Why Canada has so few supervised injection sites

Critics say an onerous application process means waiting years

Sean Leblanc. (Photograph by Tony Fouhse)

Sean Leblanc. (Photograph by Tony Fouhse)

Sean LeBlanc is over six feet tall and skinny. His arms are helicopter blades as they point to the different places in Ottawa’s busy ByWard Market where he has injected drugs. “There,” LeBlanc says. “And over there, and in the park over there.” Despite the more than 30° C heat, the 43-year-old is wearing a long-sleeved, purple button-down shirt and jeans. He briefly cuffs the sleeves to reveal thin, white, decades-old scars: track marks. “I beat myself up enough,” he says. “I don’t need strangers to, too.”

LeBlanc was a heavy intravenous drug user until 2010, the year he founded Ottawa’s Drug Users Advocacy League, or DUAL, and began doing outreach with drug users. At his peak drug use, he was injecting every day, wherever he could find a quiet space—including here, a small strip known to local drug users as “the Alley.” It’s daylight, and just steps away, a shirtless man is counting pills.

One person in Ottawa dies every 10 days due to drug overdose. That’s why LeBlanc wants supervised injection to come to the city, and soon. “You delay it three months, that’s another nine people,” he says. “I’m sick and tired of my friends dying.”

Advocates point to powerful backing for supervised injection, from the Supreme Court of Canada, for example, and the New England Journal of Medicine. So why, despite efforts in at least 10 cities, are there only two supervised injection services set up in Canada, both in Vancouver? According to supporters, it’s because they’re up against an overly onerous application process designed to ensure everyone in a community—both drug users and others—is on board.

Vancouver’s Insite, North America’s first—and for a long time, only—supervised injection service has been gathering evidence on its successess for 13 years. Thomas Kerr, a researcher at the B.C. Centre for Excellence in HIV/AIDS, says Canada’s need for more such sites is “beyond situation desperate.” Montreal and Toronto have been doing feasibility studies on supervised injection for at least a decade, but Kerr says those efforts were waged against the backdrop of the then-Conservative government’s war on drugs, and ultimately fizzled. Last fall’s Liberal election win reignited application efforts in at least nine cities across Canada.

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In 2015, the Harper government passed Bill C-2, the Respect for Communities Act, an amendment to the Controlled Drugs and Substances Act designed to respond to the Supreme Court of Canada’s 2011 decision to allow Insite to keep operating. The court unanimously ruled that Insite “has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada.” The Respect for Communities Act requires that health centres submit more information in order to open a supervised injection service, including consultations with multiple stakeholders and reports on crime rates in the area. But front-line addiction workers tell Maclean’s that the legal hurdles to approving new injection sites are “over the top,” “disproportionate,” “extremely challenging,” “daunting,” and “absurd.”

Earlier this year, the Dr. Peter Centre, just a 30-minute walk from Insite, started Vancouver’s second supervised injection service. Work on similar services is progressing in Edmonton, Ottawa, Toronto, Montreal, Victoria, Surrey, B.C., and the Ontario cities of Thunder Bay and London—with grassroots movements emerging in a handful of other cities. Montreal is closest to approvals and funding. Thunder Bay and London are at early feasibility study stages, which Kerr is leading.

“If the federal government had done the right thing and not acted like a bunch of sore losers,” Kerr says, “they would’ve gone out and created legislation to facilitate the development of new sites.” Instead, he says, they made it extremely difficult for communities to open up the services. Any centre looking to operate a supervised injection service must prove it meets more than 20 stringent conditions in an application filed with Health Canada, from getting enforcement officials to write a letter of opinion, supplying the resumés of staff members who will work in the service, providing a detailed financial plan, and compiling relevant coroners’ reports and HIV statistics.

Conservative health critic Colin Carrie says when the Tory government was in power, its major concerns were public health and public safety. “Not just for the addicts and their safety,” Carrie says, “but for community members, too. There’s a big concern about what approval for these supervised injection sites might mean for law-abiding community members.” He points to crimes committed by drug users—such as shoplifting and break-and-enters—to get money for their next fix.

But proponents argue these services actually bring intravenous drug use and improper discarding of needles out of public spaces and into a private space; help prevent the transmission of HIV and Hepatitis C by offering sterilized needles; and prevent death of drug users at high risk of overdosing. Since Insite opened in 2003, overdose deaths in a 500-m radius of the facility have decreased by more than 35 per cent. And while there have been overdoses at the centre, there have been no fatalities.

Whatever the intention of the Respect for Communities Act—public safety or to quash any attempts to spread supervised injection—applying under it for an exemption is undeniably time-consuming.

Take Ottawa, LeBlanc’s stomping grounds. Four years ago, the Sandy Hill Community Health Centre passed its first motion to pursue expanding the centre’s services to include supervised injection—between four and six stations, operating 12 hours a day, with each station doing 18 injections per hour. The centre is still months, if not years, away from approval.

In June, Ottawa’s Board of Health voted to go forward with the exemption process, but that’s just one victory in a long list of battles. The centre is awaiting recommendations and letters of opinion from multiple stakeholders, including both Ontario’s minister of health and minister of safety, Ontario’s chief medical officer, Ottawa’s municipal government, Ottawa’s chief of police, Ontario’s College of Physicians and Surgeons, and Ontario’s College of Nurses.

Rob Boyd, director of the outreach program at the centre, says he needs to submit a summary of the research evidence in support of supervised injection, a summary of local need, and conduct community consultations.

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Neighbouring business owner David Kardish is “110 per cent against it.” He runs Rideau Bakery, a family-operated institution just a few storefronts east of the Sandy Hill Centre (coincidentally, the original bakery used to be where the centre currently sits). “It’s nonsense; absolute nonsense,” he says of the proposal. “I don’t think it’s the answer, because treatment is the answer.” Kardish, who grew up in the neighbourhood and has been running the shop for 25 years, says he’s witnessed an increase in the amount of drug use in the area, and in the crime that goes with it. His own car has been broken into right outside the bakery window, and he’s had to lock the shop’s bathroom because of people using it to inject. “We have enough problems around here,” he says, pointing to a nearby methadone clinic and homeless shelters. “This is Canada’s capital city, the main street. It’s an embarrassment, you know?”

But Kerr says it should be health officials deciding whether the facilities open, not members of the community, bureaucrats and police. “Essentially, you’re putting NIMBY-ism and the opinions of enforcement officials ahead of public health,” he says.

Research shows Insite leads to a greater than 30 per cent increase of its users entering addiction treatment, from detoxification to long-term programs. Elaine Hyshka, an assistant professor at the University of Alberta’s school of public health, says supervised injection services are “off ramps” from substance abuse.

Hyska, who is active in Edmonton’s effort to get a supervised injection service, says the need for one has become even more urgent with the high rate of overdose deaths related to the drug fentanyl—though usually in pill form, it is crushed up and injected for a quicker fix. “Anecdotally, what we’re hearing, is that [fentanyl] is pretty much all that’s available in terms of opiates on the street,” she says.

LeBlanc confirms the same dangerous shift has happened in Ottawa. “It’s not the only one, but it’s the predominant one,” he says. He’s tried fentanyl half a dozen times, but around the time the drug was becoming popular, he was changing his habits. “It’s a crapshoot all the time, especially with powdered fentanyl,” he says. “This stuff, it’s 20 per cent one day, it’s 60 per cent the next.”

Overdose deaths related to fentanyl have spiked in Canada—between 2009 and 2014 there were 655—and the numbers have only escalated in the past year and a half. In March, Health Canada removed naloxone—an injectable drug that reverses the effects of opiate overdoses—from the federal prescription drug list to make it easier to obtain.

A client of the Insite supervised injection Center in Vancouver, Canada, collects her kit on May 3, 2011. The Canadian Supreme Court is to settle a conflict between the government's wishes to close the center and the center's success in fighting the spread of AIDS among drug addicts. In eight years of existence, and with more 600 visits per day on average, Insite believes it has made advances in the fight against AIDS. And in a radius of 500 meters around the center, deaths by overdose dropped by 35 percent since the opening, according to a study published in the medical newspaper The Lancet.    (Laurent Vu/The Lancet/AFP/Getty Images)

A client of the Insite supervised injection Center in Vancouver, Canada, collects her kit on May 3, 2011. The Canadian Supreme Court is to settle a conflict between the government’s wishes to close the center and the center’s success in fighting the spread of AIDS among drug addicts. In eight years of existence, and with more 600 visits per day on average, Insite believes it has made advances in the fight against AIDS. And in a radius of 500 meters around the center, deaths by overdose dropped by 35 percent since the opening, according to a study published in the medical newspaper The Lancet. (Laurent Vu/The Lancet/AFP/Getty Images)

As important as these steps are, advocates say access to naloxone and needle exchange services are just part of a harm-reduction continuum, and supervised injection should be included. “We offer needles to people to inject in the community,” Ottawa’s Rob Boyd says. “We should take some responsibility and offer to supervise that injection on-site.” For him, the bureaucratic process to make that happen seems an inappropriate response to what’s being asked.

Montreal’s chief medical officer doesn’t necessarily agree. “The preparation for the ask is not bad,” says Carole Morissette, who is coordinating the supervised injection implementation process in Montreal. “Because as a first project, I think it’s very important to be well organized, well documented.”

Compared to the rest of Canada, Montreal is arguably the furthest along. Canada’s second-largest city is seeking approval for three fixed services in three neighbourhoods and one mobile service, a model they’ve been working on since 2011. Morissette says the exemption application has been in the hands of Health Canada since May 2015, just before Bill C-2 was given royal assent.

Morissette has been working with federal Health Minister Jane Philpott since October, and is now waiting for the Quebec health ministry to approve the final budget so that they can build the sites and hire staff. Once that’s complete, Philpott will need to tour the sites and give Montreal the go-ahead to start the services. Morissette was originally hoping to have supervised injection in full swing by this fall, but now says that won’t happen. Despite the delays, she’s taking the process in stride. “It’s not a question of only Health Canada,” she says, “it’s a question of our organization, too.”

In Toronto, city council recently voted to approve three sites to host supervised injection. The Toronto Board of Health is already backing the application. Now, like in Ottawa, it’s just a matter of compiling the materials to send to the feds. And in Vancouver, on top of the two supervised injection services already running, there are approximately five more in the works. Patricia Daly, chief medical officer for Vancouver Coastal Health, is hoping the applications will be ready to go for the fall. Even for Daly and her team, who already have experience developing two services, the application process has been daunting. “We’ve had to devote significant staff resources to get the applications together to meet all the criteria in that act,” she says. “That is a big hurdle for people.”

For smaller centres, like Victoria, Thunder Bay and London, with fewer hands and less harm reduction experience, it’s even more overwhelming. In Victoria, a city of 80,000, meetings are under way with police, city council and the regional health authority to discuss what type of supervised injection model would work best in the city.

MORE: The science is in. And Insite works.

In an email to Maclean’s, Philpott said the evidence was clear: “These sites have the ability to save countless lives.” She was unable to comment on the status of any applications in the hands of Health Canada, but said once an application is received the government is committed to assessing it without “undue hinderance or delay.”

This type of response from the federal government is “heart-warming” to Ottawa’s chief medical officer, Isra Levy. “I think they’re on a great track,” Levy says, “they’re working with existing legislation.”

But Daly, in Vancouver, thinks the entire law needs to be rescinded. “They need to find an easier way for people to begin to incorporate these services into the health services we already provide to those who use injection drugs,” she says. As time goes on, Philpott said, “Health Canada will continue to assess the effectiveness of the legislation as applications are received and reviewed.”

On a steaming Thursday in late July, nearly 100 people gather for International Drug User Memorial Day. They stand in a large circle in a parking lot, just blocks from “The Alley.” Rainbow-coloured letters on a homemade sign welcome the guests, some evidently middle class, but most with the scars and stress of a life on the street.

Dakota, a thin, middle-aged woman wearing ripped jeans, makes a plea for supervised injection; a plea to get powdered fentanyl off the streets. The crowd waves children’s bubble sticks, each floating, iridescent orb in memory of the friends, sons, daughters who died because of their addiction. “They’re asking me all the time, literally pleading, ‘When’s the site opening, Sean?’ They’re hoping I have the answers,” LeBlanc says. “We’re losing the same amount of people. Nothing’s changing.”

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