How Drug Users are the First Line of Defense in the Opioid Crisis
The Portland Hotel Society's Spikes on Bikes program combats stigma and save lives with peer-level outreach.
July 13, 2017
The pavement in front of the Portland Hotel Society’s (PHS) Maple Overdose Prevention site is strewn with discarded needles and syringes (rigs)—they catch my eye in the sunshine along with the knotted groups of people lining the way to the window of the Needle Depot at the front of the building. Some are using, some are just catching up with each other. It’s a scene that’s both better and worse than what I had expected.
At the window, I am introduced to Nick Leech-Crier, a “peer” in PHS’s latest harm-reduction program Spikes on Bikes. In his yellow, reflective-striped safety vest he looks like a crossing guard and it gives him a sense of non-threatening authority. Nick himself emits a calm sense of assurance. An occasional drug user who lives in the area, he personally understands the struggles of the people around us: the trauma, the poverty and the distrust of others.
“The way I see it is I see it from the other side. I am not scared of it—I am not scared of seeing people shoot up, I am not scared of the danger and the things that are involved with it because I have been around for a long time,” he says.
As Nick walks me down the alley, it’s clear that he, bike at his side, is a welcome sight. Throughout our journey people call out to him asking for clean rigs, and they’re surprised when he produces as many packaged needles as they want from his bike pannier. Providing clean needles to users is just part of the low-barrier, non-judgemental approach that PHS has been taking to decrease the number of injection overdose deaths. So far it has paid off. The organization tracks all the overdoses attended by staff in programs like the Maple Overdose Prevention Site, (where addicts can inject safely under the supervision of medically trained workers) as well as Spikes on Bikes. So far none have witnessed a single death. In an epidemic that has already claimed 170 lives this year and is predicted to take a record-breaking 400 total by the year’s end, zero deaths is an impressive feat.
For a $7 hourly stipend, Nick plucks rigs off the concrete with barbecue tongs, dumps them in the tub of cleaning solution in his bike basket, or in needle boxes positioned along our path, and distributes clean ones. But his responsibilities as a Spikes on Bikes peer go far beyond that. Peers are consistently the first to respond to overdoses, before police and ambulance services arrive.
Unique in North America
Nick joined the program on the first day it was launched late last November and right away he was in the thick of the crisis. “Sure enough the first person I ran into was [someone overdosing] and I saved the guy’s life,” he says. He had administered the reversal drug naloxone (also known as Narcan), something PHS had trained peers to use months before the Vancouver police had given the live-saving drug out to officers. “He got up and said ‘thank you.’ It pulls at your heartstrings. I wouldn’t wish it on anybody, honestly, to have to deal with it, but I’m glad that I did. Now that I know what I am doing, I love doing it.”
All of the peers working in the program have stories similar to Nick’s. The PHS considers a peer to be current or recent drug user, and because of their shared experience, Nick says, the people in the area trust them. The directors of the program say the peer aspect is crucial to the program’s accessibility and success—there’s nothing else like it in North America. “Bringing peer workers into the program was critical for a number of reasons. It was about recognizing that they knew where to go, who to check in on and who to speak to, and they knew how that community worked,” explains Jonathan Orr head of the Maple Overdose Prevention site.
This kind of idea was exactly what the provincial government was hoping for when it made a desperate plea to public health organizations for innovative interventions when the opioid crisis was first declared in mid-April of 2016. At the time, Spikes on Bikes was a pilot program developed to assist with the PHS Needle Vans, which started providing clean needles, collecting discarded rigs and emptying the needle boxes in an effort to reduce HIV and Hepititus C transmission. But it soon became clear that taking people out of the vehicles and putting them on the streets created an opportunity to bridge the divide between different communities in the area.
“Bikes have this powerful ability to break down barriers, they’re a symbol of Vancouver,” Orr says. The visibility of the peers has already begun to win over local business owners and other residents in the Downtown East side who are mostly disconnected from PHS’s other programs and can be distrustful of drug users in the area. “People that live in brand new condos in Chinatown or business owners that have worked there for generations, they don’t really have a connection to [our other programs]… they would see the Spikes on Bikes peers coming around, people that those business owners had seen wondering the streets a year before were now working, Narcanning somebody.”
Beyond The Downtown Eastside
The success of Spikes on Bikes in the Downtown Eastside has led to an expansion into the next concentrated center of the crisis, the West End. It is an area of the city many may not think of as a hot spot of drug use or overdose, but according to the number of discarded needles tracked by the Needle Van team, or reported to the city through its VanConnect app, the neighbourhood’s glossy veneer hides a grim reality. “[We are] able to locate areas that have a high number of discards or areas where [we] think that people maybe using,” explains Susan Alexman, director of programs at PHS. “There is so much gentrification here in the Downtown Eastside, people are spreading out.”
With a $43,000 grant from the City of Vancouver, PHS has already begun to appoint peers in the area, train them and provide supplies such as naloxone. Soon, Nick will become a familiar face in the West End as well, but that neighbourhood poses greater difficulty for intervention. According to Alexman and Orr, the West End has both a surprising amount of overdoses and an unchallenged stigma towards drug users. “There are no services there. There’s nowhere for anyone to inject safely, there is no overdose prevention site. There’s nothing down there and there’s a very vulnerable community [with] a lot of young people that don’t have anywhere to go,” explains Orr. “One of the reasons is that sense of immunity, that it’s the West End, there’s palm trees down there, there are hot dog stands and tourists, it’s different down here.” However, the threat to users, be they casual or hardcore, remains the same. “Whether you are doing your one shot of cocaine you do once a year or you’re a heavy user you do not know what you are using and you cannot use safely,” he cautions.
Working Against Stigma
While law enforcement and public health officials are working to stop lethal opioids like fentanyl and carfentanil from turning up in drug supplies, the top line of defense against overdose deaths is reducing stigma. Dr. Patricia Daly, chief medical health officer for Vancouver Coastal Health emphasized this point at a recent public health forum, citing the fact that 90% of overdoses occur indoors among users who are alone and cannot call for help.
Challenging the stigma of addiction has always been part of the PHS’s agenda to encourage vulnerable individuals to seek help, Alexman points out, whether they want to get clean or simply use drugs in a safer environment. The choice, she says, is up to the individual. “[We are] really trying to reduce the stigmas that come [for] people who have mental health issues or substance-use issues. We are working to empower people in the community to better their own lives in the way that they feel [is right for them]. We are not trying to dictate a model to people.”
The job however, helps keep Nick and other peers moving towards sobriety. “The real irony of it is after 10 years of using stimulants or speed, all of a sudden it’s become useful to be alert and awake and ready all the time because everyone else is nodding off and stopping their breathing and I feel responsible,” he says, adding that although some peers continue to use, they must show up on time for their shifts and have to be able to respond quickly to overdoses.
As Nick’s shift comes to an end, I ask him how important he thinks getting rid of stigma is. He stops, his soft spoken demeanor slips and he becomes emphatic. “How can you judge people in a crisis? It’s like how do you accept the crisis but not the people?” he says, adding he as an extremely personal investment in the program’s success. “I have lost friends through this and I am trying to get people to know Spikes on Bikes so that they will call us and we will go and watch over them at home [when they use].” Building that trust with users who might be skeptical of inviting a stranger into their home has become a personal goal. “[They might wonder] ‘why would I look for someone to watch over me? That person is just going to wind up stealing my money?'” he says. “It’s a trust issue, but we are mobile, if you call us we will ride over and we will do it for free.”