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The Only Place Where They'll Inject You With Heroin for Free

In downtown Vancouver, government-approved researchers are providing drug addicts with heroin to see if a dependable supply of the substance will improve lives.
Dr. Scott MacDonald tends to a patient at Providence’s Crosstown Clinic, the site of the SALOME trial. (PHOTO: COURTESY OF SALOME)

Dr. Scott MacDonald tends to a patient at Providence’s Crosstown Clinic, the site of the SALOME trial. (PHOTO: COURTESY OF SALOME)

Every day, Randy McKinley walks into a nondescript building located in downtown Vancouver to shoot up. For no cost at all, an examiner provides him with a sterilized syringe and pure narcotic, which he then injects into his blood stream. After about 20 minutes or so, McKinley gets up and leaves, only to return two more times before the day is over.

Throughout his 50 years of life, McKinley has experienced multiple ups and downs. He has a university degree, but began struggling with drug addiction as a teen. He has a daughter, but lost his second spouse to a heroin overdose. He's worked as a paralegal, but has also earned money as an escort, stripper, and thief. He's owned a home, but now lives in a shelter, which is only open from 7:00 p.m. to 9:00 a.m.

On his peculiar arrangement with the free drugs, McKinley says, “It’s been a godsend.”

SITUATED IN VANCOUVER’S NOTORIOUS Downtown Eastside—often referred to as Canada's poorest postal code—is the four-year clinical trial known as SALOME (Study to Assess Long-Term Opioid Maintenance Effectiveness). It’s the only place in North America where government-sanctioned researchers are providing drug addicts with heroin to see if a dependable supply of the substance will improve their lives.

The basic idea is this: 322 chronic opiate users with a history of failing at conventional treatments, such as rehab or methadone programs, are divided into two groups. One group receives hydromorphone, the active drug found in the licensed medication Dilaudid; the other group receives diacetylmorphine, the principal ingredient of heroin. None of the participants know which group they're in. Between one to three times per day, participants enter the clinic, receive their designated drug, inject it under the supervision of a nurse, then exit back onto the street where they're free to do whatever they want. No one is arrested, forced into detox, or judged for his or her habit.

Now for a reasonable question: Why give heroin to a heroin addict?

"It's about creating some stability in their life," said Kurt Lock, a research coordinator for SALOME. "Rather than their days being consumed by acquiring the drug, they're provided with it so they can work on the other issues that got them into this destructive lifestyle. It's basically a timeout."

That means time to seek counseling, secure housing, find work, and perhaps even repair broken relationships with friends and family.

Furthermore, SALOME researchers are curious to know if an endless access to either Dilaudid or heroin—both of which are opium-based, though only the former is legal—is more effective at getting an addict to voluntarily remove him or herself from the drug ecosystem and all its harms. Will crime rates go down? Will the spread of HIV and Hepatitis C through shared needles decrease? Will frequent visits to the hospital and courthouse decline? Will the annual amount of overdoses drop?

According to a report published by the Canadian Centre on Substance Abuse, in 2002 illegal drugs cost the nation an estimated $8.2 billion (CAD) in terms of health care, law enforcement, and lost productivity due to illness and premature death. Therefore, if an addict is given the pure substance her body craves in a controlled environment, will this arrangement make things better for both the individual and society at large?

McKinley considers his involvement with SALOME a complete reprieve. It's allowed him time and mental space to work on his housing situation, pay outstanding bills, finish his divorce from his third spouse, and generally just clean up life's loose ends with the aid of a social worker not associated with the study.

"With the daily hustle gone, it's improved my life 100 percent," he said. "I'm not reinventing myself, but I'm rediscovering myself, and it's wonderful."

For Dr. Eugenia Oviedo-Joekes, who serves as the principal investigator of SALOME, the question is a very pragmatic one. "People are going to use drugs, like it or not," she said. "What are we going to do with that? So far, what we've been doing isn't working, so let's bring them here and see what we can do."

Will crime rates go down? Will the spread of HIV and Hepatitis C through shared needles decrease? Will frequent visits to the hospital and courthouse decline?

VANCOUVER, WHICH IS HOME to an innovative drug court and the continent's only supervised injection site, also hosted SALOME's predecessor, NAOMI (North American Opiate Medication Initiative), from 2005 to 2008. Together with Montreal, the two cities tested to see if heroin was more effective at keeping participants coming back to the clinic than methadone, which has traditionally been given to those with an opioid dependency to prevent the onset of sickness that accompanies withdrawal systems but doesn't produce the same high.

The findings were intriguing. While results of the NAOMI trial published in the New England Journal of Medicine showed that nearly 90 percent of the participants who received heroin remained committed to the program, the same was true for only 54 percent of those on methadone. Another study published in the Canadian Medical Association Journal showed that throughout an average lifetime, participants provided with heroin would generate a societal cost of $1.1 million in contrast $1.14 million for methadone, making the concept of heroin maintenance a cost-saving measure.

Although the idea is somewhat new and controversial in North America, European countries have experimented with heroin-assisted treatment programs (HATs) for decades. In the 1920s, Britain began prescribing opioid drugs to addicts on recommendation of the Rolleston Report, which framed drug addiction as a health issue, not a criminal one. In 1997, the Associated Pressreported that researchers in Switzerland had declared their novel state-distributed heroin project a success, saying it had "slashed crime, misery, and disease associated with hard-core drug addiction." Belgium, Germany, the Netherlands, and Spain have all conducted their own studies to test the hypothesis, as well.

TO SOME, HOWEVER, THE thought of giving heroin to a heroin addict simply because he's caused both himself and society at large more damage than the public is willing to tolerate is a bit hard to swallow. It's somewhat similar to a child throwing a tantrum in the checkout aisle until his parent quells the situation with the purchase of a Snickers bar.

"Basically, they're trying to reduce social harms, which I'm in favor of, but I'm not sure if this is the right way to go about it," said Gray Garten, vice president of Canada's Temperance Foundation, who himself has struggled with drug addiction for the majority of his life. "It would appear the philosophy is to give the addicts what they want as opposed to looking for how we can break the cycle of addiction."

In an email, Marc Paris, executive director of the Partnership for a Drug Free Canada, stressed the importance of reducing the desire for drugs before addiction sets in: "Our focus is strictly about prevention," he wrote.

Indeed, according to a 2011 Health Canada survey, 23 percent of youth aged 15-24 used an illegal drug in the previous year, compared to just seven percent of adults aged 25 and over. These numbers could suggest that since government resources are limited, it might be wiser to spend more funds on educating people while they're still young and capable of change than on older, chronic users who've made countless decisions in favor of digging themselves deeper into their addiction.

But even the most strident proponents of harm-reduction measures would admit that these programs won't solve everything. For many years now, the City of Vancouver has embraced the Four Pillars Drug Strategy, which enlists harm reduction, prevention, treatment, and enforcement to tackle the drug problem. All pillars are necessary. What may help a 17-year-old first-time offender who sold her mom's iPad Mini to buy a bag of weed may not help a 57-year-old homeless man who struggles with mental illness and has been injecting cocaine multiple times per day for the past 20 years.

"It's meant to be a piece of a puzzle—obviously a very complicated puzzle," said Darwin Fisher, a program coordinator at Vancouver's supervised injection site. "And when I talk about programs like the injection site or SALOME, you notice that I'm also very quick to talk about sustainable housing and the importance of things for people to do, like work. All of these pieces have to fit together. There's no stand-alone silver-bullet solution, and it's really silly to talk that way."

Due to occasional drug shortages from SALOME's supplier, pharmaceutical company Sandoz, it's unclear when the experiment will end. When it does, however, researchers intend to find participants, such as McKinley, the best conventional treatment available, as the tap of free Dilaudid and heroin will be abruptly turned off. But whether the pioneering trial eventually becomes a permanent health care program or not will be up to the Canadian politicians and legal authorities who decide such things.

For now, the researchers will keep testing to see if providing heroin to heroin addicts can both save taxpayers' money and reduce suffering, as similar programs seem to have done elsewhere. And McKinley will keep coming for his doses, three times a day, life inching toward some kind of semblance, but still frightened by the uncertainty of the future.

"The thought of going back to the hustle because SALOME wasn't there anymore makes the idea of overdosing and just calling it quits not out of the question," McKinley said. "And who the hell would miss me?"