks of Insite and significantly decreases outside that area.
The JGDPP article was written as an analysis for REAL Women of Canada and the Drug Prevention Network of Canada (DPNC). It is demonstrably a collation of highly selective, misleading, out of context and academically discredited material. The “analysis” relies time and again on a 2007 “critique of [the Insite] parent philosophy” written by co-author Dr. Colin Mangham of the DPNC. The DPNC holds a highly partisan irrational anti Harm Reduction position claiming it “leads to terror, degradation and the eventual death of the addict”, refers to supporters of HR as “enablers” and presents a grossly distorted misrepresentation of HR on it’s website.
They are dedicated to:
…advance abstinence-based drug and alcohol treatment and recovery programs, to promoting a healthy lifestyle free of drugs and to opposing legalization of drugs in Canada.
Their Mission Statement freely includes, Lobbying in the media, at the community level and in government for the support of our stated principles. At no point does the DPNC propose to hold to an evidence based approach or accommodate advances in scientific consensus. Not surprisingly the previous 2007 article by Mangham is critical of research which supports harm reduction and Insite. Even less surprisingly it too is published in Journal of Global Drug Policy and Practice.
Along with accusations of fraud, professional misconduct and research errors directed at the Lancet authors, the media release From Gary Christian also expanded on the supposed impact of the work of Marshall et al:
The article was influential in the Canadian Supreme Court hearings of May 12 this year, where the court reserved its decision on whether the Canadian Government is rightfully able to close the facility. The Canadian government has been trying to close Insite since 2006, but has been hampered by court action by harm reduction activists.
This is extraordinary. The JGDPP analysis that has so emboldened Mr. Christian was written for REAL Women of Canada and the DPNC. REAL Women of Canada were interveners in the Supreme Court in favour of the Canadian Government. The JGDPP analysis relied significantly upon material critical of Insite produced by the DPNC in 2007. The same DPNC with a mission statement to lobby community and government. Surely the time for accusations and presentation of evidence was in the Supreme Court itself. Yet the reasons why the government could produce none of this flawed “evidence” are manifestly clear.
The JGDPP piece cites the 2007 critique of Mangham in formulating the claim that changes in policing, “could account for any possible shift in overdose deaths from the vicinity of Insite”, arguing this was intentionally ignored by Marshall et al. Mangham is also cited as refuting Insite as having any impact on public crime or public disorder. Yet the Royal Canadian Mounted Police who had commissioned Mangham’s 2007 report claimed it, “did not meet conventional academic standards”.
Although every injection within Insite is sterile and safe from contraction of blood borne viruses, Christian’s JGDPP analysis further cites Mangham 2007 in arguing:
Added to this [the impact of policing] are the spurious claims by Insite researchers that the facility has impacted HIV and HCV transmission, despite the claim being possible only if ALL injections by those HIV or HCV positive are hosted by Insite, which has rarely been the case.
Unsurprisingly Mangham’s 2007 report was ignored by Canada’s Expert Advisory Committee on Injecting Site in formulating their own report. This doesn’t stop the JGDPP piece from citing data from Canada’s Expert Advisory Committee on Injecting Site that Insite statistically saves only one life per year. It’s argued that “this would not be detectable at the population level. This estimate is backed by the European Monitoring Centre’s methodology and avoids the error of naively assuming overdose rates in the facility match overdose rates in the community.”
At first blush this sounds compelling but is in fact a rogue construct manipulating entirely different methodologies, which yield entirely unrelated data sets, to imply naivety on behalf on Marshall et al. Regardless of what is “detectable at the population level”, neither study is relevant to the other. Citing the European Monitoring Centre’s methodology is simple weasel wording applied to distract the reader from the straw man of “one life per year”.
In truth the “one life per year” comes from person to person intervention in a clinical facility. It actually underscores the safety of the Insite environment in averting dynamics which may predicate a potentially fatal overdose. Community overdose rates considered by Marshall et al. cover 41 blocks surrounding Insite. The Lancet authors seek to quantify the impact of Insite’s presence on these rates.
Canada’s Expert Advisory Committee on Injecting Site is in no way at all dismissive of the “one life per year”. They write plainly [bold mine]:
INSITE staff have successfully intervened in over 336 overdose events since 2006 and no overdose deaths have occurred at the service. Mathematical modelling (see caution about validity below) suggests that INSITE saves about one life a year as a result of intervening in overdose events.
Marshall et al. write in their abstract [bold mine]:
We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city.
Furthermore it is interesting that the EMCDDA 2004 report notes such rooms can be expected to reduce high-risk behaviour beyond the consumption room setting itself and reduce exposure to and transmission of drug-related infectious diseases [p.25]. On public order and crime the same report lists two main objectives of 1.) to reduce public drug use and associated nuisance and 2.) to avoid increases in crime in and around the rooms [p. 61].
It should be noted each of these four points is in dissonance to the position of the JGDPP authors and every point they cite from Mangham 2007. More so, as noted during the Supreme Court Case the Canadian Government and the government’s only supporting intervener REAL Women of Canada, chose not to produce Dr. Mangham’s 2007 report. They effectively admitted they had no evidence to support their case to close Insite. As such it is remarkable Mr. Christian relied so heavily on Mangham to argue there were, “questions regarding research fraud and professional misconduct.”
Mr. Christian’s problem is not that the Canadian Government, “has been hampered by court action by harm reduction activists” since 2006. It is the simple reality that despite having had five years in which to produce convincing evidence in a court of law to close Insite, the Canadian Government has been unable to do so all the way to the Supreme Court of Canada. Apart from criticising Clement for undermining the purpose of the Controlled Drugs and Substances Act the ruling also acknowledged the dysfunctional nature of the prohibitionist mindset, stating:
…the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on Insite’s premises.
Other shonky tactics employed by Christian’s team include intentionally misrepresenting the findings and recommendations of other research. In attacking cost effectiveness of sterile injecting the JGDPP report states:
The 2009 Andresen and Boyd cost-benefit study calculated savings to government from 35 supposed HIV/AIDS transmissions averted by Insite annually, despite the most authoritative international review to date not finding any demonstrated effectiveness of clean needle provision reducing HIV transmission via needle exchanges.
This is a misrepresentation of the cited IOM review. Preventing HIV Infection among Injecting Drug Users in High Risk Countries: An Assessment of the Evidence, states:
The report provides evidence-based recommendations regarding drug dependence treatment, sterile needle and syringe access, and outreach and education. The report urges high-risk countries to take immediate steps to make effective HIV prevention strategies widely available.
Page 2 of the report brief includes [bold mine]:
Avenues for making clean injecting equipment more widely available—and thus reducing drug-related HIV risk—include needle and syringe exchange; the legal and economical sale of needles and syringes through pharmacies, voucher schemes, physician prescription programs, and vending machines; supervised injecting facilities; and disinfection programs….. Multi-component HIV prevention programs that include sterile needle and syringe access are effective in reducing drug related HIV risks such as the sharing of needles and syringes.
Gary Christian also claimed in his media release as part of the allusion that policing, not Insite had caused a reduction in mortality:
These researchers cannot truthfully claim they knew of no policing changes in the immediate area around Insite when some of their number produced an indignant study condemning the changed policing.
Yet in their response the authors indicate that the police initiative referred to ended “within weeks” of Insite opening. It was not ongoing during the study – which is what Christian’s team had falsely suggested. More so if the crackdown was the cause of a reduction in mortality after Insite opened then it was the cause of an increase in overdose deaths in the area prior to Insite opening. Even more crushing for Gary Christian, is that this means the decline in drug related overdose clearly demonstrated in the Lancet occurred because the policing initiative ended.
Perhaps most scurrilous as mentioned above is the suggestion by Gary Christian’s JGDPP team that the Lancet authors included 2001 in their methodology in order to skew results in favour of overdose reductions. The JGDPP report suggests a review from 2002 onwards would show an increase. Yet the Lancet authors had written an earlier report in 2009 showing stable use from 2001 to 2005:
As shown in a figure from that report (below), although the proportion of IDU reporting daily heroin use declined from 1998 to 2001, the proportion of IDU reporting daily heroin injecting remained stable from 2001 to 2005 (i.e., the period considered in our Lancet study).
Whilst this is a look at the most prominent manipulations and misrepresentations authored by Gary Christian’s team a quick reading of the Lancet author’s response – below – reveals a more comprehensive overview. Accusations of careless assessment are put to rest and a read of the original paper shows the lengths gone to in the Discussion to acknowledge other factors that may contribute to a reduction in drug induced mortality. There are also many other absurdities presented in the JGDPP article (such as “recommended reading” and citing a speech by “Christian voice in politics”, Gordon Moyes) that must condemn Christian and his team even further.
Of course like an antivaccination lobbyist Christian has not budged an inch, still insisting he is completely correct and that peer review and science itself is flawed. Now, in the shadow of their complete demolition we can review the hypocrisy and misplaced confidence of Mr. Christian in his ability to scam the public and academics alike.
Activists are never likely to provide objective science and there are dozens of other Insite studies that must now be under a cloud as a result.
Drug Free Australia has never produced any science and peer reviewed research. This shows their inhumane prohibitionist world view as without merit, and data supporting Insite as entirely safe.