Drug Free Australia’s attack on Insite really an attack on individual scientists

A close look at Drug Free Australia’s recent attack on research supporting Vancouver’s Safe Injecting Facility, Insite, suggests a long planned attack on individual authors, not evidence.

Recently I wrote a piece on Drug Free Australia’s selective and misleading use of peer reviewed publications, government reports and pseudoscience to mislead readers with the claim of academic fraud and professional misconduct in the Lancet.

Their target was Insite, Vancouver’s Supervised Injecting Facility. Yet more specifically three authors of the Lancet piece, Evan Wood, Julio S G Montaner and Thomas Kerr have earned the retributive ire of Drug Free Australia’s parent body, Drug Free America Foundation. DFAF’s “division”, the Institute on Global Drug Policy fund the Journal of Global Drug Policy and Practice, which is not a journal but a vehicle for lobbying against progressive drug policy primarily that which targets HIV control. The JGDPP was initially funded by the US Department of Justice, presently under investigation for corruption.

One of the co-authors of the paper was Robert DuPont. Present DFAF board member, past White House Drug czar and former first director of NIDA, DuPont’s history is “impressive” but shamefully controversial. A champion of drug war tactics, the long debunked random drug testing of kids in schools and suppression of individual rights suggest he’d be better suited to the role of a cat-stroking super villain in a Bond movie.

The scale of human rights abuses and the litany of egregious conduct orchestrated by the ultra-conservatives drawn toward DFAF and the morally bankrupt satellite groups they inspire, is impressive indeed. DFAF was founded by Betty Sembler. Betty and husband Mel, both lacking any qualifications founded Straight Incorporated in 1976. Over 15 years this “coercive” rehabilitation programme, based upon the infamous and crime riddled Church of Synanon‘s approach, racked up hundreds of accounts of abuse of clients and their families. Synanon called it a day in 1989, by which time tax evasion, civil suits and attempted murder cases had eventually outshone their claims of Divine Detoxification.

Neither Drug Free America Foundation nor it’s pretend “Institute” on Global Drug Policy is a scientific organisation. The purpose of the IGDP is spelled out on the DFAF website:

The Institute is charged with creating and strengthening international laws that hold drug users and dealers criminally accountable for their actions. It will vigorously promote treaties and agreements that provide clear penalties to individuals who buy, sell or use harmful drugs. […] The institute supports efforts to oppose policies based on the concept of harm reduction.

Over recent years some rather spectacular junk science was produced by Dr. Colin Mangham, (then) president of the Drug Prevention Network of Canada. Whilst harm reduction initiatives save countless lives per year Mangham’s DPNC claims it “leads to terror, degradation and the eventual death of the addict”. Consequently Mangham writes accordingly and publishes in the discredited Journal of Global Drug Policy and Practice. In volume 1, issue 2; Summer 2007, Mangham wrote a critique of Insite’s “parent philosophy”.

In a stunning display of self sabotage he churned through 20 peer reviewed articles from journals including The New England Journal of Medicine, the Lancet and The British Medical Journal. All articles had published positively on Insite’s potential. Primarily Mangham used largely belief, irrelevance, moral outrage and assumption to mount his criticisms. The Royal Canadian Mounted Police (at that time opposed to Insite) had commissioned the review and later dismissed it themselves because it “did not meet conventional academic standards”.

It’s impossible to miss Mangham’s primary evaluation targets on his self-annointed meandering journey to Super Scientific Autonomy. Evan Wood, Julio S G Montaner and Thomas Kerr.

Conservative health minister, Tony Clement, desperate for even a hint of science to uphold the government’s case against Insite seized upon it as validation. In Canada’s National Review of Medicine, September 2007, Clement is quoted as saying to the Canadian Medical Association:

There has been more research done, and some of it has been questioning of the research that has already taken place and questioning of the methodology of those associated with Insite.

The article continued:

But extensive research has shown Insite is successful at reducing crime and overdoses, getting addicts into treatment and saving money.

Asked what research Mr Clement still needs to see in order to make his decision, Erik Waddell, a spokesman for Mr Clement, answers, “To see if Insite is getting people to programs to help them get off drugs.” However, the NEJM study, published June 9, 2006, concluded that Insite increased admissions into detoxification programs and addiction treatment.

The piece, written by Colin Mangham, PhD, argues that the studies carried out by researchers from the BC Centre for Excellence in HIV/AIDS and elsewhere have been flawed and misleading. Questions about the article’s trustworthiness have arisen. Dr Mangham is the president of the Drug Prevention Network of Canada, an organization run by former Conservative MP Randy White, and has previously written commentaries criticizing the philosophy of harm reduction….

Writing in Open Medicine on September 7th, 2007 Thomas Wood noted the unscientific nature and discredited status of Journal of Global Drug Policy and Practice. He further highlighted that the non scientific conservative lobby group Drug Free America Foundation and it’s ill disguised front shop (the so-called Institute on Global Drug Policy) were behind this ambitiously named “new research”. Wood calmly observed:

We stand by the published findings from the evaluation and believe that the limitations of the research are well described in these published reports. We agree with Colin Mangham, however, that there are many instances where media reports go beyond what is described in scientific studies. A colourful example of this is the large amount of media attention given to Mr. Mangham’s recent essay in the Journal of Global Drug Policy and Practice which was funded by the Royal Canadian Mounted Police.

As scientists, we are strongly in favour of scientific debate and academic critique, but we believe what is contained in Mr. Mangham’s essay falls well short of this. The paper is fraught with a host of outright factual inaccuracies and unsubstantiated claims, which we would be happy to list should the readers of Open Medicine wish. We strongly encourage the readers of Open Medicine to read Mr. Mangham’s essay alongside the various reports examining Insite’s impacts and to judge for themselves the state of the science in this area.

Yet Dr. Colin Mangham was beyond saving. None would come to his aid. From mountain top to valley floor, from deep blue sea to desert sand, from darkened ghetto to opulent penthouse from… okay, you get the idea – his demise was complete.

By September 30th, 2007 Wood, Montaner, Kerr and Mark Tyndall had submitted to The Global Journal on Drug Policy, an article questioning the conservative Canadian government’s treatment of the scientific process and evidence. The abstract includes [bold mine]:

Although the recommendations of scientific review bodies have traditionally been free of political interference in Canada, there have recently been growing concerns raised about Canada’s new federal government’s treatment of scientific processes and evidence. This concern is relevant to the scientific evaluation of Canada’s first medically supervised safer injecting facility… […]

This commentary describes what may be a serious breach of international scientific standards relating to the Canadian government’s handling of the SIF’s scientific evaluation, and the circumstances which eventually led to a moratorium on SIF trials in other Canadian cities.

The genesis of such striking criticism was the government’s observance of a single cancer in illicit drug policy. One that had metastasised into Colin Mangham’s Drug Prevention Network of Canada, DFAF’s unscientific Institute of Global Drug Policy and the dumping ground for all conspiracy pieces by those opposed to progressive HIV control and human rights observance, the Journal of Global Drug Policy and Practice. The Australian arm of DFAF is Drug Free Australia.

Added to this was a petition signed by over 130 physicians and scientists. Released the day after Clement’s speech noted above, it condemned the government’s “potentially deadly” misrepresentation of evidence for harm reduction programs. This misrepresentation encompassed “the overwhelmingly positive evidence” of Vancouver’s Insite safe-injection site.

In September 2008 The Lancet Infectious Diseases, published Illicit Drug Addiction, Infectious Disease Spread and the need for an evidence based response, by Wood, Montaner and Kerr. It included:

To our knowledge, this is the first time a lobby group such as the Drug Free America Foundation has created for itself a venue for the dissemination of opinion essays, which to the untrained eye could easily be mistaken for a scientific journal

There is no doubt that in just a couple of years, Montaner, Wood and Kerr continually exposed and dismantled a politically driven, pseudoscientific ideology and it’s masters simply by addressing the evidence at hand. One could be forgiven for thinking these chaps might be upsetting a certain group of fundamentalists.

By this time a suit had been filed with the BC Supreme Court arguing closure of Insite would violate the Charter right of Insite patrons regarding “security of the person.” As late as May 2011 the federal government was still claiming indecision of whether to keep Insite open or not. As this was in contrast to Clement’s previous statements everybody had heard enough from the government. On May 12th the Supreme Court reserved it’s decision on whether the government could close Insite or not. On September 29th, 2011 the Canadian Supreme Court ruled unanimously to uphold Insite’s exemption from the Controlled Drugs and Substances Act, allowing indefinite operation.

A win for human rights, humane disposition and indeed for evidence based public health.

Almost certainly planning revenge for months prior was a team under Drug Free Australia’s Secretary, Gary Christian. Consisting of three Aussies of biblical repute: Joe Santamaria, Stuart Reece and Gregory Pike. Also included was present DFAF board member yet past White House Drug czar and former first director of NIDA, Robert DuPont. Finally, none other than one disgraced PhD holder, Colin Mangham.

The Lancet reportReduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study published in April 2011 was compelling evidence on reduced overdoses in a vicinity around Insite, and accepted by the Supreme Court. The problem for DFAF was that three of the five authors were Kerr, Montaner and Wood. The same three who had demolished so much of the amateur ideologists and DFAF’s non scientific lobby groups.

On September 13th hoping to besmirch the reputations of these men, the team struck. They released a collection of misleading claims cobbled together in a free range “analysis” enveloped in thunderously accusatory tone. It was designed to rebuke harm reduction in general and injecting facilities specifically. In this light it inexplicably republished many of Mangham’s already debunked criticisms as if new, misrepresented existing reputable studies by comparing unrelated data sets and publishing outright falsehoods.

If we dig up Clement referring to Mangham, from the National Review of Medicine September 2007, we can almost hear the echo:

There has been more research done, and some of it has been questioning of the research that has already taken place and questioning of the methodology of those associated with Insite

Fortunately history did not repeat. This re-choreographed material has been addressed more than once and found to be entirely baseless on each occasion. Despite the pollution of the material by Colin Mangham’s unprofessional accounts it becomes stranger when we note the “analysis” was conducted for Mangham’s Drug Prevention Network of Canada and REAL Women of Canada (the only supporting interveners for the government during the Supreme Court hearing).

Predictably published in the DFAF funded opinion rag Journal of Global Drug Policy and Practice, it’s accompanying media release included:

Three Australian doctors are part of an international team which has exposed major, inexcusable errors in a highly influential 2011 Lancet study on Vancouver’s Insite injecting facility, errors which nullify the study’s claim that it has demonstrably reduced overdoses in its immediate surrounding area.  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.

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.

A full two more paragraphs are spent attacking the individual researchers for acting dishonestly, much of which relies on the already debunked material from Mangham 2007. Using bitterly crude figures to inflate “overdose” deaths – including suicides and homicides – they maintain the authors “knew” they were acting dishonestly. They challenge the findings by increasing the sample area by a factor of 10, and hold this against the original sample area.

Christian’s team selectively quote the Lancet authors earlier work on displacement of users from the area due to an increase in policing. This would be a splendid point were it not that “this policing initiative ended within weeks of Insite’s opening and was not ongoing throughout the study period”. This claim was also a resurrection of Mangham’s still unpublished and disgraced 2007 academic corpse. The vicious “media release” finished:

Drug Free Australia’s Research Coordinator, Gary Christian, said, “…. Inexplicable errors and memory lapses is the price the Canadian government has paid for entrusting injecting facility lobbyists with its scientific evaluation. 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.”

A complaint was lodged with the University of British Columbia by Mr. Christian. This and the JGDPP piece were independently reviewed and found to be “without merit”.

Yet so many questions arise as to why this apparently devastating material was not presented in court. When I first asked Mr. Christian on December 2nd he took a superior tone claiming that they could not because they did not have it available until September 2011. “It would have been a good point but for you not checking your facts”, he replied. Let’s review these facts I supposedly failed to check.

On June 8th, 2011, the (new) President for Colin Mangham’s Drug Prevention Network of Canada, Gwendolyn Landolt insisted that data supporting Insite is flawed. In an extraordinary claim (for June) she asserted in a letter to Canada’s National Post that OD’s had actually increased around Insite in most years since it had opened and thus, Thomas Kerr was in error for accusing DPNC as presenting misinformation (as he had earlier done):

Mr. Kerr tried to discredit a report from the B.C. government — which stated that since the site opened, the area has seen an increase in drug-induced deaths every year — by claiming that it included deaths unrelated to drug use

I say! That claim seems to be lifted straight from Christian’s September debacle. The one they didn’t have… until, er… September. And what do we read on page 2 of Christian’s piece about “a report from the B.C. government”, also mentioned above?

The claims of this article are very curious from the outset, simply because a review of the statistics by the British Columbia Coroner’s Service, found at clearly indicates the contrary – since Insite commenced operations on 21 September 2003 illicit drug deaths have very clearly and unmistakably increased, not decreased.

Okay, the same claim. So they had access to this data 2 1/2 years before the Supreme Court sitting in May 2011. Every other accusation – the impact of policing, the supply of drugs, criticisms from Mangham go back to 2007. Other papers and studies used are also well before 2011. That the president of the Drug Prevention Network of Canada is shooting off unpublished material in response to a May 30th statement by Kerr suggests they were keeping their powder dry.

I put this to Mr. Christian on the same day he dismissed my poor fact checking (December 2nd). He replied on December 10th as follows:

I have received an e-mail back from Gwen Landolt of Real Women of Canada explaining that Colin Mangham’s work was not admissable to the Supreme Court because it was not available for lower court hearing. The truth, Paul, is that there were court-imposed limitations on evidence which have nothing to do with your fanciful fabrications here.

Okay. So the material was available (despite his earlier claims it wasn’t), but could not be submitted due to “court-imposed limitations on evidence”. My “inability to check facts” had disappeared in a puff of reality, but was now replaced with my “fanciful fabrications”. Oh dear!

Of course before the Court in May, the government was armed with the figures mentioned, but had stated it had “no evidence” to submit. So, a day later on December 11th, 2011 I replied in part to Mr. Christian:

The time to strike was in the Supreme Court. Exactly why information from 2007 (Mangham) and 2008 (BC report on OD’s) was not admissible for lower court hearing in 2011 is a question best answered by your colleagues, Mangham and Landolt. If there is a genuine technical reason I would be grateful if you could provide it.

Otherwise it must remain possible, indeed probable, that it was excluded due to a.) the paucity of evidence presented by Mangham in attempting to debunk 20 peer reviewed studies from esteemed journals, and b.) that the BC report on OD’s was irrelevant as a variable effecting the efficacy of Insite and thus the SC sitting itself.

If so, this renders Landolt’s comments to the media and your own use of both sources impotent.

Failing this, you must explain… exactly why it was unavailable given 4 and 3 years respectively to craft an effective rebuttal of Insite’s success with these figures.

What were those “court imposed limitations” and why were they not mentioned in your article or your media release which explicitly referred to the [Supreme Court] decision as influenced by the Lancet article and “harm reduction activists”?

As one may expect those points have never been addressed. No-one is any more the wiser as to why this apparently cutting edge demolition of the court accepted Lancet article, was not itself either in total or in substance, presented to the Supreme Court. Are we to believe an ambiguous and unmentioned “court imposed limitation” prevented the exposing of “research fraud and professional misconduct” by five authors in one of the world’s most prestigious journals, the Lancet? That these supposed academic crimes were overlooked by the Supreme Court of Canada, as they examined the material in question itself?

Or shall we accept the demonstrable trend and tone exercised throughout the ideological attempts to sabotage Insite, is now manifestly clear as an attempt to smear researchers and their work? As the media release claimed, “dozens of other Insite studies that must now be under a cloud as a result”.

The anti-drug brigade may be cruel but they are not stupid. I point this out to Mr. Christian very clearly above, and still await a cogent reply. An academic mirage supposedly good enough to undermine the work of five authors. But not offered in objection to their work. What then was it’s purpose?

It was clear any such opinion from known offenders would have no bearing against over 30 papers in 15 peer reviewed journals. The singular attack upon Kerr, Wood and Montaner is striking. Christian has never answered my queries, preferring to accuse me of “imaginations and suppositions” without facts. Exactly why this argument was not published anywhere until after the Supreme Court hearing has never been made clear.

Why it was not raised by DPNC or REAL Women of Canada (both for whom the final “analysis” was supposedly written) in court is unknown. “No evidence”, was the official position.

Yet Gary Christian gives the game away himself. On November 30th, 2011 I had written in response to his refusal to accept his ploy was found to be “without merit”:

You write as if Montaner and Kerr are under scrutiny. You had your chance. It and the complaint have been found to be without foundation.

He replied on December 19th suggesting conflicts of interest assumed on his part override the independent analysis of his attack. He offered two mundane sources and extraordinarily suggests intentional favouritism on the part of the University of British Columbia and independent reviewer, Dr. Mark Wainberg toward the Lancet authors:

Of course our complaint to the University of British Columbia was not progressed because Dr Mark Wainberg absolved Dr Montaner, Dr Kerr and Dr Wood of any errors in their Lancet article, claiming that it was exemplary science.

However, if you look at the relationship between Wainberg and Montaner, I think that you will find that the relationship breaches the most liberal guidelines in the corporate or political world as to who is qualified to conduct an independent inquiry. […]

Now tell me that the University of Britush Columbia’s ‘Independent Advice’ was absolutely according to the common understanding of independence.

More accusations of corruption. More suggestion of conspiracies. More of the same junk.

What were these devastating pieces of insight? At a meeting of the International AIDS society, 2009 Julio Montaner congratulates, “my friend and colleague, the esteemed Dr Mark Wainberg” on getting the conference to Durban in his capacity as IAS president. The other is a humdrum op-ed piece written with Stephen Lewis on urging the Canadian government to ensure HIV/AIDS therapies remain central topics.

To this day Gary Christian remains unapologetic and impervious to volumes of criticism and questions generated by his single opinion piece. There has been no apology, no explanation nor any correction of demonstrable falsehoods.

Attacks on Evan Wood, Julio S G Montaner and Thomas Kerr however, continue apace.

The “drug free” ideology is as free from compassion and evidence as it ever was.

Drug Free Australia manipulate, misrepresent data to discredit Insite

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.

Background

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 area in green is that studied by the Lancet authors showing a 35% reduction in overdose mortality. The area in red is that used by the JGDPP authors to misrepresent the Lancet finding.

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).

Figure showing that daily heroin use from 2001 to 2005 remained stable

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.