Heroin is illegal in Canada. And just like in the United States many doctors and treatment centers treat heroin addiction by providing a legal alternative, such as methadone. But methadone treatment doesn’t always work. So what do you do? Reporters Sam Fenn and Gordon Katic have this story about a small clinic in Vancouver, British Columbia that’s giving their patients legal access to the very drug they are addicted to Heroin. Our story is Heroin Town.
SAM: We’re in an empty lot off a back alley in downtown Vancouver. Christmas lights are strung up outside a mobile trailer. And a dozen people are hanging around, smoking and chatting. This is one of five overdose prevention sites that has popped up in the past year.
SAM: So what are you doing with the tinfoil?
SAMI: I’m cutting, um, tinfoil up because people use it to smoke heroin… or anything like that. So…
SAM: This is Sami. Vancouver’s health authority is paying her—and her colleagues—to supervise people as they shoot up. Some of the staff here are former drug users themselves. Some are current drug users. Others are activists and nurses.
SAM: People check in with Sami when they arrive at the trailer. She writes down the time and the drug they’re using tonight. “Down” means heroin. “Rock” means crack.
SAMI: Uh… down at 5:31. Rock at 5:35. Down 5:41. Down 5:52, down 5:52, powder 5:52.
SAM: Hundreds of people come to this trailer everyday. And they’ve all bought their drugs illegally. But the Vancouver Police Department say it’s a health issue, not a law enforcement issue and while they’ll monitor the sites they’re not going to shut them down.
SAMI: What brought me here was the amount of ODs that are going on. Working here is keeping me sober to tell you the truth.
SAMI: It is. I’m hoping I can save more lives.
SAM: How many people do you think you’ve saved?
SAMI: I’ve saved nine already. In the past…last year.
BERNADETTE: I smoke my, my heroin with my rock. So it kind like of keeps it balanced.
SAM: This is Bernadette. She’s a thin woman with no teeth. She says she comes to this trailer in case she overdoses. Dealers in Vancouver have been selling drugs laced with fentanyl—a powerful synthetic opiate. So no one really knows what’s in their street drugs anymore.
BERNADETTE: So…I’ve heard rumours about it being in the rock, right? So I’m not sure, right? So…have you guys heard of that? No? You haven’t?
SAM: Bernadette sits at a steel table inside the trailer. She pulls out a compact mirror and a syringe. And she injects into the jugular vein in her neck.
BERNADETTE: Mmmm. Ha, there you go. Sweet and simple. Okay. Now, okay I know it’s not fentanyl in it… Okay. Yeah I’m high right now actually… sorry…
GORDON: Across the street—at another overdose prevention site—a middle-aged guy named Doyle is sitting on a fold out chair. His head is hung low. A staff member named Dakota looks over at him. And then…
DAKOTA: [chair sound] Careful, careful, watch his head.
DAKOTA: Doyle! You gotta take some deep breaths for me buddy. You’re having an overdose. Okay? It’s Dakota here, we’ve got you.
GORDON: Another staff member jams a needle full of a drug called Narcan into his leg. Right through his jeans. Narcan can reverse an overdose.
PHARMACY TECH WOMAN: His oxygen is at 59.
DAKOTA: OK, do you know how to hook? Yeah under the jaw with your pinkies. Come on bro. Big breaths! Big breaths!
PHARMACY TECH WOMAN: It’s 49.
GORDON: Doyle isn’t breathing. He’s turning blue.
DAKOTA: Okay he’s back up to 98 now. Doyle, hey buddy.
PHARMACY TECH WOMAN: Yup. Just keep breathing nice and gentle, okay?
DAKOTA: Okay. Is he conscious right now?
PHARMACY TECH WOMAN: Yeah.
GORDON: Eventually Doyle starts moving around again. He says he’s okay. And life goes on at the site. Just like it never happened.
SAM: In 2016, nearly 1,000 people died of drug overdoses in British Columbia. Over half of those deaths were linked to fentanyl. At one point, the Coroners Service reported that Vancouver’s morgues were “frequently full.” So they began storing bodies at local funeral homes.
GORDON: And this isn’t just a Vancouver problem. There have been overdose spikes in Massachusetts, New Hampshire, Ohio, Rhode Island, and West Virginia—all linked to fentanyl. There’s one place in North America where drug users legally avoid this game of Russian Roulette. And it’s here, In Vancouver—just two blocks from where Doyle overdosed.
GORDON: It’s 10 o’clock in the morning. And we’re at an unremarkable-looking concrete building, right next to a country music bar. It used to be a bank. Now it’s Crosstown Clinic.
MACDONALD: So this is the injection side of the clinic. People line up here…uh, on Abbott Street. And there’s a five minute window where they can come in.
GORDON: This is Scott MacDonald. He’s the doctor in charge at Crosstown Clinic. MacDonald says, after his patients are buzzed in—the staff take them through a checklist.
MACDONALD: So here are the things we’re looking for: severely anxious or agitated. Disconnected. Overly sedated? Do they have slurred speech? Do they smell of alcohol?
GORDON: If everything checks out, the patients walk into what MacDonald calls “the IR.” Or “injection room.”
JULIE: Come on in. So I’m Julie Foreman. I’m an RN. And the coordinator of Crosstown Clinic.
GORDON: Foreman walks us past stainless steel tables. These are the eight injection stations.
JULIE: At each station there is a little kidney basin with alcohol swabs, bandaids. And some kleenex. And paper towels.
GORDON: The patients walk into the injection room. They form a line in front of a thick glass window. A nurse in blue scrubs sits on the other side of the glass, preparing syringes in a cramped room.
JULIE: Or as the nurses describes it. The cage. Or the fishbowl. Because of all the windows. We’ve got a nurse right now administering meds. So let’s take a look.
OTHER NURSE: Hi. So, uh. The client comes to the window here. They give me their name, date of birth. Birthday?
OTHER NURSE: I’ve got their syringes all lined up and ready to go. Then I just check. I scan their name. Dispense.
[B-ROLL]: syringe dropping into slot.
OTHER NURSE: And they’re good to go!
GORDON: A tall guy with a gaunt face approaches the glass. His name is Kevin Thompson. He talks to the nurse through a baby monitor. The nurse pushes Thompson’s syringe through a slot in the window. It drops into a box. Like it’s a pack of cigarettes at a security-conscious gas station.
GORDON: What does it say on there? Is that like your dose?
KEVIN: Yeah… it tells you your dose. It’s the amount of heroin they’re giving me.
GORDON: Heroin. The nurses call it by its scientific name—diacetylmorphine. Holding his syringe, Thompson walks away from the window. He leans against one of the stainless steel tables, pulls his jeans and boxer shorts down a couple inches and then, holding his pants up with one hand and the syringe in the other.
KEVIN: And I just poke it in my butt and…I just go right in, yeah…In your muscle basically.
GORDON: Thompson is on the highest possible dose the doctors will prescribe. He says if he shoots that much into a vein, he’ll go through the roof. Instead he shoots the drug directly into a muscle. But the needle tip on this syringe doesn’t work. He asks a nurse standing nearby for a new one.
KEVIN: Actually this isn’t going to work. Can I get another 7/8ths
MALE NURSE: Yeah.
GORDON: Kevin struggles for a while. And then he gets it through.
KEVIN: Takes a while cause there’s so much…I got some blood going down there.
GORDON: Thompson wipes himself clean and drops the syringe into a plastic box.
KEVIN: And that’s how I do it!
KEVIN: You gotta be a member to be in here. I love this place. If it wasn’t for this place I would probably be dead. [Laughs].
MALE VOICE: Thanks man.
KEVIN: Yeah thank you.
GORDON: Thompson says he comes to Crosstown three times a day, everyday to get heroin produced by a small Swiss pharmaceutical company. It’s prescribed by a doctor, administered by a nurse, and paid for by Canadian taxpayers. Today, Thompson is one of only 91 people in all of North America whose addiction to heroin is treated with prescription heroin.
SAM: To explain how this unique approach to drug treatment all came about, we have to take you back to 2005. Thompson is living in Vancouver, in an area known as the Downtown Eastside. One of North America’s largest open air drug markets.
KEVIN: Ended up homeless. Uh…If you fall asleep on these streets before… if you fell asleep…you know nodded off, you were done. Your pant pockets were cut out. And people’s…I mean that’s how bad it is. Your shoes were off your feet. Your jacket. I don’t care if it’s rain, wind, or snow. You were robbed.
SAM: Thompson says he frequently wakes up dopesick—like he has a horrible fever. With body aches and tight muscles.
SAM: And Thompson says the only way to make the pain stop is to get more heroin and to do that he needs money. So he steals things. Big things.
KEVIN: Walk in the store and just take it, right? The bigger the thing, the least obvious. Skil saws and put ‘em on… stack ‘em. And then an employee come running out the other door. And open the door for me… right? No one is gonna expect someone to have the balls to do that. Really, yeah, they just assume they paid for it, right?
SAM: This is pretty much Thompson’s life. Wake up dopesick. Steal something. Buy heroin. Hide from the cops. Until one day a guy walks up to Kevin and says “I’m recruiting for a clinical trial. We’re going to give out free heroin. Do you want to sign up?” —at first—Thompson is sure it’s a setup.
KEVIN: “That’s just the way they can keep an eye on us, right? What’s going on here?” Try’na get us corralled or down into—all of us—into one little section. And then just gonna arrest us all or… you never know.
MARTIN: Uh… It was called NAOMI. North American Opioid Medication Initiative.
SAM: This is Martin Schechter. He’s a professor with the School of Population and Public Health at the University of British Columbia. Schechter says, since the late 1990s he’s wanted to know the answer to one question:
MARTIN: What do you do with someone with heroin addiction—or opiate addiction—who has tried the therapies that we have available and they haven’t been successful, those therapies? So for example, methadone.
SAM: Methadone is the standard treatment for heroin addiction. But Schechter says it doesn’t work for everybody. And when a person has tried the treatment twice, three times, four times—and they keep returning to street drugs what do you do?
MARTIN: These people are currently injecting heroin in alleyways, facing overdose and risk of disease and causing all kinds of problems for the public. Why wouldn’t you want them to be getting the heroin from a doctor to bring them in off the street and in contact with the health care system?
SAM: And—so—Schechter decides to start a clinical trial.
MARTIN: There were a million hurdles. Each one of which could have been a deal breaker.
SAM: Schechter secures an eight million dollar grant.
GORDON: He holds meetings with neighbourhood groups.
SAM: He gets ethics board approval to use a controversial treatment on human subjects.
GORDON: He applies for a permit from city hall.
SAM: He asks the United Nations for special permission to import heroin from Switzerland.
GORDON: And—at the government’s request—the staff have to go through hostage training.
MARTIN: They were very afraid this heroin would escape into the community. So we had armoured car deliveries. And we had maglock panic buttons and alarms. And, uh, we actually had it in a bank and we used the vault that was still there. Ironically, the amount of drugs we had on site was probably less than your average pharmacy.
GORDON: Eugenia Oviedo-Joekes is an associate professor in the School of Population and Public Health at the University of British Columbia. Her research focuses on alternative treatments for drug users.
EUGENIA: I was working in Spain in another clinical trial testing, uh, injectable pharmaceutical grade heroin. And I joined the team of Martin Schechter.
GORDON: Her research focuses on alternative treatments for drug users.
EUGENIA: Treatment with injectables have a very small, but very important role in the addiction treatment system. This is a statement on how do you want to treat your most vulnerable individuals that are right now injecting in the street and putting their life at risk.
GORDON: Schechter and Oviedo-Joekes recruit 192 participants—people they call ‘highly-entrenched’ drug users. People who have used heroin for years, some for decades. And who have repeatedly failed conventional treatments.
SAM: The three year trial begins at Crosstown Clinic in March, 2005. Each participant will be on the trial for 15 months. Schechter randomly assigns half the participants to methadone and the other half to heroin. Kevin Thompson is in the heroin group.
KEVIN: Yeah, it was great. Cause you’re thinking, “Hmm… I can take any amount of heroin they give me I’m gonna take it.” They sit there and say “Lookit, don’t worry about the dope. We’ve got more than you can do.” It’s all pharmaceutically done. So there’s no infections. You’re in a sterile area. And I don’t have to rob or steal. Boom. All I just have to wake up in time. Heh.
MACDONALD: If you’ve been struggling everyday to get your fix. Up to three of four times a day. And then all of a sudden you don’t need to do that at all. That’s a dramatic change.
GORDON: Doctor MacDonald says almost immediately after the trial begins he sees improvement in Thompson and many other patients taking part in the trial.
KEVIN: Started going for walks. Seeing stuff. Realizing that, hey you know what? I haven’t been… I live on the ocean, a block away, and I hadn’t even been down to the ocean basically and paid attention to it in the 20 years I’ve been here. Twenty-five years.
MACDONALD: I remember one patient who probably had not showered in months. And was living in a box under some steps in the Downtown Eastside. And within a week… Reconnected with his family. Living with his uncle. And was showered and clean. He said ‘hey doc, things are going better!’ And I said ‘I’m glad to hear it.’ (laughs)
DIANNE: And the results were awesome.
GORDON: This is Dianne Tobin. She’s a NAOMI trial participant. And a community organizer.
DIANNE: Their crime rate went down, their overdoses went down, and they were starting to be…starting to think about a future.
GORDON: And Tobin says not having to worry about how and where she’s going to get her next fix means she can think about rebuilding her life.
DIANNE: I was able to focus on my job a lot more and uh not have to be out there worrying about spending my money, I was able to save some money.
GORDON: How were you on the last day of NAOMI?
KEVIN: I had my steady job. Had my life. I wasn’t using street dope. Hadn’t been arrested. No contact with the police, they don’t mess with me no more. Have housing, have a girlfriend, have a job. It was great.
SAM: As The NAOMI trial is coming to an end researchers Schechter and Oviedo-Joekes say the preliminary results look good. And based on those results, they are hopeful they can convince the government to let the clinic continue after the trial shuts down.
EUGENIA: Well that’s what we all hope when you do research. You show it’s effective, you show it’s cost effective, and its going to be considered to be implemented.
DAN: You know. I’m a medical anthropologist and I always tell my students, medicine is a lot more than science.
GORDON: Dan Small is an Adjunct Professor of Medical Anthropology at the University of British Columbia. He’s traveled throughout Europe researching other heroin trials. He says all of the randomized control trials have shown good results. But, in many cases…
DAN: It never leaves the randomized control realm. It never gets its medical exemption. Because certain things, kind of controversial things—like supervised injection facilities and heroin-assisted therapy—stay forever in a liminal zone of the temporary exception provided to them. And this is largely what has happened in the wider world.
GORDON: Small says it’s politically easier to start controversial treatments in the context of a study. But the real challenge is—what do you do next?
DAN: And so this is really one of the conundrums in research of this type: how do you get a randomized control study around heroin from the peer-review research realm and into medical practice? This is the final mile.
GORDON: So, Small meets with Schechter, the researcher leading the NAOMI Trial and tells him—“If you want to keep providing heroin to your participants after the trial ends, you are going to have to fight for it.”
DAN: And that researcher looked at me and said, “That’s not my job. My job is, essentially, lay the data at the feet of policy makers. And I’m a scientist.” I was quite taken aback when I heard that from him and I was disappointed. Now I don’t want to be hard on Martin Schechter because again he was, you know, a first rate researcher. But, the idea, hypothetically is that when the science speaks then presumably the policy makers will listen, the skies will open and they will allow this to be a medical project. But that’s not what happens. Martin thought this was a tea party and we were eating cucumber sandwiches with the crusts cut off. But it wasn’t. It was an all out, metaphoric ballroom brawl.
CBC CLIP PETER MANSBRIDGE: Alright Wendy, thanks very much, the latest report on what’s happening in Quebec. Well, we can tell you we have seen enough. We’ve been checking the numbers, checking the figures and are making our determination now…
SAM: The political brawl over drug treatment begins in 2006 with the election of Canada’s Conservative Prime Minister, Stephen Harper. Harper was a law and order candidate who pledged “not use taxpayer money to fund drug use.”
CBC CLIP STEPHEN HARPER: Thank you! Merci Beaucoup. Thank you. We will reform our justice system to make it stronger and to ensure we turn back the growing plague of drugs gangs and drugs in our cities and communities! [CHEERING].
SAM: Professor Schechter and his research team take meetings with the local health authority to present their initial findings from the Naomi Trial. They send letters to the government; they defend their work in the press; and they formally apply for compassionate access for their trial participants to heroin. But they say, all of their attempts fall flat.
MARTIN: We did as much as I think we could have to convince…um…decision makers that the clinic should continue.
SAM: The participants in the NAOMI trial will have to transition to methadone. The very treatment Tobin says she and Thompson and and the other trial participants have already failed several times.
DIANNE: Oh I was panicked, it was horrible and everybody there just felt so discouraged. So lost. They’d finally had a way to—they were doing well, they were gaining weight. Their health was good. They weren’t stealing. And all of a sudden—
KEVIN: Threw us right out in the cold, basically. Three months is up, weaned ya down, Here’s your last day, seeya later. Thanks for coming out.
SAM: Again Scott MacDonald, Crosstown Clinic’s doctor.
MACDONALD: For many, it meant returning to the street. Returning to illicit opioid use, and death. Many of my patients died. I can count at least 15 that died.
DIANNE: bang bang bang bang—dying and and it was all because of what happened with NAOMI dropping us.
SAM: The researchers say they lost track of many a lot of the participants after the study ended. So There is no official confirmation exactly how many NAOMI participants died after the trial shut down.
GORDON: At the end of trial–after all of the data has been analyzed — researchers Schechter and Oviedo-Joekes report the NAOMI trial produced exciting results—that the participants treated with heroin did significantly better than those treated with methadone: that those treated with heroin were more likely to stay in treatment and less likely to turn to street drugs.
SAM: Schechter is given the Norman Zinberg Award for Achievement in the Field of Medicine – recognizing rigorous scientific research and findings that may “be at odds with the current dogma.” Oviedo-Joekes presents the findings from the NAOMI trial in an article in one of the top medical journals in the world. But says she didn’t feel like celebrating.
EUGENIA: We used to say—I told Martin—there is a saying in Spanish, “La cirugía ha sido un éxito pero el paciente está muerto.” “The surgery has been a success, but the patient is dead.” That’s how I felt. Uh… there was no joy of publishing in The New England Journal of Medicine. No joy at all.
GORDON: In the weeks and months after NAOMI, Tobin starts looking for others who participated in the trial. She wants to start a support group.
DIANNE: It was called the NAOMI Association of Patients. We wanted to get everybody in NAOMI to come to the meetings.
DAVE: They were trying to figure out some kind of legal angle to the whole thing. That somehow we had a legal case, you know? That we should be suing somebody for it.
GORDON This is Dave Murray. Dave is another participant in the NAOMI trial. He’s 66-years old and wears big glasses held together by tape. As a young man Dave says he lived in Chicago where he got into some legal trouble.
GORDON: Can you tell me about that?
DAVE: Uh…no. [LAUGHS]. I’ve had quite a varied life and some of it I’m not that proud of. Some of it I don’t often like to talk about. And uh…Ask me another question.
GORDON: The NAOMI Patients Association–or NPA–meets every Saturday at a local center. It becomes a kind of support group. The members sometimes refer to themselves as “survivors” of the study.
BERNSTEIN: To me that is important and particularly moving. Like what other research study in modern times are participants describing themselves as survivors of the study?
GORDON: This is Scott Bernstein.
BERNSTEIN: And I am a British Columbia lawyer. I’m working on drug policy issues primarily now.
GORDON: Bernstein works with Pivot Legal Society, a not-for-profit, social justice law firm — and he begins working with NPA.
BERNSTEIN: Social justice lawyering is a bit different. At Pivot we are strongly invested as a member of the community. To a tee the lawyers at Pivot are very passionate and emotional about the issues that we are arguing.
GORDON: Bernstein says now that they have proof from the study that it works, he, Tobin and Murray and all of the members NPA want prescription heroin treatment to be available. Across Canada. But he says, they don’t know how to make that happen.
BERNSTEIN: In our system of law. You can’t just sue the government to say give us a medical treatment. There is no legal basis to say we are entitled to say receive this medical treatment that’s recognized elsewhere as the gold standard. And you have to pay for it. There’s just not…You know. There’s not that basis to do it unfortunately.
GORDON: So the NPA start to do their own research and advocacy. They teamed-up with Professor Susan Boyd a legal scholar and drug policy researcher at the University of Victoria and publish a peer-reviewed paper about their experience with NAOMI. They speak in public—and the message is: it was unethical to give them treatment that worked and then take it away.
SAM: At the same time Professor Oviedo-Jokes comes up with the idea for a new research trial.
EUGENIA: And that’s when I designed SALOME. And SALOME came just because you know we don’t have the pharmaceutical grade heroin because everybody is closing our doors, so what options can we offer?
SAM: SALOME is a brand new trial that will test another drug: hydromorphone. Hydromorphone is chemically similar to heroin. But hydromorphone is legal in Canada. Doctors prescribe it as a painkiller. So why not see it it can be successfully used to treat heroin addiction?
SAM: One day in the summer of 2011—Oviedo-Joekes meets up with drug users at the local drug user centre VANDU and there she presents her proposal for this new trial.
EUGENIA: I was expecting six people… and there was 60, 80 people using drugs that came.
SAM: And then someone asked the million dollar question. What’s going to happen to the participants at the end of this new study?
EUGENIA: To tell you the truth guys, I don’t know. I will work very hard for this to continue. But I am not in a position to make any guarantees. And I said this to them—I have two options in front of me, either do this study knowing that in six months I need to tell you to go back to the street. Or not do the study…and I decided to do the study. This way. I have know idea, right now, if that’s the right decision.
SAM: Oviedo-Joekes tells the group, if they sign up for this blind trial she will be able to put some of them back on heroin and others on injectable hydromorphone. But she adds, not everyone in the room will make it into the trial.
EUGENIA: When I tell them I can only include a short number of people. Because this is super expensive. I want the minimum number that I need to have power for my calculations. Not because I have a demonic agenda. It’s because we don’t have money and we need to get it done and get results as soon as possible—and they’re tremendously supportive! Instead of being pissed off at me they were—“no, don’t worry, we will support you. You’re doing the right thing.” I was kind of like amazed at how generous they are. So generous.
SAM: Bernstein, NPA’s attorney, says he’s not surprised at the room’s reaction. After NAOMI, the participants were desperate.
BERNSTEIN: In the NPA report one person said, “Our life depends on this drug. Well OK. So I mean, I would sign anything at this point. I would probably say, “Which finger do you want? Or which arm do you want?” Y’know?
SAM : Oviedo-Joekes begins recruiting participants for SALOME. And many of the NPA members including Thompson are the first to sign up. Murray signs up as well. But Tobin hesitates.
DIANNE: Because I didn’t know if the same thing would happen as NAOMI. I wasn’t positive that it wasn’t going to go the same routine, so I was kind of leery.
SAM: The researchers have a recruitment phone line that closes each day at 4PM. On the very last day of recruitment for the first cohort—right when the line is about to close—Tobin is with another drug user. He’s on the phone talking to the SALOME researchers, asking if he can join the trial. He’s just about to put the phone down. But Tobin says, “Wait…”
DIANNE: And I said “Don’t hang up. I want to talk.” And I said I’d be on the study. And the next thing I know they were telling me I was the first one on the study.
SAM: Do you remember what it was that made you want to give it another-go?
DIANNE: I really don’t know. It was a spur of the moment kind of thing.
SAM: Tobin walks back into Crosstown. This time as a participant in the SALOME trial. SALOME is run by a new health authority—Providence Health Care—with an entirely new nursing staff.
DIANNE: I walked into the injection room and about eight nurses and students and whoever they were that were working there, they were right in front of my face. Just, hanging over my head to watch me do it.
JULIE: It was kind of funny because all of us nurses were, you know, interested in really like her inject.
SAM: Again, Julie Foreman. The head nurse at Crosstown.
JULIE: We hadn’t actually watched somebody inject drugs before I don’t think for most of us. And luckily she was a good sport about it.
DIANNE: I told them to back off. Get away. You know like… you can’t do that. It was always a private thing for me. So when there were eight people watching me do it I said “I can’t do it. Go away.”
JULIE: And then we were all waiting for something to happen. And nothing really happened. She didn’t really change. She was this cheery women—alert and vibrant—when she walked in. And she was alert and vibrant when she left. And we were like “oh, okay.” [Laugh].
SAM: Dianne stands up and walks away from the table. The nurses are excited that SALOME is underway. So they start clapping. But Dianne says, she’s not excited.
SAM: Do you remember how you felt when everyone started clapping?
DIANNE: Nothing. It was their time to clap. It had nothing to do with me.
BERNSTEIN: So this is June 14th, 2012. The memo line says regarding the legal and ethical issues of opiate trials.
SAM: Six months into SALOME, many of the NPA members are still bitter about how the NAOMI trial ended. And they’re worried that the same thing is about to happen to them again at the end of the Salome trial. So Scott Bernstein, their lawyer, sends a forceful letter to Providence Health Care.
BERNSTEIN: It relied mostly on something called the Helsinki declaration.
DIANNE: They’re not allowed! It’s not allowed to take the medicine away. A study drug works for a person the government can’t take it away from them.
SAM: The World Medical Association’s Declaration of Helsinki. It is basically the Magna Carta of medical research ethics and it says, if researchers can’t continue an effective treatment after a trial, they need to provide another appropriate treatment option. At the end of both studies, the researchers offered only methadone. A treatment that everyone in the study had already failed multiple times.
GORDON: Over at Crosstown Clinic, Dr. MacDonald is concerned. He says he doesn’t want to see his patients lose access to prescription heroin and be forced into a treatment program that he believes won’t work. And so he tries another option.
MACDONALD: We started applying to Health Canada for through the SAP—Special Access Program—for compassionate access to diacetylmorphine, or heroin.
GORDON: Health Canada’s Special Access Program allows doctors to prescribe unlicensed drugs to patients with life-threatening conditions. MacDonald begins writing up requests. Each file includes the NAOMI study results and…
MACDONALD: Past history of the patient, whether they’ve had overdoses requiring resuscitation with Narcan. Whether they’ve been in jail, how many charges, how many related infections, Hep-C, HIV…
GORDON: This dossier is a litany of personal tragedies. That sounds like a difficult document to write.
MACDONALD: Uh… And that is what every single one would be like. Probably 150 pages. And it still uses the fax system.
GORDON: I want to make sure I understand. It’s not that your boss is breathing down your neck saying put all this work together, put these SAPs in, that’s your job right now. This is your leadership? Is that a fair characterization?
MACDONALD: I am an advocate for my patients. They are participants in a study. If this is working, they need to have access to it. The only way to have access to it is through the SAP. So…um…yeah…it was my. It was my, partly my idea and force that made that happen. But I’ve worked in research studies before. This is just what you do. Somebody needs to believe in it!
GORDON: How did you show Health Canada that you and your team really believed in this?
MACDONALD: Well we kept sending SAPs and didn’t stop. [laughs]
GORDON : On September 20th, 2013 Representatives of Health Canada, call Crosstown Clinic and ask “Is your fax machine broken?”
MACDONALD: I think we just had to put paper in the machine or something. And our receptionist Sam. I said “Sam! We need to get some paper in the machine!” They didn’t say anything, but I had an inkling that something interesting is going to come through that fax. [laughs]
GORDON: One by one letters from Health Canada buzz through the fax machine…Accepted. Accepted. Accepted. Every SAP request is approved. For the first time in North America a government agency approves the legal prescription of heroin not for a medical trial, but as a drug treatment program.
MACDONALD: It was a big deal for us. We were very, very excited. Because it’s acknowledgement that Health Canada has put its stamp on an injectable treatment option. Yes. Health Canada approves that.
GORDON: But then not much longer.
MACDONALD: That very morning.
AMBROSE ARCHIVAL: We are here oday to begin what I think is a much needed conversation on the need to focus on the treatment and recovery of those who are addicted to drugs.
SAM: This is Rona Ambrose, Canada’s Minister of Health. The same day the Special Access Requests are approved. Ambrose announces she is reversing the approvals by Health Canada, her own department. Then she holds a press conference.
AMBROSE ARCHIVAL: As you know, last week. I made public my serious concern about a decision by Health Canada to give authorization to doctors to prescribe heroin to heroin addicts. The Prime Minister and I do not believe we are serving the best interests of those addicted to drugs and those who need our help the most by giving them the very drugs they are addicted to. The answer of course is not to treat heroin addiction with heroin. That is of course, obvious to all of you. So today I am announcing that our government has taken action to close this loophole that we found in the Special Access Program.
SAM: Professor Oviedo-Joekes:
EUGENIA: This is—honestly—stigma. Pure and simple. There are very few treatments in the addiction field—that have provided evidence like the SALOME study has done. I am seeing them everyday, at least twice a day. I have an opportunity to build relationships. To provide comprehensive care. And they’re using pharmaceutical grade medications instead of opiates in the street.
SAM: Professor Oviedo-Joekes says people often ask her— “Shouldn’t you try to get drug users to stop using drugs?” “Why don’t you treat the root cause?” But she says that is unrealistic.
EUGENIA: Well, for me to treat the root cause of the 202 SALOME patients, I need the entire budget for Public Health Canada for two generations to heal. For the cultural genocides. To heal, for the child abuse that we see. To heal for the people that has been incarcerated because they can not stop using drugs in the street. So give me two generations of budget and then maybe we can treat the root cause.
SAM: Two months later, Pivot Legal, Providence Health Care, and the NAOMI Patients Association hold a press conference. They file a constitutional lawsuit against the federal government to reverse Minister Ambrose’s order to close this special access to ongoing treatment. Dr. MacDonald speaks to the pool of reporters.
MACDONALD ARCHIVAL: [crying] I need this tool in the addiction toolkit. To help the people with this severe life threatening illness. As a human being. As a Canadian. As a doctor, I want to be able to provide this treatment to the people who need it. It is effective. It is safe. And it works.
GORDON: You’re fighting the federal government. In a very very public battle. And you’re at the centre of it. At that press conference. You’re right centre stage, talking about your patients. You’re crying about this.
MACDONALD: [pause] I had a message to tell. And. Some of that message is about hope and fighting despair. And that is an emotional message. I did not want to get emotional. [laughs] But, this is an evidence-based treatment. And without it, some of my patients were going to die. Here is hope. Hope for these folks that have not had anything to give them care for years. And it’s taken away. That…I did get emotional.
SAM: But the lawsuit that would bring the trials to a full hearing where the results of the Naomi and Salome trials would be presented in court, never happens. In 2016, Justin Trudeau replaces Stephen Harper as Prime Minister. Trudeau’s government quietly reverses Ambrose’s decision and allows treatment of heroin for heroin addiction. But only for those who are approved through the Special Access Program.
GORDON: This leaves Crosstown Clinic where it is today. Every six months the clinic’s doctor, Scott MacDonald, has to reapply for Special Access Program exemptions for 91 patients, so he can continue to treat them with heroin.
SAM: This isn’t the end result that MacDonald, the researchers, and the trial drug users hoped for. They were hoping the government would approve a national program, with clinics like Crosstown all over Canada. But Professor Oviedo-Joekes says there’s little political interest in supporting that kind of comprehensive program.
EUGENIA: It is outrageous that after providing so much evidence that people continue not expanding this treatment.
SAM: Professor Oviedo-Joekes.
EUGENIA: Why is it that with so much evidence, we are not moving forward? You have to start thinking this is about the people we are serving.
GORDON: It’s an unusually cold winter here in Vancouver. It’s snowing. We’re at a pop-up injection site, just like the trailer at the beginning of our story. A handful of drug users huddle in a vestibule. They’re here to warm up and shoot up.
KEVIN: This is the main needle depot in all of North America. They hand more syringes out here than all of North America.
GORDON: Thompson works here full time now. His job is to check people in as they show up at the site.
KEVIN: Just wait until he has a booth clean Trev. How much do you usually do? Eh? Do you usually do a paper or two or…? Yeah a quarter of that purple stuff will drop ya. Thank you Jasmine!
KEVIN: These are friends that I’ve been with for years and they’re still playing the roulette game that I’m not. And I’m the one that’s, that’s saving them.
GORDON: Thompson says he sees two or three overdoses at the injection site pretty much every shift. Sometimes more. Then he walks six blocks over to Crosstown Clinic, on his lunch break. Where as one of the 91 people approved for the Special Access Program at the clinic, he takes his shot of clean prescription heroin.
GORDON: How do you deal with that knowing that you… you kind of lucked out and you don’t have to be apart of that? And then all your friends do?
KEVIN: It disgusts me really. I’ve lost more friends this year, in this crisis that’s happened than the whole 25 years I’ve been down here.
GORDON: Could you do this job if you weren’t in the Crosstown Clinic right now?
KEVIN: Well of course not. No. I’d be back probably on the street. Or…bottom line is I’d probably be dead because of the fentanyl. I’d be one of those statistics. I can guarantee you that. I wouldn’t be doing this interview. That’s for sure.
KEVIN: Okay your tables ready, you’ve got it buddy.
SAM: Down the block from Crosstown Clinic, a group of drug users are holding a vigil to remember lost loved ones. They light candles and place them at the base of a tall totem pole. It’s called “the survivor’s pole.”
GORDON: In 2017, the overdose crisis in Vancouver hasn’t shown any signs of slowing down. Dave Murray, a participant in both trials, says it’s a disaster…
DAVE: It’s pretty devastated, this community. There are 100s of people that have died. Most of us don’t even know who have died anymore. We used to put pictures on the wall at VANDU of the people that we lost…It’s hard to keep up with it nowadays. You ask anyone at the SALOME clinic, they’re just so thankful that they’re in the clinic. It’s kept people alive. So yeah, we are the luckiest junkies in North America. That’s for sure.
GORDON: Murray still goes to the clinic. He says he’s old and he’ll probably never kick heroin. Thompson says he’s weaning himself down. And Dianne Tobin says she doesn’t go to Crosstown Clinic anymore.
DIANNE: So. I was waking up every morning. Going to work and all that. I’d hear somebody else died. Somebody else died. And you didn’t have time to grieve. You couldn’t go to the memorial. I would have been at a memorial everyday.
GORDON: After 40 years, Tobin says she’s successfully kicked the opiate habit. Which would make her only one of two crosstown patients that has gotten completely off opiates.
DIANNE: I just got.. I finally. I got so tired of it. I told the doc, I’m going home. Where I don’t have to hear ambulances all day. [laughs]
GORDON: Tobin left Vancouver this year. She moved across the country to reconnect with family.
SAM: Crosstown Clinic is doing some renovations this month. They’re knocking down walls and expanding the pharmacy. Dr. MacDonald says he hopes the new space will let him squeeze at least 30 more patients in.
Dr. MacDonald says just about everyday someone will wander up and knock on the window. But for now, Crosstown is still an exclusive club. Membership is closed.
Heroin town was a co-production of Life of the Law and the producers of the podcast, Cited — Sam Fenn, Gordon Katic, and Alexander Kim. Go to citedpodcast.com for more stories about how research shapes our lives. We had production assistance from Travis Lupick of the magazine, Georgia Straight.
Life of the Law’s Senior Producer is Tony Gannon. Our Post Production Editors are Kirsten Jusewicz-Haidle and Rachael Cain.
Our engineer was Howard Gelman at KQED Radio in San Francisco. Music in this episode was composed by Ian Coss.
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Next on Life of the Law…our team will go In-Studio at KQED Radio in SF to talk about Heroin Town, the law in the news, and to share a preview of our upcoming investigative report on one of the most important Supreme Court Decisions in the 20th Century… one that resulted in a man’s execution in an election chair.
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I’m Nancy Mullane. Thanks for listening.