Defining Moments and Healing Emplotment: "I Have Cancer; It Doesn't Have Me".

Whereas illness, sickness, and disease are dark clouds on the horizon of our lives, the complex process of healing is our sunrise. In this essay, I introduce the concept of healing emplotment, a lived process of knowingly bringing together strategies for self-awareness, the creation of hope, and the management of risk to overcome psychosocial peril. This results in a purposeful re-authoring of the self in society, personhood, in the face of life-threatening events. Rather than only bringing threats to which the stricken must respond, serious illness can also present opportunities for narrative re-authoring of our biopsychosocial self.

Treating Addictions: Harm Reduction in Clinical Care and Prevention.

This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which shows that some ways of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: (1) through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, (2) by developing innovative clinical programmes that employ harm reduction, and thereby (3) changing the standard of care to include routine use of these evidence-based (but often misunderstood) approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations.

Canada's highest court unchains injection drug users; implications for harm reduction as standard of healthcare.

North America's only supervised injection facility, Insite, opened its doors in September of 2003 with a federal exemption as a three-year scientific study. The results of the study, evaluated by an independent research team, showed it to be successful in engaging the target group in healthcare, preventing overdose death and HIV infections while increasing uptake and retention in detox and treatment. The research, published in peer-reviewed medical and scientific journals, also showed that the program did not increase public disorder, crime or drug use. Despite the substantial evidence showing the effectiveness of the program, the future of Insite came under threat with the election of a conservative federal government in 2006. As a result, the PHS Community Services Society (PHS), the non-profit organization that operates Insite, launched a legal case to protect the program. On 30 September 2011, Supreme Court of Canada ruled in favour of Insite and underscored the rights of people with addictions to the security of their person under section 7 of the Charter of Rights and Freedoms (Charter of Rights). The decision clears the ground for other jurisdictions in Canada, and perhaps North America, to implement supervised injection and harm reduction where it is epidemiologically indicated. The legal case validates the personhood of people with addictions while metaphorically unchaining them from the criminal justice system.

An appeal to humanity: legal victory in favour of North America's only supervised injection facility: Insite.

Canada's federal government has once again failed to shut North America's only authorized supervised injection facility: Insite. A majority ruling issued by the BC Court of Appeal on 15 January 2010 upheld an earlier British Columbia Supreme Court ruling in 2008 that protected the rights of injection drug users (IDUs) to access Insite as a health facility as per the Charter of Rights and Freedoms component of the Constitution of Canada. The majority decision from Honourable Madam Justices Rowles, Huddart and Smith also established a jurisdictional victory safeguarding Insite as most appropriately run under the authority of the province of British Columbia rather than the federal Government of Canada. The Federal Government has appealed the case to the Supreme Court of Canada. A hearing date has been set for 12 May 2011. The appeal will be a legal one but even more so, it will be an appeal to humanity.

The Washington Needle Depot: fitting healthcare to injection drug users rather than injection drug users to healthcare: moving from a syringe exchange to syringe distribution model.

Needle exchange programs chase political as well as epidemiological dragons, carrying within them both implicit moral and political goals. In the exchange model of syringe distribution, injection drug users (IDUs) must provide used needles in order to receive new needles. Distribution and retrieval are co-existent in the exchange model. Likewise, limitations on how many needles can be received at a time compel addicts to have multiple points of contact with professionals where the virtues of treatment and detox are impressed upon them. The centre of gravity for syringe distribution programs needs to shift from needle exchange to needle distribution, which provides unlimited access to syringes. This paper provides a case study of the Washington Needle Depot, a program operating under the syringe distribution model, showing that the distribution and retrieval of syringes can be separated with effective results. Further, the experience of IDUs is utilized, through paid employment, to provide a vulnerable population of people with clean syringes to prevent HIV and HCV.

Love as harm reduction: fighting AIDS and stigma in Vietnam.

In the summer of 2009, I visited a humble orphanage for children with HIV/AIDS in Vietnam. Here, like many parts in the world, the very existence of marginalized people with stigmatized illness is hidden away. Relegated to the shadows of society, these children lacked something more fundamental than housing, shelter, nutrition and medications. They lacked families to love and care for them unconditionally. One might think it self-evident that a visit to an orphanage for children with HIV would be profound, but the profundity wasn't where I expected to find it. It was in how the children had created their own family, loving each other like brothers and sisters, and the way the priest who operated the shelters was more than a Father, he was a dad to dozens of children. This is an account of love as harm reduction in the Mai Tam orphanage in Ho Chi Minh City.

Fighting addiction's death row: British Columbia Supreme Court Justice Ian Pitfield shows a measure of legal courage.

The art in law, like medicine, is in its humanity. Nowhere is the humanity in law more poignant than in BC Supreme Court Justice Ian Pitfield's recent judgment in the legal case aimed at protecting North America's only supervised injection facility (SIF) as a healthcare program: PHS Community Services Society versus the Attorney General of Canada. In order to protect the SIF from politicization, the PHS Community Services Society, the community organization that established and operates the program, along with two people living with addiction and three lawyers working for free, pro bono publico, took the federal government of Canada to court. The courtroom struggle that ensued was akin to a battle between David and Goliath. The judge in the case, Justice Pitfield, ruled in favour of the PHS and gave the Government of Canada one year to bring the Controlled Drugs and Substances Act (CDSA) into compliance with the country's Charter of Rights and Freedoms. If parliament fails to do so, then the CDSA will evaporate from enforceability and law in June of 2009. Despite the fact that there are roughly twelve million intravenous drug addiction users in the world today, politics and prejudice oards harm reduction are still a barrier to the widespread application of the "best medicine" available for serious addicts. Nowhere is this clearer than in the opposition by conservative Prime Minister Stephen Harper and his faithful servant, federal health minister Tony Clement, towards Vancouver's SIF ("Insite"). The continued angry politicization of addiction will only lead to the tragic loss of life, as addicts are condemned to death from infectious diseases (HIV & hepatitis) and preventable overdoses. In light of the established facts in science, medicine and now law, political opposition to life-saving population health programs (including SIFs) to address the effects of addiction is a kind of implicit capital punishment for the addicted. This commentary examines the socio-political context of the legal case and the major figures that contributed to it. It reviews Justice Pitfield's ruling, a judgment that has brought Canada one step closer to putting a stop to addiction's death row where intravenous drug users are needlessly, for political and ideological reasons alone, forced to face increased risks of death due to AIDS, hepatitis and overdose.

Return to Galileo? The Inquisition of the International Narcotic Control Board.

Nearly 400 years after Galileo Galilei of Florence was arraigned and convicted of suspected heresy by the ten member Congregation of the Holy Office (Inquisition), the International Narcotic Control Board (INCB) is similarly inserting itself into matters pertaining to innovations in healthcare and the public health response to addiction throughout the world. Like that earlier Inquisition of 1633 that convicted Galileo of heresy for holding that the sun is the centre of the universe with the earth revolving around it (in contradiction to church doctrine of the time) the INCB and its thirteen-member panel, now rails against any evidence out of sync with the established doctrine of the war on drugs--particularly those innovations in public health called harm reduction. The latest healthcare and harm reduction practices to attract the ire of the INCB Inquisition are elements of Canada's most effective and innovative measures to minimize the harms of drugs in Vancouver--supervised injection facilities and, recently, the potential establishment of supervised inhalation rooms--along with the long established practice of providing safer mouthpieces for pulmonary inhalation in British Columbia. This is particularly significant as it comes in the midst of a crucial battle between municipal and provincial authorities in BC with the federal government in Ottawa, which seems determined to undermine all the most effective HR programs that are the result of years of steady local and governmental support in Vancouver and now threatens to derail all these programs and spread doubt about their usefulness despite the overwhelmingly positive findings of serous research.

Amazing grace: Vancouver's supervised injection facility granted six-month lease on life.

Addiction should be a matter, primarily, for the Chief of Medicine rather than the Chief of Police. While internationally renowned for its social kindness, Canada has not been without its share of disgraceful political mistakes in the not too distant past. Regrettably, there are many shameful events in Canada that have unfolded in the name of public policy including the banishment without medical treatment of Chinese Canadians living with leprosy to die on D'Arcy and Bentinck Islands in British Columbia while European Canadians stricken similarly enjoyed healthcare on the mainland as well as the eternally haunting treatment of people of aboriginal ancestry who were without full voting privileges in some parts of Canada until 1965 and abandoned to encampments, reserves, that paralleled South African apartheid. In due course, these public policies have come to be understood as horrific in retrospect. Many have all met with a remorseful fate where a future Prime Minister is held to public account for the sad excesses of an earlier generation. With respect to North America's only supervised injection facility (SIF), a medical program aimed at reducing fatal overdoses and infections (HIV, HCV) in injection drug users, Canada's Prime Minister Stephen Harper holds the ability to forestall a similarly heartrending fate in his political hands. The SIF currently has a temporary exemption from Canada's "Controlled Drugs and Substances Act" in order to operate until June of 2008. As such, the fate of the SIF is politically determined each time behind closed doors by the Prime Minister and his ministers. Sadly, the Prime Minister appears lost at present, content to ignore the scientific and medical evidence on the matter of population health. In light of the vast medical evidence accumulated on Vancouver's SIF, the fate of injection facilities needs to be taken out of the political realm entirely. I am hoping that the Prime Minister will be found, see the light of the scientific evidence, and lead the way towards to provision of a permanent medical exemption for injection facilities from Canada's Controlled Drugs and Substances Act (CDSA). In so doing, the Prime Minister would be on the brink of grace and would rescue a life saving health program from perpetual political interference.

Fools rush in where angels fear to tread Playing God with Vancouver's Supervised Injection Facility in the political borderland.

Healthcare does not exist in a social vacuum. Nowhere is this more obvious than in the case of people living with active addiction who are treated as social lepers: feared, despised and socially banished from the wider human family. People with addictions, and their families, fight for survival in the moral borderland between two competing understandings of their condition. According to one understanding, addiction is a concern for the criminal justice system while according to the other it is primarily a population health issue. In one orientation, addicts are troublesome offenders, while in the other they are wounded persons in need of medical attention. These competing values form a cultural web of belief that extends far beyond healthcare to the highest political office of Canadian society. This paper examines the politics of addiction over a 6-year period beginning at the municipal level in Vancouver and culminating with a confrontation between the Prime Minister of Canada and the tiny neighbourhood that provides a home for North America's only Supervised Injection Facility. Not wanting to let the medical facts get in the way of a political stand, Prime Minister Stephen Harper and his Health Minister, Tony Clement, played God this summer by playing politics with the lives of people in the shadows of Canadian society.

Closed to reason: time for accountability for the International Narcotic Control Board.

For more than two decades, the International Narcotic Control Board (INCB) has tried to stop harm reduction and its HIV prevention programs. This posture is based on a fundamental misunderstanding of their responsibilities and of drug addiction itself--i.e. as a public health and clinical care matter made criminal by decree. A recent focal point for the Board's action has been rejecting the use of supervised injection facilities to reduce morbidity and mortality of drug injectors. They single out individual countries and attempt to bully them into rejecting such programs under the banner of the United Nations (falsely) and in the name of international treaties. Their unrelenting and unjustified badgering of signatories to the international treaties that established the INCB is not only unjustified; it is an affront to one of the core purposes of the Board itself: to ensure adequate medical supplies and safe use of controlled substances. The INCB's ill-conceived obsession with intravenous addiction as a crime flies in the face of the medical view and policies of the World Health Organization and the universally endorsed principles of the General Assembly of the United Nations. The latest target of the INCB is North America's only supervised injection facility, Insite, located in the inner city of Vancouver, Canada. Using the power of their office to meddle in matters of public health for individual nations is without medical, scientific or legal justification. But, most importantly, it is a matter of life and death for these most marginalized of citizens. The empirical evidence remains that a significant portion of the continued growth of the AIDS pandemic is due to injecting drug use, and the INCB's intrusion will inevitably result in additional deaths due to preventable HIV infections and drug overdoses. So we are very pleased to call to our readers' attention to a recent report produced by the Canadian HIV/AIDS Legal Network and the International Harm Reduction Development Program (IHRD) joined by former United Nations Special Envoy for HIV/AIDS in Africa, the respected Canadian statesman Stephen Lewis. The full report, "Closed to Reason: The International Narcotics Control Board and HIV/AIDS" is attached along [see Additional file 1] with a Russian translation of the key findings of the authors [see Additional files 2] as well as Russian and Chinese translations of this abstract [see Additional 3 and 4]. As the report makes very clear, the time to inject some accountability and reason into the INCB is now.

Patient, prisoner or person?

Case studies provide rich descriptions of significant vignettes that highlight atypical systemic or clinical problems and identify potentially important research questions. The case study presented by Venters, Razvi, Tobia and Drucker (2006) describes an unfortunate set of events pertaining to an individual's experience as they were failed by s several systems all at once and neglected for having had experience with an addiction. This commentary provides some remarks on the case study with respect to differing institutional narratives as they pertain to lived experience in the context of everyday life. It is suggested that, in the special case of addiction, the mistreatment of the subject of the case study, Mr. Ortiz, is not an exception to the norm, but the norm itself for people living with addictions and their families.

Policy makers ignoring science and scientists ignoring policy: the medical ethical challenges of heroin treatment.

A decade of research in Switzerland, The Netherlands, Germany, and Spain now constitutes a massive body of work supporting the use of heroin treatment for the most difficult patients addicted to opiates. These trials concur on this method's safety and efficacy and are now serving as a prelude to the institution of heroin treatment in clinical practice throughout Europe. While the different sampling and research protocols for heroin treatment in these studies were important to the academic claims about specific results and conclusions that could be drawn from each study, the overall outcomes were quite clear--and uniformly positive. They all find that the use of prescribed pharmaceutical heroin does exactly what it is intended to do: it reaches a treatment refractory group of addicts by engaging them in a positive healthcare relationship with a physician, it reduces their criminal activity, improves their health status, and increases their social tenure through more stable housing, employment, and contact with family. The Canadian trial (NAOMI), now underway for over a year, but not yet completed, now faces a dilemma about what to do with its patients who have successfully completed 12 months of heroin and must be withdrawn from heroin and transferred to other treatments in accordance with the research protocol approved by Government of Canada, federal granting body and host institutions. The problem is that the principal criterion for acceptance to NAOMI was their history of repeated failure in these very same treatment programs to which they will now be referred. The existence of the results from abroad (some of which were not yet available when NAOMI was designed and initiated) now raises a very important question for Canada: is it ethical to continue to prohibit the medical use of heroin treatment that has already been shown to be feasible and effective in numerous medical studies throughout the world? And while this is being worked out, is it acceptable to require patients who have been successfully treated with heroin in Canada, to be forced to move back to less effective treatments (treatments that failed to be efficacious in the past)? This essay discusses this dilemma and places it in the broader context of ethics, science, and health policy. It makes the case for continuation of the current successful patients in heroin treatment and the institution of heroin treatment to all Canadian patients living with active addictions who qualify.

Potential use of safer injecting facilities among injection drug users in Vancouver's Downtown Eastside.

BACKGROUND: The Vancouver Coastal Health Authority will initiate North America's first sanctioned safer injecting facility, as a pilot project, on Sept. 15, 2003. The analyses presented here were conducted to estimate the potential use of safer injecting facilities by local illicit injection drug users (IDUs) and to evaluate the potential impact of newly established Health Canada restrictions and current police activities on the use of the proposed facility. METHODS: During April and May 2003, we recruited active IDUs in Vancouver's Downtown Eastside to participate in a feasibility study. We used descriptive and univariate statistics to determine potential use of a safer injecting facility and to explore factors associated with willingness to use such a facility with and without federal restrictions and police presence. RESULTS: Overall, 458 street-recruited IDUs completed an interviewer-administered survey, of whom 422 (92%) reported a willingness to use a safer injecting facility. Those expressing willingness were more likely to inject in public (odds ratio [OR] 3.9, 95% confidence interval [CI] 1.9-8.0). When the restrictions in the Health Canada guidelines were considered, only 144 (31%) participants were willing to use a safer injecting facility. IDUs who inject alone were more likely (OR 1.8, 95% CI 1.0-3.1) and women were less likely (OR 0.6, 95% CI 0.4-0.9) to be willing to use a safer injecting facility operating under these restrictions. Only 103 (22%) of the participants said they would be willing to use a safer injecting facility if police were stationed near the entrance. INTERPRETATION: Most IDUs participating in this study expressed a willingness to use a safer injecting facility. However, willingness declined substantially when the IDUs were asked about using a facility operating under selected Health Canada restrictions and in the event that police were stationed near the entrance.