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Seeking a safe place: Vancouver’s story

mr peabody

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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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Joined
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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Deadly fentanyl now B.C. addicts’ drug of choice

by Jeremy Hainsworth and Albert van Santvoort | June 5, 2019

While governments warn of the threat of drugs contaminated with fentanyl, the harsh fact is that the synthetic opioid is increasingly the drug of choice for British Columbia’s addicts and drug abusers.

Yes, there are admitted fentanyl addicts. And it’s growing, a Glacier Media investigation has found.

“People get used to it and that’s what they want,” said Anne Livingston of the BC/Yukon Association of Drug War Survivors.

“They sell it separately, some of the dealers,” Livingstone said.

And, fentanyl’s involvement in the overdose crisis is driving both the federal life expectancy and mortality rates.

No one’s disputing that fentanyl and chemically similar drugs – or analogues – can be fatal. B.C. accounted for 1,510 of Canada’s almost 3,500 (final figures are not available) overdose deaths. Provincially, fentanyl and analogues were blamed for 87% of those deaths last year, up from 4% in 2012, 25% in 2014 and 67% in 2016.

And, with the ever-increasing chances of other drugs such as heroin, meth and cocaine being cut with fentanyl, users have been urged to have their drugs tested to make sure they’re getting what they expect —rather than a drug laced with something fatal.

However, it’s those test results from throughout B.C. that show it’s now fentanyl most drug users expected to get when they picked up from their dealer.

In April alone, of 610 drug checks detailed by the BC Centre on Substance Use, 261 people had bought what they expected to be fentanyl. That’s more than 10 times the rate of those hoping they’d bought heroin. Those ratios remain steady for the first four months of 2019.

“The most common drugs for people to check are opioids – because there’s been the most concern about them being contaminated – and it turns out that 90% of opioids contain fentanyl,” Vancouver Coastal Health medical health officer Dr. Mark Lysyshyn said.

That’s an apparent shift from 2018, where a B.C. Harm Reduction Program survey found meth was the drug of choice.

When users were asked what drugs they’d used in the past week at the time of the survey, meth clocked in at 69%, heroin at 49%, fentanyl at 43%, crack cocaine at 26% and cocaine at 22%.

As well, more than half of respondents reported preferring smoking or inhaling their drugs, while 34% preferred injection and 6% chose snorting.

In 2018, there were 17,679 fewer injections at Insite annually than there were in 2009.

Considering that, on average, each decline of 35 injections may equal one fatality in the general addiction death rate, it may be extrapolated that there has been an additional estimated 505 deaths connected to a decline in supervised injections since 2009. It must be heavily noted that this is not the fault of Insite.

Since 2009, other drug consumption sites of various forms have opened throughout B.C. The NDP government also established its Ministry of Mental Health and Addictions, which in turn set up the Overdose Emergency Response Centre. The centre’s two top people left last year and have yet to be replaced.

Data is difficult to collect as some sites do not gather it while others do not report it in a standardized manner. Cooperation between health authorities and delivery organizations seems tenuous. Some organizations even change their reporting methods over time, making comparisons even more difficult.

B.C. overdose death rates driving national averages

The overall effects of B.C.’s opioid crisis, however, remain staggering.

In fact, B.C.’s overdose death numbers are not only lowering the provincial and national average life span figures, but they are significantly boosting the national overdose death numbers.

Indeed, new Statistics Canada rates show B.C. is also driving the federal mortality rate as a result of the opioid crisis.

“By examining changes in deaths by age and cause, in 2017, it was possible to identify the main factor that was responsible for the recent change in life expectancy in Canada, and in particular in British Columbia: accidental drug overdoses among young adult men,” a May 30 Statistics Canada report said.

Glacier Media’s investigation found fatal fentanyl-related overdoses were increasing throughout B.C. while injections of drugs such as cocaine and heroin were decreasing. Use of meth appears to be steadily increasing at Vancouver’s Insite, Canada’s first supervised injection site.

But, cautioned Lysyshyn, it’s difficult to tell if people are using more meth overall or if the statistics indicate people are choosing to use it more at Insite due to contamination fears.

Indeed, many drug users are now identifying themselves as fentanyl addicts, which is perhaps a function of a lack of heroin on the streets coupled with the more powerful high of the synthetic opioid that has wreaked havoc. Some point to problems in the prescription of heavy-duty painkillers as being part of the problem.

Provincial health officer Dr. Bonnie Henry said in February that, with an average of four British Columbians dying of overdoses each day last year, the predicted life expectancy for all British Columbians has dropped.

Her predecessor, Dr. Perry Kendall, in April 2016 declared a public health emergency.

And, that dovetails with federal Chief Public Health Officer Theresa Tam saying in October that “the national life expectancy of Canadians may actually be decreasing for the first time in decades, because of the opioid overdose crisis.”

In other words, Canadians’ average life expectancy rate had been increasing – until the opioid crisis hit.

In a June 2018 commentary, Tam said, “Over the past two years, the epidemic of opioid-related overdoses has been the most significant public health crisis, demanding a collective response from all levels of government working with frontline responders and other partners.”

And, that, observers say, means its time Ottawa declare a national crisis in order to deal with the continuing fatalities.

March overdoses declined

Meanwhile, the BC Coroners Service recently released numbers offering a glimmer of hope. The monthly average for illicit drug deaths for the first quarter of 2019 (89 deaths/month) is down 32% from the same period in 2018 (132 deaths/month).

Fentanyl-rated deaths are down 40% comparing the same two months. January 2019 compared with 2018 saw a 29.3% drop while February 2018 over 2019 was a 28%.

However, rises and falls both federally and provincially are not uncommon in the ongoing crisis, as Glacier data examination indicates.

Annually, the last decrease was in 2012, when deaths dropped 8.2%, compared with a national increase of 1.8%

In 2013, that switched. B.C. overdoses climbed 23.3% compared with a national drop of 6.3%. At the same time, Insite saw a decrease in its number of injections.

Federally, the next two years saw overdose death increases of 6.5% and 6.3%, partially driven by provincial increases in deaths of 10.5% and 44%.

Then the horrific 2015-2016 years arrived in B.C., marking fentanyl’s arrival. The death rate increased 44% and 87% in those years, respectively. In the latter year, that B.C. rate helped drive the federal overdose death rate up 24%.

Fentanyl was only seen in 4% of overdose deaths in 2012 but jumped to 25% in 2015 and then to an alarming 67% and 87% in 2017 and 2018.

Not all deaths were attributable to fentanyl, but its presence has been significant. Single or multiple drugs were found in the systems of those who have died.

Insite tracks what drugs users at the facility in the city’s poverty stricken Downtown Eastside are using.

It should be strictly noted here that no one has died at Insite since it opened in 2003. Also, fentanyl is not specifically tracked.

As well, Insite only handles injections. Overdoses also happen as a result of people smoking various drugs such as heroin, cocaine (and crack cocaine) and meth. Insite does not have an inhalation facility.

“Insite isn’t really a reflection of what people are consuming,” Lysyshyn said. “You can only consume drugs at Insite by injection. If you smoke crack cocaine, you can’t do it at Insite.”

“The most common drug is crystal meth,”
Lysyshyn said. This is consistent with Glacier’s findings.

“Possibly, also, people are choosing to use the meth at Insite because they’re worried about overdose,” he said.

More than half of the 486 respondents to a BC Harm Reduction Program 2018 survey identified smoking or inhalation as the preferred method of drug use, while 34% preferred injection and 6% preferred snorting.

The survey also found 19% experienced an opioid overdose in the six months prior to the survey, 15% experienced a stimulant overdose and 57% witnessed an opioid overdose.

The question remains, however, whether or not drug use inside Insite represents drug use outside Insite, which is located half a block from the opioid crisis’ ground zero of Main and Hastings. Lysyshyn warns against drawing comparisons.

Indeed, research shows it’s the Downtown Eastside that is taking a heavy brunt of the opioid crisis.

A February BC Centre on Substance Use report said, “In 2017, the Downtown Eastside death rate in Vancouver’s neighbourhood was estimated at almost 250 deaths per 100,000 individuals — around eight times higher than the B.C. average. The centre notes the figures as unpublished Vancouver Coastal Health statistics.

The impact of overdose deaths has led to a drop in the average life expectancy of a man living in the neighbourhood by four years, a January report said.

Heroin statistics dropping, meth rising

Heroin injections at Insite had begun to drop after climbing to an annual high of 101,496 in 2014. There were several peaks and valleys before a steady decline, dropping to 74,021 in 2018.

The climb to that 2014 peak began in 2010 when cocaine injections peaked at 69,705 injections. Cocaine injections have dropped steadily since, hitting 6,636 in 2018.

The rise of crack cocaine

Lysyshyn said there was a lot of cocaine injection at Insite when it opened. That has dropped, however, as smoking crack cocaine became more prevalent.

People have transitioned from injecting cocaine to smoking crack, which they can’t do at Insite.

He said, “In general, there has been a bit of an increase in crystal meth use in B.C., but we can’t tell that from the Insite data. All we can tell is that people are using more crystal meth at Insite.”

Lysyshyn cautioned against extrapolating from Insite data to the province in general, but he added other data indicates there has been an increase in crystal meth use. He also cautioned against extrapolating from the data to say drug use outside Insite is rising or falling, because Insite is an injection-only facility.

Meth use, however, grew steadily from 2010. Insite reported 6,071 uses of meth in 2009, 7,185 the next year and then a jump to 13,075 in 2011.

Those meth numbers from Insite are lower than those reported in the BC Centre for Disease Control (BCCDC) harm reduction client survey in 2015.

In December, the BCCDC said reported use in 2018 for B.C. was three times higher than in 2012. The change for Insite, though, was less than double. In 2012, there were 19,998 meth injections at Insite, while in 2018, there were 34,005 uses.

By 2015, the year overdose death numbers generally began rising dramatically, 39,433 uses were recorded. While those numbers declined slightly in 2016 and 2017, in 2018, 37,096 uses were reported, at about the same time opioid deaths had hit an alarming high.

More and more, anecdotal reports say, users are proclaiming themselves as fentanyl addicts, that being the drug of choice they seek out.

And that may be borne out in the BC Centre for Substance Use statistics, which show the largest number of people using drug testing to avoid overdoses are expecting to have bought fentanyl when they go to have it tested.

Back in 2015, 19% of respondents reported intentionally using fentanyl in any form, the BCCDC found.

By December, the centre was saying intentional fentanyl use has tripled over 3.5 years.

No national emergency

While B.C. has declared the public health emergency, there won’t be anything similar coming from the federal government – at least not yet.

Health Canada and the Public Health Agency of Canada spokeswoman Maryse Durette said the federal government is committed to addressing the opioid crisis and problematic substance use from a public health perspective.

“This includes supporting harm reduction initiatives, increasing access to treatment options and working to end the stigma about people who use drugs,” she said.

“A declaration of an emergency would not change our course of action.”

Prime Minister Justin Trudeau held up B.C.’s approach as a model for other Canadian jurisdictions.

“We support an evidence-based approach to countering this terrible opioid epidemic that is hitting not just in B.C. but right across the country,” he said. “We have been dismayed to see conservative governments stepping back from the harm reduction programs that have been so successful here in B.C. and elsewhere.”

Trudeau said Ottawa is working on making it easier for addicts to access prescription drug alternatives, and continue to look for supports for addicts to get help.

 
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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 — it'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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