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The Crosstown Clinic, North America's only facility offering medical-grade injectable heroin, is a few doors down and Canada's first supervised injection site has been a sanctuary across the street since 2003 for those shooting up drugs under the watchful eye of a nurse. Both places operate on a harm-reduction model that aims to reduce the risk of overdose.

While drugs have been used openly in the neighbourhood for decades, much of the focus on toxic, illicit substances has shifted in recent years to neighbourhoods across British Columbia, including in rural communities, where people seeking escape inside their homes are dying alone.

The latest data from the BC Coroners Service show that about 14,000 people have died since the province declared a public health emergency in 2016, with most of the deaths occurring in private residences. Illicit fentanyl was involved in 87 per cent of deaths in 2021.

Families whose loved ones fatally overdosed have increasingly joined drug users calling for decriminalization of small amounts of drugs for personal use as a way to reduce the stigma associated with criminalization so people are more likely to access health services and, combined with other measures, stay alive.

On Jan. 31, B.C. will become the first jurisdiction in the country to start what will be a three-year experiment on decriminalization allowing drug users aged 18 and over to carry a combined 2.5 grams of opioids like heroin and fentanyl, as well as cocaine, methamphetamine and MDMA, also known as ecstasy. The federal government is currently reviewing an application by the City of Toronto, but it does not include any thresholds.

Brian O'Donnell, spokesman for the peer-run BC Association of People on Opioid Maintenance, regularly walks the streets of the Downtown Eastside, armed with the medication naloxone to reverse any overdose.

O'Donnell was once in the grip of heroin addiction himself.

“I remember what it was like. I remember the struggle," he said, while waving hello to a passerby.

O'Donnell said he used heroin for 25 years before overdosing on fentanyl-laced cannabis. That got him started on a program offering a formulation of methadone for those dependent on opioids.

"Someone dusted my weed with fentanyl, and that was enough to scare me," he said.

O'Donnell has high hopes that decriminalization will remove some of the sting of stigma for people who are struggling with addiction. And he thinks other provinces could follow B.C.'s example.

"If we do succeed in helping people, I'm sure the rest of Canada could do the same," he said, quickly adding that greater access to a regulated safer supply of prescription drugs, like hydromorphone tablets or fentanyl patches, is part of the answer to stemming the tide of the overdose crisis.

Drug users and advocacy groups like Moms Stop the Harm, the Canadian Drug Policy Coalition and the HIV Legal Network are among those who say a cumulative threshold of 2.5 grams of drugs is not enough for many drug users, including those who live in rural and remote communities where people often buy larger quantities of substances when they can access the illicit market.

Mike Serr, co-chair of the Canadian Association of Chiefs of Police, said the organization wanted a threshold of about one gram of illicit drugs as part of B.C.'s decriminalization model.

"We did not want to see drug dealers or organized crime take advantage of any of the good intentions of decriminalization. We know dial-a-dope and groups like that will potentially take advantage of that," he said, referring to services that deliver illicit drugs.

"We want to see a system that is actually not promoting the use of street drugs but actually trying to help support people and individuals," he said.

The Public Prosecution Service of Canada directed federal lawyers in August 2020 to seek charges only in the most serious cases involving drugs, not simple possession.

That has meant fewer people have been criminalized unless there is a safety concern or other criminal conduct, Serr said, adding police are more concerned about a health-focused approach than seizing drugs.

"We know that the health supports and pathways for helping people have not stood up to the level that they need to be, especially in rural and remote communities. That's why we really wanted to be a little more conservative," he said. "We need to be prepared versus trying to build a plane while it's in the air."

Serr said he helped develop training to be rolled out to about 9,300 police officers in B.C. before decriminalization begins. It will include a 45-minute online module on stigma about drug use before a second phase in the spring on addiction, he added.

"It is going to include everything they need to understand about thresholds, how decriminalization works, including handing out resource cards to individuals and in what situations that's appropriate."

The resource cards are in keeping with a proposal by Health Canada and B.C. in cases where police happen to interact with someone struggling with addiction, Serr said.

In Oregon, where decriminalization of small amounts of almost all hard drugs began in 2021, police also hand out cards, which direct drug users to call a hotline for services to avoid a $100 fine.

Serr said the cards police will be handing out in B.C. are meant only to provide information on where people could choose to access services for addiction and homelessness, for example, based on available resources in a particular region.

However, drug-user activist Garth Mullins, who was among those sitting at a "core planning table" to discuss decriminalization for about a year before it was announced, said he is against police handing out any cards.

"We don't like the idea of police creep into health care," he said. "Decriminalization suggests that they have no interaction, that there's no reason for them to talk to us. The police are out of our lives, not telling people to go get treatment somewhere," he said.

"I'm also worried that the success or failure of decriminalization is going to be measured in how many people went and got treatment, how many people got off drugs, that it would be measured on health metrics. But it really needs to be measured on how many fewer interactions with cops were there."

The Mental Health and Addictions Ministry has said ongoing monitoring and evaluation was a critical part of B.C.'s application to the federal government, approved in May 2022, to address any unintended consequences and to ensure that people are not being recriminalized.

Sandra Ka Hon Chu, co-executive director of the HIV Legal Network, said the group advocated for no thresholds on the amount of substances drug users could carry for their personal use as part of Toronto's decriminalization application, submitted in January 2022 while revisions continue to be made.

"We were worried about a threshold that would be too low, not necessarily that thresholds are intrinsically problematic," Chu said, citing concerns in B.C.

While advocacy groups in Toronto are looking to the western province as a "progressive haven" on drug policy, the city is trying to carve out its own path by having no age restrictions and including all illicit substances in its application requesting an exemption from Canada's drug laws, Chu said.

Laura Shaver, a spokeswoman for the Vancouver Area Network of Drug Users, said decriminalization is one small but important step of an overall harm-reduction plan to save lives.

Homelessness, mental illness related to trauma and lack of doctors willing to prescribe safer alternatives are other big issues that must be addressed, Shaver said, adding far too many people have died.

"I have lost count," she said, crying. "I'm talking about people I know, that if I saw them on the street I would stop and say hello."

This report by °µÍø½ûÇø was first published Jan. 1, 2023.

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