Are We Ready to Subsidize Heroin?

For the last 22 years, Cactus Montréal has doled out needles, crack pipes and other necessities of drug use to the city's addicts. North America's first needle exchange program had humble beginnings; it once provided its services from a cockroach-infested storefront on St-Dominique St., facing a particularly seedy section of Montreal's red-light district. Today, Cactus's headquarters are a monument to respectability. Its drop-in centre and needle exchange occupy a bright, glassed-in corner of an avant-garde building in downtown Montreal, across the street from a university pavilion. "A lively and warm place," as its website advertises, "where people of all stripes come to get injection equipment, condoms, crack pipes, counselling and even to draw a picture or play an instrument."

Thanks to last week's landmark Supreme Court of Canada ruling directing the federal government to stop obstructing Vancouver's Insite supervised injection clinic, Cactus will soon be renovating once again. Cactus administrators, and those across the country who advocate harm reduction, a policy of mitigating the damage of drug use without requiring abstinence, interpret the ruling as essentially green-lighting supervised injection sites, albeit under strict conditions. By next spring, Cactus administrators hope to have an area where drug users will be able to inject drugs under the supervision of a medical professional. Many of Montreal's other needle exchange sites, as well as those in Quebec City, will likely follow suit in the coming year, if they meet the criteria the court established to win a federal exemption from drug possession laws.

You might say it's infectious. Supervised injection sites have the backing of several of the country's biggest health authorities, including those in Montreal and Vancouver. There are preliminary plans for another site in Vancouver, and possibly one in Victoria. Some advocates look ahead to a time when addicts might receive prescription heroin rather than street drugs. While many governments are reluctant to endorse giving addicts a place to shoot up, let alone the drugs to do so, every province has some sort of needle exchange program. Even Calgary gave out safer crack pipe kits for three years until health officials nixed the program over the summer.

For proponents, providing a clean, medically supervised place to imbibe drugs is simply a logical extension of a service already provided across the country. "The Supreme Court decision let us stop being hypocrites," Cactus community coordinator Jean-François Mary told Maclean's. "For 22 years, we gave people clean tools, then sent them out into the street. We were doing half the work. Now they'll be able to shoot up in complete safety."

For critics, this is tantamount to legitimizing an illegal activity and worse: providing government funding to support a destructive habit. "I'm disappointed," said Prime Minister Stephen Harper, who has made a war on crime and illegal drugs a central policy of his government. "The preference of this government in dealing with drug crime is obviously to prosecute those who sell drugs and create drug addiction in our population and in our youth," he told reporters in Quebec City after the ruling was announced. While he said the government will comply with the court's direction, he made clear he favours drug prevention and treatment. That is also the stance of REAL Women of Canada, a socially conservative family values organization that intervened in the Supreme Court hearing in opposition to Insite. "I think the drug traffickers in Vancouver are going to be the happiest people in Canada," says Gwen Landolt, both vice-president of REAL Women and president of the abstinence-based Drug Prevention Network of Canada. "The unhappiest will be the police because we know the crime rate will increase." (The Vancouver Police Department has supported Insite throughout much of its existence.)

Apart from the obvious rebuke of the Conservative government, which fought Insite over three years and in as many courts, the decision would seem to pave the way for a wholesale expansion of safe injection sites across the country. Buoyed with the Supreme Court decision (and armed with a raft of scientific evidence), proponents of Insite and related harm reduction measures are poised to take the debate several steps further, and a quantum leap beyond the comfort zone of the current federal government, and perhaps even some health care advocates. They see supervised sites providing not only clean rigging and supervision, but the very drugs that go into users' veins.

"People need to understand that Insite is not the end of anything, it's the beginning of something," says Dr. Julio Montaner, director of the B.C. Centre for Excellence in HIV/AIDS, and an outspoken advocate of Insite because of its success in limiting the spread of the virus and other infections. "We demonstrated the benefits. The question now is how do we bring Insite to the people, and make it work for all British Columbians, for all Canadians?" He sees allowing public health nurses, perhaps even walk-in clinics or pharmacies in small or rural areas, to supervise drug consumption, in much the manner that HIV medication or methadone is delivered in B.C. now. He wants his badly addicted patients to be allowed to take drugs when they are hospitalized for infections or other ailments. Too often, they discharge themselves with disastrous results at the first sign of drug withdrawal, he says. And he and Insite staff favour providing addicts with pharmaceutical-grade drugs, perhaps paid for by provincial medical health plans. As it stands now, Insite clients feed the illegal drug trade and inject street drugs of often dangerous quality, says Montaner. Studies giving pharmaceutical grade heroin to addicts in Switzerland, Germany, Spain and the Netherlands proved it was more effective than the traditional heroin replacement drug methadone in stabilizing addicts, keeping them in treatment and away from crime.

The argument for providing medical heroin to users was further bolstered by a landmark Canadian study conducted in Vancouver and Montreal between 2005 and 2008. During that time, researchers with the North American Opiate Medication Initiative (NAOMI) oversaw the administration of nearly 90,000 injections of diacetylmorphine, the active ingredient in heroin, to 115 regular heroin users. The result: these users, chosen for their resistance to methadone, were 62 per cent more likely to remain in treatment. They also used drastically less heroin and committed fewer crimes, reported the New England Journal of Medicine in August 2009.

As successful as it was, NAOMI exceeded the limits of harm reduction in the eyes of at least two governments. It was funded and conducted in Canada largely because of what its authors called "financial and logistical barriers in the U.S." Researchers were forced to cut the scope of NAOMI's second phase after the Quebec government abruptly yanked its share of the funding in 2009. As a result, "The Study to Assess Longer-term Opioid Medication Effectiveness" (SALOME) is British Columbia's alone, and even there it is stalled. SALOME was slated to begin before the 2010 Olympics; to date, not one injection or oral dose of the morphine-derived drug Dilaudid has been administered.

The delay is at least partially due to public uneasiness at any large harm reduction initiative, which feeds the worst nightmares of conservative commentators and groups like REAL Women. So does the prospect that appointed judges can derail the policies of a democratically elected majority government. "You've got nine appointed people and not on the basis of law but the basis of ideology coming out with a decision that's going to affect all of Canada," says Landolt, a lawyer. "They've removed the discretion from the [health] minister. It's appalling, I mean, who are they to rewrite the law?"

Cognizant of those sorts of objections, most public health services are prone to move cautiously on establishing supervised injection sites. Many feel these sites are to 2011 as needle exchange programs were to the 1990s: beneficial, even crucial, institutions that should nevertheless be carefully sold to the public through persuasion and cold, hard science.

From the beginning of the trial program at Insite, and a smaller pioneering supervised injection site at the Dr. Peter Centre in Vancouver's west end for those with HIV/AIDS, the facilities have hosted a steady stream of political and health care delegations. "Just yesterday it was the city of Victoria," Maxine Davis, executive director of the Dr. Peter AIDS Foundation, told Maclean's. "They've been here a number of times." Other recent visitors include delegations from Kelowna and Prince George, B.C., Saskatoon, Toronto and Halifax, as well as from Russia, Georgia, Ukraine and Asia. At Insite it's a similar story. "I think almost every major urban centre in this country has at some point sent a delegation of various health policy experts, or community health care folks, or police, or RCMP officers," says Liz Evans, executive director of the Portland Hotel Community Services Society, which operates Insite.

With that level of interest, other communities and health authorities are likely to follow Vancouver's lead, now that the legalities have been sorted out. Proponents must prove a substantial need, and the potential to save lives, before the federal health minister would be compelled to issue an exemption from drug possession laws under the criteria dictated by the Supreme Court ruling. The judges also took into account Insite's backing by its neighbourhood, by police and by public health and political leadership.

Where Tony Clement, the Conservative health minister at the time, ran afoul of the Constitution, the judges said, was in arbitrarily refusing an exception for a program that was found to save lives. The risk of death or disease by withholding health services was deemed grossly disproportionate when compared against the benefit of an absolute ban on drug possession at the site. "In accordance with the Charter, the [Health] Minister must consider whether denying an exemption would cause deprivation of life and security of the person that are not in accordance with the principles of fundamental justice," said the unanimous ruling, written by Chief Justice Beverley McLachlin, who spent much of her career as a lawyer and judge in Vancouver. "Where, as here, a supervised injection site will decrease the risk of death and disease, and there is little or no evidence that it will have a negative impact on public safety, the Minister should generally grant an exemption."

Still, you won't see consumption rooms "spring up on every street corner," says Dr. Patricia Daly, chief medical health officer for Vancouver Coastal Health, which finances Insite's $3-million annual budget. "I think people will have to do their due diligence as we did here."

Even then it will be a tough political sell. Public health officials generally support evidenced-based harm reduction strategies, but without political, and therefore financial backing, any move toward supervised consumption is likely to go nowhere fast. In Ontario, days from a provincial election when the ruling was released, there was little political appetite for tossing a grenade like supervised injection sites into the debate. Liberal Premier Dalton McGuinty said there are no plans for such sites in Ontario. Toronto Mayor Rob Ford told reporters this spring he has long been opposed to supervised injection sites. A study, approved in 2005, into whether Toronto and Ottawa would benefit from supervised drug consumption, may be released this fall, some 18 months after researchers first promised the results.

In Ottawa, Mayor Jim Watson said in a statement he does not back supervised injection sites. Watson, a former provincial Liberal minister of health promotion, said scarce public health resources should be spent on treatment centres.

Even in B.C., which has lived with the debate for more than a decade, municipal leaders have had a mixed reaction. Surrey Mayor Dianne Watts, who has led the fight to reclaim neighbourhoods plagued by drugs and crime, was lukewarm to the idea of a walk-in injection site, though the city has needle exchanges and detox facilities. "We don't have thousands of people in a Downtown Eastside," she told the Vancouver Sun. George Peary, mayor of Abbotsford, which has struggled to contain a drug-fuelled gang problem, said he considers the ruling a vindication for Insite. But he added few cities share the scale of Vancouver's "horrific" problem.

The B.C. government, however, has been unwavering in its support for Insite and the Dr. Peter Centre. Health Minister Michael de Jong said the court rendered a "wise and humane ruling." Still, he said it's up to provincial health authorities to determine where or how similar programs might be expanded.

Victoria Mayor Dean Fortin, among those who had toured both Vancouver injection sites, says the court ruling removes a significant "impediment" to establishing a facility in the provincial capital. Fortin said a holistic program like the Dr. Peter Centre, which incorporates a small injection site into an array of health and social services, therapy and counselling, is one possible model. Victoria laid the groundwork with a feasibility study on drug consumption sites, and a mayor's task force, which also supported the concept. Now, "we can continue to do our work, only more stridently," Fortin said. "This is something we can move forward on as a community: how do you want to make this work?"

Mercifully, few cities have a concentration of injection drug use anywhere near the 5,000 estimated addicts in Vancouver's Downtown Eastside. Insite, which has supervised more than 1.8 million injections without a fatality since it opened it 2003, is already at capacity. It oversees an average 587 injections daily. It sits in one of the bleakest blocks in a tough neighbourhood, across from a row of long-abandoned buildings that were recently reduced to rubble, a visual improvement. Inside, the building is bright and airy. The 12 injection stalls are kept scrupulously clean, with new needles, water and antiseptic wipes laid out on a table in front of a mirror for each new client. Nurses attend to wounds, abscesses, vein and skin conditions. "You watch folks suffer and struggle so much on a day-to-day basis," says Evans, the executive director. "And they come in here and you realize this is the only square footage in the entire continent of North America that, when a person walks through that door, they're a human being and not a criminal."

Evans says there are plans to eventually add another such facility in the city. She also wants to expand the range of services far beyond supervised drug consumption to meet the complex needs of addicts. Lost sometimes in the rhetoric is that there are actually three floors to the Insite facility. The second story houses a small detox centre, which claims a 43 per cent completion rate among the more than 450 clients that have been admitted. The third floor offers transitional housing for those finished detox. "This is just a tiny, tiny piece of what's needed, it really is just the beginning of a person's journey," Evans says.

In Quebec, where injection site proponents wholeheartedly approved of the Supreme Court decision, there is nevertheless little appetite to replicate the exact Insite model in downtown Montreal or Quebec City. Rather, a report from the province's health authority, expected later this year, will likely call for a more decentralized approach to supervised injection: small-scale injection sites scattered across the city, according to need. "Insite is located in a ghetto, and it serves a ridiculously huge number of users," says Gilles Beauregard, director of Spectre de Rue, one of eight needle exchanges in Montreal. "It is different in Montreal. We're in a neighbourhood that's gentrifying, and we need to be aware of the concerns of our neighbours." As for medical heroin, "it's very expensive," says Cactus president Louis Letellier de Saint-Just.

If Insite is less controversial in B.C., it helps to understand that it was born of desperation. In 1997, the Vancouver Richmond Health Board, as it was called then, declared a health emergency in Vancouver's Downtown Eastside in response to the level of overdose deaths and Third World levels of HIV, hepatitis C and other infections. More than 1,200 people died in Vancouver of overdoses alone between 1990 and 2000. "We were in epidemic proportions, we were in hundreds of deaths," says Larry Campbell, the former RCMP drug squad member who was appointed chief coroner in 1996. "It was deeply disturbing when you start finding two people dead at a time, with the needles not even out of their arms," he says. Philip Owen, Vancouver's mayor at the time, was convinced that a four pillar approach to the disaster was necessary: one that incorporated prevention, treatment, enforcement, and harm reduction, including a supervised drug consumption facility. The idea so appalled members of his right-wing Non-Partisan Association that Owen was forced out. Campbell then successfully ran for mayor in 2002 on a commitment to establish Owen's safe injection site. Campbell, now a Liberal senator, saw his mayoral win as a mandate from a public desperate to end the carnage. "This is a compassionate, caring community. If you show them the proof, the evidence, they will react accordingly."

The day of the Supreme Court ruling, with the future of Insite hanging in the balance, volunteers held a pancake breakfast as a crowd of activists and addicts gathered in the early morning darkness to watch a live TV feed of the ruling from the court. There were tears and speeches as the ruling was celebrated. Delanie Supernault, 57, has been using Insite for six years. She said she couldn't imagine it closing, "now that we know what good it does." After a five-week detox on the second floor she weaned herself off crack cocaine, though she still injects opiates. You take your victories where you can.

As the 10 a.m. opening of Insite approached, the crowd of clients swelled even further. Many were jubilant. A few--a woman in a black leather coat who looked too young for the weight of her troubles, and others who looked too small for their clothes--were twitching and drug-sick and raging at the world.

It's a scene that would shock sensibilities in most any other city in Canada, yet in this neighbourhood it offered a strange kind of hope.

Inside the doorway to Insite, a First Nations man in an army surplus coat swept up the remnants of celebratory confetti before the crowd of clients surged in. "It's a good mess," he said, talking about the glitter on the floor or maybe bigger things. "A good mess."

See also Non-medical Drug Use.

Maclean's October 17, 2011