Carlyn Zwarenstein is a Toronto writer and the author of “Opium Eater: The New Confessions,” a memoir and exploration of opioid painkillers and pain.
The new overdose prevention site in the basement of St. Stephen’s Community House, near where I live in Toronto, opened to exactly zero fanfare (and one breathless New York Times article) this spring, joining several other supervised injection sites in the city. Previously, users injected heroin or, more likely, an unholy mix of fentanyl and other mystery substances, in the alleys of the steadily gentrifying neighborhood of Kensington Market, leaving needles in the nearby park or overdosing in the bathrooms of the local Burger King.
Next to a bustling drop-in where a hot lunch is served most days to the community at large, drug users can inject, snort or swallow their drugs in a clean, private room with two small tables, a choice of Hep C-free and HIV-free needles of different gauges, disposal containers and a mirror so that workers, who may be current or former users, can unobtrusively check on their clients. Oxygen and naloxone, the overdose reversal drug, are nearby. There is no police presence. “We’re part of the neighborhood,” said Tyler Watts, St. Stephens’s coordinator of overdose prevention services. “This is a community response to a community problem.”
These sites (beginning with Insite in Vancouver in 2003) reduce HIV rates, hospital admissions and ambulance calls. They link users to health care, social services and addiction treatment. There are no fatalities.
Despite persistent assertions that the sites encourage or perpetuate drug use, there is no evidence to support this claim. In fact, we need more of these sites. There is no treatment for addiction if the patient is dead. Also, the lives of people who use drugs are valuable whether or not they seek treatment.
With potent fentanyl becoming ubiquitous in many regions of the country, that’s a likely outcome. Canada, like the United States, is in the grip of an accelerating drug-poisoning crisis. We went from 2,946 apparent opioid overdose deaths in 2016 to close to 4,000 in 2017, making our fatality rate now equivalent to that of the 10-times-larger U.S. population. Most were accidental deaths and often involved illicit (never prescribed) fentanyl analogues. When I started writing about opioids (I take a prescribed opioid to manage pain from a degenerative spine disease), I thought it was hyperbole to call it a crisis. But the numbers speak for themselves.
In the United States, despite some notable exceptions, the response has been to prosecute, then prosecute harder, while drastically cutting access to legal opioid painkillers (every user and advocate I’ve spoken with blames the introduction of tamper-proof OxyContin for a massive move among users to injected, illegal opioids). The prosecution of friends who share their drugs or Good Samaritans who call 911 drives the issue underground, where it festers and kills.
In Canada, by contrast, we’ve taken more of a public health approach. Mind you, the previous federal government persistently blocked the expansion of evidence-based programs such as Insite. To the frustration of advocates traumatized (sometimes into further drug use) by daily overdoses, we’re still not moving aggressively enough. As with AIDS, a stigmatized group of people suffers first and worst. One mom whose son overdosed in November told me, “Why can’t we have it be an emergency? It’s because it’s ‘junkies.’ ”
Until the June election of Doug Ford, our very own baby Trump, to lead Canada’s largest province, it seemed that Canada was at least moving in the right direction. But the allegedly (former) drug-dealing premier just halted approvals of new sites like St. Stephens (which likely includes necessary re-approvals of existing sites like theirs). It’s a devastating step backward. Other measures needed across Canada: needle “exchanges” (just give ’em out); naloxone everywhere; cautious prescribing of opioid painkillers to prevent diversion, without sending patients to the illicit market for relief; expansion of a very successful prescription heroin program shown to help those failed by other treatments (prescription hydromorphone is another option); and same-day access to medication-based (and publicly funded — this is Canada, after all) treatment for opioid-use disorder.
Last but most important: decriminalization of small amounts of any drug for personal use to immediately reduce relentless market pressures driving the move to ever-stronger opioids. This would break the cycle of compounded trauma and misery that breeds addiction as poor and, overwhelmingly, racialized people are jailed, families are torn apart, and users die because they must hide their drug use rather than learn to use more safely or seek evidence-based treatment. This approach has been successful in Portugal and elsewhere. In Canada, most residents of Vancouver (where the crisis has hit hardest) say they support decriminalization. So does Vancouver’s mayor, increasing numbers of front-line organizations and Toronto’s medical officer of health, who also suggests the government consider legal regulation. The rest of the country, only beginning to appreciate the scope of this crisis, is not quite there yet. If this continues, it will be.