André Picard
In Vancouver this week, there have been 36 overdoses in people who inject heroin. There were no deaths.
In Montreal, in May, there was a similar spate of 28 overdoses among heroin users. There were 16 deaths.
In both cases, the drug being sold as heroin was actually fentanyl, a painkiller that's many times more powerful.
So why, given the identical circumstances, was the fatality rate zero in Vancouver, and almost 60 per cent in Montreal?
The simple answer is: Supervised injection. And naloxone.
Vancouver is home to Insite, a supervised injection site that has operated for more than a decade.
Almost all the overdoses in the past week occurred at Insite. The drugs users who ODed were revived by trained nurses. They use a drug called naloxone, which can reverse an overdose of opioids.
In Vancouver, first responders like paramedics, police and firefighters carry naloxone, and B.C. has a take-home naloxone program so regular users can carry the overdose antidote and help their friends. (The drug works much like an Epipen: You jab a syringe into someone suffering an overdose.)
In Montreal, there is no supervised injection site. In that city, heroin users – and there are many – shoot up in the streets (or in their homes or offices – because let's not forget that drug abuse is not limited to those living on the streets).
There are, however, plans for three supervised injection sites in Montreal. But talk is not action, and the delays have proven deadly, and will continue to do so.
In Quebec, naloxone is approved only for use in hospital emergency rooms and for a handful of advanced care paramedics. There is no take-home naloxone program, and while the drug can be prescribed, it is not covered by the provincial drug plan, so it is unaffordable.
One would be hard pressed to come up with a more eloquent example of the benefits of harm reduction, or a more compelling illustration of how sensible, evidence-based policy-making can mean the difference between life and death.
There is nothing glamorous about addiction to heroin, methadone or other commonly abused street drugs, and nothing romantic about a life dedicated to chasing the next fix.
Nor should be proud of the fact that there are thousands of injection drug users on the streets of our cities, big and small.
But these are, for a host of complex reasons, realities that we have to deal with. And, as use and abuse of opioids becomes more common, and prices of street drugs fall, they are realities we need to come to grips with, and quickly.
The so-called war on drugs, driven by the notion that we can prosecute away illnesses like addiction and scare people straight, and make all the social ills related to the drug trade magically disappear, has failed miserably.
What the evidence shows, and what practitioners of public health know from experience, is that harm reduction works.
The concept is simple: If people are going to practise risky activities (like injecting heroin), the first thing we need to do is minimize the harm they do to themselves and others.
So you provide clean needles, give them a safe place to inject, in some cases provide them with the drug.
By doing so, you prevent the transmission of disease (needle sharing is an efficient way of transmitting HIV, Hepatitis C and more), you make the streets safer and more pleasant, and you prevent (and treat) overdoses rather than leave people do die gruesome deaths in back alleys.
And then can you start the conversation about treatment and rehabilitation, something that almost never happens when you criminalize behaviour.
Mitigating self-harm is a much better use of tax dollars than jailing someone.
Similarly, making drugs like naloxone widely available may make us squeamish, but the reality is they are needed and useful.
Are there really that many overdoses that we should make every first responder carry the antidote, and make it available over the counter or, as some suggest, make it a routine prescription whenever people (including your grandmother) get prescribed powerful opioid painkillers?
The short answer to those questions is "yes." There is very little downside to making the treatment widely available.
In Canada, we have, for many years, been having philosophical how-many-angels-can-dance-on-a-pinhead type discussions about the best way to deal with injection drug users (and drug users more generally).
Enough of the dithering, already. We know that harm reduction measures work.
We shouldn't need to arrival of another deadly batch of street drugs to remind us of the grim toll of inaction.
André Picard is The Globe's public health columnist.
André Picard