By 11 a.m. on the day I visited, there had been 54 users in the injection room. Some were in and out in moments, while others took hours. When they finished in their booths, most retired for free coffee in the "chill-out room" which had an exit back onto the street. Cocaine injectors might return many times a day, while some users merely stopped in to pick up handfuls of free "rigs," or syringes. (Three million syringes are distributed in the neighborhood annually.) In between users, each booth was swept out and sterilized by the staff. Darwin Fisher, the program's intake manager, checked in arrivals and the drugs they were using on a drop-down chart that listed among its options heroin, speedball, morphine, cocaine, crack, dilaudid, oxycontin, and methamphetamine. The user's choice of drug and the outcome of each visit was stored in a database for researchers. In keeping with the nonjudgmental ethos, there are two key rules at Insite: no sharing or selling drugs and no violence. Indeed, once they were settled in their cubicles, most of the users were as still and focused as students in library carrels.
A young woman brought a kitten which poked its head out of her bag as she fixed. A man in a cowboy hat entered carrying a set of golf clubs, offering them to Fisher for sale. Another came in with an enormous bag of aluminum cans balanced on his head, not wanting to leave them unguarded on the street. Prostitutes fixed their makeup and adjusted their hair, while others used the mirrors for "jugging"—injecting directly into the jugular vein. It's a common practice, particularly among women, although the staff tries to discourage it due to the danger of hitting a nerve or an artery. A woman sat up on the stainless steel table of her booth, pant leg hitched up, probing her calf for a vein. Others shot into their elbows or between their knuckles. The staff won't actually inject someone, but they will talk them through it, even drawing an "X" in pen on a promising spot. The front lobby filled up with overloaded shopping carts of homeless clients, as a soundtrack of Sly and the Family Stone, Joni Mitchell, and Bob Dylan came over the speakers. Fisher tried to choose the music once, but the users detested Tom Waits, and so he's settled on a heavy rotation of classic rock.
For many of the users, the injection room is a first point of contact with the health care system. Users get medical treatment from the nurses, who clean and bandage abscesses and give referrals for further care. The addicts are a deeply traumatized population, many with mental illness and histories of abuse and so require an extraordinary amount of patience. An oft-repeated dictum for the staff at Insite is to "meet people where they are." It is a constant effort to be nonjudgmental about the choices addicts make. "Pregnant women come in," says Fisher. "It's heartbreaking, but we can't force anyone down here to do anything. They've been forced to do things their whole life."
One of Fisher's main duties is to help addicts, when they are ready, make the move into treatment. For many, the first stop is Onsite, the 12-bed detox facility directly upstairs from the injection room. Onsite was opened in 2007 to offer immediate, on-demand treatment for addicts coming in off the street. It was devised as a pilot program, so there simply isn't enough space to meet the boundless demand. The need for more detox and treatment facilities is a rare point of agreement between Insite's proponents and its critics. Fisher spends his days figuring out how to prioritize the people coming to him, "begging to get upstairs."
DocRock was in booth 9, fixing a $30 flap of heroin. The syringe blossomed with blood as he released his tourniquet and pressed down the plunger. His real name is David Townsend, 52, with thick glasses and a gray handlebar moustache. He works construction, putting up drywall. Townsend has used heroin for 36 years, spending up to $700 a week. "I actually hadn't used for four and a half years," he says, "but then I forgot I was an addict." At this point he was shooting up three times a day, but it no longer made him feel euphoric. "Unfortunately you get to a stage where all you're doing is preventing yourself from being sick," he said. Now he's waiting for a room at Onsite. "I've done it once before. This time I'll make it work." Fisher supports Townsend's decision, but they both know that even with the best treatment, the odds weighing against his recovery are heavy, with a high chance of relapse occurring even after years have passed. Fisher repeated a mantra among the staff at Insite, on the Sisyphean difficulties of getting addicts to stay sober: "It's like shoveling water."
Up a flight of stairs from the injection room, another locked door buzzed open to Onsite. When addicts have made the decision to get clean, they spend an initial 14-day period isolated on Onsite's detox floor. Heroin addicts are treated with methadone, and kept under close watch by Onsite's staff. The next floor held a short-term housing facility, where 20 post-detox patients stay while waiting for further housing to come available.
Dean Caldwell, a 42-year-old who had been sober for 90 days, wore a sleeveless t-shirt that showed off heavily muscled, tattooed arms. For years he was a crack addict and cocaine injector, shoplifting and mugging small-time dealers to get his fix. There is a glassed-in smoking porch on the back of the building, and Caldwell looked down at the alley that runs behind the block, narrating a bird's-eye view of the nightmare world everyone at Onsite is trying to escape. Down below, a small group gathered by a chain-link fence. A stooped, skeletal woman, a "steerer," brought customers down the alley to a man who sold crack openly out of a backpack. In the shelter of a dumpster, they all lit up.
It may seem counterintuitive to seek treatment in such tantalizing proximity to drug use; studies cite exposure to such cues and behavior as a strong predictor of relapse. But Caldwell feels that when someone is truly ready to be clean, that temptation no longer matters. Still, he's fully aware of the chances of his own failure. He's been through treatment three times, and works security at a homeless shelter now. "You have to do away with the concept of second chances," he says, "It takes as long as it takes." Now, his experience makes him want to do something for other addicts. "When a human being gets removed from that darkness, they have a responsibility to help the next person."
Back downstairs in the injection room, a young man with curly brown hair and glassy eyes sat hunched in a chair, holding an oxygen mask to his face.* The Insite nurses had just brought him back from an overdose. Sammy Mullally, a 24-year-old nurse, had seen him slumping in his cubicle and walked over. He looked at her for a moment and then dropped, his lips blue. "He was gone," she says. "His pupils were pinpoint. He was not breathing." They lowered him to the floor and gave him a shot of naloxone, inserting a mouthpiece to force air into his lungs. A second dose still didn't bring him back, and just as a third was about to be administered, the man popped up, wide-eyed. An ambulance arrived, but he refused to go to the hospital. Mullally says that's a frequent outcome.
The man said he hasn't used heroin for four months, and his tolerance has diminished. Also he'd been drinking that morning and hadn't told the nurses. He'd been using for five years; his father, also an addict, had taught him how to inject properly, to test his dope. If he hadn't been at Insite, he wasn't sure where he would have done it. "Probably the alley," he admitted. And then what? "Dead. Gone," said Mullaly. Even this grim outcome was not enough to shake up the man. He admitted he would probably use again that day. "I don't think I'm finished just yet," he said. "I'd really like to be finished, but there's something in my body that just tells me that I'm not finished using drugs."
Working closely with such an intractable population and keeping a degree of remove from their tragic lives can create an enormous emotional strain on Insite's staff. Mullally said three regular users from the community died the previous weekend. Staffers are required to go through therapy sessions, and a lot of emotional processing is done informally, the staff downloading their feelings over drinks at a bar. "It's so important to talk to your coworkers, talk to your partner how you feel about it," said Mullally. "If I didn't talk about it I would implode. But I can't leave the Downtown Eastside."
It was a typical day at Insite, and users would filter in throughout the day until the last hold-outs were ushered out the door at 4 a.m. Then a few hours of darkness before the sidewalk was hosed off and the line formed again at the front door. It's an endless parade of haggard addicts seeking their comforts, and no constituency in Vancouver—police, scientists, addicts or politicians—can agree on how exactly to help them, or whether they can be helped at all.
Update, Feb. 6, 2014: The man's name has been removed from the original version of this article. (Return to the updated sentence.)