Does It Work?

One study of Vancouver’s injection-drug users has taken harm reduction to a level even beyond Insite. In 2003, the same year that the supervised-injection site opened its doors, an epidemiologist named Martin Schecter began planning a trial that had never been conducted in North America: heroin maintenance. Would a daily course of heroin, administered in a clinical setting, release users from the destructive aspects of maintaining their addiction? Would it benefit society and allow users to stabilize their lives? Similar studies had been conducted in Europe with positive results. Switzerland alone has 38 heroin maintenance centers, and they are a fully integrated part of its national health system; Germany followed suit last year. Schecter, who has worked in Vancouver since the first signs of the AIDS epidemic in 1983, wanted to see whether such a program would make a difference in Canada.

For the neighborhood’s recovering addicts, the ability to escape the daily demands of supporting an addiction is often achieved with a dose of methadone. Methadone’s relative benefits are well established: It is slow-acting.  It greatly reduces cravings for heroin and blocks heroin’s euphoric effects. When successful, methadone maintenance can give addicts their lives back. But there are high rates of relapse among long-term addicts.

Drawing from a population of addicts in Vancouver and Montreal who had repeatedly failed methadone therapy, Schecter began the North American Opiate Medication Initiative in 2005. The Vancouver trials were set up in an abandoned bank a few blocks from Insite; the Swiss pharmaceutical-grade heroin was delivered by armored car and stored in the empty vault. Addicts were given heroin three times a day and monitored over a three-year period. A parallel group was given an ordinary course of methadone, and the results were compared.

The results of the trials, published in the New England Journal of Medicine in August, were encouraging. Schecter found that 88 percent of the heroin maintenance group stayed on their course of treatment, versus 54 percent in the methadone group. Illegal activity in the heroin group was reduced 67 percent, versus 47.7 percent in the methadone group. Out of 89,000 injections, there were only 10 overdoses and no fatalities. Despite the positive results, the heroin maintenance program has not been adopted as part of a permanent treatment strategy. Schecter has begun a new trial, focusing on dilaudid—a synthetic opiate with similar effects to heroin, but which can be administered in a pill— to see whether that has similar results. In purely economic terms, Schecter claims opiate maintenance makes sense: An untreated heroin addict costs the state $45,000 a year in legal and medical bills; heroin maintenance costs $7,000. “Sure, it’s easy to say, ‘You’re giving heroin to junkies,’ ” Schecter says, but he witnessed the stabilization of the heroin group firsthand. “A subject told me ‘for the first time in 20 years I’m actually thinking about my life.’ That was the line that blew my mind,” he recalled. “They’re actually thinking about the future. Normally they’re thinking about eight hours.”

Some scientists remain skeptical. Keith Humphreys, a Stanford-based clinical psychologist and senior drug policy adviser to the White House, dismisses the comparison of heroin and methadone, citing the superior safety and convenience of a newer drug, buprenorphine, in treating opiate addiction. “Bupe,” in wide use since 2002 in the United States, was only approved in Canada two years ago and isn’t yet covered by the national health system. “There have been multiple randomized trials, pharmacology trials, tolerance trials, showing that compared to heroin, it’s way safer,” says Humphreys.

As the world tunes in to the Olympics in the coming weeks, Vancouver’s drug policies are sure to receive saturation coverage and stir debate. So could a supervised-injection program ever gain traction in the United States? While Insite has broad public support in Vancouver itself, criticism has at times spilled over the border. John Walters, the U.S. “drug czar” under George W. Bush, called Insite “state-sponsored suicide.” Even under the new administration, there is little sympathy for supervised injection. Gil Kerlikowske, who served as Seattle’s police chief before joining the Obama administration as director of the Office of National Drug Control Policy, is deeply skeptical of Insite’s mission and efficacy. He visited Insite on Mother’s Day, 2004, eight months after it opened, and found the experience depressing. “I thought it was just a failure,” he says. “They weren’t dying of overdose as much, but they were certainly dying a slow death in a lot of other ways.”

These doubts are shared by Thomas McLellan, ONDCP’s deputy director, whose own son died of a drug overdose in 2008. “I certainly wouldn’t be presumptuous enough to tell Canada what to do with its money,” he says. “I commend the government for attempting something, I commend them for evaluating it, and I will let the data say to the world and to them whether they’re getting what they want out of it. I can’t say I’m optimistic.” McLellan opposes supervised injection, “not because it’s immoral, not because we have a particular ideology or anything that we want to follow, but because I think there are many better, safer options.” In McLellan’s view, both Insite and Schecter’s trial suffer from a more fundamental flaw: They don’t get people off drugs, and would only be successful “in the context of ultimately bringing people to see that drug use itself is harmful and that there are effective ways of bringing it to an end.”

The ONDCP is announcing its new national drug strategy in February, and Kerlikowske says his new mantra is “evidence-based policy”: using hard science to guide decision-making. Determining which evidence to base federal policy on falls largely to Keith Humphreys, who will help draft the new ONDCP strategy. Humphreys doesn’t trust the research that has been conducted into supervised injection, which he says is often nonrandomized and lacking control groups. “Those studies are not the kind you would ever approve a medical treatment for,” says Humphreys. “They are very undeveloped, scientifically.” He cites a phenomenon in which passionate commitment to a particular intervention, like supervised injection, within a small group of researchers skews their results. “Sometimes people feel that when folks are really troubled, you know, we need to make the science softer and weaker and just kind of go with our gut. I feel the exact opposite. When people are really vulnerable, you really, really want to make sure that you’re giving them good health care.” For David Marsh, Insite’s Medical Director, the rationale for the site goes beyond scientific evidence. “We need to do things that save lives and treat drug users like real human beings who are part of society, and there’s a real moral argument why that’s the right thing to do.”

Given the death-panel hysteria attending the health care debate, a serious discussion of applying Vancouver’s policies in the United States seems unlikely. But to the proponents of progressive drug policy reform, there are a few signs of hope. New York has abandoned the mandatory minimums of its Rockefeller Drug Laws. It remains to be seen how far the new White House strategy will depart from the drug war, but President Obama has publicly declared that “drug addiction is a health issue” and has ordered the Justice Department not to pursue medical marijuana arrests in states that have legalized it. Congress has overturned the ban on federal funding of needle exchange, and a bill called the Drug Overdose Reduction Act may open the way to American policymakers studying Vancouver’s experiment. Yet there is still no simple answer to whether that experiment is a failure or a success.

Gregor Robertson, Vancouver’s 44-year-old mayor, knows well that the nightmarish scenes in the alleys of the Downtown Eastside are at odds with the Olympic image of Vancouver as a progressive green utopia. Handsome and athletic, Robertson came into office on an environmental and social-welfare platform, promising to deal with the city’s homeless and mentally ill. “It shocks some people to see the pain and suffering in the community front and center,” he says. He’s ready for the world to arrive and isn’t afraid of being judged. “I think our city, we’re open and willing to share our biggest problems, and open to ideas from the rest of the world to help us solve them. We haven’t figured them out, and we’re certainly not going to hide it.”

Vancouver is trying to avoid the mistakes of some past Olympic cities, notably Atlanta, which garnered criticism for pushing out its homeless in the months before its Games. As for the critics of Vancouver’s harm reduction policies? “They’re purely ideological,” Robertson says. “Science is on our side here. And the community supports us.” In any event, the Games will come and go, and the users of Insite will still be on East Hastings Street, waiting for the doors to open every morning at 10.

Click here to view a slide show on Downtown Eastside Vancouver.