Toronto’s supervised injection sites offer start to reducing overdose deaths

theglobeandmail.com
March 18, 2016
By Jeff Gray

Frank Coburn, 70, says he overdosed on the drug fentanyl last year while furtively shooting up in Seaton House, one of the downtown’s largest homeless shelters. He says he blacked out and his heart stopped. The next thing he knew, he woke up on a stretcher, looking up at the paramedics who revived him.

“In a safe-injection site, it would never have gotten that far,” said Mr. Coburn, who is no longer homeless but still uses drugs and the services of the Works, a harm-reduction clinic for drug users near Yonge-Dundas Square where he also serves as a “peer outreach worker.”

Instead of dying of overdoses alone in alleyways, addicts using a supervised injection site can be tended to by a nurse right away. And, in Mr. Coburn’s case, he says he would also have been able to mix his drugs himself, instead of needing to quickly and clandestinely inject a “premixed” hit inside a homeless shelter, making an overdose less likely.

Toronto Public health officials had Mr. Coburn on hand this week as they announced a proposal to open small-scale supervised injection sites for users of heroin or other injectable drugs at three health clinics across the city. The Board of Health (which meets on Monday), City Council, the provincial government and the federal government must all still approve the plan. Consultations with the affected neighbourhoods and the police are also mandatory.

The three sites under consideration are Toronto Public Health’s the Works needle-exchange clinic on Victoria Street near Yonge-Dundas Square, the Queen West Central Toronto Community Health Centre near Queen Street West and Bathurst Street, and the South Riverdale Community Health Centre on Queen Street East near Carlaw Avenue.

Toronto’s top health official, Medical Officer of Health David McKeown, and a downtown city councillor who heads the city drug strategy panel, Joe Cressy, have been championing the cause, citing numbers that show a 41-per-cent increase in overdose deaths over a decade in the city, with 206 reported in 2013. Supervised injections sites, they say, will save lives and reduce that number.

But Jurgen Rehm, a scientist at the Centre for Addiction and Mental Health (CAMH) and a leading expert on harm reduction, cautions that winning acceptance of these sites with pledges that overdose deaths will plummet right away could end in disappointment.

There is no question a “clear consensus” exists among health experts that supervised injection sites - of which more than 90 now operate around the world - are beneficial, Dr. Rehm says, and addicts who use them are much less likely to die of an overdose. But drug addiction is far from an easy problem to solve. And Dr. Rehm fears that the ideological battle lines drawn around supervised injection sites can make it harder to appreciate the benefits that they do offer, as forces pro and con debate the issue in black and white, instead of grey.

“Once such a decision is made, it is oversold. It is hyped up. It’s seen as a panacea,” said Dr. Rehm, who is the director of CAMH’s social and epidemiological research department and also holds posts at the University of Toronto and the Dresden University of Technology.

Any notion that three small-scale sites could quickly lead Toronto’s overdose death numbers to dwindle in the first few years is “rubbish,” he says. In fact, overdose numbers could rise, he said, even if Toronto goes ahead with the three clinics.

Take Insite, Vancouver’s 13-year-old supervised injection site. Inside the facility, studies say, no one has ever died of an overdose. And overdose deaths near the Downtown Eastside injection site are also down dramatically. But overdose deaths in Vancouver as a whole remain high, Dr. Rehm says, because less than 10 per cent of all of Vancouver’s drug injections take place within Insite, even with the centre’s large size and profile. And in Toronto, an even smaller fraction of drug injections would take place in the proposed three new supervised centres, if they are approved.

That is partly due to their small size: Toronto Public Health says each clinic will have just three spots for addicts to shoot up at a time, in a small room, limiting the numbers that can be accommodated. It is also partly due to the fact that, especially at first, many drug users will choose to stay away, distrusting the public-health system and fearing that police are lying in wait outside a supervised injection site in order to arrest addicts, Dr. Rehm said.

Still, he said, harm-reduction policies, including supervised injection sites but also the distribution of “overdose kits” containing the anti-overdose drug naloxone, do reduce overdose deaths. But it takes time.

Getting hard-core drug users to kick heroin or other opioids is extremely difficult. But offering a supervised injection site does get addicts in the door, Dr. Rehm and other proponents say, establishing a relationship with health workers that could see some drug users get into treatment and emerge drug free.

And there is no question, Dr. Rehm says, that operating supervised injection sites is more cost efficient for the health system than the status quo, as they will at least somewhat reduce the need for emergency-room visits and ambulance and police time that street-drug overdoses now cause.

While supervised injection sites sound radical to many in Toronto, some other countries go farther: For more than 20 years now in Switzerland, the health system actually hands out heroin to addicts, particularly those that have trouble taking methadone, a drug commonly used to replace heroin.

This ensures users are getting drugs from a “safe” source, negating the need to scrounge up money to pay for their habit as they transition into treatment programs. Programs in Vancouver and Montreal briefly experimented with giving addicts heroin, but the exemptions were cancelled by Health Canada in 2009 under the previous Conservative government.

Experts say there is no evidence that harm-reduction policies actually increase drug use. They also say safe injection sites do not attract large numbers of drug users from other parts of the city, as addicts tend to use drugs in their own neighbourhoods.

One of the advocates that spoke with reporters this week about the need for supervised injection sites said she has no intention of stopping her own habit of injecting cocaine.

“I never wanted to stop using so that wasn’t my case,” said Cindy Reardon, 47, a “peer outreach worker” at the Works, the city’s central needle exchange clinic. A member of its client advisory board, she says she has been using the service since 1989, and strongly supports expanding it to include a supervised injection site. But she said only drug users who want to quit will ever quit.

“I have a job, I went to school, I have a home, so for me it wasn’t as chaotic as for some. But if you are street-involved, it is very hard to find a place to use. So [a supervised injection site] gets people in the door, and if you so choose, there is room for that conversation. But if they don’t want to, harm reduction dictates that we approach people where they are at.”

Ms. Reardon, who says she is HIV-positive and asked reporters to refer to her as “a user, not an addict,” says she used to shoot up in the unsanitary bathrooms of fast-food restaurants when she was a student at the University of Toronto’s Scarborough campus, a practice that saw her catch a serious infection that put her in wheelchair. This, she said, could have been avoided in a supervised injection site: “If you were an injection drug user, you would want this service.”

Mr. Coburn, the overdose survivor, says his life spiralled into depression, homelessness and drug use after a personal crisis about 20 years ago. Now 70, he says he is feeling better about himself.

Allowing drug users into a supervised injection site not only reduces the risks of overdosing alone in a dark alley. Mr. Coburn said it also brings people addicted to drugs out of the shadows and helps restore some of their dignity, as he gestured out the window of the Works clinic, opposite Yonge-Dundas Square.

“Across the street, that alleyway there, a guy ODed and was passed out in the snow and was run over by a dump truck,” he said. “These stories occur all the time, over and over again...You are running around, hiding in corners. You don’t want anyone to see you.”