Insite in Vancouver: North America’s First Supervised Injection Site (2024)

Introduction

In 2003, the first legal supervised safe injection site in North America (‘Insite’) opened in Vancouver—the epicenter of the injection drug epidemic in Canada. The creation of Insite was the culmination of an extraordinary political struggle initiated by an activist movement of drug users, pioneering local elected leadership, and a delicate multi-level governance negotiation with legal, health, and public safety dimensions. Insite has been an unqualified success in its core objective: saving lives through a harm reduction model by treating drug use as a health, rather than criminal, issue. There are broader issues that intersect with drug addiction in Vancouver—such as poverty, homelessness, and mental health—that fall well outside the scope of a safe injection site to solve, and thus remain a significant policy problem. But on the specific task for which Insite was designed, it is a clear success. Insite, and the subsequent additional sites created in Vancouver, enjoy enormously high public support in the city, the province and most parts of the country, representing a robust policy success that has survived several government turnovers at all three levels of government. This firmly institutionalized policy model has also since diffused to other cities in Canada, further demonstrating its popularity among policy-makers.

A Policy Success

This chapter describes how a diverse group of people in Vancouver—activists, service providers, health professionals, policy advisors, and local elected officials—mobilized a challenge to the prevailing paradigm that viewed drug addiction as a criminal activity and offered an alternative response to the health crisis drug addiction produced. It describes how, in various public venues and behind the scenes, this coalition was able to persuade policy-makers that a harm reduction strategy would be effective in treating drug addiction.1 The chapter also appraises the extent to which the harm reduction coalition remains influential as new problems emerge.

The success of Insite is assessed by deploying the PPPE frameworks of McConnell (2010) as well as Compton and ‘t Hart (2019), which include programmatic, process, and political dimensions. In other words, an unambiguous policy success will generate measurable social value (programmatic dimension), from a set of policy-making practices that are appropriately inclusive and effective (process dimension) and enjoy broad and sustainable political support (political dimension). The PPPE framework is not binary with respect to success-failure, but rather conceptualizes tiers of success in relation to these dimensions to help understand the ‘bundles of complex outcomes’ and identify patterns in this realm. Insite is best described as a ‘durable success’ (McConnell, 2010), in that it generally achieves what it was set to do (though perhaps not perfectly), remains resilient to challenge from opponents, and any controversy around it is manageable by policy-makers. It has a demonstrated record of saving thousands of lives among vulnerable populations, for whom political attention and public empathy have traditionally been scarce. Insite was both the product of a concerted challenge to the dominant paradigm of drug policy in Vancouver, as well as the cause of a larger revolution in drug policy and treatment in Canada that now enjoys broad scientific and political legitimacy.

Marginalization and Risk in Vancouver’s Downtown Eastside

North America’s first safe injection site in Vancouver emerged out of a particular social, political, and institutional context characterized by urgency, activism, and collaboration. The Downtown Eastside (DTES) in Vancouver became what it is today through a series of economic, social, city planning, and societal changes that channelled marginalized folks into the neighbourhood. Once one of many areas in the city in which low-income residents could find affordable housing, aggressive gentrification elsewhere in Vancouver made the DTES virtually the only remaining central area not transformed to middle class aesthetic and behavioural norms. Low-income and other support services to assist marginalized populations were then disproportionately located in the DTES in response to this trend. Insufficient community support associated with the mental health deinstitutionalization movement resulted in the migration of people who were not welcome elsewhere and vulnerable to self-medication with illicit drugs.

The economic and social anxieties in the area in the late 1980s, combined with the newly inexpensive but highly addictive heroin being trafficked into the city, contributed to a neighbourhood consumed by drug use (Campbell et al., 2009). In 2012, Andresen and Jozaghi (2012) estimated about 5,000 persons who inject drugs (PWID) in the DTES, but the figure could be as high as 9,000. Widespread injection drug use and needle sharing among marginalized persons contributed to a rapid rise of HIV and Hepatitis C infections, which became among the highest in the Western world. In 1997, health researchers in Vancouver estimated that 25 per cent of PWID acquired HIV and nearly 90 per cent were infected with Hepatitis C (Campbell et al., 2009). Increasing drug potency and mixing contributed to a new problem of ‘multiple drug toxicity’ that resulted in an explosion of fatal overdoses among PWID in the mid 1990s (Boyd, 2013).

The problems associated with needle sharing and drug overdoses were the key issues that a safe injection site, as part of a harm reduction policy, was seeking to tackle. The goal was to save lives of PWID, who, until the 1990s, were generally a group that earned limited sympathy from most citizens. However, since then, the profile of drug users had evolved, and the problem had begun to touch families of diverse socioeconomics and histories. To recognize the programmatic success of Insite, it is important to understand how a safe injection site typically works. They are facilities staffed by medical professionals, usually nurses, who provide clean materials and space for drug users—who bring their own supply—to inject under supervision. Clean materials are a critical intervention to reduce the spread of HIV and Hepatitis C, and supervision by medical professionals is critical to reverse overdoses.

Insite and the broader drug use patterns in and around Vancouver’s DTES have been subject to considerable academic study, and the results of the intervention are unambiguous: HIV and Hepatitis C acquisition rates have declined (Andresen and Boyd, 2010), needle sharing has dropped among users outside of the facility (Boyd, 2013), Insite clients are more likely to initiate and maintain addiction treatment (DeBeck et al., 2011), not a single supervised overdose has resulted in death at the facility (Vancouver Coastal Health n.d.), and, prior to the arrival of fentanyl, the fatal overdose rate in the region had significantly declined (Marshall et al., 2011). Other studies have found additional benefits, such as lower public injection drug use (Boyd, 2013), positive benefit-cost ratios ranging from $3–25 million annually2 (Bayoumi and Zaric, 2008; Des Jarlais et al., 2008; Andresen and Boyd, 2010), and no evidence that this intervention ‘encourages’ drug use, (Andresen and Jozaghi, 2012) increases drug trafficking or crime (Wood et al., 2006).

The data from Insite are clear: it works for what it is designed to address. The fact that drug use, crime, and poverty are still prevalent in the DTES is not a failure of Insite. Safe injection sites (SIS) are not a solution to poverty, homelessness, and mental health crises. These are all critical issues that intersect with drug addiction, yet they are clearly broad and daunting policy challenges beyond the mandate of SIS. As such, Insite sought to address one element: reducing the harm associated with drug use.

How Safe Injection Sites Emerged

Activists and advocates in the DTES were drawing attention to this crisis throughout the 1980s, and directly challenging the dominant paradigm through which policy-makers viewed drug use. The so-called War on Drugs paradigm held that drug use in society could be curbed by the enforcement and incarceration of suppliers and users of drugs. However, there is limited evidence of its success in discouraging drug use, and considerable evidence of its unfairness and stigmatizing effects (Baum, 1996). Activists rallying against the War on Drugs paradigm had both allies and opponents among health professions and public authorities, but they sought out collaborative opportunities to marshal evidence of the emerging crisis, which they used to advance new approaches to deal with the presence of drugs in society (Lupick, 2019). Such ‘epistemic communities’ are found in all policy domains, and they mobilize knowledge to define problems and craft solutions (Muhkerjee and Howlett, 2015). The harm reduction paradigm accepts drug use as part of our world, and suggests that policy-makers should prioritize policies that reduce its harms through non-judgmental and non-coercive support services (Marlatt, 1996).

The origins of Insite in Vancouver can be unambiguously traced to community activists and advocates who, along with health professionals, continually pushed controversial initiatives and ideas into the policy debate, slowly chipping away at their opposition. Activists and advocates had been addressing the drug crisis developing in the DTES for many years before any government took notice, let alone action. In the late 1980s, recognizing the increasing transmission of HIV and Hepatitis C among injection drug users who shared needles, activists created mobile needle exchange services through private donations. This generated a sufficient demonstration of the efficacy of needle exchanges to municipal and provincial leaders, prompting them to begin funding such initiatives in 1989 (Lupick, 2019). Needle exchanges helped cut the transmission of HIV and Hepatitis C in half by 2002, but the problem was evolving. When toxicity and mixing of recreational drugs became a problem in the mid 1990s, activists once again pushed the legal boundaries by creating unsanctioned safe injection sites in back alleys or in community residences, with unofficial cooperation from street nurses who supplied syringes and other materials. From 1995 to 2003 several unauthorized SIS were opened in the DTES, some of which later closed due to community complaints or organizational funding cuts. It was clear to health professionals that they were saving lives, even while the harm reduction debate simmered in the medical and policy communities.

DTES activists worked within the system (e.g. sitting as community representatives on health boards to push for reforms), while continually applying pressure with direct action protests (e.g. mock gravesites in a prominent DTES park). They were willing to push legal boundaries with their services to the community when change was not moving fast enough (e.g. open short-lived, unauthorized safe injection sites in alleys) (Harati, 2015; Lupick, 2019; Campbell et al., 2009). This sustained push from inside and outside official corridors of power eventually moved the conversation among credentialed and mainstream policy actors, who accepted the harm reduction principles advanced by these activists.

Direct activism via protests and collaborative work with sympathetic health and policy officials by community advocates exposed the failures of the criminalization paradigm among important decision-makers in the city and province, which created space for the new lens of harm reduction to take root (Nowell et al., 2020; Lupick, 2019). Vancouver’s chief coroner, Vince Cain, was one such individual, authoring a 1994 report on the alarming rise of overdose deaths, which concluded that society needed to shift how drug use was conceptualized. In particular, Cain was one of the first high-level officials to argue that drug use should be understood as a health, rather than criminal, issue and that life experiences over which many have little control, such as trauma, poverty, and discrimination, contribute to drug addiction (Campbell et al., 2009).

Cain recommended decriminalizing the possession of small amounts of drugs and suggested the adoption of a harm reduction philosophy for PWID. His report was not openly embraced at the political level in Victoria or Ottawa (though harm reduction as a general principle was first quietly endorsed in Canadian federal policy in the late 1980s), but it moved the conversation into new terrain at the local level. Indeed, while the first ministers at the provincial and federal orders of government were cool to these new ideas, line ministers and their top officials were increasingly warming up to new approaches, presenting an opportunity to take a few steps outside the previously dominant drug paradigm (Campbell et al., 2009).

In a 1996 report, Dr. Elizabeth Whynot, a Vancouver medical officer of health, called for various reforms to the city’s approach to drug use and health. They included pioneering recommendations to create safe injection sites and allowing doctors to prescribe (clean) heroin to their patients (Campbell et al., 2009). Dr. Whynot’s report had supporters and detractors in the medical community, and its two recommendations were too controversial for any elected political leader to support publicly. However, the report pushed the conversation onto the purview of the mainstream local medical community and policy officials.

With this type of work, the harm reduction movement in the DTES began to gain powerful and credentialed allies, such as Chief Coroner Larry Campbell, former Deputy Police Chief Ken Higgins, and Provincial Health Officer John Millar (Lessard, 2011). McGann (2007) likewise credits the development of innovative drug policy in Vancouver to an ongoing dance between grassroots activists and credentialed professionals, who aimed to advance ideas and solutions that gained the authorization and financial support of the government.

In this context, community organizations in the DTES began to position themselves for bolder action. The Portland Hotel Society (PHS), which would later create and operate Insite in partnership with the local health authority, had, from its creation in 1995, a different philosophy for its services to the community. In contrast to many other housing and support service providers at the time, the services of the PHS was firmly rooted in a harm reduction philosophy, which allowed for residents to use drugs in their rooms, prevented evictions on the basis of behaviour, and fostered the offering of medical services in their buildings (Lupick, 2019). The PHS and others in the community, such as the Vancouver Area Network of Drug Users (VANDU), took unilateral action where they could, but also displayed willingness to work with local officials in order to push harm reduction principles into the mainstream. For example, in 1996, Vancouver Mayor Philip Owen created the Coalition for Crime Prevention and Drug Treatment as a vehicle for various public, private and non-profit representatives to debate innovative solutions to tackle injection drug-related health and crime problems.

The Coalition, given its diversity, was quite divided in the initial phase of its work, but as the crisis continued unabated, minds opened to new avenues of action (Campbell et al., 2009). The Coalition would later endorse the Four Pillars approach to drug policies—prevention, treatment, enforcement, and harm reduction—after hosting many public forums, participating in international conferences, and undertaking site visits to Europe. An activist in the coalition, Bud Osborn of VANDU, was the DTES community representative on the Vancouver/Richmond Health Board, and is credited with persuading the board to declare a public health emergency in the DTES in 1997 (Lupick, 2019). The declaration of a public health emergency opened up debate and consideration of novel solutions and actions that could be taken by the government.

Local Political Leadership in the Drive for Reform

It would still be several years before a state-sanctioned SIS would appear in Vancouver. In the period between 1997–2003, efforts to establish harm reduction services, and a SIS in particular, either lost steam or were killed at the eleventh hour when proposed to political decision makers. One development that some credit with generating a broader base of public support (and therefore less political risk) for the then-controversial harm reduction interventions was the early 2000s drug overdose crisis that began to reach middle class families in Vancouver. Members of these families mobilized around the issue—such as in the form of the group From Grief to Action—and brought these formerly controversial ideas further into the mainstream (Campbell et al., 2009).

Indeed, early political leadership that contributed to the movement towards a safe injection site was found in an unlikely source: the conservative Mayor Phillip Owen, who, for most of his political career had been an opponent of harm reduction ideas advocated by DTES activists (Harati, 2015). Some attribute his change in attitude to concerns over ‘social decay’ that drug addiction caused (Harati, 2015, 12). Others cite his changed attitude to his relationships with the DTES and community members (Lessard, 2011), and still others suggest he was persuaded by the report of his Chief Coroner, Vince Cain, diagnosing the problem and emphasizing the impact of the Mayor’s participation in harm reduction conferences (Campbell et al., 2009).

Vancouver Mayor Owen, sufficiently confident that public education on harm reduction was building enough public support for a dramatic policy change, asked his drug policy team to prepare a policy paper for public comment. Politically, it was critical that harm reduction not be framed as a replacement for the enforcement of drug laws, but rather as a complementary approach to existing strategies. While this would rankle some activists, many of whom rejected any part of the existing criminal-legal regime (Lupick, 2019), Owen and others were clear that this was a new layer on an existing approach, not a wholesale paradigm replacement. It was Owen’s stickhandling of the so-called Four Pillars Approach to Drugs—enforcement, prevention, treatment, and harm reduction—that legitimized harm reduction as a new, consensus position in Vancouver.

While there remained some community opposition (such as the neighbouring Chinatown Merchants Association), Mayor Owen’s positionality as a right-of-centre leader helped legitimize the approach in circles who gave him the benefit of doubt. Yet one group that grew tired of his focus on the DTES was his own political organization, the Non-Partisan Association (which, in reality, is effectively a local political party). Although it voted to approve the Four Pillars policy, the Non-Partisan Association denied Owen its support in the next election because of his ‘focus almost exclusively on drug policy’ (Campbell et al., 2009, 167). Owen would have to compete to be the leader of the party; or in the words of ally and successor, Mayor Larry Campbell, they ‘knifed’ him politically (Campbell et al., 2009, 172). Owen’s leadership in this area was politically costly, effectively ending his political career. Owen’s decision not to run in the next election propelled Larry Campbell to jump into the mayoral race under the rival left-wing banner, Coalition of Progressive Electors (COPE).

By the time the more conservative members of the NPA engineered the defeat of their leader, the centre of gravity on the debate had moved such that the new NPA leader, Jennifer Clarke, and mayoral rival COPE’s Larry Campbell, both advocated publicly and openly for the creation of a SIS in their 2002 campaign. The politics of the issue had shifted such that large majorities in Vancouver were ready for the previously unpopular and hence politically unthinkable policy, and Larry Campbell was elected on a clear mandate for a new approach in the DTES. An alignment had evolved among the Vancouver public, chief elected officials, and police, who now recognized the need for an alternative to the existing enforcement approach. Insite was a key part of that new direction (Paul, 2010). With little political space in the local political domain for those resisting harm reduction policies and programs, including a safe injection site, the focus of the struggle shifted to securing support from other orders of government. Vancouver MLAs and MPs, such as Libby Davies (New Democratic Party) and Hedy Fry (Liberal Party of Canada), were early advocates in the federal parliament (Lessard, 2011), but hardball strategies from advocates and local leaders, like new Mayor Larry Campbell, were also needed to push the federal government over the edge.

Building Momentum for Challenging Reforms

The development and implementation of Insite in Vancouver followed from the Vancouver Agreement (1999), under which city, provincial, and federal bureaucratic and political actors agreed to work collaboratively to address the complex intergovernmental issues in the DTES (Doberstein, 2011). What some conceptualize as a local issue of a neighbourhood in decline is in fact a shared responsibility by all three orders of government, who have authority over zoning, health, economic security, child welfare, criminal law, and drug enforcement, among other areas of policy. It was not so much that the municipal, provincial, and federal governments were inattentive to the needs of the neighbourhood, but rather that these problems were complex. They required a more collaborative approach not only to fund services, but also to settle the disputes around jurisdictional legalities and regulations associated with the new directions of policy and programs.

The governance context in this late 1990s to early 2000s period was thus characterized by government and nonprofit services delivered in a fragmented and, at times, contrasting fashion. For example, provincial health authorities were tacitly supporting community-driven, but formally unsanctioned, needle exchanges while local police were cracking down on them (Lupick, 2019). Local police leadership and rank and file police officers were historically hostile to the concept of a safe injection site (or any state response that implicitly or explicitly enabled drug use), but the new Police Chief, Jamie Graham, understood the link between mental health and addiction, and with some prodding from Vancouver’s mayor, embraced the pilot safe injection site as long as it was legally authorized by the federal government (Campbell et al., 2009).

An unlikely ally was BC Premier Gordon Campbell, head of the BC Liberal Party, a free-enterprise political coalition, and also a former mayor of Vancouver, who was well versed in drug use issues. Premier Campbell had enabled and funded pioneering needle exchanges as mayor but ‘needed no convincing to ante up provincial funding for the safe injection site …[since] he saw it as a healthcare issue’ (Campbell et al., 2009, 176). While some observers have stressed the importance of scientific evidence surrounding the crisis and the failures of the status quo as determinative to the creation of Insite, Fafard (2012) emphasizes that Insite emerged as a result of coalition-building and political struggle, whereby policy entrepreneurs took advantage of windows of opportunity for policy change. Area MLAs and MPs were likewise openly supportive of a safe injection site (Zhang, 2014), but the federal government was moving very slowly in finding a legal pathway for this initiative, given the immense pressure from the US government against going down this path.

The breakthrough came when newly elected Mayor of Vancouver Larry Campbell promised Vancouverites that a safe injection site would open in 90 days and put pressure on the federal government to forge a legal pathway. While the mandate of the Vancouver Agreement extended beyond public health matters, by the time Mayor Larry Campbell was elected in 2002, it already served as a vehicle to fund new health centres and creative harm reduction strategies to keep people alive. Insite was not in the initial plan of this work, but with a clear public mandate to pursue a SIS, Mayor Larry Campbell leveraged these collaborative relationships to get the legal and regulatory pieces in alignment, even as he pounded on tables in Victoria and Ottawa.

Furthermore, community activists, and Larry Campbell himself, were prepared to proceed without federal authorization (Lupick, 2019). The Portland Hotel Society (PHS) had already been preparing a site for a SIS and was seeking approvals from the local health authority. Behind the scenes, the local health authority was indicating financial support for the site, but stating that its support was contingent on political endorsem*nts from the provincial and federal governments in Victoria and Ottawa, respectively (Lupick, 2019). Victoria was not going to be a problem, given BC Premier Gordon Campbell’s long-standing philosophical (if not financial) support for harm reduction strategies. But the government of Canada still needed to be persuaded to take a leap on an issue that, in the rest of the country, remained very controversial and one that offered little electoral pay-off and considerable risk (Campbell et al., 2009).

The federal government was not prepared to radically reform drug policy in Canada to enable Insite to open, but it did agree to provide Insite with a temporary exemption from prohibitions on the sale, possession, and use of various drugs and substances in Canada’s Controlled Drugs and Substances Act (CDSA). Section 56 of the Act gave the minister the ability to exempt persons from any part of the Act for medical or scientific purposes were Insite a research study. This legal loophole made for a useful political strategy, enabling the government to exempt persons from any part of the Act for medical or scientific purposes. The minister was thus able to avoid a potentially controversial drug policy change that would affect most Canadians. Section 56 allowed the government to treat Insite as a scientific enterprise for a specific locality that was eagerly demanding a policy solution to a prevalent problem. The federal government provided $1.5 million over four years for the scientific evaluation of the pilot project, the provincial government provided $2 million to renovate the site, and another $2 million per year to cover staffing and other costs for the site (Smith and Stewart, 2006).

The political and public support for Insite remained robust in the early years when it was perhaps most vulnerable to challenge. Mayor Larry Campbell declined to run for reelection for personal reasons and an unrelated fraying of relations with his local political party COPE, but the two major candidates contesting the subsequent mayoral race were strong supporters of Insite—evidence of the local institutionalization of the concept and its implementation. The victorious Mayor Sam Sullivan, though the leader of the right-wing NPA, lent support to further innovations in this realm, such as the North American Opiate Medication Initiative (NAOMI)—a program to measure the impact of providing injectable (clean) heroin to deeply entrenched drug users. This project would lay the foundation for future debates over the safe supply of drugs when the fentanyl crisis emerged after his single-term tenure.

Overcoming an Existential Threat

Notwithstanding the powerful emerging coalition of drug users, activists, health professionals, bureaucrats, and key elected officials, there were citizen groups, professional interests, and a major national political party opposed to a safe injection site in Vancouver. First, a citizen group comprised of business and property owners in Vancouver, called Community Alliance, mobilized in an attempt to block development applications for PWID health care and support services, including Insite. It was unsuccessful at the council level and in legal venues (Zhang, 2014; Small et al., 2006). Second, the Royal Canadian Mounted Police’s (RCMP) Drugs and Organized Crime Awareness Service attempted to mobilize RCMP and Vancouver Police Department (VPD) members to write letters to the prime minister opposing safe injection sites, and later the RCMP and the Canadian Police Association released statements (without supporting evidence) in 2006 that Insite was not successful and ought to be shut down (Wood et al., 2006). Third, while the right of centre party is a coalition of liberals and conservatives (and one that tends to suppress social conservative voices) in BC, at the federal level the Conservative Party of Canada is more traditional on social issues, including drug policy, and thus represented a major threat to the maintenance of Insite in Vancouver when they came to power in 2006.

Drug problems in the DTES were generally viewed as a local matter. Normally, this may have been shielded from federal government attention, however, the fact that the issue involved tolerating (and, in the view of the federal government, enabling) drug use elevated the matter to high-level attention in Ottawa. From a policy survival perspective, Insite’s continued operation required a renewed positive decision by the new Conservative minister of health, which would exempt Insite from the provisions of the CDSA. That is, for Insite to continue to legally operate, the new Conservative government had to formally renew its exemption; simply ignoring it would not dissolve the legal basis for its operation. When the Harper government first came to power, the exemption was imminently due to expire. Although the Conservative government wanted to close Insite, it ended up renewing it until 2008, ‘under duress’ and in part as a response to their political ally BC Premier Gordon Campbell’s strong urging (Campbell et al., 2009, 230).

The Conservative federal government, however, did send signals that they would not renew Insite in the future. This prompted the Vancouver Area Network of Drug Users (VANDU) and the Portland Hotel Society (PHS) to launch lawsuits against the Government of Canada to stop them from closing Insite through their regulatory power. The two cases were heard together in the BC Supreme Court, with the provincial government intervening in support of Insite, against the Government of Canada. Various legal arguments were made by the parties as the case snaked its way up the courts to the Supreme Court of Canada, but there were two main categories of arguments from the proponents, anchored in two powerful elements of the Canadian constitution. They were, first, that federalism, in particular healthcare is the exclusive jurisdiction of provincial governments whose policy choices on health services should have paramountcy over federal criminal laws. This argument is also known as the jurisdictional immunity doctrine. Second, closing Insite, against all of the evidence of its success, was inconsistent with the Charter of Rights and Freedoms, particularly the Section 7 guarantee of life, liberty, and security of person. While lower courts flirted with the jurisdictional immunity argument as possibly important, ultimately the Supreme Court of Canada (SCC) unanimously found that the ministerial discretion in issuing CDSA Section 56 exemptions must be in conformity with the Charter, and that the current minister’s decision to not grant that waiver was arbitrary (against all the credible evidence), disproportionate in its effect, and inconsistent with the public interest (Boyd, 2013).

Many observers credit this legal success to the deep, grassroots, and addict-led movement that successfully reframed the narrative around addiction through a rights-based lens (Harati, 2015), as well as the careful and systematic accumulation of evidence of Insite’s success in saving lives (Marshall et al., 2011; Boyd, 2013). It is important to note that the SCC logic was not entirely aligned with those of the proponents, who tended to be devoted to the jurisdictional argument and the unconstitutionality of the CDSA vis-à-vis the Charter. A decision hinging on those arguments would have major implications for federalism and public policy, and thus, perhaps, the SCC found the narrowest legal argument for intervention without causing major wakes in Canadian politics writ large (Ward, 2012). The minister was required to provide a CDSA exemption for Insite and the government was given a timeline to set a legislative and regulatory framework under which the minister would consider exemptions from future SIS applicants.

Growing Public Support and Pockets of Resistance

The programmatic success of Insite has thus contributed to its political success and its endurance as the leading response to a public health crisis facing many in Canada and abroad. As a result of a broad coalition of drug users and their advocates, health professionals, local and provincial government officials, and politicians putting pressure on federal officials, Insite became the first safe injection site in Canada with authority over controlled substances and criminal law.

Various public opinion polls suggest that a consistent majority of Canadians support safe injection facilities since Insite opened. A Government of Canada-commissioned study in 2006 showed that found 58 per cent of survey respondents endorse these facilities, with BC respondents highest at 70 per cent (Woods, 2006). Such levels of support were found in a similar survey by Research Co. in 2019 (CTV News, 2019). In 2017, Mainstreet Research found that majorities in Canada’s largest four cities favoured opening safe injection sites in their own cities (Duggan, 2017). Support for SIS was well over 50 per cent among those who identified as voters of the Liberal Party of Canada, the New Democratic Party, and the Green Party of Canada, and nearly half of Conservative Party of Canada voters supported this intervention in the Research Co. survey conducted in 2019. With the programmatic and political success of Insite established, additional SIS opened across the country after receiving CDSA exemptions from the Government of Canada. As of early 2021, forty sites in five provinces were authorized in Canada (Government of Canada, 2020).

Notwithstanding the programmatic success and broad-based political legitimacy of SIS, its success remains somewhat contested. There remain critics of the approach from both the political right and the left. On the political right, Ontario Premier Doug Ford was ‘dead against’ them in his successful election campaign in 2018, claiming they encourage drug use; he favours traditional drug rehabilitation models instead (Canadian Press, 2018). The Ford government has also defunded recently opened SIS in Toronto and Ottawa due to neighbourhood concerns. The typical thrust of the conservative critique of SIS that it is inappropriate to ‘use taxpayers’ money to fund drug use’ (Stephen Harper in 2005, as cited in Boyd, 2013) and that it is ‘state-sponsored suicide’, as stated by the US drug czar under President Bush (Elliot, 2014, 19). Yet, SIS approaches are well entrenched: today most conservative politicians in Canada are reluctant to take aggressive action against them, often promising to ‘review the evidence’ or ‘listen to local concerns’ rather than dismantle them.

Surprisingly, there is also critique among a small segment of the political (namely, academic) left, which views Insite and services like it as a ‘site of surveillance, discipline, and regulation’ (Elliot, 2014, 7). Authors such as Elliot (2014, 28–29) believe Insite has become ‘fetishized in scientific and political discourse’, falling into a neoliberal trap that individualizes drug use and reinforces frames of the ‘disordered drug user’ in need of ‘regulation and surveillance’ which obscures the fact that this problem is shaped by broader structural forces. The highly regulated environments in which SIS operate in Canada have prompted the creation of more peer-driven ‘overdose prevention sites’ (more on this below) in Vancouver and elsewhere. In recognition of some users’ institutional resistance or suspicions, they are less medicalized by design.

Other commentators cite the continued public drug use in the DTES as evidence of the ineffectiveness of the harm reduction approach that Insite and associated services espouse. To some DTES residents, ‘the quality of life in the community seems to have hit an historic low’, with homelessness, poverty, and the opioid crisis ravaging the neighbourhood (Hernandez, 2019). Yet it is critical to keep in mind that a SIS, or even harm reduction policies broadly, were never conceived as solutions to systemic issues like poverty, mental health, homelessness, and unaffordable housing. The early advocates of Insite never envisioned that these services would cure the DTES of any of its perceived ills—the larger goal was to save the lives of PWID.

Policy Diffusion and Expansion

Following the constitutional challenge that limited the operational discretion of the federal minister of health around this issue, the harm reduction philosophy and associated programs have spread more widely across BC and Canada. Additional SIS opened across the country after receiving CDSA exemptions from the Government of Canada. Other similar services, such as Overdose Prevention Sites (OPS), have opened in Vancouver and elsewhere, as community (and often peer-led) initiatives that support safer drug use do not require Health Canada exemptions.

While the essential policy goals of Insite have remained robust and intact over nearly two decades, new problems in this realm reveal the limitations of SIS: the increasingly widespread presence of fentanyl and extreme drug potency and toxicity in 2015 (Kerr et al., 2017). The rise of fentanyl is often attributed to the delisting of OxyContin painkillers from western nations’ pharmaceutical formularies (shifting demand to the illicit market) and the ease with which fentanyl can be manufactured and shipped into Canada. The illicit drug supply was becoming so tainted and unreliable that, in BC, deaths from injection drug use overdose rose from a relatively stable number of 300 fatal overdoses per year to a high of nearly 1,600 in 2018 (BC Coroners Service, 2021). While Insite and other SIS in Vancouver have successfully saved the lives of every client who has overdosed on their premises, only about 5 per cent of all injections in the DTES take place within Insite (Andresen and Jozaghi, 2012). With Insite at capacity in terms of users per day, additional sites have since opened in Vancouver. However, for various reasons ranging from geographic convenience to stigma, many continue to use these dangerous drugs in isolation, greatly risking their lives.

The BC government declared a public health emergency in 2016, which, like the emergency declaration related to HIV and Hepatitis C in the 1990s, broke down some walls and made room for more innovative responses from government and civil society (McKelvie, 2020). Nationally, small but important drug policy changes have also helped. For example, injectable naloxone—an antidote to opiate drug overdose—was removed from the Drug Schedules Regulation by Health Canada, allowing for its widespread distribution without prescription. As mentioned above, the public health emergency declaration facilitated the creation of various peer-driven Overdose Prevention Sites (OPC) around Vancouver without requiring Health Canada approvals. These can be mobile sites in vacant lots, tents in parks, or in modified or single-room occupancy (SROs) hotels, which allow users to inject without the supervision of medical professionals. Subject to oversight by peers with knowledge and tools to assist with overdose prevention, these OPCs, like Insite, have a 100 per cent survival rate (BC Coroners Service, 2021). These efforts showed promising results in reducing deaths from overdose by 37 per cent from 2018 to 2019, until the Covid-19 pandemic disrupted the illicit drug trade due to border closures and trade tumult. This returned deaths to an all-time high in 2020-22, as drug dealers further adulterated the illicit supply.

Tragically, while the harm reduction policies of Vancouver were saving the lives of their users, the population at risk of overdose expanded well beyond the capacity of these sites as the drug supply became highly unreliable and toxic. The BC government, with federal government cooperation, responded by approving the ability of primary care physicians and nurses to prescribe a safe supply of opioid alternatives to street drugs, such as hydromorphone.

The idea of a safe supply had been advanced as early as the late 1990s during the debate around SIS, but had been deemed too controversial by political decision makers. But as the Covid-19 crisis compounded the fentanyl overdose crisis in Vancouver, prior political constraints and risk calculations were dislodged. Thousands of BC residents were given access to hydromorphone as an opiate alternative to the street supply. Early data from the BC CDC suggest fewer fatalities per month since this policy change, though spikes reemerged as the omicron wave of the Covid-19 pandemic further isolated folks (BC CDC, 2021). Facilitating the government distribution of free drugs to anyone at risk of overdose, once a deeply controversial proposition among Canadians, met no noticeable resistance among medical professionals, community interests, or political leaders. This response is indicative of the wide acceptance of harm reduction principles in BC and Vancouver in particular.

What Might Be Learned from Vancouver’s Harm Reduction Journey?

The development of Insite in Vancouver and its associated harm reduction approaches across the country, as well as its endurance over time, is consistent with the dominant Canadian policy style, which is characterized by strong executive power and intergovernmental negotiation in the tradition of pragmatism. A signature feature of the Canadian administrative style is the dominance of first ministers—as opposed to legislators—as key players in policy-making. This is evident in the story of Insite, when key developments proceeded principally by persuading political executives. Many observers of Canadian policy-making styles point to a pragmatic approach that supports change-oriented governments (Gow, 2004). This is consistent with how, in the context of the DTES, the debate was centred around what new solutions could save lives as opposed to how or whether they aligned with ideological priors.

Furthermore, one cannot overstate the importance of federalism to the Canadian policy-making style, in particular the province-building dynamics that have resulted in more responsibility and legitimacy in many of the most important policy areas of the contemporary period (Howlett and Lindquist, 2004). This is critical in the case of Insite as the Province of British Columbia and the City of Vancouver muscled their way into a federal government space (criminal drug policy) under the auspices of their responsibilities to health and community development, and worked cooperatively through laborious intergovernmental negotiations and institutions (e.g. Vancouver Agreement) to drive change.

Finally, the case of Insite points to the post-Charter (1982) emergence of the courts as a check on executive-dominated government in Canada. While this may not be a central avenue in the overall Canadian policy style, it is nonetheless proven to be a critical one for issues that have rights-based dimensions, like Insite (Ward, 2012). The Canadian courts can be both bold in their rulings against Charter violations (particularly in the Harper era), but also, at times, deferential to governments to legislate a path out of the violations, which is present in the matter of Insite.

While there are various lessons that can be derived from the case of Insite in Vancouver, such as the importance of channelling grassroots activism to achieve policy success and establish political institutionalization, there are unique factors to this case that may limit how broadly those lessons ought to be applied. We should not forget that Insite was subject to a political challenge that it marginally survived thanks to its effective placement into a rights-based frame for which the powerful tool of the Charter of Rights and Freedoms was deployed and recognized. Not all issues can credibly be conceptualized in rights-based terms and are thus subject to the normal policy reversals or changes that come with partisan government turnover.

Also, the context of the DTES in the early 1990s was a genuine crisis of death and despair, which mobilized actors to build a movement. ‘Crisis’ is an elastic label that can be stuck on a social condition by anyone seeking to legitimize dramatic action or to increase their jurisdiction (Edelman, 1988 Spector, 2019), but this was (and is) killing people in large numbers; the urgency surrounding this issue was extreme and, even then, it took a decade to establish Insite. In this context, there were various idiosyncratic elements to the political leadership in the history of Insite that contributed to its development, such as otherwise conservative politicians (Mayor Philip Owen, Premier Gordon Campbell) being uniquely open-minded on this issue, and unconventional politicians (Mayor Larry Campbell) with higher political risk tolerances. Safe injection sites and safe supply measures, while perhaps morally controversial, do not threaten many powerful mainstream interests that might wish to mount a resistance campaign, even in the face of overwhelming evidence of their effectiveness. Perhaps the most powerful institutional interests initially opposed to Insite were police services, but in Vancouver (and indeed beyond) they became persuaded that the criminalization approach was not working.

Ultimately, the so-called harm reduction coalition displaced the criminalization coalition by mobilizing a diverse set of people and groups united by a belief system related to drug addiction that better fit with the continuing crisis that emerged in Vancouver in the 1990s. The members of the coalition engaged in strategic action in the streets and in the corridors of power to displace a coalition that did not have answers to the crisis of the day. They did this by using activism and evidence to generate broader public and political support for their preferred policy approach. The harm reduction coalition has remained dominant, as its members have adapted their beliefs as the problem shifted from one principally of needle sharing to extreme drug toxicity in recent years. The rival criminalization/abstinence coalition remains unable to respond in persuasive policy terms. While the rival coalition is by no means dead—in fact, it has considerable support among the general public—and can occasionally block SIS in particular locations around the country, it fails in fostering a larger belief system able to shape policy decisions and ameliorate the issue.

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