On the ground floor of an old hotel in Vancouver’s Downtown Eastside, Paul Scibak recounted what it's like waking up with an addiction to heroin. It’s a crippling shot of anxiety the second you open your eyes, he told VICE.
“You literally feel like you’re being ripped apart. Your skin’s peeling, you bones are breaking, your muscles are cramping…. Waking up and not having your dose there, that’s a painful experience."
For three decades, Scibak said that nearly every morning, he rushed to get dressed, raced out the door, and did whatever he had to for his first fix of the day. He committed crimes and went to jail more than once. There were always hassles with dealers.
“The average addict is using anywhere from $20 to $100 a day. That’s baseline for their heroin addiction. And that’s a lot of money to come up with,” Scibak continued. “So you’re breaking into cars, you’re stealing from stores, you’re mugging people, you’re doing whatever it takes to get that cash. And so you’re constantly under pressure from police.”
Then fentanyl arrived and things got worse. Scibak’s addiction became “a game of Russian roulette.”
Until last month, when his life changed entirely in less than a week.
One morning, Scibak opened his eyes and the anxiety was gone. Instead of rushing out for drugs, he blinked sleepily a few times, remained in bed for a minute, and then took a lazy start to the day. Scibak made a cup of coffee and read the news online for a little bit. Simple pleasures that he once regarded as luxuries impossibly beyond his reach.
Scibak is still addicted to opioids. But instead of buying from a dealer on the corner, he visits a small clinic that was recently integrated into the social-housing complex where he lives in the Downtown Eastside. There, twice a day, Scibak receives a calculated dose of pharmaceutical hydromorphone, a semi-synthetic opioid similar to heroin.
“On the fourth day, I stopped feeling anxiety,” he said. “Then I think it was the seventh day when I started to think, ‘What am I going to do with my time?’ I had all of this spare time because I wasn’t hunting dope.”
Scibak got a job.
“Three weeks ago, I was trying to figure out what I was going to do every morning for my next fix,” he said. “Now I’m working. And I hadn’t worked in 10 years.”
In December 2017, a proposal for Vancouver to distribute prescription opioids via vending machines attracted headlines across Canada and the United States. The novel delivery method distracted from the real story: with or without vending machines, it’s a radical harm-reduction initiative that will move entrenched addicts out of the alleys and into Canada's health-care system.
Canada’s opioid crisis has hit British Columbia harder than anywhere else. Last year, 1,422 people across the province died after taking drugs. That compares to an average of 204 deaths for the years 2001 to 2010 and accounts for more than a third of all overdose deaths in Canada in 2017. The epidemic has B.C. health officials desperate for new ideas to bring the numbers back under control. And so, last December, the BC Centre for Disease Control said it plans to distribute hydromorphone (brand name Dilaudid) as a clean alternative to street drugs contaminated with fentanyl.
Controversial though it might be, the idea is not entirely new. In Vancouver, the nonprofit Portland Hotel Society (PHS) quietly launched the hydromorphone program of which Scibak is a patient more than a year ago, in September 2016.
At PHS headquarters on East Hastings Street, the program’s founder, Dr. Christy Sutherland , recounted its caution beginning.
As the staff physician for PHS, a nonprofit organization with more than a dozen social-housing projects in the Downtown Eastside, Sutherland has a lot of patients who struggle with severe addiction issues. As overdose deaths soared through late-2016, she grew increasingly concerned for one woman in particular.
“I was worried she was going to die, because of the overdose crisis,” Sutherland recalled.
Just down the street, at a facility called Crosstown Clinic, doctors had a small number of entrenched addicts on diacetylmorphine, the medical term for prescription heroin.
Sutherland had observed how Crosstown patients’ lives improved after they transitioned from street drugs to diacetylmorphine. But she doubted she could duplicate what they were doing there. In Canada, there’s no domestic producer for diacetylmorphine. The drug has to be imported from Europe and its storage and distribution in Canada comes with arduous and expensive security requirements. Alternatively, hydromorphone is similar to heroin and is readily available as a prescription painkiller widely used by doctors across Canada. Sutherland decided she would apply for permission to use the pain medication in an off-label capacity for the management of an opioid addiction.
To her surprise, Health Canada had actually anticipated such a request. “We were waiting for a doctor to apply, and you’re the first one,” an official told her. “You’re approved.”
The program began without additional funding and Sutherland proceeded slowly. For the first five months, there was just one patient and Sutherland oversaw her care personally. In January 2017, she took on a second, another tenant at one of PHS’s social-housing sites. Finally, in May 2017, Sutherland decided it was time to expand.
PHS operates a clinic just off East Hastings called the Columbia Street Community Clinic. They integrated a small supervised-injection site there where each new patient was given a prescribed dose of liquid hydromorphone that they then injected under a nurse's supervision.
Sutherland described an average patient’s profile before enrolling in the program: most had spent more than ten years addicted to heroin and had repeatedly failed with traditional treatments such as methadone. Then she recounted the rapid progress she witnessed most patients make over their first week receiving injectable hydromorphone.
“We called it the hipster effect,” Sutherland said with a laugh. “Someone would come in so ill with their opioid-use disorder, and then we would do their titration [calculating an appropriate dose], and on day-three, they would come in wearing a collared shirt, cuffed jeans, and looking like a million bucks.”
Just as obvious were improvements in patients’ mental health, Sutherland said.
“Heroin only lasts eight hours. So imagine using heroin and then realizing, ‘Okay, I have an eight-hour window until I need to get more heroin.’ Over and over,” she said. “When we start someone on injectables, suddenly, they’re free from that. They have time and they have money. It’s like, ‘What do you want to do now?’ They reunite with family, buy a computer, start going to the library. They reconnect with their life.”
The same month that Sutherland moved the program into the Columbia Street Community Clinic, she partnered with another pharmacy two blocks away, called Pier Health Resource Centre. In a telephone interview, Pier’s director, Bobby Milroy, said he’s similarly observed drastic improvements in both patients’ physical and mental health. Then he noted a third benefit: “It’s preventing deaths, without question,” Milroy said.
He emphasized the potential for other neighbourhoods affected by the fentanyl crisis, noting how relatively easy it was to make injectable hydromorphone available as an alternative treatment for an entrenched addiction to opioids.
“This is, essentially, a completely new program that did not require any additional legislation,” he explained. “We’re not violating any rules, not requiring any exemptions [from drug laws], and the medication is readily available.”
Sutherland cautioned that injectable hydromorphone does not work for everyone. Some patients experience side effects and many say they would prefer diacetylmorphine. "It works really well when it does, but it doesn't work every time," she said.
Today Sutherland and Milroy have 68 clients on injectable hydromorphone. Nineteen are administered the drug in three PHS hotels and 49 receive it at Pier Health Resource Centre.
Other jurisdictions have taken note. Ottawa, Calgary, and Edmonton are establishing small injectable-hydromorphone programs of their own. And now Vancouver is preparing to expand access with the BC Centre of Disease Control (BCCDC) proposal to distribute an oral form of the drug via vending machines.
Dr. Mark Tyndall is the BCCDC’s executive director and the man who first floated the vending machine idea, which is expected to launch in the spring. In a telephone interview, he praised Sutherland’s work and said the goal now is to reduce barriers and enroll larger numbers of patients to remove them from the risks posed by BC’s contaminated street drugs.
“There are a lot of people who are not interested in going in two or three times a day to be observed [while injecting],” Tyndall said. “About 80 percent of people who have died of overdoses [in BC] are using alone and many of them are just not interested in that kind of medicalized model.”
He described his vision for the vending-machine program: Distribution points will more-closely resemble secure ATMs (as opposed to vending machines). Each patient will have met with a doctor and received a prescription for a specific number of hydromorphone pills, likely between three and nine each day. Then they’ll use a digital membership card to access the pills via the vending machines.
“We really trained people, with criminalization and prohibition, to stay out of sight, as much as possible,” Tyndall said. “The one thing that I’m hoping to show with a low-barrier pill program is that we can draw some people out who currently aren’t engaged in care.”
At PHS’s Molson Hotel, Paul Scibak prepared for his shift working at the clinic that's integrated into the ground floor there. He said that in addition to stability, receiving a clean supply of opioids via the health-care system has had another effect he never anticipated: for the first time in years, it’s let him begin to think about getting off of drugs.
“With the anxiety of always needing, it occupies so much time and energy that you can’t think about a lot of things that are going on in your life,” Scibak explained. “I’m starting to get clarity. Not like an epiphany, but clarity. Now I’m thinking about where I’m at, what I’m doing, and where I’m going with this. Do I want to stay down here? Do I want to be involved with the people who I’m involved with? Do I still want to use?”
Travis Lupick is a journalist based in Vancouver. His first book, Fighting for Space: How a Group of Drug Users Transformed One City's Struggle with Addiction, was published in November 2017. You can follow him on Twitter, Facebook, and Instagram.