Overdose

by Benjamin Perrin

  That wouldn’t be the last time she’d ignore officialdom in order to protect vulnerable people.

  Blyth then started working part-time at Vancouver’s Insite, North America’s first “supervised consumption site.” People can use their illicit drugs and obtain clean supplies, and they’re monitored and helped if they overdose. Insite has an exemption from the federal minister of health, meaning that staff and clients are immune from criminal prosecution there, under the Controlled Drugs and Substances Act.

  The Supreme Court of Canada overruled attempts by Prime Minister Stephen Harper’s government to shut Insite down. Despite that ruling, Harper’s government imposed a series of restrictions on applications for new supervised consumption sites. The process has since been streamlined somewhat by the federal Liberal government, but it’s still lengthy and involved. When I first heard about Insite in Conservative circles, it was portrayed as a left-wing scheme that enabled illegal drug use and was open only by virtue of “judicial activism” by the Supreme Court. I had some doubts, but that’s what I’d assumed as well. I remember people using words like “junkies” and “addicts”—words I used to use, too. I now know how hurtful and dehumanizing those labels are for people who use drugs.

  “I also started working with the Street Market Society,” Blyth continued. “I became the manager. It went from a market that was one day a week to seven days a week.” The Society runs an open-air flea market on East Hastings Street. For $1 per table (if they can afford it) people sell clothing, electronic equipment, old video games and movies, personal hygiene products, and other small items. Most things look used, but some are probably new. The bazaar is closely watched by police.

  “We started seeing a lot of overdoses in 2016 in the neighbourhood,” said Blyth. “I was trained because I worked at Insite. A few of us were trained but not everybody, so we started to get our staff trained. People were overdosing in the front and in the alley. And it was just happening so frequently that we decided to set up sort of an area in the back of the market, because it was mostly in the alley where the overdoses were. It was like a medic tent. We had needles, a place to get rid of needles, a bathroom, and volunteers watching to make sure nothing happened—because if you wait five minutes for an overdose to happen, then worse things are happening.”

  “What happens if there’s an overdose?” I asked.

  “They give oxygen with a machine, they give naloxone, they become experts in overdose prevention,” said Blyth. “We get our training, some of it from paramedics, some of it from people who’ve been on the front line for 10 years at Insite.”

  Blyth and her group called themselves the Overdose Prevention Society. Their tent opened in October 2016 in the back alley between Pender and East Hastings streets, off Columbia. It looks just like any other alleyway in the area. There’s garbage strewn about, people lying in sleeping bags on hard concrete, colourful graffiti-covered walls, grime covering the asphalt. Not the kind of place most Canadians are exposed to every day.

  “We were busy all the time with people wanting our help,” Blyth told me. “When people found out what was happening there was a bit of a political kerfuffle about whether we should be able to do that or not—because it’s not a federally sanctioned thing, and we were on BC Housing property. And if we moved out to the city property, then they’re in charge of what happens, and you can’t have a tent there. There’s all kinds of reasons why you can’t have an injection site.”

  Blyth and her group were concerned citizens in a long-forgotten back alley. They were ignoring federal drug laws in order to save lives during a public health emergency that was happening right before their eyes. They’d heard an urgent cry for help, and they responded. It was an act of civil disobedience. It was an act of compassion and mercy.

  “We just said, ‘Well, we have to do it.’ What is the alternative to doing that? It would be people dying,” said Blyth matter-of-factly. “You can’t really think about it too much, because if you start asking lawyers about legality, you start hearing a bunch of things you don’t want to think about. And then you’re probably less likely to do it, you know what I mean? I’m not a big fan of worrying. People are gonna die if you don’t do something.”

  Three months after the overdose prevention tent opened, Vancouver Coastal Health gave the Overdose Prevention Society funding to keep going. Their staff includes “peers,” people with lived experience using drugs who act as front-line responders helping fellow drug users. Some of the community workers in the Downtown Eastside are mothers who’ve lost children during the opioid epidemic.

  “It took a little bit of time,” Blyth explained, “but eventually everybody came around and said, ‘Okay, well you can’t really say no to people saving lives.’ Actually, the police were supportive. They were one of the first to say, ‘You know what, let them. There’s no reason to stop them from doing it.’ So that was good.

  “The next move was the BC health minister said to the federal government, ‘Can we sanction these?’ And they said no. And the province did it anyways, which was pretty good on the part of the province at the time. They just said, ‘You know what? You can say no, but we’re going to do this because we know it’s the right thing to do.’ ”

  * * *

  ——

  On December 9, 2016, BC Minister of Health Terry Lake signed an order authorizing overdose prevention services anywhere they’d be needed in the province during the public health emergency. “Overdose prevention sites” under Minister Lake’s order are recognized by the province, although they’re not exempt from federal drug laws as “supervised consumption sites” like Insite are.

  When the Overdose Prevention Society got their authorization, they ramped up operations to try to meet demand. First they moved into a donated trailer on the same site, and then into a building right beside the street market where it had all started. They now have 24 booths for supervised consumption and an outdoor covered area where they can monitor people who are smoking their drugs. Vancouver Coastal Health evidently doesn’t much like the smoking area—it violates anti-smoking bylaws. Again, Blyth isn’t about to shut it down. These makeshift facilities are saving lives.

  “How many overdoses have you reversed?” I asked Blyth. She handed me a report listing all the data. On average, there were 377 daily visits to the Overdose Prevention Society’s site and 6.6 overdoses per week. By the end of 2017 the total number of visits had reached 175,284. There were 417 overdoses—all successfully reversed. Naloxone was administered to 397 people; 911 was called 153 times; and 70 people were transferred to the hospital. Some 90% of people who overdosed were revived before rescue services arrived. And there have been zero deaths.

  Behind these remarkable statistics are real people whose lives have been saved. When I met some of the staff and many of the clients, I was struck by how upbeat and friendly everyone was—that is, until Blyth mentioned that I was a lawyer. Then I got more cautious looks. I don’t blame them. Blyth shared a couple of the comments she’s received from clients and peers who work at the Overdose Prevention Society:

  I have personally overdosed and had my life saved at the Overdose Prevention Society. I have also lost over ten friends and family to overdose. I am extremely grateful for access to supervised consumption sites because a lot of us wouldn’t be here today if it weren’t for a place to use safely.

  —Will, 26 years old

  You guys have saved my life a few times and without the staff I wouldn’t be here today. My parents would be planning my funeral instead of camping trips in the summer. There’s frequently a lineup to get a booth and no one should ever be turned away from a safe place to use drugs.

  —Taylor, 24 years old

  There are now at least 45 provincially recognized overdose prevention sites in BC, which together have had over 600,000 visits and reversed thousands of overdoses since Minister Lake’s 2016 order. Some focu
s on serving particular groups, like women or Indigenous people.

  “What we’re finding is it’s an avenue into helping people connect. And that’s what saves lives,” said Dr. Bonnie Henry. “They may get food. They may get somebody with a clean bandage to help them with their wound. They may get a clean pair of socks for the first time. They’re not judged for their drug use, and so we think that these have turned out to be critical services for saving lives.

  “From a legal perspective, Health Canada has said, ‘Oh, well, okay. Maybe we’ll give you temporary exemptions to run these sites.’ And we’re saying, ‘No, no. They’re not under the Controlled Drugs and Substances Act. They’re medically necessary services under our own legislation and we don’t want your exemption.’ Because I don’t want them to start thinking they can control whether we operate these or not.”

  “One of the other things we learned from the overdose prevention sites,” a Pivot Legal Society representative told me, “is that there are groups of people who will access those sites because they’re peer run and not overly clinical.”

  Sarah Blyth’s off-the-grid overdose prevention site wasn’t just some clickbait news story about a rebel with a cause. It’s now part of a grassroots movement that’s spreading across the country. In 2017, her team reversed an average of one overdose almost every day. If Blyth and others like her hadn’t stepped in, the death toll would have been even greater.

  * * *

  ——

  What should our primary goal be in responding to the opioid crisis? To me, it’s crystal clear: we have to save lives. That means dumping a century of discredited myths and stereotypes about substance use and being willing to consider all options. We need to use the best available evidence about the most effective medical treatments, public health interventions, and laws and policies to achieve that objective. So, what’s the track record of supervised consumption sites?

  “The thing you’re seeing very clearly in our data is the fact that there hasn’t been a single death at any supervised consumption or overdose prevention sites in the province. I think that speaks volumes,” said Andy Watson with the BC Coroners Service. “It’s crucial that people have somewhere where they can go where they know that they’re going to be able to be helped if their drug supply is unsafe.”

  Supervised consumption sites literally have a perfect record in saving lives. There has yet to be a single documented fatal overdose at any of these facilities, anywhere in the world, ever. Since 2003, Insite has had more than 3.6 million visits from people injecting illicit drugs. Staff intervened to treat 6440 overdoses. Not a single person died.

  “The purpose of supervised consumption is to ensure that people are safe,” said Dwayne McDonald. “It’s acknowledging that these people have an addiction issue and we want to make sure they’re safe.” Before the BC public health emergency was declared in 2016, Insite staff were seeing about one overdose per day. In 2017, that had risen to six overdoses every day, or 2151 people in total. Additionally, around that same time, Vancouver’s overdose prevention sites reversed 1225 overdoses in their first year of operation.

  When you consider the impact of supervised consumption sites and overdose prevention sites, it’s an outstanding record. On average, in Vancouver one person died from an illicit drug overdose every day in 2017, while every day around ten survived an overdose at these sites. “Our position is that the science tells us, and the public policy tells us, that these sites work well in the midst of this acute crisis. They’re a bandage to stop a chest wound,” said Staff Sergeant Conor King with the Victoria Police Department. “When I look at the role of the police in the community, our single most important mission is to preserve life—and everything else comes after. If these things are preserving life, then they’re the right thing to do.”

  How is it that no one has ever died at a supervised consumption site or overdose prevention site?

  The answer is straightforward: they’re places where those who have opioid use disorder can go to use those drugs instead of using alone. Someone is there to keep watch over them—and that person knows what to do if they overdose. These places provide life-saving emergency first aid to treat illicit drug overdoses. It’s that simple.

  By May 2018 Vancouver had seven supervised consumption sites and overdose prevention sites, all of them in the Downtown Eastside. Yet we know that overdose deaths are occurring throughout the city, province, country, and continent. These sites need to be dramatically scaled up wherever there are clusters of overdoses and overdose deaths occurring.

  * * *

  ——

  “Insite saves lives. Its benefits have been proven,” wrote then-Chief Justice Beverley McLachlin for a unanimous Supreme Court in Canada v. PHS Community Services Society. The 2011 landmark decision ordered the federal government to grant Insite an exemption from federal drug laws. “There has been no discernible negative impact on the public safety and health objectives of Canada,” found the chief justice.

  More than 100 peer-reviewed studies of supervised consumption sites—30 of them specifically evaluating Insite—have appeared in top-tier medical journals. Many of the Insite studies were conducted by leading experts like Dr. Evan Wood, executive director of the BC Centre on Substance Use, and Dr. Mark Tyndall, executive director of the BC Centre for Disease Control. These studies found no evidence of negative impacts, but rather a host of benefits.

  By providing clean supplies, supervised consumption sites can reduce the transmission of communicable diseases like HIV/AIDS and hepatitis C. A study in The Lancet found that after intravenous drug users started using Insite, they were 70% less likely to share syringes than users who didn’t frequent the site. Supervised consumption sites also often provide other medical help to vulnerable populations, such as wound care and pregnancy tests. In 2017, Insite provided 3708 such clinical treatments to people who might otherwise never see a medical practitioner.

  Another benefit of safe-use places is that they provide human contact that can be critical in helping people access treatment for problematic substance use. For example, Insite has an adjoining treatment facility called Onsite, which offers short-term beds and transitional housing along with addiction programs. In fiscal 2017–18, 433 clients went to Onsite and had an average stay of 11 days, while other clients were referred to different treatment services.

  A study in the New England Journal of Medicine followed more than 1000 Insite users over a 15-month period. It found that “supervised injection facilities are unlikely to result in reduced use of addiction-treatment services,” but instead people who regularly visited Insite were 1.7 times more likely to enroll in a treatment program than those who didn’t come as often. Indeed, 18% of Insite users began a treatment program during the study period.

  As Vancouver Fire Chief Darrell Reid told me, “I’m supportive. I mean they’re going to inject anyways, so might as well be safe.” Daniel Atkinson, Deputy Fire Chief for Operations with the Victoria Fire Department, echoed that sentiment: “On a personal level, I’m in favour of the safe injection site concept. I think it’s invaluable. I think it saves lives and allows people an opportunity for care and treatment.”

  * * *

  ——

  What about the impact of supervised consumption sites on the surrounding community?

  “I think a lot of the benefit is that when people are using in these sites they’re not using in the doorways and alleyways and corners and parks,” said Staff Sergeant King. “So there’s another ancillary benefit for the greater community.”

  A study published in the Canadian Medical Association Journal bears this out. It tracked public drug usage, including unsafe disposal of used syringes, in the neighbourhood surrounding Insite before and after it opened. Researchers found “significant reductions in public injection drug use, publicly discarded syringes and injection-related litter after the opening of the medically supervised safe
r injecting facility.”

  In another study, researchers looked at crime rates in the neighbourhood around Insite before and after it opened. They found no statistically significant change in rates of drug trafficking, assaults, or robberies. But there was a drop in vehicle thefts and break-ins (302 incidents pre-Insite vs. 227 incidents post-Insite).

  The police see real value in Insite and regularly direct people there. A survey of 1090 randomly selected Insite clients found that 182 of them (17%) had been stopped by police while injecting in public and were told to go to Insite instead. Researchers saw this as doubly beneficial, concluding that “by referring people who inject drugs in public to Insite, police are helping to meet both public health and public order objectives.”

  Medical research has also found that supervised consumption sites reduce the burden on emergency services, such as ambulances and hospitals, by offering immediate support to overdose victims.

  After looking at the mountain of evidence, I realized that during all my time in politics, including working as a senior advisor to a cabinet minister and the prime minister, I’d never seen a clearer case for a public policy intervention than there is for supervised consumption sites. These places are an essential life-saving medical intervention and a key part of responding to the opioid crisis. They keep people alive, and they offer them human contact that can be an entry point for treatment and other support. Yet despite all the evidence, and even as record numbers of people are overdosing and dying, in some North American jurisdictions strident opposition remains.