From harm reduction to harm production: A frontline physician on the closure of safe consumption sites

The closure of safe consumption sites (SCS) in Ontario, as well as rules restricting needle exchanges, flies in the face of scientific evidence and my own lived experiences as a family physician who’s worked within Toronto’s opioid crisis for more than a decade.

My journey in providing substance use care started in 2011, working in Peel Region for two years before spending the next 12 in Toronto’s downtown core. During that time, I have worked at two safe consumption sites in this city – Parkdale Queen West Community Health Centre and Regent Park Community Health Centre – and the substance use service at a downtown Toronto hospital.

Safe consumption sites are essential lifelines for anyone who uses drugs and is at risk of dying from an overdose in our continental toxic drug crisis. In addition to preventing death, they reduce the spread of HIV, Hepatitis C and other blood-borne infections. They reduce costs, save lives, improve access to evidence-based addiction treatment and improve health outcomes. They also reduce crime, public drug use, discarded drug paraphernalia and the strain on paramedics and local hospital services. They are an entry point to evidence-based drug treatment and have been shown to improve the health outcomes and lives of the people who access them.

So why are we closing these sites and defunding other harm reduction services such as needle exchanges?

For starters, there is the perception that these services are new and untested, or at least that was the perception back in 2001, when Vancouver’s Insite, North America’s first safe consumption facility, was approved. However, safe consumption sites had been in operation in Europe since the mid-1980s, with the first officially sanctioned site opening in Bern, Switzerland, in 1986, followed by sites in Germany, the Netherlands and Spain. By the time Insite in Vancouver opened in 2003, there had already been close to 70 operating in multiple countries.

What was new about Insite was that it was the first in North America and attracted the attention of Canadian and American media.

In anticipation of this controversy, the Insite implementation team designed studies to assess the individual, local and broader impacts of safe consumption sites on death rates, HIV/Hep C transmission, acute skin infections, public disorder in the immediate vicinity of the safe consumption and discarded drug paraphernalia. The results showed improvement in every measured outcome in a variety of leading peer-reviewed journals. The Canadian Society for Addictions Medicine, the Canadian Association of Emergency Physicians and a variety of other health professionals have endorsed the sites.

Despite this broad-based support from the health professions, the Ontario government still promotes the narrative that SCSs “promote” the use of dangerous drugs and that we are “enabling” bad behaviour. This is analogous to saying seat belts promote unsafe driving and more accidents; remove seat belts and maybe we’ll stop people from driving and getting into dangerous accidents.

The fact of the matter is that SCS users are among the most vulnerable and will continue to use with or without SCS access. If anything, we know that these sites often are the easiest point of entry into the health-care system, which begins engagement with this population and where opioid therapy can be offered, leading to fewer deaths, less hospital use, greater cost savings and, very possibly, even abstinence, which is one part of the harm reduction continuum.

Indeed, during my time as a family physician who incorporated opioid and stimulant therapy, SCS staff members often brought me patients who had decided they would like to go on opioid therapy to make changes in their lives and their health. The bottleneck to getting people into treatment was my schedule, which was often jampacked; with more dedicated funding to provide opioid therapy, we could have expanded access to treatment and transition patients off the street supply and away from hospitals and jails to housing and jobs.

This is the evidence that was born from Onsite. This is the additional funding needed to enhance the SCS model.

Though the HART hubs – Homelessness and Addiction Recovery and Treatment – the government has invested in can be helpful, their implementation has been chaotic. The hubs have been touted as replacements rather than support for SCSs, whose users often are desperately in need of housing. Furthermore, patients would also bring drug samples to harm reduction workers for testing, giving us a much better idea of what we were treating in real time.

With the defunding of harm reduction services, this ecosystem has been eradicated, and the real-time information we have becomes poorer in an ever-changing, toxic drug supply.

To make matters worse, the provincial government has gone one step further by defunding needle exchanges, which have been the most basic of harm reduction services for drug users for the past 30 years.

Needle exchange programs have been shown to pay for themselves many times over by preventing HIV and Hepatitis C infections. For example, one new case of HIV presents a cost of nearly $500,000 in medication and health-care visits. One new case of Hepatitis C costs $50,000 to $80,000 to treat. The programs also reduce the risk of other blood-borne infections, which can lead to heart, bone and brain infections and cost hundreds of thousands of dollars in hospital stays and long, complicated surgeries. Needle exchange programs cost a fraction of this and are another bridge between drug users and the health-care system. Ending these programs is cruel and fiscally irresponsible. The money “saved” will be spent on the downstream costs of new HIV and Hepatitis C infections, sepsis and other acute infections many times over.

The ultimate measure of how much the Ontario government purports to care about drug users is borne out by the dollars spent on addiction treatment services and sadly speaks to who matters and who doesn’t.

From 2020 to 2024, more people died from alcohol or drug overdose than from COVID-19. Yet, when COVID-19 hit Ontario in 2020, the provincial government spent approximately $16 billion in urgent funds; approximately 1 per cent of that amount, or $200 million, was spent on the opioid crisis.

But why should those of us who don’t use drugs care?

Well, if you care about the state of the province’s finances, that is one good reason. If you care about our Indigenous communities, this is of importance (approximately 30 per cent of SCS users self-identify as having Indigenous ancestry). If you care about the strain on our hospitals and the increased wait times in our emergency departments, that is another reason.

However, we should all care because the users of safe consumption sites are vulnerable individuals who are suffering tremendously, and these sites allow people to improve their health on their own terms. It is kind, compassionate and ultimately cost-effective. It is to everyone’s benefit to prevent unsafe consumption.