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a killer high

People wait outside Insite, North America's only supervised injection site run by the Portland Hotel Society, in the Downtown Eastside in Vancouver, British Columbia.Rafal Gerszak/The Globe and Mail

This story is part of A Killer High: A Globe examination into the rise of fentanyl in Canada.

Before there was fentanyl, the highly addictive opioid at the centre of an ongoing national crisis, there was OxyContin, another drug that took the lives of vulnerable populations. And before Oxy, there was heroin.

In Vancouver's impoverished Downtown Eastside, heroin's ravages helped tip the province into a public-health crisis in the late 1990s. Borne of necessity 13 years ago, Insite, a supervised-injection clinic that remains the only of its kind of North America, persevered under the Conservative government's tough-on-crime anti-drug strategy, which ran counter to such treatment models. After successfully battling the government in a series of court cases, the facility has emerged as a model in harm reduction, representing a new approach to addiction treatment that the current Liberal government has embraced and one many communities, including Toronto, are trying replicate.

Federal Health Minister Jane Philpott has publicly voiced support for harm-reduction facilities and, in January, visited Insite, describing the experience as "extremely moving." Earlier this month, she further distanced her government's approach from that of the Conservatives, noting that Health Canada is looking at developing a pan-Canadian approach to monitoring prescription drug abuse, as well as projects aimed at developing safer opioid prescribing practices.

"We have sent the message out loud and clear that this is a priority for us," Dr. Philpott said.

Dean Wilson remembers the day the wheels were set in motion for this revolution in the nation's approach to drug policy.

It was 1998, and Mr. Wilson, a long-time heroin user and Downtown Eastside advocate, stood in the drizzle at Oppenheimer Park with about 500 others – municipal and provincial politicians, the chief coroner, a police drug squad, health officials, drug users and activists – for a symposium on harm reduction.

B.C., at the time, was in the grip of a public health crisis. At its worst, in 1995, the rate of positive HIV tests among adults was about 18 per 100,000; doctors were diagnosing two new cases of AIDS every day. The city's troubled Downtown Eastside had what was described as the highest rate of HIV infection in the western world. Meanwhile, a study of injection drug users in the province found that up to 90 per cent had Hepatitis C, the result of sharing needles and other drug-injecting equipment.

It was as good a time as ever to contemplate one of North America's most radical public health interventions.

"Before that symposium, a lot of people hadn't even heard of supervised injection service," said Mr. Wilson, who would later become the president of the Vancouver Area Network of Drug Users (VANDU). "A lot of people were aghast, but some of us knew that's what we needed here."

Its practices of providing drug users with sterile equipment and supervision by trained staff, as well as allowing them to connect with health and social services without fear of harassment or arrest, were deemed controversial under Conservative leadership, but the clinic prevailed.

Harm reduction programs now provide an advantage in combatting the fentanyl crisis that is sweeping the country. The powerful synthetic opioid, which is often cut into other drugs and ingested unknowingly, was detected in less than 5 per cent of all illicit drug overdose deaths in 2012 in B.C.; that figure climbed to 30 per cent last year.

Philip Owen, who served as Vancouver mayor from 1993 to 2002, remembers the calls from community groups for the harm-reduction service during his tenure.

"As a mayor, I had to understand what it was all about," said Mr. Owen, now in his 80s. "I was interested in this subject. 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. I had to go and figure out which it was."

Some of this research included travelling to Europe to learn about the experience in Germany, Switzerland and the Netherlands, where numerous consumption sites were already in operation. Some of it had the former mayor dressed down in blue jeans, wandering the Downtown Eastside at night, asking drug users about their circumstances.

"It was just unbelievable the stories that you hear about some of these people. Some of them are just in terrible shape. They convinced me that [drug abuse] is a health issue," Mr. Owen said. The conservative-minded politician with the right-wing Non-Partisan Association had become an unlikely advocate for harm reduction.

The mayor contacted Ujjal Dosanjh, then attorney-general of B.C., and Allan Rock, then federal minister of health, and discussed the idea of a supervised injection site in Vancouver. They, too, were supportive. Before long, Vancouver secured federal funding to open Insite as a pilot project, which the Portland Hotel Society, a non-profit advocacy group, and health authority would operate in partnership.

Chris Buchner, who as a 30-year-old in in 2002 had just been hired as the health authority's manager for HIV and harm reduction, was assigned to the planning for the supervised injection site.

"I remember saying to my boss at the time: 'This is a project that could make or break someone's career,'" recalled Mr. Buchner, who today is regional director of prevention at Vancouver Coastal Health. "I was nervous because it was political. I think part of what caused me a lot of anxiety was that to get a lot of the key stakeholders on board, we really had to over-promise.... To get people from their initial no to even a qualified yes, we had to tell some of the stakeholders that this would cause world peace and there would never be another overdose."

Still, the hardest work had been done by the community advocacy groups: the PHS, led by cofounders Liz Evans and Mark Townsend; VANDU, by cofounder Ann Livingston and Bud Osborn.

"The health authority and the ministry of health were Johnny-come-latelies to the picture; we weren't the ones who had to do the difficult work of socializing the idea and advocating for it," Mr. Buchner said.

Larry Campbell, who attended the 1998 symposium as B.C.'s chief coroner, took the reins from Mr. Owen in 2002, winning Vancouver's mayoral election on a campaign that promoted harm reduction as part of the Four Pillars approach to drug use.

Under Canada's Controlled Drugs and Substances Act, an operator of a supervised injection facility must first apply for, and receive, an exemption from Section 56 of Canada's Controlled Drugs and Substances Act (CDSA). Insite opened its doors in September, 2003, on a three-year exemption and received two subsequent extensions, running through to June, 2008.

Meanwhile, new HIV/AIDS cases dropped. A report in the Canadian Medical Association Journal projected the facility could avert 1,191 cases of HIV and 54 cases of hepatitis C in a decade, saving $14-million health care dollars. A 2008 study by the B.C. Centre for Excellence in HIV/AIDS found that the facility prevented up to a dozen overdose deaths a year. Police reported less street disorder and public drug use in the area. Evidence seemed to back the fledgling harm-reduction initiative.

But in 2006, Stephen Harper's Conservatives formed government, promising to change course from the 13 years of Liberal rule before it. This included a tough-on-crime approach to drugs that ran counter to harm reduction measures; on supervised injection sites, Mr. Harper pledged that his government would never use tax dollars to "fund" illicit drug use. The federal government said it would not grant Insite another Section 56 exemption.

In August, 2007, the PHS, along with Mr. Wilson and another Insite client, filed a statement of claim in B.C. Supreme Court, arguing that jurisdiction over Insite should be exclusively provincial and that federal intervention would be a violation of clients' Charter rights. The court sided with the plaintiffs, declaring that sections of Canada's drug laws were unconstitutional as they related to the supervised injection facility.

The Attorney General of Canada appealed the decision and lost at the B.C. Court of Appeal; the attorney-general filed a further appeal with the Supreme Court of Canada.

In September, 2011, the Supreme Court sent a clear message: In a 9-0 decision, it ruled that the federal government's efforts to shut down Insite violated injection drug users' Section 7 Charter rights to life, liberty and security of the person. While the federal government has the right to restrict illicit drug use under the Controlled Drugs and Substances Act, using it to prevent users from accessing the health services offered by Insite actually undermined the legislation's very purposes: the protection of health and public safety.

"During its eight years of operation, Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada," the Court said. "The effect of denying the services of Insite to the population it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics."

To date, nurses at Insite have supervised more than 2-million injections; there has never been a fatal overdose. Non-fatal overdose rates have coincided with public health alerts about fentanyl circulating in the local drug supply, suggesting that those who overdosed on it at the facility could have seen grim outcomes had it not been for the medical intervention of Insite nurses.

Last month, Health Canada, under the new Liberal government, voluntarily issued Insite a four-year exemption, green-lighting its operations until at least 2020.

Still, even the facility's staunchest supporters acknowledge it is no panacea. It won't help users who smoke or swallow their drugs. Middle-class recreational drug users will likely never set foot inside. It is just one service among a spectrum that is needed in the fight against drug abuse and addiction – but a crucial one, says Andrew Day, operations director for Vancouver Coastal Health.

"With fentanyl, it's almost like a weather front rolling over the [country], where more and more people are being impacted by toxic batches of drugs, or people think they're taking one drug and getting another," he said. "We can't give people other choices in life, and they aren't able to make other choices in life, if they're dead. What we always have to remember is that they may be addicts, but at the end of the day, that's just one part of who somebody is."

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