SCII.013.025.0018 AUSCRIPT AUSTRALASIA PTY LIMITED ACN 110 028 825 T: 1800 AUSCRIPT (1800 287 274) E: clientservices@auscript.com.au W: www.auscript.com.au TRANSCRIPT OF VIDEO PRESENTATION O/N H-1075020 IN THE MATTER OF THE SPECIAL COMMISSION OF INQUIRY INTO THE DRUG “ICE” THOMAS KERR (VANCOUVER, CANADA) HARM REDUCTION - VIDEO PRESENTATION WEDNESDAY, 11 SEPTEMBER 2019 TRANSCRIBED BUT NOT RECORDED BY AUSCRIPT AUSTRALASIA PTY LIMITED . .KERR WITNESS STATEMENT 11.9.19 P-1
SCII.013.025.0019 DR KERR: Hello. My name is Dr Thomas Kerr, and I am a Professor in the Department of Medicine at the University of British Columbia in Vancouver, Canada. I am also a Senior Scientific Advisor and Senior Scientist with the British 5 Columbia Centre on Substance Use. I’m very honoured to provide testimony today to the Special Commission of Inquiry into the Drug ‘Ice’. And I’ve been asked to speak about our experience with Harm Reduction Interventions in Vancouver, Canada. 10 Vancouver, like Sydney, is a beautiful city. It’s surrounded by the ocean and the mountains and like Sydney is consistently rated as one of the most liveable cities in the world. However, like many large urban centres it has an inner-city core which is marked by a high density of low-income housing, high levels of poverty, substance use and mental illness. In the mid-90s, Vancouver experienced what has been 15 described as the most explosive epidemic of HIV infection ever observed outside of sub-Saharan Africa. And this, really, was a result of the high prevalence of stimulant injection, in particular, cocaine injecting. This slide shows you the number of new diagnosed HIV infections among people 20 who inject drugs in Vancouver, as recorded by the BC Centre on Disease Control. And, as you can see, the number of new infections began to rise steadily in the early 90s, all the way through to 1996. At the same time, our province was experiencing an epidemic of overdose deaths due to heroin use, with about one person dying per day in the province. We now have a new problem, which is the emergence of synthetic 25 opioids in our drug supply, such as fentanyl, carfentanyl and related analogues. And sadly, synthetic fentanyl is approximately 50 to 100 times more potent than heroin, and has thus resulted in a massive escalation in drug related deaths in our setting. This slide shows you the number of overdose deaths involving fentanyl from 2007 to 30 2017. And as you can see, there has been a steady increase in the number of deaths since 2013. This data from the Provincial Coroners Office shows you the proportion of overdose deaths involving fentanyl. And this has increased, also, significantly in recent years, 35 with over 60 per cent of deaths involving fentanyl. And these are not just deaths involving heroin use. In fact, we are finding that an increasing proportion of deaths where methamphetamine is involved also involve fentanyl. In response to drug related harm in Canada, a number of Harm Reduction Programs have been implemented, including: syringe and crack and meth pipe distribution programs, a 40 range of educational initiatives, Naloxone kit distribution, overdose prevention sites, drug checking programs, substitution treatments and what has become known as ‘safe supply’ interventions and supervised drug consumption facilities. I’d like to spend a bit of time talking about each one of these interventions, including their implementation context, their limitations and what we’ve learned about them through 45 scientific evaluation where possible. So I’d like to start with syringe and pipe distribution programming. The goal of these programs is really to prevent the transmission of infectious diseases and injuries, such as oral sores that can occur from pipe smoking. But also, these 50 programs seek to make contact with people who use drugs and engage them in the .KERR WITNESS STATEMENT 11.9.19 P-9
SCII.013.025.0020 broader system of health care. These programs are delivered, typically, through community-based health services and related outreach services, as well as hospitals. They’re typically funded through our provincial health system. And, although they have been found to be effective, some of their limitations include challenges with 5 coverage, in particular, ensuring that all the people who need access to safer injecting and smoking equipment are getting it. And changes in funding over time. In Vancouver, we thought we were doing a good job with needle exchange because we had one of the largest needle exchanges in North America, exchanging over 10 2,000,000 needles per year. However, in the presence of this needle exchange, we experienced an epidemic of HIV infection among people who inject drugs. Subsequent follow-up studies revealed that, in fact, many people who injected drugs were having considerable difficulty accessing syringes. And difficulty accessing 15 syringes was associated with syringe borrowing and lending, the behaviours that account for the majority of HIV and hepatitis C infections in our setting. And the reasons why people were having difficult accessing syringes in some cases were quite simple. The needle exchange program closed at 8.00 pm and we had a stimulant epidemic with people often staying awake for days on end and needing 20 access to equipment throughout the night. As well, people would often not have a syringe to exchange or they missed the van because they didn’t know where it was. And some were also being refused syringes at pharmacies. This led to a revision of the Needle Exchange Policy in Vancouver. During 2000 to 25 2002, there were a number of changes implemented including: the program was decentralised, there was a move away from exchange to a focus just on distribution, the number of sites distributing syringes were expanded, and the limits on the number of syringes that could be obtained were removed. Also, the functions of distribution and recovery were separated. 30 We evaluated these changes in a paper published in the American Journal of Public Health in 2010. This slide shows you the rate of syringe borrowing in the period before, during and after the policy change, and as you can see, there were substantial declines in syringe borrowing following the policy change in 2002. But also, we 35 detected very large declines in HIV incidents associated with this policy change - suggesting that, really, critical to the success of the Needle Exchange Program was enhancing access and ensuring a high volume of needles were making it into the hands of people who inject drugs. 40 In response to rising crack use and related harms in our city, a crack pipe distribution was implemented in around 2009, and as you can see, the number of crack pipes that were distributed increased substantially, and in 2012, over 100,000 crack pipes were distributed. This led many people to question whether distributing pipes in this fashion would facilitate drug use, make crack use more fashionable and lead to 45 increases in crack use. However, we evaluated these effects through our Cohort Study of people who use drugs in Vancouver, which is funded by the US National Institute on Drug Abuse and is known as the Vancouver Drug Users Study. And here, we found that in the period where there is a huge increase in the number of crack pipes being distributed, there was actually a substantial decline in the number 50 of people reporting daily crack smoking. Suggesting quite clearly that providing .KERR WITNESS STATEMENT 11.9.19 P-9
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