Drugs

Canada Might Have Found a Back Door to End the War on Drugs

Buckling under the overdose crisis, Vancouver is giving people prescription opioids to save them from fentanyl on the street.

by Travis Lupick; photos by Jackie Dives
Aug 19 2019, 3:39pm

Melody Cooper struggled with a heroin addiction for years before she found stability with an injection-hydromorphone program run by PHS Community Services Society, a Vancouver-based nonprofit. The program provides her with prescription opioids as a clean alternative to street drugs.

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Every Tuesday afternoon at 4:45 p.m., Melody Cooper’s siblings and mother meet for bingo at Our Lady of Sorrows, a Catholic school in East Vancouver. Cooper, 44, smiled and spoke warmly of the tradition. But she said her heroin addiction—something she’d struggled with for 17 years—has kept her far too busy to join them.

“They’ve always gone together, but I haven’t,” Cooper recounted from a coffee shop in Vancouver’s Downtown Eastside. “Stress has always been a struggle. Trying to get my next fix, wondering where I’m going to get it from. Lots of worries. Very little sleep.”

When fentanyl emerged as a problem in British Columbia in 2013, the dangerous synthetic opioid gradually replaced heroin on the streets of the Downtown Eastside, widely known as ground zero for the opioid crisis in Canada. Across the province, overdose deaths soared: In 2013, there were 333 fatal overdoses, 15 percent involving fentanyl. In 2018, there were 1,514, and the number involving fentanyl had risen to 87 percent.

Cooper said she grew increasingly convinced she would end up among them. “I had close friends dying left and right, all around me,” she recalled. “It scared the shit out of me.”

Cooper concedes she still injects drugs every day, but what’s different is where she gets those drugs. For more than a decade, the first person Cooper interacted with most mornings was a dealer. Now it’s a nurse.

In September 2016, Cooper was nicknamed “Patient Zero” in an experimental program initiated by PHS Community Services Society (PHS), a nonprofit that operates the supportive-housing building where she lives. Twice a day, Cooper receives doses of hydromorphone, a prescription painkiller that’s better known by one of its brand names, Dilaudid. Hydromorphone is a powerful opioid that’s similar enough to heroin that it eliminates the feelings of withdrawal that Cooper once feared. More than that, access to a guaranteed supply safe from contamination has brought stability to Cooper’s life, enough to reconnect with family and take a part-time job—the first in her life. “And you know you’re not going to die from it,” she said.

The injection-hydromorphone program primarily runs out of one of PHS’s housing projects called the Molson Hotel. In the early 1900s, it operated as a bank. With a stone exterior and the sort of grand trimmings that adorn buildings of that period, the Molson brings a nostalgic elegance to its location at the corner of Main and East Hastings, the most notorious drug market in Canada.

Inside, the ground floor is largely unremarkable—it’s sparsely decorated, with a high ceiling—save for one feature. A thin white wall cuts across the middle of the space; at around eight feet tall, the wall falls short of the ceiling. All it takes is a chair for someone to peek over.

On either side of this wall, people inject drugs. But while one group knows what’s in the drugs they’re using, the other does not.

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The Molson Hotel’s hydromorphone room with a wall separating it from the building’s overdose- prevention site. On this side of the wall patients always know exactly what they’re getting, while on the other side, users under staff supervision inject unknown substances they’ve purchased on the street

Cooper is in the first group, and receives a precise dose of hydromorphone, a pure, pharmaceutical-grade opioid. Members of the other group are in one of Vancouver’s overdose-prevention sites (OPS), where people bring drugs they’ve purchased on the black market to inject under staff supervision. These users can only guess as to what they are putting into their bodies. In 2019, it’s usually fentanyl. Every shot is a game of Russian roulette.

“I hear them: ‘We got an OD! We got an OD!’” Cooper said. “It brings you right back to where you were when you were on the street, when people were dropping dead.”

In response to an especially brutal wave of fentanyl deaths that swept through Vancouver in the fall of 2016, activists in the Downtown Eastside established a number of guerrilla injection sites. At first, they were nothing more than tents pitched in alleys where volunteers offered clean needles and the overdose-reversal drug naloxone. The government eventually stepped in and, in December of that year, began providing funding. These sites continue operating today, and nonprofit organizations like PHS have integrated additional injection rooms at various housing locations. The Molson Hotel is one of the city’s busiest.

On a cloudy afternoon last April, the Molson OPS was a whirlwind of activity. Eleven booths, used for injecting drugs, line the walls. All of them were occupied. Most users calmly prepared their drugs for injection by cooking or loading needles. At one booth, a younger man rapped along to a mellow 2Pac track that was playing softly over loudspeakers. In a corner, another man, recently revived from an overdose, was lying on the ground, an oxygen mask covering his mouth and nose as an OPS staff member used an oximeter to monitor his blood-oxygen levels. In the middle of it all, a man leaned over a woman named Stephanie, helping her inject after she had trouble finding a vein.

A half hour later in a back alley behind the Molson Hotel, Stephanie explained what’s required to meet the inflated prices of the black market. She said that, for most users, there are only four ways to make enough money to pay for an opioid addiction: panhandling, stealing, dealing, and sex work. She’s tried them all. Every one of them was terrible.

Stephanie said she can’t handle the monotony of panhandling while she’s dopesick. And she’s too honest to shoplift or break into cars. She tried sex work but it wasn’t for her. “Mentally, it ruins you,” she said. “It was easy money but it ruins you completely. I would love to be the same person who I was five years ago, but I’m not, even without the dope. It does something to you.”

That leaves dealing. Stephanie said this is where the risks of fentanyl hit her. Not when she’s using, but when she’s selling. “If I get a bunch of people who OD and die on my stuff, I’m going to feel that for the rest of my life,” she explained.

Back inside the Molson Hotel, the hydromorphone program’s on-site program coordinator, Lindsay Kasting, sat inside a tiny nurses’ station that’s connected to the injection room where Cooper receives her prescription drugs. She explained that after an initial exam and admittance into the program, registered patients can receive injections twice a day, each time receiving a maximum dose of 200 milligrams, though that amount is not set in stone. Upon arriving at the Molson, patients check in, receive their specific dose from a nurse, sit at one of eight stations, and then inject themselves with the drug. They then remain there for a 15-minute observation period. A television and free coffee help pass the time.

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An injection table at the Molson Hotel’s overdose- prevention site. Here, clients use drugs that often contain the dangerous synthetic-opioid fentanyl. Staff can’t provide them with clean drugs but they can revive them in the event of an overdose

Most patients also receive a long-lasting, low-intensity opioid agonist such as Kadian (slow-release oral morphine) or Methadose (similar to methadone) once per day, which ensures they don’t experience withdrawal symptoms through the night. People don’t nod off or stumble out of the hotel too high to walk. They receive a “maintenance” dose and continue with their day.

But what kind of user is the typical patient in this program? “You have to have failed with other treatment models [such as methadone] a certain amount of times,” Kasting explained. “And if someone is perceived to be at a very high risk of overdose—someone who is overdosing a lot—those are also people we want to get into the program.”

The benefits extend beyond the individual. “The guys are shoplifting less,” Kasting said. “Women don’t have to engage in as much sex work or be as reliant on questionable relationships.”

Then there’s the program’s success in reducing overdoses. On the other side of the wall, the Molson OPS has seen more than 1,180 overdoses since it opened in September 2017. Six hundred and sixty-five of them required naloxone. Not one of them was fatal. The number of people who have died at any of Vancouver’s supervised-injection sites is zero. It’s a remarkable statistic. But with PHS’s hydromorphone program, there’s a number that’s even more impressive: Since it began, in September 2016, it’s never experienced an overdose, period.

“There’s no fentanyl,” Kasting emphasized. “People know exactly what they are getting and they are getting a prescribed amount.”

PHS’s hydromorphone program was established by the organization’s medical director, Christy Sutherland, who is also a practicing physician there, after she was inspired by a study of hydromorphone and prescription heroin that occurred just down the street. She said these treatments work by breaking the cycle of an addiction to street drugs—get money, inject, repeat—and that allows patients to take their first steps toward larger goals: sobriety, if that’s what someone wants, or stable housing, or whatever they decide is a positive change.

“Every time you use heroin, the clock starts, and you’ve got eight hours before you have to use heroin again,” Sutherland said. With fentanyl, the period between administration and withdrawal can be even shorter.

“To be addicted to heroin, it’s like a full-time job that no one signed up for,” she added.“Then, when you start them on these medications, I feel like they can just take a breath, for the first time in many years. It’s like, ‘Welcome back to the world. It’s nice to meet you. What’s the plan?’”

Sutherland maintained that the program is not as radical as some might think: Hydromorphone is widely available in North America as a prescription painkiller. And opioid-agonist programs that use methadone or buprenorphine are considered the gold standard for the treatment of heroin addiction. All she’s done at PHS, Sutherland said, is prescribe hydromorphone off-label as an opioid substitute to people for whom methadone and buprenorphine have proved ineffective.

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An injection table at the hydromorphone clinic

A common assumption, Sutherland acknowledged, is that recipients of free drugs will take as much as they can for as long as they can. But she emphasized the program’s early data shows that’s not the case.

“It was one of my worries,” she said. “But, in fact, most patients never go up to the highest dose, and most of my patients stay on it just three to six months.” Then they’ll taper off hydromorphone and continue with Kadian or Methadose.

“Once you’re doing well and you’ve got housing and maybe a job and you’ve reconnected with your family, you don’t want to come for all those injections,” Sutherland explained.

That’s exactly what happened to Colin, 47, a patient of the hydromorphone program who takes an oral form of the drug. “I wanted to get away from needles,” he said.

Colin explained that he’s had some close calls, overdosing around six times less than two years ago. “It’s very scary waking up, being that close to death,” he said. “I’ve got children, I have a family. I’m not using drugs because I want to die or because I want to kill myself. So it’s very scary.”

That all stopped when Colin found PHS’s hydromorphone program. “It’s been almost a year now and I haven’t OD’d,” he said.

In fact, Colin found a job just on the other side of the wall, at the OPS, where he said he’s helped reverse hundreds of overdoses inside the Molson Hotel’s injection room and in the alley outside. “It definitely reminds me of where I was and where I could be,” he said.

Scott Bernstein, a lawyer and the director of policy at the Canadian Drug Policy Coalition, described the Molson Hotel’s hydromorphone initiative as a “safe haven.” But he argued that positive assessment only underscores the absurdity of life outside the program.

“It’s like an exclusive club that’s only for a select group of people who no longer have to take their life into their hands every time they consume drugs,” Bernstein said. “The obvious question is: Why can’t other people get the safe stuff?”

Sutherland readily acknowledges that her program is not serving everyone it could benefit. In April 2019, she said there were 115 patients enrolled, and that’s the maximum number their infrastructure and funding allows. There’s a waitlist that stands at 45 names “and growing,” she added.

“It’s heartbreaking when one person is getting a safe medication to inject but another person is not,” Sutherland lamented. “They come in and check in, ‘Where am I on the list? What number am I?’ And it’s like, ‘Just try really hard not to die until we can start you on this.’”

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Lindsay Kasting, the injection-hydromorphone program coordinator at the Molson Hotel

PHS’s hydromorphone program is one of a number of initiatives that have placed Canada at the forefront of harm reduction. North America’s first sanctioned supervised-injection facility, Insite, opened in Vancouver in 2003. More recently, Prime Minister Justin Trudeau’s Liberal government eased regulations in 2017, and has since approved applications for dozens of supervised-injection sites in 18 cities across the country. Syringe-exchange programs operate free of cumbersome regulations that still hamper services in much of the United States. Later this year, Vancouver plans to pilot an opioid-substitution program that distributes pills via a sort of vending machine. But these services are distributed with brutal inequality. Separating them from every other category of health intervention, harm-reduction programs remain subject to the political whims of local governments, which routinely veto their establishment with NIMBY prejudice. Invisible barriers are erected with arbitrary application. A lifesaving program that’s offered in one neighborhood can be forbidden from opening in another. Sometimes, the barrier separating availability is as thin as a single wall.

For Cooper, the changes she experienced after entering PHS’s hydromorphone program were incremental, and sometimes so subtle they barely registered. But over time, they amounted to what she described as nothing less than transformative.

By November 2016, Cooper noticed that for the first time in as long as she could remember, there was always food on her shelves. “I was eating every day,” she added, “getting the color in my skin back.”

Cooper said she was no longer waking up to early pangs of withdrawal. The near-constant anxiety she’d felt for so many years began to subside. Soon enough, she took a part-time job, greeting people and serving coffee to her fellow patients at the Molson’s hydromorphone program. Another big change, she added, wasn’t for her. It was for her mom.

“She’s not losing sleep worried about me all night,” Cooper explained. “She’s not wondering if one of those sirens that she was hearing was coming for me.”

Before long, Cooper found she had the time to join her family for their weekly game night.

“I got money in my pocket for my weekly bingo with my mom,” Cooper said with a smile. “We all get together and go up the hill. Every Tuesday.”

Travis Lupick is a journalist based in Vancouver and the author of Fighting for Space: How a Group of Drug Users Transformed One City's Struggle With Addiction. Follow him on Twitter, Facebook, and Instagram.

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