Heroin Maintenance ~ The Vancouver Experiment

[Done-With-It!]

The Vancouver Experiment
Vancouver's experiment with helping addicts get high.
By Matthew Power
Updated Thursday, Feb. 4, 2010, at 10:06 AM ET
From: Matthew Power
Subject: Welcome to Insite
Posted Monday, Feb. 1, 2010, at 9:35 AM ET

At the corner of East Hastings and Carrall Streets in Vancouver, Canada, a raucous crowd milled around the sidewalk. Goods were on offer from a dozen sellers: hand tools, electronics, clothing, toiletries, all of uncertain provenance. There was a frenzy to make deals. A man opened a backpack filled with new tubes of toothpaste, smiling with stumps of teeth. Another sold cartons of orange juice out of a baby carriage. A shiny new mountain bike was on sale for $20. Below it all, a hushed chorus: "Powder. Powder." "Rock. Got rock." "Down. Need down?" This last is the local term for heroin, and there were capped syringes, tourniquets, and empty ampoules of sterile water scattered on the ground. In a shuttered doorway, a pale blonde girl in a dirty pink miniskirt, her thumb bruised black from constantly flicking her lighter, drew sunken-cheeked at a crack stem and looked up for a moment to ask, "You hooking?" A police car rolled slowly by but didn't stop.

The Downtown Eastside of Vancouver is a short walk and a world away from the glittering skyline of its business district, where a new billion-dollar convention center will soon welcome 400,000 visitors to the winter Olympics. Last year, the Economist magazine ranked Vancouver as the "world's most livable city." With a temperate climate and progressive mores, it has long been a destination for Canada's lost and dislocated. The Downtown Eastside, a dozen square blocks of dilapidated tenements and boarded storefronts, is home to one of the highest concentrations of drug addicts in the world. Scenes of open drug use recall the depths of the crack epidemic in New York City or the failed drug zone of Zurich's "Needle Park" in the early 1990's. An estimated 5,000 injection heroin and cocaine users live in the neighborhood, and the addict population suffers from HIV rates that are 30 times higher than the national average. Seventy percent have hepatitis C. Much of Vancouver's homelessness is concentrated in the neighborhood, as is 40 percent of the city's violent crime. The HIV incidence rate—the increase in new cases—hit 19 percent in 1996, the highest ever observed in the developed world. That's comparable to the situation in Botswana.

In the face of the developing crisis, the city turned to an unlikely coalition of politicians, scientists, activists, and addicts. In 2001, Vancouver's Mayor Philip Owen created a drug policy for the city that aimed to mitigate the risks of drug use through practical, evidence-based strategies. These "harm reduction" measures, as they're known among public-health wonks, include safety-first programs like condom distribution and needle exchange—relatively modest interventions that have been tested in a number of North American cities. But Vancouver has gone one step further and embraced harm reduction as both a pillar of its drug policy and a moral imperative. For the past six years, Vancouver's health authorities have been conducting a radical experiment in the way they approach and treat drug addicts. And the whole thing is centered in a nondescript three-story brick building in the heart of the Downtown Eastside.

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A few blocks beyond the sidewalk market, I met up with Darwin Fisher. He is a tall, slim 43-year-old with slick black hair and a booming voice, and he stood in front of a glass-windowed storefront, hosing the previous evening's residue off the sidewalk. A sign in the window showed a cartoon syringe, and printed above were the words Welcome to Insite. It was 9:50 a.m., and already a dozen people were milling near the entrance, pacing and smoking. Some were in wheelchairs; other pushed shopping carts loaded with their worldly possessions. Fisher smiled and chatted with them, then unlocked the door and stepped inside. Several other staff members arrived, as Fisher booted up a computer in the waiting room. The crowd outside vibrated with pent-up energy. At 10 sharp, the doors opened, and they filed in, each giving a code name to the staffer at the reception desk: Bubba63, Cosmo, Tattoorick. They were buzzed through a second door, into a large, high-ceilinged room with track lighting. A dozen stainless steel booths lined three walls, each with a large mirror. As people entered, Fisher cheerfully checked them in on another computer. "Hey there, what are you doing today?" he asked. "Down? How about number seven? Powder? Three's open." Within moments the booths were fully occupied. Pink Floyd's "Another Brick in the Wall" was piped in through the sound system. Under the watchful eyes of Insite's nurses and staff, a dozen of Vancouver's addicts began their morning ritual of cooking up, tying off, and trying to find a usable vein to inject themselves with illegal drugs.

In this one room, however, the drugs are legal. Insite is the only government-sanctioned supervised injection site in North America. Opened in 2003 with money from Vancouver's health authority and federal grants, Insite was initially given a three-year exemption to Canada's Controlled Substances Act. (The facility is operated by a nonprofit social services organization called the Portland Hotel Society.) Addicts arrive with drugs scored on the streets and inject them in a supervised environment, 18 hours a day, 365 days a year. A counter was laden with clean needles, sterile water, cookers, filters, tourniquets, alcohol swabs, condoms. The database includes more than 2,000 users, identified only by code names, and an average day will see 645 injections. There are always two staffers and two nurses on duty, standing by with oxygen masks and syringes of the overdose drug naloxone. To date they have intervened in more than a thousand overdoses without a single death.

The idea of supervised injection sites is not original to Vancouver. There are approximately 90 worldwide, in eight countries: The first was opened in Bern, Switzerland, in 1986, and when Zurich closed "Needle Park," the Swiss launched supervised injection sites nationwide. The Netherlands, Spain, Germany, and several other European countries followed suit, and a site in Sydney, Australia, opened its doors in 2001. The operating principle is simple: If injection drug use is going to occur regardless, why not create a space that mitigates its dangers? That way, say its proponents, lives will be saved and the spread of disease will be checked. The risks of unsupervised injection are manifold; public drug users are often rushed and are less likely to have sterile equipment and practices. In Vancouver, researchers described addicts drawing up puddle water to mix their drugs, or doing "shake and bake," mixing the drugs in the syringe without first cooking out their impurities. Such techniques can cause gangrenous abscesses and endocarditis, a bacterial infection of the heart valves. Public users are also less apt to test their drugs for potency. "What's really difficult on this job is finding out that people use elsewhere, because the site's not open 24 hours a day, and they die of an overdose," says Fisher. "If people aren't using here, they're using behind a dumpster."

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The raw numbers are encouraging: In 2008 Vancouver's overdose deaths were the lowest in 30 years, and the rate of new HIV infection among injection drug users was the lowest since recordkeeping began. Historically, one of the chief difficulties of scientifically studying the behavior of illegal drug users has been gathering meaningful data: Addicts aren't very forthcoming with personal information. But beginning in 1996, Vancouver's Urban Health Research Initiative canvassed the Downtown Eastside and recruited more than 1,500 participants for a study. That group, known as the Vancouver Injection Drug Users Study, participated in the longest and largest cohort study of injection drug users in the world. Combined with data from more than a thousand users in the database at Insite, researchers have had plenty to work with. Since 2003, dozens of peer-reviewed articles have been published in scientific journals like the Lancet, the American Journal of Public Health, and the New England Journal of Medicine, demonstrating the injection site's efficacy.

Thomas Kerr, a research scientist at the British Columbia Center for Excellence in HIV/AIDS, is the principal investigator of the studies. His research found that Insite's users tended to be from the most at-risk groups: the homeless, women, and Canadian aboriginals. As a result of the program, they were less likely to share needles and more likely to seek addiction treatment. The data clearly showed lives were being saved, its advocates insisted. "The international scientific community has basically endorsed our findings," said Kerr. "We thought that would be enough."

Despite a body of published research and broad local support—70 percent of Vancouverites are in favor of Insite—its existence has at times pitted police against social-service providers, scientists against politicians, and has polarized opinions at the highest levels of Canadian government. When the Conservative Party gained power in 2006, the new government targeted the center for closure. The three-year legal exemption had ended, and Kerr's application to extend his study of Insite was denied by the Health Minister, Tony Clement. Clement called it an "abomination," and told the Vancouver Sun that "allowing and/or encouraging people to inject heroin into their veins is not harm reduction. … [W]e believe it is a form of harm addition." To its critics, Insite enabled addicts, sanctioned criminality and sent the wrong message to the public about drug abuse.

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The Portland Hotel Society filed suit to force the federal government to keep the site open, on the grounds that addicts have a constitutional right to health care. The courts ruled in their favor, and a government appeal of the case was thrown out Jan. 15. Now the feds are weighing whether to take their argument to Canada's Supreme Court, and the organizers behind Insite are pondering how to expand their reach: 24-hour service, perhaps, or an "inhalation room" for crack smokers. They would also like to bring supervised injection to other Canadian cities.

So can it work? In Vancouver, a mere hour north of the U.S. border, drug policies that would be political suicide in America have become the status quo, supported by the populace and championed by a succession of progressive mayors. While the U.S. spends billions incarcerating 350,000 nonviolent drug offenders, Vancouver offers a window into an alternate reality. They've discarded the most punitive excesses of the "war on drugs" and started to re-examine the way society thinks about addicts and addiction. Here in Canada, at least, it all seems very reasonable.

Click here to view a slide show on Downtown Eastside Vancouver.

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By 11 a.m. on the day I visited, there had been 54 users in the injection room. Some were in and out in moments, while others took hours. When they finished in their booths, most retired for free coffee in the "chill-out room" which had an exit back onto the street. Cocaine injectors might return many times a day, while some users merely stopped in to pick up handfuls of free "rigs," or syringes. (Three million syringes are distributed in the neighborhood annually.) In between users, each booth was swept out and sterilized by the staff. Darwin Fisher, the program's intake manager, checked in arrivals and the drugs they were using on a drop-down chart that listed among its options heroin, speedball, morphine, cocaine, crack, dilaudid, oxycontin, and methamphetamine. The user's choice of drug and the outcome of each visit was stored in a database for researchers. In keeping with the nonjudgmental ethos, there are two key rules at Insite: no sharing or selling drugs and no violence. Indeed, once they were settled in their cubicles, most of the users were as still and focused as students in library carrels.

A young woman brought a kitten which poked its head out of her bag as she fixed. A man in a cowboy hat entered carrying a set of golf clubs, offering them to Fisher for sale. Another came in with an enormous bag of aluminum cans balanced on his head, not wanting to leave them unguarded on the street. Prostitutes fixed their makeup and adjusted their hair, while others used the mirrors for "jugging"—injecting directly into the jugular vein. It's a common practice, particularly among women, although the staff tries to discourage it due to the danger of hitting a nerve or an artery. A woman sat up on the stainless steel table of her booth, pant leg hitched up, probing her calf for a vein. Others shot into their elbows or between their knuckles. The staff won't actually inject someone, but they will talk them through it, even drawing an "X" in pen on a promising spot. The front lobby filled up with overloaded shopping carts of homeless clients, as a soundtrack of Sly and the Family Stone, Joni Mitchell, and Bob Dylan came over the speakers. Fisher tried to choose the music once, but the users detested Tom Waits, and so he's settled on a heavy rotation of classic rock.

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For many of the users, the injection room is a first point of contact with the health care system. Users get medical treatment from the nurses, who clean and bandage abscesses and give referrals for further care. The addicts are a deeply traumatized population, many with mental illness and histories of abuse and so require an extraordinary amount of patience. An oft-repeated dictum for the staff at Insite is to "meet people where they are." It is a constant effort to be nonjudgmental about the choices addicts make. "Pregnant women come in," says Fisher. "It's heartbreaking, but we can't force anyone down here to do anything. They've been forced to do things their whole life."

One of Fisher's main duties is to help addicts, when they are ready, make the move into treatment. For many, the first stop is Onsite, the 12-bed detox facility directly upstairs from the injection room. Onsite was opened in 2007 to offer immediate, on-demand treatment for addicts coming in off the street. It was devised as a pilot program, so there simply isn't enough space to meet the boundless demand. The need for more detox and treatment facilities is a rare point of agreement between Insite's proponents and its critics. Fisher spends his days figuring out how to prioritize the people coming to him, "begging to get upstairs."

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DocRock was in booth 9, fixing a $30 flap of heroin. The syringe blossomed with blood as he released his tourniquet and pressed down the plunger. His real name is David Townsend, 52, with thick glasses and a gray handlebar moustache. He works construction, putting up drywall. Townsend has used heroin for 36 years, spending up to $700 a week. "I actually hadn't used for four and a half years," he says, "but then I forgot I was an addict." At this point he was shooting up three times a day, but it no longer made him feel euphoric. "Unfortunately you get to a stage where all you're doing is preventing yourself from being sick," he said. Now he's waiting for a room at Onsite. "I've done it once before. This time I'll make it work." Fisher supports Townsend's decision, but they both know that even with the best treatment, the odds weighing against his recovery are heavy, with a high chance of relapse occurring even after years have passed. Fisher repeated a mantra among the staff at Insite, on the Sisyphean difficulties of getting addicts to stay sober: "It's like shoveling water."

Up a flight of stairs from the injection room, another locked door buzzed open to Onsite. When addicts have made the decision to get clean, they spend an initial 14-day period isolated on Onsite's detox floor. Heroin addicts are treated with methadone, and kept under close watch by Onsite's staff. The next floor held a short-term housing facility, where 20 post-detox patients stay while waiting for further housing to come available.

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Dean Caldwell, a 42-year-old who had been sober for 90 days, wore a sleeveless t-shirt that showed off heavily muscled, tattooed arms. For years he was a crack addict and cocaine injector, shoplifting and mugging small-time dealers to get his fix. There is a glassed-in smoking porch on the back of the building, and Caldwell looked down at the alley that runs behind the block, narrating a bird's-eye view of the nightmare world everyone at Onsite is trying to escape. Down below, a small group gathered by a chain-link fence. A stooped, skeletal woman, a "steerer," brought customers down the alley to a man who sold crack openly out of a backpack. In the shelter of a dumpster, they all lit up.

It may seem counterintuitive to seek treatment in such tantalizing proximity to drug use; studies cite exposure to such cues and behavior as a strong predictor of relapse. But Caldwell feels that when someone is truly ready to be clean, that temptation no longer matters. Still, he's fully aware of the chances of his own failure. He's been through treatment three times, and works security at a homeless shelter now. "You have to do away with the concept of second chances," he says, "It takes as long as it takes." Now, his experience makes him want to do something for other addicts. "When a human being gets removed from that darkness, they have a responsibility to help the next person."

Back downstairs in the injection room, Catlin Moyou, a young man with curly brown hair and glassy eyes sat hunched in a chair, holding an oxygen mask to his face. The Insite nurses had just brought him back from an overdose. Sammy Mullally, a 24-year-old nurse, had seen him slumping in his cubicle and walked over. He looked at her for a moment and then dropped, his lips blue. "He was gone," she says. "His pupils were pinpoint. He was not breathing." They lowered him to the floor and gave him a shot of naloxone, inserting a mouthpiece to force air into his lungs. A second dose still didn't bring him back, and just as a third was about to be administered, Moyou popped up, wide-eyed. An ambulance arrived, but he refused to go to the hospital. Mullally says that's a frequent outcome.

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Moyou said he hasn't used heroin for four months, and his tolerance has diminished. Also he'd been drinking that morning and hadn't told the nurses. He'd been using for five years; his father, also an addict, had taught him how to inject properly, to test his dope. If he hadn't been at Insite, he wasn't sure where he would have done it. "Probably the alley," he admitted. And then what? "Dead. Gone," said Mullaly. Even this grim outcome was not enough to shake Moyou up. He admitted he would probably use again that day. "I don't think I'm finished just yet," he said. "I'd really like to be finished, but there's something in my body that just tells me that I'm not finished using drugs."

Working closely with such an intractable population and keeping a degree of remove from their tragic lives can create an enormous emotional strain on Insite's staff. Mullally said three regular users from the community died the previous weekend. Staffers are required to go through therapy sessions, and a lot of emotional processing is done informally, the staff downloading their feelings over drinks at a bar. "It's so important to talk to your coworkers, talk to your partner how you feel about it," said Mullally. "If I didn't talk about it I would implode. But I can't leave the Downtown Eastside."

It was a typical day at Insite, and users would filter in throughout the day until the last hold-outs were ushered out the door at 4 a.m. Then a few hours of darkness before the sidewalk was hosed off and the line formed again at the front door. It's an endless parade of haggard addicts seeking their comforts, and no constituency in Vancouver—police, scientists, addicts or politicians—can agree on how exactly to help them, or whether they can be helped at all.

Click here to view a slide show on Downtown Eastside Vancouver.

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Nonprofits like the Portland Hotel Society, which runs Insite, have utterly reimagined the streetscape of the Downtown Eastside, retrofitting pockets of urban decay into a kind of social-services campus for drug addicts and the indigent. "The main goal is creating these environments where people can begin to heal," says PHS Executive Director Liz Evans. In a shuttered saloon, a café has been opened up, with a dental clinic providing free care in the back room. A needle-distribution center gives out 6,000 syringes a day, and collection teams pick up just as many from the alleys. Down the street, a live-in medical treatment facility provides courses of intravenous antibiotics for addicts suffering from endocarditis and other infections, while another housing facility houses seniors. A community bank has been established to allow savings accounts and plans to start a microcredit program. A recycling depot called United We Can collects 20 million containers a year from Vancouver's "binners," employing 150 local sorters and pumping $2 million a year back into the neighborhood's economy. A life-skills center offers classes from computers to bicycle repair to "beauty night" for prostitutes, and its kitchen delivers 700 high-protein meals a day to PHS's housing facilities via bicycle cart. Some of the kitchen's produce comes from a large community garden next door to Insite, where volunteers tend neat raised beds of tomatoes, squash, and beans. The garden is also the frequent site of memorials for the community's many dead. "The most important thing we do is give a sense of dignity," says Liz Evans.

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For more radical advocates of Vancouver's addict population, even the projects run by PHS are not enough. A storefront a few blocks east of Insite serves as the headquarters of VANDU, the Vancouver Area Network of Drug Users. Their logo is a syringe and crack pipe crossed over a red heart. VANDU conducts "user-based peer support and education" through a variety of programs, sponsored by Vancouver Coastal Health as part of the organization's overall harm-reduction strategy. Activists from VANDU were instrumental in agitating for Insite's creation, and in the years before it was implemented members ran as many as three illegal supervised injection sites around the neighborhood. Aiyanas Ormond, the office manager of VANDU, is not himself a drug user. As we talked, he sat behind his desk carefully packing brass screens into the stems of a handful of crack pipes. The pipes are Pyrex, less likely to break and cut a user's mouth, and thereby reducing disease transmission. A 2009 study found that sharing crack pipes can spread HIV, and was cited in support of opening a crack-smoking room at Insite. VANDU sells crack pipes to users at cost, $2 each. Ormond saw the organization's role as "pushing the envelope, doing things that official channels won't."

To see how far they push, I walked through the neighborhood with a couple of VANDU staffers, Ken Franklin and Diane Taubin. The organization's "Injection Support Teams" travel the alleys to hand out syringes, sterilized water, and plastic mouthpieces to crack pipes. The pair were in their 60s, both recovering addicts of methadone. They carry plastic buckets and salad tongs to collect discarded needles, and a cell phone to call an ambulance if they come across an overdose. Franklin and Taubin would also help inject addicts who were too physically limited to properly inject themselves, which the staff at Insite is forbidden to do.

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Taubin was a stout, grandmotherly woman, with thick glasses and a wide smile. "We started this because one of our members was blind, and her husband ended up in jail, and she couldn't use," she said. Franklin acquired hepatitis C while serving an eight-year sentence for a bank robbery spree; he and a group of 10 inmates had shared the same syringe for three years. Taubin got the disease in prison as well, while serving four years for heroin possession, and is frequently fatigued by the interferon treatment she is undergoing. In the alley directly behind Insite, one of them stopped to bandage the bleeding finger of a prostitute who had cut herself on a broken crack pipe.

For all the support they provide, even the VANDU volunteers admit there are limits to grassroots outreach. During the walk through the neighborhood, we saw a disheveled man writhing and crawling on the ground in the throes of schizophrenia, covered in grease and black mud as he scraped in a puddle with a bent syringe. Franklin did not even try to approach him. The severely mentally ill are among the hardest to reach in the street population, and the most likely to be exploited. Despite all the tolerant attempts at dealing with the street population in the neighborhood on their own terms, the need to institutionalize Vancouver's most severely mentally ill is undeniable. Sometimes the government is forced to get involved, and that responsibility often falls to the police.

The perennial problems of the Downtown Eastside create a particularly difficult job for the Vancouver Police Department. From a station house on Hastings and Main, an average of nine officers a night patrol the streets and alleys of the neighborhood, which accounts for 40 percent of the violent crime in the entire city. One night I met up with Sergeant Toby Hinton, a 20-year veteran of the VPD, and followed as he patrolled the alleys on foot. The alleys are hundreds of feet long, poorly lit, filled with doorways and dumpsters. Crack smokers hide their pipes long before Hinton reaches them, and for the most part he has no plans to arrest them. "The pathetic addict that's down here and using, that's not in our target sights," he said. "I'd rather see them get some type of help, go into recovery or treatment. I would far rather spend the millions of dollars that are used to operate Insite and put it into residential treatment programs that are a little bit removed from here." Hinton speaks in measured, disciplined tones, but has no reservations about his criticisms, even though they diverge from official VPD policy.

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nspector Scott Thompson, the drug policy coordinator for the VPD, says that the role of the police regarding Insite is "to be apolitical, to be neutral, and to be professional." Thompson drafted the VPD's drug enforcement strategy and has worked closely with Insite's management to establish clear protocols for police interactions with the site. But in the streets and alleys, officer discretion is the key. "When it comes to trafficking, we have very much a zero-tolerance policy," says Thompson. "When it comes to users, addicted users, there's very much an application of discretion."

In practice, the VPD's policy of "selective targeted enforcement" means not arresting anyone for drug use unless they are creating a public nuisance, like smoking crack in a bus stop or near a school. If someone is caught with drugs, they are usually confiscated, and crack pipes are smashed. On this night's rounds, Hinton took a joint from a group of young men standing in a food line, and later confiscated a Ziploc filled with low-grade pot. Generally, as Hinton put it, "I'd rather go after some bigger fish." Those bigger fish include some of the international gangs that control drug trafficking in Canada and run the networks that trickle down to the neighborhood's alleys. Hinton recently arrested a member of the notorious Honduran gang MS-13 who was wanted on a murder warrant there. Gun violence is relatively low, and Vancouver had just 36 murders in 2008—a fraction of those in a comparably-sized American city—but Hinton regularly confiscates the pipes, bats, and sawed-off hockey sticks favored in the neighborhood. (This is a place where the word pipe is used as a verb: "He stole my stash so I piped him.") In one of Hinton's undercover operations, "Project Oldtimer," makeup artists spent hours transforming him into a very convincing elderly man. He lay in an alley, pretending to be passed out drunk with money sticking from his pocket. When an unsuspecting thief robbed Hinton, he soon found himself surrounded by a dozen police. But such enforcement victories are rare, and the harm-reduction policies of Vancouver have done little to stem the violence that plagues the neighborhood.

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"This is what I would call a failed social experiment," said Hinton. "I do find it a bit ironic, a lot of people running around touting us as being on the enlightened path, and it's almost as though you're being asked to deny your eyes."

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One study of Vancouver's injection-drug users has taken harm reduction to a level even beyond Insite. In 2003, the same year that the supervised-injection site opened its doors, an epidemiologist named Martin Schecter began planning a trial that had never been conducted in North America: heroin maintenance. Would a daily course of heroin, administered in a clinical setting, release users from the destructive aspects of maintaining their addiction? Would it benefit society and allow users to stabilize their lives? Similar studies had been conducted in Europe with positive results. Switzerland alone has 38 heroin maintenance centers, and they are a fully integrated part of its national health system; Germany followed suit last year. Schecter, who has worked in Vancouver since the first signs of the AIDS epidemic in 1983, wanted to see whether such a program would make a difference in Canada.

For the neighborhood's recovering addicts, the ability to escape the daily demands of supporting an addiction is often achieved with a dose of methadone. Methadone's relative benefits are well established: It is slow-acting. It greatly reduces cravings for heroin and blocks heroin's euphoric effects. When successful, methadone maintenance can give addicts their lives back. But there are high rates of relapse among long-term addicts.

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Drawing from a population of addicts in Vancouver and Montreal who had repeatedly failed methadone therapy, Schecter began the North American Opiate Medication Initiative in 2005. The Vancouver trials were set up in an abandoned bank a few blocks from Insite; the Swiss pharmaceutical-grade heroin was delivered by armored car and stored in the empty vault. Addicts were given heroin three times a day and monitored over a three-year period. A parallel group was given an ordinary course of methadone, and the results were compared.

The results of the trials, published in the New England Journal of Medicine in August, were encouraging. Schecter found that 88 percent of the heroin maintenance group stayed on their course of treatment, versus 54 percent in the methadone group. Illegal activity in the heroin group was reduced 67 percent, versus 47.7 percent in the methadone group. Out of 89,000 injections, there were only 10 overdoses and no fatalities. Despite the positive results, the heroin maintenance program has not been adopted as part of a permanent treatment strategy. Schecter has begun a new trial, focusing on dilaudid—a synthetic opiate with similar effects to heroin, but which can be administered in a pill— to see whether that has similar results. In purely economic terms, Schecter claims opiate maintenance makes sense: An untreated heroin addict costs the state $45,000 a year in legal and medical bills; heroin maintenance costs $7,000. "Sure, it's easy to say, 'You're giving heroin to junkies,' " Schecter says, but he witnessed the stabilization of the heroin group firsthand. "A subject told me 'for the first time in 20 years I'm actually thinking about my life.' That was the line that blew my mind," he recalled. "They're actually thinking about the future. Normally they're thinking about eight hours."

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Some scientists remain skeptical. Keith Humphreys, a Stanford-based clinical psychologist and senior drug policy adviser to the White House, dismisses the comparison of heroin and methadone, citing the superior safety and convenience of a newer drug, buprenorphine, in treating opiate addiction. "Bupe," in wide use since 2002 in the United States, was only approved in Canada two years ago and isn't yet covered by the national health system. "There have been multiple randomized trials, pharmacology trials, tolerance trials, showing that compared to heroin, it's way safer," says Humphreys.

As the world tunes in to the Olympics in the coming weeks, Vancouver's drug policies are sure to receive saturation coverage and stir debate. So could a supervised-injection program ever gain traction in the United States? While Insite has broad public support in Vancouver itself, criticism has at times spilled over the border. John Walters, the U.S. "drug czar" under George W. Bush, called Insite "state-sponsored suicide." Even under the new administration, there is little sympathy for supervised injection. Gil Kerlikowske, who served as Seattle's police chief before joining the Obama administration as director of the Office of National Drug Control Policy, is deeply skeptical of Insite's mission and efficacy. He visited Insite on Mother's Day, 2004, eight months after it opened, and found the experience depressing. "I thought it was just a failure," he says. "They weren't dying of overdose as much, but they were certainly dying a slow death in a lot of other ways."

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These doubts are shared by Thomas McLellan, ONDCP's deputy director, whose own son died of a drug overdose in 2008. "I certainly wouldn't be presumptuous enough to tell Canada what to do with its money," he says. "I commend the government for attempting something, I commend them for evaluating it, and I will let the data say to the world and to them whether they're getting what they want out of it. I can't say I'm optimistic." McLellan opposes supervised injection, "not because it's immoral, not because we have a particular ideology or anything that we want to follow, but because I think there are many better, safer options." In McLellan's view, both Insite and Schecter's trial suffer from a more fundamental flaw: They don't get people off drugs, and would only be successful "in the context of ultimately bringing people to see that drug use itself is harmful and that there are effective ways of bringing it to an end."

The ONDCP is announcing its new national drug strategy in February, and Kerlikowske says his new mantra is "evidence-based policy": using hard science to guide decision-making. Determining which evidence to base federal policy on falls largely to Keith Humphreys, who will help draft the new ONDCP strategy. Humphreys doesn't trust the research that has been conducted into supervised injection, which he says is often nonrandomized and lacking control groups. "Those studies are not the kind you would ever approve a medical treatment for," says Humphreys. "They are very undeveloped, scientifically." He cites a phenomenon in which passionate commitment to a particular intervention, like supervised injection, within a small group of researchers skews their results. "Sometimes people feel that when folks are really troubled, you know, we need to make the science softer and weaker and just kind of go with our gut. I feel the exact opposite. When people are really vulnerable, you really, really want to make sure that you're giving them good health care." For David Marsh, Insite's Medical Director, the rationale for the site goes beyond scientific evidence. "We need to do things that save lives and treat drug users like real human beings who are part of society, and there's a real moral argument why that's the right thing to do."

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Given the death-panel hysteria attending the health care debate, a serious discussion of applying Vancouver's policies in the United States seems unlikely. But to the proponents of progressive drug policy reform, there are a few signs of hope. New York has abandoned the mandatory minimums of its Rockefeller Drug Laws. It remains to be seen how far the new White House strategy will depart from the drug war, but President Obama has publicly declared that "drug addiction is a health issue" and has ordered the Justice Department not to pursue medical marijuana arrests in states that have legalized it. Congress has overturned the ban on federal funding of needle exchange, and a bill called the Drug Overdose Reduction Act may open the way to American policymakers studying Vancouver's experiment. Yet there is still no simple answer to whether that experiment is a failure or a success.

Gregor Robertson, Vancouver's 44-year-old mayor, knows well that the nightmarish scenes in the alleys of the Downtown Eastside are at odds with the Olympic image of Vancouver as a progressive green utopia. Handsome and athletic, Robertson came into office on an environmental and social-welfare platform, promising to deal with the city's homeless and mentally ill. "It shocks some people to see the pain and suffering in the community front and center," he says. He's ready for the world to arrive and isn't afraid of being judged. "I think our city, we're open and willing to share our biggest problems, and open to ideas from the rest of the world to help us solve them. We haven't figured them out, and we're certainly not going to hide it."

[Done-With-It!]

Vancouver is trying to avoid the mistakes of some past Olympic cities, notably Atlanta, which garnered criticism for pushing out its homeless in the months before its Games. As for the critics of Vancouver's harm reduction policies? "They're purely ideological," Robertson says. "Science is on our side here. And the community supports us." In any event, the Games will come and go, and the users of Insite will still be on East Hastings Street, waiting for the doors to open every morning at 10.

Click here to view a slide show on Downtown Eastside Vancouver.
Matthew Power is a contributing editor at Harper's magazine and has written for the New York Times, Wired, Men's Journal, and elsewhere. He lives in Brooklyn, N.Y.

Article URL: Vancouver's experiment with helping addicts get high. (4) - By Matthew Power - Slate Magazine