The authors point out that projects like Insite "are subjected to an extraordinarily high standard of evaluation, while projects such as the school-based prevention program DARE, run by the RCMP, continue to receive funds through Canada's Drug Strategy despite a lack of evidence supporting their efficacy."

Without betraying my own opinion on the matter. I have to say the inference that people should hold a simple in-school educational anti-drug program to the same standards as a program that faciltates drug use and criminal activity is just absurd! Do these people think at all?

Careful with those accusations of thoughtlessness, Anonymous. Prevention programs are arguably more important than any other aspect of drug policy. After all, if you can prevent young people from slipping into abuse and addiction, everything else is moot.

DARE is a program started by the LA police chief at the height of 1980s drug hysteria. It was never grounded in solid research. And every evaluation of it -- and there have been many -- has shown it to be a waste of money. Despite this, it is by far the most common prevention program in use in North America. Total spending on it likely amounts to hundreds of millions of dollars. What could that money have accomplished if it had been used for programs that have proven their worth?

Insite has been rigorously tested and found to save lives and reduce disorder. The standard weapons in the war on drugs -- from DARE to stuffing prisons with drug users -- has either failed evaluations or, more commonly, never been evaluated. For anyone who puts reducing harm ahead of moral posturing, that matters.

If DARE doesn't work, then to hell with it. But I agree with Anon to a certain extent. Harm reduction programs are inherently defeatist, and I don't think it's unreasonable for them to receive more scrutiny than an "on-message" (if useless) program like DARE.

I stand by my comment. DARE and the "not quite 4 pillars program" have two completely different mandates. One program seeks to educate children at an impressionable age about the dangers of drug use and one program, while doing so in pursuit of a laudable goal, undermines our justice system and seeks to facilitate criminal drug use. Holding both to the same level of accountability is, well, stupid.

"Total spending on it likely amounts to hundreds of millions of dollars."

Could you just edit this pointless line out?

"It was never grounded in solid research."

The DARE programs goals are to educate children about the dangers of drugs at an impressionable age, before they are likely to have tried them. This is based upon some very strong inductive and deductive reasoning, and plenty of research. The same reasoning upon which our school system is based.

I call shenanigans.

"Insite has been rigorously tested and found to save lives and reduce disorder..."

No. It has been evaluated by the people who run the program and who advocated for its creation and who then advocated for its continuation - even in advance of doing the research they now trumpet. The BC Centre for HIV/AIDS is not a third-party to the INSITE project; they are a proponent. I don't know that they found what they were looking for in their review, or that they emphasized the perceived benefits and discounted the costs or adverse outcomes - but it would not surprise me.

The (much too brief) review on the Vancouver Coastal Health web site indicates that over a two-year period they referred roughly 5% of their client base to withdrawal management programs. Based on number of registered clients and prevalance of heroin use at the site, we would estimate that slightly under 3,000 heroin users use INSITE - they are able to refer 2/week to a methadone program, or ~7% over two years. Bear in mind that this is published by the guys who run the program - in their mind, these are the "success stories."

I am not convinced that this level of success justifies the cost, or the promotion of illegal activities; it would be nice to have some research by people who don't have a pre-conceived idea that the program is a success just by its existence - and equally, by people who don't come in with the opposite a priori assumption.

Chris: Can you walk and chew gum at the same time? Well then perhaps we can do what's necessary to keep drug addicts alive while simultaneously advancing prevention and other efforts. I really don't see how that can be described as "defeatist" unless you are also of the opinion that emergency wards are "defeatist" because all they do is save people's lives and send them back out into the world where they will encounter the same risks that sent them to ER in the first place.

Also, it's not just that harm reduction received more scrutiny. DARE was actually a bad example because it has -- to its credit -- been tested. Take a look at Canada's budget on this stuff and you quickly realize that most of what we spend our money on has NEVER been given the slightest scrutiny even though it has been around for many years and, in some cases, many decades. It's a little bizarre to demand gold-plated evidence of efficacy from one, small program when we spend billions on law enforcement measures, for example, that have never been tested to see if they actually do what they're supposed to do. (See the auditor general's report of a few years back.)

Eric: I haven't a clue what you mean when you say harm reduction undermines our justice system and I can't imagine it could actually have such terrible effects given that western European countries have had much more extensive programs in place for more than a decade and a half and yet their justice systems continue, miraculously, to keep on ticking. Second, your comment about "facilitating drug use" is, I think, indicative of the moralizing that underlies criticism of harm reduction. There is NO evidence that it encourages those who were not using drugs to do so. This only involves people who were using drugs anyway and who will do so whether the program is there or not. The only way this could be said to be "facilitating drug use" is in the "moral taint" sense: Good heavens, they are assisting the act! And if you would put moral sensitivities ahead of the lives of human beings, well, we see the universe quite differently.

As to your comment about cost: Have a look at the Senate report and many similar reports in the US. The dollars involved are enormous.

And as to evidence: Spare me your inductive and deductive reasoning and Google this, will you? DARE has been studied in countless jurisdictions, all with the same miserable results. Again, have a look at the Senate report before you go tossing around words like "shenanigans." My, such language.

DCardno: the studies declaring Insite a success appeared in peer-reviewed medical journals. They are not self-published puff pieces. Second, you seem to be labouring under the same misconception of our esteemed health minister. The purpose of Insite, and the measure by which it should be judged, is not how many users the staff get off drugs. If it happens, that's great, but it's a bonus. The primary purpose is to reduce overdoses and transmission of disease. It's to keep people alive, in other words. THEN we can talk about next steps. But you know it's kinda tough to kick the habit when you're dead. Stay alive first. Kick the habit second. It's not complicated.

Anonymous - the problem with the studies is that the BC Centre for excellence in HIV/AIDS was an advocate for the INSITE program before it was started, and remains one to this day. No amount of peer review can make them an impartial third party, neither can peer review reperform their observations about the impact of INSITE - all a peer review can do is ensure that given the assumptions and observations Montaner et al performed their conclusions follow from those observations. If the HIV/AIDS researchers didn't want to observe a negative outcome, there is no way for peer review to catch it.

One of the assumptions the study makes in claiming that they are "saving lives" is that every overdose that occurred in the facility would have occurred outside the facility and would likely lead to a death. In other observations of human behaviour, subjects adjust their actions to maintain a consistent level of (perceived) risk - drivers with airbags and ABS drive faster and leave less room around them than drivers whose vehicles are not so equipped, and so on. There is no reason to think that drug users don't do the same - so INSITE, by making immediate medical care available, may be encouraging users to be less careful with their dosages and thus increasing the total number of overdoses - the net effect on fatalities is unknown.

I remember several statements (prior to the inception of INSITE) by John Turvey (among others) to the effect that the users in the DE 'were a community' who looked after each other and acted to mitigate the effect of overdoses - thus the assumption that an off-site overdose necessarily leads to a death may itself be overblown. The INSITE study (at least that can be found on their website) does not compare the rate of fatalities in off-site and on-site overdoses, nor does it try to estimate the relative prevalence of overdoses.

In claiming a reduction in unsafe drug use practices like needle sharing, the study relies on addict self-reporting of what they hypothetically would have done in the absence of the INSITE facility, which presents a couple of problems. First, self-reporting is notoriously unreliable, particularly when both the interviewer and the respondent have a vested interest in a given outcome. Second, a reduction in needle-sharing is only a beneficial outcome if the overall rate of hepatitis, HIV, etc, in the community is reduced - a citation to that effect is much more relevant than a self-reported reduction in risky behaviour.

I think the anecdotal reports and the studies to date are suggestive that INSITE is worthwhile - but proponents of the program are overstating their case in relying on the Centre for HIV/AIDS's asessment. I am also disturbed that the Centre's response to the RCMP report was essentially to claim that the RCMP is incapable of assessing the impact of the program, and that the analysis should be left to 'real scientists' - sorry guys, but an observation is either true or false, and it doesn't depend on who makes it. When it comes to a question of community safety and order or disorder, it doesn't take a PhD microbiologist or medical researcher to do the study - and the RCMP may be a better investigator. Again, it would be nice if investigators would simply try to determine the facts, instead of buffing up the case they are attempting to make.

Sorry, that long post above Dcardno's is mine. Don't know why my name ain't on it.

Dcardno: The reason why there's peer review is precisely to assess the methods to ensure that, whatever the scientists' preconceptions and feelings, the work confirms with accepted standards and therefore is likely to show valid results. If you were to dismiss peer-reviewed studies by individuals committed to proving an hypothesis or possessed of an axe they wish to grind, well, you could kiss science goodbye.

But the larger point that started all this stands and nobody here has addressed it. Immense sums of money (now approx. $40 billion a year in the US and, very roughly, $1 billion a year in Canada) have been spent over the last 80 years in support of drug policies that HAVE NEVER BEEN TESTED! Of course policies should be tested. Of course Insite should be tested and continue to be tested as it operates. And it's valuable to be skeptical about those tests, ask questions, raise doubts, probe, etc. But why, oh why, do all those questioning Insite not expand their questioning and ask, hey, since we're spending huge gobs of money on various drug policies, chief among them law enforcement, why don't we test THOSE policies? The auditor general noted that the agencies that spend this money don't gather the data necessary to check on whether those policies are working and they don't even have stated policy goals against which their results could be measured! Isn't that just a wee alarming to any of you tough-minded skeptics? Rather than minutely dissecting this one, rather minor policy, shouldn't you demand a proper cost-benefit analysis of our primary drug policies be done for the first time ever?

Dan - the differnce between "peer review" of -say- drug efficacy or the effect of exposure to toxins and course of illness is rather different than peer review on social policy, since in the former cases we can conduct control studies, use double-blind methodolgy, etc. In the case of social policy, particularly a single-event test, there are no controls, no repeatability, and a huge reliance on the objectivity of the investigator. Even with all the good intentions in the world, I think it is hard to place that reliance on a crusader like Like Montaner - Dr Kerr's response to the (equally flawed) RCMP report is telling: rather than discussing their findings he simply dismissed their ability to investigate the issue while asserting his own.

I don't see a deliberate strategy of condoning and facilitating illegal drug use to be a minor policy - if it was, we probaby wouldn't be having this discussion. I agree that we should be evaluating and fully testing all drug policies (and other policies) - my comment was to warn against the assumption that we have tested this one.

"to facilitate criminal drug use"

Of course, the issue everyone is dancing around is why is drug use "criminal"? Addition to anything is a heath issue and should be dealt with more appropriately via public health rather that criminal law. Why exactly should my use of a substance on myself be illegal. The externalities of that behavior are already illegal - robbery, etc. Decriminalization would actually take the organized criminal element out of the picture (see Prohibition).

Its not like this position is something from the "moonbat" left. I share this opinion with wackos like George Shultz and much of the libertarian community.

Perhaps we save money not be getting rid of harm reduction but by dropping the idea that taking drugs should be illegal.

As for the peer review issue, might I suggest dcardno, that if you don't think the study was done right, obtain the data and analyze it yourself and see if you can replicate the results. Submit your version to peer review for analysis. That's how this works. If the study is wrong or flawed, we will here about it.

Let not forget that people are more apt to believe or disbelieved studies based on their preconceived notions. A lot of folks here are prepared to dismiss or question the harm reduction study and take away Insite funding while at the same time reject the numerous studies question the effectiveness of DARE and keep that funding flowing.

A bit odd, don't you think?

Mike - I agree that we would (probably) be better off in de-criminalizing drug use. By no means would that be considered a "rather minor policy" - and neither is decriminalization by stealth, in this case by providing a location where medical services are directly targeted to drug users and police don't enforce current drug laws. I am not arguing that current laws are the best available policy, but I take issue with Dan's assertion that INSITE is a "rather minor policy" - and that we should therefore be looking at other policy areas.

As for re-perfoming the BC Centre for HIV/AIDS study - one of the several problems with the study is that there is no baseline data, since there was no pre-INSITE data collected. Since we can't compare a control group, and we can't compare pre-INSITE data, the only way to copmpare the effect of INSITE is gather what data we can, shut the operation down, and then re-perform our observations. I don't think that's in the cards, do you? Alternatively, we could compare the rates of drug use and drug-related deaths in different metropolitan centres, although I suspect that the confounding factors of demographics, drug distribution infrastructure, and other policy responses will be insurmountable. As it is, we don't even know if INSITE is more effective than -say- the same resources used for an expanded needle-exchange program. For the second time, I will state that the anecdotal evidence to date and the study by the BC Centre for HIV/AIDS indicates that INSITE is a good program that should be continued, but advocates for the program oversell their case by claiming that (to quote Dan's orignal comment) "Insite has been rigorously tested and found to save lives and reduce disorder."

Dcardno:

First set of questions: How many users of illicit substances are there in Canada? How many have anything to do with Insite?

Second set of questions: How much money do Canadian governments spend on policies related to illicit drugs? How much money do they spend on Insite?

Last set of questions: Don't you think the enormous gaps apparent in the first set of questions justify describing Insite as minor relative to the Canadian drug policy as a whole? If not, please tell what on earth you would describe as minor?

Now, I stand by my original description of Insite but I would like to ask you this: If the review of Insite's work is so atrocious by your standard, why do you show so little interest in the fact that DARE and other prevention programs which have repeatedly failed reviews continue to be funded and used in schools? And why, if you are so passionate about accountability and rigorous research, do you show hardly a trace of interest in the fact that the law enforcement -- which receives the vast majority of all funding, amounting to tens of billions over the decades -- has NEVER been given even a cursory assessment?

Here's a suggestion: go to Google and search the word "psychology" and the phrase "confirmation bias". And then consider the possibility that it's not evidence or methodology that's driving your opinions at all. It's ideology.

"And why, if you are so passionate about accountability and rigorous research, do you show hardly a trace of interest in the fact that the law enforcement..."

No, no, a thousand times no. My interest is in not having people who claim to be making decisions on the basis of high quality (peer reviewed...oooh) research oversell that claim by relying on what is, in fact, poor quality research. This is the third time in this thread that I have stated that from the information available INSITE seems to be a program worth keeping - but the call for more and better research remains valid. That call for more research might sound something like "it would be nice to have some research by people who don't have a pre-conceived idea that the program is a success just by its existence - and equally, by people who don't come in with the opposite a priori assumption."

"Second set of questions: How much money do Canadian governments spend on policies related to illicit drugs?"
I have no idea, Dan - please point me to the comment where I claimed that current drug policies were a better or more cost-effective response to drug use than INSITE. Was it "I agree that we would (probably) be better off in de-criminalizing drug use." Yeah - I'm a real drug policy hard-liner, I guess.

"search the word "psychology" and the phrase "confirmation bias"
Right. And there's none of that in reliance on a report prepared by one of the campaigners for the facility.

"...it's not evidence or methodology that's driving your opinions at all."
My opinion (now for the fourth time) is that INSITE is probably not a bad program - unfortunately, due to the lack of reliable, independent research, I can do no more than form a tentative opinion. We are unlikely to ever get the information to form a more definite opinion, in part because proselytizing researchers like Dr Kerr polarize the debate - not least by responding to contrary conclusions with ad hominem arguments, and in part because third party advocates for the program refuse to distinguish criticism of our level of knowledge from criticism of their preferred policy.