Every morning, Kevin Thompson takes a short stroll from his apartment to the Crosstown Clinic, where he signs in, gets his prescription medicine, then sits in a small room and injects it before heading off to work.
He follows this routine up to three times a day, and has done so virtually every day for more than a dozen years.
The medicine is diacetylmorphine, the medical term for prescription heroin.
"It saved my life. No question, it saved my life," Mr. Thompson, 47, says emphatically.
Mr. Thompson has been a heavy user of street drugs such as cocaine and heroin since his early twenties. He was at college, studying hairdressing, when he was robbed and lost all his money, and ended up homeless. To get by, he started selling drugs, and soon became his own best customer.
"I'm not sure exactly how I got into drugs, but I sure did get into them," Mr. Thompson says with a laugh.
He became addicted not only to drugs, but to the "hustle" – the high-octane, high-risk lifestyle of dealing, stealing, and shooting up over and over again.
In 2005, Mr. Thompson was recruited to participate in an academic study known as the North American Opiate Medication Initiative (NAOMI), which tried to determine if diacetylmorphine worked better than methadone. NAOMI morphed into SALOME (Study to Access Longer-term Opioid Medication Effectiveness) and eventually into a special-access program run out of the Crosstown Clinic.
Along the way, the former Conservative government tried to shut down the initiative, resulting in lengthy court battles, but a small program remains.
Mr. Thompson is one of 91 people prescribed diacetylmorphine, while another 24 get hydromorphone, and a couple of dozen others have transitioned to oral drugs such as methadone, Suboxone and slow-release liquid morphine.
The philosophy behind the program is simple: It reduces harm – to drug users and to the community.
Heroin substitution is designed for intractable users who have failed repeatedly at rehab and other harm-reduction measures such as methadone.
Mr. Thompson, who was getting up to 400 milligrams of diacetylmorphine three times daily – "enough to kill a horse," in his words – has never overdosed, nor has he had complications that are common with street drugs.
He also gave up the hustle, meaning he long ago stopped shoplifting, breaking into cars and other things he did to afford his next hit.
"I went to jail a lot, but I haven't been to jail in eight years," he says.
Nor does he make regular visits to the emergency room, which were common when he lived on the streets and suffered routinely from violence, infectious disease and other health problems that accompany addiction.
"I've got my own place. I've got a scooter. I've got a full-time job. I even have a five-year relationship," Mr. Thompson says.
"If I was your neighbour, you wouldn't know I was on dope."
The "dope" he takes now is a prescription drug supplied by the state. It costs approximately $25,000 a year per person – $10,000 for the drug itself and $14,750 for the operation.
It's expensive for Crosstown Clinic to operate because the rules are onerous. Diacetylmorphine is imported from Switzerland and prescribing, dispensing and storing it requires elaborate paperwork and tighter security than some banks. Prescription heroin users must come at specific times, receive a precise dose, inject in the supervised facility, and the unused product is destroyed.
That cost would be a fraction if we were more pragmatic and treated heroin like other prescription drugs and expanded the program, allowing economies of scale.
It is estimated that about 500 people in Vancouver alone could benefit from heroin-substitution.
The research that has been carried out over the years shows this harm-reduction approach saves money because long-time drug users such as Mr. Thompson previously used an average of $48,000 annually in health-care and criminal-justice services.
Those base economic calculations don't take into account that people are kept alive and lead productive lives.
Mr. Thompson, for example, oversees an overdose-prevention site on Vancouver's Downtown East Side. Working at the coal-face of the opioids crises, he has lost track of how many people he has had to revive with naloxone and how many friends he has lost because they used contaminated street drugs.
"I kind of feel guilty sometimes because I'm getting help and others aren't. It makes me sick to know we could be saving lives and we're not."