Hubbry Logo
InsiteInsiteMain
Open search
Insite
Community hub
Insite
logo
7 pages, 0 posts
0 subscribers
Be the first to start a discussion here.
Be the first to start a discussion here.
Contribute something
Insite
Insite
Insite
View on Wikipedia
from Wikipedia

Insite is a supervised drug injection site in the Downtown Eastside (DTES) neighbourhood of Vancouver, British Columbia, Canada[1] The DTES had 4,700 chronic drug users in 2000 and has been considered to be the centre of an "injection drug epidemic". The site provides a supervised and health-focused location for injection drug use, primarily heroin.[2][3] The clinic does not supply any drugs.[4] Medical staff are present to provide addiction treatment, mental health assistance, and first aid in the event of an overdose or wound. In 2017, the site recorded 175,464 visits (an average of 480 injection room visits per day) by 7,301 unique users; 2,151 overdoses occurred with no fatalities, due to intervention by medical staff.[5] The site also offers a free checking service so clients can check their substances for fentanyl and carfentanil. Health Canada has provided $500,000 per year to operate the site, and the BC Ministry of Health contributed $1,200,000 to renovate the site and cover operating costs. Insite also serves as a resource for those seeking to use a harm reduction approach for people who inject drugs around the world. In recent months and years, delegations from a number of countries are on record touring the facility, including various U.S. states, Colombia and Brazil.[6] 95% of drug users who use Insite also inject on the street according to a British Columbia health official.[7]

Key Information

Operation

[edit]
Insite in 2008

Insite is operated in tandem by Vancouver Coastal Health and the Portland Hotel Society. Between September 2003 and July 2008, the site operated under a special exemption of Section 56 of the Controlled Drugs and Substances Act, granted by the Liberal government via Health Canada.[8] It is the first safe consumption site in North America.[1] The site was slated to close on September 12, 2006, as the exemption was for a three-year pilot project.[9] The Conservative minority government granted a temporary extension,[10] then added another six-month extension that was to end in mid-2008.[11] A constitutional challenge was heard by the Supreme Court of British Columbia to keep Insite open after Federal Health Minister Tony Clement refused to renew the exemption beyond July 2008. The court ruled that laws prohibiting possession and trafficking of drugs were unconstitutional because they denied drug users access to Insite's health services. Justice Ian Pitfield gave Ottawa until 30 June 2009 to amend the Controlled Drugs and Substances Act and bring it in line with the constitutional principle of fundamental justice (section seven of the Canadian Charter).[12] The House of Commons did not amend the law meaning Insite currently operates under a constitutional exception to the Controlled Drugs and Substances Act.[13]

Research

[edit]

When founded, Insite acquired legal exemption under the condition that its impacts be thoroughly evaluated.[14] According to the evaluation report, the site has been studied in over 30 studies,[15] published in 15 peer-reviewed journals.[16] The research indicates an array of benefits, including reductions in public injecting and syringe sharing and increases in the use of detoxification services and addiction treatment among patients. In addition, studies assessing the potential harms of the site have not observed any adverse effects.[15][17] Preliminary observations published in 2004 in the journal Harm Reduction indicate that the site successfully attracted injecting drug users and thus decreased public drug use. However, the researchers cautioned that a full assessment of the site would take several years.[14]

Additional research in the Canadian Medical Association Journal suggests that the site has reduced public injections, neighbourhood litter, and needle sharing.[18] Two studies in the journal Addiction and in the New England Journal of Medicine indicate that patients at the site have increased their use of detoxification services and long-term addiction treatment.[19][20] Furthermore, research in The Lancet indicates that the site substantially reduces the sharing of syringes.[21] A study in the journal Substance Abuse Treatment, Prevention, and Policy revealed that local police facilitate use of Insite, especially among high-risk users. The researchers concluded that the site "provides an opportunity to... resolve some of the existing tensions between public order and health initiatives."[22]

A 2008 cost-benefit analysis of the site in the Canadian Medical Association Journal observed net-savings of $18 million and an increase of 1175 life-years over ten years.[23] Another cost-benefit analysis published in the International Journal of Drug Policy in 2010 determined that the site prevents 35 cases of HIV and about three deaths per year, indicating a yearly net-societal benefit of more than $6 million.[24]

An editorial in the Canadian Medical Association Journal noted that after three years of research "a remarkable consensus that the facility reduces harm to users and the public developed among scientists, criminologists, and even the Vancouver Police Department."[16]

In 2011, the Lancet published a study by a team of researchers from the University of British Columbia (UBC), claiming 35% decreases in overdose deaths around Insite due to its presence. In the next issue of the scientific journal, a response was published led by Gary Christian, the research director of Drug Free Australia, that claimed that any decreases in overdose mortality can be sufficiently explained by drug user displacement due to a police crackdown in the area. They claimed that an increase of 48–66 police in 2003 were the cause of any reductions in overdoses.[25] The original study's authors replied in the same issue, noting that the police crackdown cited actually ended a few weeks after the start of the Insite project and, therefore, decreases can't be accredited to increased policing.[26]

Reception

[edit]
People crowd the sidewalk during a fundraiser for Insite in 2008

Letters of support and surveys show that health professionals, local police, the local community and the general public have positive or neutral views of INSITE services and the majority wish to see the service continue.

— Final Report of the Expert Advisory Committee for Tony Clement[27]

Insite enjoys strong local support.[28] While Insite is well liked throughout British Columbia, its popularity is highest inside Vancouver, where some 76% of residents expressed support for the facility.[27] Furthermore, according to a 2007 national survey by Mustel Group, some 63% of Canadians believe the federal government should renew the Insite's mandate while 27% oppose. Support is lowest among Conservatives, only half of whom believe the site should continue operating.[27]

The site drew criticism from the Bush administration; the director of the White House Office of National Drug Control Policy called Insite "state-sponsored suicide" on its opening.[29] In 2006, the Canadian Police Association voted unanimously to encourage the federal government to stop funding Insite and instead invest in a national drug strategy.[30] Moreover, Federal Health Minister Tony Clement branded Insite an "abomination," telling the Vancouver Sun that "allowing and/or encouraging people to inject heroin into their veins is not harm reduction... it is a form of harm addition."[28]

The Royal Canadian Mounted Police (RCMP) has also criticized Insite. This is despite a report commissioned by the RCMP and conducted by two criminologists that concluded in favour of the injection site.[30] The RCMP in British Columbia had agreed to announce their support for Insite in 2009 at a joint news conference with the BC Centre for Excellence in HIV/AIDS; they planned to note "an extensive body of Canadian and international peer-reviewed research reporting the benefits of supervised injection sites and no objective peer-reviewed studies demonstrating harms", and they were to admit that reports commissioned by the RCMP criticizing Insite "did not meet conventional academic standards." However, the RCMP in British Columbia were ordered by headquarters in Ottawa to cancel the news conference days before the event.[31]

The most significant published criticism has been an article by Colin Mangham, the director of research for the Drug Prevention Network of Canada, in the online-only Journal of Global Drug Policy and Practice (JGDPP), which is said to be "posing as open-access, peer-reviewed scientific journal"[28][32][33] In the article Mangham claims that "the published evaluations and especially reports in the popular media overstate findings, downplay or ignore negative findings, report meaningless findings and overall, give an impression the facility is successful, when in fact the research clearly shows a lack of program impact and success."[34] He also claimed that interviews with area treatment centres revealed no referrals from Insite, and that police presence was deliberately bolstered in the area.[34] Based on this article, Tony Clement told an August 2007 meeting of the Canadian Medical Association that his belief that Insite should close had been reaffirmed. Clement stated that "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."[32] The Journal of Global Drug Policy and Practice that Clement was referring to is run by the Drug Free America Foundation, and received much of its initial funding in a $1.5 million grant from a U.S. Department of Justice agency now under investigation for corruption.[28]

Mangham's article has been questioned because it dismisses more than 20 peer-reviewed studies published in reputable medical journals such as The Lancet, the New England Journal of Medicine, and the British Medical Journal, all of which indicate that Insite has a positive effect.[35] The Journal of Global Drug Policy and Practice (JGDPP) article, which was commissioned and financed by the RCMP, drew further criticism in the journal Open Medicine, where a commentary described it as being "fraught with a host of outright factual inaccuracies and unsubstantiated claims."[36] More than 130 scientists signed a petition endorsing the commentary, which also criticized the government's evaluation of Insite as distortive and politicized.[32] Another commentary in the International Journal of Drug Policy characterized the government's evaluation as "what may be a serious breach of international scientific standards".[37]

In answer to an op-ed in National Post by Thomas Kerr, one of the co-authors of the Lancet study, the President for Drug Prevention Network of Canada, Gwendolyn Landolt, maintained her organization's view that the research on Insite is flawed. She said that much of the research on Insite was done by scientists who had lobbied for the clinic's establishment and that they consequently lacked objectivity. She further suggested that these researchers conspire with the editors of academic journals so that their papers are reviewed by referees that supports harm reduction. Gwendolyn Landolt also maintained that data shows that deaths from drug overdoses have actually increased in the vicinity of Insite most years since its inception, contrary to the point made by the allegedly biased Thomas Kerr in his preceding commentary.[38][39] The next day the Provincial Health Officer Dr. Perry Kendall said he had never heard of the data Ms. Landolt refers to and confirmed Thomas Kerr's assertion that death from drug overdoses have indeed declined in the preceding years – especially so in the vicinity of Insite.[40]

Later in 2011 Drug Free Australia sent a complaint to the Vice President of UBC, raising concerns of the scientific integrity of the studies authors. In reviewing the matter, Mark Wainberg of McGill University found that "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."[41]

The campaign to launch Insite is profiled in Nettie Wild's documentary film FIX: The Story of an Addicted City.[42]

[edit]

While the Liberal government allowed Insite to open, between 2006 and 2015 its fate had been the responsibility of the Conservative government, which was not as supportive of it. Former Conservative Prime Minister Stephen Harper voiced opposition to the injection site in the past, saying, "We as a government will not use taxpayers' money to fund drug use."[43] In mid-July 2006, Conservative Member of Parliament David Fletcher stated that the government would let Insite's special exemption lapse before deciding whether to continue the project.[44] The following week a spokesman for Tony Clement, the Minister of Health, refuted that, saying that a decision had not been made yet.[44] During the XVI International AIDS Conference, held in Toronto, two high-ranking Liberal MPs (Bill Graham and Keith Martin) put their support behind the centre, and criticized the Conservative government for delaying their decision.[43] Insite supporters also demonstrated in Toronto during the conference, prompting the government to further delay any announcement, citing the week's "politicized" nature.[43]

On September 1, 2006, Federal Health Minister Tony Clement deferred the decision of whether to extend the exemption for the site, citing a need for more research.[30] However, on the same day the government cut all funding for future research, amounting to $1.5 million in lost research money.[45] On August 13, 2007, the Portland Hotel Society and two clients of the facility filed suit in the BC Supreme Court to keep the centre open, arguing that its closure would be a violation of the Charter right of Insite users to "security of the person."[46] On October 4, 2007, during the announcement of its $64-million drug strategy, the Conservative government announced that Insite will be granted another six-month extension, allowing it to operate until June 30, 2008.[47] In 2008 Minister Clement explained his position during a House of Commons debate period:

. . . (t)he expert advisory committee was very clear. It found that only 3% of those who attend Insite actually get referred to treatment and that only 10% of those who use Insite use it for all their injections. The expert advisory committee insisted that Insite only saved one life, and that life is important but I want to save more than one life. I want to save hundreds of lives around the downtown eastside, which is why we are focused on treatment and on professionals. Not one life should be lost.

— [48]

Mr. Clement's stance is based in part upon findings in the Journal of Global Drug Policy and Practice, a fringe science journal.[49]

In May 2008, the B.C. Supreme Court struck down sections of the Canadian Criminal Code prohibiting drug trafficking and possession, ruling that they contravened the Canadian Charter of Rights and Freedoms. While this ruling does not take effect until next year, Justice Ian Pitfield also granted Insite an immediate exemption to federal drug laws, giving it legal grounds to continue operating.[50] Several days later the federal government announced plans to appeal the decision to the B.C. Court of Appeal.[51] On 15 January 2010, the B.C. Court of Appeal dismissed the federal government's appeal in a 2–1 ruling.[52] Three weeks later the federal government announced that it would appeal to the Supreme Court of Canada.[53] On February 10, some 150 people protested the federal government's decision to further appeal.[54] The protesters barred Prime Minister Harper from attending a dress rehearsal for the Vancouver Chinatown Spring Festival Celebration.[55] On February 12, The Canadian Union of Public Employees sent an open letter to Harper, urging him to accept the ruling of the lower courts and allow Insite to remain open.[56]

Of nine interveners in the Supreme Court case, one supported the Conservative government's case to close the injection site: REAL Women of Canada, a social conservative organization.[57] The other eight, including the Canadian Medical Association argued against the case for closure of the facility.[57] The REAL Woman of Canada group argued that the site would discourage drug users from ceasing their habit, and that they would get "worse and worse until they die" while their families and communities suffered.[57]

In May 2011 a lawyer for the Federal government told the Supreme Court that the government had not decided whether to continue or end support for Insite, contrary to previous statements by Minister of Health Tony Clement; that statement was derided in court as disingenuous by Joseph Arvay, a lawyer for PHS Community Services Society.[58]

On September 29, 2011, the Supreme Court of Canada ruled unanimously in Canada (AG) v PHS Community Services Society that Clement's decision to withdraw Insite's exemption under the Controlled Drugs and Substances Act was "arbitrary, undermining the very purposes of the CDSA, which include public health and safety. It is also grossly disproportionate: 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." The Court ordered Clement to grant an exemption to Insite forthwith, allowing the facility to stay open indefinitely.[59][60]

After the Supreme Court decision in 2011, the ruling majority Conservative party tabled a bill titled "The Respect for Communities Act", which would create a federal regulatory framework for supervised injection sites such as Insite. Bill C-65 includes provision for certification and inspections. It gives the federal Minister of Health sole authority for exemptions to drug laws, but would require support letters from provincial health and public safety ministers before a site can be licensed.[61] Bill C-65 died with prorogation but its replacement, Bill C-2, was one of the first pieces of legislation tabled when the House resumed in Fall 2013. Bill C-2 is nearly identical to Bill C-65 but is slated to be considered by the Standing Committee on Public Safety, rather than the Standing Committee on Health.[62] Once this legislation passes, Insite will have to meet new requirements in order to continue operating, and it will have to report on how the facility has affected local crime rates, and both public and individual health.[63]

References

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Insite

View on Grokipedia
from Grokipedia
Insite is a supervised consumption facility in Vancouver's neighborhood, where individuals inject or otherwise consume pre-obtained illicit substances under the direct observation of trained medical staff equipped to respond to overdoses and other emergencies. Established in 2003 through a federal exemption under Canada's , it marked North America's inaugural legally sanctioned site of this nature, operated jointly by and the Portland Hotel Society to address high rates of injection use, overdose fatalities, and infectious disease transmission in the area. The facility has facilitated over three million supervised consumptions without recording a single on-site overdose death, alongside services connecting users to addiction treatment, , and housing support. Peer-reviewed cohort studies and modeling analyses attribute to Insite reductions in local overdose mortality by up to 35 percent relative to broader trends, lower incidence of and C infections through sterile equipment provision and reduced , and enhanced uptake of and programs, with no observed uptick in overall drug consumption, public injecting, or neighborhood crime rates. Insite's operations have sparked ongoing debate, including federal legal attempts to shutter it on grounds of promoting illegal drug activity, which were overturned by the in 2011 for infringing on users' rights to life and security; critics have questioned its long-term efficacy in curbing amid persistent community disorder, though longitudinal data consistently refute claims of neighborhood deterioration or failure to avert harms.

History and Background

Origins in Vancouver's Opioid Crisis

Vancouver's (DTES), a low-income neighborhood historically marked by and concentrated , experienced a severe escalation in illicit drug use during the 1980s and 1990s, exacerbated by an influx of affordable and policies that displaced indoor sex work and drug activities to public streets. By the early 1990s, injection became entrenched among an estimated 5,000 active users in the area, many facing intersecting vulnerabilities including and mental illness stemming from deinstitutionalization without adequate community support. This environment fostered widespread , as users often injected in cramped, unhygienic public spaces like alleys, prioritizing speed to evade enforcement over hygiene or safety. The resultant outbreak among injectors was among the most rapid outside , with seroprevalence reaching 30-40% by the late 1990s, translating to over 1,500 in the DTES alone by 2003. Despite the introduction of needle exchange programs in 1988, transmission surged due to factors including the rapid, frequent injecting driven by cocaine-heroin mixtures, which increased sharing episodes, and disruptions from aggressive policing that scattered users and limited access to clean equipment. Unsupervised public injection inherently amplified risks, as isolated or rushed acts precluded safe disposal or immediate medical intervention, perpetuating cycles of through contaminated needles reused in the absence of viable alternatives. Concurrently, illicit deaths in climbed, averaging around 250 annually in the and stabilizing near 200 in the early , with many occurring in the DTES amid visible disorder. Prior interventions, centered on and rudimentary like needle distribution, curbed some HIV transmission post-1997 public health emergency declaration but failed to address rising fatalities or public injecting's chaos, as prohibition-driven black-market variability in potency led to unpredictable dosing without bystander reversal capabilities. These shortcomings underscored causal realities: enforcement alone displaced rather than resolved use, while fragmented services overlooked the need for supervised environments to interrupt immediate harms from clandestine consumption.

Establishment and Early Challenges (2003–2004)

Insite opened on September 21, 2003, as North America's first legally sanctioned supervised injection facility, located in Vancouver's neighborhood. The facility operated under a temporary exemption granted by on September 13, 2003, pursuant to Section 56 of the , which allowed exemption from certain drug possession and trafficking provisions for a three-year pilot period. Funding came from the Authority, a provincial body, which supported renovations to an existing building managed by the Portland Hotel Society to include injection rooms alongside detox beds. Initial operations involved users bringing and injecting their own substances under direct supervision by nurses and staff, with immediate interventions such as oxygen administration or for overdoses occurring on-site. Visits began modestly but averaged over 500 injections per day by April 2004, primarily among chronic injection drug users in the area, many of whom were long-term injectors facing high overdose risks. Procedural adaptations included extended hours from 10 a.m. to 4 a.m. daily to accommodate user patterns and integration of basic referrals, though logistical hurdles arose in managing high volumes and ensuring sterile supply without enabling disorder. The establishment faced immediate pushback, including from federal Conservative politicians who argued it would normalize illegal drug use and undermine efforts, as well as from local businesses concerned that the site would draw more users to the area and exacerbate visible injection and discard issues. These challenges required ongoing negotiations with authorities to maintain the exemption amid fears of increased neighborhood strain during the startup phase.

Operational Framework

Core Services and Daily Procedures

Insite provides supervised injection services in a facility equipped with 12 private booths where clients consume pre-obtained substances under direct observation by trained nurses and staff. Clients are supplied with sterile injection equipment, including needles, filters, and cookers, to minimize risks of from contaminated . Staff enforce protocols prohibiting on-site drug dealing or sales, while permitting personal possession and consumption of illicit drugs brought by clients. Daily procedures emphasize immediate response to potential overdoses, with nurses administering intramuscularly or intranasally as needed to reverse effects, followed by resuscitation measures such as rescue breathing until emergency services arrive. The site operates 24 hours per day, seven days per week, accommodating an average of approximately 480 injection room visits daily by the mid-2010s, totaling around 175,000 to 200,000 annual visits. Ancillary services include basic wound care for injection-related injuries like abscesses, screening and treatment, vaccinations, and on-site referrals to programs, , and support.

Staffing, Capacity, and Integration with Health Services

Insite employs a multidisciplinary staff comprising registered nurses for medical oversight, social workers for counseling and referrals, and peer workers with of substance use to foster rapport and provide support. This team manages the facility's operations, including supervision of injections and immediate response to emergencies, while adhering to protocols that prioritize user without requiring abstinence. The site operates with a fixed capacity of 12 injection booths, accommodating an average of visits and injections daily, though estimates vary between 500 and depending on demand periods. Peak hours frequently result in wait times of 15 to 30 minutes, with approximately 10% of potential users departing without accessing services due to these constraints. Annual operating costs stand at approximately CAD 3 million, equating to about CAD 14 per visit based on 2007 data adjusted for scale. Operated under the auspices of , Insite integrates with broader healthcare systems through data collection protocols that support longitudinal research, such as the Scientific Evaluation of Supervised Injecting , enabling analysis of usage patterns without compromising user anonymity. Staff facilitate referrals to off-site opioid substitution therapies like programs rather than dispensing on-site, emphasizing linkage to external and services. Efficiency in overdose response is evidenced by over 336 successful interventions since 2006, with zero fatal overdoses occurring within the facility, averting an estimated one on-site death annually based on intervention logs relative to external rates.

Empirical Evidence on Effectiveness

On-Site Safety and Immediate Harm Reduction Metrics

Since opening on September 21, 2003, Insite has recorded no fatal overdoses on site despite supervising more than 2.9 million injections in dedicated rooms. Staff interventions, including administration and respiratory support, have reversed over 11,800 non-fatal overdoses as of September 2023, with annual overdose events increasing from heroin-related cases in early years to higher volumes amid the fentanyl crisis. This outcome stems from continuous medical oversight, which halts the causal sequence of opioid-induced leading to hypoxia and , as documented in facility logs and analyses of intervention efficacy. Mathematical simulations incorporating observed overdose rates, injection volumes, and estimated off-site fatality risks project that averts 1 to 12 overdose deaths per year. These models, validated against pre- and post-opening data, apply conservative assumptions such as uniform risk displacement to nearby areas, yielding a range from pessimistic (1 death annually) to optimistic (up to 12) scenarios based on intervention success rates exceeding 98% for non-fatal events. Insite's provision of sterile equipment and supervised environments correlates with decreased syringe reuse among frequent users, mitigating pathogen risks. Kerr et al. reported that Insite attendance independently reduced by up to 70% among participants compared to non-users, addressing a key transmission pathway for . However, while local HIV seroprevalence among injectors declined post-2003, direct attribution to Insite lacks cohort-controlled , as broader needle exchange programs and treatment access confound causality. Models extrapolating reduced sharing estimate potential HIV infections averted, but reviews note reliance on unverified assumptions rather than observed incidence drops. Data from the Coroners Service indicate that illicit deaths in the province totaled approximately 200 in the years immediately following Insite's opening in September 2003, reflecting a temporary decline from the peak of 417 deaths in 1998. However, this reduction was not sustained city-wide in , where overdose mortality rates showed no significant net decrease beyond localized effects near the facility, amid ongoing public injections and fatalities in adjacent areas.60054-3/fulltext) Provincial deaths began rising again after 2010, accelerating with the emergence of around 2013, reaching 985 in 2016 and exceeding 2,400 annually by the early 2020s, with 2,413 reported in 2022. Ecological studies, such as one by Marshall et al. published in The Lancet in 2011, attributed a 35% drop in overdose deaths within 500 meters of Insite to its operation in the two years post-opening, comparing rates from 2001–2003 (pre) to 2003–2005 (post).62353-7/abstract) Critiques of this analysis highlight methodological flaws, including the influence of anomalously low 2001 data on pre-period averages and failure to account for pre-existing overdose hotspots near the site, with 41% of post-opening deaths occurring in nearby alleys, suggesting displacement rather than elimination of risks. Broader reviews of supervised consumption sites, including provincial-level analyses in , have found no significant associations with overall overdose mortality reductions at scale, as localized benefits do not translate to aggregate declines amid shifting drug markets and user behaviors. Insite's limited capacity further constrains its potential population-level effects, serving around 8,000 unique individuals since 2003, with just 18% of users accounting for 80% of visits—equating to roughly 1,000 frequent injectors annually out of an estimated 10,000–15,000 people who inject drugs in . Approximately 95% of Insite users also inject in unsupervised public settings, indicating minimal substitution for high-risk behaviors across the user base. This scale implies that even optimal on-site interventions cannot substantially alter city-wide or provincial trends driven by widespread illicit contamination and non-participating users. The introduction of British Columbia's drug decriminalization policy on January 1, 2023, which removed criminal penalties for possessing small amounts of opioids, , , and , coincided with persistent high overdose mortality, as deaths continued at rates exceeding 2,000 annually without interruption. While some analyses note reduced arrests for possession, the policy has been linked to increased open drug use in public spaces, potentially heightening visibility and risks without corresponding mortality drops, prompting provincial requests for federal adjustments by mid-2024. These trends underscore that facility-based alone does not address underlying drivers of escalating toxicity in unregulated supplies.

Linkage to Treatment and Recovery Rates

Evaluations of Insite's capacity to link users to addiction treatment services indicate modest short-term increases in detoxification uptake but limited evidence of substantial long-term recovery. A prospective cohort study of 431 injection drug users in Vancouver found that the facility's opening in September 2003 was independently associated with a 30% rise in detoxification service utilization compared to the preceding year, with those accessing detox exhibiting 1.94 times higher odds of ceasing injection in subsequent observation periods. Similarly, analyses of facility users reported elevated rates of initiating methadone maintenance therapy and other addiction treatments, with regular Insite attendees showing higher enrollment in comprehensive programs relative to non-users. These findings support claims that Insite facilitates referrals as a potential entry point to the treatment continuum, including on-site counseling and co-located detox services. Longitudinal data, however, reveal persistent injection drug use among the majority of users, undermining assertions of the facility as a robust "gateway" to sustained recovery. In a cohort of over 8,000 registered users tracked since , approximately 18% accounted for 86% of all injections, reflecting concentrated, repeated rather than broad transitions to . Prospective follow-up of 1,336 people who inject drugs over a of 50 months documented 1,663 six-month periods of supervised injection use among 63.4% of participants, with discontinuation of facility visits often linked to external factors like incarceration or relocation rather than verified . While short-term detox episodes occur in 10-20% of users post-visits, predominates, yielding low rates of sustained —typically under 10% at one-year follow-up in comparable cohorts—consistent with the chronic relapsing nature of dependence absent intensive, abstinence-oriented interventions. This pattern aligns with harm reduction's emphasis on managed use over immediate cessation, which may attenuate the acute incentives for quitting by mitigating overdose risks and withdrawal discomfort without addressing underlying drivers. Empirical tracking thus contrasts promotional narratives of high recovery linkage, as most visits sustain rather than interrupt injection cycles, with treatment transitions remaining exceptional amid ongoing dependence.

Criticisms and Unintended Consequences

Community Impacts: Crime, Disorder, and Public Nuisance

Following the opening of Insite in 2003, the surrounding neighborhood experienced persistent disorder, including increased visible drug-related litter such as discarded needles and , alongside homeless encampments and open-air drug dealing. These issues contributed to a sense of heightened insecurity among residents, who reported feeling less safe due to the concentration of addiction-related activities spilling into spaces. Vancouver Police Department data and community observations indicate ongoing challenges with property crimes and service calls linked to drug scene dynamics in the area, with high rates of and persisting amid the influx of users drawn to the supervised facility. The facility's operation has been associated with displacement of unsanctioned injecting to nearby alleys and sidewalks, exacerbating trash accumulation and public nuisance without fully mitigating broader street-level disorder. Local businesses in the have faced significant operational difficulties, including rampant theft, vandalism, and customer deterrence from overt use and related violence, leading some owners to consider closure or relocation. For instance, a proprietor described the neighborhood as akin to a "war zone," citing daily disruptions that undermine viability and prompting suggestions that dealing could be more profitable than legitimate enterprise. Major retailers, such as , have evaluated exiting the area due to elevated security costs and crime impacts. Critics argue that supervised injection sites like Insite function as attractors for substance users, concentrating vulnerabilities in proximate zones and perpetuating a cycle of disorder by prioritizing immediate consumption over resolution of underlying and factors. This dynamic has strained community resources, with sustained encampments and open markets reflecting unaddressed externalities despite the site's intent.

Broader Failures in Addiction Reduction and Cost-Benefit Analysis

Insite's annual operating costs have been estimated at approximately CAD 3 million, covering staffing, medical supplies, and facility maintenance as of the late , with similar figures persisting in subsequent evaluations adjusted for and expansion. Proponents cite modeling studies projecting savings from averted infections—estimated at CAD 17.6 million in lifetime medical costs for 83.5 prevented cases annually—which purportedly exceed direct expenses. However, these analyses often exclude broader fiscal burdens, such as elevated policing and cleanup expenditures in the surrounding , where public disorder and discarded needles have intensified, contributing to unquantified societal costs that undermine net benefits. Despite over two decades of operation, Insite has coincided with no measurable decline in chronic among Vancouver's estimated 8,000 injection users in the , with roughly 1,500 individuals accounting for the majority of visits and sustaining high utilization rates without evidence of population-level cessation. Provincial data indicate and related harms have escalated dramatically; overdose deaths in rose from about 203 annually in the early to 2,574 in 2023, reflecting a failure to curb supply-driven or foster personal recovery pathways. Critics contend that supervised sites like Insite subsidize ongoing habits, bypassing root causes such as illicit availability and individual agency, thereby perpetuating dependency rather than incentivizing abstinence-oriented interventions. Cost-benefit scrutiny from non-academic perspectives highlights Insite's questionable relative to alternatives like expanded rehabilitation programs, which demonstrate societal ROIs of CAD 4–7 per dollar invested through sustained recovery and reduced . Academic models favoring Insite frequently originate from harm-reduction advocates within institutions, potentially overlooking opportunity costs of diverting funds from treatment modalities that address causation over symptom management. With user numbers stable and overdose trends worsening, the program's net societal value remains contested, as it yields marginal health gains at the expense of systemic inaction on reduction.

Ideological Debates: Enabling vs. Abstinence-Oriented Approaches

Supervised injection facilities like Insite embody the paradigm, which prioritizes minimizing immediate risks such as overdose and infection among active users without mandating , a stance supported by analyses from researchers indicating reduced overdose morbidity and improved care access for injectors. International organizations, including components of the , have endorsed elements of this approach as pragmatic responses to entrenched drug use patterns, framing it as a complement to broader treatment efforts rather than a pathway to normalization. However, this philosophy has drawn rebuttals from policy analysts who argue that providing state-sanctioned spaces for consumption erodes social deterrents, effectively enabling sustained by removing consequences that historically prompted quitting or family-led interventions. From a causal perspective, addiction functions as a maladaptive reinforced by repeated accommodation; first-principles reasoning suggests that facilities signaling tolerance may weaken incentives for behavioral change, as evidenced by critiques positing 's utilitarian framing overlooks long-term dependency cycles. Post-decriminalization trends in since January 31, 2023, correlate with heightened public consumption visibility, prompting policy reversals on open use and underscoring potential cultural shifts toward acceptance that dilute pressures. Rising involvement, with toxicity deaths among British Columbians under 19 increasing from 1.4 per 100,000 in 2019 to higher rates amid expanded , challenges left-leaning narratives of non-enabling effects, particularly given academia's toward accommodationist models over restrictive ones. Abstinence-oriented alternatives, emphasizing enforced and recovery incentives, offer counter-evidence of efficacy; for instance, structured programs have achieved 63.9% long-term rates among completers, outperforming models tolerating ongoing use. Sweden's restrictive framework, prioritizing zero-tolerance and treatment mandates, maintains among Europe's lowest illicit , with advocates attributing this to deterrence that abstinence-focused policies foster, in contrast to decriminalization-heavy approaches elsewhere yielding stagnant or rising use metrics. While harm proponents cite stable initiation rates in some contexts, data-driven scrutiny reveals these often derive from institutionally biased sources downplaying normalization risks, favoring instead integrated models blending with recovery to disrupt addiction's reinforcement loops.

Federal Prosecutions and Supreme Court Exemption (2003–2011)

In September 2003, Insite commenced operations as North America's first supervised injection facility, granted a temporary exemption by under section 56 of the (CDSA), allowing users to inject pre-obtained illicit drugs on-site without criminal prosecution for possession or consumption. This exemption, issued to the Authority, was framed as a three-year research pilot to evaluate outcomes amid Vancouver's overdose crisis. Following the 2006 federal election of the Conservative government, Health Minister declined to renew the exemption beyond its scheduled expiry in 2008, prompting the Portland Hotel Society (PHS Community Services Society), Insite's operator, and to challenge the application of CDSA sections 4 (possession) and 5 (trafficking) to the facility's activities. In May 2008, the Supreme Court ruled that enforcing these provisions against Insite's clients and staff would violate section 7 of the Canadian Charter of Rights and Freedoms—protecting the , , and of the person—due to the arbitrary deprivation of life-saving medical services without sufficient countervailing public safety benefits, and granted a constitutional exemption permitting continued operations. The federal appealed to the Court of Appeal, which in 2009 upheld the lower court's decision, affirming that the Minister's refusal to exempt Insite was unreasonable and Charter-infringing given of reduced overdoses and disease transmission. The federal government further appealed to the , which heard Canada (Attorney General) v. PHS Community Services Society in 2011. On September 30, 2011, the Court unanimously ruled 9-0 that denying a section 56 exemption would infringe section 7 rights, as the blanket criminal prohibition failed principles of fundamental justice by disregarding site-specific evidence of efficacy while imposing undue risks on vulnerable users; the decision rejected federal arguments on interjurisdictional immunity and ordered the Minister to grant the exemption forthwith. This outcome secured Insite's legal viability, though it highlighted persistent federal-provincial tensions over discretion, with the ruling emphasizing evidence-based ministerial decision-making under the CDSA rather than ideological opposition.

Post-Ruling Policy Evolution and Recent Backlash (2012–2025)

Following the 2011 ruling exempting Insite from federal drug laws, the Conservative government under introduced the Respect for Communities and Communities' Safety Act in 2015, which sought to impose stricter federal oversight on new supervised consumption sites () by mandating community consultations and ministerial approval to address public safety concerns. However, the bill faced legal challenges and did not advance significantly before the Liberal Party, led by , formed government in November 2015 and prioritized expansions. Under the Liberals, federal regulations were streamlined in 2017, facilitating approvals for over 40 across by 2020, including additional sites in and expansions of services at Insite's operator, the Portland Hotel Society. The Trudeau administration's policies emphasized and safer supply programs, culminating in British Columbia's three-year exemption from federal possession laws effective January 31, 2023, allowing adults to possess up to 2.5 grams of opioids, , , or without criminal penalty. This pilot, supported by federal funding of $2.85 million for evaluation, coincided with increased public use but showed no reduction in overdose mortality; a 2025 study analyzing dispensing found associated with higher overdose rates rather than decreased harms. Meanwhile, illicit deaths in BC escalated from 270 in 2012 to 2,511 in 2022 and 2,482 in 2023, with provisional data indicating over 1,800 by mid-2025, undermining claims of policy efficacy amid a toxic supply contaminated by . By 2024, the persistent crisis—exacerbated by visible public disorder and no verifiable decline in deaths post-decriminalization—sparked empirical and political reevaluation of 's scalability. Conservative Leader criticized , including Insite, as "drug dens" that exacerbate community decay without addressing root causes, pledging to defund federal support for such facilities and redirect resources to mandatory treatment and 50,000 recovery beds. This stance gained traction amid data showing policy expansions correlated with rising fatalities rather than reversal, prompting provincial reviews like Alberta's 2024 closure of select sites and broader calls for abstinence-focused interventions over unchecked enabling. Into 2025, with overdose rates remaining elevated despite billions in harm reduction spending, Conservative platforms framed the backlash as a necessary pivot from ideological experimentation to evidence-based enforcement and recovery, citing the absence of causal links between SCS proliferation and population-level mortality reductions.

Comparative Analysis and Future Implications

Following the 2011 ruling affirming Insite's constitutionality, supervised consumption sites proliferated across the country, with federal exemptions granted for new facilities under section 56.1 of the . Toronto opened its first permanent site in 2017, followed by expansions in and other cities amid rising overdose concerns. By September 2023, operated 39 such sites, though provincial actions like Ontario's 2024 announcement to close most of its 17 sites signal emerging retrenchment. Nationally, these sites recorded approximately 4.3 million visits from 2017 to June 2023, equating to roughly 985,000 annual visits based on 2,700 daily averages across 39 facilities. Staff reversed over 21,000 non-fatal overdoses on-site in alone from 2020 to 2024, with zero fatalities recorded at any Canadian site, demonstrating efficacy in immediate overdose prevention. However, this expansion coincided with escalating national overdose mortality, reaching over 8,000 apparent toxicity deaths in 2023—part of 53,821 total such deaths since 2016—amid policy shifts like British Columbia's 2023 of small drug quantities, which correlated with increased visits for non-fatal overdoses in some jurisdictions. Empirical assessments indicate sites reduce overdose risks for frequent users, with one analysis linking proximity to facilities with lower neighborhood mortality rates, yet population-level data show no reversal of broader or drug use declines. Critics, including evaluations of site closures like Lethbridge's, highlight persistent displacement of public drug use and disorder to surrounding areas without commensurate reductions in overall injection rates or treatment uptake. Operating costs strain public budgets, with individual sites requiring $1.6–3 million annually and federal allocations exceeding $40 million for related in 2022, yielding debated net benefits amid unchecked national overdose trajectories.

Lessons from International Models Emphasizing Decriminalization Without Supervised Injection

Portugal's 2001 of personal drug possession treated use as a issue rather than a criminal one, redirecting users through administrative "dissuasion commissions" that could impose fines, suspend proceedings conditional on treatment, or refer individuals for therapeutic evaluation, often with elements of to encourage abstinence-oriented recovery. This model eschewed supervised injection facilities, prioritizing instead to maintenance, , and residential programs addressing underlying factors like disorders and social instability. Overdose deaths declined sharply post-reform, dropping by about 80% from peak levels in the late —around 369 in 1999 to 30 by 2016—while new infections from injecting fell from over 1,000 annually to under 100. Treatment entries rose substantially, with commissions facilitating voluntary or mandated assessments that boosted overall engagement rates to levels where a majority of problematic users accessed services, contrasting with lower uptake in systems reliant on optional infrastructure. Empirical contrasts highlight how Portugal's approach, without public injection normalization, achieved broader reductions by integrating with supply interdiction and root-cause interventions, yielding Europe's lowest drug mortality rate—around 3-10 per million by the 2010s—versus persistent high overdose figures in exceeding 100 per million amid partial experiments. Jurisdictions like report treatment initiation rates below 20% for users, underscoring the limitations of models lacking coercive pathways to ; Portugal's commissions, by contrast, resolved over 90% of cases through treatment referrals or compliance, fostering sustained recovery without enabling ongoing use. This causal emphasis on disrupting dependency cycles—via mandatory assessments over symptom accommodation—correlates with decreased injecting and fewer new addicts, as resources shifted from to resolution. Switzerland and the Netherlands, incorporating supervised sites since the and alongside partial , demonstrate mixed results: while site-level overdoses are averted, population-wide recovery remains modest, with abstinence-based programs outperforming in long-term remission rates. Swiss four-pillar policies, blending sites with , stabilized but did not sharply reduce hard use, as critiques note insufficient allows supply persistence, unlike Portugal's balanced enforcement yielding steeper declines in availability. Dutch facilities similarly contain acute risks but show limited progression to abstinence, with data indicating higher sustained sobriety in models prioritizing therapeutic coercion over supervised consumption; overall, these cases reveal that sites may mitigate immediate harms without addressing causal drivers like untreated trauma, perpetuating dependency where integrated treatment mandates succeed. Such evidence supports prioritizing interventions that compel engagement with recovery pathways, avoiding normalization of injection that can entrench habits absent rigorous supply controls.

References

  1. https://www.vch.ca/en/location/insite
  2. https://www.phs.ca/program/insite/
  3. https://www.canada.ca/en/health-canada/corporate/about-health-canada/reports-publications/vancouver-insite-service-other-supervised-injection-sites-what-been-learned-research.html
  4. https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0154-1
  5. https://www.vch.ca/en/news/health-canada-gives-green-light-new-supervised-injection-service-vancouver
  6. https://pmc.ncbi.nlm.nih.gov/articles/PMC1562403/
  7. https://www.ccsa.ca/sites/default/files/2024-10/SCS-Evidence-Brief-en.pdf
  8. https://pmc.ncbi.nlm.nih.gov/articles/PMC2942917/
  9. https://pmc.ncbi.nlm.nih.gov/articles/PMC3665976/
  10. https://www.hrw.org/reports/2003/canada/canada0503-03.htm
  11. https://www.vancouverbiennale.com/wp-content/uploads/2015/03/DTES-A-Community-in-Need-of-Balance.pdf
  12. https://www.ojp.gov/ncjrs/virtual-library/abstracts/abusing-user-police-misconduct-harm-reduction-and-hivaids-vancouver
  13. https://open.library.ubc.ca/collections/52383/items/1.0340699
  14. https://www.hrw.org/report/2003/05/07/abusing-user/police-misconduct-harm-reduction-and-hiv/aids-vancouver-canada
  15. https://pmc.ncbi.nlm.nih.gov/articles/PMC4947565/
  16. https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-6-9
  17. https://www.sciencedirect.com/science/article/pii/S0955395925003184
  18. https://www.cbc.ca/news/canada/british-columbia/insite-20-year-anniversary-1.6966605
  19. https://journals.library.ualberta.ca/constitutional_forum/index.php/constitutional_forum/article/view/12428/9429
  20. https://www.phs.ca/the-insite-story/
  21. https://www.cbc.ca/news/canada/british-columbia/supervised-injection-site-granted-6-month-extension-1.672128
  22. https://www.ccsa.ca/sites/default/files/2019-04/ccsa-010657-2004.pdf
  23. https://pmc.ncbi.nlm.nih.gov/articles/PMC517857/
  24. https://thecanadianencyclopedia.ca/en/article/injecting-truth-vancouvers-controversial-insite-facility
  25. https://vancouversun.com/health/inside-the-battle-to-open-insite-20-years-ago-and-why-it-never-ended
  26. https://pmc.ncbi.nlm.nih.gov/articles/PMC4450732/
  27. https://vancouver.ca/people-programs/safe-injection-site-and-needle-exchange.aspx
  28. https://www.vch.ca/sites/default/files/import/documents/Overdose-Prevention-Site-OPS-Manual.pdf
  29. https://www.cbc.ca/news/canada/british-columbia/insite-supervised-injection-24-hour-1.3728044
  30. https://pmc.ncbi.nlm.nih.gov/articles/PMC6415769/
  31. https://www.uvic.ca/research/centres/cisur/assets/docs/international-consensus-statement-on-the-role-of-nurses-in-supervised-consumption-sites.pdf
  32. https://pmc.ncbi.nlm.nih.gov/articles/PMC535533/
  33. https://www.ohtn.on.ca/rapid-response-83-supervised-injection/
  34. https://pmc.ncbi.nlm.nih.gov/articles/PMC2556397/
  35. https://www.vch.ca/en/news/canadas-first-supervised-consumption-site-celebrates-20-years-saving-lives
  36. https://journals.lww.com/cja/fulltext/2022/12000/opioid_overdose_and_naloxone_dosing_at_insite.4.aspx
  37. https://nida.nih.gov/sites/default/files/NIH-RTC-Overdose-Prevention-Centers.pdf
  38. https://www.bccsu.ca/wp-content/uploads/2016/11/Deaths-prevented-by-Insite.pdf
  39. https://pmc.ncbi.nlm.nih.gov/articles/PMC1766348/
  40. https://pmc.ncbi.nlm.nih.gov/articles/PMC6034966/
  41. https://www.researchgate.net/publication/287258956_Analysis_of_the_2011_Lancet_study_on_deaths_from_overdose_in_the_vicinity_of_Vancouver%27s_Insite_supervised_injection_facility
  42. https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-45-no-9-2025/supervised-consumption-sites-population-level-overdose-mortality-systematic-review-recent-evidence-2016-2024.html
  43. https://pmc.ncbi.nlm.nih.gov/articles/PMC11929020/
  44. https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-024-01108-5
  45. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2007.01818.x
  46. https://bccfe.ca/news-releases/insite-leads-to-addiction-treatment-among-users-study/
  47. https://pmc.ncbi.nlm.nih.gov/articles/PMC5658025/
  48. https://www.sciencedirect.com/science/article/abs/pii/S0749379719302181
  49. https://www.heritage.org/public-health/commentary/safe-injection-sites-arent-safe-effective-or-wise-just-ask-canadians
  50. https://www.ourcommons.ca/DocumentViewer/en/39-2/HESA/meeting-32/evidence
  51. https://globalnews.ca/news/11246918/dtes-business-crime/
  52. https://globalnews.ca/video/11244877/downtown-eastside-business-struggles-to-stay-open-amid-rampant-public-disorder
  53. https://www.reddit.com/r/vancouver/comments/1ibcai5/downtown_eastside_at_tippin_point_as_london_drugs/
  54. https://www.city-journal.org/article/the-harm-in-harm-reduction
  55. https://www.sciencedirect.com/science/article/pii/S1098301524000731
  56. https://pubmed.ncbi.nlm.nih.gov/20653622/
  57. https://cchcs.ca.gov/wp-content/uploads/sites/60/ISUDT/Impacts-ISUDT-Program2019-22.pdf
  58. https://pmc.ncbi.nlm.nih.gov/articles/PMC8541900/
  59. https://www.thelancet.com/journals/lanam/article/PIIS2667-193X%2824%2900216-3/fulltext
  60. https://pmc.ncbi.nlm.nih.gov/articles/PMC7679315/
  61. https://www.sciencedirect.com/science/article/abs/pii/S0955395901000858
  62. https://www.bbc.com/news/world-us-canada-68621012
  63. https://cihr-irsc.gc.ca/e/54342.html
  64. https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-024-01063-1
  65. https://www.tandfonline.com/doi/full/10.1080/14659891.2023.2226204
  66. https://journals.sagepub.com/doi/10.1177/00914509231159394
  67. https://transformdrugs.org/blog/drug-policy-in-sweden-a-repressive-approach-that-increases-harm
  68. https://www.coloradohealthinstitute.org/blog/harm-reduction-or-criminalization-two-opposing-legislative-approaches-overdose-deaths
  69. https://www.constitutionalstudies.ca/2017/08/safe-injection-sites-how-the-supreme-court-got-it-right-with-insite/
  70. https://www.nnpbc.com/what-did-it-take-to-get-insite/
  71. https://albertalawreview.com/index.php/ALR/article/view/275
  72. https://pmc.ncbi.nlm.nih.gov/articles/PMC5437687/
  73. https://www2.gov.bc.ca/gov/content/overdose/decriminalization
  74. https://www.canada.ca/en/health-canada/services/opioids/federal-actions/overview.html
  75. https://vancouversun.com/news/bc-drug-decriminalization-safer-supply-associated-more-overdoses-study
  76. https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/bccsjan2025pdfdashboard.pdf
  77. https://www.cbc.ca/news/canada/british-columbia/supervised-consumption-site-scale-back-poilievre-1.7262063
  78. https://www.conservative.ca/poilievre-will-make-recovery-a-reality-for-50000-canadians/
  79. https://www.reuters.com/world/americas/canadian-drug-deaths-rise-programs-keep-users-safe-face-backlash-2024-07-24/
  80. https://thehub.ca/2025/09/10/deepdive-the-battle-over-supervised-consumption-sites-in-canada/
  81. https://nationalpost.com/news/canada/poilievre-50000-addictions-recovery-spaces
  82. https://www.ctvnews.ca/federal-election-2025/article/conservative-plan-to-close-overdose-prevention-sites-would-cost-lives-researcher-says/
  83. https://health-infobase.canada.ca/datalab/supervised-consumption-sites-blog.html
  84. https://cdpe.org/wp-content/uploads/2024/11/CDPE-SCS-Toronto-Nov-2024-.pdf
  85. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
  86. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667%2823%2900300-6/fulltext
  87. https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-025-01251-7
  88. https://transformdrugs.org/blog/drug-decriminalisation-in-portugal-setting-the-record-straight
  89. https://www.npr.org/2024/02/24/1230188789/portugal-drug-overdose-opioid-treatment
  90. https://www.statista.com/chart/20616/key-developments-since-portugal-decriminalized-drugs/
  91. https://www.scientificamerican.com/article/portugal-drug-decriminalization/
  92. https://www.apa.org/monitor/2018/10/portugal-opioid
  93. https://pmc.ncbi.nlm.nih.gov/articles/PMC12185153/
  94. https://transformdrugs.org/assets/files/PDFs/Drug-decriminalisation-in-Portugal-setting-the-record-straight.pdf
  95. https://hri.global/wp-content/uploads/2022/11/Harm-Reduction-in-Switzerland_FINAL.pdf
  96. https://pmc.ncbi.nlm.nih.gov/articles/PMC12124055/
  97. https://journals.sagepub.com/doi/10.1177/00220426221087590
  98. https://www.sciencedirect.com/science/article/abs/pii/S0376871614018754
Add your contribution
Related Hubs
Contribute something
User Avatar
No comments yet.