Watching an addict fill a syringe with puddle water, former senior RCMP officer Raf Souccar imagined a radical shift in how Canada could deal with people in the grip of drug addition – by providing them with medical-grade heroin and giving them a chance to survive.
"I've always thought of these people as victims," he said, recalling the scene in Vancouver's Downtown Eastside, where the man added heroin to the dirty water and injected the contents into his arm.
"I've seen a guy injecting with a needle he was sharpening on the side of the curb," said Souccar, a former RCMP deputy commissioner who spent 35 years fighting the illicit drug trade and is now concerned about the death toll from the fentanyl overdose crisis, which has killed hundreds of people in Canada this year.
The country's two supervised-injection sites, including Insite, are both in Vancouver. Addicts are provided with clean needles and a nurse who watches over them as they shoot up their own drugs. People who unwittingly overdose on fentanyl-laced substances are given another drug, naloxone, to reverse the effects and then sent to hospital.
Souccar said addicts should be given medical-grade heroin along with housing and mental-health services to save overall health-care costs and money for policing, courts and incarceration.
"I'm not advocating drug use. I'm saying in the situation of people who need help, we need to find a way to help them with quality-control products," Souccar said from Ottawa.
"I don't think we should just turn our heads and say, 'Continue to be preyed on by drug dealers and we'll just allow you to come in and inject and call an ambulance for you if you overdose.' "
On the sidewalk in front of Insite, a man pouring milk into a tall plastic container full of cereal said at least 40 people he knew died in the past year from heroin containing the powerful painkiller fentanyl.
Addicts would inject at Insite if a pure form of heroin were provided, said Dale Gonzales, 35.
"I only dropped once and it was a couple of months ago," Gonzales said of overdosing at a hotel where he was using with three friends a couple of months ago.
"I did my shot and all of a sudden I said, 'Oh shit.' And I freaked out. I blacked out, and they told me I turned blue and everything." One of his buddies had naloxone, which brought him back to life. Six hours later, he shot up again so he wouldn't get "down sick."
British Columbia declared a public health emergency in April, after a rising number of fatal overdoses. The coroner's service recorded 622 deaths between January and October, most of them involving fentanyl.
An increasing number of overdoses elsewhere in Canada has cities including Toronto, Montreal, Edmonton and Victoria wanting approval from the federal government to open their own supervised-injection sites. The federal government has introduced a bill to streamline the approval process.
Souccar would like legislation that would permit existing and future supervised-injection sites to dispense medical-grade heroin that must be injected by a doctor, akin to a clinic he visited in Switzerland, where addicts' multiple needs were met.
Souccar, who is part of a nine-member task force that worked on a report examining marijuana legislation for the federal government before the drug is legalized, said the presence of carfentanil â€” which is 100 times more powerful than fentanyl â€” in B.C., Alberta, Manitoba and Ontario means government action is urgently needed.
Vancouver's Crosstown Clinic is the only facility in North America that provides injectable heroin, or diacetylmorphine, to chronic addicts who have tried an average of 11 times to kick the habit through other methods including drug-substitution programs that prescribed suboxone or methadone.
Dr. Scott MacDonald, who runs the facility, said Crosstown is modelled after similar programs in eight European countries and that Canada needs to catch up to save lives.
"If we're watching somebody inject, coming into a place like Insite, every day using illicit opioids and forced to engage in the illicit stream of opioids and the illegal activity associated with that, I don't think it's medically, ethically or morally appropriate not to offer them a supervised pharmaceutical-grade option," he said.
Crosstown currently has 150 clients who also get other support including counselling, housing, nutritious food, services for conditions such as mental health, HIV and hepatitis C, along with job training, MacDonald said.
He said the annual $27,000 cost to treat each addict at Crosstown has spin-off benefits and has kept patients out of a cycle of crime.
"My most recidivist patient at Crosstown has been in and out of jail over 200 times. Since he's had access to treatment here, (it's been) zero. He's been here since 2012, so that's going on four years."
Dr. Patricia Daly, chief medical health officer of Vancouver Coastal Health, which runs Insite, said discussions to expand the Crosstown model are underway in order to serve "hundreds more people who inject drugs multiple times a day."
"We're almost standing on the bottom of the waterfall, letting everything come down," she said, adding fentanyl-related deaths outside the two clinics have continued despite thousands of naloxone kits being handed out at clinics and emergency departments.
"This is the next thing that we'd like to start pursuing here, is how to expand the availability of the legal substitute of this illicit drug," Daly said of potentially providing pharmaceutical heroin at Insite.
However, current laws do not allow heroin or any drug substitute to be stored at supervised-injection sites, unlike at the high-security Crosstown Clinic, which was granted a special exemption by the federal government, initially for a study.
Daly said she has been in talks with medical health officers across Canada as part of the Urban Public Health Network on how other cities could replicate the model at Insite, where an average of 440 injections take place every day, though she added that entrenched addicts need a more comprehensive program, such as Crosstown.
She said about 80 per cent of the heroin that users voluntarily tested recently at Insite contained fentanyl, but testing is not available for carfentanil, an opiate often used to tranquilize large animals, such as elephants.
Camille Bains, The Canadian Press