Jason Mercredi saw Saskatchewan’s overdose crisis coming.
Mercredi is the executive director of Prairie Harm Reduction (PHR), a non-profit organization based in Saskatoon, Sask. previously known as AIDS Saskatoon. PHR has been working toward opening Saskatchewan’s first safe consumption site for five years.
“We knew that the opioid crisis was just going to be getting worse […] it felt like the storm’s coming to port, the tsunami’s about to hit,” Mercredi said.
The site is set to open in Saskatoon on Oct. 1, directly in the wake of a Saskatchewan Coroner’s Service report estimating that overdose deaths in the province in 2020 are already higher than any previous year.
Including deaths for which a coroner’s report has yet to be completed, 230 people in Saskatchewan died from an overdose in the first eight months of this year. That’s already 59 more deaths than the entirety of 2018, the most recent year for which complete data is available.
Alongside the overdose crisis, Saskatchewan is facing an ongoing HIV/AIDs epidemic. According to the same 2018 survey, Saskatchewan has led the country in HIV diagnoses—more than twice the national average—for over a decade.
Safe consumption sites provide substance users with the resources to consume drugs without risk of being exposed to HIV/AIDS or experiencing a fatal overdose. There, users administer the drugs themselves with clean drug use equipment provided by the site, and with trained medical staff on site to prevent deaths.
For PHR, that trained medical professional will be a primary care paramedic named Tessa Park. Someone using the site will walk in, register with a support worker, and be assigned a booth, where Park will monitor them as they take their supply of drugs.
PHR’s site is equipped to allow visitors to snort, eat, inject, or smoke drugs. Other sites, referred to as safe injection sites rather than safe consumption sites, have fewer options for consumption.
PHR’s services extend beyond just safe drug consumption. Substance use has an established relationship to other struggles such as lack of housing and untreated mental illness. In a 2018 study of Saskatoon’s homeless population, substance use or addiction was the leading cause in housing loss for adults.
According to Mercredi, when visitors are done in the booth, they will exit into a drop-in centre where PHR has set up support services ranging from transportation and housing to crisis management.
Mercredi noted that users of safe consumption sites often feel alienated from the healthcare system, and the site can be a point of entry into accessing care.
Last year, PHR applied for $1.3 million in funding from the Saskatchewan government for their safe consumption site. In the 2020-21 budget, they received just $130,000 for the salaries of two support workers who will serve visitors in the drop-in centre.
The $1.3 million PHR sought was for the salary of enough paramedics and support workers for the site to stay open 24 hours a day, 365 days a year.
With the reduced budget, the site will be open 10 a.m. to 4 p.m., Monday to Friday, and the $60,000 necessary to pay Park, the onsite paramedic who will work alongside the government-funded support workers, is being financed through crowdfunding.
Mercredi said they were determined to proceed with or without full financial support from the government.
“We can’t [let] the government dictate community needs.”
In an email statement to The Pigeon, a staff member from Saskatchewan’s Ministry of Health highlighted the $630,000 increase in harm reduction funding in their 2020-2021 budget. $130,000 of that increase went to Prairie Harm Reduction, and the remaining $500,000 will reportedly go toward take-home naloxone kits and safer inhalation supplies, needle exchange programs, and “other harm reduction services across the province.”
Overall, the Ministry of Health increased their mental health and addictions service funding by $33 million—to a total of $435 million—in the past year. They stated that the bulk of the funding will be “used to increase access to mental health and addictions treatment beds and supports and to provide intensive children and youth supports.”
So far, they have invested $1.4 million in reopening an addictions treatment centre in Estevan which will focus on detox and treatment for crystal meth, as well as 28 more beds for detox patients across the whole province. Currently, provincial funding in Saskatchewan remains more invested in recovery than harm reduction.
In an interview with The Pigeon, Guy Felicella, a former substance user who overdosed six times before going into detox, said harm reduction needs to be as much of a priority as recovery.
“You can’t just put all your eggs in one basket with recovery and expect people to make it there. People don’t recover when they’re gone,” he said.
Felicella, who now works as a harm reduction educator and advocate in B.C., believes that a “full spectrum of care and health,” including harm reduction techniques like safe consumption sites, will be vital in dealing with the overdose crisis.
When Insite, Canada’s first safe consumption site, opened in Vancouver, B.C. in 2003, Felicella had been a drug user in the city for ten years.
He recalls living through the public health crisis of the 1990s in the Downtown Eastside, dealing with the high risk of contracting HIV and overdosing. In 1997, injection drug users in the Downtown Eastside neighbourhood were contracting HIV/AIDS at an estimated rate of 20 per cent per year.
Intravenous drug use raises the risk of contracting HIV/AIDS through the possibility of sharing needles with someone who has HIV/AIDS.
In 2017, 67 per cent of people who were newly diagnosed with HIV in Saskatchewan reported injection drug use, compared to 28 per cent of the infections that year being related to sexual contact.
Into the early 2000s, Felicella said “There was a huge public outcry for drug users to have a safe injection site,” as it would address both the high rates of overdose and HIV/AIDS in the neighbourhood.
In 2002, Larry Campbell, a former Royal Canadian Mounted Police officer, was elected Vancouver mayor, and promised to open a safe injection site. However, a police crackdown on drug users hit Vancouver’s Downtown Eastside before Campbell’s promise could be fulfilled.
In response, local activists and injection drug users protested by opening an unapproved safe injection site which operated for 184 days.
While police, drug users, activists, and multiple levels of government continued to clash over the issue, a Vancouver non-governmental organization called the Portland Hotel Society began building the first safe injection site in North America. Once they announced Insite had been built, government support began trickling in, first from the regional health authority and finally from the federal health ministry.
The federal government granted approval under an exemption within the Controlled Drugs and Substances Act (CDSA) to allow the sites to host consumption of illegal substances, and the site opened with $3 million dollars of annual funding from the B.C. government in 2003.
Russell Maynard, who works in community engagement for the Portland Hotel Society, reflects that Insite was ahead of its time, both in its approach to drug use, homelessness, and the intersections of those issues.
Just a few decades ago, Maynard recalls the common-sense approach to homelessness being less accessible.
Maynard describes the past attitude toward homelessness as being, “We can’t house someone who’s chaotic or living on the streets with obvious mental health and addiction issues. You have to somewhat manage those issues, and then those people are houseable.”
“We often talk now […] about an approach to homelessness called housing first,” he said.
The housing first model advocates for the opposite, based on the idea that once someone has the stability of being housed, they can better overcome their mental health issues and addictions.
The Portland Hotel Society had been working on homelessness with this model since the early 1990s, and opening a safe injection site was an opportunity to approach the addiction crisis in a similar way: by reducing the risks of drug use first, then working toward recovery.
Since its opening, Insite has been the subject of dozens of studies to determine the effectiveness of safe injection sites as a response to HIV/AIDS, overdoses, and the public cost of addiction.
These evaluations have found Insite to be not only effective in reducing overdoses and transmission of disease, but also cost-effective and successful in transferring users to detox and addiction treatment programs.
A 2017 study from The College of Family Physicians of Canada found that Insite led to 88 fewer overdose deaths per 100 000 persons in one year in Vancouver—a decrease of roughly 35 per cent—as well as 67 per cent fewer ambulance calls for treating overdoses, and a decrease in HIV infections.
The difference between more widely-funded needle exchange programs and a safe injection site is that while both help reduce the risk of HIV/AIDS by providing sterile drug supplies, safe injection sites also provide controlled areas staffed by health professionals who can directly prevent users from dying of an overdose.
Felicella said almost all his overdoses occurred at a safe injection site, and credits Insite with saving his life.
“My last overdose was the longest. Sarah Gill was the nurse that revived me, she said I was gone for almost eight to ten minutes,” he recalled. “When I did come to, I remember she was crying.”
“I pulled the tube out of my throat and said, ‘Why are you crying?’ and she said, ‘Well, I care about you,’ and then I started crying.”
Amidst rising overdose numbers across the country, Felicella wants more substance users to have access to the care he found at Insite and its attached detox centre, Onsite.
“These are preventable deaths,” he said.
With such high provincial rates of overdose and intravenously contracted disease, why has it taken this long for Saskatchewan to open a safe consumption site?
Marie Agioritis of advocacy group Moms Stop the Harm said support for safe consumption sites is “an unpopular political message to deliver depending on the policies of the party that’s running things at any given time.”
Saskatchewan’s western neighbour, Alberta, currently has seven active safe consumption sites. In 2019, when United Conservative Party leader Jason Kenney became the province’s Premier, one of his first actions was to freeze funding to any new safe consumption sites in development. He also pulled government funding from Lethbridge’s only safe injection site after performing a financial audit.
The site closed in August, downsizing to a mobile van due to lack of funds.
Kenney said the funding freeze was in response to “a massive increase in crime” related to the safe consumption sites, as well as “harassment of people who can no longer live safely in their own community.”
Mercredi is frustrated with the prevailing idea that safe consumption sites increase crime and promote drug use.
“We’re trying to deal with the actual issues that are happening in the community on a structural, systematic level,” he said.
Mercredi wants more people to reassess who they’re blaming for the disruption in their neighbourhood.
“The NIMBY-ism attitude makes it so that you actually don’t have to deal with the […] issue, you just push it further down the road.”
NIMBY, an acronym for “not in my backyard,” is a popular term in the discourse around harm reduction. In this case, Mercredi is wary of those who complain about people in their neighbourhood who are visibly experiencing homelessness and other personal crises.
He thinks that people tend to blame those who are suffering rather than those with the power to end homelessness or help substance users.
“If you’ve got an issue with homeless people, then lobby your government to […] provide them the support so that they can be successfully rehoused.”
Kenney’s review of Alberta’s existing safe injection sites found them to be contributing to higher rates of crime and social disorder. However, the document was criticized by public health experts as being more political than factual in its methodology and findings.
Insite’s existence was similarly threatened in 2006, when Canada’s federal government moved from Liberal to Conservative leadership after the 2006 election and the new prime minister, Stephen Harper, selected Tony Clement as the federal minister of health.
Clement repeatedly limited the length of Insite’s criminal exemption, and was quoted saying the government’s drug strategy was going in a different direction.
“We believe the best form of harm reduction is to help addicts to break the cycle of dependency,” he explained at the time.
Earlier this year, in a tweet, Kenney called safe injection sites “NDP drug sites.”
The researcher behind the study Kenney shared in his tweet, Em Pijl, spoke out, saying that the increase in crime and discarded needles isn’t necessarily directly related to the consumption site, as the drug crisis and poverty levels have climbed independently. Pijl stated that potential negatives to the sites shouldn’t be considered without the well-researched positives.
When The Pigeon asked Vicki Mowat, the opposition’s Health Critic for the Saskatchewan NDP, whether her party supports the opening of the safe consumption site in a phone interview, she said yes.
“There has been wide consultation with community,” she said. “I know there’s quite a bit of support for the safe consumption site in Saskatoon and we were quite disappointed to see the government’s decision not to grant the funds that the site had requested for this budget year.”
In 2007, the Portland Hotel Society began a legal battle against the Attorney General of Canada and then-Health Minister Clement that ended in the Supreme Court.
In 2011, the court unanimously ruled that attempts by the federal health minister to close Insite violated the Charter of Rights and Freedoms, by “threatening the safety and lives of the people who need to use it.” They ordered the minister to grant an exemption to Insite.
Then, in 2018, when current premier of Saskatchewan Scott Moe was interviewed as a candidate in the conservative Saskatchewan Party leadership race, the Leader Post asked him if he was supportive of safe injection sites. His answer was no.
“The province will continue to provide current services for people who are suffering with substance abuse,” he said.
Margaret Kîsikâw Piyêsîs, CEO of the All Nations Hope Network (ANHN) and the Canadian Aboriginal AIDS Network (CAAN), sees the Saskatchewan government’s refusal to fully fund PHR’s new site as “another example of our government and how they are being […] racist and ignorant and providing stigma and discrimination against people who are actively using.”
“They know research has proven that safe consumption sites save lives, and save money, if they want to talk about money,” she said.
Piyêsîs has worked for the ANHN in Saskatchewan for over two decades and recently stepped into a position with CAAN, which has moved its base to Fort Qu’Appelle, Sask. Both organizations provide support and services to First Nations, Mètis, and Inuit families impacted by HIV/AIDS and Hepatitis C.
The overdose crisis and the ongoing HIV/AIDS epidemic in Saskatchewan disproportionately affects Indigenous populations.
According to the most recent census, Indigenous people make up 16.3 per cent of Saskatchewan’s population. The Saskatchewan Coroners Service, however, reported 66 per cent of the confirmed overdose deaths this year to be Indigenous people, and in 2016, they made up 79 per cent of the province’s new HIV cases.
Several of the experts and advocates The Pigeon spoke to for this piece cited Indigenous racism as a central cause for the Saskatchewan government’s lack of action on the overdose and HIV/AIDS crises.
The term intergenerational trauma has entered the public discourse as a way to sum up the effect historical abuse and genocide by the Canadian government still has on present-day Indigenous communities.
The present Indigenous health and addictions crisis is worsened by the lasting effects of the Canadian government’s anti-Indigenous cultural genocide. Organizations like ANHN don’t just provide Naloxone kits and disease testing; they provide meals, traditional medicines, ceremony, and programs that address trauma in their communities, and reconnect Indigenous people to their culture and spiritual heritage.
Piyêsîs said that for the 21 years they’ve been running, they’ve received only $37,000 dollars each year from the provincial government. A 2008 study out of Alberta found that the average treatment cost of a single HIV positive patient was $13,908 per year.
“As Indigenous people at All Nations Hope Network, we’re saying that we have the solutions, [but] we need the government to support us,” she said.
PHR was the 2019 recipient of the Canadian Aboriginal AIDS Network Holistic Wellness Promotion/Harm Reduction Award. The organization has prioritized Indigenous methods of care in its framework.
“For us, it starts at hiring,” said Mercredi, meaning they make sure that PHR’s recruitment, hiring, and employee retention strategy specifically supports Indigenous workers.
“When you have Indigenous employees and Indigenous board members and Indigenous managers, then you’re better able to implement Indigenous programming.”
In 2018 both PHR and the All Nations Hope Network were denied renewal of funding from the federal government as the Public Health Agency shifted from a focus on peer support and care to prevention.
Substance abuse is a symptom of larger systemic issues in a community, and signals an inability or refusal to effectively support vulnerable populations. Mercredi is critical of those who place the blame on the individual.
“Don’t sh—t on the person who […] got washed out of the foster care system at 18, and now has a substance abuse issue because they never got the mental health supports they needed to deal with the years of abuse they experienced,” he said.
“It doesn’t make any sense to me that instead of going after the folks who can do something, who are in power, you have this attitude to say, ‘Yeah, it’s on the homeless person. They just need to tighten up their bootstraps and work harder.’”
“We’re not coming close to scratching the surface of addressing [their] needs, let alone asking them what they want. Instead we always have this paternalistic, colonial approach to tell people what they need.”
She said every person she met in CAMH was desperate to leave, “despite some of them having nowhere to go other than the streets. There was very little, if any, dignity, respect or genuine compassion found inside those walls. How is that healing?”
Elliott also noted there wasn’t a 12-step program being run within the facility and they initially refused to give her an Indigenous psychiatrist. She called for a system that respects the agency of those struggling and concluded by stating “the best funded facility in Canada to help me with my addiction and mental health actually made my health worse.”
An essential aspect of safe consumption sites is that entering the site grants employees and drug users immunity from criminal prosecution for possession of illegal substances under the CDSA. Outside of sites with this CDSA exemption, if a health official comes in contact with someone who is in possession of illegal substances, they are obligated to report them.
These lines are getting blurry. In March 2020, Calgary police announced that an undercover officer was able to obtain illegal drugs on the grounds of the city’s safe consumption site, but they didn’t clarify whether it was from a worker or a visitor.
That incident was used in the Kenney government’s report, and was inaccurately phrased as connected to what police confirmed was a separate incident.
A central pillar of harm reduction as an approach to substance abuse treatment is the acceptance that drug use exists, and that quitting drugs entirely shouldn’t be a requirement for receiving care from the health system and community.
Sandra Ka Hon Chu is the director of research and advocacy for the Canadian HIV/AIDS Legal Network. From the perspective of a human rights lawyer, she sees the decriminalization of drugs as essential to harm reduction.
“We need to stop criminalizing people for drug use,” she said in a phone interview. “It’s another manifestation of stigma and if you truly believe you want to assist people who are using in a way that is affecting their health and safety, then you don’t throw them in jail.”
In 2018, Prime Minister Justin Trudeau legalized marijuana. That same year, Trudeau’s government signed a UN document endorsing US President Donald Trump’s renewal of the war on drugs.
In mid-August of this year, the Public Prosecution Service of Canada altered their guidelines for prosecution of simple possession offences. According to the new guidelines, if the possession “relates to a substance use disorder” the judge should “pursue” alternatives to traditional prosecution such as drug treatment programs.
They specify that these alternatives include “Indigenous culture-based programming.”
Despite this legal shift towards harm reduction over incarceration, on Sept. 2, Prime Minister Justin Trudeau said decriminalization of the possession of hard drugs isn’t a priority in the federal government’s approach to the overdose crisis.
Trudeau’s statement comes after calls from health officials across Canada to decriminalize possession in the face of the rising overdose crisis, months of protests advocating for diverting funds from policing to social and health services, as well as public statements from organizations like the Canadian Association of Police Chiefs in favour of decriminalization.
Presently, only nine of 43 federal Canadian prisons have safe needle programs. Without access to clean needles, drug users who enter the prison system are contracting infectious diseases such as HIV and Hep C.
When asked what the greatest barrier is to bringing effective harm reduction services to prisons, Chu cited systemic racism.
“I think that has a lot to do with racism—anti-Indigenous racism—and a neglect of Indigenous health. We’ve seen that, historically, in so many ways.”
Chu, who has advocated for clean needles in prisons, said being incarcerated in Canada can mean giving up your right to be well.
“It’s this notion that people in prison, who are disproportionately Indigenous and racialized, are less deserving of healthcare,” she said.
In the past twelve years, the Indigenous population in prisons increased by 43.3 per cent. Between 2017 and 2018, 39.9 per cent of all women in Canadian prisons were Indigenous, and 27.2 per cent of men. However only 4.9 per cent of the population in Canada is Indigenous.
Black Canadians are similarly overrepresented in Canadian prisons, with Black people making up 7.3 per cent of Canada’s incarcerated population between 2017 and 2018, while being only 3.5 per cent of the total population in 2016. Both Black and Indigenous prisoners are also more likely to be incarcerated in higher security prisons in Canada.
With the existing correlation between drug use, criminalization, and mistreatment in the prison system for Black and Indigenous people in Canada, advocates say a harm reduction approach could stop the prison pipeline at its origin.
In the same interview in which he shied away from supporting decriminalization, Prime Minister Trudeau responded to the criticism that he isn’t listening to health officials’ call for decriminalization. He argued that he has been listening by supporting the opening of temporary safe consumption sites that allow for better social distancing and safe supply.
Safe supply is a harm reduction strategy even newer and more controversial than safe consumption sites. Safe supply sites like the one the federal government is funding in Toronto will provide opioid-reliant people with pharmaceutical-grade opioids such as Hydromorphone.
Advocates for safe supply initiatives say too much depends on political—not medical—priorities. Agioritis was brought into harm reduction advocacy after she lost her son, Kelly Best, to a fentanyl overdose in 2015. She said, in her experience, these issues come down to “political will” and the underinformed public.
She has observed that because much of the general public does not understand harm reduction and believes drug use should be treated as a criminal justice issue, most politicians act and vote in the interest of that perception.
Best died because the pill he took was unevenly laced with fentanyl. Best’s unexpected death led Agioritis to her work with Moms Stop the Harm: “A switch went off for me, I thought, this is insane,” she said.
Felicella said Fentanyl hitting the streets of Vancouver immediately increased the number of overdoses. Substance users thought they were still taking a drug familiar to them, such as heroin, but suddenly found it to be laced with Fentanyl.
Fentanyl is considered to be more dangerous than previous opioids because it is odourless and tasteless, making it easy to mix into heroin or cocaine, and it is 20 to 40 times more potent than heroin.
Safe supply programs directly address the concern that the current opioid overdose crisis is a “drug poisoning crisis” caused by contamination of illicit drug supplies.
On the subject of safe supply, Dr. Peter Butt, a professor of medicine at the University of Saskatchewan, a consultant in Addiction Medicine in the Saskatchewan Health Authority, and a member of Saskatchewan’s opioid and methamphetamine task forces, said there is no singular path forward.
“I think it’s important to keep in mind that when substance use is out of control […] people will use what’s available sometimes to the point that they overdose, even if it is a so-called safer supply,” he said.
“There is going to be a certain mortality rate attached to [safe supply], will it be less than that related to illicit fentanyl? Probably, so it is an intervention that would have some success.”
Still, Butt does not see it as any kind of simple solution.
In the face of this crisis, experts in fields from health to justice agree that combatting the overdose crisis will require a myriad of approaches with unprecedented government funding, as well as significant shift in the way drug users are treated in Canadian society.
As Canada faced the additional crisis of COVID-19, existing harm reduction services had to be put on hold and substance users were further isolated from healthcare services. During the early months of the pandemic, many treatment and harm reduction services across the country were forced to reduce their services or close altogether.
The impact of these closures is clear in Alberta, which currently has six safe consumption sites, and was seeing a 24 per cent decline in Fentanyl overdoses related to the increase in harm reduction services before the pandemic hit.
This week, the Alberta government released a report on opioid-related overdoses which noted that beginning in March of 2020, opioid overdoses began to rise, and directly attributed the rise to “a decrease in the utilization of treatment and harm reduction services.”
The same report clearly outlined that COVID-19 reduced the number of visits to safe consumption sites in the province. From January to March, there were 114,430 visits to Alberta’s safe consumption sites. From April to June 2020 there were only 40,755 visits to those same sites.
Despite B.C. having seven safe consumption sites currently active, when the provincial coroner’s service released a report on illicit drug overdoses earlier this week, the numbers mirrored the Saskatchewan Coroner’s Service report released last month. Like Saskatchewan, B.C. had more fatal overdoses in the first eight months of 2020 than the whole of 2019.
Both Prime Minister Trudeau and former substance user Felicella agree that the most recent uptick in overdoses is due in part to increased isolation of individuals related to the COVID-19 pandemic. However, even in a year without a global pandemic, illegal substance users are forced to live on the outskirts of society, to the detriment of themselves and those who care about them.
Harm reduction workers like Piyêsîs and Mercredi are far from giving up. They firmly count themselves among those who care about substance users, and they do so unconditionally.
“Our Indigenous teachings tell us no one is thrown away,” Piyêsîs said. “If they choose for the rest of their life to use drugs or alcohol, then that’s their choice [and] we don’t judge them. We acknowledge them and their spirit and help them as much as possible with their day to day struggles of being homeless, living in poverty, and actively using.”