Pubdate: Thu, 24 May 2018
Source: New York Times (NY)
Copyright: 2018 The New York Times Company
Author: J. David Goodman


TORONTO - An aging construction worker arrived quietly in the
building's basement, took his seat alongside three other men and
struck his lighter below a cooker of synthetic heroin.

A woman, trained to intervene in case of an overdose, placed a mask
over her face as his drug cooked and diluted beneath a jumping flame.
He injected himself, grew still and then told of the loss of his wife
who died alone in her room upstairs - an overdose that came just a few
months before this social service nonprofit opened its doors for
supervised injections.

"I don't want to say, 'What if, what if,'" said the 52-year-old man,
known as Gordie. He said his wife, Carol, had talked about kicking her
habit before her death in September. "It never happened," he said.

He repeated a kind of mantra, born of personal grief, that is quickly 
becoming a guiding principle for many heroin users and advocates across 
Canada, Europe and, now, a handful of United States cities like New 
York: "Don't do it alone."

As Mayor Bill de Blasio has come out in support of supervised
injection centers in New York, his stance has been shaped by Canada's

The country has been a pioneer; its first supervised injection
facility, where heroin can be used under supervision, opened in
Vancouver in 2003. A decade of political and legal wrangling followed,
culminating with the Canadian Supreme Court ruling in favor of the
approach in 2011.

No such federal approval exists in the United States, and none is
likely to come from the Trump administration. But cities from
Philadelphia to San Francisco - which could open the nation's first
sites this summer - are discussing going forward anyway, risking a
potential showdown with federal authorities.

In New York, where as many as four sites are being envisioned as part
of a one-year pilot study, officials suggest that the Justice
Department may be reluctant to interfere with a city-backed effort to
combat the seemingly unstoppable surge of deaths from prescription
opioids, heroin and the powerful opioid, fentanyl.

In Toronto, the largest city in Canada, opening sites became a recent
imperative: In 2013, there were 104 fatal opioid overdoses; in the
first 10 months of 2017, there were 263, according to the latest data
available from the city's health department.

Two official sites opened here last year; four more have opened so far
this year. In some, users can only inject drugs; in others, they can
snort or swallow them. At the moment, none allow drugs to be smoked.

Days before Mr. de Blasio announced his decision this month, he and
John Tory, the conservative mayor of Toronto, spoke by phone for about
30 minutes, mostly about doing the "preparatory work" to ensure public

"I think that many people in the public would feel as I did - a bit
uneasy at first," Mr. Tory said in an interview. But as he
familiarized himself with studies of the benefits of supervised
injection facilities, he said he was "persuaded of the view that it
really is about saving lives."

The New York Police Department sent a small camera-toting contingent
to Toronto and Vancouver to see how officers there handle the sort of
drug-related disorder that for years has been anathema to New York's
policing culture.

They did not like everything they saw.

"We did see quality-of-life issues; we did see drug dealing,"
Commissioner James P. O'Neill said at a news conference this month.
"It wasn't a 24/7 operation, so at one point we actually saw someone
shooting up in the doorway of the center."

"It was good for us to see that to make sure that it doesn't happen
here," he added.

The Toronto police are currently studying crime trends to figure out
whether the quality-of-life issues have worsened because of the new
facilities or from other factors like the general rise in drug
overdoses in the city over the same period.

In Toronto, calls to 911 have risen near the biggest sites. "Public
urination, public defecation, prostitution, sexual assault, robberies,
noise, you name it, we're hearing about it," said Staff Superintendent
Mario Di Tommaso of the Toronto Police Service. "And that's all coming
from the public."

Indeed, groups of users, drugs in hand, are a common sight outside the
biggest of these centers; many arrive before the doors open, some
unable to wait to use inside.

For health officials, users and advocates, that underscores the need
to have a place safe from overdose, or from worries about robbery
while the drugs are taking effect. Several times in recent weeks,
staff members had to revive people overdosing outside a center.

"It's like the AIDS crisis; we've had people dying for a decade and
nobody cared," said Councilor Joe Cressy, 33, among Toronto's most
assiduous advocates for the sites. "The question we're asked today is:
Why can't you open more sooner?"

Other cities in Canada are moving forward as well. Montreal has opened
several supervised injection sites in the last year. Ottawa got its
first site in April. Vancouver now has more than a half-dozen places
where users can inject. (Police in Vancouver said their sites have not
caused crime to increase.)

Toronto's path was not exactly smooth. Last August, activists fed up
with waiting for Canadian federal approval took over a section of a
downtown park, pitched a tent and began a volunteer site. They did so
after a particularly bad week in which a half-dozen people fatally
overdosed in the city, said Sarah Ovens, 28, a social worker and
volunteer who helps run the site in Moss Park.

Soon Mayor Tory came down. Then Ontario's premier, Kathleen Wynne,

The tents have since been replaced by a trailer. Since August, about
7,500 injections have been supervised by a rotating cast of hundreds
of volunteers; 214 overdoses have been reversed, usually with oxygen
rather than naloxone, an overdose reversal medication, said Ms. Ovens.

Crowds now gather in the muddy grass outside before its doors open at
4 p.m. Soon the renegade site will get an officially sanctioned
location in a nearby storefront.

Across the street, in an officially sanctioned site at the nonprofit
Fred Victor, Gordie, the construction worker, said he comes daily when
it opens in the evening.

Nick, a 28-year-old Ojibwe man who took fentanyl at the injection
site, said he had been through treatment but could not make it stick.
"It's the devil," he said of opioids, adding that he and his
girlfriend come to Fred Victor because it is safe to use there. The
site will eventually be open around the clock, everyday.

Not everyone is sold.

"If your son, daughter, loved one ever had an addiction, would you
want them to go in a little area and do more drugs?" Doug Ford, a
conservative populist running for Ontario premier and the brother of
the former Toronto mayor Rob Ford, told reporters in April. "I am dead
against that."

Mr. Ford, who hosts big rallies and campaigns on a bus with a huge
image of himself giving a thumbs-up, is the front-runner in next
month's election, and has invited comparisons here to President Trump.
In a statement to The Times, Mr. Ford said he had his own personal
views, but would consult with experts on the issue. "Helping people is
my top priority," he said.

His big lead in polls has worried some city officials that provincial
funding for supervised injection sites could be at risk should he win.

"I am concerned," said Kristyn Wong-Tam, a city councilor whose
downtown ward contains a city-run site called The Works. "We don't
push people out. We draw them in. To me, that's the Toronto way."

The Works, a harm reduction center and methadone clinic, has already
overseen nearly 9,000 injections. The site, open 12 hours, six days a
week, sits a few steps from a university campus and just off the
corner of Yonge-Dundas Square, the equivalent of New York's Times Square.

Intake is still done by paper - the computer system could not be
developed fast enough - and visitors are asked to provide some
information, such as gender, age, the drug they will be using and
whether they have overdosed; they can remain anonymous. About
three-quarters of those who come are men, many are homeless and less
than 10 percent are first-time visitors, according to Toronto Public
Health, which operates the site.

Each person gets a kit that includes saline solution for mixing with
heroin or other drugs, a choice of different gauge needles, a cooker -
thinner than a spoon and single-use - and a spot at one of the five
booths. (Other sites may also have straws for snorting.) Because it
can get crowded, there is a 30-minute time limit in the injection area
and in the nearby "chill out" room.

Each month, about half of those who come receive referrals to other
health or city services.

There have been 123 overdoses through April, and most are brought back
with oxygen. The goal is to treat the overdose without reversing the
high - a result when naloxone is used - so that the user is not thrust
into immediate withdrawal and a new search for drugs. Staff
administered naloxone in fewer than a third of overdoses.

The city-run site gets heavy traffic and its presence can be felt on
the streets outside.

Discarded needles can be found in streets and alleys. At a Tim
Horton's across the street, an "out of service" sign hangs on the
bathroom door as a decoy to dissuade people who would deal or use
drugs inside. (Customers are buzzed in.)

Business owners want the disorder contained.

"I think we're at a time when the Giuliani mentality needs to come to
Toronto," Mark Garner, the head of the local business improvement
area, said, referring to the former mayor of New York. "The perception
of safety" is diminished by the facility, he said, but added that he
wanted more outreach workers and better data, not more police.

As it is, officers keep a low profile. They do not enter the site,
though undercover officers do conduct buy-and-bust operations
targeting dealers in the area.

Mayor Tory did not dispute the idea that some upheaval can be found at
the sites. But he said Commissioner O'Neill's team may have
misinterpreted what they saw in Canada.

"Far be it for me to substitute my judgment for that of your police
commissioner," Mayor Tory said. "But the same people had the same
issues before, and maybe they were a little bit out of view in
alleyways, taking drugs.

"I think if we're bringing them to a place now where professionals are
helping them to deal with their drug issues, maybe that's why they're
more in plain view."
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