Homeless in Vancouver: the CAST trial

Issue: BCMJ, Vol. 49, No. 4, May 2007, page(s) 173 Editorials
Heidi M. Oetter, MD

I am sure that many of you will have heard or read about Mayor Sam Sullivan’s proposed Chronic Addiction Substitution Treatment (CAST) trial and have wondered what it involved. Meanwhile, anyone frequenting the centre of Vancouver will have long ago recognized that a significant number of the citizens of Vancouver struggle to stay alive in a milieu of poverty, homelessness, and addiction. Barricading access to the undersides of bridges and overhangs is hardly a long-term solution to homelessness, yet during my daily commute from the suburbs I often wonder where I would start to solve these problems if I were mayor.

I applaud the mayor for thinking outside the proverbial box. That said, let me bring some ethical considerations and imperatives to novel thinking. Historically, many clinical trials and research projects, even those designed by intelligent and well-meaning scientists, have abused human subjects. The classic example is the Tuskegee syphilis study, which led to the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. If you are unfamiliar with the Tuskegee study and its unconscionable harms, I encourage you to start your reading at www.en.wikipedia.org/wiki/Tuskegee_Syphilis_Study.

Clinical research is essential to modern medicine, and those suffering from addiction are just as deserving of new therapeutic inventions. Physicians engaging in research must honor the ethics of clinical research by abiding by the requirement for informed consent of subjects and the review and approval of research methods by competent research ethics boards. Any conflict of interest that may exist must be disclosed to subjects. Physicians must exercise caution when they appear to be both the treating physician and the researcher.

So the next time you exit Highway 1 at First Avenue and see the new metal fences that have blocked access to the underside of the bridges, remember the enormous problem facing the homeless in Vancouver, and the need to ensure that the principles of justice and fair-share are applied to those who suffer from chronic addiction. Clinical trials that seek to define new therapeutic interventions for the treatment of addiction are worthy of our support, providing that scientific rigor and research ethics board approval has been confirmed. The homeless in Vancouver deserve better, and a well designed CAST proposal deserves our support.