The Positive Side

Spring/Summer 2006 

Out of Harm’s Way

Help, say the experts, not judgment, is what HIV-positive drug users are in need of. We take a look inside Vancouver’s controversial safe injection site

Story and Photography by Elaine Brière

TWO YEARS AGO, when Vancouver became the first city in North America to open a safe injection site where people can use narcotics in a medically supervised setting, a storm of controversy ensued. Critics claimed that the facility, called InSite, would increase drug use and make taking drugs easier — that addicts from all over the country would move to Vancouver.

These days it’s clear that by providing a benign environment for injection drug users, InSite (located on the infamous 100 block of East Hastings) has, if anything, reduced the harm and severity of the drug problem in the Downtown Eastside. “Given how new InSite is, the results are amazing,” says Dr. Thomas Kerr, a research scientist with the B.C. Centre for Excellence in HIV/AIDS, which is overseeing the evaluation of InSite. “There has been a substantial reduction of people injecting in public, less discarded syringes on the streets, reductions in needle sharing and elevated rates of entry into detoxification services.”

A pilot project funded by the Vancouver Coastal Health Authority, InSite also provides a point of contact for education, counselling and treatment. Its approach to street drug addiction is part of a philosophy and practice known as harm reduction. The central concept is to help people, without making judgments about their addiction or requiring them to stop using before receiving help. As Dr. Kerr says, “We have to invest in strategies that keep people alive and as healthy as possible until they get to that place where they quit on their own or their use stabilizes so they can manage their lives better.” Many say this is an approach whose time has come for North America.

At InSite, staff initially worried that people might be slow to use the facility, says coordinator Sarah Evans. “But after four months we were running at maximum capacity.” With 12 booths open 18 hours a day, InSite can handle up to 800 visits — just a fraction of the number of injections happening daily in Vancouver. But many users, like Wayne and Carla, are willing to wait their turn for the measure of safety and security the site offers.

Both are injection drug users who travel from their apartment in Kitsilano to use the facilities at InSite. Because both are HIV and hepatitis C positive, infections and abscesses from unclean needles and paraphernalia could prove fatal for them. About 17 percent of users at the facility are HIV positive.

 

CARLA IS AN ATTRACTIVE, articulate woman in her early fifties. She grew up in a small town near Montreal where her parents owned a hotel. “I was well taken care of,” she says. “I had everything I wanted. We had money. We lived by a lake. I skated. I skied. But I was a very high-strung kid; nervous and scared all the time. My mother didn’t know what was wrong with me. I was afraid of airplanes. It was the time of the assassination of John F. Kennedy and they were saying scary things on television… I took it as being real. I had to tape down the blinds in my bedroom at night and tack the drapes to the wall.”

When Carla was 11 her mother took her to a pediatrician who put her on Librium. Ever since, Carla has been taking drugs in the benzodiazepine family for anxiety and panic attacks. During the ’70s she experimented with hard drugs off and on but never became addicted until 1983, when her first husband died in a head-on collision in Montreal. She was working in the film industy at the time. “When I lost my husband, I started going out with a bisexual guy and fixing coke with him… anything to take away the reality.”

Her present husband, Wayne, is 38, but seems older. “Wayne is the best thing in my life,” Carla says. “I don’t know what I would do without him… my biggest fear is being alone and dying… with Wayne I can share my fears, someone to be honest with who sees every side of you and still accepts and loves you.” Lean and stoic, he looks like a sailor straight off the deck of a WWII merchant ship. His heavily tattoed right arm is lifeless from the elbow down after he accidentally injected a nerve two years ago, and he has a steel bar from his left knee to his ankle from an assault in 1999 during a botched robbery attempt he was involved in.

 

WAYNE FIRST INJECTED LSD at a party when he was 14. “To be honest,” he says, “I was petrified of needles. There was a big party. I was coerced into it. I had very low self-esteem. I wanted to be cool. I come from a small town just outside of Winnipeg. All my family were big drinkers.” That same year Wayne’s life in prison also began.

“My first conviction, for robbery, was when I was 14 years old,” Wayne says. “I got nine months in juvenile detention. From there it was nothing but prison. I matured very quickly in prison. The worst part was the loneliness; being locked down and nobody there. I’ve been in the prison system most of my life. I was in the penitentiary twice, once in Winnipeg, and once in Drumheller. I started with property crime — business, not residential — then it escalated. I have eight years’ experience as an industrial spray painter, which I learned in jail, but I can’t work now because of my health.”

Carla was diagnosed HIV positive in 1998 and began to take HIV medications to fight the virus. At first she had a strong negative reaction. “A nurse came every day to my hotel to make sure I took it. I had nausea, headaches — like the flu — right away. But my numbers were great. Undetectable. It was like the operation was a success but the patient died. So I went off the meds and I got better. The ones I’m now on are great. I don’t get sick at all.”

Both Wayne and Carla take daily methadone, an oral synthetic opiate administered by a pharmacist. It has a long-lasting effect that stabilizes the nervous system but without the euphoric effect of heroin. Many people on methadone, which is a depressant, still use stimulants like cocaine and heroin to get high and overcome the slowing-down effect of the methadone. Wayne is not on antiretrovirals right now because they conflict with his methadone treatment — to find a solution for this problem, he is having blood work done.

Before the safe injection site opened, Wayne and Carla injected in the alleys on the Downtown Eastside. “I had a rat run over my feet when I had a needle in my arm,” Carla tells me. “That’s the power of addiction. I was more concerned with my injection than the rat. This is not me at all. I still think about it and quiver. It just blows me away that I didn’t stop immediately and scream.”

“When you take that drug,” Wayne says, “whether you’re smoking it or injecting it or snorting it, you get this euphoric feeling of ‘nothing matters.’ You could have a cable bill you haven’t paid in three months, your life could be a total mess, a total disaster. You don’t have a nickel in your pocket. You’re at your wit’s end and then you take the drug and none of these things bother you anymore. You have energy, you feel that you can conquer anything.”

 

USING OPIATES CONTINUALLY over the long term creates opiate dependency — the drug is needed to generate an endorphin-like high. Bill Nelles, founder and director of The Methadone Alliance, a user-led group of activists and professionals in the United Kingdom (U.K.), talks about the long-term effect of opiate use on the brain. After six months or so of continual use, dependency takes place. “Opiates, unlike alcohol, are easy on the body,” he says, “but what does happen is that the brain shuts down the whole endorphin system…. In many, if not most users, these changes may not be reversible.”

The Alliance, which is funded by the British government, does educational work and lobbies for better treatment and services for addicts, such as safe injection sites, inhalation rooms, prescription narcotics and detox. The first harm reduction initiatives, Nelles says, were taken in the early ’80s by Amsterdam drug users who were worried about the spread of HIV and hepatitis C. “We took the Dutch work and brought it to the notice of the English-speaking world.”

A former opiate addict now on methadone, Nelles became addicted while he was a student nurse involved in a relationship with a doctor who easily obtained the drugs. No methadone program existed in eastern Canada in 1977, although there was one in Vancouver. Because he had a British passport, Nelles chose to go to the U.K. to get into methadone treatment. “All of the people I started doing opiates with in Ottawa are dead now,” he says. “We have this lovely idea that people who are addicted can come off the drugs if they want to… that they are making a choice to stay addicted.”

It’s the users themselves, Nelles says, who are the experts on drug use. He credits the work of the Vancouver Area Network of Drug Users (VANDU) and its feisty director, Ann Livingston, for taking the lead in pushing for a safe injection site in Vancouver. In 2003, in response to a large-scale police crackdown and government inaction, VANDU, along with other like-minded organizations, opened an unsanctioned user-led safe injection site that operated for 181 days and supervised more than 3,000 injections.

According to Livingston, novice users coming to the Downtown Eastside area contract HIV and/or hepatitis C within six months. “If you grab 100 addicts, 35 of them are likely to be HIV positive and Aboriginal people are seven or eight times more likely to be HIV positive…. Because this place is like a village, people won’t out themselves about their HIV. Everyone from the community will know. Their lives are already hard enough…. But if nothing else is working for you, that’s the last thing you’ll do. Many have never taken AIDS meds. I call it dying with your boots on.”

Indeed, what Kerr calls “the most explosive outbreak of HIV infection in the Western world” — a 19 percent incidence rate — happened in Vancouver’s Downtown Eastside in 1996 – 1997. The Vancouver Richmond Health Board declared it a public health emergency. Today, of the 12,000 people living in the area, approximately 5,000 inject or inhale drugs daily. Estimates are that 90 percent of drug users have hepatitis C and 35 percent are HIV positive.

Marcie Summers, director of the Positive Women’s Network, echoes these concerns. “Seventy percent of the women who access our services are Aboriginal. This is an epidemic. Recently the Health Officer for Northern b.c. declared it a health crisis. Only a small percentage of women with HIV are on meds.” She adds that domestic violence and a lack of stable housing are the two biggest barriers for women seeking treatment. Funding from the province has remained flat though the disease is spreading to many parts of B.C. There are long waiting lists and few places where women can go for treatment with their children.

Livingston credits InSite with reducing harm but would like to see the facility open up an inhalation room for crack smokers and do something about the problem of assisted injections. Many older users have badly scarred veins or, like Wayne, injured limbs, and have a great deal of trouble injecting themselves. Present policy at InSite is for self-injection only. Many of the most vulnerable users, who are physically unable to inject themselves, cannot take advantage of the safer, more congenial atmosphere of InSite. And using in the alleys makes them easy prey for robbers and thugs.

InSite has saved lives. Because the drugs brought into the facility are obtained on the illegal market, they can be toxic and sometimes deadly. This past February Wayne almost died when he injected speed that he thought was cocaine. “I wouldn’t be here today if it wasn’t for InSite,” he says. “Thank God they had the medical staff to supply oxygen and keep me breathing. I came close to dying. I had nine seizures in 20 minutes.”

 

COMPOUNDING MATTERS, PREJUDICE ABOUNDS. As Marcie Summers puts it, “We see people with HIV/AIDS as marginal people, disposable people.” Kerr’s view is that from an ethical, legal and human rights perspective, society has to do something.

Apart from offering a safe injection site, InSite refers on a daily basis about four clients to addiction treatment and an average of two clients to methadone treatment. But most of the assistance the facility gives to people involves essentials such as housing and food. “You can’t even talk about detox until you have a home,” says Sarah Evans, InSite coordinator.

The number of homeless on Vancouver streets has doubled in the past year, according to The Vancouver Regional District. And many are inhalation or injection drug users. In an attempt to restore “public order,” Vancouver’s Police Chief Jamie Graham announced on February 22 that there would be a crackdown on open drug use in the Downtown Eastside.

David Eby, a lawyer with the Pivot Legal Society, whose mandate is to advance the interests of marginalized persons, calls this a step back to police practices of the past. “Since the big HIV outbreak in the area 10 years ago the police backed off and quit arresting people for simple possession of narcotics,” he says. “This seems to be part of a strategy to clean up the area before the 2010 Olympics…. Everyone knows it’s a joke because there is no way the police could arrest everyone using drugs openly and ever have a chance of processing them. The courts couldn’t handle it, the judges couldn’t handle it. It would bring the system to a standstill.

“But what is happening is that users are hiding themselves away in a little nook or cranny in the alley where they won’t be found for hours if they overdose.” Since people are afraid of having needles and rigs on them, Eby continues, they toss them away instead of bringing them into the needle exchange, increasing disposal problems and the risk of accidental infection.

Incarceration in the wake of crackdowns leads to additional serious problems for people with HIV/AIDS (PHAs). According to Kerr, “Being in jail is one reason people stop taking their meds. Appointments with physicians are posted in public places and everybody will know that you’re HIV positive…. Also, in jail a syringe is shared between 20 and 30 people. If you declare, you won’t get access to the syringe that’s going around.”

Of course there are other reasons that half of those who are HIV positive and injection drug users discontinue treatment prematurely — reasons such as side effects. “Injection drug users have so many health issues,” Kerr says, “that adding antivirals can be too difficult to tolerate.”

Still, the crackdown has got a lot of people worried, since police cooperation is fundamental to effective harm reduction. With the exception of the NAOMI project, a trial heroin prescription program in the area, the only place to inject besides InSite is in the alleys.

 

AND THE VIOLENCE THAT accompanies the street drug trade is a daily occurence in this part of town. In March, a 44-year-old Aboriginal man was knifed to death on the corner of Hastings and Main over a $5 crack transaction. As well, the criminal nature of the global drug trade is a growing issue in Europe, the U.S., Australia, Canada and in many Third World countries where the drugs are produced.

Yet in 2001, the Auditor General’s report on the problem of street drugs in Canada concluded that 94 percent of all federal resources directed toward the drug problem were spent on enforcement and incarceration — with no measurable benefits. Society can’t afford “no measurable benefits” — the costs are staggering: property crime, criminal gangs and the spread of bloodborne diseases like HIV and hepatitis C.

With an eye to combatting all these costs, the Health Officers’ Council of British Columbia (2005) and The City of Vancouver Prevention Report (2005) produced papers recommending experimenting with a regulated market for illegal drugs. This wouldn’t be unprecedented. The countries most progressive in drug reform, such as Holland, Switzerland, Britain and Spain, are advancing harm reduction to include things like the sale and regulation of certain narcotics and soft drugs.

Mark Haden, an addictions expert who works for the Pacific Spirit Community Health Centre in upscale Kerrisdale, agrees. “If these drugs are available only on the black market, people become enormously engaged in the criminal system. They do a lot of crime to pay for the drugs…. I think it is immoral of society to allow the existence of a black market that creates so many pathologies, criminalizes our youth and creates so many problems for society.”

VANDU’s Ann Livingston estimates that at least $150,000 a day is spent on illegal drugs in the 10-block area of the Downtown Eastside. The resulting expenses for society involve the police force, ambulances, medics and the like, she says. “The public needs to understand the cost to them; the risk that your children will get involved in injecting drugs. This risk is very high if you don’t have a regulated market.” But it takes time for people to adjust their attitudes around prescription narcotics, particularly when Hollywood and the media reinforce the notion that abstinence is the only goal. And, as Livingston says, the public has to go at its own pace. “Harm reduction is a new idea that people often have to warm up to.”

Still, it may well be an idea whose time has come. “I think that Vancouver is so ready for someone to do something really radical to deal with the problems of the Downtown Eastside, up to and including the legalizing of prescription heroin and cocaine,” David Eby says. “To treat this as a health and social problem and not as a criminal problem.”

Carla and Wayne, like many others, would both like to see more safe injection sites as well as market control and regulation of the drugs they use. “Crime would decrease,” Wayne says. “Death would decrease. A lot of people would get their humanity back, their self-respect…. People wouldn’t look down on you and you would have a little bit more self-esteem so you might make that change to go over to the other side of the room, to recovery.”

The couple is thinking of going into detox through InSite. “I don’t want my legacy to be on a billboard with a body count in an alley,” Carla says. “I’d like to change that.”

Elaine Brière is a Vancouver writer, documentary photographer and filmmaker. She was the last photographer to visit East Timor before the Indonesian invasion of 1975. Her book East Timor: Testimony was published by Between the Lines, Toronto, in 2004.

CATIE’s treatment guide for HIV-positive injection drug users and their caregivers, pre*fix: harm reduction for + users, is available at http://www.catie.ca/en/practical-guides/prefix-harm-reduction-users or by calling 1.800.263.1638. For more info on harm reduction, visit www.canadianharmreduction.com

 

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