At the heart of Canada's fentanyl crisis, extreme efforts that US cities may follow

VANCOUVER, B.C. - Beneath a blue tarp that blocks out a gray sky, Jordanna Coleman inhales the smoke from a heated mixture of heroin and methamphetamine, sucking the addictive vapor deep into her lungs.

The drugs and pipe, acquired elsewhere, are hers. But the shelter, the equipment she uses to prepare her fix and the volunteers standing by to respond if she overdoses are provided by a small nonprofit group. Funding and supplies come from the city of Vancouver and the province of British Columbia.

"I was outside. It's warmer in here," says Coleman, 22, although the tent is open to the damp and chill of a western Canadian winter. "It's just safer."

In barely a year, five sites like this one have opened within a few blocks of one another to contend with a surge of fentanyl on Vancouver's streets. In December, the organization that runs this location, the Overdose Prevention Society, took over a vacant building next door, giving users a clean indoor place to inject drugs. There are 29 similar sites in British Columbia, the epicenter of Canada's drug crisis, and more across the country.

"To save lives, you need a table, chairs and some volunteers," said Sarah Blyth, the manager here. "We literally popped it up in one day. And then you have people saving lives. Immediately."

As fentanyl rampages across North America, several U.S. cities have announced that they will open the first supervised drug-consumption sites like those in Canada. Their plans illustrate the gulf between the two nations: While Justin Trudeau's government is doubling down on its "harm reduction" approach, any U.S. organization that tries to follow suit would be violating federal law and risking a confrontation with the Justice Department.

U.S. researchers say that at least one underground site is operating on American soil, and they predict that a public operation will open despite the potential consequences.

"That's the way that drug policy issues have moved forward in this country [over the] last 25 years," said Alex Kral, an epidemiologist at the think tank RTI International, who has studied supervised drug consumption. Cities enduring the deaths, disease, crime and cost of drug epidemics have taken the lead in handing out free needles and distributing the overdose antidote naloxone - sometimes after legal battles.

San Francisco plans to add supervised injection services to an existing community health facility. Those could start as soon as July 1.

"We just have to do what's best for the client, and we hope the federal government will understand," said Barbara Garcia, director of health for the city and county of San Francisco. "I'm not looking to change federal law. I'm looking to save lives."

Canada's plans do not stop at supervised injection. Some sites now test users' drugs for fentanyl, and some are aiming to provide prescription opioids from vending machines.

The most far-reaching intervention is just two blocks from the pop-up site, where the Providence Crosstown Clinic provides 130 of the city's hardest-core drug users with pharmaceutical-grade heroin and other narcotics. Users come to inject themselves as often as three times a day, and some also swallow a morphine tablet to carry them through the night.

Freed of the need to steal, beg and trade sex for drug money, some now have apartments and jobs. The clinic, run by a medical center, hopes to add 50 more clients soon.

"The ability to say 'I'm receiving treatment, I'm not a dirty user' does so much for their self-esteem," said Jennifer Mackenzie, the clinical nurse leader. "It opens so many doors for them. They're getting medical treatment, and they look at themselves differently."

Research shows that the approach, like supervised drug consumption, saves lives, cuts criminal justice and health-care costs, limits the spread of diseases such as HIV and helps reduce used needles and other debris in its immediate neighborhood. A similar facility recently opened in Ottawa, and Canada has loosened requirements to encourage still others.

But British Columbia's programs have not blunted its opioid crisis. Overdose deaths have skyrocketed from fewer than 400 in 2014, when fentanyl became widely available on the street, to more than 1,400 in 2017. Eighty-one percent of last year's deaths involved fentanyl.

Critics said that statistic speaks to the futility of harm reduction. "To say the best we can do is to revive people who are victims and are going to be victims again . . . is reprehensible," said John Walters, drug czar under President George W. Bush and now chief operating officer of the Hudson Institute, a conservative think tank in Washington.

Walters favors a dramatic expansion of drug treatment in the United States, which recorded 42,000 opioid deaths in 2016, coupled with a much more concerted effort to keep drugs such as fentanyl out of the country. He questions the rigor of the academic studies that support harm reduction. And he believes that normalization and tolerance of drug use are reasons that addicts crowd the streets of this city's small Downtown Eastside district.

"Look at Vancouver, it's tried every bad policy you can try," Walters said. "This is another step in that whole policy that has made Vancouver a nightmare."

"This is my flail," Coleman said between hits on her pipe, scattering the contents of her backpack on a table. A coloring journal, cellphone, some clean socks. "It's what I do when I'm high."

She does not yet have the battered look of the legions of longtime drug users who are everywhere in this neighborhood. Yet her story is typical: She fled an abusive mother, got into hard drugs at 17 and soon was pimped out by her supplier. She has an 18-month-old son in foster care, lives with friends and is trying, again, to find her way out through treatment.

"It looks like I'm enjoying it because I'm high," she said. "I don't have anything in my life that really means anything. All the drugs that I have [are] not going fill the emotional void that I have."

Drug smokers like Coleman are still restricted to the Overdose Prevention Society's outdoor tents because the new building, a former grocery, has no ventilation system. It is home mostly to injection drug users. A long, narrow main room is nearly bare except for 13 stainless-steel tables and some posters on the walls. Red partitions divide the rest of the floor, making space for a couple of desks, a cot where workers can calm down after resuscitating an overdose victim, and supplies piled high in boxes.

The most critical are oxygen and naloxone, the antidote that has saved countless lives. In the 30 years that supervised sites have been open in Europe, and the 15 years that they have existed in Canada, no site has suffered an overdose death, Kral said.

Users enter here through a guarded door off a back alley that used to be the scene of widespread drug use, dealing and prostitution. A small street shrine to a dead woman sits just outside the entrance.

From a small table of supplies they pick up what they need: syringes, matches, elastic strips to tie off veins, water to dilute drugs, small squares of foil, tiny tins for cooking heroin. Also available are condoms and lube.

Some of the volunteers who greet them are current or former users themselves. They usher clients to the tables. On a clipboard, one staff member logs names (usually aliases), gender, the drugs being used and the time a person comes in. Between the indoor and outdoor sections, 300 to 700 people show up daily. The largest crowds are on days when welfare payments arrive.

The pop-up was born of necessity in late 2016, when fentanyl was overwhelming the neighborhood and a 15-year-old supervised-use program. Overdoses on the street would send panicked bystanders to a nearby open-air market to find naloxone or call an ambulance.

"If there was an overdose, they would come running to the market and we would have Narcan ready," Blyth said, using the antidote's brand name. "Then it became so frequent that it was happening all the time. We had no choice really." A GoFundMe campaign started the tent facility. Aid from the government followed.

The organizers acknowledge that their main goal is just to keep people alive, though they have seen a few clients get into treatment and off drugs.

"If these services didn't exist, trust me, it would have been a catastrophe, especially in the past year and a half, when the fentanyl crisis spiked," said RonnieGrigg, a large, soft-spoken man with a chest-length beard who helps manage the site. In the past three years, Grigg said, 100 people he knew have died of overdoses.

At adjacent tables, Vinney Taylor, 23, is sitting with a friend, Dylan, who will only give his first name. They use a cooked mixture of "down" - heroin - and "side" - meth - that forms a bubbling brown liquid when heated in the tin. They inject themselves several times during their stay.

Taylor is homeless. He lingers for quite some time, protected from the cold, surrounded by his possessions. He is so high that he cannot stand still. He bounces, sways and rocks. He pokes through his stuff, which is spilled out on the table. At one point, he shaves lines into his left eyebrow.

The two men are clearly enjoying themselves. Both are users and dealers, which is common; selling drugs helps them collect money for their next fix and avoid the agonies of withdrawal.

"That's the number-one reason we still use, to not be sick," Taylor said. "I wouldn't wish that on anyone."

At the Providence Crosstown Clinic a short walk along West Hastings Street, the atmosphere is different. Some users here measure their addictions in decades, and it shows.

With an ample supply of diacetyl morphine - the heroin equivalent - and other narcotics on the premises, the clinic is a cross between a medical facility and a bank. Users must first step into a small vestibule. Only when the outside door locks behind them will the inside door open. The drugs are kept in a vault, doled out to users in pre-measured syringes through a thick glass window with a slot at the bottom.

There is a waiting room, an exam table, desks and a big room, where users shuffle in to inject themselves. The doctor and nurses speak of "treatment." They are prohibited from administering an injection themselves.

Nothing else has worked for these men and women, who clinically are in the grip of "severe opioid disorder." Methadone has proven ineffective, as have therapeutic approaches such as 12-step programs. Most of them no longer feel any pleasure from the drugs; they take them simply to function and prevent severe withdrawal symptoms.

Here, users are sure their drugs contain no fentanyl. And paradoxically, by providing them with the substances they need, the clinic does more than just keep them alive.

"It makes me feel normal," explained a 52-year-old woman named Lori, who did not want her last name used.

Other than more than a decade on drugs, Lori leads a fairly unremarkable life. She has two grown children who don't know about her twice-a-day clinic visits. She is married and holds a part-time job in a call center, taking customer service complaints. She is clearheaded and contemplative.

Over time, the cost of her habit reached $200 a day. In 2011, she heard about a research study at the clinic and began getting her drugs there.

"Thank God, because I would be on the street," she said. "Everything would be finished. My marriage would be over. I don't think I'd be here."

The medical staff counsels clients on vein care, HIV, hepatitis C and treatment options. The price of all the services is high: about $25,000 (Canadian) annually per client. But the cost of not having them is much higher, said Scott MacDonald, the clinic's physician lead.

Remove the stigma attached to narcotics, he contends, and the clinic's model is not much different from therapy for high blood pressure or diabetes.

"One hundred thirty people [here] are able to access injectable treatment," he said. "And we see that their lives are transformed."