From Canada, ideas on keeping people safe from ‘poisoned’ illicit drugs

A client of an Insite supervised injection center in Vancouver collecting a kit.AFP/Getty Images/File 2011

The state’s Harm Reduction Commission recently held its first meeting to study the controversial proposal to open a place or places where people could inject illicit drugs under medical supervision. The commission, created by the opioid legislation signed into law in August, has until February to report to the Legislature on the risks and benefits of establishing “supervised injection facilities” or “safe injection sites.”

The sites provide a clean, safe place for people to inject illicit drugs obtained elsewhere, with medical staff on hand to rescue them if they overdose, as well as opportunities for health care and links to addiction treatment.

More than 100 such sites operate around the world, including dozens in Canada. But so far none has opened in the United States, despite interest in several cities. The first such facility in North America — Insite — opened in Vancouver, British Columbia, in 2003. The Globe recently sat down with Dr. Mark Tyndall, a Canadian health official who helped found Insite and has published extensive research about safe injection sites. Here are edited excerpts of the conversation.

Is there strong evidence about the effectiveness of supervised injection sites?

When we were setting up Insite, I was obviously looking for evidence [from safe injection sites in Europe]. But you talked to people running these sites in Europe and they were, “Oh, we just did it. Why wouldn’t you do it?” It was a common sense thing.

When Insite opened, crime went down in the area. Overall drug use intensity went down. So did overdose deaths in that neighborhood, in the years after Insite opened. People were less likely to access emergency departments or to be admitted to hospitals. The number of needles discarded went down. Over a three-year period, Insite clients were more likely to go into treatment than people not using the site. We’ve had over 3.5 million visits to Insite, and no one has ever died there.

Today there are 31 safe injection sites in British Columbia and several others in other provinces.

But no matter how much evidence you have from one site or one city, it’s never going to be enough to satisfy. The scientific approach will never be enough for the naysayers.

So I’m really going to the common sense thing. People have the idea, if we don’t allow them to inject at supervised site, then they won’t inject. But we know what they’re doing right now — taking their needles into public washrooms or children’s parks or abandoned buildings. Any alternative to that has to be better.

Why has the overdose rate gone up in British Columbia in recent years despite the presence of safe injection sites?

All the excess deaths we’ve seen are due to the introduction of fentanyl and carfentanil [the powerful, synthetic black-market opioids]. If we took fentanyl out of the equation, the number dying would be steady. People who are using heroin often have long careers of heroin use. If they get the amount of drug they’re used to, overdoses are pretty unlikely. The drugs people are buying on the street — they have basically no idea of the toxicity.

Do safe injection sites become a route to recovery?

Many people, given the opportunity to stabilize, will choose a better route for themselves. I don’t think we should judge that they have to stop using drugs, and recover, and get a job and move to the suburbs. That’s just an impractical expectation for a lot of people.

By stabilizing, people tend to make the best decisions for themselves and get as far as they can. It’s not for me to judge where that ends. But I do see a lot of healthier people because they’ve got harm reduction services, and to me that’s important.

The current debate now is how we get people a safe supply of drugs.

A safe supply of drugs?

All the harm reduction in the world doesn’t stop people from buying street drugs in the alley and using them and dying. We can intercept them at supervised injection sites. We can find people who have overdosed and give them naloxone [the chemical name for Narcan]. But that’s a very late intervention.

I’ve given so many tours through Insite, and the first question is, “Well, don’t you give drugs here?” Oh no. People go perform sex acts and break into cars. That how they get their drugs. Isn’t that ridiculous. If people are using these things, I think we should give them a safer supply and then we can start engaging them down the road.

We’re hoping to start a pilot study in the next three or four months. We’d give people a secure supply of drugs from a dispensing machine. It would give out hydromorphone pills, using biometrics [to ensure only those authorized can get the pills]. It would give them time to interrupt their chaotic cycle of finding drugs.

Doesn’t that amount to giving up on people with addiction, giving up on their recovery?

What’s the alternative? People buying poison drugs in alleys from gangsters? The biggest benefit of it is to let people have an opportunity to do something else. If they spend 24/7 either obtaining or thinking about where they’re going to obtain their drugs, how do we ever expect them to get back on track? If you take that out of the equation, maybe they can do something better.

There are people who could go through a progression. We give you safe drugs, we engage with you, we help you with housing, help you with your health. You eventually get on methadone or Suboxone. Then you go into longer-term recovery. I’m all for that journey — but the journey has to start where people are at.

For most people in a poisoned drug environment, the journey should start with giving you a safe supply of drugs that won’t kill you. And then, we can work on the other things.