Vancouver is world famous for taking a progressive, experimental approach to drug addiction. Now its mayor is either determined to take that reputation to a new level -- or help scuttle an existing harm reduction program with proven success.

Those are the stakes, depending on who you talk to, riding on Mayor Sam Sullivan's desire to launch a legal drug substitution trial -- the first of its kind in Canada.

Sullivan's proposed Chronic Addition Substitution Treatment (CAST) is criticized by some supporters of Insite, North America's only medically supervised safe injection site, located in Vancouver's poorest neighbourhood. They fear CAST is a watered down, scientifically unsound approach to harm reduction, yet federal politicians might find it easier to support CAST while pulling the plug on Insite.

But CAST is also garnering support from those who hope it will work to get people off needles and the harmful cycle of drug abuse, permanently, with the aid of prescription oral drugs.

Insite waffling

Sullivan has voiced support in the past for alternatives to drug prohibition such as Insite, where addicts can inject themselves with narcotics illegally scored on the street, and the NAOMI trials, which gives medical quality heroin to users.

But Sullivan lately has sent contradictory signals about his commitment to Insite.

CAST, meanwhile, may raise fewer legal and ethical concerns among conservative officials, because it aims to wean people from stimulants such as cocaine and methamphetamines, as well as opiates, by giving them legal painkillers and other prescription drugs instead.

The drug substitution trial was Sullivan's idea, Lois Johnson, executive director of Inner Change, the non-profit behind the CAST project, told the Tyee. Over the past year, Sullivan studied research on small-scale substitution trials in Texas and Australia, where results have been promising.

After the initial idea phase, Sullivan called on friends -- from politicos like Johnson and Conservative MP John Reynolds to seasoned physicians like Dr. Don Rix -- to head up Inner Change's board of directors.

'Inner' workings of CAST

CAST would be a research trial consisting of four or five separate clinical trials of about 150-300 people each -- comprising a sample size of about 1,000 -- lasting a maximum of three years. Users would receive counselling and job training, in addition to oral prescription drugs which ideally would be weaned away over time.

But first Health Canada must approve a clinical trial proposal for CAST to use prescription medications in this novel way.

Johnson hopes that Inner Change will submit its application to the federal government next month for an exemption 56 under the Controlled Drugs and Substances Act, granting criminal exemption for medical and scientific use of controlled substances.

Although Johnson is unsure whether the exemption is necessary because the drugs are already legal, she is taking the precaution because CAST would experiment with "off labelling," prescribing drugs for uses other than what they are intended or approved for.

"This is very different than NAOMI or Insite because the drugs are currently available for legal purposes, like painkillers. But they are still listed as controlled substances, so we need approval to prescribe them for drug addiction."

$10 million price tag

If the trials prove successful, any physician in addiction treatment will legally be able to dole out prescriptions to those trying to kick their opiate or stimulant habits -- an innovative step because there are currently no legally available substitutions for cocaine and methamphetamines.

The trials would cost about $10 million over three years. And the money would come from both private and public pockets. Inner Change is actively fundraising from the private sector first. Ultimately, if the government agrees to grant funding for the program, some money would come out of the health care budget, though Johnson was unsure how much.

Harm related to injection drug use means taxpayers already incur considerable costs. A 2004 study estimated the costs of HIV among injection drug users in the Downtown Eastside to be $215,852,613. And taxpayers are already paying for methadone clinics and problems associated with alcohol and tobacco use.

Where's the science?

Aside from short term, small-scale clinical trials in Texas and Australia, there isn't much research on stimulant substitution treatments, Lois Johnson admitted. But she said the 1,000 person trial program is "apparently" enough to draw valid conclusions about the efficacy of drug substitution. "It depends on retention rates. They haven't been great in other trials. That's why we need a more extensive study," she added.

While methadone maintenance programs have proven effective, there is absolutely no consensus among experts in the health policy community that substitution programs work for stimulant drugs, said Joanne Csete, executive director of the Canadian HIV/AIDS Legal Network.

"The trials in Australia and Texas are based on small numbers on an individual basis, but they haven't had the kind of success that you need to implement trials on a population the size the mayor is talking about," she said.

Sullivan's idea is driven by the premise that everyone can get clean or substituted one way or another, said Csete. "When, in fact, we have to bolster programs that have a track record like Insite and methadone maintenance programs. Investing in treatment that doesn't have a track record without a strong investment in harm reduction renders the first ineffective."

Vancouver's drug policy coordinator, Don MacPherson is in the process of composing a report for city council on the efficacy of substitution treatment. He believes Vancouver is the perfect place to begin a large-scale trial like CAST because the city is building a "cadre of addiction specialists," thanks to programs like Insite and NAOMI.

He believes that with the help of Insite, as a first point of contact to initiate volunteers into the CAST program, the 1,000 person trials will be sufficient to draw scientifically valid conclusions.

Insite's record

On June 14, Vancouver city council passed a motion 9-1 supporting the "objectives and principles of CAST." But the vote has no binding legal basis because the decision involves the federal and provincial governments only, although the effects of illicit drug use are most apparent at the municipal level.

While study after study has shown Insite helps reduce HIV and public disorder, the mayor needs to provide much more information on drug substitution before council can approve such a measure, said Councillor George Chow, the sole objector to the city's motion.

"I want to know how and where and who and also what is the goal of CAST and how they will measure success. I want to see whether mayor is really doing anything to resolve drug problems and not divert attention from the Insite dilemma."

Harm reduction supporters like Chow and Joanne Csete say the mayor's priority should be to keep pushing what works.

"There's been more good peer-reviewed research on InSite than any public health program I've heard of in my 25 years of working in the sector. I don't know how anyone that reads doesn't ask: 'Why aren't there more of these places?'" said Csete.

In Toronto, where Csete lives, and in cities across the country, conversations about starting harm reduction programs have fallen silent because the federal Conservatives placed a moratorium on safe injection sites until further review of Insite.

Csete said she understands Sullivan faces opposition to Insite in Ottawa these days. But she reminds that Insite has a scientific track record of success.

"Just don't turn people into guinea pigs and say that's better than turning them into criminals," Csete warned. "That's not an encouraging policy direction."

Federal Conservative Health Minister Tony Clement did not approve a renewal of a three-year Health Canada exemption for supervised injection of drugs at Insite last year. Instead, he put off any decision about the site until December 31, while he called for more research into the efficacy of the program.

While the Minister waits for additional research to pour in, CAST's approval is in doubt. In 2005, Harper declared "We as a government will not use taxpayers' money to fund drug use." And a spokesperson for the health minister told the Tyee it would be inappropriate to speak to the possibility of more trials while waiting for the research to come back on Insite.

Tory-friendly program?

The Conservatives currently operate within a drug policy framework that focuses on prohibition, which means drug use is treated as a criminal problem, not a public health issue. This climate provides limited flexibility to act on harm reduction measures, which must be created through criminal exemptions to existing legislation or de facto decriminalization.

While there is no current plan to unveil the new national anti-drug strategy in the near future, according to the health minister's spokesperson, if March's federal budget is any indication, harm reduction measures may be slashed. While Conservatives allocated an extra $64 million over two years for enforcement, treatment, and prevention, no mention was made of harm reduction programs that reduce the spread of HIV and hepatitis C.

Csete recently wrote a letter to parliamentarians accusing the Conservatives of contemplating "a U.S.-style war on drugs, an approach that has proven time and time again to be counter-productive and a tragic waste of public funds."

But there is a glimmer of political hope for the CAST program. Unlike the safe injection site, it doesn't involve needles or illegal drugs. Moreover, it's a new strategy the Tories can claim credit for, unlike the exemption for Insite, which was granted by the Liberals in 2003.

Accusation of trade-off

Some critics believe the CAST proposal is Sullivan's attempt to strategically compromise with the federal government.

City Councillor Raymond Louie, who wasn't present when the city passed the CAST motion because it was a surprise, said the mayor's renewed commitment to Insite is little more than a political response to public outcry. "Sullivan truly believed he'd be able to shut down Insite and had conversations in Ottawa to trade the medical exemption for CAST," Louie said.

According to the Vancouver Courier, Sullivan told its reporter Mike Howell that he decided giving legal drugs to addicts was the best alternative to pushing the injection site because the Tories wouldn't support the consumption of illegal drugs. "I've tried to structure my proposals around the thinking of the people in Ottawa," Sullivan told Howell.

Despite recent media reports, Sullivan is not abandoning support for Insite, said his spokesperson David Hurford. The June 14 motion also called on council to support the Vancouver Coastal Health Authority's federal application for an extension of the safe injection site.

"CAST will receive referrals from the injection site as a first point of contact for people that need help. While ultimately the goal is to get people off needles, it's not going to happen in the foreseeable future," Hurford said.

Councillor Louie says Sullivan's support for CAST is politically motivated. "It is more about having a project to attach his name to like 'Eco-density' or 'Civil City.'" CAST is little more than a re-election ploy because it will take longer than the next election cycle to set it up and the measurements will not be available until after the next election, he said.

But Councillor Chow believes Sullivan has higher aspirations. "This motion is an election ploy because he's gone as far as he can in city politics; he's looking for a spot as a Conservative MP," he said.

An Olympic PR problem

Other critics like Csete think CAST amounts to an Olympic clean-up strategy.

Vancouver was recently rated among the top three cities in the world to live. But for residents of its infamous Downtown Eastside life is anything but quality. It has become host to one the most explosive HIV/AIDS epidemics in the Western world. The problems associated with illicit drugs, especially in the Downtown Eastside, are considered one of the greatest threats to the image Vancouver is trying to present to the world.

"I've been working in human rights a long time and I don't think there's a better way to follow the history of human rights violations than to follow the Olympics around the world. All cities want to 'clean the streets' before the global spotlight is on them," Csete said.

The attempt to clean up the city shouldn't be controversial, said Don MacPherson, who studied stimulant substitution research long before the Mayor's announcement. "We all want more measures in place by 2010."

He believes that when Sullivan speaks of closing down the safe injection site, he is speaking ideally -- of changing the culture from an injection based drug climate to a safer oral based system in the long term.

Both Insite and CAST are only tiny, complementary interventions into a bigger problem -- necessary, but small pieces of the four pillars approach, he said. "We need to worry about safety first, about weaning people off the dangerous routes of drug use before we can imagine a drug free society," he added.

Regardless of the intentions of the city's political leadership, he said, drug substitution is a completely valid area to explore. "People are really interested from the clinical perspective."

Vancouver's four pillars initiative, a comprehensive strategy to battle drug addiction at the prevention, enforcement, treatment and harm reduction levels, has drawn the attention of other Canadian cities with marginalized populations of drug users like Ottawa and Kitchener --Waterloo, said MacPherson.

Related Tyee stories:

• Sullivan Backs Insite, For Now
  New plan to complement, not replace site, says spokesman.
• Where Carla and Wayne Shoot Up
  Inside the world of the Insite safe injection clinic.
• An Island Called Insite
  Clinic struggles to 'reduce harm' amidst a health disaster zone.