Overdose

by Benjamin Perrin

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  “I don’t believe in safe-injection areas, as I call them,” said Ontario’s Progressive Conservative Premier Doug Ford on April 20, 2018, during the provincial election. “I’m dead against that.”

  A month earlier, Jason Kenney, leader of Alberta’s United Conservative Party and current premier, had told the Lethbridge Herald that “helping addicts inject poison into their bodies is not a solution to the problem of addiction. I think the focus should be on interdiction and law enforcement to keep this stuff off the streets.” The next day Kenney tweeted, “Why isn’t the federal government massively increasing resources for the Canada Border Services Agency to interdict these poisons? Why isn’t our federal government demanding that the Chinese government crack down on these factories?”

  During the 2019 federal election, Conservative Party leader Andrew Scheer slammed the expansion of supervised injection sites as “terrible.” There has been even more strident opposition to supervised injection sites south of the border. “SIFs [safe injection facilities] are counterproductive and dangerous as a matter of policy, and they would violate federal law,” said the U.S. Attorney’s Office for the District of Vermont. “As to policy, the proposed government-sanctioned sites would encourage and normalize heroin use, thereby increasing demand for opiates and, by extension, risk of overdose and overdose deaths.”

  None of these objections to supervised consumption sites hold any water. First, as we’ve seen, trying to crack down on the supply of illicit drugs has been futile, and has even backfired. It contributes to an increasingly toxic contaminated drug supply. The war on drugs has led to cheaper and more potent illicit narcotics. It hasn’t worked to stamp out any other drug, and it especially won’t work with potent synthetic opioids that can be manufactured anywhere in the world. Not to mention those millions of letters and packages arriving every month from China, any one of which could contain fentanyl.

  Second, as for preferring to get people into treatment rather than supporting supervised consumption sites, the two go hand in hand and are part of a more effective response to the opioid crisis. Supervised consumption sites keep drug users alive so that they can get into treatment when they’re willing and able. As demonstrated by the New England Journal of Medicine study cited above, users of supervised consumption sites are actually more likely to enroll in treatment.

  Third, the evidence shows that supervised consumption sites do not encourage or normalize drug use. A study in the American Journal of Public Health found that “the average Insite user had been injecting for 16 years. Only one person out of 1,065 reported performing their first injection at Insite. This strongly suggests that Insite has not promoted illicit drug injecting, but rather that it has attracted individuals with long histories of injection drug use.” That’s right, only one person was found to have had their first injection at Insite. Politicians might as well start blaming rap music for the opioid epidemic—that’s how ridiculous their claims are opposing supervised consumption sites. As Leslie McBain, co-founder of Moms Stop the Harm, put it, “There was drug use when we didn’t have safe consumption sites. All that’s ever happened there is lives have been saved.”

  I was also impressed with the high level of support among law enforcement officers for safe consumption sites and the benefits they see in them.

  “I personally have never met anybody who is a drug user who cites the availability of a safe consumption site as a reason why they use drugs,” said Staff Sergeant King. “In my experience that hasn’t been the case. I don’t believe that they encourage drug use.”

  “In 22 years of policing, of drug enforcement, I can tell you pretty confidently that nobody became a drug addict because of Insite,” agreed Inspector Bill Spearn with the Vancouver Police Department. “One of the big fears when Insite opened was that it was going to act as a big magnet, drawing in people who use drugs from all around the world to come to Vancouver. But the truth of the matter is that if you’re an addicted person and if you live a few kilometres away from Insite, you’re not going to go because you’re just too sick to get there. People who use Insite live within a few blocks of it. It’s not enabling. Really, it’s just being humane with people. It’s giving them clean supplies. Something as simple as clean water rather than using water from a puddle. It’s a way of keeping people healthy and keeping them alive so that one day they can get into treatment.”

  Even the faith-based community organizations I spoke with were supportive of the important role played by supervised consumption sites. “I mean they help people. They reduce morbidity and mortality and so, for us, that’s important,” said Bill Mollard, president of Union Gospel Mission. Although his organization doesn’t run any supervised consumption sites or overdose prevention sites, Mollard is convinced they play an important role. “Firstly, we’re glad they do. If my daughter was in the Downtown Eastside, I’d be doing it personally every day.”

  I wanted to know what Sarah Blyth with the Overdose Prevention Society thought about politicians who oppose such sites.

  “People will just die with no safe injection sites,” she said. “We’ve saved hundreds of lives in the past year. That many people would be dead because of what they’re saying. I would say, Don’t vote for those guys, because they’re idiots and they don’t really understand the issue. And I think the public is gonna understand that they don’t understand the issue because that will actually kill more people. Conservative people’s children use opioids too. It’s not a political issue, really; it’s a health crisis issue, and there’s things that can be done that are known and scientifically proven, legally proven, and economically proven about how safe injection sites help.”

  Politically motivated opposition to supervised consumption sites represents nothing short of playing politics with people’s lives. It’s driving a wedge based on fear and stigma to win votes. People are afraid of crime despite the fact that, according to Statistics Canada, police-reported crime has declined significantly since the early 1970s. But many voters can be easily manipulated to vote for so-called “tough on crime” measures that don’t actually make them any safer. And by demonizing people who use drugs, there’s political gain to be had by those willing to play that game. Even progressive politicians can get caught in the trap—delaying the expansion of supervised consumption sites in the face of local opposition that’s based on nimbyism and stigmatizing those who use drugs. And as a result of such delays, more people will die during the opioid crisis.

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  Vancouver has the most supervised consumption sites and overdose prevention sites of any city in North America. They’re saving lives, yet they aren’t enough. Record numbers of people still died. Although a further increase in safe-use places would undoubtedly help (they’re all currently in the Downtown Eastside, as I mentioned above; many have limited hours; and sometimes there are lineups), new ideas are needed to reach people who are using and dying alone.

  “What we need to be doing is looking at how we can make this a normal health service and provide it in a variety of different settings,” said Dr. Paul Hasselback, a medical health officer with Island Health. “The overdose prevention sites serve a population within a range of about 500 or 800 metres.”

  “Overdose prevention sites, supervised consumption sites are great for a half-mile radius around them,” agreed Jordan Westfall. “There’s still people who just don’t necessarily want to use them. I just think that it would be nice to get to the point where people didn’t have to worry. But we do need this right now.”

  Some creative solutions are being launched so that people don’t have to use alone. Peers are often first responders in the opioid crisis: these can be friends looking out for each other, or even strangers. For example, the Vancouver Area Network of Drug Users (VANDU) has a group of peers on foot doing overdose prevention in the Downtown Eastside, while PHS Communi
ty Services Society manages “Spikes on Bikes” teams that get around on bicycles with clean supplies and naloxone. There are major challenges in reaching rural and remote communities, and one way of addressing these are the mobile overdose prevention sites based out of vans operating in the BC Interior.

  Another approach that’s being used in social housing buildings when there’s a spike in overdoses is “witnessed use rooms,” where people who use drugs can go to use them under supervision instead of the much riskier alternative. “Individuals were in their own rooms and they were alone; they were injecting and overdosing and nobody would know,” said Bonnie Wilson, operations director (Inner-City Eastside) and co–program lead for mental health and substance use at Vancouver Coastal Health. “We couldn’t call it an overdose prevention site and we couldn’t call it a supervised injection site, but what it would be is a designated space in a supported housing building where an individual could say ‘I’m going to inject right now.’ They would go in, they would inject, or they could come down there with a peer, a friend, another tenant in the building—it was a safe place for them to inject and have someone check in with them. If there was a concern, if there was an overdose, a staff member or the tenant could respond right away.” Of course, these witnessed use rooms work only if the housing is low- or no-barrier, meaning that they won’t kick you out for using illegal drugs. They know that people have mental health and substance use issues and they want to keep them safe instead of forcing them out onto the street to fend for themselves or silently die of an overdose alone in their room.

  Fraser Health has even been working on some tech-enabled ideas to try to reach people, recognizing that there’s no one-size-fits-all approach to overdose prevention. “We’re in the process of developing something where somebody can use an app [that would] call in a response if they don’t turn it off in a specific amount of time after using drugs,” said Chris Buchner, director of communicable diseases and harm reduction at Fraser Health. “What is an overdose prevention site? It can be everything it needs to be.”

  These are all interesting ideas. But what came up again and again in my research interviews is that, despite the risk of dying, there’s one big reason why people have continued to use alone during the opioid crisis.

  “We haven’t been able to deal with the stigma,” said Linda Lupini, executive vice president of the BC Provincial Health Services Authority and BC Emergency Health Services. “The stigma is what’s making people shoot up in the bathroom in their house and their parents don’t even know they use drugs every day. Or the professional person, or the construction worker. Whoever it is. There’s still this huge number of people who just won’t tell anybody.”

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  “Hey, I’m here to get my drugs tested.”

  “Folks will come in; they’ll walk to the front counter,” said Troy Balderson, downtown projects manager for Lookout Society, which runs the Powell Street Getaway in the Downtown Eastside. Balderson has a buzz cut, a goatee, and tattoos that travel along his arms and up his neck to just below his ear. He’s also got a heart for people with addiction and substance use challenges.

  “We’ll bring them into the room. They’ll sit with our technician. They’ll pull out a very, very small sample. Put it on the spectrometer. He’ll give them a breakdown,” Balderson explained.

  The Powell Street Getaway, which opened a supervised consumption site in July 2017 (almost nine months after its application was sent in to Health Canada), is one of just two locations in Vancouver that are piloting a sophisticated on-the-spot, no-questions-asked drug-checking program for people using street drugs. The Fourier-Transform Infrared Spectrometer (FTIR), shared with Insite, can detect a range of substances, including fentanyl. It can give detailed information about the composition of a sample in less than two minutes. Plus, it’s portable. However, results can vary depending on what part of the drugs are sampled, since fentanyl may not be uniformly distributed.

  The other way of testing for fentanyl is with test strips, which are being distributed to all supervised consumption sites and overdose prevention sites in BC. They’re much cheaper, although after you mix your drugs in water and dip the strip into the solution, they offer only a basic yes/no indicator for the presence of fentanyl. So in order to know with more certainty whether your street drugs contained fentanyl and what else is in them, ideally you’d use both a spectrometer and a strip.

  “I think drug checking is something that really should be rolled out in a huge way,” said Dr. Evan Wood. “And despite announcements about drug checking, if someone wanted to go and get their drugs checked right now, I actually don’t know where they would go to get that done.” Indeed, unless it’s during the very limited days and hours currently offered at Insite or the Powell Street Getaway, sophisticated drug testing isn’t readily available for people wanting to know what they’re actually getting from their dealer.

  “Knowledge is power in these types of circumstances,” said Dr. Aamir Bharmal, medical health officer and medical director of communicable diseases and harm reduction with Fraser Health. But although the medical experts, community organizations, and law enforcement officials I spoke to were supportive of drug checking, they also noted that it has its limitations.

  What impact does drug checking actually have? Given the widespread contamination of the illicit drug supply, a positive test for fentanyl isn’t much of a surprise anymore to people who regularly use such substances. There haven’t yet been any published clinical trials on how it might directly affect substance use behaviours, so that’s something that’s being studied through Vancouver’s spectrometer pilot. Preliminary data from Insite suggests that while regular opioid users don’t tend to dispose of drugs that test positive for fentanyl, they’re 10 times more likely to use less and 25% less likely to overdose. Drug checking is also seen as providing another opportunity to connect with illicit drug users. “What I’ve been hearing about the drug checking is the presence or absence of fentanyl. People haven’t said ‘I’m not going to use’; it’s ‘I might use a bit less’ or ‘I’ll use safer’ or something like that,” said Dr. Bonnie Henry, BC’s chief medical officer. “When they get that positive fentanyl outcome, they may be less likely to use alone—they’ll use with a peer, or go to a supervised consumption site or overdose prevention site just to be sure there’s someone there to help if they overdose.”

  Drug checking could also play a role in preventing casual or recreational drug users from overdosing, since they’re typically not seeking fentanyl but rather other illicit drugs. For them, a positive fentanyl test could make a difference in their decision not to use that hit at all. “We’ll do it for long weekends as well,” Balderson told me. “Especially around the fireworks festival and stuff, we’ll do extra testing. A lot of rave party drugs are going to come in—Ecstasy, suspected MDMA—you know, folks that go party on long weekends. If there’s fentanyl in it, we’ve had people leave and say ‘I don’t want it.’ ”

  I was surprised when I heard about another group of individuals who are using public drug-checking services: drug dealers. “Even the low-level dealers—some of them are my patients—who didn’t realize that their own drugs had fentanyl in it,” said Dr. Ronald Joe, medical director for substance use services at Vancouver Coastal Health. “In fact, they’re the ones who actually came to Insite to check whether there was actually fentanyl in their drugs.”

  “They wanted to know if what they were selling had fentanyl in it?” I asked.

  “That’s right. It’s fascinating,” said Dr. Joe. “For the sake of themselves and also for the sake of the people—you know, the circle that they’re actually distributing and selling drugs to. Because they didn’t want to harm their small group.”

  Despite the apparent advantages of drug checking, bureaucrats have put up roadblocks by once again citing our federal drug laws—ones based on a prohibitionist model that
is singularly obsessed with inanimate substances instead of living people. “Drug checking is another area where Health Canada actually said, ‘Oh, no, you can’t do that. It’s in contravention of the trafficking provisions under the Controlled Drugs and Substances Act,’ ” said Dr. Henry. “So, how we got around that, people purchase their own drugs and they do the test. They don’t actually hand a sample over to a technician. I think any changes that can make the drug-checking process easier would be helpful.”

  As a Pivot Legal Society representative told me, “There’s a pharmacy I spoke with that was providing drug testing for folks who needed it with drug-testing strips, and they were actually issued a notice to stop doing so because it supposedly constituted trafficking. The drugs were passing over, the doctor or pharmacist was testing and handing them back.”

  Some have raised concerns about how much reliance we should put on drug checking as a tool to respond to the opioid crisis. “All these tests—test strips, for example—aren’t perfect,” said Dr. Bharmal. “There’s a little bit of a safety concern here in terms of thinking that if this is a negative test strip you have no concerns and you can just use these drugs with no repercussions.”

  Taking that even further, is it possible that drug checking could encourage drug use?

  It turns out, no. A review of published research by the BC Centre on Substance Use found “no adverse effect on recreational drug using populations, refuting early arguments that these services may increase drug use in this population by offering a false sense of confidence.”

  “It’s a piece of the puzzle that’s important,” said Jordan Westfall. “[But] I feel like we dedicate way too many resources to it right now. Honestly, most people, they don’t have a choice. They know the drugs have fentanyl in them. You can’t get that exchanged for other drugs.

  “It’s just way too much effort and money being put into that compared to just making sure people have a safe supply. It’s counterproductive to ultimately a better drug policy. But we do need it right now. I’m sure there’s people who rely on it too, but I just don’t see the uptake of it that I think people were expecting.”