What is a supervised consumption site?
In February 2020, I spoke with Stephen Finlay, who managed addiction services in the Surrey region of British Columbia for Lookout Housing and Health Society. Among other programs, he oversaw SafePoint, the second federally sanctioned supervised injection site in Canada.
For years, I had assumed places like this existed everywhere. Only when I read about a group in Philadelphia trying to open a site did I realize that our country did not have any. This is an archive episode, recorded when the show covered addiction and recovery broadly.
At 1:44, Stephen explained the name. His site is called a supervised consumption site because people may also snort or swallow their drugs there, although nearly everyone injects. He prefers the word supervised to safe, partly for political reasons and partly because street drugs remain risky wherever they are used.
What happens when someone walks through the door?
At 2:57, I admitted I had pictured a tent in a back alley. The video he sent me showed something closer to a modern bank, with individual booths.
From 3:29, Stephen walked through a visit. A worker at a locked door lets people in, and they can register under an alias. Inside, they pick up sterile supplies, choose one of seven booths, tell staff what they are using, and use while staff watch for an overdose.
Interestingly, he put a lot of weight on the relationships staff build. Staff learn each person’s tolerance and will warn someone just out of jail to use less. In his account, that trust can lead to detox, treatment, or simply a clinic visit for an untreated abscess.
Why is starting buprenorphine harder in the fentanyl era?
At 5:46, I asked whether Canada had the same medication programs we have, with methadone clinics and doctors who prescribe buprenorphine. Stephen said it did, and that Suboxone was being used more because some people found it worked better for them than methadone.
At 6:22, I described a problem we were seeing here. A person usually waits until moderate withdrawal before the first dose of buprenorphine. Yet with what seemed to be fentanyl analogs in the heroin, people could wait more than a day and still go into precipitated withdrawal.
How does a site handle an overdose?
At 13:57, Stephen said that SafePoint had never had a fatal overdose. When someone is being watched, he explained, there is time to restore breathing before the lack of oxygen does lasting harm.
From 16:41, he described the team: a nurse from the regional health authority and harm reduction workers from his organization, with oxygen, an oximeter, and a defibrillator on hand. In his account, many milder overdoses are reversed by talking to the person, stimulation, and oxygen, without naloxone at all.
When naloxone is needed, staff call an ambulance. Many people refuse to go. So, staff try to keep them on site, because naloxone can wear off while a longer acting opioid is still in the body.
Do sites like this ease the load on police and hospitals?
At 14:43, Stephen shared what he had learned from the police and the health authority. Before the site opened, officers in the area were reversing overdoses on the street every week. Afterward, that number fell to very few, and ambulance calls and emergency room visits for overdoses turned around and stayed down.
He also praised an unusual collaboration, which he described from 10:06. In 2017, the local police formed an outreach team that worked with the people living in a tent city instead of simply arresting them. Every weekday morning, police, his organization, the health authority, faith-based groups, and bylaw officers met for half an hour to share what they were seeing.
What is in the street drug supply?
At 18:32, Stephen described the weekly drug checking at his site. Most of what was sold as heroin contained fentanyl, and much of it contained no heroin at all.
From 35:53, he described mixtures that also contained etizolam, a drug that resembles a benzodiazepine. After the opioid is reversed, the person can stay deeply asleep, and some participants have woken hours later with no memory of what happened.
Still, he pushed back on some of the scarier stories at 37:47. His staff work around fentanyl every day, and the only time anyone was affected was when a participant broke the rules and blew smoke in a worker’s face.
Does supervising drug use encourage it?
At 26:50, Stephen said the common fear misses the target. In his view, the drug is almost secondary, and the real drivers are the trauma and mental illness underneath. While reversing an overdose, he often thinks that the time to stop it was decades earlier.
He rejected the idea that a site condones drug use. People are already using, and the harm to them and to everyone around them is greater in alleys and on sidewalks. In fact, what surprised him was the social change. People who arrived aggressive and threatening became, over months of steady contact, people who talked with staff and with each other.
At 31:43, I said that these are not expendable people. Stephen answered with the story of a man who overdosed many times at the site in its first months, later went through detox, and became a peer support worker on his team. That, he said, is why he would never want to stop reversing someone’s overdose.
How does a site fit into a larger system?
At 21:54, Stephen explained that most local shelters are low barrier, so people do not have to stop using to have a bed. Unfortunately, when someone is finally ready to try detox, a space is often not available quickly, and that moment can pass.
At 33:43, he credited wider naloxone availability for the drop in overdose deaths in 2019. However, he said the next step is preventing overdoses in the first place, with more detox and treatment and with prevention work in families long before trouble begins.
At 40:34, I asked what an ideal situation would look like. In his view, it is not a matter of how many sites. A supervised site, like medication-assisted therapy, helps put out the fire, while treatment, counseling, mental health care, and help moving off the street deal with what caused it.
Who is Stephen Finlay?
At the time of our conversation, Stephen Finlay was the addiction services manager for Lookout Housing and Health Society in the Surrey region of British Columbia. He oversaw an intensive case management team, a supervised drug smoking site, and SafePoint.
What can listeners take away from this conversation?
A supervised consumption site does more than reverse overdoses. In Stephen’s account, it is often the first place where people who have been pushed away by the health care system are treated as human beings, and that trust can open the door to detox, treatment, health care, and a different life. He was just as clear that it is only one part of what a community needs.
How do I approach this today?
My thinking has kept developing since this conversation was recorded. Today my practice is built on one idea that runs through all of it: when the body has adapted to a substance, the safest way off is usually gradual, with the smallest steps the person’s nervous system can tolerate. Physical dependence is not addiction.
For opioid dependence I prescribe buprenorphine, which steadies the body so a person can rebuild their life without the cycle of withdrawal. Visits are monthly, or weekly when needed. Some people stay on it for a long time, and that is a legitimate choice. Others later taper slowly, using the same gradual approach I use for every other medication.
I believe medication for opioid dependence should be available wherever people need it. I prescribe in Florida only.
Call 911 or go to an emergency department if there is a seizure, confusion or hallucinations, or thoughts of self-harm. For thoughts of suicide or any mental health crisis, you can also call or text the 988 Suicide and Crisis Lifeline.
This page is educational. It is not medical advice, and listening to the episode or reading this page does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
Full transcript
A note from Dr. Leeds: my guests speak from their own experience and expertise, and the terminology they use is their own. Whatever the topic, this show holds to one distinction: physical dependence on a prescribed medication is not addiction. This transcript is educational content, not medical advice, and nothing here creates a doctor-patient relationship.
Read the full transcript (44 minutes)
Dr. Mark Leeds [00:09] Welcome to The Rehab on the Mental Health News Radio Network. I am Dr. Mark Leeds and I will be your host. Join me in exploring the world of addiction treatment. How can we improve the ways that we help individuals to overcome addiction? The goal of treatment is to save lives and help people to get back on track to a path towards success and happiness in life. Today on the Rehab Podcast, my guest is Stephen Finlay, a manager of addiction services in the Surrey region for Lookout Housing and Health Society. Lookout is a nonprofit organization that provides homeless shelters, supportive housing, subsidized housing, outreach, harm reduction, and related services throughout southern British Columbia, including Vancouver. As Addiction Services Manager, Stephen oversees an intensive case management team, a supervised drug smoking site, and SafePoint, which is the second federally sanctioned supervised injection site in Canada. Stephen, welcome to the podcast. For years, I had assumed that these places were out there, that they were everywhere. I’ve heard of safe injection sites. And it never occurred to me until I recently was reading about a situation in Philadelphia where they’re trying to open the very first safe injection site in the United States. It never occurred to me that these places don’t exist in our country. Safe injection site, supervised consumption site. And actually, what do you call it? What is the name for that kind of a facility?
Stephen Finlay [01:44] We generally call them supervised consumption sites. The first one that was approved in Canada, which is Insite in Vancouver. It was a supervised injection site because the exemption they received from Health Canada authorized people injecting drugs in the site. Ours is called a supervised consumption site because people are also able to snort their drugs or take them orally in our site. However, the reality is that practically all of the people use it by injection. The forms of consumption other than injection are still extremely rare. 99.5% of the time, it’s injection. We use the word supervised rather than safe generally because one reason is political. There can be a lot of political backlash from people who say there’s no such thing as safe drug use, so you can’t call it safe. The other reason is that there’s truth in that because although we supervise and although it’s far safer for the person than using it in an alley, the fact remains that they are using street drugs and those drugs are generally quite risky. Although it’s much less dangerous than using the drug out in the alley or worse, on your own in your home, we call it supervised because it’s not truly safe. There’s inherent dangers.
Dr. Mark Leeds [02:57] In my imagination, I had always thought that this was like somebody setting up a tent in a back alley with a little table and some supplies. You sent me a video of your facility and a success story of someone that was coming there and has now joined you and working with you and has had great success in getting clean. But in looking at the facility, it’s really very high-tech and modern. I mean, it almost looks like a bank, you know, with individual spaces where people can sit down, and it looks like they sit at a window across from somebody. So what exactly happens when someone walks in and sits down at one of those spaces? What happens?
Stephen Finlay [03:29] It starts when they come to the door. The door is locked. They buzz at the doorbell. Our worker who’s in charge of the door looks to see who they are, if they’re one of our users or if they’re a new person. As long as there’s no indication of the person being in some kind of dangerous state, That does occasionally happen. The person at the door opens the door. They come in. If they’ve been there before, we have them entered in our computer system. Under an alias, the person can give us the real name if they want. They don’t have to. So the person at the door logs them in, logs their visit in. As soon as there’s space in the consumption room, the person at the door lets the participant into the consumption room. In there, they first pick up their supplies from what we call the smorgasbord. That’s where we’ve got the sterile needles, the sterile cookers, the sterile water, alcohol swabs, gauze, all that stuff. They pick that up. They go into the consumption area where there’s seven booths you saw and pick a booth. They tell the people in the consumption area what they’re using. Those people record that in the database. And then they use their drugs while the people in the consumption area monitor them. If there’s an overdose, the people in the consumption area treat the overdose, bring them back. The staff does a great deal of relationship building and talking with the people who come in. They often do education. Our overdose rate started out at about 1.5% of visits. There would be an overdose. And over time, that’s gone down to typically around 0.7% of visits. One of the factors there is that the staff gets to know everyone who comes in, what their tolerance is, what their typical reaction is, and they’ll warn a person. For instance, you’ve just come out of jail, your tolerance is low, you’d better use less today. And this kind of advice and recommendation and knowing the people reduces the overdose. And having a good relationship with the people and the people getting to trust our staff, that becomes an entryway into detox or treatment, sometimes even just primary health care. Many of the people who come in have had very bad experiences going to hospital or going to doctors, and they have things like untreated abscesses. Our staff can get them to go to our clinic next door and start getting some decent health care for that sort of thing.
Dr. Mark Leeds [05:46] Do you have in British Columbia or in Canada the same kind of medication-assisted treatment programs that we have in the U.S. Where we have methadone clinics and then we have buprenorphine treatment that doctors are allowed to do if they become qualified?
Stephen Finlay [05:59] Yes, we do have that. And as you probably know, with methadone, for instance, It’s sometimes a challenge to find the honest providers versus the dishonest providers. But we do have that. We’re getting more use of Suboxone now because some people find that Suboxone is more effective than methadone for them, quite a few people. Yet we have all that available, and we often refer people to those services as well.
Dr. Mark Leeds [06:22] One issue we’ve had here, and I’m sure it’s happening everywhere, is that typically when a person comes off of opioids and they start Suboxone, there’s a waiting period where they have to go into a moderate withdrawal state. And usually for a short-acting opioid, which heroin would be one of them, the waiting period might be a minimum of 12 hours and usually 18 to 24 hours. But for some reason with current heroin, that time period can be extended to 48 hours or more. It seems like it’s something to do with fentanyl analogs that’s in the heroin that while fentanyl should be short-acting, people can wait over 24 hours, get into that moderate withdrawal state, start taking their Suboxone, and then they still go into a precipitated withdrawal. And it’s becoming a problem where suboxone is hard to start for a lot of these patients.
Stephen Finlay [07:06] I do know that there’s some degree of effort and thought and maybe even trial and error going into how do you titrate and time the suboxone.
Dr. Mark Leeds [07:13] One person has suggested to me, well, why don’t you put them onto pure heroin first before you get them on the suboxone, then you’re working with more of a known quantity. And of course, my answer was we’re not allowed to. Now, I did read an article about heroin buying clubs providing safe or pure heroin to people?
Stephen Finlay [07:29] The heroin buying clubs was a suggestion made by Dr. Kendall, and they don’t exist at this point. My perception of that, only my personal perception, is that he was trying to suggest a way of doing it that might be politically acceptable. I personally don’t think that is an effective way of doing it. I can see why he would suggest it, because it’s something that might appear to be less offensive to the public than simply providing heroin. What we do know is effective is that the Crosstown Clinic in Vancouver for, I think, almost 10 years has been providing prescription heroin, and that works very well for those clients. It’s been given to people who have tried to get off opioids using methadone, using suboxone, using other methods, and have been unable to do so repeatedly. They can, if they’re accepted, get into the Crosstown Clinic and get a medically supervised clean dose of heroin, I believe twice a day. And we now in Surrey have a smaller program of the same type, which just started. And it is very effective because heroin, contrary to what some people think, if it’s in the correct dose, it’s not particularly hard on the body. It’s certainly not as hard on the body as things like meth or alcohol. If heroin’s in the right dose, The person can function quite well. Switzerland has also proven this and often will, after a while, simply no longer need it. So that is an option that we should be using more of.
Dr. Mark Leeds [08:58] And it seems like it would be an ideal transition in stepping down from the street drugs on the way to medical management. And if we were able to step down from street heroin to a safer heroin that’s provided medically, that would be ideal.
Stephen Finlay [09:13] I believe it’s a good transition. I know the Swiss experience has been that something like 60% of the people that they have on their program simply quit from heroin to nothing. What happens is that because their entire life is no longer revolving around finding the money for the fix, it’s 10 minutes twice a day to get their heroin. They have all this time and they start finding real life, finding ways of filling their time with real life. And after they’ve been doing that for a few years, the need for the heroin could just fade away because they’ve built a life around living like people who aren’t stuck on drugs will live. It’s an effective approach. And you’re right that the difference in risk between street drugs and medical heroin is quite enormous.
Dr. Mark Leeds [09:58] I see that you work with providing homeless shelters and housing and subsidized housing. Is that something in coordination with your work at SafePoint? Right?
Stephen Finlay [10:06] Yeah, the people who work at SafePoint are focused on the harm reduction aspects and on serving the clients in SafePoint. But other parts of the organization and other organizations around here do a lot of efforts to try to bring people into housing. Because obviously, if you’re homeless, the problems that go with that tend to give you more need and more desire to escape by using drugs or alcohol. So if you can get someone in a home, it improves their quality of life. It also makes it easier for them to do things like get to appointments. So an important part of moving towards recovery is getting housing. It’s also very difficult in this city because accommodation costs and land prices and therefore rents are extremely high. It’s really increasingly difficult to find housing that people can afford on welfare payments or on very low incomes. So we work hard at it. We do our best, but it’s always a challenge. One interesting thing about our particular or location, is that there’s a very high degree of cooperation among the non-profit agencies, the regional health authority, the regional health authorities, in fact, who funds our site, police, faith-based organizations, and anyone else who’s working on the problems of homelessness, addictions, and mental illnesses. Beginning of 2017, about January 2017, the Surrey Police Force, which is the Surrey Division of the RCMP, started what might be called a new experiment. They created what they called the Surrey Outreach Team, and it was a dedicated group of roughly 12, 16 selected officers. And they basically set up 24-hour, 7-day-a-week operations right on the location where the homeless tent city and the center of the drug trade was. They, of course, were familiar with this area for many years, And for years, they’d been working on the traditional approach of you arrest people. You know, you arrest people when they’re using or when they’re dealing and send them to jail. And what was happening is that they’d arrest them and send them to jail and they’d come out of jail. And they’d use or deal again and you’d arrest them and send them to jail. They’d come out of jail and kept going around and around like this. So they tried a different approach where the team focused on building relationships with the people who were living in the tents. They would try to selectively target predatory dealers, but otherwise they’d be more or less working with the people rather than trying to arrest them. They started that at the beginning of 2017. Then we opened our site in June 2017, and we joined in with the meetings that they were already running. So from June 2017 until about July 2018, because in July 2018, BC Housing led an effort to move everyone who was in the tents into different kinds of shelter. So between June 2017 and 2018, when the tent city was removed, literally every weekday morning for half an hour, the RCMP, my organization, the Regional Health Authority, the Surrey Urban Mission, Night Shift Ministries, and Bylaw would meet for half an hour in the police headquarters trailer. And we’d share information about what are the problems we’re seeing? What are we planning on doing that day? Is there somebody we’re worried about? Has anybody seen George? We’ve lost touch with him. All this kind of stuff. And that collaboration is still going on, although it’s now three days a week. I can’t say enough about how valuable our collaboration with our local police force and with the health authority has been and still is.
Dr. Mark Leeds [13:44] Since you started these efforts with the police and the opening of SafePoint, how many lives are being saved at this point? And have you studied also the effect on the spread of contagious diseases such as HIV and hepatitis?
Stephen Finlay [13:57] Since we opened, this is two and a half years now, there have been around 190,000 visits to the site, 2,600 different people. There have been just over 1,400 overdoses. When an overdose happens in a site like this, there’s not a great risk of a fatality, and we’ve never had one, neither has InSite. The reason there’s not a great risk is that when you’re right there monitoring, you have enough time to get the person breathing again. And the death from an overdose is from hypoxia. Hypoxia. So the fact that you’re able to get the person breathing again, that really reduces the risk of dying. I can give you some interesting statistics that I’ve learned from the police and other sources. One of the factors in having a site like this is that there’s an economic cost benefit because in the first half of 2017, before our site opened, the RCMP were, their officers were responding to 25 to 30 overdoses per week on the street. They all carried naloxone, they were all trained, and that’s how many overdoses they were reversing before we opened. After we opened, the number of overdoses they had to reverse began to drop, and it stabilized at zero to five per week. So there’s a huge saving in police time and effort there that they don’t have to treat the overdoses anymore because we’ve got that, and they can actually do what they’re meant to do. We also saw in the regional health authority statistics ambulance calls and emergency visits. The number of ambulance calls for overdoses and emergency room visits for overdoses had been climbing, climbing, climbing rapidly. When we opened, that number turned around and then dropped for about six months and then stayed down. So we were able to reduce the number of ambulance calls, which is a very big cost savings, and reduce the load on the emergency department somewhat.
Dr. Mark Leeds [15:48] That’s really interesting because as far as giving naloxone, and that’s been an issue here with some law enforcement officials getting frustrated with naloxone being given to the same people over and over again. And they’ve made statements in the media saying that they want to put limits on that, which is a terrible thing. But as far as naloxone, which is Narcan, available as an injectable or nasal spray, blocks opioids that can reverse an overdose. Naloxone is short-acting, usually shorter-acting than the opioid that the person is taking, and it often has to be administered more than once. So if someone were to give naloxone to a person to reverse an overdose, they would typically call 911, the emergency number. The ambulance would come and take the person to the hospital, and then the ER doctor would take over from there and treat them appropriately and hopefully get them into a treatment program. Not all of that happens all the time. So do you fully handle the overdose at your facility without even having to call for an ambulance?
Stephen Finlay [16:41] Typically, now, our staffing in the overdose facility or in the supervised injection site, we’re staffed by both staff from my organization and from the Regional Health Authority. The Regional Health Authority provides a nurse, and our organization provides three harm reduction workers. But because we have a nurse there, and we also have oxygen, and we have an oximeter, we even have a defibrillator, which we haven’t had to use yet. We reverse, I’d say, 65% to 70% of overdoses. We are able to reverse them without using naloxone. And it’s because we’ve got the nursing care there and we have the oxygen. Because a low-level overdose, you can pretty easily reverse with talking to the person, pain stimuli, and if necessary, oxygen to keep their oxygen saturation up. If it’s a more severe overdose, then we’ll be using naloxone. So our policy, and this is only possible because we have the nursing expertise, and the equipment we have is that we call for an ambulance if we use naloxone. Otherwise, if we didn’t have to use naloxone, we don’t call the ambulance yet. Then when we do call the ambulance and use naloxone, depending on the severity, we’ll try to recommend that the person go with the ambulance. They often refuse. Then we will try to get them to stay in our site so we can keep an eye on them because if they have a long-acting opioid in their system, after 45 minutes, an hour or so, the naloxone will wear off and the opioid will kick back in and they’ll start to go down again. And if they’re in our site at that time, we can bring them out of it again.
Dr. Mark Leeds [18:12] An ER doctor had told me that it’s possible that if a naloxone drip is started via IV and it’s titrated just right, their breathing can be restored without even waking them up and causing any distress, as opposed to when it’s being given on site, usually enough is given to wake the person up and there’s that risk that they’re going to be aggressive because they’re now shocked out of their overdose.
Stephen Finlay [18:32] That makes sense. I was not aware of the naloxone drip, but it makes sense that if you could titrate it just right, which is a challenge because you never know and the user never knows what exactly went in. We have, and I think I mentioned this to you, we have the drug tester who comes on Thursday afternoons. And what his results are showing is that about 85% to 90% of the, in quotes, heroin that people are using contains fentanyl. About 20% of the so-called heroin that people are using contains any heroin at all. So typically what we have as so-called heroin, it rarely is. It’s usually fentanyl. And the people know this, they’ve typically become more cautious as a result because they have to assume there’s fentanyl in whatever they’re using.
Dr. Mark Leeds [19:21] And I think you also mentioned that there’s test strips that people can obtain to test their own heroin to see if it’s fentanyl.
Stephen Finlay [19:27] We have. We have those test strips. Typically, what happens now is because people have so often found fentanyl, they are more often just assuming there’s fentanyl. Occasionally, they’ll take a test strip and check it to confirm, but usually without the test strip, they just expect that’s in there. And they’re usually right.
Dr. Mark Leeds [19:43] Now, can a person come back to the facility to use more than once a day? Is there a limit to how long a person can stay or how often they can come in?
Stephen Finlay [19:50] No limit to how often they can come in. And there’s also no specific limit to how long they can stay. When it’s busy, the staff will encourage people who have finished using and who aren’t having any serious effects, they’ll encourage them to either leave the side or move to the side and wait at the side so that we can free up the booth for the next person. So if it’s busy, we’ll be asking people who are finished and who are all right to make room for the next person. Other than that, there’s no limits.
Dr. Mark Leeds [20:17] Is there any significant impact on the surrounding area as far as people using heroin outside or needles being found in the area or any other problems like that?
Stephen Finlay [20:26] We put this site in the place where the open-air drug scene already existed, and that’s typically where you would put a site like this. You’d put it in a place where you’ve already got a lot of homelessness, a lot of street drug trade, a lot of street drug use. We put it in this kind of location. Then the police would encourage people to come into the site. If they’d see someone using, they’d say, look, you’ve got a site to use in now. You can go in there and we won’t bother you. If you keep using out here, I might arrest you. So the police helped us to move people into the site. And in that way, we managed to reduce public drug use quite a bit.
Dr. Mark Leeds [21:05] I would imagine if people are using heroin, that they’re probably not taking care of themselves as far as getting food or being able to get food.
Stephen Finlay [21:13] The Surrey Urban Mission and Night Shift Ministries provide a lot of meals. And of course, our emergency shelters provide meals for the people who have shelter beds. So there is a lot of effort to do that. What we could really use and don’t have is a drop-in location where people could come in and, for instance, have a shower, do laundry. That would be a very valuable thing to add. And at this point, we haven’t got permission to have that.
Dr. Mark Leeds [21:39] Can a person get housing there or shelter? And once the person goes into a shelter and gets off the street? Are they required to stop using drugs and to do some kind of a rehabilitation program where they have to make progress and graduate from the program at some point?
Stephen Finlay [21:54] It varies with the shelter. Most of our shelters are low barrier, so people can come in and live in the shelter. They don’t have to quit using in order to be in the shelter. Once they’re in the shelter, the caseworker works with them to, first of all, try to find more stable housing. Second, to try to get them to start getting medical care, treatment, stuff like that. And if the person is interested in quitting, the caseworker will try to get them into a recovery location, into a treatment place. One challenge is that we really could use more detox space. I’ve several times had cases where the person’s in our site, they’re ready to try detox, detox, they’re ready to try quitting. But if we can’t get them into a detox space quickly, you sort of miss that opportunity. And so one of the fundamental challenges is meeting more detox spaces that we can start people on that path with. And of course, another challenge, and you’re familiar with this, I’m sure that when you get someone into detox, you want to have arranged a transitional treatment place for when they come out in a week or so. Because if they come out of detox and don’t go into a program, they’re almost certain to go back. That’s also something we need a lot more of.
Dr. Mark Leeds [23:09] And that’s a huge problem. People going into short-term detox programs, it might last two weeks and the relapse rate is very high. And you had mentioned that it was a very, very difficult task to even open this facility, that there was a lot of resistance to it.
Stephen Finlay [23:23] We were at the stage where we opened SafePoint. It was starting to get better because the political history is that Insite was opened under one government and using an exemption from the Federal Controlled Drugs and Substances Act. Then after a change in government, the new federal government actually tried to get it shut down, and it was kept open by a Supreme Court decision. Before SafePoint was opened, that government went out, and a new government came in that was ideologically more favorable. However, at the time SafePoint was opening, they hadn’t made any changes to the regulations as yet. So the Regional Health Authority, in order to fund an open SafePoint, went through a good year-plus-long process of seeking approval and dotting all the I’s and crossing the T’s. We didn’t have really drastic opposition to it. One reason was that the homeless situation in the location where we’re at, at that time when we opened was extremely serious. The entire street was covered with tents, a lot of crime, a lot of drug use. It had been a problem for many years. So there was a lot of willingness to try to make it better in various ways. And ours was one of that. Early on, there was a visit unannounced and unprepared by the city mayor, who was at that time, as far as I could somewhat opposed to us. And she asked some questions and she was fairly aggressive, but I answered the questions as well as I could. And there were a lot of things she said that I could agree with. She became a supporter after that. We didn’t have a huge amount of political opposition. Another reason we didn’t have so much political opposition is that the end of 2016, because of the number of overdose deaths, the provincial health minister used his emergency powers to authorize basically pop-up supervised injection sites. And he essentially said, I don’t care that these are federally illegal. I’m using my powers to authorize them in BC for the time being because we have to. So those started up in January 2017. We had some of them, a number of other organizations started them up. And those ones were the tables in the tent type of thing, a lot of them. But the political mood was, it’s an emergency, we need to do something. So in that background, then when we opened our Health Canada sanctioned site, the way had already been opened in a way politically by these previous events. We opened our site, we were able to shut down our temporary sites in the area because we now have the real thing, as it were. We have not had a great deal of political issues since then. We work hard to cooperate with the police, with BC Housing, and with the Regional Health Authority.
Dr. Mark Leeds [26:12] That’s really good that there’s been government support and so many people working to address the crisis. And it’s hard to believe that there’s people fighting these kind of things. I don’t know if you follow the story in Philadelphia. I’ve read some articles about it where there’s a non-profit group trying to start a supervised injection site where they already have a needle exchange program. And the federal government is fighting them and saying that it’s going to promote more drug use and illegal drug use. And I think part of the case, there was a judge that said this can only save lives and needs to be allowed to open. But it’s hard to believe that our government would be against such a thing that would clearly save lives and reduce the spread of disease. It’s hard to believe that they wouldn’t be in favor of it.
Stephen Finlay [26:50] There are an awful lot of people who have that attitude about it. And yes, I certainly have followed the Philadelphia story quite a bit. It’s not surprising in a way that misconceptions are widespread. And to some extent, people have been trained by decades of not very accurate information to miss the target when they’re worrying about the problem. There’s a tendency to perceive the problem as the drug itself. And the drug is almost secondary. What the drug happens to be is not the primary driver of the problem, the primary driver of the problem is the addiction and the trauma and mental illnesses that underlie the addiction. You’re almost always going to find a mental illness behind an addiction and usually, the vast majority of the time, you’re going to find a trauma and probably a childhood trauma, probably a lot of it, behind that mental illness. You’re probably familiar with the adverse childhood experiences study and certainly we see that all the time. So many times I’m seeing my staff or helping my staff reverse an overdose and in the back of my mind is the time to stop this overdose was 35 years ago so many times especially when we’ve got to know the person and know a little bit of their history we know where it has come from one of the misconceptions is if you have a supervised injection site you are quotes condoning drug use and by condoning it you’re encouraging it. What we’re doing is we’re recognizing the reality that the people are using drugs and that the impacts not only on them but also on society are worse if they’re using in the back alleys on the sidewalks than if they’re using in our site. So there’s the basic fact that there’s more risk of disease spread, there’s more risk of needle left around, all those other bad effects if you don’t have places like this. The other thing is people have been trained to regard drug users as morally defective and evil. And certainly a lot of people who have drug use have mental illnesses or personality problems that you might not like dealing with. However, if you want to do something that works in terms of moving this person from an unhealthy and dangerous way of living into a way that is going to make them more a part of society and more of a person that all the rest of us can live with. If you want to make that change, the approach of we’re going to make life as miserable for you as you possibly can, which has been the effect of the last few decades, that approach doesn’t have the right effect. It doesn’t make that change. It tends to make things worse. And one of the things that surprised me about our site, I expected, of course, to be reversing overdoses, to be handing out clean supplies and taking care of the, quote, medical aspects of it. But what I didn’t anticipate is that our staff, by seeing the same people regularly and by building relationships with them, they do two things. One is we actually help train people in ways of behaving that work better socially. We’ve had a lot of people who come in, and when they first come in, they’re aggressive, they’re threatening violence, they walk around the site waving an uncapped needle, they get into conflicts with other people on the site, all kinds of problems like this. And so they’ll get a prohibition. They’ll come back and they’ll do it again, they’ll get another prohibition. But in the meantime, we’re always talking with them. And after several months, the aggressive and violent and conflicting behavior goes away or goes down, and they start having conversations with our staff, with other people. They start socializing. And so we’re actually developing the life skill of being an ordinary social human being. Because when you’re out on the street and you don’t have any place to live, you can’t get washed and you can’t get food, and there’s all sorts of predators around, you have to learn all sorts of behaviors that are antisocial. So what surprised me is we become a place where people learn and develop their basic social skills that are part of getting out of it, part of getting back into the regular world and out of the world they’re in. The other thing that the staff do is because they build relationships, this becomes a place where for the first time for a lot of these people they feel like the health care system is treating them like a human being so through our staff they’re willing to consider detox or treatment or talking to a counselor or even just going to a medical clinic to get their abscess treated for some people that’s a huge barrier so our place becomes the entry point to the health care system that they didn’t have before because anytime they bumped into the healthcare system, it became a nasty experience from their point of view.
Dr. Mark Leeds [31:43] These are not expendable people. These are real people with real lives who came from somewhere, they have families, they may have had careers and education before they ended up on the streets. Definitely people who are intelligent and creative and have potential to move forward with their lives and do important things in their lives and help other people.
Stephen Finlay [31:59] We certainly had a great example of that. I sent you the video and that gentleman, he started using in our site. When we opened in 2017, through June to October 2017, he overdosed 23 times in our site. He was working at the time, working in trades. And as you know, that’s a risky area. So he’d come to the site, he’d use, he’d go to work, he’d come back, he’d use again. But he was a very high overdose risk. Then he went into detox, he then went into treatment. And as the video said, after some time in treatment, he came back and was working with us as a peer support worker. He’s now a part-time regular employee in the intensive case management team. My friend in the regional health authority has just hired him away. He’s going to be a full-time member of the assertive community treatment team starting next month. And so whenever somebody gets frustrated, I’m Narcanning the same guy again and again and again. Well, this is my answer that I wouldn’t have wanted to stop Narcanning him after 10 times or 20 because he’s making a huge contribution now.
Dr. Mark Leeds [33:08] Narcan is way too expensive. In most states, you can get it without a prescription at a pharmacy, but it’s still not an over-the-counter drug. I believe the FDA is working on fast-tracking it to become over-the-counter. At this point, you can walk into a pharmacy and go up to the pharmacy counter, and just like getting a flu shot, do some basic paperwork, and they’ll give it to you. It still costs $150 per dose. It’s still very expensive. It seems like it’s something that should be everywhere. I’ve heard stories of people overdosing in the middle of a Narcotics Anonymous meeting. You can imagine someone using their last dose of heroin, and then they walk into a meeting and fall down halfway through the meeting. It’s happening everywhere.
Stephen Finlay [33:43] Yes, that’s been known to happen. And we’re fortunate here because the BC Center for Substance Use supplies Narcan fully funded to approved sites. So we are an approved site, and there’s quite a few others. So anyone who’s an approved site with the BC Center for Substance Use simply orders the amount of Narcan kits they want. We go through about 300 a month, and I’ve got the kit right in front of me here now. It has three VanishPoint syringes, three vials of Naloxone, rubber gloves, alcohol prep pads, a small face mask. I carry it everywhere. My wife has one. She carries it everywhere. She’s a paralegal in a downtown law firm. We have them in the site. Anybody who needs one, we give it to them. And this availability of Naloxone, I think, is the main reason why in 2019, we’re on track for two-thirds as many overdose deaths as last year. So we’re definitely getting better at preventing the deaths and the availability of Naloxone is a big factor in that. What we now need to do is we need to get better at reducing the overdoses in the first place. Naloxone Availability and even my site, we are at the tail end of the spectrum. We are the piece that handles the problem after almost everything else has already gone wrong. We need to strengthen the other parts of the system, the detox and treatment parts. We are often experiencing a shortage. We’ve got the person to be ready for detox and we can’t get them in. The other thing that is more fundamental is prevention. And that prevention means working at the family level 30, 40 years in advance to reduce and prevent those adverse experiences that increase the risk. And there have been some successful programs involving public health nurses visiting and working with at-risk families. Some in the U.S. Have been extremely successful, but it’s hard for those programs to maintain their funding. Governments have a tendency to cut. We need vastly more of that.
Dr. Mark Leeds [35:46] I had also read about that there’s machines that dispense Dilaudid on the streets in some areas to give people a safe source of opioids to use.
Stephen Finlay [35:53] Yeah, we have the first one of those in Vancouver. Quite a sophisticated biometric dispensing machine so that only the person who’s signed up can get it. And that is a form of safer supply. Generally, all of us in the business here, we know that a safer supply would be very helpful. It’s a strange thing. I’ve often read critics of sites like mine saying, first you’re doing a supervised injection site. Next thing you’re going to want to do is provide them with drugs. And my answer to that tends to be, if you saw the results coming out of that spectrometer, you’d want to provide them with drugs too. There’s some pretty beastly stuff. Some of the worst we’ve had recently is when in addition to the opioid, which as I said is usually fentanyl, If the mixture has etizolam in it as well, then you have a quite unpleasant overdose. After the opioid has been neutralized, the etizolam is still in there and the person is still deep asleep. And we’ve heard stories from some of our participants. I used that stuff and I woke up 10 hours later in a field with my pants off and I have no idea what happened. Some of the mixtures are nasty. The etizolam resembles a benzodiazepine, and apparently it can cause amnesia.
Dr. Mark Leeds [37:12] So it’s almost like a date-rape drug. A lot of people think of date-rape drugs as being something that gets slipped in your drink at the bar when you turn around. People who are using drugs, sometimes people consider them to be expendable in a way, and they become easy targets for stuff like that.
Stephen Finlay [37:27] Very easy targets, that’s right.
Dr. Mark Leeds [37:29] In a way, it also seems like the fentanyl issue is a form of chemical warfare. And I guess people in the 60s were afraid that the Russians were going to put LSD in our water supply. And now here we are in 2020, and we have dangerous fentanyl analogs being imported from China. And we need to be doing anything we can to combat this.
Stephen Finlay [37:47] Although fentanyl is dangerous, some of the scare stories are a little excessive. When you consider that 85%, 90% of the so-called heroin that comes into our site is actually fentanyl. And in our site the heroin or fentanyl the opioid in general is the most used it’s 65 to 70 percent of all the drugs people use are the opioids so when you consider that we have that much prevalence of fentanyl in our site we haven’t had any fatal overdoses from in the site as I said they are reversible and the only time any of our staff have been affected by the fentanyl or any other drug is when a person violating the rules of the site actually smoked their drug in the site and then blew it in the staff member’s face. That made the staff member feel high and dizzy, no wonder. And of course, the person gets a prohibition because they’re not allowed to smoke in the site. The ventilation can’t handle it. But other than that, we are in a relatively small area with fentanyl present all the time. And we haven’t actually had one of those staff rush to hospital, dying of overdose situations that you read about in the media. So although it’s dangerous, it’s not quite as dangerous as what some of the stories would make you think.
Dr. Mark Leeds [39:09] I like the stories of carfentanil being a thousand times the potency morphine and there’s stories that it can even go through the pores of a latex glove and law enforcement has to be concerned about touching it. So that probably hasn’t really been as big of a problem as they’ve talked about.
Stephen Finlay [39:23] Not as big of a problem. Where that happens is if you’re law enforcement and you’re dealing with a place where you have a dealer and there’s a lot of fentanyl there and it’s more pure, then it’s dangerous. But the amount that a typical drug user will have doesn’t reach quite that level of danger. So the risk to law enforcement especially comes when they’re at a place that’s a factory or a dealer’s place. You can have very high concentrations and it can be very dangerous. Carfentanil, we get that occasionally. Luckily, we don’t have as much of that as we have of fentanyl now. It is more powerful. The amount that somebody would have in a dose is actually less than the spectrometer can detect because the spectrometer doesn’t detect anything less than 5%. If you had 5% carfentanil, you’d have a problem. So fortunately, we’re not seeing a lot of that yet.
Dr. Mark Leeds [40:19] In an ideal world, if nobody was fighting this, if they allowed supervised injection sites to open up, what would be an ideal situation? How many would we need? How many facilities? Would it just be as many as possible? What would be an ideal situation?
Stephen Finlay [40:34] Well, the ideal situation is that the supervised injection facility is part of a much larger system. We’re a valuable piece, but we’re not the biggest piece and we’re not the most important piece. It should be a part of an entire system involving detox, treatment, medically assisted therapy, access to clean heroin for the people for whom that is the best way off, counseling, psychiatric and mental health care. The underlying mental health issues are very severe for some people. So that’s the ideal situations where this is just one part of a well-integrated system for managing the addiction. We in the supervised injection, we are part of managing the addiction. The bigger parts of it, besides managing the addiction, are then dealing with the underlying mental health and trauma, working to resolve that and changing the entire life context and life habits, moving a person from a homeless or crime-based lifestyle into becoming part of society. So the supervised injection site and some of the other stuff like medication-assisted therapy, like heroin prescription, that’s just to manage the addiction and to put out the fire. Then the rest of the system is dealing with the basic structure and the underlying issues and problems and motivators that caused the fire. So that’s how I see it. We are needed to put the fire out, but we are only part of a larger system, and the rest of the system is needed to deal with what caused the fire in the first place. So that’s what I see as the ideal situation. Not a matter of quantity. It’s a matter of putting it into and including it in an overall care and you might say social development system that changes the underlying factors and doesn’t stop with just dealing with the addiction.
Dr. Mark Leeds [42:38] Thank you, Steve Finlay. And I want to thank you for the work that you’re doing to save lives and change lives and provide an incredible positive example to other communities around the world to what they could be doing to also help to save lives from opioid overdose and opioid addiction. Thank you for joining me.
Stephen Finlay [42:55] Thank you very much, Mark.
Dr. Mark Leeds [42:58] Thank you for joining us today on The Rehab on the Mental Health News Radio Network. I hope that you have found this show to be interesting and useful. If so, please subscribe to The Rehab Podcast and share on social media. I appreciate your taking the time to listen to The Rehab. Thank you. Thank you.
