Roger-Luc Chayer (Image : Pixabay)

We cannot hide from the fact that there is a growing debate surrounding supervised injection sites in several countries, and that public health issues, as well as moral questions, are being raised by the very existence of these sites.

Before these centres existed, people who used injectable drugs were hiding in alleys, at home or in the restrooms of businesses to inject substances purchased on the street, often without knowing exactly what they were made of. Consequently, when an overdose occurred, these people often lost their lives alone, especially since naloxone, the antidote now used to reverse opioid overdoses, was not yet as widely accessible to the general public as it is today.

Sharing contaminated needles turned every injection into an additional risk. HIV, hepatitis B and C and serious bacterial infections could be transmitted through contaminated equipment, sometimes with irreversible consequences. At a time when access to sterile syringes was much more limited, the reuse and sharing of injection equipment contributed to the spread of infections among people who injected drugs, while some of these infections could subsequently be transmitted to other people through other routes.

It was under these conditions that the idea of opening supervised injection centres was implemented in many countries. These centres could provide sterile equipment, such as single-use syringes and disinfectant swabs, under supervised conditions that made it possible to detect signs of an overdose as quickly as possible directly on site.

The idea of supervised injection sites did not come from a single person. The concept developed gradually in Europe, particularly in the Netherlands, and was subsequently adapted elsewhere.

The First Experiments

The first forms of facilities where people could consume drugs in a tolerated environment appeared in the Netherlands in the early 1970s, particularly in Amsterdam. These early initiatives were associated with organizations providing assistance to drug users and with what was known as a low-threshold approach.

The logic was relatively simple: since some people were already using drugs in the streets, alleys or dangerous places, it was possible to move that consumption to a safer location, with clean equipment and potentially the presence of staff.

The model subsequently developed in Switzerland in the 1980s, followed by Germany and other European countries.

And in Canada?

In Vancouver, the idea was not simply imported by governments. It came in particular from activists, people who used drugs, healthcare professionals and community organizations confronted with the HIV epidemic and overdose deaths in the Downtown Eastside.

In 1994, the Chief Coroner of British Columbia created a working group on the overdose crisis. Its report recommended, among other things, that Vancouver study the possibility of creating supervised injection sites, taking European experience into account.

Then, in 1995, a group led by drug users, IV Feed, with the support of activists Ann Livingston and Bud Osborn, secretly opened Back Alley, a peer-run injection site. It could accommodate more than a hundred people on certain nights before being closed by police.

In Montreal, the idea of supervised injection sites is the result of several decades of harm reduction and community work, particularly around needle exchange. The first legally authorized services eventually opened in June 2017. In the United States, underground initiatives already existed, but the first officially authorized sites opened in New York in November 2021, after years of political and legal debates and resistance.

But with the many social crises shaking major cities around the world, and particularly since the pandemic, many street drug users no longer have jobs or a place to live. Too often, this means that they are found on the streets. And the debate before us today is precisely why we provide them with injection equipment to save their lives, but above all, what kind of life these people actually exist in.

Montreal, San Francisco and Paris are facing a growing presence of people experiencing homelessness and scenes of drug use in public spaces. Behind these images, public health data reveal complex realities in which precariousness, lack of housing, addiction, mental health problems and trauma intersect. For some people, the consumption of drugs can also become a way of trying to ease deep suffering. But one question remains, and it is difficult to avoid: if we are capable of saving a life at the moment of an overdose, are we also capable of offering that person a life in which they will genuinely want to remain alive?

And what about all these syringes in public spaces?

But there is another aspect of this crisis that is discussed much less: the number of syringes and injection equipment that end up in public spaces. When the consumption of drugs moves into streets, alleys, parks and makeshift encampments, the waste associated with this consumption follows the same path. Syringes, needles, swabs, containers and other objects that may have come into contact with blood can end up on sidewalks, in bushes, in public restrooms or near places frequented by children.

And that is where the problem changes nature.

An abandoned syringe is not simply waste. It is a sharp object that can cause an injury and a potential exposure to blood. A person walking in a park, a child playing in the grass, a municipal employee cleaning a property or a homeowner maintaining their yard should never have to wonder whether they have just been pricked by a potentially contaminated needle.

However, it is important to avoid creating unjustified fear: an abandoned syringe does not automatically mean that a person will become infected with HIV or hepatitis. The risk of transmission of HIV in this community setting is considered extremely low and no confirmed case of transmission of HIV from an abandoned needle in the community has been documented. But that does not make these objects harmless. Hepatitis B and C are blood-borne infections, and the hepatitis C virus can remain infectious on surfaces for several days, or even several weeks under certain conditions.

This is therefore the paradox our cities are facing: saving a person from an overdose through harm reduction is one thing; managing the consequences of drug use spilling into public spaces is another. Harm reduction programs specifically provide mechanisms for the recovery and safe disposal of used equipment, and Health Canada recognizes that these services can help reduce the presence of discarded injection equipment in communities.

The question is therefore not whether to choose between compassion and public safety. It is whether our cities are capable of doing both at the same time.

One of the many telling examples in Montreal

I was recently discussing this with a fellow journalist who wondered why, in a small park behind his home, there were so many small brown bags and syringes scattered here and there on the ground. I then informed him that he lived directly behind a supervised injection centre that provided the equipment necessary for drug users to inject outside. Obviously, once their injection was completed, they left everything behind, leaving volunteers to come and collect these potentially hazardous biomedical wastes every day.

We are continually being asked to learn to live with these realities, but in practice, it is on the shoulders of the population that we are shifting a management problem that we clearly no longer have under control. Going back is impossible, but is there a vision that would allow these situations to evolve positively?

Going back is impossible, and it would probably be neither realistic nor humane to pretend that an addiction crisis can be solved simply by removing syringes, naloxone or supervised consumption sites. But we must have the courage to ask the following question: should saving a life be our final destination, or simply the beginning of the real work?

A person who survives an overdose does not merely need to survive the next one. They need a roof over their head, care, a safe environment, real access to treatment when they want it and, above all, an opportunity to regain a life that is not entirely organized around the next dose.

Harm reduction can prevent death. But society must now ask itself how it can also make life possible. Otherwise, we risk becoming extraordinarily effective at keeping people alive in conditions that themselves remain profoundly inhumane.

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