The foresight of insite

Dispelling the myhs of drug addiction on Vancouver's downtown eastside

ERIC SZETO CUP WESTERN BUREAU CHIEF

VANCOUVER (CUP) — On any given morning on the corner of East Hastings and Columbia in front of the Radio Station Cafe, a drug dealer can make up to $35,000. Their customers approach them in a nonchalant fashion, do their business and quickly scuttle off in various directions. Some may venture back to their hotel rooms, rented out at cheap monthly rates. Many will drift into the nearest alley and quickly dose. But these days, most will probably walk into Insite, Vancouver’s highly publicized and contentious safe injection facility, open to all and just eight doors down.

15,000 NEEDLES ON THE WALL, YOU TAKE ONE DOWN, PASS IT AROUND . . .

Even on the slowest day, the Vancouver Area Network of Drug Users (VANDU) estimates that nearly 15,000 heroin injections take place in the Downtown Eastside, and Tyrone Caldwell, 39, used to take his fair share.

Caldwell spent the last 14 years of his life dabbling with different drugs, but it was during the last five years things began to get really heavy. After nearly a decade of drug use, he lost control, and in order to support his $300-a-day cocaine habit started dealing narcotics himself, including heroin.

It was in May that he went into the facility as he would on any normal day. He proceeded into the injection area to shoot up. The area is the width of a desk, with a mirror in front and two walls, giving an individual the suggestion of privacy. Immediately after dosing, Caldwell had an ominous feeling that something was not right.

“The minute the buzz or rush started coming on, I knew it wasn’t a cocaine rush,” he says. “I knew I was in trouble and that’s the last thing I remember.”

Caldwell was put into an ambulance after the paramedics gave him a shot of Narcan, a drug that reverses the effects of opiates, to revive him. Caldwell later discovered that what he had injected into himself wasn’t just cocaine, it was a nasty trail mix of heroin and cocaine, which led to his overdose. And it was solely because of the staff at Insite that Caldwell didn’t die that day. Caldwell knows this full well.

“If Insite wasn’t there and I was in the alley, I’d be dead,” he says.

Caldwell isn’t the only one. Since its inception in 2003, Insite has grown in popularity among drug users on the Downtown Eastside, averaging around 700 visits per day. Section 56 of the Controlled Drugs and Substances Act allows Insite, in addition to housing doctors prescribing methadone for those in rehab, to have legal possession of controlled substances. Because of this exemption, Insite is currently the only place in Canada where a person can legally carry narcotics on them.

Before Insite, the number of overdoses and rates of infection for HIV and hepatitis A, B, and C were soaring on the Downtown Eastside. According to Anne Livingston, a project co-ordinator for VANDU, deaths by overdose climbed from 35 in 1989 to 350 in 1994. The 1995 Vancouver Injection Drug User study sampled 5,000 users in the Downtown Eastside and estimated that the prevalence of HIV/AIDS in the area was around 40 per cent while hepatitis C hovered around 90 per cent.

The community was dying.

With already alarming rates of infection and death escalating rapidly, the city soon realized traditional drug enforcement and treatment strategies were failing. Vancouver subsequently adopted its “Four Pillars Drug Strategy,” which consists of harm reduction, prevention, treatment, and enforcement. Insite was implemented as a progressive step towards increasing harm reduction, though some might argue it promotes all four pillars.

Open 18 hours a day, Insite has become one of the busiest safe injection facilities in the world. There is no limit to how many times a day a person can use the site. Accounts of its successes have been exhaustively documented. There are over 7,000 registered members and there have been 500 overdoses, none of which have resulted in death. Furthermore, Insite has found that users of the site are twice as likely to get into detox.

And while there is no evidence yet to suggest that the rates of HIV or AIDS have gone down since Insite opened, neither have there been any studies investigating this issue. It would be counterintuitive to think that the facility has been anything less than a bastion of prevention. The evidence of its success speaks for itself.

In spite of this, at the end of August the future of the facility was in limbo. The federal exemption that allowed Insite to operate was due to expire on Sept. 12 and Canadian Health Minister Tony Clement, rather than extending it for another three years, has reluctantly bowed to public pressure and renewed the exemption only until December 2007. The scientific evidence, according to Clement, was inconclusive.

“Do safe injection sites contribute to lowering drug use and fighting addiction? Right now the only thing research has proven conclusively is that drug addicts need more help to get off drugs,” said Clement in a media release. “Given the need for more facts, I am unable to approve the current request to extend the Vancouver site for another three and a half years.”

Despite scientific evidence and public support of the facility from all levels of government, the Ministry of Health opted to shy away from granting proponents of the site its full demands — the disconnection between those in Ottawa and the people at the frontlines is unsettling. Jeff West, a co-ordinator at Insite, has witnessed firsthand the changes the facility has brought to the Downtown Eastside. He’s seen its successes and its failures. His apparent modus operandi is to dispel the myths circulating in Ottawa and educate people about the many other services that Insite provides.

“We teach people, we never hold or touch the needle, that’s the bottom line,” says West. “[The staff] can tie people off, help them find a vein, [pick] what kind of angle to insert the needle. We also have a prosthetic arm that has veins and use that as a teaching tool.”

West stresses the strictness of these guidelines. If someone dies and they have gone beyond their immediate duties, says West, it’s an automatic charge of manslaughter.

But the big appeal for Insite, West says, is giving a shelter to the people living in squalor. It provides the lost and hopeless a place where they can go. This is fundamental, he says.

“People are complex souls.Addictions are a result of other stuff going on. Ultimately you could really just focus on the addiction, and they can go to detox.”

Caldwell and many others can attest to the success of this program.

“If Insite wasn’t there . . . I really wouldn’t be here,” says Caldwell, who now volunteers at Insite. “I’m living on borrowed time and I’m here to help them. No questions.”

MEANDERERS, MISCONCEPTIONS, AND MISDEMEANORS

When her sister became a crystal methamphetamine addict, Darcy (who is using only her first name to protect her identity) took custody of her sister’s children. She was only 22. For the next 25 years, she was an operating engineer in northern B.C., making almost a six-figure income for many years.

But after injuring her back and losing the pension she spent her entire life working for, everything came crashing down. She eventually moved to the Balmoral Hotel in Vancouver’s Downtown Eastside. She had nowhere else to go.

On welfare for the first time of her life, she started using drugs. From A to Z, she did it all, everything except crystal meth — something she promised herself she would never do after seeing it kill her sister.

“It was from 25 years of being straight, I wanted to experience it all. You name it, I did it. My sister was a junkie; it was like I wanted to experience what she experienced.”

At the height of her drug addiction she was visiting Insite nearly four times a day.

“What I went for was the congeniality and I’d go there because it’s a nice, clean place. I don’t actually inject anymore.”

She can barely describe some of the atrocities she’s seen because they are so egregious. Before Insite, she says, women were contracting HIV at enormous rates. She attributes this to the fact that women are most vulnerable in the Downtown Eastside.

Often times, she says, prostitutes, too messed up to do their own drugs, ask their pimps to shoot them up. But instead of using a clean needle, her pimp uses a “rake,” a needle that has already made the rounds, which is almost inevitably tainted and ridden with disease. As soon as that needle is used, the woman has contracted HIV.

Insite, she says, offers these women an alternative.

“This is a place where women go to control disease,” she says. Closing the site would force many women back into the alleys.

The misconceptions about Insite were clearly shown in an online Globe and Mail debate between former mayor of Vancouver and current Senator Larry Campbell and Randy White, the founder of the Drug Prevention Network of Canada held in August, before the extension to the exemption was granted.

During the debate, White, a former Reform-Alliance-Conservative MP and vice-chairman of the parliamentary committee studying the non-medical use of drugs, gave a list of reasons why Insite’s exemption under the Controlled Drugs and Substances Act should not have been renewed and why the site should have been shut down.

Among the reasons:
1. Injection sites do not prevent and treat drug use.
2. Since the opening of the site, crime and addiction have become more problematic in Vancouver, and the injection site has contributed to the problem.
3. Responsible government does not sanction a person walking through a door and getting assistance to shoot up crystal meth.
4. Injection sites are the exception, not the rule, in most countries worldwide.

Campbell retorted: “To be blunt, [White] is a dinosaur and refuses to even consider scientific, peer-reviewed evidence. I suspect that deep in his mind, he believes the earth is flat.”

The inability to get past archaic misconceptions about the realities of drug use is at the root of the problem, says Nathan Allen, an organizer for Insite for Community Safety, an advocate group for Insite.

“[The] federal government doesn’t fund any component. Insite doesn’t provide drugs. They aren’t asking for a single red cent, just for the blessing, just for the exemption to be renewed,” Allen said.

Libby Davies, a proponent of Insite and an NDP MP, echoed Allen’s concerns. She herself is baffled as to why the scientific evidence that has accumulated over the past three years is being disputed.

“The evidence [about] Insite is irrefutable, there’s no research that suggests it’s not working as it should be . . . They’re dead wrong with the disputes. You can’t ignore the scientific evidence from incredibly reputable sources. It’s been under a microscope for three years. It’s not a panacea for the drug solution, it's part of the solution.”

Echoing Davies’ concerns, Darcy adds a more extreme viewpoint. She believes that Ottawa has given the addiction situation and Insite a lack of attention, and the subsequent drug-related deaths in the Downtown Eastside area is a form of population control.

“[Drug addicts] are seen as a subhuman species here, but they aren’t. It’s tough to make it as a man down here but it’s even tougher to make it as a woman. They’ll stab you, knife you. That’s the element you have to be in.”

Even if you don’t believe in what Insite does, there are many right-wing libertarian arguments that point to a decrease in tax dollars being spent. According to VANDU and Insite, every ambulance coming into the Downtown Eastside costs $1,000. Each case of HIV/AIDS costs the health-care system $320,000. The financial burden the area once carried has decreased significantly.

Surprisingly, one of the strongest messages of support comes from the Chinatown Merchants Association. Before the site opened, the association was among the groups most vehemently opposed to the injection site. Now they are one of Insite’s biggest supporters.

“There aren’t any people shooting up in front of the businesses anymore and Insite has [shown] by example that it works,” says Allen.

Perceptions of addiction differ drastically between “experts.” People like White, hell-bent on sticking to anti-drug dogma, see addiction anachronistically as a crime rather than an illness. But what people like White fail to see in almost all drug addiction cases is that there’s often a story behind it that is overlooked. Traumatic events — rape, abusive pasts, a string of bad luck — all these things can act as catalysts to addiction.

“[Drug addicts have] lost their self-esteem,” Darcy says. “A lot of people are forced here. Just like myself. You end up getting down here because bad things happen to you. A lot of people are unable to take care of themselves and they get into drugs.”

ROGUE SQUADRON: DISPERSE AND RESIST!

Six to eight hours after the last dose of heroin, a person can begin to have withdrawal symptoms that include severe anxiety, depression, diarrhea, convulsions, vomiting and uncontrollable body movements. Mary Miller used to dose at Insite frequently to avoid these symptoms.

“You don’t want to go sleep because when you wake up you’ll be too sick to move,” she says. To alleviate these symptoms she now gets a portion of her welfare check deducted to pay for her methadone.

Months before the creation of Insite, a group called the Vancouver Area Network of Drug Users (VANDU), started in 1998 by a group of intravenous drug users that advocated living healthy, productive lives, opened their own de facto safe injection site for people like Mary.

The rogue site could barely operate and their hours were limited (10 p.m. to 2 a.m.), but according to Ann Livingston, it was what gave the city the gumption to eventually open a legally sanctioned facility in 2003.

Livingston, a project coordinator for VANDU who also ran unsuccessfully for city council in 1996 and 1999, says it was this critical pressure from VANDU that finally started to change minds. The municipal government, she says, had repeatedly neglected the idea for the site for a number of years.

When the Sept. 12 shutdown seemed imminent, VANDU sought an injunction on Aug. 31 to the B.C. Supreme Court, stating it was unconstitutional for the site to be closed. The following day Tony Clement made his statement stating the government would extend the exemption for another 17 months.

The news wasn’t so encouraging to Livingston, who says that the federal government is just stalling in making a “real” decision. The noncommittal attitude Ottawa had taken during the whole ordeal seemed to indicate to Livingston that a shutdown, regardless of the extension, is imminent. The extension doesn’t really mean anything, she says.

“[Tony Clement] hasn’t read the studies, he doesn’t know what he’s talking about. Most of our struggles in the long-term [have been to] provide public health facilities and it will save you money in the long run,” she says in response to the health minister’s recent statements.

“It’s unprecedented to have a minister of Health ignoring info that’s published in the [New England Medical Journal],” Livingston adds, referring to studies published about the impact of Insite.

Even with the cynical outlook, she is still lobbying to open four more government-sanctioned sites. One site, she says, isn’t enough.

“It’s the equivalent of your whole body covered in running sores and one patch is cleared up,” she says. “We know it works but we can’t put it on the rest of our bodies. I said ‘Fuck you, we can’t.’”

Her plan is to put three more sites on the perimeter of the Downtown Eastside. By surrounding the area with sites it would, in theory, be easier for addicts to get to a nearby site.

But the likelihood of three more sites popping up once the exemption expires in December 2007 seems a stretch. Livingston knows it, and that’s why VANDU is doing whatever they can to help.

The group has already taken the matter into its own hands. If you know what they look like, you can spot them a block away. A team of 10 people in fluorescent vests patrol the streets educating and, in many cases, illegally assisting the injections of addicts in the area who are unable to perform them alone.

These rogue patrols complement the limited services Insite can legally provide. Often, people have to be rejected from Insite because they are not capable of injecting their own drugs, and Insite workers cannot do it for them. These people — the most impaired, and the most at risk of contracting disease — are the ones the patrollers put first when on the street.

This squadron of injectors, all trained health-care workers certified in CPR, assist in any way they can. If you’re blind and have an amputated arm, for example, they will help you inject.

“It’s considered illegal,” Livingston admits. “But if I inject you with drugs the joke is that you won’t die. You’re much less likely to die with a trained expert who knows CPR and has gloves on.”

Livingston is sure that if the government in Ottawa decides to pull the plug after December 2007, rogue sites will replace Insite. Before Ottawa announced the extension on Sept. 1, VANDU and other groups were already getting one ready. They were just waiting for the signal.

The rumour is that the Portland Hotel Society, a Vancouver-based substance abuse advocacy group, has already built a site.

“The only way to find out,” says Livingston, “is if you find one of their workers and literally follow them around until you see them all going to the same place.”

* * *

The future of Insite remains uncertain until December 2007, but there is no doubt that whatever decision is made in Ottawa, it will not sway supporters of Insite from fighting on behalf of their growing and evolving community.

Livingston can attest to that. If Ottawa says no to an exemption beyond 2007, the gloves are going to come off.

“[Ottawa is] going to mud-wrestle with us,” she says. “I don’t think that they want that because we would win.”