Canada’s Drug Crisis Has a Solution. Politicians Don’t Like It.
Decriminalization saves lives. But Canada is only just accepting that reality—and the United States is even further behind.
Sometimes calculating the human impact of policy decisions can be hard. Research takes time. Making sense of the data, and the noise around it, is a laborious process, and even years of research can culminate in couched, hedged, and caveated conclusions, if you come to a clear conclusion at all.
Which is why the conclusion of a recent study was so striking. It found that a trio of policies adopted to combat the opioid overdose epidemic saved, combined, an estimated 3,030 lives in the Canadian province of British Columbia alone, between April 2016 and December 2017.
The findings, published in June in the peer-reviewed journal Addiction, are a ringing endorsement of the policies adopted by the government of the province hit hardest by the epidemic: promoting access to the overdose-reversing drug naloxone, expanding access to supervised consumption or injection sites, and providing access to treatment known as opioid agonist therapy.
The clear evidence of their success has come amid a federal election in Canada, spurring those concerned over the ongoing crisis to push for more.
Vancouver Mayor Kennedy Stewart has challenged the party leaders vying for seats in Parliament to step up and endorse policies that would allow groups to obtain and distribute safer opioids to users, in hopes of supplanting contaminated drugs from the streets.
Despite the ongoing deaths, the election has hardly focused on the crisis.
Conservative Party leader Andrew Scheer, who is polling neck-and-neck with incumbent Prime Minister Justin Trudeau of the Liberal Party, has even staked a position against all forms of harm reduction for opioid users. He snubbed the Vancouver mayor, rejected the proposal, and even pledged to roll back the harm reduction programs that have saved lives. “The focus of government should be getting people off dangerous and harmful narcotics, not on maintaining a life of addiction,” Scheer told Foreign Policy last week.
His position closely mirrors that of U.S. President Donald Trump, underpinned by a belief that policing and anti-drug campaigns can fix the crisis.
Foreign Policy traveled to Vancouver to meet with the activists and researchers on the front lines of the crisis. They say what’s being done, currently, will slow the crisis but it won’t end it. Rolling back those policies will only worsen the catastrophe. The solution, they say, is staring us in the face—the only thing standing in the way is political opposition.
Researchers, health care workers, and drug users have come to a bold consensus: Ending the opioid epidemic demands decriminalization of the drugs causing it.
Ann Livingston has been at the center of the fight for justice for Vancouver drug users for 20 years. While drug use had long been common, it was early in the 1990s that a rash of overdose deaths ravaged the Downtown Eastside neighborhood. It wasn’t an uptick in usage but a new supply of extremely potent heroin that appeared to cause the deaths. Over 200 people were dying each year from overdoses, a twelvefold increase from the late ’80s. Compounding the impact of the deaths, an explosion of HIV and hepatitis C transmissions also struck the community.
The governments of the day, however, were slow to act. They focused on abstinence-based programs, figuring that overdose deaths would end if only they could discourage drug use in the first place.
Livingston’s radical idea was to meet drug users where they were at—forgoing the rules and regulations in the process.
“If you ask for permission and bureaucratic approval, you’ll never get anything,” she told Foreign Policy.
Livingston, a single mother, began trying to offer services for drug users without permission from the city. But without support, these services never fully got off the ground. So, in 1998, she formed the Vancouver Area Network of Drug Users (VANDU) in a neighborhood park.
As VANDU’s manifesto reads, the movement is fighting for nothing less but “the right to obtain, prepare, and ingest drugs, and to be intoxicated on drugs, according to our own personal decisions without criminalization or unsought interference from other individuals or organizations, as long as our drug use does not directly harm other people.”
It served as a vehicle for what Livingston had tried to do solo, and what drug users said they needed. They set up safe injection sites in tents, trailers, and vacant buildings in the following years to allow users to consume their drugs safely, with clean needles, and support in case they overdose. Each would be, eventually, shut down by the city or province.
The crisis of the 1990s abated. Overdoses leveled off and eventually fell. Livingston and VANDU kept agitating and, eventually, policymakers slowly came around.
In 2003, Vancouver’s health authority started a safe injection site, Insite, with support from the provincial and federal government. It had 12 well-lit, monitored injection bays for users.
In 2006, a new Conservative government took power in Ottawa. The new prime minister vowed, “we as a government will not use taxpayers’ money to fund drug use.” He would prioritize “enforcement, prevention, and treatment” instead. And, true to his word, he tried to shut down Insite. So Insite took him to court.
The issue made its way to Canada’s Supreme Court, which delivered a landmark ruling in 2011, finding that “Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada.” They ordered it must stay open and opened the door for scores more such centers across the country.
Ottawa feigned compliance with the ruling but made the rules so onerous that opening new sites was next to impossible.
In those intervening years of foot-dragging, a new drug arrived on the streets: fentanyl, an incredibly powerful pain reliever believed to be orders of magnitude stronger than morphine. Overdose deaths tracked up again in Vancouver. The government remained unmoved.
By the time Trudeau was elected in 2015, partly on a pledge to legalize marijuana, the epidemic was growing. Trudeau’s Liberal government set out to open the safe injection sites his predecessor had fought.
New sites finally began opening in 2017. By that time, 4,100 people would die of overdose in Canada that year, with 67 percent attributed to fentanyl or its analogues.
Ottawa was finally moving on the workable strategies activists like Livingston had identified 20 years prior. But these safe injection sites were never meant to be a solution, just one tool to stop the deaths. The study published in Addiction estimates that 230 lives saved were thanks to British Columbia’s safe injection sites.
As we spoke, Livingston hooked her index finger and grabbed the inside of her cheek with it, tugging her head back. “It’s catch and release,” she said. Someone can come into the site, shoot up, and head back out into the city. There’s little support, follow-up, or attention paid to the drugs causing the epidemic.
Safe injection sites are a “bandage over a gaping chest wound,” said Garth Mullins, a punk musician-turned broadcaster, activist, and the host of Crackdown, a podcast dedicated to covering the crisis. The first episode opens with guitar distortion rising above a woman’s voice: “Well I’m sorry we can’t take it anymore,” she says, straining her voice. “When we have to go home to our communities and they’re fucking dead!” She spits out the last two words as the drums kick in, and the show begins.
Even today, just a few blocks away from Insite, you can see people shooting up on the sidewalk. On a Thursday morning this summer, two paramedics knelt over someone, reversing an apparent overdose.
They were likely armed with the same drugs inside a black bag clipped to Mullins’s belt. There’s a bright red cross emblazoned on it, the telltale sign of a naloxone kit. These kits usually contain two nasal sprays containing the opioid-blocking drug naloxone, which can effectively reverse an overdose. Ottawa made the drug available, over the counter, in 2016. A year later, British Columbia and Alberta allowed the kits to be sold anywhere—other provinces still require them to be dispensed by pharmacies. In recent years, pharmacies have begun giving away the kits for free.
The study published in Addiction found approximately 1,580 lives were saved by these take-home naloxone kits.
The third strategy explored by the Addiction study concerns opioid agonist treatment, which puts drug users on replacement opioids in hopes of weaning them off the drug outright. The study showed that this therapy saved 590 lives over the 19-month period.
But trying to get users onto new drugs has its pitfalls. The classic example of this treatment is methadone, which can be a difficult form of treatment, in part due to government over-regulation.
The first episode of Mullins’s podcast, Crackdown, introduces Chereece Keewatin, an indigenous woman who sat on the editorial board for the podcast. “This whole lifestyle is not what I signed up for,” she says through a hacking cough. Keewatin had been on methadone and had kicked heroin for a decade. In 2014, the provincial government abruptly switched methadone users onto a new drug, methadose, without much consultation. Keewatin, and many others, hated the switch. They went into intense withdrawal. Many turned back to heroin, shaken by what’s referred to as “dopesick.”
Episode two begins with the news that Keewatin had died.
Keewatin wasn’t the only one. While drugs such as methadone can be effective at first, long-term tracking has shown that many users abandon the treatment, often due to the onerous government rules around them. Alternatives to methadone, such as slow-release morphine pills, are showing promise but do have some of the same drawbacks.
Maybe the most striking number included in the Addiction study is not the number of lives saved but the number still lost. Over the same period the paper estimates 3,030 lives were saved, it found more than 2,000 were still lost to the opioid crisis in British Columbia alone.
“If one of the questions is why isn’t it working—it’s the wrong response,” said Donald MacPherson, the director of the Canadian Drug Policy Coalition and an adjunct professor at Simon Fraser University. He has been on the front lines of the drug problem since the 1980s, having worked with Livingston and others to advance harm reduction efforts. His research was instrumental in the Supreme Court case on Insite.
The government is not treating this like an emergency, he said.
“We could open up 30 more [overdose prevention sites] and they’ll save some lives. But we can’t rely on the cartels to change their supply,” MacPherson said. “The sad part is that the government abandoned the opportunity to take a big drug supply from organized crime and replace it.”
If Canada has been slow out of the starting gate, the United States is still in the stall.
In a New York Times op-ed in August 2018, then-Deputy Attorney General Rod Rosenstein played all the old hits, calling for better treatment and drug prosecutions instead of harm reduction approaches.
“Americans struggling with addiction need treatment and reduced access to deadly drugs. They do not need a taxpayer-sponsored haven to shoot up,” he wrote.
The Trump administration has consistently raised the specter of criminal prosecutions for those who open or patronize safe injection sites and even filed a lawsuit against Safehouse, which was seeking to start a site in Philadelphia. Safehouse is forging ahead regardless.
Sites in the United States are few and far-between. One site operates secretly, by invitation-only: Even still, the site, which operates in an undisclosed location, invited researchers to observe what was happening. Their research showed that hundreds of people have benefited from the site, and dozens of overdoses were reversed thanks to on-site naloxone.
Even naloxone access in the United States is spotty. It took until this January for the Food and Drug Administration to decide to permit the drug to be sold over the counter. A recent Centers for Disease Control report found that access to naloxone is inconsistent, especially in communities hit hardest by the opioid crisis. The cost of the drug has also limited its uptake.
In Canada, life expectancy has stopped rising due to the crisis—in the United States, it has actually fallen.
Overdose deaths increased dramatically year-over-year in the United States, hitting more than 70,000 dead in 2017. New data suggests that number may have fallen slightly in 2018, but it remains staggeringly high.
In Canada, 2018 was the worst year on record, with nearly 4,500 overdose deaths. On a per capita basis, the rate of opioid overdoses is similar in the two countries.
Nothing has substantially changed about drug use and addiction between the 1990s and today. What is different is the drugs.
Governments have professed to want to stop the flow of deadly drugs such as fentanyl and their ilk, but that has often meant beefing up drug interdictions and policing. And yet research from British Columbia and elsewhere suggests that not only do those busts not affect usage in any significant way, but they may actually drive down prices, as competing drug dealers try and fill a void.
Jane Philpott was appointed Trudeau’s minister of health in 2015. She made it a priority not to try to cut off the supply of one drug or another, but to introduce a dependable, safe supply of a drug users wanted to use.
In 2017, Philpott started a program to allow doctors countrywide to prescribe patients heroin. Rather than treating the overdose, trying to end addiction, or working to push users onto a new drug, the government would let users continue using the drug of their choice but would ensure it didn’t contain dangerous additives, like fentanyl.
To do that, Philpott arranged to import heroin from a supplier in Switzerland, a country that has embarked on a harm reduction-first approach for decades.
“I will not say all of that was easy,” Philpott told Foreign Policy in May, recalling how much resistance existed in her own government. “The further you push, the more anxious political staff get.”
Philpott is candid about her position. She was moved from the health portfolio before ultimately resigning from cabinet on principle—she is now running against her former party, and Trudeau, as an independent.
“I had hoped to push things even further, in an evidence-based way,” she said. Philpott specifically cited the “fantastic” international models of Switzerland and Portugal, the latter of which fully decriminalized all drugs in 2001 and has seen, broadly, positive health and social incomes across the board.
Philpott’s successor in the job, Ginette Petitpas Taylor, has continued to advance some of the same priorities. Speaking to Foreign Policy in Ottawa in June, she said her priority was to expand the projects started by Philpott.
“We’re getting rid of the red tape—making some regulatory changes, making sure we can address the issue of safe supply, addressing the issue of medication replacement therapy. That is really where we’re putting our energy,” she said.
While safe injection sites and naloxone only help users who have already acquired or used their drugs, getting users onto a safe supply of heroin or a legal, prescribed, opioid does address the supply issues. But these programs remain small and require users to enter the health care system. Thus far, only several hundred users have taken advantage of them.
Thomas Kerr, a University of British Columbia professor who has run a long-standing study of drug users in Vancouver, said it’s clear introducing safer and more reliable drugs is a way to stop the “poisoning epidemic.” His research has been instrumental in tracking those who have overdosed and those who have died.
And yet in an editorial to the Journal of Epidemiology and Community Health, Kerr wrote that “access to these newer treatments remains unacceptably low and efforts are needed to bring these programmes to an appropriate scale.”
MacPherson, Canadian Drug Policy Coalition, is more direct. He calls it “a total drop in the bucket.”
A lack of access and distrust of the official system has pushed some users in Vancouver and elsewhere to start up what are known as compassion clubs, where users pool their resources to buy heroin or other drugs in bulk from a more reliable or consistent source. These approaches are, much like Livingston’s early safe injection sites, illegal and strongly discouraged by the government.
But researchers say that approach is the only smart way forward.
Even with Canada’s liberal attitudes, decriminalization has been a nonstarter for this government. Whenever Trudeau has been asked directly about drug decriminalization, he has balked.
“I believe that the decriminalization of drugs is a terrible idea, and one that we will not ever consider,” Conservative leader Scheer told Foreign Policy on the campaign trail last week. He reiterated that even after the research showing the efficacy of these harm reduction strategies, repeating that “communities that are impacted by these supervised injection sites should have their voices and concerns heard.”
In 2017, Trudeau was confronted by a front-line worker at a Vice town hall on the opioid crisis. Her hands were shaking as she told him “it’s a national disaster, you are not doing enough, the bodies keep mounting.” Decriminalization, she said, was the solution.
“I’m not there yet,” he said, flanked by his deputy tasked with handling marijuana legalization, a former chief of police in Toronto who had run his share of drug busts.
Asked directly about the issue on the campaign trail this week, Trudeau said that “our approach is based treatment, on harm reduction, on safe consumption, on measures of stigmatization that have been proven to work.” But he again brushed off the idea of decriminalizing drug use in anyway while still recognizing “we know there’s more to do, and we’re committed to doing it.”
Philpott tried pushing the prime minister on drug decriminalization, but he wasn’t having it. “Decriminalization is not popular when you poll it,” Philpott said, summarizing Trudeau’s position.
Trudeau and his challenger in the Conservative Party are dead set against decriminalization. But opinions are changing.
British Columbia’s chief health officer is in favor, as are a raft of other public health officials.
The leader of the center-left New Democratic Party, Jagmeet Singh, has advocated for the full decriminalization of illicit drugs—for this campaign ahead of next month’s election, his party platform calls for the “end the criminalization and stigma of drug addiction.”
The ecologist Green Party has also endorsed decriminalization, with its platform committing the party to “ensuring people have access to a screened supply.”
While the Greens and New Democrats are duking it out for a distant third place in the election, one or both could hold the balance of power in a minority Parliament, putting them in a position of kingmaker or junior partner in a coalition government.
British magazine the Economist has long been an advocate for some kind of legalization or decriminalization model, and the Canadian paper of record, the Globe and Mail, has recently come to the same conclusion.
The Pew Research Center has found that just a quarter of Americans think prosecuting drug users ought to be the priority, while a firm majority support treatment instead. The pollster Angus Reid found nearly half of Canadians support the idea of decriminalization.
In his narrow office, MacPherson sounded weary.
Even if his research has put a fine point on what needs to happen, progress has seemed to hit a brick well on the governmental level. He sighed and explained why.
“It’s the fear and loathing of the criminalized drug user.”
Justin Ling is a journalist based in Toronto.