Injecting doubt: the rhetoric of harm reduction and the fate of Insite

The debate over the future of Insite, the successful safe-injection and drug health centre in Vancouver's Downtown Eastside, grew more impassioned this month after the federal government's so-low-key-as-to-be-well-nigh-subsonic release of a report by a panel of experts tasked with assessing existing scientific research on the facility.

Perhaps the loudest squawk came from the authors of the report's most quoted studies: "This government may already have garnered a reputation for being the most antiscience government in Canadian history." In a sharply worded article published last week on Straight.com, Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accuse the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite's work with injection drug users.

Doing exactly what it was set up to do
Kerr and Wood charge the government with attempting to "cloud science" and "manufacture uncertainty." In the Tories' get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including 22 studies by the authors which appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

• contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
• helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
• achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
• not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to "deviant behaviour" is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite's articulate defenders — not even the largely positive conclusions of the government's own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

The most negative finding the Committee could come up with was that Insite did not show a record of addiction prevention. However, as the Canadian Medicine blog points out in an April 14 post, "it should come as no surprise that prevention hasn't improved. Perhaps the prevention of further harm and more death should be prevention enough, and we shouldn't expect one single intervention to solve the problem of drug addiction itself. After all, this is a 'harm reduction' project we are talking about — not harm prevention." However, as is the case with global warming, no amount of compounding detail is enough to disabuse the determined believer.

Ideological warfare
Given the significant disagreement on this issue, perhaps the very term "harm reduction" is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have "sufficiently inflamed ... drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented." Leshner advocates the avoidance of ideological intensity. "Let's get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense." This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one's-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

The worst part of having success is trying to find someone who is happy for you, as Bette Midler once said. Insite's harm reduction achievements are being deliberately downplayed as time runs out on the facility's exemption from federal legislation that would otherwise see operators charged under federal drug laws. The current licence expires on June 30, when Health Minister Tony Clement must decide whether to grant another exemption to the Controlled Drugs and Substances Act or amend legislation that prohibits it. Battle lines are being drawn as two law suits challenging the federal government's jurisdiction over the matter head to the British Columbia Supreme Court, and experts like Thomas Kerr demand publicly that the Minister honour the findings of his own researchers and stop injecting doubt by his disingenuous questioning of Insite's raison d'être.

The only dope worth shooting is ...
On the other side of the ideological divide, the Vancouver Police Union issued a recent statement criticizing Insite, which operates near capacity, for serving only a tiny minority. That's like denouncing underfunded and understaffed day care centres in this country for serving only a small number of Canadian children. According to the Canadian Press, Chief Superintendent Derek Ogden, the RCMP's director general of drugs and organized crime, echoed his masters by stating he would like to see further research. "I absolutely cringe when I hear people talk of a safe injection site," he said in an interview from Ottawa. How about that for informed comment. The Chief Superintendent probably also cringes at the thought of certain sexual practices, religious rituals, or undergraduate film studies courses. It's comforting to know that federal law enforcement policies are being planned based on the cringe factor. Health Canada spokespersons ran for cover and would only respond to emailed questions from the media. Predictably, they intoned the mantra that the Minister was "examining" the Expert Advisory Committee's report.

Perhaps Ottawa's balmy spring weather is distracting Mr. Clement. But the question needs to be asked. What further research is really needed, and how much more examining must he do? The money spent on this lengthy and redundant investigation (no cost figures for the Committee's efforts seem to be readily available) could probably finance the start-up of another harm reduction program in, say, Toronto or Montreal. Insite remains the only safe injection site in North America.

The strange timing of the report's appearance has not gone unnoticed. The surreptitious nature of its release late on a Friday afternoon seemed designed to minimize media coverage. The ideological reasons for the health minster's coy and constrained behaviour are obvious. As David Eaves so aptly comments on his blog, "for what must be the first time in Health Canada’s history the department is trying to bury a study that highlights how one of its programs improves healthcare outcomes to Canada’s most marginalized citizens."

Scientific arguments are insufficient in themselves
In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as "legalizers" in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction's muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science.The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, "Without commitment to 'strong rights' and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really 'legalizers' harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention."

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. Noam Chomsky once said, "The sign of a truly totalitarian culture is that important truths simply lack cognitive meaning and are interpretable only at the level of 'Fuck You', so they can then elicit a perfectly predictable torrent of abuse in response." Let's hope that the continuing controversy over harm reduction and safe injection sites will not sink to that level.

References:

1. Leshner AI. By now, "harm reduction" harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

A PDF version of the Expert Advisory Committee's report has been created by David Eaves (www.eaves.ca) and is available here.

And here are the reports from the independent researchers as provided by the Vancouver Sun: http://www.canada.com/vancouversun/pdf/FinalCost-BenefitAnalysis_.pdf http://www.canada.com/vancouversun/pdf/finalEnvironmentalScan-IDU.DOC http://www.canada.com/vancouversun/pdf/boydetalfinalsis.pdf

PubMed sends out a few new blooms: simplified web links

As the snow melts under the tall spruces around my house and flocks of Canada geese honk in the skies overhead like roaring twenties traffic, the blooming bottle brush trees and ocotillos of Palm Springs occupy my dreams, disquietingly alien, like science fiction flora. The Day of the Triffids meets flip-flops and Ray-Bans. On a California oldies station a snatch of the opening number from The Rocky Horror Picture Show: "And I really got hot when I saw Janette Scott / Fight a triffid that spits poison and kills." Those lurid red blooms nodding in the desert breeze seem to be searching for something. My pale raw flesh perhaps? The desert is strangely alive with growing things.

Half a continent away from the riotous brittle bushes of Tahquitz Canyon, flowers are merely in potentia here as the earth slowly thaws and scatters the snow lice in my boreal soul. But spring has come. Like my labs, I'm blowing my coat after a snarling winter. Frisking red squirrels and fisking politicians are chattering away, the sun's warmth is infectious, and my thoughts turn towards spring cleaning, perennials, and ... PubMed updates.

A recent NLM Technical Bulletin informs us that the URL parameters used to generate web links to PubMed have been simplified. I hadn't realized they were excessively complicated, but I'm all for simplicity, and I suppose eliminating the tiresome "entrez" filler in PubMed URLs is progress. I never did see the point of it. Although you'd think it would have made more sense to dump "entrez" during the past francophobic furor, when victory fries were flung in the face of l'ennemi du jour, that nation of cheese-eating surrender monkeys.

Creating Simplified Web Links to PubMed
Nothing of earth-shattering importance here, but the Bulletin's terse summary is as digestible as human flesh to a triffid and saves trawling through the user guide. It gave me some ideas about how I might use these PubMed features more frequently.

1. Simplified URL The base URL to retrieve citations and search PubMed is http://www.ncbi.nlm.nih.gov/pubmed/. Just add the PMID. I would have liked it even better if they could have eliminated most of the alphabet soup. What prevented them from achieving a del.icio.us-like simplicity by allowing us to use http://pubmed.com? This very simple URL actually works, even with a PMID stuck on. Now that's spitting poison. Pubmed.com is resolved into an ncbi.nlm.nih.gov-type URL. But, curiously, not the new, "simplified" URL that is the subject of this announcement. If, for example, you enter

http://pubmed.com/1386390

it resolves to the following:

http://www.ncbi.nlm.nih.gov/sites/entrez/1386390

You get to the citation, but there's that annoying surrender monkey word in the non-simplified URL. Can anyone explain why this happens?

2. Retrieve one or multiple citations

Here's something that I haven't used much. You can separate PMIDs with a comma after the base URL to retrieve citations in the default AbstractPlus HTML format:

http://www.ncbi.nlm.nih.gov/pubmed/10742334,1386390

My staff use this trick regularly to call up multiple records in order to print articles for our patrons from written requests. I can see myself using it — along with the code to change the format to text (see below) — for producing quick, painless citations.

3. Change the format To change the format from html to text, use format=text:

http://www.ncbi.nlm.nih.gov/pubmed/1386390?format=text

I like the way this technique lets you create a quick-and-dirty citation, no matter which display you're working from. Go up to the URL, erase everything after the question mark, and enter the code "format=text." Remove the carriage returns from the resulting citation, erase the extraneous text, and you have a decently formatted citation. (It would be so nice if PubMed had a convenient button for each reference which would create a proper citation in one of the leading bibliographic formats and copy it to the clipboard for easy insertion into a document. But I'll make do with this.)

Wiswell TE. John K. Lattimer Lecture. Prepuce presence portends prevalence of potentially perilous periurethral pathogens. J Urol. 1992 Aug;148(2 Pt 2):739-42. No abstract available. PMID: 1386390 [PubMed - indexed for MEDLINE]

Of course, the easiest option is to find the reference in PubMed and select Text on the Send to pull-down menu. Send multiple references to the Clipboard first and then send to text. But make sure you're looking at the Summary display. If you send to text from the Abstract display, you're left with a fragmented citation full of blank lines, even more extraneous material to delete, and all the clicking-cutting-pasting that spells kluge.

Until we get that magic button, I'll continue to use this method for quick citations from PubMed. I know that a program like RefWorks will give me perfectly formatted citations, but all the required loading and clicking and waiting is too much effort just to produce a simple reference to insert into a blog post or an email.

4. Change the display To change the display, add the URL parameter ?report=display (where "display" is the name of the desired PubMed display format such as citation, MEDLINE, etc.).

5. Search strategy URLs: To search PubMed, use the URL parameter ?term=search (where "search" is the actual strategy):

http://www.ncbi.nlm.nih.gov/pubmed?term=tp53+cancer

Note that the + sign takes the place of spaces, which are not allowed in the URL. This looks less useful. It's the rare day that my searches are so simple.


My NCBI Collections added to PubMed Send To Menu
Finally! I think everyone will appreciate this small improvement. My NCBI Collections is now available as a selection under the PubMed results Send to menu. Sending results to a Collection was previously only available from the Clipboard. Works like a charm.

From critical care to comfort care: the sustaining value of humour

He who has laughter on his side has no need of proof. ~ Theodor Adorno, Minima moralia

(Plagiarized from a UPI news item) A study by a Winnipeg researcher shows that humour can play an essential role in intensive or end-of-life care. Continuing research begun in her 2003 dissertation, Ruth Dean of the University of Manitoba Faculty of Nursing, with her colleague Joanne Major, a nurse at the Health Sciences Centre, spent hundreds of hours observing and carrying out interviews with staff, patients and families in an intensive care unit and a palliative care unit.

Their paper, published in the Journal of Clinical Nursing, demonstrates how health care staff use humour not only to reduce tension and express frustration, but to connect with patients, making them feel cared for as individuals and alleviating their embarrassment. They conclude that humour plays an essential role in promoting team relationships and adding a human dimension to the care and support of seriously ill patients and their families. "Our research suggests that nurses and other health care professionals don't need to suppress humour," Dean said in a statement.

The researchers found that staff used humour in a number of ways:

• To cope with, and sometimes distance themselves, from difficult situations. As one person commented: "When you've had the most stressful day and you're ready to cry, sometimes it's easier to bring out humour and take it in the other direction instead of bawling on somebody's shoulder."

• To connect with other health care professionals and provide mutual support. Shared laughter energized and nurtured a sense of community. "If you have those fun moments and that connectedness even the worst hell can happen," said one person who worked with terminally ill patients. "You sail through it as opposed to walking out really wounded."

• To reduce tension when things don't go as well as they could do. A doctor who admitted he had been hasty suggesting that a terminally ill man give up his apartment so soon was greeted with the quip: "Shall I chart that you made a confession or that you made a mistake?"

• To express frustration at life-prolonging measures that staff disagreed with. Staff in the intensive care unit told researchers how they paralleled what was happening to one patient by using an inflatable dinosaur called Dino and putting him through the same interventions. He became a symbol of their dissatisfaction with the situation.

• To connect with patients and make them feel cared for as individuals. When a health care aide took a joke picture of a patient with a bubble bath helmet on his head to put him at ease, it became one of his prized possessions. He showed it to everyone who visited as evidence of the special treatment he was receiving. And when he died, it was displayed alongside important family photos.

• To reduce patients' embarrassment with the indignity of needing help with toileting and other highly personal functions. When a patient suffered an episode of incontinence she reported that she found the nurse's matter-of-fact humour — "what goes in must come out" — made her feel less distressed.

It wasn't just the staff who used humour to alleviate difficult situations. One nurse recalled how a patient's monitor kept going off in the intensive care unit. "Don't worry, if I can hear it I'm still alive," the patient joked.

"Some people feel that humour is trivial and unprofessional in health care settings, but this study shows that it is neither," said Dr. Dean. "Despite major differences between the work of the intensive care and palliative care units, they are both areas where serious illness, high anxiety and patient and family distress are prevalent and staff are placed in emotionally demanding situations. Crises are frequent, death is close by, and emotions tend to run high."

The authors conclude that humour was very important in these stressful health care settings. "One member of staff referred to humour as the glue that holds human connections together, a statement that was clearly reinforced by our findings," said Dr. Dean. "Our research suggests that nurses and other health care professionals don't need to suppress humour. They should trust their instincts about when it is appropriate. Combined with scientific skill and compassion, humour offers a humanizing dimension in health care that is too valuable to be overlooked."

Reference:

Dean RA, Major J E. From critical care to comfort care: the sustaining value of humour. J Clin Nurs. 2008 Apr;17(8):1088-95.