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Harm reduction

mr peabody

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Welcome! Following is a DIGEST of articles and reports that is constantly updated. Jump in!




Seeking a safe place: Vancouver’s story

by Felice Freyer | Boston Globe | May 12, 2019

VANCOUVER, British Columbia — If you didn’t know better, you might walk right past one of the most famous places in this city. Insite, the first program in North America to allow people to inject illegal drugs, occupies an unmarked and unremarkable three-story building.

Much more noticeable, and notorious, is the scene on the broad sidewalk out front and on nearby streets — an open-air drug market and homeless encampment known as Downtown Eastside.

On a recent day, a couple huddled on the ground under a black-and-red umbrella, next to Insite’s front door. Nearby, a woman in a pink sweater was sobbing on the sidewalk, then stood up to yell at someone. Around the corner in an alley, a man leaned over a woman sitting on the ground and injected something into her neck. “OK, the show’s on,” she said with satisfaction. A siren wailed not far away.

As American cities, including Boston, debate whether to allow injection sites — clean rooms where people use illicit drugs, watched by trained staffers who can rescue them from overdoses — Vancouver is often held up as an example by both sides of the argument.

Opponents point to the appalling street scene, asserting it shows that such sites can wreck a neighborhood. Advocates talk about Insite’s 16 years of saving lives and referring people to treatment.

But a visit here reveals a more complex reality: The safe-injection site doesn’t cause the street drug use that surrounds it. But it doesn’t eliminate the problem, either.

Downtown Eastside, which encompasses about seven or eight blocks, has been a gathering place for the lost, sick, and addicted for many decades, starting long before the idea for Insite was conceived. People in need are drawn by the availability of drugs, low-cost housing, and social services. And Vancouver’s mild climate allows a homeless person to survive the winter.

The police welcome Insite’s presence. Constable Steve Addison, a spokesman for the Vancouver Police Department, said that "Insite clearly saves lives, but," he added, “nobody believed Insite was going to clean up the Downtown Eastside.”

The rules at Insite are simple. People enter a waiting area and give a name to the receptionist; it can be any name they want, but they’re asked to give the same one each time. Then they are ushered into the injection room, where they can spend up to 30 minutes at one of 13 booths with stainless steel tables and mirrors, using drugs they have obtained elsewhere.

Nurses and other trained professionals are on hand if anyone asks for help or seems to be in trouble, but otherwise people are left in peace to do what they need to do.

Afterward, they can grab a cup of coffee in the “chill-out room” before returning to the street.

This means that drug users aren’t sharing needles or drawing water from filthy puddles to inject, so they’re less likely to get sick with infections.

It means that if they overdose, someone will immediately revive them.

And it means a vulnerable person might make a connection with a staffer who can help with any number of problems, including addiction itself.

Since Insite opened in 2003, dozens of similar programs have sprung up throughout Canada. No such site operates legitimately in the United States, and the Department of Justice insists they are illegal.

Even so, several cities are working on getting one opened, notably New York and Philadelphia. In Massachusetts, the Legislature is expected to consider an advisory commission’s recommendation that the state pilot one or more safe-injection sites.

On a recent day at Insite, all the booths were occupied with people in various stages of preparing to inject drugs, injecting them, or finishing up. A red-haired young man lay on the floor, an oxygen tank and tangle of tubes at his side.

The man was probably brought in from the street by friends, said Darwin Fisher, the senior program manager. Oxygen is often all a person needs, rather than Narcan, the overdose-reversing drug, which throws people into immediate withdrawal and can prompt them to inject and overdose again.

About 500 injections occur at Insite each day, Fisher said. And about 30 times a week, a nurse or another trained staffer revives someone who has overdosed.

People who use Insite aren’t called patients or clients — they’re “participants.” Insite pointedly avoids any resemblance to a medical facility, where people suffering from addiction are accustomed to being judged and shunned, Fisher said. Insite’s appearance has been likened to a hair salon’s.

Participants are urged to wash their hands ahead of time and are provided clean needles and other sterile supplies. Staffers chat with them, typically about movies and sports at first, Fisher said. As they become more comfortable they may ask for help treating infections or other problems.

Fisher recalled an Insite participant, a big tough-looking fellow, who once started weeping uncontrollably, revealing that he’d been raped repeatedly as a child.

“There’s a reason people are using — it’s pain relief,” Fisher said. “They’re on fire inside. They’re like third-degree burn victims. That’s the context of their need for heroin.”

Dr. Mark Tyndall, a British Columbia health official who has studied Insite, put it this way: “We think of drugs as people’s problem. For many, it’s their answer.” And people will stop “when they find something that’s better than using drugs.”

An affiliated detox center called Onsite operates on the floor above, and Fisher said its intake person is always around to talk with participants. Some 400 a year decide to enter treatment. But treatment is hardly a new idea for them; most Insite participants already have been through it multiple times.

In a five-year period, Tyndall said, about 60 percent of Insite participants entered some sort of treatment. But he added that probably the same could be said about drug users who didn’t use Insite.

“The idea that you’re a drug user, you’re introduced to treatment, then you’re off to the races — I’ve never seen that linear approach work,” he said. People bounce in and out of treatment repeatedly. Eventually, many do give up drugs, or cut back, Tyndall said, “but the timing of that is totally unpredictable.”

The idea behind Insite is to keep people alive for that unpredictable moment.

A study in the years after Insite opened found that overdose deaths declined 35 percent in the immediate neighborhood. Since then, thousands of people have been revived at Insite, and some of them surely would have died otherwise.

But as much as he supports Insite’s lifesaving mission, Tyndall doesn’t see it as a solution, especially now that the illicit drug supply is contaminated with highly deadly fentanyl. He advocates for providing addicted people with a safe supply of drugs, something that is happening on a limited basis in Canada.


Dr. Mark Tyndall (right) spoke with Darwin Fisher, a program manager at Insite, in front of the safe-injection site.

Many drug users never visit Insite, and 95 percent of those who do say they also inject on the street, he said. With 8,000 to 10,000 drug users living in the neighborhood and shooting up multiple times a day, the 500 daily injections at Insite are “just a drop in the bucket.”

Around 2014, that bucket started getting much, much bigger. People were dying of overdoses at a stunning rate, with such deaths throughout the province almost tripling from 2014 to 2016.

Sarah Blyth, a local activist who manages a flea market where people can sell scavenged goods in Downtown Eastside, saw it with her own eyes. Two or three times a day, people were dying on the street.

Fentanyl, the same drug implicated in most of the overdose deaths in Massachusetts, has been poisoning the illicit drug supply.

In 2016, Blyth set up a tent with a table on a city-owned lot adjacent to the market, trained volunteers to administer overdose-reversing drugs, and made it known that people could be saved there.

She started a GoFundMe page for supplies, raising $40,000, she said.

Blyth’s tent, probably illegal or at least operating in a legal gray area, was the first pop-up overdose-prevention site. Within three months, near the end of 2016, the provincial government decided to legalize and sponsor more sites.

Blyth’s Overdose Prevention Society moved into a trailer and eventually a nearby building.

“It’s the bare minimum of what any government should be doing,” Blyth said — to give people a chance to “get out of the alley, not use alone, not die alone.”

Five pop-up injection sites are now operating in Downtown Eastside. They are more loosely regulated than Insite. Many are staffed by active drug users, who show up for regular paid shifts, often finding purpose and stability.

Cindy Bell, an employee at one of the sites, said that “everything fell into place” once she had money and could find housing. At 51, her blond hair pulled back with a headband and eyes bright with blue-tinted contacts, Bell said she still uses heroin and methamphetamine to treat chronic pain. “I’m not getting high,” she said. “I’m maintaining.”

She doesn’t keep count of how many people she’s revived. “It’s stressful,” she said, “but you get a lot of satisfaction.”

Trey Helton works at the Overdose Prevention Society with Sarah Blyth. Unlike Bell, he has abstained from drugs for three years, he said.

For 3½ years before that, he lived on Vancouver’s streets, and he’s convinced that he’d be dead if not for Insite. In those days, he said, he was "emaciated, yellow-eyed from hepatitis, covered in infected sores — the sort of person that people cross the street to avoid."

But at Insite, he was accepted and treated kindly. The staff chatted with him, took him out for lunch. They were his only friends.

“I’m eternally grateful to the people who treated me like that,” Helton said.




Dean Benton, a volunteer at the reception desk of VANDU, one of Vancouver’s safe-injection sites.
 
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Hornywhenhigh

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May 25, 2019
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We really need places like this in the United States. I think that it really would help a lot of people and also help cut down on the spread of diseases like aids that is being passed on by sharing dirty needles with others who are infected and either don't know that they have it or don't care and think that it is only fair to pass it on to others since they got it from someone else. There is no telling how many lives would be saved here by having a place like this for addicts to be able to use.
 

mr peabody

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In Vancouver, a growing coalition of doctors and researchers are advocating for a “safe supply” of
opioids to fight the overdose crisis that killed more than 1,500 people in British Columbia last year.



One doctor’s answer to drug deaths: Opioid vending machines

by Issie Lapowsky | WIRED | April 17, 2019

Across North America, tainted opioids are killing people who use drugs. Vancouver’s Mark Tyndall says we should start dispensing safer pills using high-tech machines.

It’s a winter afternoon in Vancouver, and Mark Tyndall is taking me on a tour of all the places people can go if they want to use drugs and be pretty sure they won't die.

Blue tarps and shabby tents with people sleeping in them line our route in the Downtown Eastside, where the wail of an ambulance siren is always around the corner. We see handwritten signs taped up in the back alleys, warning “Danger: Green Heroin. Use ¼ usual dose.”

This is Canada’s skid row, a place where almost everyone can tell you about the friends and neighbors they’ve lost to an overdose. This city has seen a sixfold increase in overdose deaths over the last decade, with more than 1,000 of those people dying since 2016 alone. According to the British Columbia Centre for Disease Control, more than 300 of those deaths happened in the last two years here in the Downtown Eastside, a roughly seven-block strip that contains one of North America’s densest populations of injection drug users.

When we reach the dingy door marked Overdose Prevention Society, Tyndall swings it open and ushers me through. Inside the long, narrow space, there’s a red partition, behind which more than a dozen people sit at sterile metal tables. They come here because it’s a place where they can get a clean needle and inject drugs they buy off the street, with trained staff standing by to save their lives if that heroin turns out to be lethal.

It’s one of six so-called overdose prevention sites (alternately known as supervised consumption sites or supervised injection sites) to open up in the city since 2016. That’s the year that the line charting illicit drug overdose deaths in British Columbia ticked sharply upward.

Tyndall walks past the partition to a young guy with a septum piercing named Colm, who’s keeping watch over the room. “Hi, I’m Mark Tyndall,” he says, extending a hand. At 59, Tyndall looks lean and youthful in a pair of light wash jeans and a sporty rust-colored jacket. He has big, round eyes that crinkle at the corners when he smiles.

“Did you say Mark Tyndall? I definitely recognize that name,” Colm says, admiringly. “I imagine a lot of people do.”

Colm is right about that. Tyndall is an unlikely local hero in a neighborhood that’s generally suspicious of bureaucrats. Tyndall has spent much of his career as one, most recently serving as executive director of the British Columbia Centre for Disease Control, or BCCDC. But if Tyndall is a bureaucrat, he’s a bureaucrat with a rebel’s heart.





“Mark is a doctor who has contempt for the medical profession, which is a really valuable thing,” says Darwin Fisher, a manager at Insite, North America’s first official supervised consumption site, which is located just down the road. “He actually knows something about the people he’s dealing with.”

A Harvard-trained doctor of infectious disease and epidemiology, Tyndall moved to Vancouver in the late 1990s after a stint treating HIV patients in Kenya. At the time, AIDS was decimating this neighborhood, and Tyndall took a job working at a local hospital, tending to patients’ injection-related diseases and helping research needle exchanges in their early days. He spent a night sleeping in one of the neighborhood’s single-room occupancy hotels to better understand his patients’ barely habitable living conditions and pushed the government to give drug users access to lifesaving antiretroviral medications—still an experimental idea at the time.

When the overdose spike hit, it was Tyndall, already head of the BCCDC, who called up a local community group and urged them to set up a pop-up overdose prevention site inside a tent and invite the press to watch them work. And he has co-authored dozens of peer-reviewed studies on the various benefits of supervised injection sites, which officials and advocates in cities across the US now use as evidence that they need to take a similar strategy in addressing their own careening crises.

But the thing that most likely triggered Colm’s memory—the thing that has landed Tyndall in the news recently, and the thing that, if you ask around, may have cost Tyndall his job at the BCCDC earlier this year—is his latest and most audacious idea for combatting the overdose crisis. It’s not enough to just give people safe spaces to use drugs anymore, he says. He also wants to give them safer drugs to use. And he wants to distribute them in vending machines.

Throughout North America, according to Tyndall, people who use drugs are being poisoned, not by the drugs themselves, but by all the other substances that have made their way into those drugs. Sure, the greedy pharmaceutical companies that made billions encouraging doctors to shower their patients in Oxycontin bear much blame for creating the addiction crisis. But what’s killing most people these days isn’t the pills. It’s not even the heroin people turn to when they get cut off from the pills. It’s the synthetic drugs—mainly fentanyl—that are cheaper, more potent, and easier to traffic. These substances have turned the drug supply toxic. In Vancouver, they’ve swallowed it whole.

To be clear, heroin was never safe, but before 2015, at least, there were about 200 to 400 overdose deaths in British Columbia per year. Last year, there were 1,510. Today, the BC coroner reports, fentanyl is detected in four out of five of those deaths. That’s not unique to Canada. The same devastating trend is playing out in America, where synthetic drugs that scarcely registered a few years ago are now killing nearly as many people as heroin and prescription opioids combined.

“The plight of people using drugs didn’t change four years ago,” Tyndall says. “The drugs they’re using changed.”





Under President Donald Trump, the US has responded to this crisis by doubling down on law enforcement and beefing up border security. Canada, on the other hand, has embraced a philosophy known as harm reduction—which holds that it’s far more important to prevent people from dying of a drug overdose than it is to prevent them from doing drugs in the first place.

In addition to getting people on opioid replacement therapies (like methadone and suboxone) and making overdose reversal drugs (like naloxone) widely available, Canada has allowed overdose prevention sites to proliferate. In just the last few years, dozens of them have opened from Vancouver to Toronto. Health authorities have begun placing fentanyl testing strips and spectrometers at supervised injection sites to help people figure out what’s in the drugs they’re about to take.

These interventions—free of the kind of moralism that sometimes drives drug policy—have saved countless lives. The problem is, only a small slice of drug users ever step foot in these facilities. And so, the death toll continues to rise.

As an infectious disease researcher, Tyndall notes, the trend lines almost defy logic. “Any epidemic by now would be falling, just because the vulnerable population is being culled,” he says.

He believes a drastically new approach is in order. Which is why, about two years ago, in his role at the BCCDC, Tyndall began pushing Canadian health regulators to make a safer supply of opioids available to people. The thinking was, when iceberg lettuce starts poisoning people, the government does whatever it can to clear the produce aisle and replace the bad batches with fresh, uncontaminated romaine. But with a product as physically addictive as heroin, somehow, the most common response is to tell people to use smaller amounts or, more often, not to use drugs at all. “We’re acknowledging people will go to any extreme to use this drug,” he adds. “To tell them not to use because it’s unsafe is ridiculous.”

Last year, the BCCDC won a $1.4 million grant from the federal health authority, Health Canada, for a pilot program, led by Tyndall, that will study the effects of giving the Downtown Eastside’s most at-risk drug users a regular allotment of hydromorphone pills (the chemical name for Dilaudid) which they can take home and use instead of buying street drugs.

That, in and of itself, isn’t such a radical idea. Countries throughout Europe have been using opioids to treat people with opioid use disorder for decades. And in Vancouver, a growing community of researchers have turned the city into a sort of living laboratory for the scientific study of safe supply programs.



Jonathan Orr, a manager at The Molson Overdose Prevention Site, prepares injectable Naloxone,
a drug that blocks opioid receptors and reverses the symptoms of an overdose.


At Providence Crosstown Clinic in the Downtown Eastside, chronic injection drug users have been receiving injections of medical-grade heroin for years as part of two landmark longitudinal research projects. A few blocks away, at the Molson Overdose Prevention Site, another 104 patients are currently being treated with hydromorphone as part of a separate study.

But so far, all of these studies have required patients to visit a clinic every day to get their drugs. Tyndall worries that’s too high a bar for a chaotic and often homeless population, already wary of institutions. With his new project, Tyndall wants to uncouple drug delivery from the doctor’s office. In fact, he wants to remove human beings from the equation almost entirely by distributing the pills in a high-tech, heavy-duty vending machine.

The machine, designed in partnership with a Canadian tech company, would allow preapproved drug users who receive a prescription from their doctors to access safer opioids using a biometric scan of the veins in their hands. Such a mechanized approach, Tyndall believes, is the only way that an intervention like this can match the scope of the problem. After a year and a half of development and endless delays, Tyndall expects the first of these machines to arrive in Vancouver before summer. Whether he’ll ever get the government approval or funding to actually test the thing is another question altogether.



The vending machine that would dole out safer opioids can identify a person with a prescription by
scanning the unique pattern of veins on their hand.


The concept of a vending machine for drugs is controversial, to say the least. Since he first floated the idea in December 2017, Tyndall has fielded endless knee-jerk reactions accusing him of enabling drug use, as well as legitimate fears about the pills being diverted to school kids and soccer moms.

In January, the Provincial Health Services Authority, which oversees the BCCDC, unexpectedly removed Tyndall from his position, as part of a leadership change that the agency said would have forced Tyndall to focus less on research and more on administrative work. Now he’s continuing to lead research on the opioid crisis, albeit in a less prominent position with the CDC. The shift fueled speculation that Tyndall had pissed off one too many government officials with his unyielding activism.

“They want someone who’s effective, but politically savvy,” speculates Russ Maynard, a community engagement manager at the local housing nonprofit Portland Hotel Society. “Don’t push too hard.”

The Provincial Health Services Authority denies that had anything to do with it. “Mark’s a colorful, well-known guy,” says Laurie Dawkins, the agency’s vice president of communications. “These qualities make him amazing at his research and at advocating for things that are controversial and difficult, and we’re totally happy he’s carrying on with that.”

In the midst of the changes, Tyndall also has struggled to get buy-in from regulators, like the College of Pharmacists. A vending machine is neither a pharmacy nor a pharmacist, meaning it doesn’t fit neatly into the existing rules regarding who can distribute drugs and where they can distribute them. “We have had many conversations with Dr. Tyndall, but we’ve yet to find a way for what he’s proposing to meet the requirements,” says Bob Nakagawa, the registrar for the College of Pharmacists.

All of this opposition stands to reason. Tyndall’s proposal does sound radical, flying in the face of traditional treatment programs that preach the value of sobriety. If the government just gives people drugs, his critics ask, why would people ever quit using them? Isn’t offering this option tantamount to giving up on them?

Tyndall’s heard it all before and he’s a little tired of the questions. Because his answer almost always boils down to the same darkly pragmatic, but profoundly empathetic point: Recovery, he argues, is a great option for people who recover. But lots of people never do. Right now, those people are at a greater risk of dying than ever before. The very least he, as a doctor, and we as a society, can do is find a way to keep them alive. “To me,” he says, “it’s only ethical.”

Tyndall is leading me to another stop on the tour, just past the litter-strewn, triangular spot of concrete generously named Pigeon Park, when he spots a familiar face. “Hey, Dean!” Tyndall calls out.

Dean Wilson walks toward us, smiling wide underneath his goatee, a leather jacket zipped up tight, hiding the canvass of tattoos that cover his back. Wilson is 63 now and carries more meat on his bones than he used to, but he still bears some resemblance to the wiry revolutionary, who once marched a black coffin into a Vancouver city council meeting to send a message about HIV and overdose deaths. Wilson has been using heroin since he was 13.

If it hadn’t been for people like him, banging on doors to advocate for supervised injection in the early 2000s, Tyndall wouldn’t have much to show me on this tour. But in 2003, Wilson and an army of his fellow drug users succeeded in getting the city to open North America’s first sanctioned supervised consumption site, called Insite.

From the outset, Insite was as much a public health intervention as it was a scientific experiment. The Canadian government granted the nonprofit a temporary exemption from the country’s Controlled Drugs and Substances Act, while researchers studied the program’s effects. Tyndall, who was working at the British Columbia Centre for Excellence in HIV/AIDS at the time, was one of the lead investigators on the project.

In the earliest days, he and his co-investigators were wary of overwhelming Insite’s participants with lengthy surveys and probing questions. So they started off small, assigning research assistants to simply sit across the street and count the number of people walking in the door. Gradually, though, their research expanded. And the results were profoundly counterintuitive or at least inconsistent with conventional wisdom.

In 2005, they published a study showing that Insite visitors shared syringes at substantially lower rates than the rest of the community. In 2006, they published another report which found that while a large number of overdoses had taken place inside Insite, there had been no fatalities. (That finding holds true to this day.) Tyndall’s team produced evidence that, contrary to people’s concerns, Insite did not increase drug use, that it did not lead to more drug-related crime, and that it had ancillary benefits, like increasing condom use among visitors. They also published two separate studies showing that, although recovery isn’t the goal of supervised injection, Insite did increase people’s likelihood to enter detox and other treatment programs. Upstairs from Insite is a detox facility called Onsite, where people can go whenever they feel ready.

Over the years, the team produced an invaluable trove of evidence. “There was an agreement that no research would be in the public domain until it was externally peer-reviewed and published,” says Evan Wood, Tyndall’s co-author on these papers and the current director of the British Columbia Centre on Substance Use.

Nevertheless, Insite’s critics remained resolute in their opposition. Among the most vocal was Stephen Harper, the man who would become prime minister in 2006, and who was quoted in 2005 saying, "We as a government will not use taxpayers' money to fund drug use."

Once Harper was in office, it seemed certain that Insite’s days were numbered, and so in 2007 the Portland Hotel Society filed a lawsuit against the government, arguing that denying drug users access to these health services was a violation of the Canadian Charter of Rights and Freedoms. One of the plaintiffs named in the case was none other than Dean Wilson. “I’m articulate. I’ve got a big mouth, and I was sick and tired of my friends fucking dying,” Wilson tells me all these years later. “I decided I was the lion who was going to protect the lambs.”

The case dragged on for four years, weaving its way through the provincial court system. As Wilson and the other plaintiff, Shelley Tomic, racked up wins, the government kept appealing. Finally, the case landed before the Supreme Court of Canada, which issued a unanimous 9-0 ruling in Insite’s favor in September 2011. The day of the decision, Wilson says, the residents of the Downtown Eastside threw a party.

The celebration wouldn’t last long. Because while Wilson and others were fighting for Insite’s survival, efforts to expand these initiatives around town largely stalled. At the same time, fentanyl was just starting to creep into the North American market. “There wasn’t a lot of progress made around harm reduction in the years following that, because of our Conservative government,” says Mark Lysyshyn, a medical health officer with the local regulator, Vancouver Coastal Health. “I think it left us really, in some ways, unprepared for the crisis.”

Most people who live or work in the Downtown Eastside can instantly call to mind the first time they realized something new and lethal had hit the drug supply. For Wilson, it was seeing the unusually large number of collapsed bodies in the alleyways the day after welfare checks came out. For Tyndall, it was the coroner's reports. Between 2014 and 2016, his first two years at the helm of the BCCDC, the overdose death rate in British Columbia nearly tripled, and an increasingly large share of those deaths were from fentanyl.

In April 2016, the province declared a public health emergency. By December of that year, the situation was so dire that the local health authorities dispatched a military-style mobile medical unit to the Downtown Eastside. It was intended as temporary triage. By March, the unit had intervened in 269 overdose cases.

At the time, Insite was still one of just two supervised consumption sites approved by the federal government. But in the face of this surge, British Columbia’s minister of health took the extraordinary step of allowing more sites to open, even without federal approval.

Almost overnight, new spaces began popping up in the Downtown Eastside and across the province. At first, the federal government gave its tacit consent by simply looking the other way, but eventually, Health Canada approved the creation of these overdose prevention sites in emergency situations. Different from Insite, which is officially categorized as a “supervised consumption site,” the overdose prevention sites are more informal, less medicalized, and require fewer regulatory approvals to start up. And yet, even with these sites in place, the body count kept rising.

For that, Tyndall saw two obvious explanations. The first: Plenty of people who use drugs would rather not be supervised while doing so, and are never going to supervised injection sites to begin with. (That, or they go to the sites, just not for every injection.) The second: People were still using tainted drugs they bought on the street.

More than that, they still needed to shoplift, break into cars, and sell their bodies to make the money to buy those drugs. That locked people into a cycle of poverty and trauma, which often has everything to do with why they’re using drugs in the first place. “Once you get to Insite with a pocket full of dope, most of the problems are over,” Tyndall says. “The biggest stress is how to get that dope.”

Giving people a safe supply of prescription opioids, Tyndall believed, would eliminate some of those societal stresses, and he began telling that to anyone who would listen.

The timing, as it turned out, was apt. In April 2016, researchers who had been working with the Downtown Eastside’s Crosstown Clinic published a set of breakthrough findings from the so-called Study to Assess Long-term Opioid Medication Effectiveness trial, or SALOME.

It was a follow-up to an earlier study, also run out of Crosstown, which found that participants who received daily shots of heroin in a supervised setting were more likely to stick with addiction treatment and less likely to commit crimes and take illicit street drugs than participants who were being treated with methadone.

The problem was that heroin is both expensive and hard to come by in Canada, making it a tough sell as a broad medical intervention. So, for the SALOME trial, the researchers wanted to see if hydromorphone, a more readily available alternative, would have the same effect.

They divided 202 participants into two groups. One received shots of heroin; the other got shots of hydromorphone. After six months of treatment, not only did the effects hold, but crucially, the participants couldn’t tell the difference between the two drugs.

That was all the proof Tyndall needed to assert that a safe supply of hydromorphone pills could be a workable alternative to street drugs. But when he pitched the pilot to a federal grant program at Health Canada, he still hadn’t thought through how, exactly, he would go about distributing them. It wasn’t until much later that he even considered the option of a vending machine, blurting it out in an unscripted moment in December 2017.

Tyndall was speaking at an overdose symposium in Victoria, British Columbia, and calling on the crowd to help him figure out a way to securely distribute the pills to a broad population. By way of getting the brainstorm started, he offered up the extreme option of using an opioid dispensing vending machine. “It was kind of off the top, and I didn’t really think about it,” he says. The remarks instantly got picked up—and picked apart—in the press.

But the more Tyndall thought about it, and the more he fielded reporters’ questions, “I came to the conclusion this was the greatest idea ever.”

All the coverage caught the attention of Corey Yantha, a young tech entrepreneur in Nova Scotia, whose company, Dispension Industries, had been tinkering away on vending machines to distribute cannabis, which is now legal in Canada. A few days after the symposium, Tyndall got a call from Yantha. “I hear you need vending machines for drugs,” Tyndall remembers him saying. “We have vending machines for drugs.”

Yantha didn’t know much about harm reduction at the time, but after watching Tyndall’s TED talk and meeting with him in Halifax, he was sold on the idea. “He’s taken a lot of flak for his vision, but I think Mark is maybe one of the most forward-thinking people that I’ve ever heard speak or met,” Yantha says.

The machine they’ve spent the last year and a half tweaking looks nothing like the metal-coiled contraption that holds potato chips and Snickers bars. Instead, it’s a more than 750-pound kiosk with a 24-inch shatter-proof video screen on the front that can be programmed to, say, broadcast public health alerts or display information about treatment programs. To the right of the screen is a small, square scanner that uses Fujitsu’s PalmSecure technology to take a biometric reading of the vein patterns in a person’s hand.

Before accessing the machine, every user will have to get a prescription from a doctor and create a profile that determines their allotment of pills and how often they can access them. The bar to get into Tyndall’s trial would be set intentionally high so as to include only the most at-risk people in the Downtown Eastside.

People will have to prove they are already injection drug users and face frequent urine tests to ensure they’re actually taking the prescription drugs. When people scan their hands, the machine will find their profiles, distribute the pills, then lock their accounts until it’s time to receive another dose. All of that biometric data, according to Yantha, is fully encrypted, and the machines themselves will be equipped with alarms and cameras to keep watch over the supply.

Officials at Health Canada will be vetting the technical specifications to determine if Tyndall will receive more funding for this part of the project. So far, the $1.4 million grant that Health Canada gave the BCCDC is set aside for the first phase of the trial, in which human beings will distribute the drugs. “The professionals signing their names to this would want to see specifications that the machine can do what it says it can do, and that there’s a maintenance cycle and a backup plan in case there are errors,” says Kirsten Mattison, director of Health Canada’s Office of Drug Policy, Science and Surveillance. “We wouldn’t want people to get used to having access to a service, and that service gets taken away and they’re at risk again.”

Getting the technology right is certainly a challenge, but not an insurmountable one. A far trickier thing for Tyndall is figuring out the best way to allay fears about people selling the pills off in the suburbs, or even worse, facing violence and threats from drug dealers who coerce them into handing them over. An even bigger question is how to accurately study whether any of this is happening at all.

“Once a drug gets diverted, it’s outside your control,” says Vancouver Coastal Health’s Lysyshyn, who is supportive of the vending machine project. “What’s to prevent someone from taking the hydromorphone, adulterating it with a bunch of other drugs, then selling them? Then we’re part of the problem we’re trying to prevent.”

That’s not a reason to avoid studying it, Lysyshyn hastens to add, but it’s critical to consider. “We need to do due diligence in making sure we’re doing no harm in the process of trying to do good,” says David Patrick, Tyndall’s successor at the BCCDC, who has known Tyndall for decades. “I think Mark’s got a brilliant hypothesis on this, but I don’t confuse a hypothesis with a conclusion.”

Tyndall hasn’t quite come up with the most satisfying answers to these questions. He isn’t certain there is a way to do no harm. “There’s nothing in public health that we do that there are no unintended consequences,” he says. What he underscores the most is that buying drugs from dealers is already plenty dangerous. He doubts this will make it any worse.

Knowing this vulnerable population the way he does, Tyndall thinks it’s unlikely that people who use drugs will do anything other than use the drugs they’re getting for free. Still, ever the realist, he admits there may not be a foolproof way to ensure that not one of the hydromorphone pills ends up in the wrong hands. He just believes it’s better than the alternative.

“There’s a distinct possibility that one of these pills could slip into a high school,” Tyndall says. “But in the whole scheme of things, with 1,500 people dying, it’s a very small price to pay.”

About two blocks away from Pigeon Park, inside the old Molson bank building that’s been converted into a single-room occupancy hotel and an overdose prevention site, Christy Sutherland is leaving less to chance. Sutherland is a family and addiction doctor and medical director for the Portland Hotel Society, and like Tyndall, she also started thinking of ways to give people who use drugs safer access to those drugs around the rise of the fentanyl crisis in 2016, shortly after the SALOME paper published. “It started with a patient,” she says.

That patient was Melody Cooper, better known in the Downtown Eastside by her nickname, Rambo. Now 44, Cooper had been using hard drugs since she was 27, often mixing heroin and crystal meth and at times working as a prostitute to make money. As a kid, she says she was raped by family members, and later, by a rotating cast of foster parents. Her husband abused her, her children were taken away from her, and though she’d tried to quit using drugs with methadone, suboxone, and various rounds of detox, nothing ever stuck.

As the overdose death rate rose, Sutherland feared her patient would be next. So in September 2016, Sutherland decided to begin prescribing Cooper injectable hydromorphone. Unlike Tyndall’s approach, Sutherland designed it so that Cooper could only receive the injections under a nurse’s supervision. This is known as injectable opioid agonist treatment, which is different from safe supply programs in that it’s more tightly regimented. If the treatments succeeded in keeping Cooper off of street drugs, Sutherland explained, she would seek funding to study the idea with a much larger group.

“I felt privileged. I felt special,” Cooper told me the day I visited the Molson.



Melody Cooper, 44, started using hard drugs when she was 27.

With just one patient, Sutherland didn’t need the blessing of any regulators. Hydromorphone is already legal, and in Canada, physicians have considerably more autonomy than they do in the US. In fact, Sutherland started dozens more patients on hydromorphone without seeking any government approvals.

But as Cooper began to wean herself off of street drugs, Sutherland decided to turn her small-scale experiment into a broader study. She worked with the regulators in British Columbia that govern physicians and pharmacists to develop a set of guidelines, and now she’s treating about 100 patients at a time as part of a five-year research project, which will track their long-term results.

On a typical morning outside the Molson, a handful of Sutherland’s patients will gather by a side door in the alley, buzzing the doorbell until it’s time to be let in. When the doors open, they take their seats at the metal tables inside and wait for one of the nurses to bring them a clean syringe, preloaded with liquid hydromorphone. Patients who opt, instead, for hydromorphone tablets, which are far less expensive than the liquid stuff, get a syringe and a premade slurry of ground-up pills, served in a sterile cooker.



The overdose prevention sites are staffed with nurses like Leah Bennett.

Some patients inject themselves intravenously, while others let the nurse deliver it like a flu shot to the shoulder. This gives patients a longer-lasting, less euphoric effect. Afterward, the patients sit around, sipping coffee and munching on muffins, catching up on each others’ lives as a brown and white dog named Sage sniffs at their feet. After 15 minutes, they’re cleared to leave. A few hours after that, they return for a second shot, and the cycle repeats.

The scene inside feels like a hybrid between a chemo floor and a community center. It’s staffed at all times by two nurses and a mental health worker as well as a group of peers who are all either former or current drug users. It’s far narrower and more medicalized than anything Tyndall has suggested, but for roughly 300 people who have cycled through the program, it’s at least safer than the street—making it a sort of middle ground between opioid-dispensing vending machines and the broader black market.

“It’s not like going to a drug dealer,” BeeLee, one of the patients who asked to be called by her nickname, tells me, as a nurse plunges a syringe into her arm muscle. “I’m going to a health care facility that’s run by nurses and doctors, and they’re giving me my medication for the day.”

Before she started the program, BeeLee says she was afraid she was about to become a statistic. She had started using Oxycontin when she was 28, after a doctor prescribed it for her fibromyalgia pain. At the time, she was married with two kids and had a thriving career as a lab technician. While she had always used drugs, she describes herself as a “functional” drug user. It wasn’t until she started using Oxycontin that, she says, “something switched in my brain.”

When she got cut off from the pills, BeeLee moved on to heroin. She left her family for a man who also used drugs, and together they fell into street life, shoplifting in vast quantities to pay for their addiction. By the time she was 36, BeeLee had a criminal record and had been homeless for a stint. At times, she turned to selling drugs.

She too had been in and out of detox and treatment programs more than a dozen times since 2012. She too had tried opioid replacements like methadone and suboxone and had worked the 12 steps through Narcotics Anonymous. But by December 2018, at the age of 44, she was still using fentanyl, and friends and family had repeatedly found her unconscious. “I was like ‘I’m going to die, and you’re not helping me,’” she remembers telling a nurse at her doctor’s office. That nurse soon found BeeLee a spot in Sutherland’s program. The day we met in February, BeeLee told me as a point of pride that she was going on her 18th day without using street drugs. By April, she'd been off them so long, she'd stopped counting.

The results of Sutherland’s research won’t be published for some time, but anecdotally, at least, she says she’s seen a change in the people she treats. Cooper has felt the difference too. “I’m not scrounging or worried about where I’m going to get my next shot, or how I’m going to get it, or where I’m going to get the next $10 to get my fix,” she says.

For Tyndall, these sorts of stories are encouraging but ultimately overshadowed by the number of people dying. What the country (if not the continent) needs, he says, are options that more than a few dozen people at a time can access without a doctor present.

To some extent, Sutherland agrees. Despite her belief that doctors like herself are an important part of the equation, she has also co-authored a paper for the British Columbia Centre on Substance Use, calling for the creation of heroin buyer’s clubs, where people who use drugs can pay for access to a stable supply of clean heroin—sort of like joining a tightly regulated food co-op. Because people would have to buy the heroin at market rates, she says, they’d be less likely to sell it all over again than if they got the drugs for free.



Christy Sutherland, a family and addiction doctor and medical director for the Portland Hotel Society,
runs an experimental program treating about 100 drug users with hydromorphone.


Tyndall admits there are some academic turf wars playing out through these proposals, as researchers compete for public and regulatory approval. Sutherland, for her part, politely declined to comment on Tyndall’s vending machine idea, as did Evan Wood, her co-author on the buyer’s club paper, who studied Insite at Tyndall’s side all those years ago.

Yet at a time when so many people need help, it’s hard to view these minor skirmishes and efforts to out-innovate each other as anything other than evidence of progress. If Tyndall or Sutherland lived south of the Canadian border, they’d be competing to accomplish a lot less.

On a rainy day nearly 5,000 miles southeast of the Downtown Eastside, Pennsylvania’s former governor Ed Rendell ambled up to a podium inside the Washington, DC, headquarters of the Cato Institute, with a red, white, and blue pin affixed to his lapel. In front of him sat dozens of health care workers, academics, and local officials who had gathered for a daylong discussion on harm reduction, or as the pamphlets being distributed in the hallway put it, “shifting from a war on drugs to a war on drug-related deaths.”

Earlier that morning, the crowd had sat rapt as Darwin Fisher, a program manager at Insite, told the story of the supervised consumption site’s struggle for survival, the thousands of lives that had been saved there, and the dozens of scientific studies that helped prove its value to the government and the courts. When it came time for Rendell to speak, the consummate politician started with perhaps the only joke appropriate for a day of talks about overdose deaths. “After hearing the first two speakers, I am compelled to act upon an urge I had after the 2016 election,” Rendell said. “That’s to move to Canada.”

As a board member for the Philadelphia nonprofit Safehouse, which is trying to open the country’s first supervised injection site, Rendell now finds himself in much the same position as Insite’s supporters did more than a decade ago. Only now, the stakes in Philadelphia are even higher than they were in Vancouver, back when Dean Wilson and his comrades marched that coffin into City Hall.

More than 1,000 people in Philadelphia have died of overdoses every year for the last two years. The vast majority of those deaths involved fentanyl.

The crisis has prompted city officials, including the mayor and district attorney, to openly back the idea of supervised injection; some have even made the trip to Vancouver to tour Insite for themselves. They’re not alone: Cities including Boston, Denver, New York, San Francisco, and Seattle are all considering the possibility of opening similar sites, as the US loses more than 70,000 people a year to overdoses.





The plans these cities are proposing are far less expansive than what Tyndall is requesting. Safehouse wouldn’t give people drugs or even any paraphernalia—just a clean space and some supervision. Even so, the US Justice Department is working overtime to stop these efforts before they start.

In America, the so-called Crack House Statute makes it a felony to “knowingly open, lease, rent, use, or maintain any place, whether permanently or temporarily, for the purpose of manufacturing, distributing, or using any controlled substance.” Passed in 1986, it was intended to prevent crack-den proprietors from making a profit on people who use drugs. Now the Trump administration is wielding it as a weapon against activists trying to keep those same people alive.

In February, the Justice Department filed a lawsuit in the Eastern District of Pennsylvania, stating that “it does not matter that Safehouse claims good intentions,” and asking the court to declare that supervised injection sites are in fact illegal. Safehouse, meanwhile, contends it wouldn’t violate the Crack House Statute, because supervised injection sites are created “for the exclusive purpose of” providing medical care, not unlawful drug use, as the law states.

Both sides are awaiting a decision, which could have a ripple effect on harm-reduction efforts across the country. No matter how the judge rules, Rendell said that Safehouse’s board is determined to open. “I think we’re going to win,” he added. “But if we lose, we’re going forward,” even if that means risking jail time. Of course, that wouldn’t be a great look for the feds, Rendell explains; one of Safehouse’s advisors is a Roman Catholic Sister of Mercy.

But Vancouver’s example suggests that sometimes it takes a little civil disobedience to prove the effectiveness of these interventions. “You have all these people saying ‘This is bad. This is going to happen,' and you’re like, ‘Actually ... we saved 100 lives this week,’” Lysyshyn says. “The more you have that data, the less they can tell you why you can’t do it.”

That was the case in Canada, at least. But the US government’s battle against Safehouse squares with the overarching, tough-on-crime approach the Trump administration has taken regarding the overdose crisis. In promoting draconian immigration policies, the president repeatedly has cited the opioid crisis as one reason for the crackdown. In speeches, Trump has openly expressed admiration for countries that sentence drug dealers to death.

Meanwhile, members of his administration have pointed to Vancouver as a symbol of harm reduction’s alleged failures. In an op-ed for The New York Times last year, deputy attorney general Rod Rosenstein denounced the concept of supervised injection sites, writing that they “destroy the surrounding community” by bringing drug dealers and violence to the area. As proof, he quoted a Redmond, Washington, city council member, who visited the Downtown Eastside and called it “a war zone” with “drug-addled, glassy-eyed people strewn about” and “active drug dealing going on in plain sight.”

It’s a revisionist history that ignores much of the evidence Tyndall and others have worked hard to produce over the years. That’s not to say this is an inaccurate description of the Downtown Eastside. It’s just that it was accurate long before supervised injection sites existed there. Insite opened in the neighborhood explicitly because it was in rough shape.

The people who pushed for it never promised they would do anything other than save people’s lives, and they’ve held up that end of the bargain. Insite alone has intervened in 6,440 overdoses without a single death. That doesn’t even include the thousands more people who’ve been saved at the other overdose prevention sites that have opened since then.

At the same time, it’s hard to blame Rosenstein and the Redmond city council member for connecting the dots between the Downtown Eastside’s squalid condition and the city’s progressive drug policies. Tyndall says he’s taken other American visitors interested in harm reduction on much the same tour that he took me on and struggled to explain how, while all these lives were being saved, things were getting so much worse. “They’re like ‘This is it? You’re telling me this is progress?’” Tyndall recounts.

You can blame the fact that there haven’t been enough sites or that the drugs themselves are still illegal. But the inconvenient truth that sometimes gets lost in the conversation about harm reduction is that drugs can do a lot of harm all on their own. Yes, fentanyl may be what kills people, and yes, the criminalization of drugs may be what’s landing many of them in jail.



Opioids have devastated Vancouver’s Downtown Eastside neighborhood.

But even if no one winds up dead or behind bars, using drugs can still torpedo a career, break up a family, and drain a bank account. Harm reduction isn’t synonymous with harm elimination, and activists pushing for supervised injection sites in the US would be wise not to hang too many hopes on what a single clinic can do.

These interventions, at the most basic level, are a last resort designed explicitly to keep people who use drugs alive. That means they may continue to live in a cycle of addiction, and it means they may continue to look like “drug-addled, glassy-eyed” masses on the streets of Vancouver or Philadelphia or San Francisco.

That’s not pretty to watch, and it’s natural to seek different results. It’s also natural to want to know how many people are getting and staying sober. And if that number isn’t charting up and to the right, it’s natural to wonder, well, what was the point?

If any one of those people were someone you loved, the point would be abundantly clear. As an oft-cited motto in harm-reduction circles goes: You can’t get sober if you’re already dead.

Twenty years after he first started treating people in the Downtown Eastside, and a year and a half after he concocted a crazy plan that could help save their lives, Tyndall is realizing he might need to start playing by the rules.

Even as he continues to advocate for his vending machines, he’s pushing the first phase of his less-ambitious pilot project through an ethics review board at the University of British Columbia, where Tyndall is also a professor of medicine. That one-year study, which will likely operate out of one of the Downtown Eastside’s overdose prevention sites, will include 50 subjects and will require a health care worker to dole out the medication.

Initially, subjects will have to inject under supervision, but Tyndall hopes most of them will be able to begin taking the pills with them within a week. To get honest feedback from his subjects, Tyndall hopes to work with peer staffers to survey participants on whether they’re diverting the drugs.

“I’ve been trying to do this for long enough that some progress is better than no progress,” he says. Whether his vending machines will ultimately collect dust or someday be effectively deployed and persuade their doubters remains unclear.

What is clear, though, is that over the last year and a half, Tyndall’s radical proposal did help shift the Overton window around a safe supply, broadening the conversation even at the highest reaches of government about what might be possible. In Vancouver, the city’s newly elected mayor, Kennedy Stewart, has thrown his full support behind the vending machine idea and says he has discussed the need for a regulated supply of safer opioids with Prime Minister Justin Trudeau.

At the provincial level, British Columbia’s health officer Bonnie Henry put out a press release last year calling for “safer alternatives to the unregulated and highly toxic drug supply.” The push has spread well beyond Vancouver and British Columbia too. Last year, Toronto’s chief medical officer also called for the regulated distribution of drugs as a way to flush toxic fentanyl from the market. And this year, Health Canada has set aside part of its budget to fund even more safe supply experiments. “Watch this space as that gets rolled out,” Health Canada’s Mattison says.

Lysyshyn believes Tyndall’s vending machine idea deserves much of the credit for forcing these discussions into daylight. “The first time it came out in the papers, the government was like ‘Oh my God, I can’t believe he’s saying this.’ People told him to stop talking about it,” he remembers. “The discussion that’s happened since then and the concepts that have come out are totally out of the box. It really brought those issues forward.”

If Tyndall were better at being a bureaucrat, he might be patting himself on the back. But he’s not. Instead, he remains devoted to the people who continue to be at risk of drowning while the governments of the world decide whether and how to give out life preservers.

That includes people like Cooper. For about nine months after Sutherland started giving her shots of hydromorphone, Cooper says she was able to quit heroin altogether. In a 2017 Globe and Mail article that made Cooper briefly famous in the Downtown Eastside, Sutherland boasted that her patient didn't “meet the criteria for substance use disorder anymore."

“I had people asking for my autograph,” Cooper remembers, laughing. For most of her life, Cooper says, she felt like the rest of the world viewed her as a “plague,” parting like the Red Sea whenever she walked into a room. It felt good to have her picture in the paper and to hear Sutherland talk about her as a success story.



Cooper, who also goes by the nickname Rambo, was the first patient in Sutherland’s program. “I felt privileged,” Cooper says. “I felt special.”

But not long after, Cooper started missing her shots, and when she did, she’d go back to using heroin. Eventually, Cooper dropped out of Sutherland’s program altogether and stayed out for 11 months. It was only within the last few months that Cooper finally found her way back to the Molson and started back on the hydromorphone injections.

She even took a job there as a peer staffer, but as of mid-April, she was still using street drugs from time to time. Cooper told me she hopes to get back to where she was in 2017, when she got her picture in the paper and when her doctor told the world that she had gotten better. “I just don’t think I’m ready yet. One day,” she says. “Hopefully I’m not dead by then.”

 
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Twice a day Kieran Collins, 39, injects prescription-grade heroin at the Crosstown Clinic in Vancouver.

Free heroin? Unusual clinic offers 'chance at being human again'

by Nick Purdon & Leonardo Palleja | CBC News | Jun 09, 2019

When I first met Kieran Collins in Vancouver three years ago, he had a $100-a-day street heroin habit that he fed any way he could.

"You're doing things that you don't really want to do — things that you weren't raised to do," said Collins, who was 36 at the time. "You know they are wrong, but you get accustomed to having to feed it."

He's still hooked, but a lot has changed.

Back then, Collins was haggard and desperate. He referred to his 20-year addiction to opioids as "a monster" as we sat in a park in Vancouver's Downtown Eastside, and he talked about what he thought would happen to him if things didn't change.

"I will be dead in not long," Collins said. "I have overdosed a couple of dozen times ... one of these times I won't come out of it."

"It's not the way I would like to go,"
he added. "Especially how that would make my family feel."

Since I spoke with Collins in 2016, the opioid crisis gripping Canada has killed more than 10,000 people in less than 3 years

In British Columbia alone there have been so many overdose deaths that average life expectancy is actually going down in the province.

Collins has managed to stay alive through this crisis. He credits a unique, controversial clinic's approach to dealing with people who use drugs.

Free heroin

Twice a day, Collins visits the Crosstown Clinic in Vancouver's Downtown Eastside. A nurse hands him a syringe of prescription-grade heroin.

It's just enough of a dose so that he doesn't go into withdrawal.

"It's not like this makes the problem just go away," Collins says, but it allows him to function.

In total, 140 people are prescribed heroin at the clinic. For each of them, other treatments such as methadone haven't worked.


After they take their shots, clients of the Crosstown Clinic in Vancouver gather in the meeting room while the drugs
take effect to make sure there are no complications.


The idea behind the program, which is publicly funded by the province, is that if users like Collins have a clean supply of heroin, they won't take street drugs like fentanyl — which was responsible for about 87 per cent of illicit-drug overdose deaths in B.C. last year.

After his shot, Collins takes a seat in the waiting room with some of the other users. It's a precaution in case there are complications.

Another patient sitting nearby, 58-year-old Kevin McGarragan, says the program has saved his life.

"If I wasn't here I'd probably be in an urn or underground."


Kevin McGarragan says the Crosstown Clinic has saved his life by allowing him to avoid street drugs.

Dr. Scott MacDonald, the lead physician at the clinic — the only one in the country that prescribes diacetylmorphine, the medical term for heroin — says the way to curb the crisis is to stop viewing opioid addiction as a criminal problem.

"This is a treatment for a chronic relapsing illness, just like diabetes and high blood pressure," he says.

"We need to get away from thinking this is a criminal problem — it is a medical problem and it is a chronic, manageable illness."

A chance at being human again

When Collins is cleared to leave the clinic, he thanks the staff and heads off to meet his father who works across the city in a design studio.

On the way I ask Collins how his life has changed since he began getting his heroin from the clinic.

At first he's a bit defensive.

"They're not medicating us to the point where we are like 'arghhhh,'" he says throwing his head back and rolling his eyes. "They just give us enough so that we are not a mess. So we can feel what it is to have a chance at being human again.

"Before, it felt like I was almost just existing,"
Collins explains. "But now, some days I wake up and it's like whoa, I am lucky to be alive."


Kieran Collins says low-dose injections keep his addiction under control and allow him to live a more normal life.

Collins stayed in touch with his father throughout his 20-year addiction — but only since he started on the program has he reconnected with the rest of his family.

"I'm an uncle now, my little sister has a kid," he says proudly. "I see him all the time."

Kieran's father, Wayne Collins, likes to joke that his hair is white from worrying about his son.

"I've nursed him through comas," he says. "I've nursed him through him having fallen out of a three-story window, wondering if he's going to come back to me."

Father and son hug for a moment before Wayne gives Kieran directions about the work he wants him to do cleaning up the studio. He says the biggest change in his son since starting on the heroin program is that now when Kieran says he'll do something, he follows through.


Kieren's father Wayne says his son has changed for the better since he started visiting the clinic for regular injections.

When Kieran was feeding his habit on the street, he'd disappear for months — sometimes longer. And there were many times when Wayne feared he'd lost his son forever.

"I've had the phone call from the landlord that says, 'he's DOA, you gotta go down to the hospital and ID the body' — and he's back. He's just got a spirit that keeps coming through."

"I believe in my heart that he is going to walk out of this,"
Wayne adds. "Some people go, 'Oh you are crazy — 20 years.' But that's part of knowing the whole person."

Over the years Wayne says many people have told him the best way to deal with his son's addiction is through "tough love." But he insists Kieran has taught him about a different kind of love.

"I think people who talk about tough love for addicts — that's the easy way out," Wayne says. "It's way harder to stay engaged and practice unconditional love, and show love for somebody who is lost."

A drop in the bucket

In the afternoon Kieran returns to the clinic to get his second shot of heroin.

"People get addicted to drugs," he explains. "They don't do them because they want to do them, they have to do them — like a frigging slave."

That's the reality for many people in Vancouver's Downtown Eastside.

According to statistics obtained by the Georgia Straight newspaper, a two-block area along Vancouver's East Hastings Street had more than 3,000 overdose calls in just two years. That's seven per cent of the entire province's 911 calls for suspected drug overdoses.

If anyone understands these statistics, it's the Crosstown Clinic's research coordinator, Kurt Lock. He has worked in the Downtown Eastside for 20 years.

When I walk with him through the neighbourhood, it's clear that most people know who he is. Lock explains that when you're the guy who can get people free heroin, it increases your popularity.


The Crosstown Clinic’s research coordinator, Kurt Lock, says the focus is on improving the quality of life of people
dependent on heroin, and this has positive benefits for society as a whole.


He says the 140 spots for patients at the Crosstown Clinic are "a drop in the bucket." To meet demand, he estimates they'd have to open five more clinics.

But is it really a solution to expand a program that gives out free heroin and doesn't push people to quit — after all, isn't heroin a poison?

Lock shakes his head. "If you have a clean, regulated supply, the drug itself it's not harmful for you," he says.

"I won't say it is good for you, but someone could live to be 100 years old and use heroin every day if it's not tainted with any contaminants."

Lock explains that many long-time opioid users look older than they really are because of what it takes to feed a street habit. Bad nutrition, homelessness and the contaminants found in street drugs are some of the things that hurt most long-time, chronic users.

Lock also counters critics who say health programs should be focused on getting people to quit rather than giving them the drug.

"The reason we provide heroin to people and we don't just expect them to quit is just that simply doesn't work," Lock says.

"We tried that for the last many decades … Why don't we put people in treatment? Well, we have done that. Why don't we put people in jail? Well, we have done that too. But the problem still exists."

Instead, Lock says the clinic focuses on quality of life.

The idea is to attract users to the clinic by providing them with the drug, and then once they are in a health care setting, try to address the issues that led to their dependence on narcotics in the first place.

Typically, the retention rate in opioid replacement programs that use methadone is around 30 per cent. In comparison, the Crosstown clinic's retention rate is more than 80 per cent.
Life without drugs

To supply a single user like Kieran Collins with heroin for a year costs around $27,000.

Proponents of the Crosstown program argue that this is cheap, because if Collins was getting his drugs on the street then society would pay twice as much through things like social, policing and hospital costs.

Toronto Public Health, for example, says "the social cost of one untreated person dependent on opioid drugs, which is attributed to crime victimization, law enforcement, productivity loss, and health care costs, is estimated at $45,000 a year."


Wayne has taken what he calls the more difficult approach of showing unconditional love for his son.
'I think people who talk about tough love for addicts - it’s the easy way out.'


Beyond the financial costs, there's no escaping the fact that 11 Canadians die of opioid-related overdoses every day.

Collins says he sometimes runs into the mother of a friend who died, and it's a reminder of the human toll of street drugs. "I was there when he overdosed and died. She always kind of stops me and she's obviously mad because she's lost her son — but I think she kind of blames me."

Perhaps the most surprising thing Collins said during the two days I spent with him is that now his drugs are supplied to him, for the first time he's started to think of a life without them.

"I would like to know what it's like to live without having a vice of putting narcotics in my body every day," he says.

"I would like to know what it feels like, when I leave this world, to be in a clear mindset."

 
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‘Treatment facilities’ aren’t what you think they are

by Leo Beletsky and Denise Tomasini-Joshi | New York Times | Sep 3 2019

Convicted of no crime, more people are being forced behind bars to undergo involuntary addiction treatment.

The Stonybrook Stabilization and Treatment Center at the Hampden County Jail in Ludlow, Mass., where men involuntarily committed were forced to receive addiction treatment in 2018.

The Stonybrook Stabilization and Treatment Center at the Hampden County Jail in Ludlow, Mass., where men involuntarily committed were forced to receive addiction treatment in 2018.

Imagine your aunt has developed diabetes and you want her to get better. Medical science suggests that medicine might help, but you decide that the better strategy is to lock your aunt in a room and force her to eat only lettuce — even though she hates vegetables. No medication, no discussion of other options.

Does this seem absurd? Illegal? It’s both of those, and no medical professional would advise it. But we are doing more or less the same to people who use drugs.

Laws in many states authorize family members, health care providers or police officers to ask courts to send someone who has not been convicted of any crime to be detained for involuntary addiction treatment; in many cases this means being locked in a jail or prison.

In places like Massachusetts, where the overdose crisis has been particularly destructive, these jails and prisons are being rebranded as “treatment facilities.”

As we continue to hear the mantra that we can’t arrest our way out of this crisis, policymakers are facing more pressure to expand treatment. Involuntary treatment has become an attractive response because it allows them to keep the punitive status quo, while also boasting they’re shifting toward a public health response.

There are many ways this approach falls short. For one, people are held in jail cells under lock and key. The facilities typically offer only one approach to treating addiction — abstinence. Medicines proved to effectively address addiction to heroin or other opioids are typically unavailable.

Troublingly, coerced treatment is becoming increasingly popular, spurred by the overdose crisis. At least 38 states allow civil commitment for substance use, up from 18 in 1991.

And while politicians, families and others view involuntary commitment as a good solution, research suggests that involuntary treatment is actually less effective in terms of long-term substance use, and more dangerous in terms of overdose risk.

A study by the Massachusetts Department of Public Health found that people who were involuntarily committed were more than twice as likely to experience a fatal overdose as those who completed voluntary treatment. Just as with other forms of incarceration, people with addiction who are forced into withdrawal behind bars are very likely to relapse upon release. Lower levels of tolerance makes the risk of fatal re-entry astronomically high.

Changing a name without a change in approach is dangerous. Jails masquerading as “treatment centers” make clear how harmful it is for the health of patients — and public discourse — to describe detention in correctional facilities as “treatment.” In a Massachusetts treatment center, for example, patients are required to wear orange uniforms, carry a badge with the word “inmate” and are monitored by corrections officers, without having committed a criminal offense. Patients can’t even have visitors.

Moreover, unlike at treatment centers not tied to the judicial system, judges can override clinicians’ recommendations in making medical decisions in involuntary commitment cases. Would we want family members with cancer or diabetes to have their course of treatment mandated by a judge?

We have the evidence that voluntary treatment can drastically reduce overdose, cutting risks from 50 to 80 percent. The World Health Organization recommends that anyone likely to be a lay “first responder” — a relative, friend, fellow drug user — should have access to naloxone, which reverses opioid overdose. It has saved lives in the United States and across the world. The medicines buprenorphine and methadone also reduce injection of illegal drugs. Safe injection facilities, which provide an environment for the most vulnerable to consume drugs under medical supervision and without fear of arrest, help reduce overdose. Syringe service programs, though under constant threat in the United States, have helped people who inject drugs control H.I.V. infection effectively.

We need a more profound cultural shift to embrace solutions that are both scientific and ethical. Encouraging people to be active participants in their care and recovery improves the impact of treatment, while empowering people to take control of their lives. Reams of evidence on the success of harm-reduction programs refute the idea that people who use drugs cannot make healthy or rational choices.

Making meaningful changes is more than mere rebranding — it’s about dismantling outdated systems and reinvesting in alternatives that are more effective and humane.

People entering addiction treatment deserve ethical and effective care. While some may find the idea of involuntary treatment alluring, a suspension of civil rights is not just unnecessary — it hijacks efforts to solve our overdose crisis. Civil rights violations in the name of “treatment” are still violations. And jails called “treatment facilities” are still jail.

 
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Ontario’s brutal cuts fueling the overdose epidemic*

by Carlyn Zwarenstein | June 11, 2019

Viewed from the United States, Canada’s comparatively liberal social mores and universal healthcare would seem to set the stage for some kind of polite, frozen harm reduction paradise.

Indeed, our responses to an overdose crisis as bad, proportionally, as in the US have been both innovative and pragmatic—measures range from Health Canada’s recent approval of injectable prescription hydromorphone to treat opioid use disorder to Good Samaritan laws protecting overdose 911 callers from prosecution. While Donald Trump’s Department of Justice fights the opening of safe consumption sites (SCS), we have dozens of them.

True, the Canadian response still falls badly short of the safe (decriminalized or legally regulated) drug supply and low-barrier, evidence-based addiction treatment which advocates demand. Still, harm reduction policies may even be slowing the long–accelerating overdose rates in Vancouver, on our west coast (there were four suspected overdose deaths there the week I wrote this and five the week prior, compared to a weekly average of seven last year.

Vancouver, British Columbia hosts our oldest SCS, Insite, which was founded in 2003 and permitted to remain open thanks to a successful 2008 legal challenge to the previous, Conservative federal government. The city, with its 10-block Downtown Eastside area of deep poverty and open drug use, is both the epicenter of opioid addiction and overdose in Canada, and an area with the country’s highest concentration of harm reduction services, scrambling to keep up.

A grotesque social experiment

But I live over on the other side of the country, in Ontario—a province over one-and-a-half times the size of Texas with a population of over 14 million, 6.3 million of whom live in the Toronto region. Belatedly anticipating the eastward spread of fentanyl and now carfentanil, we copied many of British Columbia’s innovations, although not at the scale needed. Still, it was a start.

Until, that is, we elected a new provincial government late in 2018.

Swift, brutal policy and funding changes broadly in line with Thatcherism or the US Republican Party.

Our new premier is right-wing populist and millionaire Doug Ford (brother of the late Rob Ford, best known as “that Toronto mayor who smoked crack on video while in office”). Doug, who has been investigated by the Globe and Mail for his own alleged past as a teenage hash dealer, campaigned for office in part on his opposition to SCS, along with austerity and privatization policies.

Doug Ford’s Conservative government has enacted swift, brutal policy and funding changes broadly in line—in their emphasis on stripping protections from the most vulnerable—with Thatcherism or the US Republican Party.

So what happens when you take a state in which an accelerating overdose crisis has been somewhat mitigated by a range of harm reduction policies and a fairly strong social safety net—and then you dramatically worsen social determinants of health such as poverty, and access to healthcare and housing, heralding a more typically American, law enforcement-centered approach to substance use? And simultaneously cut back on those emergency harm reduction measures?

I visited the OPS (Overdose Prevention Site, a bare-bones, provincially funded version of an SCS) at St. Stephen’s Community House in downtown Toronto the week that it opened last May. One year later, I return after the provincial government abruptly pulled its funding—along with that of five of Ontario’s other 21 existing sites, also ending the provincial legal exemption allowing them to operate.

All the sites scrambled to seek new legal exemptions from the federal government and to cobble together temporary funding: combinations of GoFundMe, shifting scarce host organization budgets, and neighborhood donors. As a result, an emergency public health response has been privatized. "St. Stephen’s is funded until December; a legal exemption from the federal government will also take it through to 2020," says Tyler Watts, its coordinator of Overdose Prevention Services.

The local community in the fast-gentrifying Kensington Market neighbourhood was welcoming even from the start, largely appreciating that the facility prevents many community harms. “The businesses here aren’t equipped to deal with overdoses in their washrooms, which was happening before we opened,” says Watts. He has seen barely any public illicit drug use in the area since the site opened last year.

We’re sitting in the chill-out room next to the OPS. The room itself has two seats where people can sit to inject; clean syringes; naloxone; mirrors. The chill-out room is decorated with a mural inscribed with messages from clients; a photo of Crystal Papineau, a homeless woman who died in a preventable accident on a brutally cold night this winter.

There is also a large photo of Angela Kokinos; that wasn’t there last year, either. The last time I was here, I spoke with Kokinos, a vibrant, newly-abstinent 41-year-old. She died of an overdose in September—at home, not at the OPS. Watts tells me now, “When Ang died, I didn’t think we could withstand it any more.”

The small, tight team of overdose prevention workers considered closing the OPS for a day or two to mourn. Ultimately they decided they could not risk lives by not being there when people showed up first thing in the morning.

In Toronto, overdose deaths in these first few months of 2019 have nearly doubled.

The drug user population, which overlaps substantially with the local frontline overdose prevention worker population, was already suffering severe burnout when Doug Ford was elected in June of last year.

“People are exhausted,” says Franky Morris, an injection drug user who also staffs an OPS in Ontario (she isn’t allowed to speak on behalf of her employer, so Filter agreed withhold its name). “There’s just been an intense amount of stress and anxiety and grief.”

And then there’s the impact in the north of the province. Mae Katt, nurse practitioner at Dennis Franklin Cromarty, a high school for First Nations students in Thunder Bay, Ontario, explains that she sees young people who often come to Thunder Bay from much smaller communities in the far north, unprepared for life in the city. Specifically, the city has astonishingly high rates of racism and violence against First Nations people, a dearth of safe, affordable recreation options, and a lot of illicit fentanyl in the drug supply.

The government has now cut a range of programs that would provide some protection to Katt’s patients. It has also made some medication-based treatment for addiction more expensive for low-income patients, Katt says—removing brand-name Suboxone from the Ontario drug benefits formulary and forcing healthcare practitioners to prescribe higher doses of the generic version to their lower-income patients, who must pay an extra 25 percent that was previously covered by the drug company.

Perhaps worst of all, the climate is increasingly hostile to First Nations people and people who use drugs. “I find the hate right now is really detrimental to every person in Ontario,” Katt says. For her patients, that’s an extra burden they don’t need. “They’re in a world where they feel the shame of having to be a drug user. Even if they’re in treatment they feel this stigma.”




Past cuts sowed the seeds of today’s disaster

Back in 1995, Ontario’s newly-elected provincial Conservative Party set about restructuring the province with changes they called the “Common Sense Revolution.” Premier Mike Harris made devastating cuts to Ontario’s previously-strong social safety net, while weakening worker health and safety protections. Readily available opioid painkillers were an alternative.

“Harris disenfranchised tens of thousands in this city alone,” says James, who asked that his last name not be used. He was using heroin and became homeless in Toronto as a result of the Harris cuts. “That led to widespread poverty, persistent unemployment, recidivism—and if you check the figures it was the point when our homeless issue exploded in scope. Those victims are the homeless opioid users of this current crisis.”

Now in safe housing and taking Suboxone, James fears the new wave of drastic cuts will destabilize people like him who’ve just barely regained stability after years of extreme poverty. “We made a permanent underclass, which Ford is basically targeting for extermination.”

Dr. Ritika Goel, a Toronto physician who works with many patients who use drugs and who are insecurely housed, notes that the new cuts come against a background of services that never returned to pre-Harris levels.

“Income,” she notes, “is the number one determinant of health.”

Changes that will affect her patients’ health now include making it harder to qualify for disability benefits (which will reduce income for most OPS regulars), and cutting other income support programs; reducing incentives for developers to build affordable housing; loosening regulations protecting tenants from eviction; cuts to funding for subsidized childcare in Toronto; a dramatic but still-opaque restructuring of the provincial healthcare system; cuts to legal aid; and erosion of worker protections and worker safety oversight. Public health units are facing millions of dollars in cuts, and their numbers are to be slashed from 35 to 10.

Dr. Goel’s insecurely housed patients who use drugs already experience high rates of diabetes, high blood pressure, chronic obstructive pulmonary disease, smoking-related diseases, hepatitis C, HIV, liver disease, skin-related infections, endocarditis, PTSD, depression, anxiety, schizophrenia and bipolar disorder. And that’s before adding the overdose issue.

Overdose rates in Ontario, Dr. Goel explains, are already much higher than actual patterns of drug use would predict—likely the result of illicit fentanyl and other contaminants in the drug supply. “People are being poisoned at this time.”

As in the US, where a generation of older heroin users are dying of fentanyl and polydrug overdoses, survivors of Ontario’s Common Sense Revolution are now succumbing—along with their younger peers. Less risky opioids became dramatically harder to acquire following the introduction of tamper-proof OxyContin to Canada in 2012, driving a move to riskier, more potent illicit substances.




A bleak near future

Other jurisdictions provide hints of what might happen next.

In the UK, a pilot heroin-assisted treatment program ran between 1982 and 1985—with no overdose deaths among its 450 participants. When the program was cancelled, 41 patients died within two years, among other health harms.

In Portugal, decriminalization and a range of harm reduction measures slashed rates of HIV and hep. C and dramatically reduced injection drug use. But between 2010 and 2014, austerity measures resulted in cuts to the harm reduction part of the plan, as well as a general increase in misery among marginalized drug users. Injection drug use has climbed again to the point that the country has finally opened its first SCS, a measure previously considered unnecessary.

“People know they are under attack.”

In Ontario, “people are going to die should these cuts have their effect,” says Watts, echoing Toronto’s medical officer of health, Dr. Eileen de Villa, who has also predicted deaths if SCS are forced to close.

“When you shut down an established service, you put people at risk,” Dr. Goel agrees.

As each new cut or change comes into effect, we can expect to see the impact in infectious disease rates, public drug use, public misery, punitive law enforcement response and finally, preventable deaths.

Dr. Goel describes a climate of fear among her patients. “People know they are under attack. They know cuts are happening and they know it’s going to affect them.” She doesn’t want to speculate on the impact of this stress on drug use patterns or recovery, saying only that people turn to different coping mechanisms in the face of an anxiety that is “totally warranted.”

Jessica Hale is a member of the Ontario Coalition Against Poverty and a nurse practitioner at another Ontario OPS that can’t be named. She puts it like this: “The whole issue with the cuts is that the community was already in absolute crisis.”

The site where Hale works, which unlike St. Stephen’s faces constant, sometimes aggressive opposition from local property-owners and businesses, serves a large population of Indigenous people and women of color. Some 60 percent of clients are women who are precariously housed or homeless (Hale’s site collects formal data on gender and age only, so most of this is her personal observation). The site has hosted 2,000 injections that would otherwise have taken place in parks, bathrooms, stairwells and alleys, she says.

Overcrowded shelters and an increase in evictions as neighbourhoods gentrify and housing prices skyrocket have been accompanied by an increase in pressures from police, who push homeless drug users out of parks, streets and other public places. Increasingly, they are not allowed to be anywhere.

Defiance against the odds

Most people I spoke with described a climate of anxiety, fear and extreme stress among people who use drugs in Ontario, particularly those who are poor and insecurely housed or homeless. But they also describe a sense of defiance.

Mae Katt, working with teenagers in Thunder Bay, believes that “their determination to change their life is much stronger than cuts.” She describes one patient—a single dad on Suboxone, who had to cancel plans to advance his education due to the government’s closure of a groundbreaking basic income pilot—who, she says, is seeking other options to improve his family’s life.

Despite cuts to most of a CA$500 million mental health and addiction budget intended in part as a response to the opioid-involved overdose crisis. And despite a legacy of residential schools in Ontario that—through family separation, widespread abuse and attempted cultural genocide—weakened social protection against addiction (Canada’s last residential school closed in 1996), Katt declares, “I don’t want to give Ford that much power to say that he will cause my patients to relapse.”

“I think people are really fed up,”
Dr. Goel says. “Communities of people who use drugs have experienced so much trauma in the last few months. People are reaching a tipping point.”

As I write these words, harm reduction and drug user communities in Toronto are reeling from the overdose death of Leon “Pops” Alward, one of the original group of drug user activists who brought SCS to Ontario with an illegal, volunteer-run site opened under a tent in a Toronto park in summer 2017. Ultimately, that initiative forced governments to belatedly acknowledge the public health crisis here, and to publicly authorize and fund the emergency response services that are now being cut back.

“It’s a public health crisis that’s not being treated as a public health crisis, that’s being put back on community and agencies and individuals to manage,” says Watts. “I had big plans for case management, better wraparound services, talking groups, harm reduction training. Instead of fulfilling all of those pieces, we’re always worrying about where the next dollar is coming from.”

At a large demonstration against the cuts to OPS in Toronto in April, I watched people shed tears as they spoke of loved ones lost to overdose. Demonstrators hugged each other and spoke defiantly. Angela Kokinos’ face was on a sign held aloft (pictured top) as the crowd marched from Queen’s Park, the provincial legislature, to the office of Ontario’s Medical Officer of Health, where they staged a die-in.

“We have to take care of each other. Lord knows nobody else is.”

*From the article here:

 
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Drug addicts to be given free heroin as UK's Home Office awards first licence

by Charles Hymas | The Telegraph | 15 June 2019

Drug addicts are to be give free heroin under a new scheme backed by police.

Addicts will be able to attend centres licensed by the Home Office where they can inject the class A drug up to three times a day.

The scheme is being introduced in Cleveland in the autumn, and will cost an estimated £12,000 a year for each addict.

Cleveland’s police and crime commissioner, Barry Coppinger, wrote to home secretary Sajid Javid to say the scheme will “help to save lives, save money, and reduce crime.”

He insisted the “heroin assisted treatment scheme” in Middlesbrough would offer a “different and innovative approach.”

The centres will be open to addicts seven days a week, and other police forces, such as West Midlands, Durham and Avon and Somerset, have supported the project.

The Home Office said: “We must support people dependent on drugs through treatment and recovery.”

Mr Coppinger told Teeside Live: “Entrenched heroin dependency continues to be a key driver for acquisitive crime offending in Cleveland and elsewhere.”

He said "the addicts selected for the scheme are those for who all previous treatment has failed."

"They are the most prolific offenders with severe impact on themselves and their families, on the public and shopkeepers and the local economy as a whole as well as police and health resources."

“They lead chaotic lifestyles in which virtually every minute is focused on funding their next hit."

"If we can remove that obsession we can then look to engage other agencies, including health and housing, to finally get these users off the streets and back into society."

“It’s clear that for this hardcore of substance addicts the current strategies are not working."

"If we don’t try something new the cycle of offending and the enormous costs to society will simply continue and in all likelihood increase.”


But the scheme has been criticised by those who claim it will cause further drug dependency.

David Green, director of the Civitas think tank, told the Sunday Telegraph: “If it becomes accepted, you could increase the amount of addiction. I would like to see a heavy emphasis on getting people off drugs all together.”

But Ian Hamilton, a senior lecturer in addiction at the University of York, believes the project will have a positive impact.

“There has been considerable misunderstanding and reporting of this proposed scheme in Cleveland,” he said.

“They will not be setting up drug consumption rooms, but they will be providing heroin assisted treatment (HAT)."

“Providing a small group of people who use opiates with pharmaceutical grade heroin is a proven way of engaging them in treatment, particularly for those people that have not responded to traditional opiate substitutes like methadone."

“Heroin assisted treatment has been offered in the United Kingdom before and should help reduce the risk of an overdose. This is an important initiative as the UK has the highest rate of drug related deaths in Europe.”


 
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How Portugal tackled its addiction epidemic to become a world model

CBC Radio | Jun 18, 2019

Since decriminalization, Portugal has one of the lowest drug addiction rates in Europe.

In the late 1990s, Paul Mendes was deported from the U.S. back to his birth country of Portugal. And within months of arriving, the former fisherman was hooked on heroin.

"It was crazy," Mendes remembers, standing on the side of a busy street in Lisbon after getting his methadone dose from a white van nearby.

"I'd lived in New York where they had drugs in buildings, people doing it in a corner or something. Here? They had lines from here to like to [way] over there, two people, double line-ups. You got a guy with a bag of coke, and bag of heroin — and the guy with the money… So many people died."

At the time, Portugal was in the grip of a nation-wide drug epidemic.

After the 40-year conservative authoritarian regime of Antonio Salazar ended in 1974, soldiers fighting the country's colonial wars returned to a once closed-off nation where even Coca Cola had been banned as a corrupt, habit-forming drug. But many of these ex-soldiers had become addicted to drugs while abroad.


Dr. João Goulão was tasked with putting together a proposal that included the full decriminalization of drug use,
and the recognition of addiction as a disease and a social problem.

"More than one million people suddenly came to the mainland, bringing their habits and tonnes — literally tonnes — of cannabis that suddenly was made available for everybody,"
explains Dr. João Goulão, the head of Portugal's Intervention on Addictive Behaviours and Dependencies service.

"In a completely naïve society, we knew nothing, not even the differences between different drugs."

A blueprint intervention

The rates of addiction and overdose soared so high that virtually every family in the small country was affected — one percent of the population. In Canada, that would be 360,000 people at risk of overdose.

The dire situation led the country's leaders to a radical, daring solution: the decriminalization of the possession for use of all drugs and a health-care approach to dealing with addiction, rather than a criminal one.


Drug dealers (left) in downtown Lisbon, where drug use and addiction are among the lowest in Europe.

Goulão was then a young doctor struggling to treat addicts in the south of Portugal. when he was tasked with writing the blueprint for dealing with the crisis.

At the time, drug dealing was still illegal and was overseen by the courts. But the issue of drug consumption was transferred to the auspices of the Ministry of Health.

Those caught with more than 10 days' worth of anything from cannabis to heroin would receive an administrative order to report to a Drug Dissuasion Commission, where they would meet a psychologist to talk about addiction or any other issues they may have.


There are two Threshold Mobile Units around Lisbon treating approximately 1,200 people a day.
They’re part of Portugal’s nationwide, co-ordinated holistic response to addiction.


Methadone clinics, clean needle handouts, programs to encourage small businesses to hire addicts in treatment, and a pan-ministerial network of support for those struggling to stay off drugs were set up and are still operational today.

The results: addiction rates plummeted. As did those for HIV and AIDS. The court system declogged, and what began as the "Portuguese Experiment" is now studied by experts and officials around the world as the "Portuguese Model" — including Canada.

Could the Portuguese Model work in Canada?

In June 2019, the House of Commons Health Committee urged the federal government to look at Portugal's decriminalization of simple possession of illicit drugs and examine how the idea could be "positively applied in Canada."

Some Liberal MPs are working on introducing a private member's bill to have Canada treat drug use as a health issue, and to decriminalize simple possession of any drug currently subsumed by the Controlled Drugs and Substances Act.

"Policies restricting drug use are fueling the drug crisis," says Dr. Carl Hart

B.C. doctors look to Portugal for drug decriminalization lessons

However, Conservative critics point out that Canada can't simply copy the Portuguese model. In Portugal, there are 170 recovery facilities for 11 million people. The country also provides mental-health treatment and mandatory education about the harmful effects of drugs.

They argue that it's unrealistic to think Canada could achieve the same results without the same support systems.


Portugal decided in 2001 to decriminalize possessing small amounts of all drugs – from cannabis to heroin. Dr. Goulão
says the decision focused on the correlation that the individual establishes with the substance, not the substance itself.


A testament of success

Whatever route Canada takes, Paul Mendes can attest to its success in Portugal.

He's been off drugs for a decade now. He's one of the 1,200 men and women who get their methadone and any other medications they need from one of the two Threshold Mobile Unit vans that moves throughout Lisbon every day.

And thanks to Portugal's healthcare approach to addiction, he's stayed out of prison, and has been working as a landscaper. He's now cured of the hepatitis C he'd contracted in the days of the epidemic.


Paul Mendez holds a document that shows he is cleared of Hepatitis C.

However, there are still elements of the program he doesn't like — the people coming to the van to get their methadone, for instance — who pick up clean needles to then go and shoot up.

But he says he's convinced the whole world should adopt the Portuguese Model.

"I can think better. I don't have to make money every day to go get high. I have no dope sickness," he says.

"You feel normal. So I'm with this program."

 
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Overdose death toll would be more than double without harm reduction, study says

by Rafferty Baker | CBC News | Jun 05, 2019

The overdose crisis has killed an astonishing number of people across Canada, and British Columbia has been hit especially hard. A new study published Wednesday in the journal, Addiction, found that without harm reduction efforts, the death toll would have been more than twice as horrific.

Researchers looked at nearly two years of data, beginning when the public health emergency was declared in B.C. in April 2016 and ending in December 2017.

According to the study led by the B.C. Centre for Disease Control (BCCDC), there were 2,177 people killed by overdose in the province in that time.

But more than 3,000 deaths were prevented.

"It was one of these things that — you almost had to go back and check the numbers to make sure they were correct — that they actually were that high," said Mike Irvine, a post-doctoral fellow at BCCDC who works with the Ministry of Mental Health and Addictions and the Mathematics Institute at the University of British Columbia.

Irvine said the impact of widely distributed take-home naloxone kits was the most significant, in terms of lives saved.

"In 2017, there were 60,000 kits that had been distributed, so this is paying tribute, really, to how much that program had ramped up and rolled out across the whole province," he said.

In contrast, from 2012 to 2015, about 5,000 naloxone kits were distributed.

'Safe supply' program will distribute free opioids to entrenched users

In the period from April 2016 to December 2017, the study found there were:

- 1,580 deaths averted due to access to take-home naloxone kits.

- 230 deaths averted by overdose prevention and supervised injection sites (with 23 sites operating by the end of 2017).

- 590 deaths prevented by opioid agonist treatment or opioid replacement treatment (with 22,191 people receiving treatment in 2017, including methadone, Suboxone and hydromorphone)

According to Irvine, the three health interventions combined resulted in more overdose deaths prevented than they would have if each were carried out alone.

He said the team's research found that as the prevalence of fentanyl analogues like carfentanil began to increase in late 2016 and 2017, so too did harm reduction services.

"We know that this [crisis] is being driven by a toxic, highly variable street drug supply," said Irvine. "There's a huge number of deaths that were averted, in part because of the sheer volume and the scope of these services, but also the fact that the street drugs had become so toxic within that period."

Irvine said the study's findings are a reminder that health officials' response to the overdose crisis in the province is effective, but also that the deadly crisis is still a major challenge.

"Deaths are still very, very high, and there is so much more to be done," he said.

https://www.cbc.ca/news/canada/british-columbia/bc-od-crisis-lives-saved-1.5163581
 
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Portugal’s decriminalization of drug use, explained

by Sessi Kuwabara Blanchard | Filter

In 2001, Portugal was experiencing an opioid-involved overdose crisis, similar to the one gripping the United States. The country used criminalization and incarceration to try to manage drug use, while HIV rates among people who use drugs were the highest in Europe.

In response to this emergency, Portugal launched its decriminalization program that year, and the rest is history. Overdose deaths have plummeted by 80 percent, while the percentage of drug users diagnosed with new HIV infections fell from 52 percent in 2000 to 7 percent in 2015. Rates of problematic drug use and drug-related incarceration have also fallen, while numbers of people voluntarily entering treatment for substance use issues have increased.

In March 2018, the US-based advocacy organization Drug Policy Alliance led a large delegation to Portugal to learn more about the impacts of decriminalization of drug use on health outcomes and society. DPA has just released the above video to tell part of the story.

Portugal decriminalized possession of small amounts of any drug—even though the substances themselves remain illegal. In practice, this means police records, jail time and other major sanctions no longer apply to people who use drugs. In the place of a punitive regime, dissuasion commissions were established through the Ministry of Health, without any association with law enforcement or the Ministry of Justice.

When police encounter someone with a small quantity of illegal drugs, the attending officer confiscates the substances and refers the person to a dissuasion commission. These are comprised of a legal professional and a health or social services official.

“If you are a person who uses drugs and appears before the dissuasion commission, you are given access to treatment on demand. If you don’t want to or can’t stop using drugs, harm reduction services are available to anyone who needs them,” says Hannah Getzer, DPA’s senior international policy manager, in the video.

As a result of the commission’s assessment of potential drug dependency, the person may also face sanctions, like fines or required therapy, according to DPA’s briefing paper.

“Drug criminalization fuels the United States’ dual crises of mass criminalization and overdose deaths,” said Widney Brown, managing director of Policy at DPA. “The Portuguese experience demonstrates that decriminalizing drugs—alongside a serious investment in treatment and harm reduction services—can significantly improve public safety and health.”

 
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Attempts to build a Safe Injection Facility for San Francisco drug users pushed to 2020

by Scott Shackford | 6.21.2019

Lawmakers struggle to pass a bill protecting operators from arrest and prosecution.

A new effort by California lawmakers to permit a safe injection facility to be built in San Francisco has been put on hold until next year apparently due to struggles getting it through the State Senate.

Safe injection facilities (SIFs) are centers where drug users who have nowhere else to go (often very poor or homeless) can safely use without fear of arrest under the monitoring of caregivers who can prevent or respond to overdoses. There have been successes in other countries using these sites to save lives and reduce the harms of overdoses and threats of disease transmission, but none openly operate in the United States (there is, however, a secret one), thanks to our punitive drug war, which threatens operators with arrest and prosecution.

San Francisco leaders would like to build SIFs in the city to help deal with the significant problem they have of homeless people injecting drugs in public. To reduce the risk that site operators would be prosecuted, last year state lawmakers crafted a bill that would guarantee that people running a permitted SIF in San Francisco wouldn't be arrested by local or state police. That bill passed through both the state's Assembly and Senate, but when it got to Gov. Jerry Brown, he vetoed it. In his veto letter, he argued that the state needed to have the power to coercively force mandatory treatment on people addicted to drugs.

Brown is no longer governor and new Gov. Gavin Newsom has said he's open to the idea of allowing a SIF in San Francisco. So a new version of the bill was drafted, A.B. 362, and was reintroduced in February. The bill, similar to the previous version, would allow San Francisco to build injection sites without fear of civil liability and criminal sanctions from the state, so long as the program is actually authorized by local government.

The bill passed the Assembly in late May, 44–26, but now, surprisingly it's stuck in the Senate. It's been sent to three separate committees for evaluation, and on Wednesday the bill's authors canceled a hearing in the Senate. SF Weekly reported that due to concerns that they don't have the votes in the Senate (it passed by just four votes in the Senate last year), they're going to push the bill to 2020 in the hopes of building alliances.

San Franciscans are largely supportive of launching the first safe consumption site in California. In January, the San Francisco Chamber of Commerce and Dignity Health conducted a poll on San Francisco voters, which uncovered that 77 percent believe overdose prevention programs are a solution to many of the health crises seen on our streets. One of the largest local supporters of the facilities is the San Francisco AIDS Foundation — which operates several needle exchange sites throughout the city. On Thursday its staff expressed "deep disappointment" in the postponement of the bill, and launched a petition to encourage Sacramento to move it forward faster.

If the bill eventually passes, unfortunately the city will still have the federal government and Department of Justice to deal with. A U.S. attorney in Philadelphia is taking the city to court to try to get a federal judge to rule that a SIF they're proposing there would violate federal "crackhouse" statutes.

It seemed as though there might have been some possible interest in federal lawmakers in some reforms here. Rep. Pramila Jayapal (D–Wash.) had introduced an amendment to an appropriations bill that would have stopped the Department of Justice from spending money trying to fight states and cities from establishing SIFs. Seattle is also attempting to build SIFs there. But Jayapal has since withdrawn her amendment and her office did not respond to request for comment about the amendment.

 
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mr peabody

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What to expect when your city is planning a supervised injection site

by Abraham Gutman | The Philidelphia Enquirer | Jun 29, 2019

Philadelphia, where another 1,100 people died of an overdose in 2018, is slowly navigating toward opening a supervised injection site, a move that has prompted a debate among harm reduction advocates and law-and-order types about the best way to address the overdose crisis. Safehouse, a nonprofit, has been incorporated with the sole purpose of opening a site to save lives. After incorporating, the U.S. attorney sued Safehouse, arguing that the site is illegal, in an attempt to prevent them from opening. The suit is currently in court, but Safehouse has made progress. In March they announced a potential location.

While Philadelphia’s alarming overdose rate adds urgency to this initiative, the city doesn’t need to reinvent the wheel. There are already about 120 supervised injection sites around the globe.

The Inquirer wanted to hear from people on the ground who made some of these sites a reality (or are trying to do so) with the hope that as Philadelphia moves forward, those involved can learn from the hard work of people who have already been through the process. Here are my takeaways from these discussions, followed by a deeper reflection from the people doing the work to launch and operate these sites.




Dublin, Ireland

How a painstaking legal process can provide political clarity

What Philly can learn from Dublin:

- Patience is key: For supporters of supervised injection sites, it can feel like Philadelphia’s process is moving too slowly. But Dublin’s story is a reminder that even with legal approval, opening a site can take a very long time.

- Bureaucracy can help define roles: Because the government took ownership over Dublin’s site, it set clear guidelines for what needs to happen to open it. The government chose the model, location, and provider. Those with grievances can complain to their public officials. This is something Philadelphia should consider, given that Mayor Kenney has expressed disapproval toward Safehouse’s proposed location.


In January 2012, because of serious harm caused by street-based injecting that Dubliners witnessed on a daily basis, Ana Liffey Drug Project, an Irish harm reduction charity, began to advocate for mobile supervised injecting facilities (SIFs) in Ireland’s capital city.

Building political support took time. It wasn’t until 2016 that the Irish minister of state allocated funds to support the establishment of a pilot SIF in Dublin’s downtown area. Then, in May 2017, President Michael D. Higgins signed into law the Misuse of Drugs (Supervised Injecting Facilities) Act 2017, which created a legal framework within which an SIF could operate, a victory celebrated by harm reduction advocates.

Once the law was changed, the Health Service Executive (HSE), Ireland’s state health-care body, invited organizations to submit proposals to become the provider of a pilot, non-mobile SIF in downtown Dublin. The HSE designed the service requirements similar to the successful model of a SIF in Sydney, Australia.

Through this process, Merchants Quay Ireland, the provider of a busy needle and syringe program, was identified as the preferred provider for the SIF service, with their premises in the heart of Dublin assessed as the best location.

But there were still more legal steps before the SIF could become reality.

In November 2017, Dublin City Council ruled that planning permission would be required to re-purpose Merchants Quay’s premises to allow for the SIF. Merchants Quay applied for planning permission in September 2018 — and the application met with almost 100 objections from local residents and businesses.

Currently, Merchants Quay Ireland is still working through the planning process and no realistic commentator thinks that (even assuming there are no additional planning hurdles to overcome) any service could be operational before the second half of 2020.

In the interim, there is still a significant problem with street-based injecting in Dublin. While we await the implementation of supervised injecting in Ireland, the related harms continue to impact people who inject drugs, their families, and the people who live in, work in, or visit the capital.




Toronto, Canada

How an illegal supervised injection site can speed up the legal process

What Philly can learn from Toronto:

Show, don’t tell: Sometimes the best way to show people how something will work is just to do it. While Toronto’s police worked closely with the people behind the unsanctioned site, Philadelphia advocates shouldn’t necessarily expect similar treatment, considering that federal law enforcement has already taken action against Safehouse. If they choose this route, they must be prepared for some risk.

In 2004, the city government of Toronto developed a strategy for dealing with its drug problems. The strategy recommended an evaluation of Toronto’s need for a supervised injection site.

Fast forward to 2010, when a group of researchers released a study that said that the city needed three sites at minimum. There was quite a bit of public support at that time. But the process with the federal government required a lengthy application process to get an exemption under the law.

While activists, including myself, were waiting during that process, some of us went into a park and opened Toronto’s first overdose prevention site. We opened it in the area that is the epicenter of the overdose crisis. No organizations wanted to take on the role of advocating for supervised injection sites in this area because it was so political and challenging. In August 2017, we just went and opened one up — illegally.

People in that area were so happy that we were there because they were so burdened with reversing overdoses and seeing people die. The police were very open to this, too. They were saying things like, “You guys are here for the preservation of human life, and we also have a responsibility to preserve human life, so we are going to allow you to be here even though it’s not legal.” They let us operate from 4 p.m. to 10 p.m. We picked those hours because we all worked in the daytime.

By November 2017, the sanctioned sites started to open, but we stayed in a park for about another eight months. We reversed 251 overdoses while we were there and we received about $250,000 in donated funds from people in the city of Toronto. And then we moved inside and became a legally sanctioned funded overdose prevention site as part of South Riverdale Community Health Centre.

The illegal site added pressure to get the sanctioned sites open sooner. It put pressure on other harm reduction organizations to open a site in a neighborhood where no one wanted to open one at the time. Now, we have four in that neighborhood.

What we learned is that somebody has to go ahead and just do it. These are just sites. There is no big deal about opening a site and saving someone’s life. We went ahead and did it and the sky did not fall. Actually, it did the opposite: It changed everybody’s minds.




Ottawa, Canada

What happens on opening day of a supervised injection site

What Philadelphia can learn from Ottawa:

- Day 1 isn’t everything: Philadelphia shouldn’t expect a supervised injection site to be full on the first day. It may take time for people to feel comfortable to use there. But at some point that is likely to change. Safehouse should be prepared for a scenario in which they get more clients than they can accommodate.

- Building coalitions: The success of a site depends on the comfort of clients. Working with the police and the community is of utmost importance to ensure a welcoming environment. If potential clients know that the police and/or angry neighbors are waiting outside the site, they won’t use it.


After the opioid overdose deaths in Ottawa, a city of about a million people, increased from 40 in 2016 to 64 in 2017, harm reduction advocates had an urgency to open a supervised injection site. An unsanctioned site opened in August 2017. It was just a tent in a park. The first legal site opened in October 2017. A few months later, the site in the Sandy Hill Community Health Centre, where I now work, opened. There are now four sites in Ottawa.

On the first day that our site (which was the third site overall in Ottawa) opened, there was no line outside the door. We had maybe five people come in.

Prior to opening the site, we didn’t do a big outreach campaign. We just spread information by word of mouth in our needle distribution center. We told people who came to get needles, “Here’s the room and you can have a look at it.”

There was very low interest from people who use drugs at the beginning. We still had people coming in to get needles, but they weren't ready to use the site yet.

The issue for many people was comfort level. They wondered: What is going to happen in that room? How is this going to work?

It took them a long time to feel comfortable. It’s like going to a new bar. That feeling when you walk in, who else is going to be there? Some people can’t go to a new place without 10 of their friends coming with them. Some people needed to hear how it was from their friends who went before them.

As the months went on, more and more people came. Now, on our busiest day, which was about two weeks ago, we had 96 visits in a 12-hour period. Our numbers far exceed what we planned in the beginning and we are probably over capacity. We had to impose a time limit on staying in the site because if we don’t, we simply don’t have the space to serve the amount of people who want to use it.

When a site in Philadelphia opens, I think it will be slow at the beginning. People will have to trust that the staff knows how to respond to overdoses, that they won’t be bothered by people injecting drugs in front of them, that they will be nonjudgmental, and that the cops are not going to sit outside. There won’t be a line outside the door in the first day, and that’s probably a good thing because it will let the community around the site get used to it.




Mexicali, Mexico

How permits, not laws, can get in the way

What Philadelphia can learn from Mexicali:

- The work is never done: Philadelphia should anticipate and plan for an evolving situation. As long as supervised injection sites are not explicitly codified in law — which is a federal issue — the sites are at risk.

- Pay attention to permits: Community support might matter, but at the end of the day, having the proper permits to open can be the difference between staying open and being shut down. This is especially interesting in light of a recent City Council attempt to block Safehouse through the use of zoning.


In October 2018, Verter, a harm reduction organization in the border city of Mexicali, the capital of the Mexican state of Baja California, opened a supervised injection site, which they called a safe consumption room, in a community health center. The site was unique because it only served women, unlike most of the co-ed services that Verter provides. Verter did not advertise the site and kept it discreet, even though under Mexico’s law there is no explicit prohibition of supervised injection sites. A few weeks after the site opened, someone tweeted about it. The tweet went viral and made national news. A few days later, the city shut down the entire community center, arguing that Verter did not have the proper permit. Since then, Verter has gotten a permit to operate a community health center but not an injection site. The fight continues. The Inquirer talked to two board members of Verter about how community inclusion might have helped or hindered their process.

Jaime Arredondo Sánchez Lira, professor at the Drug Policy Program at the Centro de Investigación y Docencia Económica (CIDE) in Aguascalientes, Mexico: “The lesson from Mexicali is to try to keep it under the radar for a little bit longer in order for us to share some information about how the world is not going to end [because of a supervised injection site]. If we were able to, for example, provide that service for three months or six months and show that nobody died and the community didn’t decay since the introduction of the service, [we could’ve proved] to decision makers in the community that nothing went to hell and they didn’t even notice. We were already giving it, and there were no negative consequences ... or maybe they noticed it because there are fewer dropped syringes on the streets or fewer people using drugs on the streets. Would it have been better to do this more with community consultation? My first step would have been to prefer to keep it under the radar for a little bit longer, but knowing what I know now, would doing more community consultations have made a difference? No.”

Said Slim, coordinator of projects and founding member of Verter: “The community around us thinks that the problem is the project. That we started the problem in the area. But the truth is that the problem existed before we came here. We hosted two meetings with neighbors and businesses. Only two or three people came to these meetings. Most people don’t view the relevance and the benefits to start supervised consumption services in a safe space. They only want to call the police and arrest other people. I’m optimistic because we have a large number of clients. Always. As long as the people in this area need these services, we promise to continue with our project. In the future, if we don’t have clients ... we’ll close down."

 

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Great documentations

Fantastic studies

Amazing info
☺❤
i know i'm readin it
 

mr peabody

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To fight the opioid epidemic, treat drug use with compassion, not judgment

by Travis Rieder | USA Today | Jul 9 2019

I know from personal experience: We cannot expect people who use drugs to get better on their own or overnight. It is vital that we meet them where they are.

If news is what happens to editors, I suppose that scholarship is what happens to professors. At least, that was the case for me.

As a researcher at the Johns Hopkins Berman Institute of Bioethics, I didn’t start thinking about America’s problems with pain and drugs through dispassionate research. I got there thanks to a motorcycle accident, after which I was given lots of prescription opioids and then left to my own devices.

The result was that I formed a profound dependence on the drug, and then went through the agony of withdrawal as I tried — with no help from my doctors — to get off the meds.

That experience gave me a new perspective on the risks and benefits of prescription opioids, as well as a deep desire to help the millions of Americans who are suffering from addiction (and to prevent some of the tens of thousands of overdose deaths each year).

I’ve since turned my intellectual and professional energy toward thinking about America’s drug overdose epidemic. That has taken me far from my initial experience of withdrawal management, eventually leading me to what many people find a rather uncomfortable conclusion.
What opioid policy leaves out

We often hear that we know what we should do regarding the opioid epidemic; we simply aren’t doing it. But we’re only sometimes right about this, and it’s often much harder than we think.

For instance: If you’ve been reading the news for the past five years, you might think that doctors are the problem, and that they simply need to stop prescribing so many pills. But this response is too ham-fisted, and risks harming pain patients. It also won’t solve the drug overdose epidemic, which has transitioned to a crisis driven largely by heroin and illicit fentanyl.

It’s also regularly said that we need to massively scale up addiction treatment. True enough, as only about 10% of those with substance use disorder get specialty treatment. But it also hides some nuance, as the fact remains that not everyone with an addiction is ready to seek treatment.

Thus, policy that focuses only on the supply of opioids and on capacity for treatment leaves out something important: Some people are and will become addicted despite their best efforts, and they are at risk of dying until we can help them recover. This means we need more. We need to keep people struggling with an addiction alive until they are willing to enter recovery. We need harm reduction.

If harm reduction saves lives, then why the opposition?

Many of the harms of drug use can be mitigated or avoided entirely if a society is willing to put resources and effort into doing so. Needle exchange programs can reduce the disease burden for people who use drugs. And the drug naloxone can reverse opioid overdoses, saving lives.

More radically: Safe injection sites provide a physical space for people to use drugs, offering a respite from the street, sterile equipment, contact with health care and recovery services, and naloxone on hand in case of overdose. In more than a hundred such sites around the world, not a single fatal overdose has been recorded.

All of these strategies save lives and reduce harm from drug use. Yet many Americans reject some, if not all, of them. To date, the United States still hasn’t opened its first sanctioned safe injection site. Why? It’s clearly for moral reasons. Some people don’t want to do anything they see as enabling drug use, which they take to be morally wrong.

They may also have a view that people are responsible for their own actions and so deserve the consequences. These notions of personal responsibility and a sense of “dirty hands” are perfectly understandable to most of us, and even professional ethicists and philosophers continue to debate the use of these concepts.

We can’t just focus on the evidence

This is why ethics can make a real contribution here. It’s not that I agree with the criticisms of harm reduction. To be clear: I don’t. But too many of us working in public health or drug policy dismiss arguments against harm reduction as unscientific and not worth considering.

We hammer on the evidence — noting that needle exchange programs reduce disease burden among people who use drugs, that naloxone saves lives, that safe injection sites prevent overdoses and connect people who use drugs with the health care system, and that virtually all harm reduction approaches have positive side effects, like saving money in the long run and keeping used needles off the street.

We think that if we quote these claims from the literature loud enough and often enough, we’ll win the debate through sheer volume. And this is a mistake. Because the objection isn’t, generally, about evidence; it’s about ethics. Opponents of harm reduction think we shouldn’t "help people to do drugs," whether doing so saves lives or not. We need to have the discussion clearly in the moral realm.

My view, in short, is that an ethic of personal responsibility is the wrong justification for health policy. If a person is injured in a motor vehicle accident in which she was speeding, we don’t thereby refuse a life-saving operation. Although she chose to speed and is responsible for her actions, it is not the case that she should therefore be forced to accept the potentially deadly consequences. That’s not how we do, or should, think about medicine and health care.

Replace the instinct to punish with the instinct to care

A complete defense of harm reduction, then, must offer a counterproposal for how we justify health care for people who appear intent on harming themselves. Having gone through my own struggle with opioids, I learned something important both when I gratefully took high doses of the drugs to quell the pain, and when I tried to quit and went through hellish withdrawal: People take drugs for reasons. Opioids can appear to fix us, or make life worth living. Quitting can feel impossible. Whether the drug is oxycodone or heroin, they do many of the same things. And when people find themselves in mortal danger because the drug has its hooks in them, the appropriate response is compassion, not judgment.

As the drug overdose crisis continues to burn across the country, I know that many people have similar close encounters with drugs, dependence and addiction. Too many of us — and our friends, loved ones and neighbors — have been hurt. But we can lessen that hurt. If we see people who use drugs as people we know and love, people who deserve respect and health care, we can save many of them. But we have to replace our instinct to punish what we see as bad behavior with an instinct to care.

This is not a discussion about evidence. It’s about ethics and the dignity of human beings — about what each of us deserves.

 
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mr peabody

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Three of the six victims of drug overdose-induced death at music festivals being investigated at a
NSW inquest in July 2019.



Kids are dying while we maintain a supposed moral veneer*

by Van Badham | The Guardian | 11 Jul 2019

“Prohibition,” said Al Capone, “has made nothin’ but trouble.”

It’s a truism for which present Australian drug policy seems determined to supply evidence to maintain.

This week it was reported that Alex Ross-King, 19 years old, “took an unusually high amount of MDMA before arriving (at a music festival) because she was afraid of being caught with the drugs by police.”

She died a few hours later, of a drug-related cardiac arrest.

Her death is one of six the New South Wales coroner is investigating this week within the context of a recent “substantial increase in drug related harms associated with a small number of music festivals.” In all six cases, the victims had consumed more than one tablet of MDMA. In all six, MDMA was the primary cause of death.

The aim of the inquest is to determine ways that these harms may be prevented. “Pill testing” at festivals has its advocates – especially since a recent trial of such in the Australian Capital Territory found seven pills contained traces of dangerously toxic chemicals. The NSW premier, Gladys Berejiklian, infamously decided in advance of any trial, and without evidence, that pill-testing would not work. The Royal Australasian College of Physicians, the Australian Medical Association and former Australian federal police commissioner, Mick Palmer, disagree.

But in the present debate about harm minimisation, it’s the NSW deputy coroner, Harriet Grahame, who’s willing to identify what so many – least of all the NSW premier – just will not. In March, releasing findings from a previous inquest into deaths related to opioid drugs, Grahame recommended “decriminalising personal use of drugs, as a mechanism to reduce the harm caused by drug use.” To do so, no less than the entire framework of drug policy in this country needs to be rethought.

Hear, hear, and thank god – yes, it does, and please listen to her.

Listen to her because pill-testing alone is not a magic bullet. Not when 19-year-old Callum Brosnan, whose MDMA death is also within the purview of this week’s inquiry, was likely consuming pills of “very high purity” that would not have failed a pill test, as per the evidence cited by counsel assisting the inquiry.

Listen to her because an increasing, visible police presence at festivals is not actually impeding the desire of young people to take drugs – in the case of Alex Ross-King, it’s driving kids into lethal behaviours to avoid the risk of detection. Listen to her because we have to face up to the fact that as a country and community we have wasted so much time and incinerated so much money fighting a lost war on drugs. Rather than learning the lessons of America’s historical Prohibition disaster, we’ve doubled down on making trouble for ourselves repeating the inanity with drugs.

It’s not like as a society that we don’t know this. Again and again, examples of communities that have ceased fighting the drug war have shown peace and harm reduction follow.

What happened when Portugal decriminalised drugs in 2001?

"The opioid crisis soon stabilised, and the ensuing years saw dramatic drops in problematic drug use, HIV and hepatitis infection rates, overdose deaths, drug-related crime and incarceration rates. HIV infection plummeted from an all-time high in 2000 of 104 new cases per million to 4 cases per million in 2015,” reports this publication.

Even limited liberalisation efforts make observable differences: in America, the states that have recently legalised cannabis have shown a marked decrease in opioid-related deaths. We know that the most dangerous drug on the market in Australia is legally available – alcohol – and we deal with alcohol through a stringent regulatory environment that governs its manufacture and supply to ameliorate its effects.

We should know that the legal framework of present drug policy is a legacy from a 100-year-old Temperance movement, whose outdated understanding of addiction has been exposed by science and analysis again and again and again. “There’s a lot of evidence to show that a punitive drug policy doesn’t really work,” says Dr Richard Wise, a clinical psychologist who specialises in addiction. “Yet punitive responses to drug use are persistently adhered to in public policy development and enforcement.”

Studies show 43% of Australians over the age of 14 admit to having used illegal drugs at some point in their lifetime; statistically, that places likely drug users in Gladys Berejiklian’s own cabinet. Imagine! So where does the misguided moralism come from that maintains our dangerous, present regime?

I hate drugs, with the passion that comes from the lived experience of seeing the damage they can wreak. The dead friends, the broken bodies, smashed lives, wasted potential. I understand the fear and anxiety provoked by the very existence of the substances, the chaos of their effects, and their risk. I also understand that listening to a stoned person offer political insights for an entire 10 minutes can motivate a desire to destroy all the weed in the universe. But maybe – just maybe – emotive, individual instincts aren’t a sound basis for public policy.

We spend a lot of time as a society picking over the psychology of drug use; it’s high time to analyse the political reticence towards drug decriminalisation, because repeating strategies that fail over and over is not rational. And maintaining the supposed moral veneer with prohibition is – while teenagers are dying – rank narcissism.

*From the article here:

 
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Global forum on nicotine asserts urgency of harm reduction

by Will Godfrey | Filter | June 17, 2019

Delegates at the Global Forum on Nicotine in Warsaw were left in no doubt of the scale of challenges facing tobacco harm reduction. Despite the potential of safer nicotine delivery to save more human lives than any other harm reduction initiative, the hostility, lies and bad policies⁠ being aimed at the initiative are daunting.

“The death of truth is very real,” said Sweanor, who is chair of the advisory board of the University of Ottowa’s Centre for Health Law, Policy and Ethics. “Not just in the US—but the US has certainly taken a huge lead.”

“In Australia, we have appalling laws about nicotine delivery,”
said politician Fiona Patten, leader of the country’s Reason party. “Our reduction in smoking is pretty much stagnating. When I ask the minister of health about vaping regulation, I get told that vapes are ‘a gateway for children’, that they ‘re-normalize smoking.’”

As harm reductionists have long known, much opposition is fundamentally due to narrow-minded tenets about what is and isn’t acceptable for other people to do. “We know that it’s not arguments about facts and evidence,” said Professor Gerry Stimson, director of GFN host organization Knowledge Action Change* and a veteran of harm reduction responses to HIV/AIDS. “It runs much deeper than that.”

GFN was a diverse gathering of 600 delegates⁠—directly impacted people, advocates and activists, scientists, clinicians and social workers, and industry representatives, who also attended an accompanying tech convention⁠—from 70 countries on every continent except Antarctica. Scores of international journalists also attended the annual event—the biggest yet, which speaks to the movement’s forward momentum.

While climbing a mountain, as Sweanor pointed out, the peak may seem miles away, but you also have to turn around sometimes and look at how far you’ve come. The fact that millions of smokers have already switched to exponentially safer vaping or non-combusted forms of tobacco⁠—to vapes in the UK, for example, to snus in Scandinavia, or to heat-not-burn devices in Japan and South Korea—is to be celebrated.

“For the first time in 120 years,” Professor David Abrams of the NYU College of Global Public Health reminded us, “we could eliminate the death and disease caused by the cigarette rolling machine⁠—and I believe we will.”

But with a billion people still smoking worldwide, the barriers to giving them safer choices remain pernicious and pervasive.

Almost everywhere you look, “Think of the children” is the politicians’ and public health establishment’s refrain, as Eveline Hondius of Dutch vaping consumer group Acvoda expressed. The well-worn phrase is familiar to those who have campaigned for cannabis legalization, for example.

“They have used the kids issue absolutely ruthlessly,” said Clive Bates, THR advocate and former director of Action on Smoking and Health (ASH). “Essentially where they’re heading is to treat harm reduction products exactly the same as combustible tobacco. And I hate to say that they’re doing quite well with that agenda.”

“This is a battle we’re losing, and losing badly,”
said Dr. Saul Schiffman, a researcher and senior scientific advisor at Pinney Associates. “We’re being outplayed in the US.”

Joseph Magero from Kenya, who is chair of Africa’s Campaign for Safer Alternatives, described problems including ostracization from the public health and tobacco control community, lack of funding and lack of locally applicable research.

In Africa, he said, “The World Health Organization and the Campaign for Tobacco-Free Kids [two organizations that have significantly opposed THR] decide in matters of regulation.”

These challenges are mirrored by those of advocates from Mexico to India who spoke at GFN—all as 7 million people continue to die annually from smoking-related causes.

Science strikes back

The THR cause is bolstered by the work of many scientists, a number of whom spoke in Warsaw.

“We have massive evidence now that giving nicotine to smokers can help them—over 130 randomized controlled trials,” said Professor Peter Hajek of the Wolfson Institute of Preventive Medicine’s Tobacco Dependence Research Unit at Queen Mary University of London. His own work showed this year that vaping is nearly twice as effective as traditional nicotine replacement therapy, like patches or gum, in helping smokers quit.

“We have a lot of literature on snus, and by-and-large snus has been shown to be not very harmful,” added Professor Neal Benowitz of the departments of Medicine, Biopharmaceutical Sciences, Psychiatry, and Clinical Pharmacy at UCSF, while also cautioning of the need for more research into long-term outcomes of inhaled nicotine products.

At the same time, “Junk science is escalating,” said Professor Riccardo Polosa of the University of Catania, Italy, who also runs the Center of Excellence for the Acceleration of Harm Reduction. He decried widespread methodological flaws and lack of rigor in studies that are deployed against THR, declaring, “We can make tobacco harm reduction research credible again.”

Some heavyweight researchers lined up to debunk the “junk.” Dr. Konstantinos Farsalinos⁠, a research fellow at the Onassis Cardiac Surgery Center in Greece among other institutions, analyzed how, in the media-fanned “epidemic” of US teen vaping, daily use among youth who have never smoked stands at the decidedly non-epidemic level of 0.5 percent.

Dr. Roberto Sussman, a researcher and lecturer in physics at the National University of Mexico who also runs the advocacy organization Pro-Vapeo Mexico, deconstructed alarmist claims about the particles produced by secondhand vapor—suggesting that if we must have a moral panic, it might be more rational to apply it to candles or vacuum cleaners.

Yet for all the importance of the scientific evidence underpinning THR, advocate Samrat Chowdhery, who leads Association of Vapers India, noted that quite often, “research simply validates what consumers already know to be true.”

And as Prof. Abrams declared: “It’s about the people, the people, the people.”

GFN heard from many who conduct groundbreaking research or hands-on tobacco harm reduction delivery with the marginalized, low-income groups who smoke at far higher rates than the general population—the people who will be harmed the most if we fail to drive policy forward.

“Tobacco harm reduction is a social justice issue,” declared Professor Kevin McGirr of the UCSF School of Nursing.

“Empower people to lead,” exhorted Rebecca Ruwhiu-Collins of her holistic THR work in her Māori community, which she said has been “decimated” by smoking harms.

“The most important group to do research in is pregnant women who smoke,” said Dr. Marewa Glover, whose work also centers on Indigenous populations.

“People take part,” said Dr. Sharon Cox of London South Bank University’s Centre for Addictive Behaviours Research, who is conducting research focused on THR for homeless populations. “This group isn’t hard to reach. We’re just not reaching out.”

“People with serious mental illness don’t live long enough to get cancer,”
said Dr. Sarah Pratt, a clinical psychologist and an assistant professor of Psychiatry at Dartmouth University’s Geisel School of Medicine. “They die of smoking-related heart attack and stroke.”

She also reminded delegates: “It’s great to listen to so many smart people here, but what we all need to do more of is listen to consumers, listen to members of these vulnerable populations.”

With the clock ticking on too many lives, there’s huge pressure on THR advocates to deliver. Clive Bates’s advocacy tips included: “Get organized” and build networks; “Don’t be too clever, but communicate your lived experience;” and “Be inclusive: You are not in competition with people on the same side as you … be advocates for the entire category of non-combustible products, rather than highlighting differences between them.”

“Money talks,”
stressed Fiona Patten of Reason. “If you can talk about the health economics of new nicotine delivery systems … particularly for conservatives, it is those messages that can work.”

The need for THR to learn from the winning strategies of the wider harm reduction movement was another point made by many.

When it comes to politicians and officials who refuse to recognize THR’s massive potential to save lives, suggested David Sweanor: “Challenge them, ridicule them, get people to laugh at them is what’s necessary.”

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Poorest kids exposed six times more often to tobacco retailing

University of Glasgow | 8 Jul 2019

Children from the most income deprived areas experienced similar exposure to tobacco retailing in one day as children from the least deprived areas experienced in one week.

This was the finding of new collaborative research between the Universities of Glasgow and Edinburgh, which was published today in the journal Tobacco Control. The researchers used GPS-trackers to follow a group of 700 10-and-11-year-olds from across Scotland. They found that children from the most deprived neighbourhoods encounter a shop selling tobacco 149 times a week, compared to just 23 times a week for the least deprived.

The researchers mapped the location of all shops selling tobacco products across Scotland and followed the movement of 10-11-year-olds for eight consecutive days. They were able to identify how often, and for how long, the children went within 10m of a shop selling tobacco. The children were part of the Growing Up in Scotland study and both they, and their parents, agreed to them wearing the trackers.

The researchers found much bigger differences between children from more and less deprived areas than expected. Previous research showed that tobacco outlets are twice as common in deprived areas. But by following where children went using GPS devices, the researchers were able to show that children from the most deprived areas were exposed to tobacco retailing six times more frequently than children from the least deprived areas.



Most exposure came from convenience stores and newsagents selling tobacco, with peaks just before and after school. There was also a higher than expected amount of exposure from supermarkets on weekends.

Children from more deprived areas are already more likely to start smoking themselves, and pre-adolescence is a critical period where the path to starting smoking begins.

Dr. Fiona Caryl, University of Glasgow, lead author of the research said: "Our findings provide a significant contribution to the policy debate on tobacco availability. Identifying ways to reverse the normalising effects of ubiquitous tobacco retailing is key to policies aimed at preventing people from starting smoking."

Professor Jamie Pearce, an expert in in tobacco-related health from University of Edinburgh and co-author of the study, said "This exciting and novel work suggests any moves to reduce tobacco availability, whether to reduce the number of retail outlets, or restrict the timing of sales, will have a greater benefit for more deprived groups who suffer the greatest amount of tobacco-related harm."

Dr. Garth Reid at NHS Health Scotland said: "As a national health board working to reduce health inequalities and improve health, we were pleased to support this innovative research into children and young people's exposure to tobacco products in Scotland. We welcome the findings, which will inform a report that we will publish later this year, considering the implications for health inequalities and tobacco control in Scotland in greater detail."

 
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mr peabody

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So festival season is upon us.

Hordes of EDM enthusiasts and drug freaks gather to shake off the shit of the rest of the year.

It's like Christmas for 8 weeks straight. Now a friend of mine, who acquired a mass of it for festival season saying to me this is all that is going around right now, showed me this huge crystalline greyish blue brick that smelled heavily like some kind of hospital steriliant.

I know that's not right. It was very clear to me that they used some kind of direct p2p synthesis rather than any kind of organic sources.

So from 112 grams there was 30 grams of loss
3 of those grams were aluminum dust
15 of those grams were methamphetamine
and the rest and oxidative precursor left over to add weight.

WHAT THE FUCK!!!!

Listen, in the past 2 years.... I've lost 35 friends. I bet you some of these friends didn't even know they were doing things like meth and fentanyl. Fentanyl is now appearing is the ketamine scene near Nelson out in the Kootenays. So Shambhala go'ers be ware. My friend Dylan in Rossland called me to tell me that his business was succeeding and that he was going to stop by my home to see me on his way to Sask to see his family. He had purchased some ketamine and he was telling me about how he was going to have an amazing weekend. He never showed up. His father found him dead with naloxone kit in hand. His Father owns the festival grounds for Electric Sky. Its such a fucking loss and a crime.....

Now for the darkness, so imagine you are a nefarious drug cartel. You know if you have 454 grams and if you mix in 5 grams of a fentanyl its going to make the ketamine more addictive. Its going to be undetectable to most test kits, and you are going to have to chemically remove it to find it or you are going to have to have a mass spec. Now if its not mixed properly, people like my friend Dylan pay the cost.

Whoever the fuck is responsible for allowing this kind of sloppy contaminated synthesis out into the market should be found and then explained to fully that people will pay for purity. It doesn't even take any amount of extra time of polish it up to 99.9 white crystalline structures. Why is the methamphetamine in there? I mean its in there at 10% which I'm telling you right now, is not detectable using ERLICH or MANSKE test kits. EVERY festival needs a Mass spec which can break down exactly what is in peoples drugs.

Anyways.... be careful out there.... crystalline or not, shit can be woven into the fabric.

- Psychonautical (BL)
 
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mr peabody

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Sarah Blyth of Overdose Prevention Society in Vancouver, B.C.


Vancouver’s overdose task force calls for safer supply of drugs

BY Andrea Woo | THE GLOBE | Jul 22 2019

Vancouver’s overdose emergency task force wants support from other Canadian cities and the federal government for expanded access across Canada to a safer supply of drugs.

The call comes as Ottawa announces new funding to support safe supply initiatives across the country. Together, they signal a recognition by government of the toxicity of the illicit drug supply and a cautious step toward drug-policy reform.

Jordan Westfall, co-founder of the Canadian Association for Safe Supply, said he was pleased to see government broach the issue.

“It’s a really positive signal that government is starting to understand how dire the situation is, how disturbing it is to have about 4,000 people die over the last few years in British Columbia and that we’re desperately in need of some change,” Mr. Westfall said.




The recommendation by Vancouver’s overdose emergency task force is one of several in a report going before council on Tuesday. It proposes that council approve a motion for Mayor Kennedy Stewart to share with the Federation of Canadian Municipalities (FCM) board of directors meeting taking place in September, advocating for a regulated supply of “opioids or other substances.”

The motion calls on the federal government to “expand access to safe supply by proactively supporting all doctors, health authorities, provinces and all relevant professional colleges, including physicians and surgeons across Canada, to safely provide regulated opioids or other substances through a free and federally available pharmacare program.”

As well, it asks the federal government to declare a national public health emergency and provide the necessary exemptions under the Controlled Drugs and Substances Act to allow cities to implement safe supply pilot programs.

Providing a safer supply of drugs means offering regulated, quality-controlled substances in place of illicit drugs, which often include toxic additives. In 2018, fentanyl was detected in about 87 per cent of all overdose deaths; other substances such as carfentanil and benzodiazepines have also driven overdoses and overdose deaths.

Current safe supply initiatives available in Vancouver include providing a relatively small group of people with the opioid-use-disorder drug hydromorphone – an opioid medication commonly used in palliative and acute care – or diacetylmorphine, also known as pharmaceutical-grade heroin, to inject under supervision in a medical setting.

Asked Monday about the role that cities play in advocating for drug-policy reform, Mr. Stewart said he has received requests from mayors of other cities “to be a little bit more active on this file,” and that lessons from Vancouver can help advance public understanding elsewhere.

“Perhaps in smaller municipalities, where overdoses are also occurring, perhaps a motion like this, and a debate like this, at the FCM would help change the national dialogue,” he said.




Ottawa has already signalled some receptiveness to expanding safe supply. Last week, federal Health Minister Ginette Petitpas Taylor announced more than $76-million in new funding to combat the overdose crisis, with $33.6-million of that going to safe supply projects.

Community groups would apply for that funding through the Substance Use and Addictions Program, which was created to support innovative, evidence-informed projects to address problematic substance use.

Ms. Petitpas Taylor said the funding is a direct result of her hearing from front-line service providers.

“We’ve heard time and time again that one of the number one issues that we are grappling with is the issue of a contaminated drug supply,” she said, noting that her government also made regulatory changes last year to make diacetylmorphine available as a treatment option outside of a hospital setting.

Donald MacPherson, executive director of the Canadian Drug Policy Coalition, said it is important that Canada’s Minister of Health is discussing safe supply because it is “an acknowledgment that the toxicity of the illegal drug market is a significant problem.”

Mr. MacPherson said Canada ultimately needs to re-evaluate its approach toward drugs, and acknowledged drug-policy reform is a process.

“The money that’s being allocated is for innovation, it’s for pushing the envelope. And that’s all a good thing,” he said.

“When you have a deadly crisis on your hands, you don’t necessarily start with passing legislation. You start by putting the fire out. And that’s what the safe supply discussion has been all about.”

 

mr peabody

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Munroe Craig is the co-founder of Karmik, a Downtown Eastside harm reduction group.


New evidence from British Columbia provides a strong case for harm reduction strategies

by Jeffrey Singer | CATO Institute | Jul 8 2019

"If harm reduction requires a compromise in principle, it’s one with a blindingly obvious payoff: living human beings who would otherwise be dead."

A study published last month in the peer-reviewed journal Addiction by researchers at the British Columbia Centre for Disease Control and the British Columbia Centre on Substance Use found that harm reduction strategies were responsible for the province’s opioid-related overdose death rate being less than half of what it otherwise would have been between April 2016 and December 2017.

The researchers noted that 77 percent of opioid-related overdose deaths during that time frame involved illicit fentanyl. Vancouver has long been a major port of entry for fentanyl and fentanyl analogs, produced in China and other parts of East Asia, often using historic seaborn drug trade routes.

During the 23 months ending December 2017 there were 2,177 overdose deaths in British Columbia, according to the British Columbia Centre for Disease Control. Using mathematical modeling methodology to estimate monthly overdose and overdose-death risk along with the impact of harm reduction interventions, the researchers concluded an estimated 3,030 overdose deaths were averted.

The three harm reduction strategies investigated were take-home naloxone kits, safe injection sites, and “opioid agonist therapy”— known in the U.S. as Medication Assisted Treatment (which includes methadone, buprenorphine, hydromorphone, and heroin assisted treatments in British Columbia). The researchers employed counterfactual simulations with the fitted mathematical model to estimate the number of deaths averted for each harm reduction strategy as well as the three strategies in combination.



While harm reduction strategies are directly responsible for averting more than 3000 deaths, the number of lives saved by each strategy breaks down as follows:

- 1,580 (1,480-1,740) deaths averted by take-home naloxone

- 230 (160-350) deaths averted by safe injection sites

- 590 (510-720) deaths averted due to opioid-agonist therapy

All three interventions worked in synergy to greatly reduce the death rate, but the widespread distribution of naloxone saved the most lives.

Michael Irvine, the study’s lead author, told Canadian Broadcasting Company reporters that in recent years the overdose crisis has been driven by a prevalence of fentanyl and fentanyl analogs.

Among the developed nations, Canada has been one of the hardest hit by the overdose crisis on a per capita basis, with overdose deaths in Vancouver, BC approximating those of some of the worst-hit states in the U.S. as recently as 2017. This recent study gives us reason to conclude that, had British Columbia not embraced harm reduction strategies, the per capita overdose rate would have far-exceeded that of the U.S.



Canadian policymakers are being urged to curtail the prescription of opioids to patients in pain, despite the fact that more than three-quarters of overdose deaths involve fentanyl and, as in the U.S., the majority of overdose deaths involve multiple other drugs as well, including cocaine, heroin, benzodiazepines, and alcohol. This approach is driven by the failure to recognize there is no correlation between the number of prescriptions written for patients and the incidence of non-medical use of prescription opioids or prescription opioid use disorder.

The Canadian government has also given in to pressure by the U.S. government to double down on its war on drugs. But in the U.S., researchers have learned that overdoses from the non-medical use of licit and illicit drugs has been on a steady exponential increase since the 1970s–the only variation being which particular drug is in vogue in any particular era–with no evidence of any slowing. It appears to be a result of sociocultural and psychosocial factors. There is no reason to believe things are much different in Canada.

Efforts to approach this problem by doubling down on supply-side interventions and the War on Drugs are doomed to fail—and will only cause more people to die.

If the British Columbia experience should teach policymakers anything, it should be that harm reduction is the most effective way to end the overdose crisis. Ending prohibition would be the most consequential form of harm reduction.

 
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