Source: Toronto Sun (Canada) Contact: Website: http://www.canoe.ca/TorontoSun/ Pubdate: May 31, 1998 Author: Jean Sonmor -- Toronto Sun CRACK USERS MINE A WHOLE NEW VEIN "Once I found out about needles I wouldn't smoke anymore. You're in seventh heaven. It's a different high -- stronger and it lasts longer." There's a glint of pleasure in Ted's grey-green eyes when he talks about injecting crack, and a slow smile spreads over his weathered face. Even though the habit he abandoned nine months ago drove him on to the street and made him do things and keep company with people he can scarcely talk about, the memory of the awesome pleasure remains -- and makes him smile. And that's the problem. Crack, which users claim is the most addictive and most debilitating of all illegal drugs, has moved into another, more dangerous space. For the last year or so at The Works, the needle exchange at Dundas and Victoria Sts., counsellor Leah Boelhouwer has been seeing vein abscesses and other grim evidence that a new, more dangerous method of getting high is gaining ground. Shooting crack is an instant high. Touch your finger to the spot of blood the injection draws and then touch it to your tongue, a two-second process, and you're there, in seventh heaven, blissing out, indifferent to pain, trouble, the future, the past, even the present. And for many street people without much else going on in their lives, it's way too seductive to resist. At least at first. But, as Ted found, once you start injecting it doesn't take long for the health problems to catch up with you. VINEGAR IN HIS VEINS One of the big problems is the liquid used to dilute the crack. Vinegar was Ted's choice. He'd take a $20 rock of crack, crush it with the end of his syringe and then heat it in a spoon with a bit of vinegar. One of the vinegar pouches from Harvey's would be enough for four or five syringes if friends are sharing. (One Ottawa researcher believes HIV can be spread through sharing the liquid and the spoon, but Ted never worried about that.) He didn't like to see the occasional fizzing in the spoon. That meant too much cut, too much baking soda. Some users dilute with lemon juice but for Ted that wasn't an option. The high wasn't as good. "I never used anything but vinegar," he says with a certain macabre pride. He knows vinegar in the veins is a nasty business. He's had the abcesses, and seen the veins in his hands blacken after an injection. And now that he's volunteering a bit at The Works, he knows the staff are worried enough about it to have bought a big supply of ascorbic acid to offer as an alternative for those addicts now using vinegar. "Besides the vinegar there are so many chemicals in crack," says Boelhouwer. "It's very, very hard on the veins. For us this a hot issue right now -- and that's without even mentioning the health issues with needles." * * * But in other Canadian cities those "health issues with needles" are causing concern bordering on panic. In Vancouver, in a recent study, the rate of new HIV infection among injection drug users is the highest in the world, says Nate Hendley of Addiction Research Foundation. "Injection drug use is now driving the train of infection," says Michael O'Shaughnessy of the B.C. Centre for Excellence in HIV/AIDS. "We went from a prevalence rate of 5% in '94 to 40% in '97." The 1,300 injection junkies they followed in their study may be more high-risk users than the average among the 10,000 injection drug users in the city, but nobody knows for sure. At any rate the explosive numbers in the study got the folks in B.C. into a tizzy and there now seems to be political will to try to stop the spread of HIV in the drug culture. "This phenomenon has been seen before in other cities," says Martin Schecter, the lead investigator in the Vancouver study. "The virus can stay a low level for a while, creep up slowly and then explode." In Vancouver and cities such as New York and Edinburgh, the point at which the momentum suddenly explodes has arrived when about 10% of the drug users become HIV positive. While "there is nothing magic about 10%," says Toronto researcher Dr. Peggy Millson, that does seem to be the spot of critical risk on the graph. While not all of the data from Millson's most recent study has been analysed, the research suggests that 9.5% of Toronto injection drug users are already infected with HIV/AIDS. In Ottawa, the situation is already "unstable" says University of Toronto epidemiologist Rob Remis. "It's the highest anywhere in Ontario." Lynne Leonard, the social science researcher who conducted the Ottawa-Carleton study, points out a number of worrying highlights: * The prevalence rate nearly doubled from 10% to 19.2% between '93 and '97. * The age at which the user got infected was younger. * All of this happened despite a very active needle exchange with no caps on the number of needles, unlike Vancouver and Montreal. * In Ottawa there is no concentration of low-rent flophouse hotels as there is in Vancouver's downtown east side. The numbers in Montreal are very similar to Ottawa's -- 18% to 20% of the injection drug users are HIV positive. * * * So why is the number so much lower in Toronto? And more importantly, how can we keep it low? Part of the reason seems to lie in the difference between the drug culture here and elsewhere in the country. But it's a difference, as Ted's story shows us, that could be changing. In Toronto -- alone among the major Canadian cities -- the drug of choice for injection is heroin, not cocaine. Although Millson's work showed 70% of those attending the needle exchange and followed had injected coke in the past six months, only 34% listed it as the drug of choice. Injecting crack is so new the question wasn't even asked. In Vancouver the drug of choice for 80% of the people surveyed was cocaine. In Ottawa cocaine was preferred by 82% and in Montreal 70%. MARKET MANIPULATION In Vancouver, experts believe the trigger that touched off the HIV epidemic among injection drug users was the switch in preference to cocaine from heroin. Why that happened is a complex question, but Shechter believes market manipulation by drug dealers had something to do with it. If pure cocaine were suddenly available in Toronto at a very reasonable price, the drug of choice might quickly change here too -- with similarly devastating consequences. The most vulnerable people on the drug chain are those like Ted who, through illness or poverty, have come to rely on crack as a reality assist. As Toronto's associate medical officer of health, Richard Gould says: "We have a fair amount of crack use here ... A lot of the people who get more heavily dependent don't have a lot to lose. For those people feeling good with crack is a rational choice." * * * Ted's story begins -- as many injection drug users do -- with medical problems. He broke his neck and his back in three places in a fall at a horse farm. At the time he was a 49-year-old workaholic who managed a farm for one of the country's wealthiest race horse operations. Drugs were the farthest thing from his mind except when one of his grooms messed up. In fact, in an irony that now makes him laugh, he was one of the few tough bosses who banned drugs from the shedrow. The successful spot Ted was sitting in at 49 had been a tough climb for a little boy who had been given up by his mother at seven and raised (and abused) by the Christian Brothers at St. John's Training School. At 12 he started to work and after an adolescence full of beatings and abuse, he began to make his mark at the track. "I was a workaholic and celibate because of all the things that had happened to me," he says. His work and his success were his greatest interest and his proudest accomplishment. But that ended in '92 with his fall from the hay mow. "I was finished and I knew it," he says. Throughout the recuperation period he was using barbituates to cope with the physical pain. He was also avoiding the track in order to deal with the mental anguish of losing his foothold in life. In '94, living alone in Parkdale, he attempted suicide. For his family and especially his nephew, this was a wake-up call. "My nephew saved my life and helped me in a major way. My life was just shutting down." But it was also through his nephew that he started using drugs. He had his first toke of crack at Christmas '94 and it was "as if a new world had opened up. No more pain. No more depression. I even called my boss at 4 a.m. and said I was coming into work." * * * For Ted, the toking and the occasional moderate use led, within a month, to the "unbelievable buzz" of injection. This is far from the usual progression, but Ted was using under the careful supervision of his nephew, an experienced junkie. In early '95 shooting crack was a novel practice in Toronto. The anecdotal evidence from the street is that it's still not widespread, but it's becoming attractive to street-level users because it allows a cheaper, longer and more intense high. It also, of course, has a very significant downside. Injecting either cocaine or crack promotes recklessness. A heroin addict uses a couple of needles a day. If you're injecting cocaine or crack, you might need 30, even 40 needles in a run. "It impairs judgment way more than heroin," explains O'Shaughnessy. "When they're injecting coke they may start with their own needles, but as they go on they might not even be aware they're sharing. "Are they going to walk to the needle exchange in the middle of a coke run to get the needles they need?"Schecter asks. "Highly unlikely. Through our misguided public policy we set the table for the epidemic in Vancouver." He urges other cities that have yet to experience the huge jump in infection rates to take the Vancouver experience to heart. He believes some of the factors that caused "the massive increase in infection" are cuts to social housing so the addicts ended up concentrated in the downtown east side in residential hotels that charged a monthly rate as well as $10 for every re-entry at night. (The policy allows the hotels to make money from the prostitution trade.) What happened was the junkies couldn't afford to go out for clean needles, and the hotels became huge "shooting galleries." Then the Vancouver needle exchange put a cap on the number of needles each user could exchange. Those public policies "created a powder keg," Schechter says. It's a powder keg we don't want to recreate in Toronto where there are an estimated 13,000 injection drug users (3,000 more than Vancouver), Associate MOH Gould says. "We could see it here too. There is a fair amount of crack in Toronto -- if they switch to injectible, then you greatly increase the risk of HIV." He also points out that the most vulnerable members of society, such as injection drug users, are the most likely to end up on the street as a result of recent government policy changes including the elimination of rent controls. LIVED IN BUS SHELTER (Those changes affected Ted and his nephew very quickly. They were evicted and lived with their dog in an unused bus shelter at Bay and Gerrard for 21/2 months in the winter of '96-97. At that point Ted stopped injecting for a while. "It's hard to get your veins up when you're cold," he says.) "Recent cutbacks may put us closer to the Vancouver situation," says Millson. "It's impossible to expect safe injection when they have no clean water, no place to keep clean needles. Even if they're trying, it's incredibly difficult." But even with political will to stave off the epidemic, there are those such as medical epidemiologist Remis who say the information on Toronto is falsely reassuring. We don't know what the rate of spread is here, he says. "This is already a huge problem in Ottawa and we don't really know what the situation is in Toronto." - --- Checked-by: Richard Lake