Boyd et al. Harm Reduction Journal (2017) 14:27 DOI 10.1186/s12954-017-0152-3 RESEARCH Open Access Telling our stories: heroin-assisted treatment and SNAP activism in the Downtown Eastside of Vancouver Susan Boyd1, Dave Murray2, SNAP2 and Donald MacPherson3* Abstract Background: This article highlights the experiences of a peer-run group, SALOME/NAOMI Association of Patients (SNAP), that meets weekly in the Downtown Eastside of Vancouver, British Columbia, Canada. SNAP is a unique independent peer- run drug user group that formed in 2011 following Canada’s first heroin-assisted treatment trial (HAT), North America Opiate Medication Initiative (NAOMI). SNAP’s members are now made up of former research participants who participated in two heroin-assisted trials in Vancouver. This article highlights SNAP members’ experiences as research subjects in Canada’s second clinical trial conducted in Vancouver, Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), that began recruitment of research participants in 2011. Methods: This paper draws on one brainstorming session, three focus groups, and field notes, with the SALOME/NAOMI Association of Patients (SNAP) in late 2013 about their experiences as research subjects in Canada’s second clinical trial, SALOME in the DTES of Vancouver, and fieldwork from a 6-year period (March 2011 to February 2017) with SNAP members. SNAP’s research draws on research principles developed by drug user groups and critical methodological frameworks on community-based research for social justice. Results: The results illuminate how participating in the SALOME clinical trial impacted the lives of SNAP members. In addition, the findings reveal how SNAP member’s advocacy for HAT impacts the group in positive ways. Seven major themes emerged from the analysis of the brainstorming and focus groups: life prior to SALOME, the clinic setting and routine, stability, 6-month transition, support, exiting the trial and ethics, and collective action, including their participation in a constitutional challenge in the Supreme Court of BC to continue receiving HAT once the SALOME trial ended. Conclusions: HAT benefits SNAP members. They argue that permanent HAT programs should be established in Canada because they are an effective harm reduction initiative, one that also reduces opioid overdose deaths. Keywords: Heroin-assisted treatment, Drug user groups, Community-based research, Overdose, Ethics, Activism As we complete this paper in April 2017, the Downtown were a total of 931 overdose deaths in the province of Eastside (DTES) of Vancouver, in the province of British BC, an increase of almost 80% from 2015 [2]. Thus far, the Columbia (BC), Canada, is experiencing the worst opioid federal government has refused to declare a federal public overdose crisis in its history. Due to the unprecedented health emergency, even though opioid drug overdose number of overdose deaths in the province (since 2012, deaths have been rising in other areas of Canada too (as illegal fentanyl-detected deaths have accounted for a they are in regions of the USA). Following the release of steep rise in overdose deaths), in April 2016, a public the total overdose deaths in BC for 2016, the federal health emergency was announced by Dr. Perry Kendall, Health Minister announced that the government is assem- the BC Provincial Health Officer [1, 2]. In 2016, there bling a roundtable of experts to consider expanded treat- ment options such as heroin-assisted treatment (HAT), * Correspondence: [email protected] hydromorphone, and slow release morphine [3]. Mean- 3Canadian Drug Policy Coalition, Centre for Applied Research in Mental Health and Addictions, Simon Fraser University, #2400 - 515 West Hastings while, provinces, municipalities, and health authorities in Street, Vancouver, BC V6B 5K3, Canada Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Boyd et al. Harm Reduction Journal (2017) 14:27 Page 2 of 14 Canada continued to work without increased funding not set up publicly funded drug treatment programs from the federal government to stem the crisis. after heroin and other drugs were criminalized in the Due to the lack of a full response by the federal gov- early 1900s. It was not until the late 1950s and 1960s ernment to the overdose death crisis, in September that the first publicly funded drug treatment programs 2016, in defiance of federal law, activists set up two were set up in secure units in prisons, rather than in the unauthorized supervised injection tents in the DTES of community. These programs were abstinence based. Vancouver. These community actions were followed up In 1959, the Narcotic Addiction Foundation of British by the BC Minister of Health, announcing in December Columbia (NAFBC) began to prescribe methadone to 2016, that rather than waiting for formal federal ap- ease withdrawal for some of their patients [5]. This was proval for safer injection sites, “overdose prevention possible because some of the legal restrictions enacted sites” (small sites established in community services) in the 1920s that made it illegal for doctors to issue a would open in Vancouver and other areas of BC. Ten prescription for “non-medical” or addiction maintenance months into the public health emergency, the federal purposes to “known addicts” were finally lifted in the government announced in February 2017 that it has ear- Narcotic Control Act of 1957 and 1961. Thus, physicians marking $10 million in health care funds to address the could begin to provide some alternative treatments. opioid crisis in BC. However, it is unclear how funds will Following the dramatic increase in drug use among be spent. Meanwhile, calls for expanded heroin-assisted Canadians in the 1960s, the Canadian Commission of treatment and hydromorphone have grown. Inquiry into the Non-Medical Use of Drugs (the Le Dain This article explores, through the voices of SALOME/ Commission) was established in 1969. After completing NAOMI Association of Patients (SNAP), the benefits of its research and consultations, the Le Dain Commission HAT, the necessity for the immediate establishment of recommended expanding public funded drug treatments HAT and other alternative harm reduction programs and services and establishing methadone maintenance throughout Canada, and the need to legalize and regu- programs throughout Canada. The Commission also late currently criminalized drugs to stem the crisis. recommended that prison time for possession of crimi- This paper begins with a short historical summary of nalized drugs such as heroin should end [6]. drug treatment and two clinical trials in Canada to Following the Le Dain Commission, drug treatment contextualize our research, drawing on one brainstorm- options expanded in Canada alongside increased crim- ing session and three focus groups with SNAP members inal justice control [7]. However, abstinence-based pro- conducted in late 2013 about their experiences as re- grams predominated. Yet a change was brewing, and by search subjects in a second HAT clinical trial in the the late 1980s and early 1990s, harm reduction was DTES, the Study to Assess Longer-term Opioid Medica- emerging in and outside of Canada as an alternative to tion Effectiveness (SALOME). Also included are findings abstinence-based models of treatment. In the DTES, one from ethnographic fieldwork over a 6-year period of Canada’s poorest urban neighborhood, harm reduc- (March 2011 to March 2017) with SNAP members. tion initiatives were seen by many as a practical tool to SNAP is a unique peer-run independent drug user group save lives [8]. The DTES has long been a place where made up of former research participants who partici- residents actively come together to demand and make pated in one or both HAT trials in the DTES. change, and they did so in the 1990s to implement drug This paper highlights SNAP’s ongoing advocacy for policy reform [9, 10]. In the early and mid-1990s, the HAT, including their involvement in a constitutional DTES experienced rising overdose deaths. In 1993, the challenge in the Supreme Court of British Columbia, to Minister of Health and the Attorney General of BC continue receiving HAT once their participation in the responded by appointing the Chief Coroner, Vince Cain, SALOME trial ended. In 2013, HRJ published SNAP’s to lead a task force inquiring into the rise of overdose (formerly NPA) first article about their experiences in deaths in the province. Following 8 months of consulta- the first HAT trial in the DTES [4]. Because the second tions, the task force released its 1994 report, “The Re- HAT trial differed quite substantially from the first, and port of the Task Force into Illicit Narcotic Overdose the social and political environment had also changed, Deaths in British Columbia.” The report made clear that SNAP set out to conduct a follow-up study of its mem- the “War on Drugs” was “an expensive failure” and bers’ experiences. linked prohibitionist policies to overdose deaths in the province ([11], p. vi). The Chief Coroner recommended Background expanded treatment and harm reduction programs and As noted above, in order to contextualize the experi- access to naloxone. The Chief Coroner also recommended ences of SNAP members, we provide a brief history of that heroin-assisted treatment and the legalization of publicly funded drug treatment and two clinical trials in drugs be considered. In the meantime, the report recom- Canada.