Insite, North America’s first supervised drug-use site, turns 20 as overdose crisis evolves

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In 2003, Vancouver was in the throes of a double-barrelled public-health crisis. British Columbia had suffered a surge in overdose deaths, the majority of them in its biggest city, and an explosion of HIV and hepatitis C cases was disproportionately devastating the city’s injection drug users, the result of sharing syringes.

Insite, North America’s first public supervised consumption site, would be credited with dramatically curbing needle-sharing and reducing blood-borne infections in Vancouver. Overdose deaths fell and would remain stable for a decade. As the site marks 20 years of operation this month, it has logged roughly three million visits to its injection room, 11,800 overdose reversals and zero deaths. Thousands of clients have been connected to other services; the detox centre upstairs gets a couple of visits every day.

But that milestone takes place against the backdrop of a new public-health crisis, one whose carnage eclipses that of the late 1990s. A volatile drug supply awash with fentanyl, benzodiazepines and a cocktail of other adulterants has driven the death rate up tenfold, and the enduring debates over supervised consumption are now being applied to a new hot-button issue in harm reduction: a safer drug supply.

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In a coffee shop in Vancouver’s Downtown Eastside, Dean Wilson reflects on the past two decades. A long-time drug policy activist and user of 50 years before quitting last year, Mr. Wilson was among a core group of people who lobbied for Insite’s opening.

“It’s a completely different scene now, but the similarity is that the stigma still exists for drug users,” he said. “Stigma still pervades the whole conversation about drugs, still to this day.”

Mr. Wilson, 67, first learned about supervised consumption in the fall of 1998, when the non-profit Portland Hotel Society (PHS) convened an international symposium on solutions to drugs, crime and addiction at Oppenheimer Park, in East Vancouver.

Among the hundreds in attendance were local politicians, health officials, police and the chief coroner, who stood in the rain as experts shared experiences from their countries. Mr. Wilson listened intently as drug policy co-ordinators from Switzerland and Germany spoke of legal drug consumption spaces with sterile supplies and staff trained to reverse overdoses. He became convinced that such places were needed in Vancouver.

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Researchers estimate that, in the late 1990s, roughly a quarter of Vancouver’s injection drug users had been infected with HIV and up to 90 per cent with hepatitis C. Meanwhile, Mr. Wilson recalled, drug users seemed to occupy every bus shelter along the East Hastings Street corridor: “It was the only thing we had, because if you overdosed in the alley, you died. If you overdosed at a bus stop, you were usually found before you died.”

The idea of a sanctioned supervised consumption site percolated. Mr. Wilson became president of the Vancouver Area Network of Drug Users and advocated for a site alongside community organizer Ann Livingston, poet and activist Bud Osborn and PHS executives Liz Evans, Mark Townsend and Dan Small. They marched in the streets, attended health and police board meetings and flew to Ottawa to lobby policy-makers. Critics balked at the idea, seeing it as state-sanctioned drug use.

Meanwhile, Ms. Livingston – a single mother and non-user spurred to action by the despair she witnessed – paid out of pocket to open several small-scale and short-lived clandestine sites in the neighbourhood, both to support drug users and provoke authorities. “Without civil disobedience, you get absolutely nothing,” she said.

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Philip Owen of the centre-right Non-Partisan Association was mayor from 1993 to 2002 and initially embraced a law-and-order approach to drug use. But after a friend’s daughter died of an overdose, he spent more time learning about the issue, including the calls for supervised consumption.

“It was fascinating to me that some people were saying, ‘This is terrible, encouraging drug use,’ and so on, and other people were saying it’s a health issue,” he told The Globe and Mail in a 2016 interview. “I had to go and figure out which it was.”

The mayor’s research took him to Europe, where he learned about the sites in Germany, Switzerland and the Netherlands, and to the Downtown Eastside, where he would walk the streets dressed in jeans and a baseball cap, asking drug users about their circumstances. He eventually became an unlikely supporter of harm reduction, hiring the city’s first drug policy co-ordinator, Donald MacPherson, and securing federal funding to operate Insite as a three-year pilot project, with PHS and the local health authority operating the site in partnership.

In late 2002, Chris Buchner had just been hired as Vancouver Coastal Health’s new manager for HIV and harm reduction when he was given his first task: plan the new supervised consumption site. He recalled piles of paperwork and countless meetings with community members, city officials and police.

Drug users demanded that their peers be involved in the process. The International Narcotics Control Board said opening such a site would violate international drug control treaties and tarnish Canada’s reputation. Workplace safety required proper ventilation. The College of Nurses questioned whether supervising drug injections was within the scope of nursing. Health authorities worried that the chairs and linoleum flooring selected for the site would be seen as “too nice” – frivolous spending.

Mr. Buchner, who is now the executive director of public health at the health authority, says he felt lucky and scared – in equal measure – to be involved in the project. “There were so many hopes and fears pinned on this one site,” he said. “In some people’s stories, it was going to solve everything: It was going to eliminate public drug use, it was going to eliminate HIV transmission among drug users, it was going to ensure there were no more overdose deaths. To get it across the line, we almost had to overpromise its impact.”

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In mid-September, 2003, the health authority invited media and dignitaries to tour the 1,200-square-foot site, showing off the injection room’s two sinks, 12 mirrored booths and postinjection “chill-out room.” Director Heather Hay showed reporters the kidney-shaped dishes of harm-reduction supplies that would be given to visitors.

Later that afternoon, with the cameras gone, Mr. Wilson and PHS executives Mr. Townsend and Mr. Small sat quietly in the site.

“When do you want to open?” Mr. Townsend asked.

“Tomorrow morning?” Mr. Wilson said.

“How about right now?” Mr. Townsend replied.

“Do you want to be the first?” Mr. Small asked Mr. Wilson. He did. Mr. Wilson brought a tray of sterilized supplies to booth nine and quietly injected heroin into his arm as a nurse looked on.

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The facility would not be the silver bullet to Vancouver’s drug crisis. But along with expanded harm reduction measures and a new HIV strategy, it did lead to a dramatic reduction in infection rates. According to a 2013 report by the Urban Health Research Initiative for the B.C. Centre for Excellence in HIV/AIDS, HIV incidence rates in Vancouver fell from a high of 8.1 cases per 100 person-years in 1997 to 0.37 in 2011. Over the same period, hepatitis C rates fell from 37.1 cases per 100 person-years to 1.1. Meanwhile, overdose deaths, which peaked at 400 across B.C. in 1998, were roughly halved and would remain stable for about a decade.

In 2006, Stephen Harper’s Conservatives took office and pledged that Ottawa would no longer use tax dollars to “fund” illicit drug use at Insite. PHS took the matter to court, with Mr. Wilson as a plaintiff. The case reached the Supreme Court of Canada, which ruled unanimously in 2011 that the federal government’s efforts to shut down Insite violated injection drug users’ Charter rights and ordered the government to stop interfering with the clinic.

Mark Lysyshyn, the deputy chief medical officer for Vancouver Coastal Health, said he believes strict government regulations limit the potential of Insite’s clinical services, but the site has still found ways to adapt to the changing drug landscape.

In 2016, for example, when drug deaths began soaring with the growing prevalence of fentanyl in the illicit supply, the health authority wanted to offer clients a drug-checking service. However, federal rules stipulated that staff could not handle users’ drugs outside of exceptional circumstances.

“We didn’t ask Health Canada if we could do that because we were confident they would say no,” Dr. Lysyshyn said. “Instead, we chose a very simple drug-checking technology that we could teach people to use themselves, so they could test their own drugs.”

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In the first month of the project, 86 per cent of samples tested contained fentanyl – a discovery that surprised many in what was still considered the early years of the crisis.

Shortly after, Health Canada created a mechanism to allow staff-facilitated drug checking. The BC Centre on Substance Use purchased several Fourier-transform infrared spectrometers – sophisticated devices that can test a range of substances and identify multiple compounds within minutes – which then opened the door to more detailed drug alerts. And when people began exhibiting unusual overdose symptoms – such as chest wall rigidity and involuntary, erratic writhing – clinicians were able to share notes from Insite nurses.

“Nobody else in the world really had the same type of ability to observe overdoses in this context of changing contaminants in the drug supply,” Dr. Lysyshyn said. “It was very useful for us to have their observations and to be able to share them with the world, to help people outside of supervised consumption sites understand that this behaviour you’re seeing is actually a fentanyl overdose, and naloxone will help.”

In December, 2016, a particularly deadly month, then-B.C. Health Minister Terry Lake issued a ministerial order to regional health boards to immediately open what would come to be known as overdose prevention sites – essentially lower-barrier supervised consumption sites, often run by peers, that did not require approval from Health Canada. There are now about 50 such sites across the province, including 19 that offer inhalation services, an adaptation that reflects the fact that the most common mode of consumption in drug deaths today is not injection but smoking.

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At Insite, an area once used for storing coffee and powdered drink mixes has been turned into the site of a program that offers select clients access to pharmaceutical alternatives to street drugs – an intervention commonly called safer supply. Launched last year, it has just 17 participants, each of whom was assessed by a clinician before being prescribed a regulated fentanyl medication.

It’s a tiny example of a provincewide initiative that has rolled out in fits and starts. Proponents say making legal drugs available is the most immediate way of addressing the skyrocketing number of deaths caused by the toxic illicit supply; critics counter that it is no more than government-subsidized drug use.

Provincial Health Officer Bonnie Henry said she is distressed by the political rhetoric over the issue. The province is working to amplify the benefits of safer supply while mitigating unintended consequences, which have included reports of young people accessing diverted safer supply medications. Her office is reviewing the program and is expected to release recommendations to the government in the coming months.

Elizabeth Holliday, the operations director for overdose emergency response and harm reduction at the health authority, sees similarities between the fight for Insite in the 1990s and today’s push for a safer drug supply.

“Insite had a pivotal role in disrupting HIV transmission,” she said. “We can draw a parallel to the current crisis and the work Insite is doing to generate evidence for novel medications for people who use drugs.”

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