Five of the Ways Unsanctioned Harm Reduction Continues to Blaze Trails

August 22, 2019

Unsanctioned grassroots initiativesfrom the unofficial to the plain illegal—are both the origins and the soul of the harm reduction movement. From syringe programs and drug-checking services to safe consumption sites and heroin-assisted treatment, harm reductionists have long been willing to move much faster than evolving laws and regulations to protect marginalized people’s health and save lives.

While these interventions are now legal in many places, they remain illegal or unsanctioned in many more. Amid a crisis of drug-related deaths in many parts of the world—and despite concerns in some places that medicalization has sidelined drug-user activism—the determination not to waste time waiting for the official go-ahead while people are dying remains strong.

In the US, harm reductionists working in the face of formidable political barriers nevertheless have cause for hope. “I think we’re in a moment of change in the US,” Miriam Krinsky, a former federal prosecutor who is now the executive director of Fair and Just Prosecution, told Filter. “I think it’s not out of the question … that we might see a major change in how the US approaches a host of drug policies.”

From my perspective in Canada, where harm reduction regulation is further advanced but still sorely lacking, I looked into several areas where forward-thinking activists and practitioners are driving change today. 


Safe Consumption Sites

Informal safe consumption sites (SCS) have long been run by people who use drugs to protect each others’ health. Filter reported on three different models for such spaces being operated in Seattle, for example. In the US, where SCS remain illegal, the bathrooms of many syringe programs also operate as de facto consumption spaces.

But a far more professionalized unsanctioned SCS has also been running somewhere in the states for nearly five years. Although its existence and preliminary results have been reported before, Dr. Barrot Lambdin, a senior epidemiologist with RTI International, presented the first “official” data from this site at the 26th Harm Reduction International Conference in Porto in April. The need for secrecy under US policies is such that Lambdin won’t even confirm whether the site is in the mainland US or not. Wherever it is, it’s working.

In four and a half years after opening in September 2014, the site hosted 9,000 injections by about 540 invited participants. Each time they attended, these people were asked where they would have injected if not at the site. A total of 8,400 of the injections would otherwise have taken place in parks or alleys, McDonald’s bathrooms or other public locations.

“What we also know,” said Lambdin, as quoted in my report in April for the Globe and Mail, “is that 85 per cent of people [injecting in such settings] rush their shot,” which increases a number of health risks. “For every 165 injections there is an overdose,” he added. Staff at the site reversed 26 overdoses with naloxone during the study period.

In Toronto, a site operated illegally in a downtown park for nearly a year. Ontario finally agreed to fund it.

Although Canada permits SCS⁠—with Insite in Vancouver, famously the first legal facility in North America,opening in 2003more activism has still been required to spread access.

In Toronto, for example, a site operated illegally in a downtown park for nearly a year. It opened under a tent in summer 2017, and then moved to a 40-foot trailer. The province of Ontario finally agreed in 2018 to provide the necessary exemptions and fund it in the same way as other services in the provincially-funded single-payer healthcare system—and then to open further sites to meet the demand.

It was a clear example of activism driving government change—although funding cuts by the Conservative provincial government elected in late 2018 are threatening to reverse this progress, as I recently reported for Filter.


Prescribing Safe Supply

Harm reductionists and people who use drugs are increasingly calling on physicians to prescribe a safe and legal supply of opioids. Here in Canada, that can include heroin. Diacetylmorphine (heroin) prescribing has been shown to be effective on a range of measures, including reducing mortality and use of illicit heroin, and stabilizing people’s lives where other treatments have failed. Several countries have successfully implemented this.

After a conservative Canadian federal government attempted to restrict access to heroin-assisted treatment in 2013, the organization Pivot Legal brought a case representing five subjects of a scientific trial to test its long-term effectiveness. Pivot won an injunction to keep them, and 202 other study participants, on diacetylmorphine until the case went to trial. In 2016 the government repealed its legislation rather than defend it in court.

Although several prescription heroin applications are now in the works, only one program, Crosstown Clinic in Vancouver, has to date managed to navigate major bureaucratic challenges to getting government permission. In the US, of course, heroin is a Schedule I drug, considered to have no legitimate medical use.

A fairly effective alternative, though, is hydromorphone (Dilaudid), a strong opioid commonly prescribed for chronic or acute pain. No special permission is needed to prescribe it; studies have found that at the right dose, it’s often indistinguishable from heroin to people dependent on that substance.

Yet no medical bodies in Canada have actually advised their members to prescribe safe supply to people at high risk. Instead, individual doctors have been making the decision to do so, quietly but legally creating their own versions of larger programs like Crosstown Clinic or Ottawa Inner City Health’s residential managed opioids program (which dispenses hydromorphone and long-acting morphine under supervision).

“Any doctor who thought that their patient was very vulnerable as a result of the drug supply could do this.”

In London, Ontario, the largest safe-supply prescribing program to date operated for three years before going public in June. According to prescribing physician Andrea Sereda, MD, the first patients in this program were three women with severe opioid use disorder, histories of chronic homelessness and many unsuccessful attempts at addiction treatment. They all had untreated HIV as well. Given the severity of their addictions and the unpredictability of the illicit market, all were at imminent risk of overdose death.

Dr. Sereda inherited these three patients from another physician, who prescribed hydromorphone as an emergency measure to keep them alive and off the street in order to receive hospital treatment. Having a safe, steady supply of opioids to prevent withdrawal proved dramatically positive in ways the doctors had not expected.

Sereda made the decision to continue prescribing, and began selecting other patients whose chaotic lives might likewise be transformed if they no longer needed to seek street drugs—exposing them to contaminated supply at unknown dosages, rushed use and accompanying criminal activities—to prevent withdrawal. She (along with another prescribing physician, who did not wish to be publicly identified) now has 100 such patients.

“Hydromorphone is not restricted,” Sereda told Filter. “Any doctor who thought that their patient was very vulnerable as a result of the drug supply could do this.”

Although doctors may fear censure from professional bodies more concerned with reducing opioid prescriptions than in providing a safe supply, Sereda believes that the regulatory body governing her work “wants our patients to be alive and well.”

And she and her colleague have achieved that. Despite an escalating fatal overdose rate in Ontario, her high-risk patients have suffered no overdoses.

This even though the hydromorphone is taken not under supervision, like methadone, but prescribed to be taken at home, with the medicine likely being crushed and injected. The patients are dispensed up to 16 pills daily, with long-acting morphine provided for observed consumption if necessary to prevent withdrawal symptoms. (Health Canada recently approved injectable hydromorphone for this purpose due to the solid evidence of its effectiveness, but it is not yet funded in Ontario.)

“A solid cohort of patients stopped engaging with the street supply altogether,” Sereda said. Others have moderated their use, with a significant group now taking fentanyl only occasionally, rather than several times a day. Almost all of the patients selected for the hydromorphone program were homeless; now, about half are housed. A significant proportion were HIV-positive, and adherence to treatment was low before—now all such patients are being effectively treated for HIV, with almost all having viral load suppression, stabilizing their health and reducing transmission risk. All of Serada’s patients tested positive for hepatitis C, and she now hopes to move them through that treatment cycle too.

Other results that Sereda has noticed include a reduction in the use of methamphetamine, which patients often use when in withdrawal and unable to afford opioids, or to stay awakea safety measure for life on the street.

“An open door back to healthcare.”

“We are not claiming to treat opioid use disorder with this program,” Sereda emphasized. “We’re claiming to reduce the harm from drug use to give people the breathing room to start to work on their social determinants of health.” Interactions at her clinic help with that. As well as daily contact to pick up prescriptions, patients have weekly appointments where they are supported to work on chronic health conditions and social determinants of health. An on-site ID clinic connects patients with government services, and the clinic works with some Housing First programs. It provides what Sereda describes as “an open door back to healthcare.”

Since announcing the results of the first three years to significant media attention, Sereda has fielded inquiries from doctors across Canada about her program. She is now working both with other local prescribers and some who want to start offering this in Toronto and other cities.

Official support seems to be following fast. In July, the month after Sereda went public, a funding announcement from the federal government invited proposals (due in September) for safe supply initiatives, including both hydromorphone and heroin. This represents a significant investment in, and acknowledgment of, the importance of this intervention. It’s now more likely than before that models of this kind for people with opioid use disorder could become routine in Canada.


Drug Checking

Dana Larsen, a cannabis-turned-safe-supply activist in Vancouver, has been the public face of at least two initiatives pushing at the edges of legality in Canada. (It should be noted that others do similar work behind the scenes, and that Larsen is an entrepreneur as well as an activist.)

One is a drug checking service, to which anyone in Canada (and, if you trust the mail, anywhere in the world) can mail a tiny sample of whatever substance they’re using for sophisticated testing using a mass spectrometer as well as fentanyl test strips.

Technically, it’s illegal. Larsen says he could be charged with trafficking, possession or other offences, although the amounts mailed are vanishingly small. “The reality is that there’s a lot of drugs going through our mail system anyway,” he told Filter.

He posts the results: “ketamine” that contains 20 percent methamphetamine; “speed” that is 55 percent caffeine and 45 percent cellulose.

The service, which uses a $40,000 machine and pays a technician through the profits from Larsen’s legal cannabis dispensary, is free. Music festivals have begun to invite Larsen and his associates to provide drug checking, which again helps to subsidize the cost.

He posts the results online: the white powder sold as ketamine, for example, that turns out to contain 20 percent methamphetamine; the white pill sold as speed that is actually 55 percent caffeine and 45 percent cellulose; or the brown chunks sold as heroin that, surprisingly, do not contain any fentanyl, to give just a few examples of recent findings from mailed samples.

Many groups in the US also provide drug checking services at festivals and online⁠—and frequently reckon with law enforcement pushback or censorship by retail sites like Amazon. The Netherlands, which has a government-funded drug checking service capable of issuing large-scale national alerts about dangerous batches, is an example of how far North America has to go⁠—but it’s important to remember that that, too, was originally created by unauthorized harm reductionists.


Mushroom Microdosing

Larsen’s other project involves the country’s first open sales of psilocybin mushrooms, which may have just been decriminalized in Oakland, California and Denver, Colorado but remain fully scheduled substances at the US federal level and in Canada.

“I don’t think cannabis would have been legalized across the country if there hadn’t been 200 dispensaries openly selling across the country,” Larsen said. Now, he is trying to apply the same model of gradual normalization to other drugs. “That’s why I started this mushroom microdosing.” 

Among the many harms of prohibition is a loss of knowledge about safer use of certain substances.

Larsen is selling very small amounts of psychedelic mushrooms by mail to anyone with a doctor’s note (the definition of “doctor” being very loose⁠—it includes naturopaths and traditional Chinese medicine practitioners) attesting to medical need. Psilocybin has been studied for its potential to treat conditions like sleep disorders, ADHD and PTSD, as well as anxiety relating to terminal illness.

At the amounts Larsen is selling so far, users would not experience intoxication. Larsen sees this aspect as not just a way to attract less of the wrong kind of attention, but also a way to reform psilocybin’s image: “Cannabis went from being seen as a hedonistic and bad thing to do to being seen as a medicine.”

The governing Liberal party were the architects of Canada’s current legal recreational marijuana regime. “I don’t think any judge in Canada is going to put me in jail for any length of time for selling microdoses [of psilocybin] for medicinal purposes,” Larsen said. On the other hand, he says he’s ready for a court challenge if he turns out to be wrong on that.

“In Canada because of our tradition of civil liberties and [the Canadian Charter of Rights and Freedoms], it’s easier to do this stuff,” he said. “It’s always been drug users and activists leading the way, and then governments reluctantly come on board.”

Larsen supports a legally regulated market where substances are recognized as having benefits as well as potential harms—and he sees civil disobedience as a way to get there. And, really, once The Economist starts advocating for mushrooms to be legalized, how radical can the idea be?

Prohibition, of course, is a 20th century invention. Among its many harms is a loss of knowledge about safer use of certain substances. Prior to colonization and prohibition, many naturally occurring psychoactive substances were routinely used in ritualistic or otherwise meaningful ways across Indigenous cultures. When prohibition ends, Larsen emphasized, we will need to learn how to best “reintegrate powerful substances back into our society.” 

“We’ve lost the best cultural context [for more moderate drug consumption] to prohibition,” he said. “Part of the challenge after prohibition is rebuilding that.”


Heroin Buyers Clubs

The Downtown East Side of Vancouver is known around the world for the intense poverty and open drug use visible in an area spanning several blocks. It is also known for its pioneering and effective harm reduction initiatives, like Insite. One assessment by the British Columbia Centre for Disease Control estimated that harm reduction initiatives prevented up to 3,000 deaths in the province between April 2016 and December 2017. Yet even these interventions have not kept up with the scale of the overdose crisis.

In 2019, a white paper published by the British Columbia Centre on Substance Use (BCCSU) made another proposal that would be a non-starter in much of the world: legal heroin buyers clubs⁠—modeled on a combination of the medical marijuana compassion clubs that thrived in Canada as well as in the US pre-legalization, and on buyers clubs in which activists pooled resources to buy expensive HIV treatment drugs in bulk.

It’s a daring, well-argued proposal for safe, affordable supply based on an urgent need at a time when highly-dependent drug users are dying en masse. It’s also based on the logic that illicit fentanyl represents a prohibition-fueled intensifying of potency of street opioids that many people don’t want. While many who use opioids are now seeking out fentanyl, most people who used it originally did so unwillingly or inadvertently—and everyone deserves the protection of knowing what they’re about to take.

The BCCSU concept paper describes a user-led approach, neither criminalized nor, like Sereda’s program, medicalized, in which people who are at risk of overdose death are approved for membership in a club that jointly purchases heroin. It would be affordable, thanks to group buying power; and pure and provided at known dosages, thanks to testing using mass spectrometer technology. The groups could also provide valuable peer support.

“We’ve got to stop the bleed.”

But as the white paper mentions, heroin buyers or compassion clubs already exist—in Ontario and British Columbia, and likely elsewhere—and have for years.

“We’ve got to stop the bleed,” a woman who belongs to one such unsanctioned group told Filter in reference to the torrent of opioid-involved deaths. Her club is a small one, consisting of four women and one man. She works in healthcare somewhere in Canada, and requested anonymity for obvious reasons. She believes that clubs like hers can prevent deaths among people who are dependent on the illicit market—in large part by facilitating a move from fentanyl to heroin. “We go from fentanyl backwards,” she said.

Like Larsen, she imagines a world where drug use is rooted in reliable knowledge about the risks and benefits of substances. “Who has the knowledge of therapeutic dosing [today]?”

She explained (accurately) that many people are able to function normally on heroin. The effects of a dose can last eight-to-12 hours, allowing users to work and take care of social obligations like anyone else. By contrast, the strength and half-life of illicit fentanyl results in extremely high tolerances and a need to inject as often as every couple of hours, making “recovery”—in the sense of recovering the ordinary activities of life—almost impossible.

For some people dependent on illicit fentanyl, otherwise well-evidenced alternatives like methadone or buprenorphine have proven inadequate time and time again⁠—as have less-well-evidenced approaches like Narcotics Anonymous and multiple attempts at detox and abstinence. For these people, a reliably pure supply of heroin would be a less potent but effective alternative to Russian roulette on the street.

The woman explained how she helped an acquaintance with severe opioid use disorder who had been through multiple attempts at treatment, including with Suboxone, to acquire a reliable source of uncontaminated heroin as a stop-gap alternative to the illicit market.

She knows her action would legally constitute trafficking. “It would be looked at as criminal activity, not as a health initiative.” Being found out could be devastating to her and to her group.

And yet, after working with a trusted physician, the patient in question has now qualified and moved from illicit heroin to (legal, Health Canada-approved) injectable hydromorphone. Uncontaminated heroin served as a bridge.

The group’s “line” on tested, un-contaminated heroin worked for a while, stabilizing everyone’s daily routine. Then the line was lost. Doing this clandestinely means the supply is unstable. It’s not like ordering it legally from Switzerland, as Crosstown Clinic is able to do, with exactly the same medical rationale. Still, the club continues.

“We’ve been left to fend for ourselves. We just have to break the law and hope they follow.”

“Our ethical dilemma,” my source explained, “is we absolutely have to break the law right now to help people. We’ve been left to fend for ourselves. We just have to break the law and hope they follow.”

She told me that she conducted informal interviews at an organized event for people who use drugs, asking those present whether they would be interested in supportive and low-cost transition from street fentanyl to uncontaminated heroin. Twenty-nine out of the 30 people in the room said that they would be willing to titrate down to the lower-strength opioid. The 30th, a young man also dependent on illicit fentanyl, said that he’d never tried heroin at all⁠—but was also willing to give it a try.

My source firmly believes in the power of unsanctioned activism to drive official change. “We start the initiative anyways, then they co-opt it,” she said of official harm reduction policy initiatives led by non-governmental organizations, health authorities or governments. “It does push them into action.”

But she also laments that secrecy is necessary, because it prevents important conversations. “Anything is possible when you provide the space for people to talk about it.”

She told me that she knows of groups similar to hers in at least two other provinces, as well as groups much larger than hers⁠—and groups that focus on providing people with a reliable, non-poisoned supply of methamphetamine, rather than opioids. They all share the ethos of people who use drugs protecting each other in a non-medicalized, judgment-free environment, including supporting the choice to reduce use or seek treatment for addiction.

So long as they can face a sentence for doing so, it’s going to remain difficult to evaluate and compare the strengths and weaknesses of different unsanctioned structures in order to keep improving the model. But for many people, until government catches up, it’s the only protection they’ve got.


Photo by Annie Spratt on Unsplash

Carlyn Zwarenstein

Carlyn is the author of On Opium: Pain, Pleasure, and Other Matters of Substance—a book about pain, opioids, harm reduction and the overdose crisis. She's based in Toronto.

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