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First, Reduce Harm

• October 27, 2008 • 3:00 PM

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

On a chilly, overcast morning in downtown Vancouver, British Columbia, a steady trickle of sallow-faced 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 syringes from one of the buckets by the door and head out again. But about 600 times a day, others walk in with pocketfuls of heroin, 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 North America’s only officially sanctioned “supervised injection 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 Canada. The area is home to an estimated 4,700 intravenous 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 mountains 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 United Nations Population Fund, a rate on par with Botswana’s. Twice that number have hepatitis C. Dozens die of drug overdoses every year.

Largely in response to this nightmare neighborhood, Canada’s third-largest city has embarked on a radical experiment: Over the last several years, it has overhauled its police and social services practices to re-frame drug use as primarily a public health issue, not a criminal one. In the process, it has become by far the continent’s most drug-tolerant city, launching an experiment dramatically at odds with the U.S. War on Drugs.

Smoking weed has been effectively decriminalized. The famous “B.C. bud,” rivaled in potency only by California’s finest, is puffed so widely and openly that the city has earned the nickname “Vansterdam.” A single block in the Downtown East Side hosts several pot seed wholesalers, the headquarters of the British Columbia Marijuana Party and the toking-allowed New Amsterdam Café.

But that’s nothing next to the city’s approach to drugs like heroin and crack. Impelled by the horror show of the Downtown East Side, prodded by activists and convinced by reams of academic studies, the police and city government have agreed to provide hard drug users with their paraphernalia, a place to use it and even, for a few, the drugs themselves.

More than 2 million syringes are handed out free every year. Clean mouthpieces for crack pipes are provided 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 prescription 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 inhalation 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 “harm reduction.” 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 peasants to peyote-chomping Navajos to caffeine-fueled office workers to the junkies of Vansterdam, human beings 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 compassion than it is about enlightened self-interest. The idea is to give addicts clean needles and mouthpieces not to be nice but so they don’t get HIV or pneumonia from sharing equipment and then become a burden on the public health system. Give them a medically supervised place to shoot up so they don’t overdose and clog up emergency rooms, leaving their infected needles behind on the sidewalk.

Give them methadone — or even heroin — for free so they don’t break into cars and homes to get money for the next fix.

These aren’t just theoretical notions. Some harm reduction tactics have been researched extensively — and the findings are often impressive. In recent years, no fewer than eight major studies in the U.S. on needle-exchange programs — probably the best-known and most widespread harm reduction technique — have concluded that they work. As then-Assistant Surgeon General David Satcher summed up in a 2000 report, “There is conclusive scientific evidence that syringe exchange programs … are an effective public health intervention that reduces the transmission of HIV and does not encourage the use of illegal drugs.”

Methadone maintenance, first introduced in the 1960s, has been the subject of hundreds of scientific studies. “The findings … have been consistent,” according to a recent article in the Mount Sinai Journal of Medicine. “Methadone maintenance reduces and/or eliminates the use of heroin, reduces the death rates and criminality associated with heroin use and allows patients to improve their health and social productivity. In addition, enrollment in methadone maintenance has the potential to reduce the transmission of infectious diseases associated with heroin injection, such as hepatitis and HIV.”

In Vancouver, harm reduction seems to be delivering. Since the city began seriously supporting needle exchanges and other such tactics in the 1990s, HIV infections have fallen by half, and hepatitis C rates have plunged by two-thirds, according to city and provincial health authorities. The annual number of drug-induced deaths has dropped from a peak of 191 in 1998 to 46 in 2005, the most recent year for which statistics are available.

Nonetheless, harm reduction remains controversial, even in relatively liberal Vancouver. “People are always going to beat each other up, too — so should we be handing out boxing gloves to reduce the harm they do?” asks Al Arsenault, a recently retired Vancouver cop who spent much of his 27-year career in the Downtown East Side and now makes documentaries about the area. “That’s just normalizing the behavior. The whole premise is nonsense.”

It took a careful, sustained campaign to convince politicians and a critical mass of voters that such critics were misguided. Philip Owen, who as Vancouver’s mayor from 1993 to 2002 was one of the key forces pushing the city to embrace harm reduction, was convinced by the research on the subject, some of which was brought to his attention by the U.S.-based Drug Policy Alliance Network and other advocacy groups.

Once on board, Owen set about building support. “You need to walk slowly before you can run,” he says. Owen organized dozens of public meetings with community groups and cultivated provincial and federal officials. He even took the then-federal Minister of Health on an undercover tour, both of them wearing blue jeans and old hats, of the Downtown East Side to see the problem firsthand.

Owen’s groundwork helped Vancouver secure a special exception to federal drug laws that allowed Insite to open. The heroin maintenance program won approval on a trial basis. “If you set something like that up as a scientific experiment rather than a policy change, it’s easier to sell,” says Ethan Nadelmann, executive director of the Drug Policy Alliance Network. Meanwhile,
a local activist group, the Vancouver Area Network of Drug Users, kept up the pressure with noisy street demonstrations.

• • • • • • • • • • • • • • •

A quick visit to the Downtown East Side is enough to convince anyone that the city had to do something. The area was always sketchy, but Vancouver’s booming economy and rapid growth have combined to gentrify most of downtown, pushing the dope fiends and crackheads and mentally ill homeless into an ever smaller, more densely concentrated island of cheap housing, where their addictions and pathologies and sundry bad behaviors feed on each other.

Today, the Downtown East Side protrudes like a gangrenous limb from the city’s sleek core. Literally from one block to the next, a world of chic clothing boutiques, jewelry shops and high-rise luxury condos suddenly gives way to Planet Junkie. Haggard, prematurely aged men and women with sunken cheeks, missing teeth and feral expressions drift along trash-strewn sidewalks lined with abandoned buildings. The only legitimate businesses are check-cashing operations, pawn shops, bars, squalid residential hotels and 24-hour convenience stores with barred doors and windows. It’s a bit like an unsupervised, open-air hospice where the patients have been left to find their own medications and get them into their bodies however they see fit, a dark carnival of misery smack in the middle of what The Economist recently dubbed “the most livable city in the world.”

In just an hour of randomly walking around one recent morning, I passed at least a dozen people smoking crack in plain view, stepped over countless discarded needles and turned down muttered offers of a whole pharmacopeia of substances. The worst that police are likely to do to street-level users is take away their drugs. That evening, I accompanied a couple of constables walking the beat who passed a grizzled man with long, greasy hair smoking crack at a bus stop on busy Hastings Street. Sighing at his stupidity — couldn’t he have at least gone around the corner into an alley? — the cops made him drop his pipe, crushed it underfoot, gave him a warning and walked away without even searching him.

That’s more or less official policy. “If you look at an addicted drug user, who likely has a mental illness, you have to ask, ‘What’s the best bang for our buck?’” says Inspector Scott Thompson, the Vancouver Police Department’s drug policy coordinator. “If we lock them up, it costs between $75,000 and $90,000 per year. By dealing with it as a health issue, we’ll save a lot of money and hopefully solve more problems.” The department focuses instead on traffickers and producers, he says.

Efforts to keep drug use as healthy as possible are everywhere in the Downtown East Side. Free needles, tourniquets and clean crack-pipe mouthpieces are available in soup kitchens and clinics on practically every block. Blue metal syringe disposal boxes are installed at alley entrances.

The supervised injection site is the most visible and controversial of these measures. Opened in late 2003, it’s a newer and much-less-tested tactic than needle exchange. So far, a flock of peer-reviewed studies has found the program has not led to increased crime or drug use in the area. Last March, a report commissioned by the Canadian federal government concluded 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 surrounding 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 anything better? Studies indicate that Insite has reduced needle sharing, one of the major transmission routes for HIV. But Colin Mangham, a researcher 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 standard 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 surprisingly 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 resuscitated 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 recent pneumonia outbreak. The site has even added a small residential rehab facility.

A couple of blocks away, a small clinic is stashed behind papered-over windows on the ground floor of an unmarked, 1930s-era building. Here, every day for three years, nurses behind bulletproof glass handed dozens of addicts a tourniquet, a needle, an alcohol swab and a carefully measured dose of pure heroin.

The theory being tested in this program, which wound up its pilot phase in August, was that it would keep junkies from having to steal or prostitute themselves for their fixes. As a side benefit, they would have more time and energy to take advantage of the program’s treatment component.

Official results were slated to be released in October, after this story was published. Dr. David Marsh, the program’s medical director, says he’s already seen its participants benefit. “They’re eating better, getting their health problems dealt with, getting into better housing,” he says. “Some are even going back to work. One guy started out homeless, got clean and now runs a business with 15 employees.”

Much of what Vancouver is doing is already long-standing policy in many countries, especially in Europe. Methadone and needle-exchange programs are commonplace in many nations. Six European countries and Australia are home to dozens of supervised injection sites. Holland, Denmark, Switzerland, Germany and Spain have experimented with heroin maintenance. Even Iran, of all places, recently launched a pilot program to distribute clean needles through vending machines.

• • • • • • • • • • • • • • •

In the United States, however, conservative politics and “Drug-Free America” rhetoric keep punishment as the primary response to drug use. Mandatory minimum sentencing and “three strikes” laws have sent the number of drug offenders in America’s prisons skyrocketing. There are more than half a million inmates currently locked up on narcotics charges — more than the total of all prisoners in 1980. Each of those prisoners costs taxpayers on average more than $22,000 per year, according to the federal Bureau of Justice Statistics — several times the price of providing them with treatment.

The U.S. doesn’t seem to be gaining much from the billions of dollars it invests in incarcerating drug offenders. Perhaps the decades-long “War on Drugs” has kept illicit substance use from growing, but it certainly hasn’t done anything to reduce it. The most recent annual survey of drug use by the University of Michigan found that about 85 percent of 12th-graders in America say marijuana is easy to get. Almost 1 in 3 of those teenagers has smoked up in the past year, a number that has not changed much over the last 30 years.

All told, some 8 percent of Americans over age 12 — about 20 million people — use illicit drugs, according to the most recent estimates from the U.S. Department of Health. That’s a higher rate than the same agency found in the early 1990s. 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.

Meanwhile, tens of thousands of people in the U.S. are infected with HIV or hepatitis C every year thanks to shared needles. And according to the Centers for Disease Control and Prevention, nearly 20,000 people died of drug overdoses in 2004 — the most recent year for which statistics are available — way up from the 12,000 reported fatal ODs in 1999.

No surprise, then, that there is a small movement pushing for more harm-reduction-based policies. Voters in California, Arizona and Maryland have passed initiatives in recent years mandating treatment instead of incarceration for first-time drug offenders. Not long ago, needle-exchange programs were banned everywhere; now there are nearly 200 such programs in 38 states.

The liberal, forward-operating base of San Francisco is at the vanguard of these efforts. Surging overdose deaths among the city’s estimated 16,000 intravenous drug users spurred the city to officially embrace harm reduction in 2000. “We’ve tried to take drug addiction from being seen as a moral issue to being seen instead as a chronic disease,” says Barbara Garcia, deputy director of the San Francisco Department of Public Health.

Today, a welter of programs hands out more than 2 million clean syringes every year, more than in any other city. At one storefront needle exchange in the notoriously skivey Tenderloin district, for instance, visitors can choose from three different sizes of syringes; speed shooters and junkies with narrow veins prefer smaller hardware. They can also pick up little metal cups and tubes of sterile water to cook the drugs in, hand wipes and alcohol swabs to clean their skin before stabbing it and other handy accessories, including tourniquets and crack-pipe mouthpieces.

One recent evening, Ian Johnson, a veteran local drug user dressed in pinstriped slacks, a soiled white shirt with a neatly knotted tie and a stained double-breasted jacket two shades darker than his pants, came in for another service: overdose prevention training. A friend had recently died from a too-big shot of heroin, he explained, and he didn’t want to see that again. A volunteer trainer sat Johnson down with a torso-and-head CPR mannequin and showed him how to inject a dose of Narcan into someone’s shoulder. Satisfied that Johnson had the simple procedure down, the trainer passed him along to a nurse who wrote a prescription making it legal for Johnson to walk out with a little black plastic box containing two needles and a vial of Narcan.

More than 1,200 people have been trained to administer Narcan this way, and trainees have used it at least 260 times to intervene in potentially fatal overdoses, according to the Harm Reduction Coalition, a nonprofit group that runs the trainings for the city. San Francisco also puts up the money to give methadone to about 5,000 people a year and to train dozens of “peer counselors” — current and former speed users — to advise their drug buddies on basics like remembering to eat while on multiday meth binges. There’s even talk of opening a supervised injection site.

Outside of New York, Baltimore, Chicago and a few other places, though, harm reduction is a tough sell in the United States. Congress forbids federal dollars from funding needle exchanges. In many jurisdictions, it’s illegal to possess a syringe without a prescription, making widespread needle distribution impossible, no matter who funds it. Federal drug czar John Walters has denounced Vancouver’s Insite program as “state-sponsored suicide” and harm reduction in general as a Trojan horse for the goal of legalizing drugs outright.

Even in Canada, the Vancouver experiment is under pressure. The country’s ruling Conservative Party has denounced the safe injection site and is pushing for a tougher line against drugs nationwide. “Allowing and/or encouraging people to inject heroin into their veins is not harm reduction,” said Health Minister Tony Clement at a recent AIDS conference. “We believe it is a form of harm addition.”

• • • • • • • • • • • • • • •

At first blush, the proposition that making drug use easier for addicts will benefit everyone does seem a bit far-fetched. As many critics have pointed out, it seems to send the message that hard drug use is all right, as long as you’re careful about it. It’s a message that, critics insist, could lead more people to experiment with narcotics and leave fewer addicts inclined to seek treatment.

Though the “wrong message” idea makes intuitive sense, the overwhelming preponderance of research on the subject does not bear it out. Over and over again, studies find that measures like needle exchange and even supervised injection sites do not promote drug use and do help curb some of the damage it causes.

The critique of harm reduction best supported by actual evidence is that it doesn’t do enough.

“The harm reduction approach within the UK appears to have had only modest success in reducing the breadth of drug-related harms,” University of Glasgow researcher Neil McKeganey wrote in a recent overview published in the journal Addiction Research & Theory. “Despite a plethora of initiatives aimed at increasing drug (injectors’) awareness of the risks of needle and syringe sharing, and of providing drug users with access to sterile injecting equipment, around a third of injectors are still sharing injecting equipment.”

That’s a weighty objection to Insite, considering the facility costs $3 million a year to operate. On a typical day, only about 5 percent of all injections in the Downtown East Side are done in the facility’s relative safety, according to the federal government’s study. I found discarded syringes in the alley right behind Insite.

Creating a safe place to shoot up may make good sense, but that’s not necessarily relevant to people whose cravings regularly trump their judgment. Watching Liane Gladue, a longtime junkie, searching for a vein under a streetlight in a Downtown East Side alley, I asked why she didn’t go instead to the injection site just a few blocks away. “It’s too crowded in there,” she answered. “I didn’t want to wait.”

Though Vancouver is cutting the collateral damage caused by hard drugs, the city is making far less progress in reducing the number of users. Surveys report that drug use is higher in British Columbia than in the rest of Canada. A recent poll found that almost half of all Vancouverites consider drugs a major problem in their communities — a figure double that for residents of Canada’s biggest cities, Toronto and Montreal.

With serious drug users come rip-offs, break-ins and holdups for fix money. So it’s no surprise that Vancouver’s property crime and bank robbery rates are higher than most of Canada’s. The city also has more gun-related crimes per capita than any other in the nation, a fact at least one criminologist has linked to the number of substance abusers.

All of this underscores why widespread drug addiction is ultimately everybody’s problem. Obviously, getting street addicts to clean up takes more than free needles. It takes affordable housing, mental health services, counseling and treatment, all of which are in short supply, even in Vancouver. For some addicts, it might also take the threat of jail.

But it doesn’t have to be an either/or choice. As the American Medical Association states in its official position on the issue, “Harm reduction … can coexist, and is not incompatible, with a goal of abstinence for a drug-dependent person, or a policy of ‘zero-tolerance’ for society.”

Advocating anything that sounds “soft on drugs” is generally considered political suicide for elected officials in most parts of the U.S. But as Vancouver has proved, a coalition of health care officials, activists and courageous politicians armed with solid data can change that equation. “No one in the U.S. wants to touch this stuff because they’re afraid they won’t get elected if they do,” says Philip Owen, Vancouver’s former mayor. “Well, I was re-elected three times.”

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Vince Beiser
Vince Beiser is an award-winning journalist based in Los Angeles, California. Follow him on Twitter @vincelb.

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