Harm expansion
BC has been a leader in harm reduction for decades. That could change.
Content warning: substance use and death
A week ago I was walking home from work in Victoria. As I crossed the street, I spotted someone slumped next to a retaining wall. He was pale — too pale — and his lips were blueish. Two workers from Solid Outreach were there, and a naloxone kit was open next to him. He was alive, but he had likely overdosed.
In 2023, British Columbia Emergency Health Services responded to over 42,000 overdose and drug poisoning calls — an average of 116 calls per day. This represented a 25% increase over 2022, with the largest increase in the Vancouver Island Health region — 45%; or 9,086 calls.
British Columbia declared a public health emergency in 2016 because of the rapid increase in overdose-related deaths. The primary driver of the increase has been contamination of fentanyl — an extremely powerful synthetic painkiller — in other substances, or in unexpectedly large amounts. Once someone has overdosed, it can take as little as a few minutes for someone to die, but a dose of naloxone can stabilize them long enough to get them help.
A fundamental point of harm reduction — one of the four pillars response to addiction — is that in order to treat people for addiction, they first need to be alive.
Harm reduction and the AIDS crisis
British Columbia, and Vancouver in particular, has been a leader in harm reduction long before the current overdose and poisoning crisis. Much of what formed Vancouver’s model of the four pillars strategy was rooted in the success of harm reduction during the HIV/AIDS crisis.
As the virus began to spread in the 80s, Vancouver activists gathered to figure out how to respond to GRID — then termed “Gay-Related Immune Deficiency” but later known as Acquired Immune Deficiency Syndrome (AIDS). As more people died, two major causes of transmission were identified: unprotected sexual contact, and the sharing of contaminated needles by substance users.
There was a recognition that people were likely to continue to engage in these activities — sex and drugs — which led activists to focus on reducing the potential harms associated. For sexual activities, this involved initiatives like the provision of free condoms and lubricants, particularly in gay bars. For substance use, this involved the creation of a needle exchange program in 1989, so that if people were using intravenous substances they would not spread the virus. This would eventually lead to the creation of Insite in 2003, where people who use substances could access clean, safe supplies and use under the supervision of a nurse who could intervene if they experienced an overdose.
It’s estimated that thousands of people’s lives were saved by these interventions. By preventing the immediate harms of substance use, people lived and could later seek treatment and support to address their addiction. Since 2003 there have been over 6 million visits to Insite and not one overdose death in the facility. In addition, people who visit Insite and are looking for treatment can be referred upstairs to Onsite, where they can access recovery-oriented programs along with health and housing supports.
The battle for InSite
Insite is able to operate under a special exemption from prosecution under federal drug laws from Health Canada. Despite huge public support for extending the exemption, in 2006 the incoming Harper government made shutting down Insite one of its top priorities. Health Minister Tony Clement called it an “abomination”, and the Canadian Police Association called for it to be shut down.
This went all the way to the Supreme Court. In their challenge to the government’s decision to refuse to extend the exemption, Insite argued “as a healthcare facility, Insite falls under the jurisdiction of the BC government, and that denying drug users access to health services at Insite would violate their rights to life, liberty and the security of the person established under the Canadian Charter of Rights and Freedoms.”
In 2008, the BC Supreme Court ruled that enforcing the Controlled Drugs and Substances Act (CDSA) regarding Insite violated the Canadian Charter, giving Insite a temporary constitutional exemption. The exemption was upheld at the BC Appeals Court in 2010. Finally, the federal Supreme Court unanimously ruled in 2011 that “the federal health minister’s attempts to close Insite went against the country’s Charter of Rights and Freedoms by threatening the safety and lives of the people who need to use it”.
Since then, research done on Insite has consistently shown it works — overdose deaths decreased, there are fewer hospital admissions for infections related to substance use, fewer emergency dispatches requiring naloxone, and a significant reduction in the spread of HIV.
Decriminalization
As Insite and safe consumption sites helped shift the approach on addictions to a being an issue of health, a new crisis emerged — poisoned drug supply. At the same time that Insite was saving lives, people elsewhere were dying in rapidly increasing numbers. 2015 saw a 27% increase in overdose deaths above the previous year, and in 2016 the province declared deaths by overdose a public health emergency.
The province tried to find ways to reduce harm to substance users. Once again, Vancouver led the way. Community activists began setting up spaces where people could get substances checked for contaminants, giving people an opportunity to ensure their supply was safe to use. These services were available at Insite, again providing people struggling with addictions the opportunity to go upstairs to Onsite for detox and treatment. This also allowed monitoring of the results of that testing, which made it clear that poisoned drugs were a massive problem.
Overdose deaths still climbed. Many of the people who die of overdoses do so alone, and did not access services for fear of being arrested and charged. Illegal drugs come from unregulated, criminal sources, and a person may not know it has been contaminated with something until it was too late. People feel shame and stigma around substance use and will often avoid asking for help or services for fear of being judged.
In an effort to bring substance use out of the shadows, and give people using drugs an opportunity to find the health and social services they need, the province applied to the federal government for a new exemption to the Controlled Drugs and Substances Act.
Under this exemption, a person may be in possession of an illegal substance up to a maximum cumulative quantity of 2.5 grams, if they are within a designated health care clinic, shelter or private residence. Trafficking, or selling illegal substances, remains a criminal offense. This took effect in January 2023, which was still the deadliest year on record for overdose deaths.
While support for decriminalization was still high in in the spring of this year — 62% of Canadians felt that decriminalization would make it easier to access health and social services — 51% also believe it increases harms associated with substance use. 46% of respondents believe decriminalization makes their community less safe.
According to recent polling, 55% of people said "the level of criminal activity in their community has increased." 74% said crime and violence "are impacting the quality of life in their community." This is not necessarily because of decriminalization, and violent crime has actually decreased in the last year, but it becomes an easy target for politicians in the coming election.
The opposite of reduction is expansion
“John Rustad, Leader of the Conservative Party of British Columbia, and Teresa Wat, Conservative candidate for Richmond-Bridgeport, today announced their commitment to shutting down every single drug den injection site in the City of Richmond and launching an aggressive campaign against David Eby’s radical free drug agenda.”
On September 22nd, the BC Conservatives sent out the above statement within a news release.
It did not take long for people to point out the first flaw in Rustad’s intent — there are no safe injection sites in Richmond to close down. Additionally, safe consumption sites are not a result of last year’s move to decriminalization — some have been in place for well over a decade. Rustad did not explain his plan to challenge the Supreme Court of Canada ruling.
Only a week prior, Rustad gave a speech where he talked about meeting someone whose life had been saved in a safe injection site, giving him the opportunity to eventually seek support and treatment. He told reporters at the time he would keep such facilities open, and expand treatment and intake options for people accessing them. His sudden switch shocked advocates, especially the guy he talked to.
Rustad is not alone. Premier Eby has pulled back some of his support for decriminalization, amending the exemption from Health Canada to make possession of small amounts criminal in public spaces. The problem, as decades of dealing with this issue has shown us, is that criminalization doesn't stop people from using substances — it forces them to do it where no one can see them.
Despite all the research showing what is effective in reducing the harms of substance use, the NDP has reduced access to clean substance use paraphernalia, aligned with the Conservatives on involuntary care, and rejected the recommendations of the provincial health officer to find ways to regulate and monitor the supply.
It is clear that decriminalization, overdose deaths and perceptions of public safety are going to play a major role in the coming election. Politicians will debate their approaches, policies and commitments to tackling the issues. It will feature highly in their campaign messaging and literature.
Meanwhile, all over the province, overdose deaths keep rising.
Moms Stop the Harm (MSTH) is a network of Canadian families impacted by substance use related harms and deaths. Consider supporting their work.
To their credit, the BC Greens at least presented an alternate plan that was backed by leading voices in public health including the former chief coroner.