Responses to Canada's overdose crisis
Tampering with science
A crisis of opiate overdose deaths is spreading across the country, and how we respond could save lives. But the drug war is still being waged from Ottawa, despite its abject failure around the world.
Over the past two decades, overdose deaths have shot way up in Canada— now between 1,000 and 2,000 every year. But in Vancouver’s Downtown Eastside (DTES), the numbers have gone down dramatically over the last decade, according to the Urban Health Research Initiative. The difference? In the DTES, the war on drugs is somewhat in retreat. Dr. Benedikt Fischer, an expert in mental health, addiction and drug policy, explains that “targeted interventions like naloxone [a drug that reverses the effects of overdose], methadone and [the safe-injection site] InSite have caused a strong relative decrease” in overdose deaths.
But it wasn’t always this way. Back in the 1990s, someone died of an overdose in the DTES almost every day. The tiny neighbourhood had the highest HIV transmission rate in the industrialized world.
Back then, there was little in the way of gentrification, weekend hipster invasions, and pricy condo towers. People didn’t go jogging down Columbia Street—any running was strictly law enforcement related. Intravenous drug users were isolated individuals. The few services that did exist were often restrictive.
So the community started to organize. There were meetings and protests. In 1998, the Vancouver Area Network of Drug Users (VANDU) was formed. A politicized movement of users, community workers, and allies emerged. The stigma of addiction began to lift—at least in this neighbourhood.
The war on drugs is an old-school, law and order approach: cops, jails and “just say no.” It’s a favourite of right-wing governments.
Harm reduction is evidence- based, seeking better health and social outcomes for the user and the community, but accepting that some drug use may continue. The difference between the two is whether you believe drug addiction is a moral failing or a medical condition.
Injecting evidence into the debate
A friend tells me about how he overdosed a couple years back. “I got really high—then nothing, like when you get your wisdom teeth out,” he recalls.
His breakfast that day was a sizable hit of heroin. But rather than being alone, as he would have been in the '90s, my friend was at InSite, where trained staff keep a sharp eye out for overdoses. “I woke up on the floor, on my back with a bunch of people looking down at me.” Had he not been given naloxone [more commonly known as Narcan] twice, in short order, my friend would have been “dead as a doorknob,” as he describes it. This story has been repeated hundreds of times each year since InSite opened.
Before there was InSite, activists organized their own unsanctioned, guerilla safe injection sites. This pressured and embarrassed authorities into moving ahead with an official pilot facility in 2003—an experiment that became what is now North America’s only supervised-injection facility. After more than a decade, thousands of saved lives, a stack of research and lengthy legal battles, InSite is here to stay. Even police publicly encourage drug users to go there.
But it’s not enough.
With 700 to 800 visits each day and long line-ups, many users have to find other places to inject. So, just like the guerilla sites of the '90s, VANDU operated a second, underground, peer-run safe injection site for four years (Megaphone broke the story on its existence in June). The site was shut down in December 2013, but Vancouver Coastal Health’s chief medical health officer, Patricia Daly, told The Georgia Straight, “we know that we need to expand supervised injection as a nursing service.”
Elsewhere in Canada, overdoses are on the rise. There is nowhere else like InSite, but organizations across the country are working to turn that around. Montreal’s Cactus needle exchange continues to push for the four supervised injection sites that were promised to the city in 2013. And last summer in Toronto, the city’s public health agency recommended opening several small sites.
Not everyone is a believer. The federal government’s National Anti- Drug Strategy provides the public with advice on “the effects of drugs and how you can say ‘no’.”
Conservative Party supporters are invited to add their names to a current online campaign titled “Keep heroin out of our backyards,” which states, “add your name if you demand a say before a supervised drug consumption site is opened close to your family.”
After losing a protracted legal battle to close InSite in 2011, the government proposed legislation in 2013 that would erect a number of barriers to the opening of any new safe injection sites.
Today, another court battle is underway, where the government is trying to block prescription heroin to a small group of entrenched heroin addicts for whom methadone is not effective. Prescription heroin trials have proven to have positive health and social outcomes for these patients.
Howls of outrage also greeted news of clean crack pipes being distributed vending machines by the Portland Hotel Community Services Society in the DTES. In February, the Minister of Public Safety, Steven Blaney, said in the House of Commons: “we don’t believe that handing heroin and needles to people who are suffering from addiction is a solution.”
According to the Canadian Drug Policy Coalition: “Rates of overdose from opioids are on the increase in Canada.” Every year, between 1,000 and 2,000 people die from opiate overdose in Canada, according to drug policy expert Dr. Benedikt Fischer. This year, there have been 550 opioid-related deaths in Ontario, where it’s the third leading cause of accidental death. In June, a spate of overdoses in Montreal had public health officials worried. Overdose deaths are also alarming medical authorities in Hamilton, Ontario. In suburban Vancouver, there were 13 fatal overdoses in the first four months of this year. About 900 people have died of accidental overdose in Toronto between 2002 and 2010.
Tampering with science
So, how are the feds proposing to stop the overdose crisis? Recently, Health Canada announced plans to require that all prescription opiates “at high risk of abuse” be made physically tamper resistant—difficult to crush and snort, or cook up and inject.
The British government did the same thing to morphine tablets when I lived in London. As a result, regular morphine pills started being manufactured as little green jelly bean- looking things. People shot them up anyway, but a new additive caused the drug to congeal in the veins or under the skin. There were terrible abscesses. On the street, I heard of users losing limbs—and still people kept injecting.
Making pills that turn to jelly in the bloodstream, and other forms of tamper-proofing, won’t necessarily address the overdose problem. For Dr. Fischer, it’s about the over-prescription of opiates, not their diversion into the arms or noses of users. “It won’t make a big dent. Most overdose deaths don’t involve tampering,” he said.
Methadone in B.C. has already been made tamper-resistant. In February, patients were switched to a methadone syrup which is supposed to be much harder to shoot up than the old stuff. But like the morphine pills in the U.K., people are doing it anyway, and some are getting very bad abscesses. As I reported in Megaphone in June, many patients are also finding it does not last as long, leaving them in withdrawal and relapsing back to heroin use.
Drastic measures, unintended consequences
Dean Wilson was a plaintiff in the 2011 InSite case and used heroin for decades. As a methadone patient, he’s angry about being used as “a guinea pig.” He told me that trying to tamper- proof prescription drugs is pointless: “Junkies are always going to find a way to beat the system,” he laughed, with dark humor.
Fischer agrees. “Drug users can circumvent tamper-proofing,” he says. “Weeks after the new [tamper- proof] OxyNEO came out, people had figured out a way around. It’s not an effective deterrent and there can be complications ... people can get sick, it can be a horrible experience.” He also said that users often simply switch to a riskier option.
When OxyContin was pulled from pharmacy shelves, Ontario Health Promotion found that users were just “shifting to other opioids, with heroin most commonly reported, which may pose a much greater health risk.” The Canadian Drug Policy Coalition agrees drastic measures can have unintended consequences: “Recent policy changes to contain the supply of opioids may have the unintended effect of increasing overdoses.”
Fischer says tamper-proofing “serves political and corporate purposes but not so much public health purposes.”
The illicit use of prescription drugs cannot simply be banned or engineered away. In the depths of addiction, people often do not have the capacity to respond to the ‘deterrent’ of tamper proofing. And, such high-handed solutions can cause new problems— health complications and riskier behaviours.
What does work, experts say, is involving, empowering, and educating users and community members— giving people the agency to help themselves, not taking it away with authoritarian measures.
After a recent rash of overdoses on the DTES, the Drug Users Resource Centre rushed to put on a Narcan course.
During the heat wave last month, about 40 of us packed into a hot, airless room for a training session. People were keen to listen. The cranky crowd shouted down anyone who dared interrupt Portland Hotel Society nurse manager Kirsten Locher. We were sweating and a fight nearly broke out, but everyone was also very aware of the stakes. Most people in the crowd knew someone who died of an overdose. Locher explained the signs of overdose, and demonstrated how to administer Narcan.
One attendee played the overdose victim, sprawling out on the floor.
“This training empowers people to take care of themselves and others in the community,” Locher tells me. “We have an amazing community. Instead of just walking by someone who is passed out, they are checking on them.”
As people signed up to get their own Narcan kits, staff cautioned that police have been confiscating them. I’d heard rumours about this too.
Tamper Proof Consultation
Health Canada is accepting public comments on tamper resistant drug regulations, under the Controlled Drugs and Substances Act until Aug 28. Email: tamper. firstname.lastname@example.org
I asked the Vancouver Police about it. Their media relations officer, Randy Fincham, states in an email: “I am unaware of our members seizing Narcan. Nor have our members been directed to do so.” I asked if the police currently carry Narcan as part of their kits. Fincham says the VPD is leaving that to medical professionals.
Locher thinks anyone with the training should have access to Narcan.
“It’s a tool, like a pocket map. We need to increase accessibility,” she says. “I hope that Canada will make it available over the counter, as it is in other countries... available to all, not just active and past users, but friends, family—non-users, good Samaritans.”
The Canadian Drug Policy Coalition agrees, lamenting in a recent report that “the tragedy is that many [overdose] deaths could have been prevented with measures such as training, [and] increased availability of naloxone.”
Back in Ottawa, it may be hard for some to accept any approach that’s not about totally quitting drugs. But putting aside ideology, looking at the science, and most importantly, listening to those contending with addiction, it’s easy to see that “just saying no” is not possible for everybody.
Chronic physical pain and deep psychological trauma have launched many long and pernicious habits. The chance for health, security, staying out of jail and a modicum of dignity should not be sacrificed on the altar of abstinence.
Like any war, a never-ending war on drugs will just bring more funerals.
-with files from Lisa Hale
Garth Mullins is a writer, activist, musician and award-winning broadcaster living in East Vancouver. Follow him on twitter: @garthmullins