Inconvenient evidence on injection sites

Ontario Premier Doug Ford’s war with the elites has several fronts. He’s battling teachers on sex ed, environmentalists and economists on carbon pricing, transit boffins on light rail and most of the medical community on safe-injection sites. There’s little evidence Ford gives half a fig about sex ed, personally. But his aversion to “job-killing carbon taxes,” “streetcars” (as he calls any form of surface rail) and helping opioid addicts shoot up safely seems to be immovable.

“I believe in supporting people, getting them help,” he said on the campaign trail in April. “I ask anyone out there: if your son, daughter or loved one ever had an addiction, would you want them to go in a little area and do more drugs?”

Indeed, that’s exactly what a lot of terrified parents want: a “little area” in a community health centre under a nurse’s care, rather than a “little area” between the garbage and recycling bins out back of a convenience store.

Not Ford, though. “I’m dead against that,” he said. His government installed a moratorium on new safeinjection sites.

Health Minister Christine Elliott promises to consult experts and review all the evidence before deciding what comes next. Her opponents say the evidence is overwhelmingly in these facilities’ favour. And it’s true: there’s vastly more published research in favour of safe-injection sites than against. But a new study by researchers at the University of South Wales, published in the International Journal of Drug Policy, throws a bit of cold water into the mix.

The meta-analysis — i.e., a study of other studies — found safe-injection sites correlated with a “significant” drop in drug crime in the area of the facilities; but also with “a significant unfavourable result in relation to problematic heroin use or injection.” The researchers found safe-injection sites provided no significant effect at all on sharing syringes or, crucially, on overdose deaths.

The methodology is in dispute. The researchers excluded 32 of 40 studies they considered for lack of complete data or control groups. The authors admit it’s a small sample. Furthermore, they note, “it was not possible to test whether there were variations in outcomes by relevant factors such as program design, cohort composition, or demographic factors such as gender and age.”

But this might be the most rigorous analysis yet conducted. “If you impose even a modest methodological bar, and then (supportive studies’) effects go away, to me that’s worrisome,” Stanford health policy professor Keith Humphreys told Vox.

And anyway, this is politics, not science. Every politician claiming to be looking for evidence is almost certainly, first and foremost, looking for evidence to support her existing policy preference (which in Elliott’s case, to be fair, is unclear). And research aside, there’s no question Toronto’s experience with safe-injection sites has not lived up to their billing. They were supposed to reduce the number of needles and garbage and public drug use; in Moss Park, especially, many otherwise supportive residents will tell you the opposite has occurred in spades.

That’s not just anecdote. In June, city staff announced they would need $1 million extra a year for more needle-and-garbage removal and added security in Allan Gardens and Moss Park. Even area city councillor Kristyn Wong-Tam, darling of the left, supports a moratorium on other facilities in the area, citing “a dramatic increase of criminal activity, assault and theft in the neighbourhood.”

There are lots of potential explanations for this that don’t impugn the idea of supervised injection sites. There is evidence that safe-injection site clients are more likely than other opioid users to be homeless and in general to be “socially marginal and have higher-risk drug-use patterns,” as the study’s authors put it. No Toronto facility is open past midnight. If you draw such people to a given area, then shut the doors overnight for 16 hours, you can easily see how it goes wrong.

The idea that safe-injection sites might not actually reduce overdoses is a more existential problem. But it doesn’t change the basic case for the facilities: it’s better someone shoot up under medical supervision than not. And since only a tiny fraction of fatal overdoses occur at the facilities, which serve only a tiny fraction of opioid users, it could just as easily be an argument to expand service.

One inclined to oppose safe-injection sites could conclude, however, that the facilities are actually facilitating more drug use, and thus more overdose deaths. And the premier might be so inclined, I’m afraid.

The good news for harmreduction proponents is that this genie might not be re-bottlable. Toronto Mayor John Tory, a former skeptic, is now firmly behind safeinjection sites — and no friend of the premier’s. Even as official safe-injection sites have opened, police in Toronto haven’t just turned a blind eye to unsanctioned “pop-up” facilities; they have praised their organizers’ “absolute professionalism.”

If it’s going to happen anyway, one might argue, you might as well make it as safe and warm and sterile as possible. But then, that’s exactly the calculation Ford rejects in the first place.