VANCOUVER'S RADICAL APPROACH TO DRUGS: LET JUNKIES BE JUNKIES

On a chilly, overcast morning in downtown Vancouver, British Columbia,
a steady trickle of sallow-faced drug addicts shambles up to a
storefront painted with flowers and the words "Welcome to Insite." One
by one, they ring the doorbell and are buzzed into a tidy reception
area staffed by smiling volunteers.

The junkies come here almost around the clock, seven days a week. Some
just grab a fistful of clean syringes from one of the buckets by the
door and head out again. But about 600 times a day, others walk in
with pocketfuls of heroin, cocaine or speed that they've scored out on
the street; sign in; go to a clean, well-lit room lined with stainless
steel booths; and, under the protective watch of two nurses, shoot
their drugs into their veins.

Welcome to North America's only officially sanctioned "supervised
injection site." The facility sits in the heart of Vancouver's
Downtown East Side, 10 square blocks that compose one of the poorest
neighborhoods in all of Canada. The area is home to an estimated 4,700
intravenous drug users and thousands of crack addicts. For years, it's
been a world-class health disaster, not to mention a public relations
nightmare for a town that is famous for its beautiful mountains and
beaches (and is gearing up to host the 2010 Winter Olympics). Nearly a
third of the Downtown East Side's inhabitants are estimated to be
HIV-positive, according to the United Nations Population Fund, a rate
on par with Botswana's. Twice that number have hepatitis C. Dozens die
of drug overdoses every year.

Largely in response to this nightmare neighborhood, Canada's
third-largest city has embarked on a radical experiment: Over the last
several years, it has overhauled its police and social services
practices to re-frame drug use as primarily a public health issue, not
a criminal one. In the process, it has become by far the continent's
most drug-tolerant city, launching an experiment dramatically at odds
with the U.S. War on Drugs.

Smoking weed has been effectively decriminalized. The famous "B.C.
bud," rivaled in potency only by California's finest, is puffed so
widely and openly that the city has earned the nickname "Vansterdam."
A single block in the Downtown East Side hosts several pot seed
wholesalers, the headquarters of the British Columbia Marijuana Party
and the toking-allowed New Amsterdam Caf.

But that's nothing next to the city's approach to drugs like heroin
and crack. Impelled by the horror show of the Downtown East Side,
prodded by activists and convinced by reams of academic studies, the
police and city government have agreed to provide hard drug users with
their paraphernalia, a place to use it and even, for a few, the drugs
themselves.

More than 2 million syringes are handed out free every year. Clean
mouthpieces for crack pipes are provided at taxpayers' expense. Around
4,000 opiate addicts get prescription methadone. Thousands come to the
injection site every year.

On top of that, health officials just wrapped up a pilot program in
which addicts were given prescription heroin. And it doesn't stop
there. The mayor is pushing for a "stimulant maintenance" program to
provide prescription a lternatives for cocaine and methamphetamine
addicts. Emboldened advocates for drug users are even calling for a
"supervised inhalation site" for crack smokers.

Vancouver has essentially become a gigantic field test, a 2
million-person laboratory for a set of tactics derived from a school
of thought known as "harm reduction." It's based on a simple premise:
No matter how many scare tactics are tried, laws passed or punishments
imposed, people are going to get high. From winemaking monks to
coca-leaf-chewing Bolivian peasants to peyote-chomping Navajos to
caffeine-fueled office workers to the junkies of Vansterdam, human
beings have never been willing to settle for our inherently limited
palette of states of consciousness.

If you accept the notion that people aren't going to stop abusing
drugs, it makes sense to try to minimize the damage they inflict on
themselves and the rest of us while they're at it. Harm reduction is
less about compassion than it is about enlightened self-interest. The
idea is to give addicts clean needles and mouthpieces not to be nice
but so they don't get HIV or pneumonia from sharing equipment and then
become a burden on the public health system. Give them a medically
supervised place to shoot up so they don't overdose and clog up
emergency rooms, leaving their infected needles behind on the sidewalk.

Give them methadone -- or even heroin -- for free so they don't break
into cars and homes to get money for the next fix. These aren't just
theoretical notions. Some harm reduction tactics have been researched
extensively -- and the findings are often impressive. In recent years,
no fewer than eight major studies in the U.S. on needle-exchange
programs -- probably the best-known and most widespread harm reduction
technique -- have concluded that they work. As then-Assistant Surgeon
General David Satcher summed up in a 2000 report, "There is conclusive
scientific evidence that syringe exchange programs are an effective
public health intervention that reduces the transmission of HIV and
does not encourage the use of illegal drugs."

Methadone maintenance, first introduced in the 1960s, has been the
subject of hundreds of scientific studies. "The findings have been
consistent," according to a recent article in the Mount Sinai Journal
of Medicine. "Methadone maintenance reduces and/or eliminates the use
of heroin, reduces the death rates and criminality associated with
heroin use and allows patients to improve their health and social
productivity. In addition, enrollment in methadone maintenance has the
potential to reduce the transmission of infectious diseases associated
with heroin injection, such as hepatitis and HIV."

In Vancouver, harm reduction seems to be delivering. Since the city
began seriously supporting needle exchanges and other such tactics in
the 1990s, HIV infections have fallen by half, and hepatitis C rates
have plunged by two-thirds, according to city and provincial health
authorities. The annual number of drug-induced deaths has dropped from
a peak of 191 in 1998 to 46 in 2005, the most recent year for which
statistics are available.

Nonetheless, harm reduction remains controversial, even in relatively
liberal Vancouver. "People are always going to beat each other up, too
- -- so should we be handing out boxing gloves to reduce the harm they
do?" asks Al Arsenault, a recently retired Vancouver cop who spent
much of his 27-year career in the Downtown East Side and now makes
documentaries about the area. "That's just normalizing the behavior.
The whole premise is nonsense."

It took a careful, sustained campaign to convince politicians and a
critical mass of voters that such critics were misguided. Philip Owen,
who as Vancouver's mayor from 1993 to 2002 was one of the key forces
pushing the city to embrace harm reduction, was convinced by the
research on the subject, some of which was brought to his attention by
the U.S.-based Drug Policy Alliance Network and other advocacy groups.

Once on board, Owen set about building support. "You need to walk
slowly before you can run," he says. Owen organized dozens of public
meetings with community groups and cultivated provincial and federal
officials. He even took the then-federal Minister of Health on an
undercover tour, both of them wearing blue jeans and old hats, of the
Downtown East Side to see the problem firsthand.

Owen's groundwork helped Vancouver secure a special exception to
federal drug laws that allowed Insite to open. The heroin maintenance
program won approval on a trial basis. "If you set something like that
up as a scientific experiment rather than a policy change, it's easier
to sell," says Ethan Nadelmann, executive director of the Drug Policy
Alliance Network. Meanwhile, a local activist group, the Vancouver
Area Network of Drug Users, kept up the pressure with noisy street
demonstrations.

A quick visit to the Downtown East Side is enough to convince anyone
that the city had to do something. The area was always sketchy, but
Vancouver's booming economy and rapid growth have combined to gentrify
most of downtown, pushing the dope fiends and crackheads and mentally
ill homeless into an ever smaller, more densely concentrated island of
cheap housing, where their addictions and pathologies and sundry bad
behaviors feed on each other.

Today, the Downtown East Side protrudes like a gangrenous limb from
the city's sleek core. Literally from one block to the next, a world
of chic clothing boutiques, jewelry shops and high-rise luxury condos
suddenly gives way to Planet Junkie. Haggard, prematurely aged men and
women with sunken cheeks, missing teeth and feral expressions drift
along trash-strewn sidewalks lined with abandoned buildings. The only
legitimate businesses are check-cashing operations, pawn shops, bars,
squalid residential hotels and 24-hour convenience stores with barred
doors and windows. It's a bit like an unsupervised, open-air hospice
where the patients have been left to find their own medications and
get them into their bodies however they see fit, a dark carnival of
misery smack in the middle of what The Economist recently dubbed "the
most livable city in the world."

In just an hour of randomly walking around one recent morning, I
passed at least a dozen people smoking crack in plain view, stepped
over countless discarded needles and turned down muttered offers of a
whole pharmacopeia of substances. The worst that police are likely to
do to street-level users is take away their drugs. That evening, I
accompanied a couple of constables walking the beat who passed a
grizzled man with long, greasy hair smoking crack at a bus stop on
busy Hastings Street. Sighing at his stupidity -- couldn't he have at
least gone around the corner into an alley? -- the cops made him drop
his pipe, crushed it underfoot, gave him a warning and walked away
without even searching him.

That's more or less official policy. "If you look at an addicted drug
user, who likely has a mental illness, you have to ask, 'What's the
best bang for our buck?'" says Inspector Scott Thompson, the Vancouver
Police Department's drug policy coordinator. "If we lock them up, it
costs between $75,000 and $90,000 per year. By dealing with it as a
health issue, we'll save a lot of money and hopefully solve more
problems." The department focuses instead on traffickers and
producers, he says.

Efforts to keep drug use as healthy as possible are everywhere in the
Downtown East Side. Free needles, tourniquets and clean crack-pipe
mouthpieces are available in soup kitchens and clinics on practically
every block. Blue metal syringe disposal boxes are installed at alley
entrances.

The supervised injection site is the most visible and controversial of
these measures. Opened in late 2003, it's a newer and much-less-tested
tactic than needle exchange. So far, a flock of peer-reviewed studies
has found the program has not led to increased crime or drug use in
the area. Last March, a report commissioned by the Canadian federal
government concluded that "(t)here was no evidence of increases in
drug-related loitering, drug dealing or petty crime in areas around
Insite (and) police data for the (Downtown East Side) and surrounding
areas showed no changes in rates of crime." Moreover, the report
noted, "(T)here is no evidence that (supervised injection sites)
influence rates of drug use in the community or increase relapse rates
among injection drug users."

In short, Insite is not making things worse. But is it making anything
better? Studies indicate that Insite has reduced needle sharing, one
of the major transmission routes for HIV. But Colin Mangham, a
researcher with the Drug Prevention Network of Canada, points out that
much of the data is based on injection drug users' reporting of their
own behavior -- not exactly the gold standard of credibility.

The facility is, however, clearly saving at least some lives. Its
staff has intervened in more than 336 potential overdoses. Rico
Machado, a surprisingly healthy-looking heroin addict whom I met in
Insite's check-in area, was one of those cases. "I did my normal dose,
but this stuff was too strong," he says. "I hit the ground. But they
gave me Narcan (a drug that reverses opiate overdoses) and
resuscitated me. Before this place was open, I would have been in an
alley. I would have been dead."

Moreover, Insite has provided a gateway into detox programs for a
number of addicts and served as an immunization center during a recent
pneumonia outbreak. The site has even added a small residential rehab
facility.

A couple of blocks away, a small clinic is stashed behind papered-over
windows on the ground floor of an unmarked, 1930s-era building. Here,
every day for three years, nurses behind bulletproof glass handed
dozens of addicts a tourniquet, a needle, an alcohol swab and a
carefully measured dose of pure heroin.

The theory being tested in this program, which wound up its pilot
phase in August, was that it would keep junkies from having to steal
or prostitute themselves for their fixes. As a side benefit, they
would have more time and energy to take advantage of the program's
treatment component.

Official results were slated to be released in October, after this
story was published. Dr. David Marsh, the program's medical director,
says he's already seen its participants benefit. "They're eating
better, getting their health problems dealt with, getting into better
housing," he says. "Some are even going back to work. One guy started
out homeless, got clean and now runs a business with 15 employees."

Much of what Vancouver is doing is already long-standing policy in
many countries, especially in Europe. Methadone and needle-exchange
programs are commonplace in many nations. Six European countries and
Australia are home to dozens of supervised injection sites. Holland,
Denmark, Switzerland, Germany and Spain have experimented with heroin
maintenance. Even Iran, of all places, recently launched a pilot
program to distribute clean needles through vending machines.

In the United States, however, conservative politics and "Drug-Free
America" rhetoric keep punishment as the primary response to drug use.
Mandatory minimum sentencing and "three strikes" laws have sent the
number of drug offenders in America's prisons skyrocketing. There are
more than half a million inmates currently locked up on narcotics
charges -- more than the total of all prisoners in 1980. Each of those
prisoners costs taxpayers on average more than $22,000 per year,
according to the federal Bureau of Justice Statistics -- several times
the price of providing them with treatment.

The U.S. doesn't seem to be gaining much from the billions of dollars
it invests in incarcerating drug offenders. Perhaps the decades-long
"War on Drugs" has kept illicit substance use from growing, but it
certainly hasn't done anything to reduce it. The most recent annual
survey of drug use by the University of Michigan found that about 85
percent of 12th-graders in America say marijuana is easy to get.
Almost 1 in 3 of those teenagers has smoked up in the past year, a
number that has not changed much over the last 30 years.

All told, some 8 percent of Americans over age 12 -- about 20 million
people -- use illicit drugs, according to the most recent estimates
from the U.S. Department of Health. That's a higher rate than the same
agency found in the early 1990s. More than 1 in 3 Americans --
including, by their own admissions, Sarah Palin and Barack Obama --
have tried some kind of illicit substance at least once.

Meanwhile, tens of thousands of people in the U.S. are infected with
HIV or hepatitis C every year thanks to shared needles. And according
to the Centers for Disease Control and Prevention, nearly 20,000
people died of drug overdoses in 2004 -- the most recent year for
which statistics are available -- way up from the 12,000 reported
fatal ODs in 1999.

No surprise, then, that there is a small movement pushing for more
harm-reduction-based policies. Voters in California, Arizona and
Maryland have passed initiatives in recent years mandating treatment
instead of incarceration for first-time drug offenders. Not long ago,
needle-exchange programs were banned everywhere; now there are nearly
200 such programs in 38 states.

The liberal, forward-operating base of San Francisco is at the
vanguard of these efforts. Surging overdose deaths among the city's
estimated 16,000 intravenous drug users spurred the city to officially
embrace harm reduction in 2000. "We've tried to take drug addiction
from being seen as a moral issue to being seen instead as a chronic
disease," says Barbara Garcia, deputy director of the San Francisco
Department of Public Health.

Today, a welter of programs hands out more than 2 million clean
syringes every year, more than in any other city. At one storefront
needle exchange in the notoriously skivey Tenderloin district, for
instance, visitors can choose from three different sizes of syringes;
speed shooters and junkies with narrow veins prefer smaller hardware.
They can also pick up little metal cups and tubes of sterile water to
cook the drugs in, hand wipes and alcohol swabs to clean their skin
before stabbing it and other handy accessories, including tourniquets
and crack-pipe mouthpieces.

One recent evening, Ian Johnson, a veteran local drug user dressed in
pinstriped slacks, a soiled white shirt with a neatly knotted tie and
a stained double-breasted jacket two shades darker than his pants,
came in for another service: overdose prevention training. A friend
had recently died from a too-big shot of heroin, he explained, and he
didn't want to see that again. A volunteer trainer sat Johnson down
with a torso-and-head CPR mannequin and showed him how to inject a
dose of Narcan into someone's shoulder. Satisfied that Johnson had the
simple procedure down, the trainer passed him along to a nurse who
wrote a prescription making it legal for Johnson to walk out with a
little black plastic box containing two needles and a vial of Narcan.

More than 1,200 people have been trained to administer Narcan this
way, and trainees have used it at least 260 times to intervene in
potentially fatal overdoses, according to the Harm Reduction
Coalition, a nonprofit group that runs the trainings for the city. San
Francisco also puts up the money to give methadone to about 5,000
people a year and to train dozens of "peer counselors" -- current and
former speed users -- to advise their drug buddies on basics like
remembering to eat while on multiday meth binges. There's even talk of
opening a supervised injection site.

Outside of New York, Baltimore, Chicago and a few other places,
though, harm reduction is a tough sell in the United States. Congress
forbids federal dollars from funding needle exchanges. In many
jurisdictions, it's illegal to possess a syringe without a
prescription, making widespread needle distribution impossible, no
matter who funds it. Federal drug czar John Walters has denounced
Vancouver's Insite program as "state-sponsored suicide" and harm
reduction in general as a Trojan horse for the goal of legalizing
drugs outright.

Even in Canada, the Vancouver experiment is under pressure. The
country's ruling Conservative Party has denounced the safe injection
site and is pushing for a tougher line against drugs nationwide.
"Allowing and/or encouraging people to inject heroin into their veins
is not harm reduction," said Health Minister Tony Clement at a recent
AIDS conference. "We believe it is a form of harm addition."

At first blush, the proposition that making drug use easier for
addicts will benefit everyone does seem a bit far-fetched. As many
critics have pointed out, it seems to send the message that hard drug
use is all right, as long as you're careful about it. It's a message
that, critics insist, could lead more people to experiment with
narcotics and leave fewer addicts inclined to seek treatment.

Though the "wrong message" idea makes intuitive sense, the
overwhelming preponderance of research on the subject does not bear it
out. Over and over again, studies find that measures like needle
exchange and even supervised injection sites do not promote drug use
and do help curb some of the damage it causes.

The critique of harm reduction best supported by actual evidence is
that it doesn't do enough.

"The harm reduction approach within the UK appears to have had only
modest success in reducing the breadth of drug-related harms,"
University of Glasgow researcher Neil McKeganey wrote in a recent
overview published in the journal Addiction Research & Theory.
"Despite a plethora of initiatives aimed at increasing drug
(injectors') awareness of the risks of needle and syringe sharing, and
of providing drug users with access to sterile injecting equipment,
around a third of injectors are still sharing injecting equipment."

That's a weighty objection to Insite, considering the facility costs
$3 million a year to operate. On a typical day, only about 5 percent
of all injections in the Downtown East Side are done in the facility's
relative safety, according to the federal government's study. I found
discarded syringes in the alley right behind Insite.

Creating a safe place to shoot up may make good sense, but that's not
necessarily relevant to people whose cravings regularly trump their
judgment. Watching Liane Gladue, a longtime junkie, searching for a
vein under a streetlight in a Downtown East Side alley, I asked why
she didn't go instead to the injection site just a few blocks away.
"It's too crowded in there," she answered. "I didn't want to wait."

Though Vancouver is cutting the collateral damage caused by hard
drugs, the city is making far less progress in reducing the number of
users. Surveys report that drug use is higher in British Columbia than
in the rest of Canada. A recent poll found that almost half of all
Vancouverites consider drugs a major problem in their communities -- a
figure double that for residents of Canada's biggest cities, Toronto
and Montreal.

With serious drug users come rip-offs, break-ins and holdups for fix
money. So it's no surprise that Vancouver's property crime and bank
robbery rates are higher than most of Canada's. The city also has more
gun-related crimes per capita than any other in the nation, a fact at
least one criminologist has linked to the number of substance abusers.

All of this underscores why widespread drug addiction is ultimately
everybody's problem. Obviously, getting street addicts to clean up
takes more than free needles. It takes affordable housing, mental
health services, counseling and treatment, all of which are in short
supply, even in Vancouver. For some addicts, it might also take the
threat of jail.

But it doesn't have to be an either/or choice. As the American Medical
Association states in its official position on the issue, "Harm
reduction can coexist, and is not incompatible, with a goal of
abstinence for a drug-dependent person, or a policy of
'zero-tolerance' for society."

Advocating anything that sounds "soft on drugs" is generally
considered political suicide for elected officials in most parts of
the U.S. But as Vancouver has proved, a coalition of health care
officials, activists and courageous politicians armed with solid data
can change that equation. "No one in the U.S. wants to touch this
stuff because they're afraid they won't get elected if they do," says
Philip Owen, Vancouver's former mayor. "Well, I was re-elected three
times."