— Feature —

Site Unseen

A year after supervised consumption sites opened downtown, hundreds of overdoses have been reversed but calls for closure remain

Carl* stepped on top of the 100,000-barrel tank at the oilsands site in Fort McMurray. It was toward the end of his shift. As the head of a work crew, he went on the tank to check that his grunts were off the site and that he could head home. Carl looked from his perch, nearly 15 metres in the air, and confirmed his guys were gone. Quitting time. He walked to the edge of the tank, where scaffolding was rigged to its edge, and stepped onto it.

*Carl’s full name has not been used to protect his identity

“The next thing you know – I didn’t realize they were taking the north side of the scaffolding apart – it just tumbled,” Carl says. “I came down with it. Four storeys.” Carl’s next memory from that day is being in a helicopter, struggling to breathe. Memory two is coming to in a hospital bed, feeling tubes in his mouth. He tugged at them. Number three is his doctor, who stood at his bedside and told him he was lucky to be alive. Then came the news. “He said, ‘I’m sorry but I have inform you, you’re paralyzed from the waist down,’” Carl says. “That was a shocker.” After his fall, which happened about two years ago, Carl fought to walk again. One day, he says he suddenly felt one of his toes. Later, friends put him on a treadmill, almost willing him to walk. Three months later, he says he walked out of the University of Alberta hospital, shakily, but on his own two feet. But from there, life didn’t much return. He couldn’t walk well or work. The pain from his injuries was overpowering. He was still mourning his wife, who had died a few years earlier. He treated his pain, in part, with a doctor-prescribed supply of hydromorphone, a powerful opioid. But challenges overwhelmed him. Recently, he ended up on the street. And since March 2018, when Boyle Street’s supervised consumption site opened, Carl has been a regular client. At last count, nurses at the site have resuscitated Carl five times.

A man rings a doorbell and staff inside beckon him through the door. When Erica Schoen, director of supervised consumption services at Boyle Street, sees him, she scrambles across the room. “We’ve been worried about you,” Schoen says.

“At last count, nurses at the site have resuscitated Carl five times”

“We didn’t know what was happening. How are you?” says another nurse, on her way over. The man keeps his eyes low. He’s white, wears a black coat and jeans, and a woman is with him. The woman says nothing but keeps looking at the man, as if she’s worried. “I’m okay,” he says, to everyone, not making eye contact. He just needs to use today. And some food. The man has walked into a controversial space. On the right side of the hallway at Boyle Street Community Services is an unlabeled white door without a window. One must ring a doorbell and be beckoned through this door to enter. Like a faberge egg, what you find on the other side is the first of three inner rooms that form one of Edmonton’s four supervised consumption sites.

Here, in room one, nurses ask questions, like: What are ways we can identify you? What are you consuming today? What drugs have you used in the last 12 hours? Have you had any lapses in use recently? Do you need any other supports, like mental health, shelter, first aid? How are you feeling? And also, more warmly, what’s new?

Deaths linked to opioids climbed from 443 in 2015 to 714 in 2017. It took years of these numbers increasing, and outrage from advocates, for this space to exist. In 2018, harm-reduction proponents in Alberta successfully pushed the federal government to allow agencies to apply for an exemption to the federal Controlled Drugs and Substances Act, for one year. Four have been granted this exemption in Edmonton. This means nurses can legally sit beside someone injecting drugs and keep them alive if they overdose. Advocates say the four sites – at Boyle Street, the George Spady Centre, the Royal Alexandra Hospital and, as of November, the Boyle McCauley Health Centre – lead to fewer deaths and fewer needles on the ground.

But critics say much the opposite. They say the sites are increasing needle debris as well as crime. In Calgary, crime statistics show that a site there has, in fact, been linked with a spike in criminal activity in its vicinity. This led the Alberta government, in January, to hastily commit $200,000 toward crime deterrence. Meanwhile, in Edmonton, a national columnist has argued the downtown sites are leading to increased needle debris in his neighbourhood, while the Chinatown Business Association, part of a community that hosts several of the sites, has taken its opposition to the sites to the courts (see sidebar).

Within this push and pull is a larger truth: the sites save lives. Between March 23, 2018 to January 31, 2019, Elliott Tanti, spokesperson for Boyle Street, says visits at the three community sites (the fourth, at the Royal Alex hospital, is run by Alberta Health Services) in Edmonton totalled 34,990. At the Boyle Street site and the Boyle McCauley Health Centre sites, nurses saw 1,257 unique individuals, referred them to other services 13,416 times and, staggeringly, reversed 221 overdoses. Back in the site, and after answering questions in room one, a client is next welcomed into room two: the consumption room. This is the area few people are allowed to see while clients actually use it. Today, I’ve been allowed.

I stand at the cusp, just outside the door, to give the two clients currently inside some privacy. To my right is a cart with metal trays filled with blue and red elastic straps, plastic-wrapped syringes, cotton filters, hand wipes and other tools to work with opioids.

One of the people inside, a lean, white man, wearing steel-toed work boots and a blue coat with reflective tape, works away in one of five booths, which have sharps container and a mirror. He’s grinding pills he’s brought, preparing to inject them. This make a loud “crunchcrunch” sound. To his right, a 20-something white woman is several steps ahead in the process. She releases the elastic around her arm. Moments later, she transitions from chatting with a nearby nurse to resting her head in her arms. The nurse sits on a chair at an arm’s length, checking in to confirm she’s okay. She is.

Schoen, who has stayed back to let me observe, next shows me room three, the monitoring room, where clients are asked to stay for at least 15 minutes after using, so staff can continue keeping tabs. This is an important spot. It’s also here, Schoen says, where referrals are often made. Mental health supports are a big one, as is housing. One client, who staff had helped find housing – which in turn led to the woman reducing the amount of drugs she uses to a trickle – also has an upcoming operation at the hospital for a long-standing injury. One of Schoen’s staff is going to go with her, like a friend would.

It’s this part of the consumption site – the relationships, empathy and knowledge of the healthcare system – that’s lost in the debate about whether they should exist or not. And it’s the part that Schoen says is powerful. “We instill hope for people,” she says. “If you want everyone to go to detox or treatment and for them to make all these changes, and at the same time we’re kicking them while they’re down, how will people have the motivation to do this? Sleeping in the shelters is difficult. Living on the street is extremely difficult. These people are dealing with so much stuff and then, on top of things, we’re going to blame them for trying to treat mental health, emotional and physical pain? I think we could be doing a better job of supporting people with that.”

Consumption sites were never about solving the opioid crisis, Schoen says. Instead, they’re just one of many tools. “There are many other things we could be doing, including decriminalization, providing people safe drugs, giving people alternatives to having to buy poison off the street,” she says.

Outside the focus on the drugs and consumption, these tools lead to shifts, she says. “I do believe someone who has a sense of purpose is less likely to use drugs. If they have something better to do, or they get tired of the chase, it’s not necessarily because they did what we wanted, go to detox and go to treatment. There are people who have gone to treatment 30 times and it hasn’t worked for them. And then there’s people who have been housed and say, ‘Oh Erica, I have my own space now and I don’t feel so hopeless and I’m decorating and now maybe I want to do something else.’”

But fentanyl, the poison Schoen refers to, is a powerful force. When the Boyle Street site first opened, she says it was common to “hit” a person who had overdosed once or twice with naloxone. But recently, they’ve had to hit people with up to eight doses to bring them back, she says. “The overdoses have got worse since we opened.” I ask Schoen why she showed so much concern for the man who appeared at the door earlier. The stigmatization of drug use creates barriers for people like him to get help, even though the underlying issue is mental-health related, she says. “We’ve just been very concerned with his mental health. If we build those relationships, people feel welcome and they keep coming back and they know they can trust us. I’ve seen him in the hallway before, and he’s like ‘Do you have any food?’ and I’m like, ‘Come on in, I’ll try to find you some.’ He knows our faces and trusts us.”

People like him often fall through the cracks, she says, because drugs create barriers to addressing what’s really leading to drug use. “Regardless of what the behaviour is, regardless of what’s happening with them, if they’re walking out into traffic, people think it’s because of the drugs. If they are barefoot in minus 35, it’s because of the drugs.”

It’s an easy scapegoat, she says, and a barrier to making real change.

Carl sits in the office at Boyle Street Community Services. He’s white, in his 60s, wears a beige puffy parka, an orange baseball hat that says ‘Netherlands’ and dark blue jogging pants. He walks deliberately with a walker, and grunts and clenches with pain whenever he sits. His face can look somewhat ragged, intimidating, but that’s only if he doesn’t know you. If he does, and he likes you, Carl shifts dramatically. His eyes can almost smile. If Carl likes you, it’s hard not to like Carl back.

The thing you need to know about Carl is that he used heroin, daily, for nearly 40 years. He’s proud of this record. He suggests it shows how deliberate he has been, how he scrutinized suppliers, injected test shots, lived with deep respect for his drug’s potency despite his strong tolerance for it. This approach, he says, allowed him to maintain a marriage, raise his kids and run a wildly lucrative construction business while also using.

“In all my years, from 1982 to 2017, I never dropped once,” he says. What took Carl down was fentanyl. After falling from the oil tank, fighting through his paralysis, and after fentanyl came to push heroin out of the drug supply in western Canada over the past few years, Carl found himself forced to use it, as an additive to his prescription opioids – which was either not strong enough or something he sold for his pre ferred fix, heroin. His addiction requires he feed his body lots of opioids, daily. If he doesn’t, he says withdrawal can be so powerful it could eventually kill him. And so in recent years, Carl couldn’t find heroin and had to use fentanyl. He did this at the consumption site close to where he spends his time on the streets. “I came here, and you can ask the staff – I think in one day I dropped five times with fentanyl. I wasn’t used to it,” he says. “I can do heroin all day long. They had to give me the oxygen mask, NARCAN. Unbelievable.”

Few things about drugs really scare Carl. What does is a situation he describes as an epidemic, with meth flooding the streets on top of the existing opioid crisis. “Until you realize that and start dealing with the problem, it’s going to be worse and worse,” he says. “It’s already in middle-class suburbia and the schools. I’ve seen people from schools come down and buy from people off the streets here. So it’s here, it’s here to stay, and as far as us having injection sites, it’s important. More crystal meth users are

“Until you realize that and start dealing with the problem it’s going to be worse and worse”

coming in, but in turn that pushes opioid users out. And there lies your dilemma. We have four sites that are here within the city now and all four are to maximum capacity. It has to be enlarged. You’ll start turning people away. And when you turn people away then it engrains in them not to even go near it. And they’ll just go out and use in back alleys and public places and bathrooms.”

But Carl is most concerned with Edmonton itself. He says it’s a place with a drug problem that doesn’t want to look at it very often or work to fix it. Having lived in Vancouver, eastern Canada and spent time with users in different parts of the country, he has some wisdom about the situation. “I say this sincerely,” he says. “I’ve been to a lot of cities, and I’ve never seen it like it is here in Edmonton.”