[18 Sep/18 Edit: This post is getting a lot of attention which is great. Comments are welcome, but overtly derogatory or threatening ones will be deleted. Thanks for your respectful discussion.]

Like many places, my medium sized Alberta city has been experiencing a crisis of illegal drug abuse, and a second crisis of outrage over the public risk from drug associated crime, needle debris and other fallout. While frustration and fear for the community and public safety is completely understandable given current conditions, I worry that misinformation and a lack of background understanding is generating a lot of unfocused or misdirected anger towards people and institutions that are either not responsible for or are unable to directly address people’s concerns. There is a lot of blame being placed on organizations trying to address the problem, and while feedback and accountability are important, so is understanding what they are doing and why. With a bit more background perspective, I’m hopeful this public energy could be better directed towards efforts for realistic and workable solutions.

I work as an Emergency department physician in the city, but my views are my own, and I’ve had no direct professional involvement with the safe consumption site or the organization that runs it. While I can’t speak for the program or its management, I can provide a few insights on the nature of the drug crisis as I have seen it. I also can’t tell you what the best solutions may be, except to reassure you they are neither quick nor simple. Perhaps what I say will at least broaden a few perspectives, and stimulate someone to learn more about the roots of the crisis in our community and explore how they can be part of the solution.

Illegal drug abuse and the associated crime, violence, disease and death is not new here. It has been in our city for a very long time. There have been community outreach programs for many years offering clean needles, disease screening and treatment, addictions counselling, and access to nearby detox facilities. It is a hard thing for people to escape and a hard thing for health care providers to treat. The roots of addiction often run deep within communities and families, and are often linked to inter-generational trauma and childhood abuse and abandonment. There are a lot of poor choices being made for sure, but often by people who never had the benefit of someone to teach them how to think about making choices.

Getting out of this addiction requires a community of supports and often complete socioeconomic and cultural life changes. This requires deliberate and repeated choices by the addict to accept help and make these hard changes, often developing an entirely brand new way of thinking. That’s in addition to traditional medical detox. Detox can be an important step, but if you leave a facility and return to an old life with family and friends who are addicted and have little to no resources to change their circumstances, you have a very poor chance of staying clean. There are success stories, but not enough. The purpose of harm reduction is to hopefully keep a person alive and healthy enough through their addiction years that they have the chance to go through this process when they have decided it’s time to change, and can achieve a reasonably healthy life in recovery.

Drugs have always ruined too many lives, but a few years ago the illegal drug market in North America changed. What we call “synthetic opioids” arrived and started killing users in unprecedented numbers. Opioids are powerful pain killers. They are effective but can be dangerous if misused. They are addictive because in addition to numbing physical pain, they can also temporarily release you from emotional pain and distress, and replace it with a sense of comfort and euphoria. Those who have lived lives of pain and disconnection from loved ones are primed for opioid addiction. Additionally, regular use will make you more susceptible to both physical and emotional pain when you stop using them. Too much will sedate you. A little more will slow your breathing and eventually stop it. This is how they kill.

Over-prescription and street diversion of medical opioids is a problem that has been around for a while that the medical community is working to address. However, when the “meth lab” industry learned how to make cheap synthetic opioids the game changed. This is the fentanyl crisis you may have heard of. It is NOT diversion of carefully regulated prescriptions, but the black market distribution of crudely made crystals, liquids or pills containing entirely variable and unknown doses of synthetic fentanyl (or its more potent cousins carfentanil and remifentanil). Because small amounts are so potent, and illegal drug labs are not known for their quality control, drug concentration is variable and dangerously unpredictable. One pill might give you a bit of a buzz. The one next to it might kill you. Distribution of the drug spread quickly because it was cheaper to get than other drugs, and it could be cut into anything else (cocaine, meth, marijuana) to provide a “better buzz,” that would bring customers back more often, and at less cost to the supplier. If they survived of course.

Front line police, paramedics, and emergency staff began to see the effects immediately. Opioid overdoses became common, daily occurrences. When a new batch of drugs hits the streets we see dozens of cases a day for several days, slowly tapering off over a few weeks until the next batch arrives. Administering Naloxone (brand name: Narcan) – a medication that rapidly reverses opioid effects – became the obvious first treatment for almost any suddenly unresponsive patient, and often quickly turned around a life threatening event. During my residency training not many years ago, I hardly saw Narcan used at all. Back then, it was rare to see someone who had managed to consume or inject a life threatening dose of opioids outside of a few inner city hospital centers. Now it is common almost everywhere.

Not only is fentanyl killing regular drug abusers who risk death with each high, but it is a serious risk to more casual drug users. You might not know this, but there are people around you living normal lives, holding good jobs who indulge in the occasional “cocaine party” or similar on the weekend. These people’s bodies are not as accustomed to opioid exposure as those of a drug addict, and a lower dose of fentanyl cut into whatever they think they are taking is often enough to kill them. Despite a few years of this madness, drug abuse continues. In fact, I suspect for whatever reasons, rates of abuse are even higher.

Consider this: right now, nearly every drug addict I and my ED or EMS colleagues treat and pull back from the brink of a self induced death, has at least one – usually several – dead friends and family members, recently killed by the same drugs they are still taking. These people know they are risking their lives every time they indulge. I have discussed it with many of them. To anyone who believes the threat of greater legal consequences for drug use is going to be an effective deterrent, or that this is just the life users have chosen, consider how damaged a mind and disordered a thought process this activity suggests. It’s literally playing Russian roulette with every pill or injection, but they still do it. If a gun to the head won’t “change a druggies mind,” then will a fine, a court date, or a jail cell? The answer is obvious to anyone who works with this population.

Let’s look back to about a year ago- perhaps the height of the opioid crisis so far [EDIT: from my local ED perspective at least]. We did see periods of decreased overdoses, I suspect in large part due to stepped up police enforcement to get the deadly stuff off the streets. We handed out a lot of home administered Naloxone kits- saving a few more lives for a time. Still, when more opioids hit the streets, there were deaths and near deaths in droves. While I was not personally involved, it was during this time of many calls to “do something,” we heard word that the city would be rushing to set up a supervised consumption site (SCS). This was not specifically to distribute clean needles – that is something that was already long in place in our city to prevent transmission of HIV and hepatitis. This was to provide a place where someone was supervising drug consumption that was already happening in order to reduce and respond more quickly to potentially fatal overdoses. It is not a new idea, has worked elsewhere, and ideally comes as just one part of a greater package to treat drug addiction and address the multiple social and economic factors that prevent people from getting and staying clean.

I was not on any planning committees, but my suspicion is that in order to address the alarming death rates, this facility was rushed more than it would have been in less pressing times. I’m certainly led to understand that when opened the facility was immediately overwhelmed by the unexpected level of demand, and since implementation has continued to increase its capacity and hours. Predictably, this site has become somewhat of a destination for drug abusers, many of whom are homeless and do not generally have other places they are welcomed to go. I don’t know if there are more or less users than there were previously, but this centralization effect has certainly made the population more visible. It has also increased the public’s sensitivity to the negative impacts of drug abuse on the community; crime, public drug consumption, and needle and drug paraphernalia debris in particular. These are not new issues, and not caused by the SCS. They are the result of a growing drug abuse crisis, and have become more visible because 1- the crisis has deepened over the last two years, and 2- the SCS has made the issue more visible, and probably shifted more of the problem to a single area where people now know to look for it. Additionally, more public awareness and controversy also means people are more likely to publicize their experiences with drug users and needle debris on social media, and these experiences are more likely to be widely circulated than they would have been in the past.

From my perspective in the ED, I am seeing fewer fatal and near fatal overdoses. I don’t have any stats to share, but many of my colleagues have noticed the same thing. We certainly don’t experience the regular parade of overdoses we used to, including days when we ran out of Naloxone. It’s hard to confidently state cause and effect in these type of phenomena, but I believe the SCS almost certainly is behind much of that decrease.

I am very concerned about the risk to children and the public from contaminated needle debris. No one wants local businesses or tourism to suffer because people feel unsafe in certain parts of their community. Of course I want to let my children play in city parks without worrying about them encountering dirty needles or individuals using drugs nearby. But wishes don’t solve problems, and neither does attacking those who are trying to help. There’s another part to this story that might not be on everyone’s radar right now. I heard about it from a friend who works security at the safe consumption site. The site has contracted a firm to provide 24 hour security for their site, and a certain radius around it. You might assume this is to protect people and property from drug addicts, and you’d be partially right. Their mandate includes watching for crimes (including theft, drug dealing or displaying drugs in public) and either intervening or calling the police depending on circumstances and exact location. The friend I spoke with indicated he spends a surprising amount of time protecting these same people from other members of the community who seem out to cause harm.

[Edit: I have removed details of a few alleged events of violence in the proceeding and following paragraphs, not because I disbelieve the source, but because I have no first hand evidence to share, and the readership of this post has spread far beyond my original expectations. A subsequent report by global news has confirmed with both the police and SCS that violence against facility clients has been a problem. The Global report details some incidents. My intention in sharing these anecdotes in the first place was to bring attention to the fact that violence around the SCC is not only perpetrated by some site users, but also against them by members of the public]

I bring up this less publicized side of crime associated with the safe consumption site mostly to urge caution in the spreading of inflammatory material that demonizes addicts, and stokes anger at the public and non-profit facilities that help them. There may be more people than you think in our community who are easily incited to vigilante violence and will feel more justified to commit it as they hear the outrage and frustration of others.

We are well aware in the health care field that drug abusers tend to be very unpleasant people to deal with. We have all been sworn at, spit on, and assaulted by someone whom we just saved from death, while they were about to storm out and try to reverse the help we just gave them. They can be aggravating, threatening, unthankful, and frustrating to treat, and it’s hard to make a positive difference in their lives. We also know they are still people who are vulnerable and living terrible lives with very few options and opportunities to turn things around.

So yes, I would like to see fewer needles in the community. Yes, I’m concerned about crime rates, and the safety of public spaces in the city. But I know closing the doors of facilities that serve users and hoping the problem will go away is not going to solve the problem. It certainly won’t stop needles from showing up in parks. It is a complex issue, and won’t quickly or easily be resolved. All large cities, and even many smaller deal ones with it. If it is a bigger problem here than in other similar sized cities, then we need to look at the socioeconomic reasons why, and try to address them. We need better addiction treatment facilities, so when someone tells me in the ED that they want to change, I have a workable and accessible program to immediately point them towards. We are opening new detox beds at the hospital in November (EDIT: changed from October with new information]. That’s a good next step, but won’t make a big difference alone. Hopefully there are more solutions coming, and I’d encourage anyone passionate enough about seeing change to get engaged and find out how they can help these changes come to pass. We need to continue good law enforcement to keep drugs off the street. We need to continue educating kids that yes, drugs are still bad – even if there is a trend towards more legalization and less punishment for use and possession, they are still potentially life destroying.

And yes, it’s appropriate to talk about how needles are being distributed to achieve harm reduction while minimizing risk to the community. It’s important to continually re-examine harm reduction programs to make sure we are helping without enabling, and minimizing unintended negative consequences that may arise from these programs. It’s important to talk about neighbourhood solutions in trouble areas and respect local businesses, homes and parks. Accountability on the part of city and organization officials working on the problem should be expected. Making those expectations reasonable requires some education about the problem and thoughtful consideration on the solutions. I hope my musings have been helpful to some. Thanks for reading.