Peddling a myth-based addiction strategy Government cherry-picks details in shunning harm-reduction methods By: Katrina Clarke Posted: 7:00 PM CST Friday, Feb. 10, 2023 Last Modified: 12:31 PM CST Sunday, Feb. 12, 2023 Updates

Manitoba’s government says its decision to reject supervised consumption sites is based on “evidence.”

But a Free Press analysis of that evidence reveals little — if any — backs up the province’s decision to outright reject the sites. In fact, some of it contradicts the government’s position, arguing in favour of safer drug use spaces.

Meanwhile, advocates say no quantity — nor quality — of testimonials or research will be enough to convince a government whose opposition is rooted in ideology.

Seeking to understand how the province reached its decision, the Free Press has reviewed hundreds of pages of studies, reports and commentaries — some obtained via a freedom of information request; others referenced by the government in news releases or provided on request.

The Free Press analysis shows the province’s research on recovery approaches to tackling addiction was fulsome, but little addressed the value of supervised consumption sites. It’s only a partial picture though, as some research was heavily redacted.

One renowned harm reduction expert went so far as to call some of the cited research “a mess,” labelling the province “ill-informed.”

“They’re holding up low-quality, often ideologically driven, commentaries to justify doing something that they don’t want to do for ideological reasons,” said Ryan McNeil, director of harm reduction research at the Yale University school of medicine and a researcher with the B.C. Centre on Substance Use.

Manitoba’s Progressive Conservative government, however, insists its position is based on evidence, not ideology.

“The province is committed to ensuring a Recovery Oriented System of Care, which includes availability of evidenced-based supports across a continuum of care — prevention, early intervention, including harm reduction, treatment and recovery — and a relentless pursuit of recovery for individuals impacted by substance use/addiction,” read a statement from a spokesperson for the minister of community wellness.

The numbers, however, are clear: 407 drug overdose deaths in 2021; more than 200 in the first six months of 2022; and a trajectory that’s expected to climb in 2023.

What are supervised consumption sites:

Supervised consumption sites, also known as safer injection sites, are spaces where people can consume their own illicit substances, knowing if they overdose, staff will revive them with naloxone, oxygen or other life-saving interventions. The spaces typically operate with provincial funding and support and, thanks to federal exemptions, allow people to consume drugs without fear of being arrested.

Advocates say the sites promote safer injection practices, save lives, decrease the spread of blood-borne diseases, reduce emergency room visits and calls to paramedics, limit public consumption of drugs, reduce the presence of discarded needles in community spaces and connect people who use drugs with supports, including treatment, housing and jobs.

At the federal level, Health Canada says the sites provide “evidence-based harm reduction services.”

Canada’s first legal supervised consumption site, Insite, opened 20 years ago in B.C. But even with a long history in this country, the sites remain controversial, often dismissed by conservative governments as problematic or encouraging drug use. Still, Quebec, Ontario, B.C. and all Prairie provinces have adopted them — with the exception of Manitoba.

In November, the Stefanson government cemented its position, rejecting the sites in an announcement about its “recovery-oriented” approach to addictions. The announcement prompted outcry from harm reduction advocates who said the spaces are urgently needed to help address the toxic drug crisis.

Manitoba’s overdose data shows death rates are steadily climbing — over a five-year period overdose deaths more than doubled, with 188 deaths in 2016 and 407 in 2021. Experts say the pandemic played a role, which resulted in people being less able to access harm reduction services, people using drugs alone during lockdowns, and illegal drug supply chain disruptions, making the product more toxic.

Amid the urgent health crisis, and in the face of strongly held opposing views, the Free Press has sought to independently assess the evidence on both sides.

The evidence:

The research provided by the province on request to the Free Press, or otherwise cited in government news releases, includes:

● 2017 report from the Canadian Centre on Substance Use and Addiction that focuses on recovery but makes no mention of supervised consumption sites;

● 2015 report from the Mental Health Commission of Canada that also focuses on recovery but makes no mention of supervised consumption sites;

● 2022 report on the opioid crisis in North America published in the Lancet medical journal, which briefly touches on supervised consumption sites, calling research on them “methodologically weak” but noting people do not die when using them;

● 2018 paper titled Assessing the Evidence on Supervised Drug Consumption Sites, which calls for more research but notes the sites do not cause harm and could be a useful tool to address the evolving toxic drug crisis;

● and a similar 2019 article by the same authors in Addiction, a journal by the Society for the Study of Addiction, titled Supervised Consumption Sites: A Nuanced Assessment of the Causal Evidence, which questions the ethics of decision-makers setting a high bar for research on supervised consumption sites amid a crisis.

McNeil, the Yale expert, called the Manitoba case a “perfect example” of confirmation bias — seeking out evidence to back up an already established position.

“What we really see is resistance to implementing a life-saving intervention… coded in different ways depending on what’s convenient,” he said. “The reality is it’s just something that for whatever reason they don’t want to do. And I think quite frankly people should find that quite deeply offensive.”

The evidence, part 2 (The FIPPA request):

Some of the information the province relied on to make its decision remains secret.

In November, the Free Press filed a freedom of information request asking the Department of Mental Health and Community Wellness for all records discussing supervised injection sites over the past two years. The department’s response included four partially redacted pages discussing a 2019 Alberta report that was later panned by experts, and a 2018 Manitoba report that sparked claims of political interference.

The remaining 94 pages were redacted.

“The silence is deafening,” said Thomas Linner, provincial director of the Manitoba Health Coalition, a group mentioned in the FIPPA response as leading a call for the sites. “What I see is 94 blank pages that for whatever reason they don’t want you to see.”

“What I see is 94 blank pages that for whatever reason they don’t want you to see.”–Thomas Linner

Linner questioned why so much was redacted, saying it was a “golden opportunity” for the province to showcase its research and evidence. He called the province’s approach to research, including the two documents in the FIPPA, “cherry-picking.”

Two of the partially redacted pages also show the province’s internal response to an open letter in November from more than 80 community organizations, including the Manitoba Health Coalition, calling on the government to fund and support supervised consumption sites.

The department’s response notes, labelled “advice to minister/cabinet,” include a summary of what supervised consumption sites are: “a low threshold service typically run by nurses, social workers and public health workers who provide sterilized injection equipment and counselling to users, but are not typically allowed to provide drugs or directly assist in the process of injection.” It lists the main goals of such sites as: reducing morbidity deaths, connecting drug users with social, health and addiction services, and reducing “public order problems” including public drug use and discarded needles.

The Alberta report:

The response notes go on to include key points from a 2019 Alberta government-led review of the seven supervised consumption sites in that province.

The document notes the review committee heard “predominantly negative” feedback about the Alberta sites — the first of which opened in 2017 — including: that residents “complained about aggressive and erratic behaviour of substance users leaving the sites”; that crime, “as measured by police calls for service” generally increased in the area of the sites; and that residents complained about used drug paraphernalia in the area.

However, a 2021 article published in Harm Reduction Journal, criticized the review methodology and premise, dismissing the work as biased and flawed.

The article’s author, Jamie Livingston, an associate professor in the department of criminology at Saint Mary’s University, concluded that “the magnitude of methodological flaws in the (Alberta) report undermine the validity of its criminological claims and raise significant issues with the soundness of its conclusions.”

McNeil said the Alberta review’s framing of the sites was problematic, but not surprising.

“The politicization of supervised consumption sites is ongoing and completely counter-productive in the context of a drug-poisoning crisis,” he said.

The Virgo report:

The other document unearthed via FIPPA has also been the subject of controversy.

When the 2018 Virgo consultant’s report on Manitoba’s mental health and addictions services was first released to media, it included a recommendation to implement supervised consumption sites in Winnipeg. But when it went up online, that recommendation was removed, prompting critics to accuse the then-Brian Pallister-led government of political interference.

The report’s author, Dr. Brian Rush, later insisted the report released to media was only a draft — he denied political interference was involved in removing the recommendation.

The Free Press requested an interview with Rush to ask if his position on supervised consumption sites for Manitoba has changed but he declined, saying he hasn’t followed local developments since the Virgo report.

Why the document was redacted:

Asked for comment on the heavily redacted document, an unnamed spokesperson for the Minister of Community Wellness — formerly Sarah Guillemard, but now Janice Morley-Lecomte following a cabinet shuffle in late January — referred the Free Press to the reasons listed in the response letter.

They range from “unreasonable invasion of privacy” to “advice to a public body” — provisions in privacy legislation that allow public bodies to keep public records secret. It’s not clear why the four partially redacted pages, labelled “privileged and confidential” and “advice to minister/cabinet,” were not considered private or advice. The response letter notes “much of the redacted content in the records is not related to the topic of your request, but rather to the broader topic of addiction services.”

Kevin Walby, an associate professor in the department of criminal justice at the University of Winnipeg and director of the Centre for Access to Information and Justice, said the response follows a pattern of information request refusals in Manitoba.

“I think they are conveniently using the cabinet confidence section to block access and then using the other sections as sort of distractions for mass severing of the records,” Walby said.

What the research doesn’t say:

Beau Kilmer, a co-author on two of the reports cited by the province, told the Free Press his work is intended to highlight the limitations of existing studies and the need for more rigorous research on the topic of supervised consumption sites — it doesn’t outright say they should be rejected.

In fact, he encourages governments to test them out as part of a continuum of care that includes a focus on treatment, recovery and harm reduction. He’d like to see more reports studying burgeoning sites alongside cost-benefit analysis to assess their value.

“We need to innovate, we need to try some different things,” said Kilmer, co-director of the U.S.-based RAND Drug Policy Research Center. “In some of these cases, you’re not going to know (if it works) unless you try it.”

The 2019 article Kilmer co-authored, Supervised consumption sites: a nuanced assessment of the causal evidence, digs into who might support the sites and who will remain opposed.

For politicians grappling with a toxic-drug crisis, “the existing evidence justifies moving forward,” the article states. It likens hold-outs to those who would insist on seeing the evidence of parachutes “before donning one when leaping from a plane.”

“However, for sticklers wedded to traditional hierarchies of evidence, the evidence base has limitations. It is also minimal for planners who need to gauge the magnitude of benefits and potential for SCS to solve a large proportion of the national overdose problem.”

Kilmer’s research papers suggest there is not enough evidence to draw causal conclusions such as how effective the sites are at saving lives in the long term, preventing HIV transmission and other related claims. He advocates for more “rigorous” research, including randomized control trials.

McNeil is critical of such calls, saying sufficient evidence exists and control trials in these cases are inappropriate and unethical.

“The reality is that that’s not a research design that’s appropriate for the evaluation of supervised consumption sites to begin with,” McNeil said. “(Randomized control trials) would effectively involve denying people access to what is established as a life-saving service.”

“People should be quite deeply offended that governments are positioning this as one or other.”–Ryan McNeil

But he acknowledged this research limitation “muddies the waters,” giving critics the opportunity to argue the evidence is weak and as such, the sites shouldn’t be implemented.

Existing evidence is “compelling” and “methodologically appropriate,” he said.

McNeil said existing evidence shows the sites result in a reduction in overdose deaths; reductions in the transmission of HIV; reductions in drug-related risks, like syringe sharing; increased referrals to substance-use treatment and access to medical care; and contributes to a broader feeling of safety amongst those who use drugs.

Furthermore, he notes that support for treatment and recovery — which the bulk of the province’s research appears to focus on — can and should co-exist with support for supervised consumption sites.

And even with treatment, relapses happen.

“People should be quite deeply offended that governments are positioning this as one or other, when the reality is you need investment in both to have a thoughtful combination response to an ongoing public health emergency,” McNeil said.

The advocates’ perspective:

Advocates question why the province doesn’t focus on existing evidence showing the sites are needed.

Last February, the Manitoba Harm Reduction Network released a report titled Harm Reduction Services in Winnipeg: A Consolidating Report and Call to Action. The report includes a review of the literature about supervised consumption services, citing evidence from peer-reviewed studies, alongside 15 recent reports and position statements — including those from groups supporting vulnerable Winnipeggers, the Manitoba Police Commission, the Office of Manitoba’s Chief Medical Examiner and others — on the growing problem of substance use in Winnipeg.

“You can see that we have done lots of work at the community level to collate and create evidence and strategies in support of SCSs,” said Kim Bailey, a co-author of the report and director at Nine Circles Community Health Centre. “We did this with the hopes that if we provided the evidence, it would influence our system to move in this direction.”

Asked if the province considered the report in its research, the spokesperson for the minister of community wellness said it had reviewed one of the network’s documents.

“We have read the report referenced on ‘safer consumption spaces’ but would like to ensure that the reporter is aware that changes in public policy that would have significant lasting impacts on individuals, families, and communities should be based off of quality, scientific evidence — e.g. RCT (randomized control trials), quasi-experimental designs — not only anecdotal information,” the statement read.

Harm reduction advocates, however, insist it’s the province that refuses to look at the science.

“The current provincial government has been clear that they support ideology and not science when discussing Supervised Consumption Services in Manitoba,” said Shohan Illsley, executive director of the Manitoba Harm Reduction Network. “The community has expressed concerns with the approach this government is taking when conducting its research regarding SCS.”

Illsley pointed to two recent controversial incidents involving the province’s research.

“Most recently this government’s research has included Premier Stefanson citing false information about ‘California’s decades of experience with SCS,’ a state that has in fact never had SCSs,” she said. “Further, Minister Guillemard’s research included visiting Vancouver’s Downtown Eastside and making inferences about what she saw.”

While Guillemard said she “witnessed” supervised consumption sites in Vancouver, the Free Press revealed she never went inside.

B.C. government injects truth into Manitoba official’s account of drug-site visit

Notably, some of the province’s own research directly contradicts its own claims.

While Stefanson has routinely said supervised consumption sites lead to “unintended consequences” — specifically, increases in crime, the 2019 paper, Supervised consumption sites: a nuanced assessment of the causal evidence, states: “There is no evidence that SCS increase crime. Multiple studies of (a site in Sydney, Australia) find no effect on crime, and one examining Vancouver suggests that crime may have fallen after Insite opened.”

Illsley said advocates remain undeterred and continue to fill harm reduction gaps the province has left open. She pointed to Sunshine House’s mobile overdose prevention site, which travels around the city and gives people who use drugs a safe space to inject, and the organization’s recent accomplishment: securing funds for drug-testing equipment.

“Ending this crisis in Manitoba is important to all of us,” Illsley said. “We all love someone who uses drugs. The harm reduction community will continue to advocate and move forward to establish safer consumption services in this province.

“Our hope is that the province will be a strong supporter and collaborator with us on this life-saving initiative.”

katrina.clarke@freepress.mb.ca

Katrina Clarke
Investigative reporter

Katrina Clarke is an investigative reporter with the Winnipeg Free Press.

   Read full biography