, the safe injection site on ’s Downtown East Side.

First, Reduc e Harm Faced with a horrific drug problem, Vancouver is trying a radical experiment: Let junkies be junkies.

By Vince Beiser

n a chilly, overcast morning in downtown Vancouver, , a steady trickle of sallow- Ofaced drug addicts shambles up to a storefront painted with flowers and the words “Welcome to Insite.” One by one, they ring the doorbell and are buzzed into a tidy reception area staffed by smiling volunteers. The junkies come here almost around the clock, seven days a week. Some just grab a fistful of clean syring- es from one of the buckets by the door and head out again. But about 600 times a day, others walk in with pock- etfuls of , cocaine or speed that they’ve scored out on the street; sign in; go to a clean, well-lit room lined with stainless steel booths; and, under the protective watch of two nurses, shoot their drugs into their veins. Welcome to ’s only officially sanctioned “supervised in- jection site.” The facility sits in the heart of Vancouver’s Downtown East Side, 10 square blocks that compose one of the poorest neighborhoods in all of . The area is home to an estimated 4,700 intravenous First, Reduc e Harm drug users and thousands of crack addicts. For years, it’s been a world- class health disaster, not to mention a public relations nightmare for a town that is famous for its beautiful moun- tains and beaches (and is gearing up to host the 2010 Winter Olympics). Nearly a third of the Downtown East Side’s inhabitants are estimated to be HIV-positive, according to the

Photo credit Photo Photographs by Christopher Morris United Nations Population Fund, a

Miller-McCune.com 61 rate on par with Botswana’s. Twice and social services practices to re- Smoking weed has been effectively that number have hepatitis C. Dozens frame drug use as primarily a public decriminalized. The famous “B.C. die of drug overdoses every year. health issue, not a criminal one. In bud,” rivaled in potency only by Largely in response to this night- the process, it has become by far the California’s finest, is puffed so widely mare neighborhood, Canada’s third- continent’s most drug-tolerant city, and openly that the city has earned largest city has embarked on a radi- launching an experiment dramati- the nickname “Vansterdam.” A single cal experiment: Over the last several cally at odds with the U.S. War block in the Downtown East Side years, it has overhauled its police on Drugs. hosts several pot seed wholesalers, the

62 Miller-McCune / november-december 2008 vided at taxpayers’ expense. Around 4,000 opiate addicts get prescription methadone. Thousands come to the injection site every year. On top of that, health officials just wrapped up a pilot program in which addicts were given prescrip- tion heroin. And it doesn’t stop there. The mayor is pushing for a “stimulant maintenance” program to provide prescription alternatives for cocaine and methamphetamine addicts. Emboldened advocates for drug users are even calling for a “supervised in- halation site” for crack smokers. Vancouver has essentially become a gigantic field test, a 2 million- person laboratory for a set of tactics derived from a school of thought known as “.” It’s based on a simple premise: No matter how many scare tactics are tried, laws passed or punishments imposed, people are going to get high. From winemaking monks to coca-leaf-chewing Bolivian peas- ants to peyote-chomping Navajos to caffeine-fueled office workers to the junkies of Vansterdam, human be- ings have never been willing to settle for our inherently limited palette of states of consciousness. If you accept the notion that people aren’t going to stop abusing drugs, it makes sense to try to minimize the damage they inflict on themselves and the rest of us while they’re at it. Harm reduction is less about compas- sion than it is about enlightened self- interest. The idea is to give addicts The Downtown clean needles and mouthpieces not East Side is home to to be nice but so they don’t get HIV a reported 10,000 or pneumonia from sharing equip- drug addicts. ment and then become a burden on the public health system. Give them a medically supervised place to shoot headquarters of the British Columbia academic studies, the police and city up so they don’t overdose and clog Marijuana Party and the toking- government have agreed to provide up emergency rooms, leaving their in- allowed New Amsterdam Café. hard drug users with their parapher- fected needles behind on the sidewalk. But that’s nothing next to the city’s nalia, a place to use it and even, for a Give them methadone — or even approach to drugs like heroin and few, the drugs themselves. heroin — for free so they don’t break crack. Impelled by the horror show of More than 2 million syringes are into cars and homes to get money for the Downtown East Side, prodded by handed out free every year. Clean the next fix. activists and convinced by reams of mouthpieces for crack pipes are pro- These aren’t just theoretical no-

Miller-McCune.com 63 If you accept the notion that people aren’t going to stop abusing drugs, it makes sense to try to minimize the damage they inflict on themselves and the rest of us while they’re at it.

tions. Some harm reduction tactics ing to city and provincial health have been researched extensively — authorities. The annual number of and the findings are often impressive. drug-induced deaths has dropped In recent years, no fewer than eight from a peak of 191 in 1998 to 46 in major studies in the U.S. on needle- 2005, the most recent year for which exchange programs — probably the statistics are available. best-known and most widespread Nonetheless, harm reduction re- harm reduction technique — have mains controversial, even in relatively concluded that they work. As then- liberal Vancouver. “People are always Assistant Surgeon General David going to beat each other up, too — Satcher summed up in a 2000 report, so should we be handing out boxing “There is conclusive scientific evi- gloves to reduce the harm they do?” dence that syringe exchange programs asks Al Arsenault, a recently retired … are an effective public health inter- Vancouver cop who spent much of his vention that reduces the transmission 27-year career in the Downtown East of HIV and does not encourage the Side and now makes documentaries use of illegal drugs.” about the area. “That’s just normal- Methadone maintenance, first in- izing the behavior. The whole premise troduced in the 1960s, has been the is nonsense.” subject of hundreds of scientific stud- It took a careful, sustained cam- ies. “The findings … have been con- paign to convince politicians and a sistent,” according to a recent article critical mass of voters that such critics in the Mount Sinai Journal of Medicine. were misguided. , who as “Methadone maintenance reduces Vancouver’s mayor from 1993 to 2002 and/or eliminates the use of heroin, was one of the key forces pushing reduces the death rates and criminal- the city to embrace harm reduction, Side to see the problem firsthand. ity associated with heroin use and al- was convinced by the research on the Owen’s groundwork helped lows patients to improve their health subject, some of which was brought to Vancouver secure a special excep- and social productivity. In addition, his attention by the U.S.-based Drug tion to federal drug laws that allowed enrollment in methadone mainte- Policy Alliance Network and other ad- Insite to open. The heroin mainte- nance has the potential to reduce the vocacy groups. nance program won approval on a transmission of infectious diseases as- Once on board, Owen set about trial basis. “If you set something like sociated with heroin injection, such as building support. “You need to walk that up as a scientific experiment hepatitis and HIV.” slowly before you can run,” he says. rather than a policy change, it’s easier In Vancouver, harm reduction Owen organized dozens of public to sell,” says Ethan Nadelmann, ex- seems to be delivering. Since the city meetings with community groups and ecutive director of the Drug Policy began seriously supporting needle cultivated provincial and federal of- Alliance Network. Meanwhile, exchanges and other such tactics ficials. He even took the then-federal a local activist group, the Vancouver in the 1990s, HIV infections have Minister of Health on an undercover Area Network of Drug Users, fallen by half, and hepatitis C rates tour, both of them wearing blue jeans kept up the pressure with noisy have plunged by two-thirds, accord- and old hats, of the Downtown East street demonstrations.

64 Miller-McCune / november-december 2008 A Vancouver police officer, with horse, in the Downtown East Side.

quick visit to the protrudes like a gangrenous limb pervised, open-air hospice where the Downtown East Side from the city’s sleek core. Literally patients have been left to find their is enough to convince from one block to the next, a world own medications and get them into anyone that the city of chic clothing boutiques, jewelry their bodies however they see fit, a had to do something. shops and high-rise luxury condos dark carnival of misery smack in the TheA area was always sketchy, but suddenly gives way to Planet Junkie. middle of what The Economist re- Vancouver’s booming economy and Haggard, prematurely aged men and cently dubbed “the most livable city rapid growth have combined to gen- women with sunken cheeks, missing in the world.” trify most of downtown, pushing the teeth and feral expressions drift along In just an hour of randomly walk- dope fiends and crackheads and men- trash-strewn sidewalks lined with ing around one recent morning, I tally ill homeless into an ever smaller, abandoned buildings. The only legiti- passed at least a dozen people smok- more densely concentrated island of mate businesses are check-cashing ing crack in plain view, stepped over cheap housing, where their addictions operations, pawn shops, bars, squalid countless discarded needles and and pathologies and sundry bad be- residential hotels and 24-hour con- turned down muttered offers of a haviors feed on each other. venience stores with barred doors whole pharmacopeia of substances. Today, the Downtown East Side and windows. It’s a bit like an unsu- The worst that police are likely to do

Miller-McCune.com 65 Inspecting a crack pipe in Vancouver. to street-level users is take away their alley? — the cops made him drop his for our buck?’” says Inspector Scott drugs. That evening, I accompanied a pipe, crushed it underfoot, gave him Thompson, the Vancouver Police couple of constables walking the beat a warning and walked away without Department’s drug policy coordinator. who passed a grizzled man with long, even searching him. “If we lock them up, it costs between greasy hair smoking crack at a bus That’s more or less official policy. $75,000 and $90,000 per year. By stop on busy Hastings Street. Sighing “If you look at an addicted drug user, dealing with it as a health issue, we’ll at his stupidity — couldn’t he have at who likely has a mental illness, you save a lot of money and hopefully least gone around the corner into an have to ask, ‘What’s the best bang solve more problems.” The depart-

66 Miller-McCune / november-december 2008 the program has not led to increased crime or drug use in the area. Last March, a report commissioned by the Canadian federal government con- cluded that “(t)here was no evidence of increases in drug-related loitering, drug dealing or petty crime in areas around Insite … (and) police data for the (Downtown East Side) and sur- rounding areas showed no changes in rates of crime.” Moreover, the report noted, “(T)here is no evidence that (supervised injection sites) influence rates of drug use in the community or increase relapse rates among injection drug users.” In short, Insite is not making things worse. But is it making any- thing better? Studies indicate that Insite has reduced needle sharing, one of the major transmission routes for HIV. But Colin Mangham, a re- searcher with the Drug Prevention Network of Canada, points out that much of the data is based on injection drug users’ reporting of their own behavior — not exactly the gold stan- dard of credibility. The facility is, however, clearly saving at least some lives. Its staff has intervened in more than 336 potential overdoses. Rico Machado, a surpris- ingly healthy-looking heroin addict whom I met in Insite’s check-in area, was one of those cases. “I did my normal dose, but this stuff was too strong,” he says. “I hit the ground. But they gave me Narcan (a drug that reverses opiate overdoses) and resusci- tated me. Before this place was open, I would have been in an alley. I would have been dead.” Moreover, Insite has provided a gateway into detox programs for a number of addicts and served as an immunization center during a re- ment focuses instead on traffickers ery block. Blue metal syringe disposal cent pneumonia outbreak. The site and producers, he says. boxes are installed at alley entrances. has even added a small residential Efforts to keep drug use as healthy The supervised injection site is the rehab facility. as possible are everywhere in the most visible and controversial of these A couple of blocks away, a small Downtown East Side. Free needles, measures. Opened in late 2003, it’s clinic is stashed behind papered-over tourniquets and clean crack-pipe a newer and much-less-tested tactic windows on the ground floor of an mouthpieces are available in soup than needle exchange. So far, a flock unmarked, 1930s-era building. Here, kitchens and clinics on practically ev- of peer-reviewed studies has found every day for three years, nurses be-

Miller-McCune.com 67 Bob Heibert injects cocaine into his neck in the Downtown East Side. He subsequently died of HIV-related liver failure.

hind bulletproof glass handed dozens “They’re eating better, getting their recently launched a pilot program to of addicts a tourniquet, a needle, an health problems dealt with, getting into distribute clean needles through vend- alcohol swab and a carefully measured better housing,” he says. “Some are ing machines. dose of pure heroin. even going back to work. One guy start- The theory being tested in this ed out homeless, got clean and now n the United States, how- program, which wound up its pilot runs a business with 15 employees.” ever, conservative politics phase in August, was that it would Much of what Vancouver is do- and “Drug-Free America” keep junkies from having to steal or ing is already long-standing policy in rhetoric keep punishment as prostitute themselves for their fixes. As many countries, especially in Europe. the primary response to drug a side benefit, they would have more Methadone and needle-exchange use.I Mandatory minimum sentenc- time and energy to take advantage of programs are commonplace in many ing and “three strikes” laws have the program’s treatment component. nations. Six European countries sent the number of drug offenders in Official results were slated to be and Australia are home to dozens of America’s prisons skyrocketing. There released in October, after this story supervised injection sites. Holland, are more than half a million inmates was published. Dr. David Marsh, the Denmark, Switzerland, Germany and currently locked up on narcotics program’s medical director, says he’s Spain have experimented with heroin charges — more than the total of all already seen its participants benefit. maintenance. Even Iran, of all places, prisoners in 1980. Each of those pris-

68 Miller-McCune / november-december 2008 More than 1 in 3 Americans — including, by their own admissions, Sarah Palin and Barack Obama — have tried some kind of illicit substance at least once.

smoked up in the past year, a number tion in 2000. “We’ve tried to take that has not changed much over the drug addiction from being seen as a last 30 years. moral issue to being seen instead as a All told, some 8 percent of chronic disease,” says Barbara Garcia, Americans over age 12 — about 20 deputy director of the San Francisco million people — use illicit drugs, ac- Department of Public Health. cording to the most recent estimates Today, a welter of programs hands from the U.S. Department of Health. out more than 2 million clean sy- That’s a higher rate than the same ringes every year, more than in any agency found in the early 1990s. More other city. At one storefront needle than 1 in 3 Americans — including, exchange in the notoriously skivey by their own admissions, Sarah Palin Tenderloin district, for instance, and Barack Obama — have tried some visitors can choose from three differ- kind of illicit substance at least once. ent sizes of syringes; speed shooters Meanwhile, tens of thousands of and junkies with narrow veins prefer people in the U.S. are infected with smaller hardware. They can also pick HIV or hepatitis C every year thanks up little metal cups and tubes of ster- to shared needles. And according to ile water to cook the drugs in, hand the Centers for Disease Control and wipes and alcohol swabs to clean Prevention, nearly 20,000 people died their skin before stabbing it and other of drug overdoses in 2004 — the most handy accessories, including tourni- recent year for which statistics are quets and crack-pipe mouthpieces. available — way up from the 12,000 One recent evening, Ian Johnson, reported fatal ODs in 1999. a veteran local drug user dressed oners costs taxpayers on average more No surprise, then, that there is a in pinstriped slacks, a soiled white than $22,000 per year, according to small movement pushing for more shirt with a neatly knotted tie and a the federal Bureau of Justice Statistics harm-reduction-based policies. Voters stained double-breasted jacket two — several times the price of providing in California, Arizona and Maryland shades darker than his pants, came in them with treatment. have passed initiatives in recent years for another service: overdose preven- The U.S. doesn’t seem to be gain- mandating treatment instead of incar- tion training. A friend had recently ing much from the billions of dollars ceration for first-time drug offenders. died from a too-big shot of heroin, it invests in incarcerating drug offend- Not long ago, needle-exchange pro- he explained, and he didn’t want to ers. Perhaps the decades-long “War on grams were banned everywhere; now see that again. A volunteer trainer sat Drugs” has kept illicit substance use there are nearly 200 such programs in Johnson down with a torso-and-head from growing, but it certainly hasn’t 38 states. CPR mannequin and showed him done anything to reduce it. The most The liberal, forward-operating base how to inject a dose of Narcan into recent annual survey of drug use by of San Francisco is at the vanguard of someone’s shoulder. Satisfied that the University of Michigan found that these efforts. Surging overdose deaths Johnson had the simple procedure about 85 percent of 12th-graders in among the city’s estimated 16,000 down, the trainer passed him along America say marijuana is easy to get. intravenous drug users spurred the to a nurse who wrote a prescrip- Almost 1 in 3 of those teenagers has city to officially embrace harm reduc- tion making it legal for Johnson to

Miller-McCune.com 69 What Insite provides to addicts. walk out with a little black plastic you’re careful about it. It’s a message drugs, the city is making far less prog- box containing two needles and a that, critics insist, could lead more ress in reducing the number of users. vial of Narcan. people to experiment with narcotics Surveys report that drug use is higher More than 1,200 people have been and leave fewer addicts inclined to in British Columbia than in the rest of trained to administer Narcan this way, seek treatment. Canada. A recent poll found that al- and trainees have used it at least 260 Though the “wrong message” idea most half of all Vancouverites consider times to intervene in potentially fatal makes intuitive sense, the overwhelm- drugs a major problem in their com- overdoses, according to the Harm ing preponderance of research on the munities — a figure double that for Reduction Coalition, a nonprofit subject does not bear it out. Over and residents of Canada’s biggest cities, group that runs the trainings for the over again, studies find that measures and Montreal. city. San Francisco also puts up the like needle exchange and even super- With serious drug users come money to give methadone to about vised injection sites do not promote rip-offs, break-ins and holdups for 5,000 people a year and to train doz- drug use and do help curb some of fix money. So it’s no surprise that ens of “peer counselors” — current the damage it causes. Vancouver’s property crime and bank and former speed users — to advise The critique of harm reduction robbery rates are higher than most their drug buddies on basics like re- best supported by actual evidence is of Canada’s. The city also has more membering to eat while on multiday that it doesn’t do enough. gun-related crimes per capita than any meth binges. There’s even talk of “The harm reduction approach other in the nation, a fact at least one opening a supervised injection site. within the UK appears to have had criminologist has linked to the num- Outside of New York, Baltimore, only modest success in reducing ber of substance abusers. Chicago and a few other places, the breadth of drug-related harms,” All of this underscores why wide- though, harm reduction is a tough sell University of Glasgow researcher spread drug addiction is ultimately ev- in the United States. Congress forbids Neil McKeganey wrote in a recent erybody’s problem. Obviously, getting federal dollars from funding needle overview published in the journal street addicts to clean up takes more exchanges. In many jurisdictions, it’s Addiction Research & Theory. “Despite than free needles. It takes affordable illegal to possess a syringe without a a plethora of initiatives aimed at in- housing, mental health services, coun- prescription, making widespread nee- creasing drug (injectors’) awareness of seling and treatment, all of which are dle distribution impossible, no matter the risks of needle and syringe shar- in short supply, even in Vancouver. who funds it. Federal drug czar John ing, and of providing drug users with For some addicts, it might also take Walters has denounced Vancouver’s access to sterile injecting equipment, the threat of jail. Insite program as “state-sponsored around a third of injectors are still But it doesn’t have to be an either/ suicide” and harm reduction in gen- sharing injecting equipment.” or choice. As the American Medical eral as a Trojan horse for the goal of That’s a weighty objection to Association states in its official posi- legalizing drugs outright. Insite, considering the facility costs $3 tion on the issue, “Harm reduction … Even in Canada, the Vancouver million a year to operate. On a typical can coexist, and is not incompatible, experiment is under pressure. The day, only about 5 percent of all injec- with a goal of abstinence for a drug- country’s ruling Conservative Party has tions in the Downtown East Side are dependent person, or a policy of ‘zero- denounced the safe injection site and done in the facility’s relative safety, tolerance’ for society.” is pushing for a tougher line against according to the federal government’s Advocating anything that sounds drugs nationwide. “Allowing and/or study. I found discarded syringes in “soft on drugs” is generally considered encouraging people to inject heroin the alley right behind Insite. political suicide for elected officials in into their veins is not harm reduction,” Creating a safe place to shoot up most parts of the U.S. But as said Health Minister at may make good sense, but that’s not Vancouver has proved, a coalition of a recent AIDS conference. “We believe necessarily relevant to people whose health care officials, activists and cou- it is a form of harm addition.” cravings regularly trump their judg- rageous politicians armed with solid ment. Watching Liane Gladue, a long- data can change that equation. “No t first blush, the propo- time junkie, searching for a vein under one in the U.S. wants to touch this sition that making drug a streetlight in a Downtown East Side stuff because they’re afraid they won’t use easier for addicts alley, I asked why she didn’t go instead get elected if they do,” says Philip will benefit everyone to the injection site just a few blocks Owen, Vancouver’s former mayor. does seem a bit far- away. “It’s too crowded in there,” she “Well, I was re-elected three times.” m2 fetched.A As many critics have pointed answered. “I didn’t want to wait.” out, it seems to send the message that Though Vancouver is cutting the Vince Beiser is a Miller-McCune hard drug use is all right, as long as collateral damage caused by hard contributing editor based in Los Angeles.

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