What’s It’s Like on the Frontlines of Helping Toronto's Drug Addicts

With the rise of more powerful drugs like fentanyl being sold on Canada's streets, there have been hundreds of deaths across the country due to opiate usage, and there doesn't seem to be any sign of it slowing down.

The debate around drug safety and the criminalization of illicit substances has been a long-fought battle. With efforts by the former Conservative government to thwart safe injection sites like Vancouver's Insite and bills aimed at cracking down on addictive substances and their users, the official attitude towards drugs in Canada has become incredibly complex, especially now that the new Liberal majority government has taken a more progressive approach to drugs.

On the ground level, however, little has truly changed. People are still shooting up, snorting pills and, sometimes, overdosing. The support systems that exist in communities more susceptible to drug use—particularly those that are low-income and marginalized groups—are often few and far between, but one of the main pillars for drug users to lean on are harm reduction clinics.

To gain a little more insight into what it's like for medical professionals working to save lives on the ground level, we spoke to Kristel Guthrie, a former frontline nurse and current coordinator at a Toronto harm reduction clinic called The Works.

VICE: I'll start off by asking: tell me about what you do. I know a little bit already, but I'd like to hear it from you.

Kristel Guthrie: So, we're a needle exchange program through Toronto public health and we're mandated to combat the spread of infectious disease through drug use. It's a harm reduction approach and with that it's not necessarily about stopping drug use or preventing the spread of it, but mitigating the harm related to [their use]. It's not about cessation drug use, either. It's just ensuring the safe usage of drugs. We provide clean needles and injection equipment because that's the proven model to reduce harm, based off research. We also provide educational seminars, support groups, and access to infectious disease testing through blood tests. Then we have health care and treatment for these diseases, such as Hep C treatment, which is done on site. There's many different facets, but we're just trying to make drug users live safer lives. What do you specifically do?
Specifically? Well, I used to be a frontline nurse—which means I dealt with patients on the ground level—and I did that for a few years here. Now I'm a health promotion specialist—which is very vague. My role here is sort of multi-pronged. I coordinate and oversee our naloxone program. Do you know anything about naloxone? A little bit, yeah.
Great. So it's the medication that reverses opiate overdose, and we distribute "take-home" naloxone. I put that in sort of air quotes, y'know, because folks don't have to have a home, obviously. [They] come here and get prescribed the drug and get training on how to use it, so it's more like community distribution, let's say. That's on a drop-in basis. It can be a quick pickup or we can walk them through from start to finish on how to use the drug effectively. That's a big thing—it is the direct program that saves lives. About 40 percent of my job is that—the other part is supporting harm reduction. We have our mandate, but we work with other agencies to help provide all the necessities for safe drug use. The needles, the pipes, the tubes, and all of that stuff comes through the Ontario government or Toronto Public Health, so I'm responsible for keeping that all flowing in the right direction. I'd like to ask you about your time as a frontline nurse. What was that like? Oh god. Um, to speak broadly, patients see us on a drop-in basis, so somebody comes in and says, "I'd like to see a nurse," and that's the end of the conversation. It's a very discreet way to come in for healthcare, which is obviously a big part of what we do. As a nurse, you're involved in everything from screening people for infectious diseases like Hep C to wound care. Like, a lot of wound care. People who administer certain drugs that are laced with chemicals or have other effects like skin decay often come in very scared and in need of treatment. We try to tend to cases like that first. Education is another big thing. Just the other day, someone came in and said, "I have been using crystal and someone dexxed me [editor's note: the meth was swapped with dextroamphetamine]. I want to know how to test my drugs." We can help them discern whether what they're using or buying is good or bad stuff. We obviously can't teach them how to use the drug, but we can show them safe practices that can help them out. Things like how they use, where they use it—making sure they're in a safe place when they use it—and how to gauge how they're feeling when they use it. This seems impractical to people who might not understand drug culture, but there is a level of awareness to this. It is very controlled. How many people actually visit the clinic?
There's a good amount, but we're definitely not getting everybody and that's a problem. There's such a stigmatization around drug usage that makes people feel evil and guilty, so they don't get the healthcare that can help them do it safely. Thankfully, people who do come here see this as a conversation starter that can help to reverse that mindset. Do you see trends in what people come in for depending on the time of year?
Definitely, but it's more on a week-to-week basis. We might see a slowdown of people when bills come in because they have to tend to those first and aren't necessarily using as much, so we see fluctuations in that sense. It also depends on the weather. Extreme weather presents a lot of problems for people using. I imagine you see quite a few overdoses or people on the verge of overdosing. What's the procedure when somebody comes in that state?
There's a strict protocol we have for dealing with overdoses but it all starts with assessment. Someone might be what we call "on the nod," let's say, which means they're not quite overdosing but they're having trouble remaining conscious and are severely intoxicated. At that point, we're monitoring all the vital signs and keeping a constant eye on them in case someone does go down and their basic life signs are starting to fade. When someone does go down, and you have to administer naloxone, is there any ramifications from doing that? Are there any risks health-wise?
To naloxone? Absolutely not. It's a very safe medication and there are almost no instances of somebody having an adverse reaction to the drug. We have a directive that anybody on staff—the nurses, the coordinator, even the peer supporter worker—has the ability to administer naloxone if no one else is available. I can't hit home enough that it is is extremely easy to administer and is incredibly effective. Unfortunately, a lot of people who overdose are not at a harm reduction clinic, they're actually somewhere else entirely. That's why it's so important that we get as much awareness and access to naloxone out as possible. I'm curious what you think about safe injection sites. There's Insite in Vancouver, which has been incredibly successful, but we don't have one here in Toronto. Do we need one?
I can't actually comment on that, unfortunately. May I ask why?
Well, I work within the TPH and the government is very sensitive to that issue right now. I could tell you my personal opinion but not under this authority. Understandable. Let's change gears. Are the clinics a safe space? Do the police ever come there?
No, absolutely not. We're a completely safe space. I'm sure the police could come here looking for people and they do sometimes show up if there is a medical emergency, but they've been pretty good about it. With that said, when calling 911, we often are say, "We just need a paramedic." That's all I can really say about that. There has been a rise in opiate use in Canada and the introduction of fentanyl has some people worried. In terms of people coming into the clinic, what are they generally using?
It's interesting. We estimate around 40 to 60 percent of our patients are opiate users, but around 50 percent of them are using "heroin," and I'm air-quoting that because there is a strong suspicion that most of the heroin is either laced with or completely made up of fentanyl. It looks of a bit of what people are used to, sometimes they can tell the difference, but sometimes they just try to use a fraction of their regular shot to combat the difference in potency. A lot of them still end up dropping. I think it's an issue but we can never know what's in it, unfortunately. Have you started to see a spike since fentanyl has become more popular?
I don't know if fentanyl is a specific cause and I don't want to attribute it to that, but I can say that, yes, needle distribution is up, which is a huge indicator. What's the process after somebody overdoses?
When people go through something like that, we get the unique experience of hearing their story that we may not have heard otherwise. Our role is more of a supportive model. We have someone sit with them and listen to them and see what we can do for them to prevent it from happening again, and to point them to any services that can help them get back on their feet, just because it is such a traumatic experience. I know this is a sensitive subject, but has had the clinic had anybody die under its care?
Since our program started in 2011, we've had 335 opiate overdose reversals recorded. We have not had anybody pass away during our operation, thankfully, but we commemorate Overdose Awareness Day every August 31 and we have a memorial here where we honor who we've lost and be aware of the context of drug use in our community. Obviously, it takes some sort of toll on you, and it's not about seeing people use drugs, it's really not that simple. Here, we have a lot of people passionate about this work, and to work with somebody, to make contact with someone and help them through some hard times, it becomes a touchstone for a lot of people. Like, we're an additional support network. When people we know pass away or people in the community pass away, people come here for help and advice. It has an impact on everybody, I think. How has your time at the clinic affected you as a person, for better and for worse?
I'd say it's largely for better, actually. I learn a lot from our clients. Like, a lot. I try to make this service client-driven and be really in touch with what is going on out there on the ground level. I think it's really easy to get caught up in the bureaucracy when you're working in a government program, but I think that staying in touch with the folks I'm serving helps me stay aware of all the things that are being ignored: housing, healthcare, equity, etc. There's a phrase in this job that goes, "Nothing for us, without us," and I genuinely try to live by that. My patients are my job and by extension, they are me. Follow Jake Kivanc on Twitter.