Video and news report: Montreal's efforts aim to 'demystify' realities of supervised injection sites
MONTREAL — The bearded man had 20 minutes to go until the doors opened at Cactus Montreal, so, he paced up and down the sidewalk.
Cactus Montreal is one of the Canadian city's four supervised drug-injection sites.
The clinic is tucked along a side street in a busy commercial downtown, and its only indication is a nondescript LED sign fixed to the side of the brick building.
When clinic employees unlocked the facility's doors a few minutes before 4 one recent October afternoon, the man walked in.
This scene today is different compared with the years preceding the opening of Montreal's supervised injection sites, according to a number of this city's residents interviewed by The Eagle.
The local Police Department commander notes the change, too.
"We had a lot of calls for people injecting in alleys, in the entrance of a building. People were overdosing in alleys alone. No help," said Simon Durocher.
Before Montreal opened supervised injection sites, Durocher said, "We had a lot of calls for that and also calls for syringes on the pavement. Now, it's very different."
This month, an Eagle reporter and photographer visited Montreal, the closest city with legalized supervised drug-injection sites, to see what the program looks like, if it helps and how it has worked. Massachusetts lawmakers are debating the idea here, and Berkshire District Attorney Andrea Harrington has drawn attention to them. Proponents say safe-injection sites would save lives in Massachusetts.
More than 100 supervised consumption sites exist in 11 other countries, including Canada. The U.S., where about 70,000 people die each year from overdoses, has none. Staff at supervised injection sites don't provide drugs or assist drug users to inject, but provide clean equipment, consultation and they intervene to save lives in the event a drug user overdoses.
Health and safety officials in Montreal fought for nearly 15 years to open safe spaces where drug users could use intravenous drugs under the supervision of nurses and outreach workers.
In 2017, the city, in collaboration with several nonprofits, opened three fixed sites and one mobile unit that have since served clients during more than 51,000 visits.
Durocher said the facilities have cut down significantly the number of drug-related calls to the Police Department.
"I'm not telling you we don't have calls for that, but we have less because all the syringes stay in the safe-injection sites," Durocher told The Eagle during an interview in the city's mobile injection site — a bus.
Durocher joined Dr. Carole Morissette, medical adviser for the Montreal Public Health Department, and Kim Bri re-Charest, clinical coordinator for the nonprofit l'Anonyme, during the interview.
Bouncing between English and French, the officials talked about the opioid epidemic in Montreal, calling it a public health crisis that has required the response and collaboration of a broad array of agencies and the communities they serve.
In Montreal, home to nearly 2 million, four to five people a month, or an average of 56 a year, die from overdoses.
When the officials learned that Berkshire County, which has fewer than 130,000 residents, had 40 suspected fatal overdoses in 2018, that paused the conversation.
"Forty last year?" city spokesman Justin Meloche said. "That's very high for the population you have."
With the opioid epidemic killing young people across the world in droves, some cities in Canada and Europe have turned to supervised injection sites as an attempt to keep drug users from overdosing at home or on the streets.
Philadelphia is now leading the charge to open the first injection site in the United States, prompting discussions across the country about whether their regions are ready for the harm-reduction strategy.
"There is a need that is clear. We're now at thousands of overdoses a year in Canada and the numbers are higher in the United States," said Bri re-Charest. "I do think, at some point, you need to deploy the most diverse actions you can ... to be able to address it from different angles."
L'Anonyme, which translates in English to "The Anonymous," is a nonprofit that, since 1989, has served homeless and drug-addicted people in the city through the use of its mobile outreach unit. In the early 1990s, the organization, along with several other nonprofits in the city, began combating the AIDS epidemic by supplying drug users with free syringes, antibacterial wipes and other sterile tools to use during drug use.
For the past two years, l'Anonyme has been operating a new bus, this one with metal cubicles in which individuals can use intravenous drugs. During a tour, Bri re-Charest gestured to the white Christmas lights hanging in the bus. At night, traditional overhead lighting would be too harsh, she said.
Every person who uses drugs at city sites registers with the Department of Public Health, providing their name, birthdate and information about their drug-use habits.
The information is kept confidential but is collected in case the client needs emergency intervention. It also is used for data collection on public health in the city, according to Morissette, the doctor.
"If you need to have emergency attention, you'll have emergency attention," Morissette said.
From June 2017 to May 2019, the sites served 1,400 people, for a total of 51,000 visits. Of those, there were 121 emergency interventions.
Nurses provided oxygen to clients 81 times, administered naloxone — it's the overdose-reversal medication — 35 times and made 59 calls to 911, according to the city's data. Twenty-six clients required ambulance transport to an emergency room.
Outside of care involving the drug use itself, nurses commonly discuss soft-tissue infections and mental health issues with clients. Outreach workers assist clients with housing and other needs that can be at the root of drug use.
Bri re-Charest disputed the notion that injection sites encourage drug use. Outreach workers provide users with an array of harm-reduction strategies, one of them being abstinence from drugs, she said.
When clients use drugs under the supervision of l'Anonyme, they receive medical care and are educated on how to stay safe. If someone is using heroin in a dark alley, nobody is there providing that information, Bri re-Charest said.
"We never push them to use," she said.
Years in the making
Montreal cleared its biggest hurdle en route to opening supervised injection sites when it won an exemption from Canada's federal criminal code.
While it wasn't until 2014 when Montreal declared heroin use a public health emergency, the city's Department of Public Health had been lobbying the federal government to allow supervised injection sites since the early 2000s, Morissette said.
The federal government changed three times since Montreal began its efforts, and regulations surrounding the criminal code exemption changed twice.
"It was kind of discouraging, because we were not sure if we would be able to fight, but we were ready to go to court," Morissette said.
In 2016, though, Montreal was granted its exemption to the criminal code. The next step was to meet with neighborhood leaders and residents who had concerns about the new program.
"We put forward a local committee of all the stakeholders," Morissette said. "We did a lot of consultations, but mini-consultation, one-on-one, not large groups."
Together, Morissette, Durocher and representatives from participating organizations met with residents who were nervous about what supervised injection sites would mean for their neighborhoods and businesses. They also conducted more than 400 interviews with local, national and international media to thoroughly explain every aspect of the initiative.
"Never refuse an ask coming from the media," Morissette said. "We did a lot of interviews, not only reactive, but we also did proactive interviews to explain."
"To demystify," added Durocher, the police chief.
From the beginning, the Police Department wasn't expecting neighborhood crime to drop just because supervised injection sites opened, according to Durocher.
Drug users still would have to visit "their dealer on the corner," so the only change would be where they would use the drugs, he said.
Crime didn't go up, either.
"Every site was analyzed a year before for criminality, and when the site opened we set the counter to zero," he said. "We looked after three and six months, a year, two years and nothing. Nothing changed, so, we were very happy about it."
The criminal code exemption allows for possession and use of otherwise illegal drugs only in a specific area at the supervised injection sites. Nurses and staff are not allowed to handle the drugs themselves, unless they are left behind and need to be disposed of.
Police visit regularly to collect used syringes and any drugs left behind, which later are destroyed, Durocher said. Of the syringes that are distributed by l'Anonyme, 80 percent are returned and disposed of.
If there were to be an issue in the areas immediately surrounding the sites, police would make arrests, Durocher said. It never has been necessary.
"There are a lot of people in the neighborhoods who are supporting the sites," said Bri re-Charest, the l'Anonyme clinical coordinator. "I would say it wasn't as easy at the beginning, but there was a warm welcoming."
In the neighborhoods
One recent morning, several hours before Cactus Montreal opened for the day, several complimentary metal mixing cups, which are distributed by the organization to be used in lieu of spoons during heroin consumption, littered the outside of the building.
Mitch Stroll, who runs a family-owned clothing business on the main street around the corner, said that drug use and prostitution have been an issue in the commercial downtown for as long as he can remember.
Lately, though, the city and businesses have been investing in the neighborhood, and things have been improving, he said. As for Cactus, people already had been going there to use its health clinic, and Stroll hasn't noticed any changes since it added the supervised injection service.
"They really have it nicely hidden," Stroll said. "It's been very quiet."
Melissa David, an employee of a guitar store in the neighborhood, echoed Stroll's comments. While there still is petty crime, like theft, David said she sees fewer people around looking drug-sick.
"There has been a big increase in safety around here," she said.
Later in the day and about a mile north of Cactus, bakery owner Sandro Carpene was spotted kneading dough through the windows of his shop on Rue Ontario Est, a neatly kept street lined with independent cafes and bookstores.
Carpene, whose bakery is located next door to Spectre de Rue, a supervised injection site, was one of the residents who spoke out against it before the opening.
At the time, Carpene sometimes would find people using drugs in his bakery's bathroom. On occasion, people would steal. Carpene said he considered moving his bakery, fearing that those problems would only get worse with the addition of a nearby supervised injection site.
Instead, he has noticed the opposite.
"They've done a lot of work in the area to keep it safe," Carpene said while twisting ciabatta dough between his hands. "I was so worried, but it's actually better."
Problems haven't completely disappeared, though. And having the services offered in a neighborhood with so many children is less than ideal, he said.
"It's not amazing," Carpene said.
Lessons from the trenches
Morissette, the medical adviser, said that if American cities are going to begin pursuing supervised injection sites, collaboration is key.
"We had the support from not only the Police Department, but from the College of Physicians, the College of Nurses," she said. "We visited all the politicians working in Montreal, to give them all the information to see what would be the conditions to their support.
"Now, it's not as difficult to discuss this project, or defend it, as it was just 10 years ago," she said.
For l'Anonyme's Bri re-Charest, getting police officers on board with the project and making sure they understood what would happen at the site was essential.
"I believe it was really useful to visit the police stations to inform the police what were the services," she said. "I think it's important that anyone might be seeing the services around know how it's operating and why it's in place."
When asked whether Montreal's success could, in part, be attributed to the decade the city had to prepare, Morissette shook her head.
"No, no, no," she said.
From the time Montreal was granted the criminal exemption, it took a year to build the program, staff it, create policy and find funding for the supervised injection sites, she said. All four locations operated on a $3 million annual budget, she said.
"We shouldn't have to wait over 10 years to implement social services. Thousands of people are dying a year in Canada, and even more in the United States," Bri re-Charest said. "There is no reason to wait for it other than legal or administrative barriers or obstacles."
Haven Orecchio-Egresitz can be reached at firstname.lastname@example.org, @HavenEagle on Twitter and 413-770-6977.
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