Darryl Dyck/AP

Vancouver: Giving junkies a fix to keep them off the street

A controversial program offering heroin to addicts goes to court


VANCOUVER, Canada — Walking back alleys in Vancouver’s impoverished Downtown Eastside, Kevin Thompson, 43, tells stories from roughly two decades of cocaine and heroin addiction.

Drug deals would sometimes go bad, and he was robbed and assaulted. One notable incident involved a fight over a waffle iron that ended with a golf club being broken over his head. “It can be a lot of hassle just to get what you need for the day,” Thompson recalls.

But even trouble-free buys weren’t much of a relief. A high never lasts long enough, he explains.

Life often consisted of little more than scrounging for money or shoplifting, getting through a drug deal, injecting cocaine or heroin, and then doing it all over again a few hours later. Years went by like that, always waking up anxious, enduring the early symptoms of withdrawal until he could find the next fix.

Thompson was finally able to break away from the risks and complications of scoring drugs on the street, he says, thanks to diacetylmorphine, or prescription heroin.

Thompson participated in two studies that provided access to the drug, which is administered following the protocol of a traditional treatment, like methadone. There was the North American Opiate Medication Initiative (NAOMI) from 2005 to 2008, he says, and the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), in which he participated in 2013. Three times a day, Thompson explains, he would visit a clinic in Vancouver’s Downtown Eastside, receive a free dose of pharmaceutical heroin and leave, without having to worry about where his next fix was coming from. Heroin maintenance, as this sort of therapy is known, falls into a category of public health policies called harm reduction, a bold strategy that Vancouver has long championed.

Kevin Thompson, a former patient in the NAOMI and SALOME academic studies of prescription heroin.
Travis Lupick

“I’ve gone from using hard-core every day and being homeless to having a roof over my head and working,” Thompson says. “With your heroin habit supported, you can start thinking about bettering your life. It gives you a chance to think and get your head back together.”

For years, a small fleet of vans has functioned as a mobile needle distribution system throughout the greater Vancouver area, offering addicts clean syringes free of charge. Crack pipes are sold in vending machines for 25 cents. At Insite, North America’s only legal supervised injection facility, drug users inject heroin, cocaine and methamphetamines, under the watchful care of nurses, at a rate approaching 200,000 visits a year. Last year the facility celebrated its 10-year anniversary.

The February 2014 death of Academy Award winner Philip Seymour Hoffman attracted some attention to harm reduction. New York State — where the 46-year-old actor was found unresponsive with a needle in his arm — is lowering access barriers to a drug called naloxone that counters the effects of an opiate overdose. But the legacy of America’s “war on drugs” makes it politically complicated to get a harm-reduction program like Insite off the ground in the U.S.

Even in relatively progressive Canada, heroin maintenance is controversial.

In October 2013, federal Health Minister Rona Ambrose implemented a regulatory change that closed a “loophole,” as she called it, banning the prescription of drugs like heroin, cocaine and ecstasy. But Vancouver doctors refused to accept what they described as Ottawa’s interference in the treatment of their patients.

On March 25, a local health care provider and opiate users will enter the Supreme Court of British Columbia in a battle with the federal government to continue with the city’s efforts to prescribe pharmaceutical heroin. The plaintiffs are Providence Health Care and five SALOME patients.

David Byres, vice president of acute clinical programs at Providence, says that lawyers will argue that the federal government’s move against prescription heroin is unconstitutional in that it infringes on access to evidence-based care. In the short term, they will also seek an injunction that aims to exempt past and present SALOME patients from the federal government’s prohibition on the prescription of diacetylmorphine.

Doug King is a lawyer with Pivot Legal Society, a nonprofit that has helped prepare the SALOME patients’ case. He explains that by providing an addict with heroin on a routine basis, you bring them into the health care system, and lift them out of a lifestyle that often involves criminal activity.

Lawyers’ arguments will largely rely on the findings of the NAOMI study, King says. He notes that according to trial results published in the New England Journal of Medicine, heroin-assisted therapy can be more effective than methadone in improving the health of long-time addicts.

“When you look at their stories and their situations, you see that a lot of the harm they bring upon themselves and upon society is not necessarily the drug itself, but the process of getting that drug,” King says. “We’re dealing with people who have been heroin addicts for decades. For them, addiction is not really about getting high anymore.”

Affidavits drafted by the five SALOME patients participating in the court challenge recount how heroin administered on a prescribed basis alleviated the challenging circumstances of opiate addiction.

Douglas Lidstrom wrote about using hard drugs for more than 40 of his 59 years. “Before the SALOME study, I did not properly care for myself and did not take steps to treat my hepatitis C,” his affidavit reads. “I only thought about the heroin.”

In the study, it continues, “I did not engage in any criminal (activities) … because I had no need to. I was able to maintain my relationship with my children better because I was stable and less concerned about getting heroin on the street.”

Deborah Bartosch’s affidavit describes SALOME as “the best thing that ever happened to me”.

“My life was freed up to do other things, including taking care of myself and producing art,” it reads. “I felt less stress and anxiety about finding drugs, and was able to focus on my health and well-being.”

Registered nurse Sammy Mullally holds a tray of supplies to be used by a drug addict at the Insite safe injection clinic in Vancouver, B.C.
Darryl Dyck/AP

In Vancouver’s Downtown Eastside, doctors run a tight ship at Providence Crosstown Clinic, where SALOME continues today. Arriving at appointed times, participants pass through security and proceed to an administration point where a nurse behind a glass window distributes predetermined doses of diacetylmorphine. They have seven minutes in a sterile environment to inject themselves with the drug. Then, for 20 minutes, they must remain in a lounge where they are monitored for possible adverse effects.

Those orderly conditions are part of what led British Columbia Health Minister Terry Lake to voice his support for the program.

“I know that the thought of using heroin as a treatment is scary for people, but I think we have to take the emotions out of it and let science inform the discussion,” he says. “We have a very effective methadone program in British Columbia, but for some people, it hasn’t been successful.... For some people, those other methods haven’t worked, so this [diacetylmorphine] was deemed to be something that was compassionate for them.”

When SALOME patients exit the trial, they lose their supply of pharmaceutical heroin and often resume buying on the street. Making the best of a bad situation, many return to Insite, where, compared to Crosstown, the scene is more chaotic.

In the injection room at Insite, more than a dozen drug users are sitting in semi-private booths, creating a cacophony of muttered conversations. A nurse gently shakes one young woman who has begun to slide out of her chair. In the adjacent “chill room,” a man in an oversize hoodie is on the floor curled up in the fetal position.

Daniel Benson, peer supervisor at Insite.
Travis Lupick

Daniel Benson, a peer supervisor at Insite, nevertheless maintains that it is lifesaving work. The numbers support him: In 2012 alone, the facility recorded more than 193,000 visits to the injection room, 497 overdoses and not one death.

Benson, a self-described “functioning drug addict,” says that what SALOME really gives users is time. He explains that when addicts aren’t spending every minute they have trying to score heroin, they can devote their time and energy to finding work, maintaining relationships with family and taking better care of themselves.

“When the SALOME project started, one of the first things I noticed was that you could tell who was involved in it because all of a sudden, they started to look healthier,” Benson says. “That speaks to the essence of the whole program and the huge change it can make in so many people’s lives.”

Dr. Thomas Kerr is co-director of the addiction and urban health research initiative at the British Columbia Centre for Excellence in HIV/AIDS. He emphasizes that numerous peer-reviewed studies have shown that when a supervised injection facility opened in the Downtown Eastside, overdose deaths became less frequent, more people entered detox programs, HIV rates declined, and public order improved. Kerr says we might now be beginning to see the same sort of success with heroin maintenance.

“I think it (NAOMI) showed, once again, that for a select group of patients who are very difficult to treat through conventional methods, providing prescription-grade heroin is very effective in reducing their illicit drug use, reducing their engagement in criminal activity and improving their quality of life,” he continues. “It’s not a therapy that’s recommended for all people. But for those who don’t do well on more traditional therapies, this is highly effective.”

Kerr notes that NAOMI’s findings are supported by similar academic studies conducted in Germany, Spain, Switzerland and the United Kingdom.

“This whole idea that somehow harm reduction enables drug use and prevents people from quitting is garbage,” he says. “It just isn’t reflected in the evidence.”

Canada’s Ministry of Health declined to make a representative available for an interview. An emailed statement emphasized that Canada’s National Anti-Drug Strategy focuses on prevention.

“The Government of Canada recognizes the unique challenges faced by certain populations who are especially vulnerable and hard-to-reach,” the statement reads. “While treatment services fall mainly within provincial/territorial jurisdiction, Health Canada helps to improve treatment systems and services through its Drug Treatment Funding Program.”

A crack pipe vending machine and Mark Townsend, co-executive director of the Portland Hotel Society
Travis Lupick

Mark Townsend, co-executive director of the Portland Hotel Society, the umbrella organization under which Insite operates, explains harm reduction by addressing criticisms leveled at crack-pipe vending machines, which began appearing in Vancouver through 2013.

“We have crack and we have people that use little glass pipes,” Townsend says. “Our purpose was to provide better-quality ones that don’t crack and risk cutting people’s lips, and also to make them cheap, to try and encourage people to use a clean pipe rather than a dirty pipe, just on the basic principle that it’s probably better.”

Townsend emphasizes that harm reduction is mostly about bringing marginalized people into health care systems, and offering safer ways to engage in risky behaviors that addicts are going to go ahead with no matter what.

Liz Evans, who founded Insite alongside Townsend and Bud Osbourne, describes heroin maintenance as a natural next step for Vancouver. Though not involved in SALOME, she emphasizes that she supports the program because long-time opiate users are generally not doing drugs to get high, and don’t want to spend all their time dealing with life-consuming addictions.

“The sad truth is, most drug users hate themselves and hate their addiction,” Evans says. “The population of people that we see, it’s a sort of desperate survival for a lot of people. So if we can find a mechanism to give people access to a controlled supply of something safely that helps people to achieve a higher level of health, their options for living a more stable life are going to be greater, and they’re more likely to do better.”

That argument is echoed by Dr. Gabor Mate, author of “In the Realm of Hungry Ghosts: Close Encounters with Addiction.” A 12-year veteran of health care work in the Downtown Eastside, he stresses that the ultimate goal is getting everybody off of drugs, but cautions that that might not be possible.

“The SALOME trial is an attempt to acknowledge that these people are hooked on this substance, and if we don’t give it to them, they’ll go to any length to get it,” Mate says. “They’re going to commit crimes; they’re going to inject themselves with dirty needles and spread HIV. So why not treat them in a more humane and reasonable fashion to prevent all that? What’s the controversy?”