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.
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.