As the fentanyl crisis continues, one Vancouver doctor moves people out of the alleys and into a clinic

This article was written in partnership with Cited Podcast for a program distributed on NPR stations across the United States. Listen to a related radio documentary about the fentanyl crisis and a controversial fix for addiction.

There are two very different groups of heroin addicts in the Downtown Eastside. Bernadette is a member of the first.

She describes her life as an endless game of Russian roulette. A half-dozen times every 24 hours, her physical dependence on opioids, combined with an intense craving for cocaine, forces her to inject unknown substances.

“I always do a little amount,” she tells the Georgia Straight. “Because if I use too much, I’m not going to be here to use again. But if I don’t use enough, I can always use more.”

Interviewed at an overdose-prevention site that faces an alley off East Hastings Street, the thin First Nations woman describes the fear that crept into the community when the toxic synthetic opioid fentanyl arrived.

“Even if I’m buying from the same person, it doesn’t matter,” Bernadette says. “Just because my guy doesn’t fuck with it doesn’t mean the guy that gives it to him doesn’t fuck with it. That’s why they call it a game of Russian roulette.

“And that’s why I come here,” she continues, looking around at the tent she sits beneath. It’s just a few plastic tables and chairs, but they’re always filled with people injecting or smoking drugs on account of the relative safety offered there. If she overdoses, there’s someone around to revive her.

As she prepares a needle, Bernadette says she worries about buying heroin. She knows it probably contains fentanyl. She prays it doesn’t contain carfentanil, the even more dangerous synthetic opioid that health authorities confirmed had reached Vancouver last November.

"Depending on how it’s mixed, one part can be a lot stronger and the other part can be a lot weaker,” Bernadette continues. “So every time I get it off my guy, I always test it.”

Repeat overdoses have become a fact of life for members of this group of drug users. Bernadette has had two in recent months. In both instances, a friend used the so-called overdose antidote, naloxone, to bring her back to life.

“That’s a nasty drug,” she says of naloxone. “It’s like having the worst hangover that you could possibly imagine. It’s like a whole bunch of bad things happening all at one time. It’s just nasty. You don’t want to experience that….But it is better than dying.”

Last year, there were 922 illicit-drug overdose deaths in B.C. Fentanyl was detected in about 60 percent of them. From 2001 to 2010, the average number of fatal overdoses each year was 212.

Because heroin and cocaine are addictive and illegal, government policies of prohibition condemn Bernadette and people like her to find them on the streets. In addition to the chances they take with each injection, they burn through savings and sell possessions to pay for drugs. Many of the women in this group resort to sex work. Every single day is a circular hustle: wake up, get money, find drugs, use them, hopefully don’t overdose, and start the process over again.

Creating stability

Kevin Thompson is a member of Vancouver’s second group of illicit-drug users. His life is very different from Bernadette’s.

Thompson works 40 hours a week at another of the city’s new overdose-prevention sites, located near the intersection of Main Street and East Hastings.

He still uses heroin. But instead of buying from dealers on the street, he gets his drugs from Crosstown Clinic, the only facility in North America that dispenses diacetylmorphine, the medical term for prescription heroin. It's a harm-reduction program that aims to stabilize people's lives.

Three times a day, Thompson visits a building that once housed a bank on the corner of West Hastings and Abbott streets. A nurse gives him a specific dose that has been prescribed by a doctor. Then he carries on with his day.

Kevin Thompson is one of 91 long-time addicts in Vancouver who receives prescription heroin paid for by taxpayers from a clinic in the Downtown Eastside.
Travis Lupick

Thompson wakes up to an alarm clock and is seldom late for work. He doesn’t nod off on the job. The police never show up looking for him, because it’s been years since he’s committed a crime.

“I’m living a normal life,” Thompson says. “Walk next to me and you probably wouldn’t even know that I use drugs. I have a full-time job. I’m a functional addict.”

At Crosstown Clinic, there are virtually no overdoses. The patients enrolled there don’t wake up in a panic each morning not knowing where their next fix is coming from. They don’t need to steal or sell their bodies. The vast majority have found stable housing. They’ve left the street life behind them.

Thompson says he thinks about the first group of addicts every day and almost constantly. In his job at the overdose-prevention site, he has used naloxone to save many of their lives.

“It disgusts me, really,” Thompson adds. “That they don't have this [diacetylmorphine] for everybody else. It should be open to everybody.”

The new normal

There are 91 people in Vancouver like Thompson: long-time opioid addicts who receive prescription heroin at Crosstown Clinic. Another 24 patients receive injection hydromorphone, an opioid better known by the brand name Dilaudid.

The clinic’s operator, Providence Health Care, estimates that the number of drug users in Vancouver for whom prescription heroin is appropriate likely numbers about 500. The facility is currently under renovation so it can squeeze in 30 more patients. But when that work is complete, its maximum client load will still only be between 150 and 200 people.

Travis Lupick

The arrival of synthetic opioids has led some advocates to argue that with B.C.’s drug supply now so contaminated with fentanyl and carfentanil, the threshold to qualify for prescription heroin should be lowered to allow less-entrenched users to access a relatively safe supply of the drugs to which they’re addicted.

Among them is Donald MacPherson, who from 2000 to 2009 was the drug-policy coordinator for the City of Vancouver. At his office at SFU, where he holds the position of executive director for the Canadian Drug Policy Coalition, he argues that access to prescription heroin should extend beyond the group of long-time addicts to whom it’s offered today.

“With the experience we are seeing with the overdose crisis across North America, why are we withholding a clean pharmaceutical drug from people who are overdosing on toxic, poisonous substances like fentanyl and carfentanil?” he asks. “Why do we not allow people to enter some sort of program where they can acquire a clean pharmaceutical product at a dose that works for them, that doesn’t kill them?”

In a recent interview with a local podcast, Dr. Patricia Daly, the chief medical health officer for Vancouver Coastal Health, warned that there is no end in sight to the fentanyl crisis.

“Public health officers across B.C. recognize this may be the new normal for some time to come,” she told the Vancouver Courier in February. “We are going to have to get used to the fact that there are going to be contaminants in the illicit-drug supply that are going to increase the risk and increase deaths.”

In response, Daly continued, B.C. must “rapidly” expand addiction-treatment options that work by transitioning people from illicit drugs to legal substitutes obtained with a doctor’s prescription.

“We’re going to have to do much more than we have up until now to expand injectable-opioid treatment, injectable prescription heroin, or hydromorphone,” she said.

There are signs other policymakers don’t share Daly’s enthusiasm for this less-conventional treatment option.

On February 7, the new B.C. Centre on Substance Use, a research body based out of St. Paul’s Hospital, unveiled a highly anticipated set of revised guidelines for the treatment of opioid addictions. Absent from the document was prescription heroin and other injectable-substitution therapies like those offered at Crosstown Clinic.

At a news conference that day, its director, Evan Wood, defended his decision to omit injectable opioids from the treatment guidelines he drafted.

“I spend time—at least I used to—about a half a day a week at Crosstown Clinic, where people get diacetylmorphine or hydromorphone, so I know all about it,” he said in response to reporters’ questions. “But it’s a small proportion of the population who are severely opioid addicted who that would be most appropriate for. So it’s a very important conversation. But we need to look at the full continuum.”

At Crosstown Clinic in the Downtown Eastside, patients receive prescription heroin in a medicalized setting.
Amanda Siebert

And so Crosstown Clinic’s 91 patients remain the only people in Canada for whom prescription heroin is available.

A long road

Drug users at Crosstown are not required to wean themselves off heroin, but the stability that the program provides has helped many do just that.

Twenty-five former injection-drug users have transitioned to oral therapies, according to statistics provided by Providence Health Care. Nine of those people transitioned to oral hydromorphone and 16 to methadone, Suboxone, or slow-release oral morphine.

An additional two Crosstown patients are completely free of drugs for the first extended period of time since they began using heroin decades ago.

After more than four decades injecting drugs, Dianne Tobin became the first patient of Crosstown Clinic to transition to an oral medication and then to total abstinence.
Travis Lupick

Dianne Tobin was the first. She went from injecting diacetylmorphine to ingesting oral hydromorphone and then to abstinence. It’s the first time her body has been without opioids in more than 40 years.

From her family’s home in Bridgewater, Nova Scotia, Tobin acknowledges it was a long road to get there.

In a telephone interview, she recounts a childhood of trauma. She came from a happy middle-class home and got along well with her parents. “But I couldn't handle society the way it was,” Tobin begins.

It was the 1960s and after repeated problems at school, the courts intervened and she was sent to the Ontario Training School for Girls, an old-fashioned institution where young Canadian women could be held for transgressions involving truancy, drugs, or promiscuity. Tobin was one of the youngest boarders there and the older ones treated her badly.

When she was 16, authorities let her attend Grade 12 at a public school. Terrified of being sent back to the institution, Tobin figured out a way to ensure that she wouldn’t be.

“I got married,” she says. “I married the worst person in the whole world. Once we got married, I was black and blue all the time.”

In 1968, the young couple moved to Vancouver, to the Downtown Eastside. At their apartment at Jackson and Pender, their neighbour was a heroin dealer. He gave Tobin the first drugs she ever tried.

“It gave me courage and made me feel more like myself instead of an abused victim,” she recalls. “After the first time I took heroin, from then on I was a woman of my own and I was able to stand up for myself.”

Her husband drank and grew more abusive. After she tried to leave him, he tied her to a chair and confined her for six days in a room at the Patricia Hotel, which still stands today at the intersection of Dunlevey and East Hastings. Fully addicted to heroin at the time, Tobin suffered through a cold-turkey withdrawal.

“I was in total withdrawal that whole time, and it was terrible,” she says. “You don't sleep; you don't sleep; you don't sleep. And then it gets worse.”

By this point, it was 1973 and Tobin was 22 years old and had two young children. She took them, ran to Edmonton, and never saw that man again.

She was free of her husband but stuck with an addiction to heroin that would last the next 40 years.

The drug scene of the Downtown Eastside pulled her back from Edmonton. The hassles and tragedies of an addict’s life followed. Tobin tried and failed to get clean. A long-time romantic partner was killed while he was in prison. She once spent three months in a coma after two guys smashed a brick over her head in a robbery that turned violent. Decades passed.

Going clean

Then, on March 15, 2006, she was one of the first Vancouver residents to receive prescription heroin as part of an academic study at Crosstown Clinic. A similar research project followed, beginning in 2011. Then, in November 2014, Vancouver doctors began using the federal Special-Access Program to administer prescription heroin to patients outside of those clinical studies.

It brought stability to her life. Tobin recounts how she became more involved in activism, for several years serving as president of the Vancouver Area Network of Drug Users (VANDU). She also helped organize patients involved in those earlier prescription-heroin trials and successfully fought the former Conservative government to allow for the program to exist as it does today.

In late 2016, Tobin transitioned to oral hydromorphone and, for the first time since she was 17 years old, spent an extended period of time without using needles. Next, with the help of her doctor at the clinic, she lowered her hydromorphone intake in increments, from 425 milligrams per day to 125 per day and then to a 75-milligram dose just twice a week. On December 5, she visited Crosstown Clinic for the last time.

She remained in the Downtown Eastside for a short while after that. But the fentanyl crisis began to get to her.

“I just finally got tired of it and I told doc, ‘I'm going home, where I don't have to hear ambulances all day.’”

Sitting alongside Tobin at their home in Nova Scotia is her niece, Jenna Zinck.

“It’s like I finally have a chance to meet, you know, to meet my aunt and get to know her,” she says over the phone. “I'm just proud of her. With tears in my eyes right now, I am so proud of her.”

There’s a pause, and then Tobin responds indirectly.

“To have my family trust me again, it's a gift,” she says.

In a subsequent interview, Tobin describes herself as homesick but not ready to return to the Downtown Eastside. She thinks about it every day and the people she knows who used to ask her about Crosstown Clinic.

“So many of my friends wanted to get on it,” Tobin says. “A lot of them died before they could.”

Patients at Crosstown Clinic visit three times a day to receive a prescribed dose of diacetylmorphine, the medical term for heroin.
Amanda Siebert

Ottawa points the finger at the provinces

Whenever Health Minister Jane Philpott is asked about prescription heroin, the first thing she says is something about traditional forms of treatment. The second is that the former Conservative government tried to ban prescription heroin, and that it was her office that reopened the door on heroin maintenance via the Special-Access Program.

On the phone from Ottawa, Philpott reiterates those points, then emphasizes that she supports a medicalized model for prescription heroin, where doctors have deemed it appropriate.

“Communities will need to decide according to the challenges that they are facing,” Philpott says. “Obviously, Vancouver is one of the places that has some of the highest instances of problematic substance use. So it makes sense in Vancouver.”

Asked what the Liberal government has done to facilitate the expansion of heroin-assisted treatment beyond Crosstown Clinic, the minister responds: “This isn’t anything that the federal government can do on its own, because the delivery of health-care services falls largely into the jurisdiction of provinces.”

But at the clinic, physician lead Dr. Scott MacDonald makes clear that it is the federal government that must act to facilitate wider access to prescription heroin.

“It’s a complicated process to prescribe, dispense, and store diacetylmorphine,” he explains. “It is not like an HIV medication or a cancer treatment. If it was, you could call up the manufacturer and have it delivered overnight by courier. For us, getting it [diacetylmorphine] from Switzerland, there is a whole series of import and export permits….For importing and storing, it also involves the office of controlled substances….We need to have level-eight security, which is more than some banks.”

MacDonald goes on like that for another full minute.

“So there are many obstacles for diacetylmorphine to expand beyond Crosstown,” he says. “If it is going to be available, those regulations need to be streamlined and some of the obstacles removed. This [diacetylmorphine] needs to be produced, stored, just like any other pharmaceutical or opioid.”

Dr. Scott MacDonald is the physician lead at Crosstown Clinic, the only facility in North America that dispenses prescription heroin as a form of treatment for addiction.
Travis Lupick

MacDonald emphasizes that the benefits of making those changes will extend beyond individual addicts. He notes that studies of his patients found that since entering the Crosstown program, they cost taxpayers less in emergency services and hospital stays, they interact significantly less with police, and they are no longer passing through the revolving doors of the justice system, along the way stacking up taxpayers’ bills for lawyers and judges. Many have also gone back to work.

“This is a chronic disease, it’s manageable, and if we can attract this most-difficult-to-reach group into care, they will benefit,” MacDonald says. “That, ultimately, will reduce societal costs.”

Long walks

Stories like Tobin’s—of past abuse or neglect—are common among heroin addicts.

Kevin Thompson took a different road to the Downtown Eastside but one that is similarly shared by a lot of drug-addicted people living there.

He started recreationally, using at parties and then more regularly. Eventually, when the cocaine became increasingly difficult to come down off of, Thompson began using small amounts of heroin.

“I'd snort a line of it, take the edge off, and go home, chill out, and go back to work the next day,” he says. “Then one day I wake up thinking I'm sick and had the flu.

“That's the day I knew I was wired,” he continues. “Haven't stopped using heroin since.”

When he entered Vancouver’s first prescription-heroin study alongside Tobin, in 2006, Thompson discovered it wasn’t only the drug he was addicted to but also the lifestyle around it.

“Some people are addicted to the needle; some people are addicted to the hustle,” he explains.

Once Thompson was guaranteed three shots of heroin a day at Crosstown Clinic, he found he had so much free time on his hands that it was oddly unnerving.

“I didn’t have to run or chase the dope,” he says. “It was overwhelming at first. Too much time. I started getting bored and going, ‘Well, what does everybody do?’”

Thompson started going for walks.

“I realized, ‘Hey, I live on the ocean. It’s a block away. And I haven’t been down to the ocean and paid attention to it in 20, 25 years.’”

He began visiting Crab Park and then ventured farther from the Downtown Eastside, to Stanley Park and the public swimming pool there.

Soon enough, he felt it was time to go back to work. He was hired by the nonprofit Portland Hotel Society as a peer-support staffer. It was his first job in roughly two decades.

After he was enrolled in a prescription-heroin program and removed from the street life, Kevin Thompson found he had so much free time on his hands that he wasn't sure what do with it.
Travis Lupick

Meanwhile, at Crosstown, Thompson slowly began to reduce his prescribed dose of diacetylmorphine.

“I’m starting to wean myself,” he says. “I do want to quit one day. But it’s nice to know that this is here for me if I need it.”

When B.C.’s overdose epidemic began to claim more lives over the course of the winter, Thompson took a new job at the overdose-prevention site attached to the Maple Hotel, where he still works today.

Since then, he’s lost track of the number of overdoses he’s reversed there. He feels good about that, adding, “I love my job.” But Thompson says he also can’t help but feel guilty.

“My friends that I’ve been with for years, they’re still playing the roulette game that I’m not.”

This article was written in partnership with Cited Podcast for a program distributed on NPR stations across the United States. Listen to a related radio documentary about the fentanyl crisis and a controversial fix for addiction.