“People need to feel comfortable using.”
These are the words of Darwin Fisher, manager of InSite, a supervised injection facility in Vancouver, Canada. Here, Fisher manages 13 booths, each one lined with mirrors and bright bulbs resembling those of a dressing room — and they are in demand.
As he stands and watches, all the booths are being used by people staring closely at their reflections. Their goal is to inject themselves safely with illicit drugs — and do so legally.
Up to 1,000 people visit here each day.
Fisher’s team at Insite includes a front line of nurses, counselors, mental health workers and peer-support workers to ensure people inject their drugs safely — reducing the risk of overdose and of infections such as HIV and Hepatitis C.
“It’s about helping people who have been marginalized to the alleys and bring them into the light of healthcare,” says Fisher. The booths at InSite are used by people from nearby streets hoping to satisfy their addiction, but with a nurse close by.
Music plays gently in the background as people approach a table stocked full with the equipment they came here for — needles, cotton pads, antiseptic and more. All sterile. All safe to inject with.
This creative approach includes a crack-pipe vending machine at a nearby drug resource center, which dispenses clean pipes for just 25 cents. People bring their own drugs.
These controversial facilities are located in the heart of Downtown Vancouver, on its Eastside, infamous for its high concentration of homelessness and drug use. Back in 1997, Vancouver had the highest rate of HIV in the developed world. Today, experts say this area has the lowest life expectancy in all of British Columbia and 27% of intravenous drug users are HIV positive.
“This vibrant part of the city became abandoned and then reoccupied by individuals who are predominantly poor and have very high rates of injection drug use,” says Julio Montaner, professor of Medicine at the University of British Columbia, who has seen the health impact of this rise in illicit drug-use. “It’s one gigantic shooting gallery,” he says.
Locals include Wesley Jerilla, 53, who moved to the neighborhood in the 1990s after developing an addiction to substances as a teenager. “I lived life on the edge,” says Jerilla, who began injecting at the age of 13. “I couldn’t keep $5 in my pocket, I had to get crack,” he says.
Jerilla began visiting Insite in 2007 and although he continues to inject today, he no longer has the urge every day and now volunteers at the facility to help others. “I’ve now gotten a few people into detox,” he says.
The impact of supervision
Since Insite opened in 2003, the neighborhood has seen things change — for the better. Among those using the injection rooms, the likelihood of them entering detox increased by 30%, and people are 70% less likely to share needles, according to a study by the British Columbia Center (UBC) for Excellence in HIV/AIDS.
“I was as skeptical as anyone else … and we’ve shown a decrease in overdose, HIV transmission decreased and safer practices became the norm,” says Montaner.
At the start of this century, one third of all overdoses in Vancouver occurred in this part of the city, but the UBC study found a 35% reduction in deaths from drug overdose in the immediate neighborhood, compared to 9% across the rest of the city.
“We should expand this so it’s available to more Canadians and more people who use drugs internationally,” says Thomas Kerr, who led the study.
InSite is funded by taxpayers, at a cost of $3 million Canadian per year. The facility says that for every tax dollar spent, four are saved, by preventing expensive medical treatments for addicts further down the line.
But Insite is not without critics. Some drug counselors believe the facility acts an enabler, which feeds addiction, and ultimately hurts the addict.
The facility was also opposed by Canada’s previous Prime Minister, Stephen Harper. In September 2011, judges at the Canadian Supreme Court ruled in favor of keeping InSite open against the wishes of Harper, stating that InSite allows drug addicts access to the same healthcare as other Canadian citizens.
Today, Insite is one of more than 90 supervised injection sites worldwide, but remains the only one of its kind in North America.
“The predominant concept [to date] has been a drug-free world, rather than a pragmatic acceptance that substance use is common,” says Chris Beyrer, director of Johns Hopkins Center for Public Health & Human Rights.
Supervised injection is yet to cross the border into the U.S. where even the more accepted approach of needle exchange is limited by a federal ban on funding for such services.
Beyrer believes the approach of a “War on Drugs” is preventing countries like the U.S adopting strategies that can make a difference in other ways and hopes continued evidence on the benefits of harm reduction will help his home country move forward.
The world’s first official supervised injection facility opened in Berne, Switzerland in 1986, and multiple cities in Europe then followed in the decades thereafter. Today, the majority of injection rooms continue to be found in Europe.
The goal for Insite, and other supervised injection facilities, is to establish contact with users who are otherwise lost to health services and help them detox when they are ready.
“When people are ready and want to get off drugs, they have to have access,” says Beyrer, who is trying to influence policies in the U.S.
The rooms in Vancouver now host Onsite, a detox facility located above the injecting rooms, and it is constantly full with people trying to get clean.
But critics believe it’s not enough.
“Very few people make it upstairs,” says Marshall Smith, an addiction expert from Cedars at Cobble Hill Treatment Center, and a former addict who once found himself on the streets of the Eastside. After ministerial positions with the Government of British Columbia, Smith has long been advocating for drug users to have greater access to treatment for their addiction rather than simply reducing harm.
“Turnstile programs keeping addicts in their disease are not helpful overall except to reduce this small section of disease,” says Smith, who wants more focus on recovery. He feels health services need to increase their capacity to get more people into detox.
“These programs are not designed to deal with addiction … we can make it better by including assertive programs to get people into recovery,” Smith says.
Advocates maintain that getting users to inject off the streets has improved everyday life in the local community, with fewer needles left on the streets and fewer people collapsed from using them.
“If you’re someone who lives in a neighborhood with injection drug use and you don’t like discarded syringes and seeing people shooting up on your street, then what you want in your facility is a supervised injecting site,” says Kerr.
“It makes communities safer and makes drug users get the help they need.”