Every day, Karen Salmon wonders whether this will be the day she hears her daughter has died of an overdose.
A loving and active child growing up, Lorraine (her middle name, used at her mother’s request) began experimenting with drugs in high school. Things quickly spiralled out of control as addiction took over.
While Lorraine has experienced some time living clean and sober in the past 25 years, she is now 34, addicted to heroin/fentanyl and living on the streets of Victoria, her mother says.
“It’s heartbreaking to see her now. She’s just a shell of the person she was.”
Lorraine has cycled through detox and stabilization several times.
But the combination of no treatment beds, wait-lists for detox and stabilization beds, and lack of system support make it all but impossible for someone like her daughter to kick their drug of choice and get well, her mother says.
“That’s a huge piece that’s broken,” Salmon says of the lack of treatment.
There’s a wait of at least two weeks for any one of the 36 detox beds in Victoria. Beyond that, there can be an even longer wait to get a stabilization bed, where someone can live in a drug-free environment while they try to put their life back together. There is no publicly funded residential treatment facility for women on the Island.
There is a need for treatment on demand, Salmon says, noting that just trying to navigate the system can be daunting for her daughter.
“Sometimes she has a phone and sometimes she doesn’t. Sometimes there’s a way to communicate with her and sometimes there isn’t,” she says.
Keeping appointments is near impossible: “If she has an appointment to meet someone at Umbrella at three o’clock next Friday, well next Friday rolls around and that’s long gone out of her head.”
Her daughter cycles in and out of social housing and is currently sleeping in a park, Salmon says.
“I understand the harm reduction and finding housing and everything, but treatment is what’s lacking. We’ve got all this new housing and everything. We’ve got safe-injection sites. We’ve got all these things put in place and everybody’s got Naloxone kits, but where’s the treatment? Where is the repair? That’s the piece of the puzzle that’s missing. There’s just not enough treatment.”
Twenty years of harm reduction
For the past 20 years the provincial approach to drug addiction has focused on harm reduction — a global term for initiatives such as distributing clean needles or providing replacement drugs like methadone.
The strategies have increasingly been used in public health efforts — first to combat the spread of HIV and hepatitis C amongst intravenous drug users, and now to combat the overdose crisis exacerbated by fentanyl in the illicit drug supply.
Initiatives began with the supply of clean needles and supplies and needle exchanges. That’s been followed by the opening of supervised consumption and overdose prevention sites and the distribution of overdose-reversing Naloxone kits, and an increased emphasis on opioid replacement therapies. (Some say opioid replacement is an addiction treatment others argue it’s harm reduction.)
Calls for decriminalization of illicit drugs and for the introduction of a regulated, clean drug supply are getting louder as the next step in the harm reduction approach to the drug crisis.
Some experts note that harm reduction was never meant to be a stand-alone strategy. It has always been promoted as one leg of a four-pillar approach that also includes treatment, enforcement and education/prevention.
“Of course they really only put in resources behind the one pillar — harm reduction,” says Dr. Ray Baker, an addictions specialist in Vancouver for more than 30 years. “They didn’t do enforcement and they didn’t increase the amount of treatment and there was virtually no prevention done at all.”
Many say it’s past time to shift some of the focus to treatment, enforcement and prevention.
“We can’t just focus on saving people [by reversing overdoses] and giving them clean needles and safe consumption sites and what not,” says Victoria Police Chief Del Manak, who has been warning city council of the strains increasing street disorder and rampant open drug use are putting on his officers.
“You cannot just look at one pillar, and many of our social agencies do focus just on the one aspect. That’s why you’re not going to get success when you’re disproportionately putting resources, money and focusing just one of the pillars and not the other three.”
Trying to keep people alive
B.C. declared a public health emergency in April 2016 in response to a spike in drug overdose deaths.
There were 474 apparent illicit drug overdose deaths in 2015, a 30 per cent increase from 2014, when there were 365 deaths. Last year had the highest number to date, with 1,535 overdose deaths.
The increase has been blamed on fentanyl, a powerful synthetic opioid that is several times stronger than heroin. It has been detected in 82.1 per cent of overdose deaths since 2016.
Kelly Reid, director of operations for South Island Mental Health and Substance Use, admits that there’s been no new investment in detox and recovery treatment services on the South Island in the face of the fentanyl crisis.
Faced with people dying from at such an alarming rate, the public health approach has been to try to keep people alive, he says.
Island Health has been working with peer groups to get overdose-reversing Naloxone kits distributed as widely as possible, setting up supervised consumption sites and getting those at risk of overdose on Suboxone or methadone.
It is having some impact, but hundreds of people are still dying from overdose.
Overall, 462 illicit overdose deaths were recorded in B.C. to the end of May this year — down from 651 the same period in 2018. Victoria saw 13 deaths from Jan. 1 to March 31. If the trend continues, that would be a projected 52 deaths in 2019, compared with 96 for 2018.
“The numbers we see of people who have died of overdose would be so much worse if there wasn’t the amount of Naloxone out on the streets that there is,” Reid says.
Safe consumption sites and supervised injection sites have also played a role. Such sites provide drug-users with a clean, safe space to use drugs under the supervision of health professionals.
Katrina Jensen, executive director AIDS Vancouver Island, notes that in the past two years there have been 240,000 visits to the 10 safe consumption and supervised injection sites in B.C. While there have been more than 1,000 overdoses at the sites, there have been no deaths.
In Victoria, there have been 14,000 visits to overdose prevention sites, where 120 overdoses have been reversed.
Creating a continuum of care
Despite the crisis, as of 2018 there were only nine publicly funded residential treatment beds on south Vancouver Island — an increase of two in the previous five years. The number of detox beds actually decreased to 36 in 2018 from 55 in 2013, and the number of detox beds for youths dropped by one to 12.
The resulting wait-lists for detox make a mockery of any notion that safe consumption sites are points of contact or pathways for people wanting to recover from their addictions, says addictions counsellor Sue Donaldson, founder of Pegasus Recovery Solutions.
“[With wait-lists] there’s a whole bunch of people that are asking for help and they’re basically being denied it,” Donaldson says.
“So basically we’re saying ‘No’ to all of those people on wait-lists for detox, for stabilization, for treatment, to see a counsellor at the outpatient clinic … And that’s a huge issue.”
But that’s the reality. For detox there’s a wait-list. For treatment you need cash. Unless someone has $30,000 to $60,000 to spend on a private facility, the prospect of getting addiction treatment is virtually nil.
That is an opportunity lost, says Baker, who notes addiction issues currently have the attention of both the government and the media.
“The opportunity here is to take this motivation and put in place a continuum of care — including harm reduction, there’s a huge place for harm reduction — but it should be recovery-orientated harm reduction so that we broaden the gateway,” Baker says.
That means if a choice is made to stabilize someone with an opioid replacement, then that should be ultimately be replaced by non-pharmacological treatments, “of which there are many, many, many that are evidence-based,” he says.
Salmon says every time she sees her daughter she says she wants to wants to get off drugs.
The same is true for the vast majority of drug addicts, says Scottish researcher Neil McKeganey, who has surveyed some 1,200 illicit drug users about why they contact drug and alcohol services.
The number that says they wanted harm reduction advice as to how they could continue to use their drugs more safely was “minuscule,” he says.
“Overwhelmingly the addicts says: ‘We want help to become drug free because we have come to understand that it’s our addiction that is the problem here and we want services to help us become drug free.’ ”
Don Evans, executive director of the Our Place community drop-in in Victoria, has been studying approaches that other countries have taken.
Evans doesn’t think decriminalization of drugs, as was done in Portugal, would make any difference in stemming the tide of overdoses. He notes Portugal employed a number of co-ordinated strategies, not just decriminalization, to address addiction.
“They tell me that decriminalizing was an important factor, but it wasn’t the most important factor and you couldn’t have done that without the other ones,” says Evans, who has twice visited Portugal to study their system.
“They have access to treatment for anybody who wants it that is government funded. And the availability is there for people, so if you want to get help, you can get help. They use therapeutic communities there. So if anyone wants to get into a therapeutic community, the government pays for it for up to 18 months.”
Evans is behind the therapeutic recovery community that just opened in View Royal’s former youth detention facility.
Patterned after the San Patrignano Therapeutic Community in Italy and similar to those in Portugal, the View Royal facility will eventually see up to 50 men — drawn from the prison system and the homeless community — live in the community for up to two years. While there, they work with peers and professionals to gain sobriety, heal from past traumas and develop the recovery capital they need to try to cope without drugs or alcohol.
Evans hopes it’s the first of more such facilities to come and that the province will provide incentives to non-profits and private organizations to help build more.
“Our intent is to open another one next year and another the year after. We believe that is one of the missing pieces and that’s long-term recovery for people who are struggling severe addiction and complex underlying issues,” Evans says.
In Portugal there are 60 such therapeutic communities in operation, he says.
“We’re at the beginning. I think we have a long ways to go,” he says, adding that key will be following a process that brings everybody to the table and developing a strategy that everyone — politicians, police, judges, medical professionals and addicts — can buy into.
Evans also believes more has to be done to address education and prevention.
“I think the amount of education in schools is very minimal. So we haven’t dealt with preventing people from coming into it and we haven’t dealt with how to help people maintain long-term recovery.”